Nationwide survey on training and device utilization during tracheal intubation in French intensive care units.

BACKGROUND: Intubation is a lifesaving procedure that is often performed in intensive care unit (ICU) patients, but leads to serious adverse events in 20-40% of cases. Recent trials aimed to provide guidance about which medications, devices, and modalities maximize patient safety. Videolaryngoscopes are being offered in an increasing range of options and used in broadening indications (from difficult to unremarkable intubation). The objective of this study was to describe intubation practices and device availability in French ICUs. MATERIALS AND METHODS: We conducted an online nationwide survey by emailing an anonymous 26-item questionnaire to physicians in French ICUs. A single questionnaire was sent to either the head or the intubation expert at each ICU. RESULTS: Of 257 ICUs, 180 (70%) returned the completed questionnaire. The results showed that 43% of intubators were not fully proficient in intubation; among them, 18.8% had no intubation training or had received only basic training (lectures and observation at the bedside). Among the participating ICUs, 94.4% had a difficult intubation trolley, 74.5% an intubation protocol, 92.2% a capnography device (used routinely to check tube position in 69.3% of ICUs having the device), 91.6% a laryngeal mask, 97.2% front-of-neck access capabilities, and 76.6% a videolaryngoscope. In case of difficult intubation, 85.6% of ICUs used a bougie (154/180) and 7.8% switched to a videolaryngoscope (14/180). Use of a videolaryngoscope was reserved for difficult intubation in 84% of ICUs (154/180). Having a videolaryngoscope was significantly associated with having an intubation protocol (P = 0.043) and using capnography (P = 0.02). Airtraq® was the most often used videolaryngoscope (39.3%), followed by McGrath®Mac (36.9%) then by Glidescope® (14.5%). CONCLUSION: Nearly half the intubators in French ICUs are not fully proficient with OTI. Access to modern training methods such as simulation is inadequate. Most ICUs own a videolaryngoscope, but reserve it for difficult intubations.

Critical incidents related to invasive mechanical ventilation in the ICU: preliminary descriptive study.

OBJECTIVES: To establish a preliminary list of critical incidents (CIs) associated with mechanical ventilation and to describe a CI reporting method. DESIGN: A list of CIs was established based on a consensus among ICU caregivers. The list was compared to CIs collected prospectively during a predefined study period. SETTING: The clinical observations were conducted in two intensive care units. PATIENTS: All patients receiving mechanical ventilation were included. MEASUREMENTS AND RESULTS: The list of CIs included death and 62 other CI types categorized as immediately life-threatening, secondarily life-threatening, or non-life-threatening. The observational study identified 527 CIs in 137 patients. Virtually all non-life-threatening CIs were ascribed to failure to comply with safety rules or to equipment failure and 40% of life-threatening CIs to the course of the disease or to patient-related factors. The match between CI types on the list and CI types observed in the ICUs was excellent. CONCLUSIONS: Use of our reporting method to create a CI database in a multicenter study including ICUs with varying recruitment patterns may help to identify markers suitable for routine continuous use as part of a quality-assurance program.

Prevention of ischemia-reperfusion lung injury by sulfated Lewis(a) pentasaccharide. The Paris-Sud University Lung Transplantation Group.

Inhibition of polymorphonuclear neutrophil (PMN) adhesion to the pulmonary endothelium attenuates ischemia-reperfusion (I/R) lung injury. We hypothesized that 3'-sulfated Lewis(a) (SuLa), a potent ligand for the selectin adhesion molecules, may have a beneficial effect on I/R lung injury, as measured by the filtration coefficient (K(fc)), and reduce pulmonary sequestration of PMN as assessed by the lung myeloperoxidase (MPO) activity. Blood-perfused rat lungs were subjected to 30 min of perfusion, 60 min of warm ischemia, and 90 min of reperfusion after treatment with either SuLa (200 microg) or saline. Effects of SuLa on PMN adhesion to cultured human umbilical vein endothelial cells (HUVEC) stimulated with tumor necrosis factor-alpha and calcium ionophore were also investigated. Compared with preischemia conditions, I/R induced a significant increase in K(fc), which was attenuated with SuLa (80 +/- 8 vs. 30 +/- 5%; P < 0.001). SuLa reduced lung MPO and PMN adhesion to stimulated HUVEC. These results indicate that SuLa reduces I/R-induced lung injury and PMN accumulation in lung. This protective effect might be related to inhibition of PMN adhesion to endothelial cells.

Spontaneous ventilation with halothane in children. A comparative study between endotracheal tube and laryngeal mask airway.

BACKGROUND: It has been reported that, in children breathing spontaneously via an endotracheal tube, halothane depresses ventilation with paradoxic inspiratory movement. Endotracheal tubes have a higher airflow resistance than do laryngeal mask airways (LMAs). Therefore, the aim of this study was to compare spontaneous ventilation via the LMA with that via the endotracheal tube in children anesthetized with halothane. METHODS: The authors studied two groups of 6-24-month-old children with no cardiorespiratory and neurologic disorders, undergoing elective minor surgery with halothane anesthesia: one group breathing via LMA (n = 10) and one group breathing via endotracheal tube (n = 10). They measured tidal volume, respiratory rate, minute ventilation, and end-tidal CO2. They assessed paradoxic inspiratory movement using amplitude index and phase delay index. RESULTS: Age and weight were similar in both groups. Mean +/- SD tidal volume (7.5 +/- 1.9 ml/kg in the LMA group vs. 5.3 +/- 1.1 ml/kg in the endotracheal tube group; P < 0.05) and minute ventilation (325 +/- 105 ml.min-1.kg-1 in the LMA group vs. 246 +/- 38 ml.min-1.kg-1 in the endotracheal tube group; P < 0.05) were lower in the endotracheal tube group. The phase delay index (18 +/- 11% in the LMA group vs. 41 +/- 19% in the endotracheal tube group; P < 0.05) and the amplitude index (25 +/- 43% in the LMA group vs. 74 +/- 72% in the endotracheal tube group; P < 0.05) were significantly smaller with the LMA than with the endotracheal tube. CONCLUSIONS: In 6-24-month-old children anesthetized with halothane, paradoxic inspiratory movement is less when breathing through an LMA than through an endotracheal tube.

Amelioration of reperfusion injury by pentoxifylline after lung transplantation. The Université Paris-Sud Lung Transplant Group.

BACKGROUND: Pentoxifylline attenuates neutrophil-mediated lung injury in several models of acute lung inflammation. METHODS: Because pulmonary neutrophil sequestration is the main determinant of lung reperfusion injury, we sought to determine whether pentoxifylline prevented reperfusion injury in isolated perfused rat lung (4-hour cold ischemia, 1-hour reperfusion; pentoxifylline intravenously 40 mg) and in pigs after left lung allotransplantation (24-hour cold ischemia, 4-hour reperfusion; pentoxifylline 1.5 mg/kg/hr intravenously). In the pigs, inflatable cuffs placed around each pulmonary artery enabled us to evaluate each lung separately. RESULTS: In rat lungs, the coefficient of lung permeability increased by 75% +/- 10% in controls and by 3% +/- 2% (p < 0.01) in pentoxifylline-treated lungs. In the pigs, with blood flow to the transplanted lung alone and ventilation with an inspired oxygen fraction of 1, the arterial oxygen tension was greater in the pentoxifylline group than in the control group (423 +/- 49 versus 265 +/- 43 mm Hg, p < 0.05), whereas the total pulmonary vascular resistance was lower (15 +/- 1 versus 30 +/- 9 mm Hg/L/min, p < 0.02). After reperfusion, the decrease in circulating leukocyte count fell by 35% +/- 3% in the control group and remained unchanged in the pentoxifylline group, and the leukocytes count per microscopic field in the transplanted lung was lower in the pentoxifylline group than in the control group (15 +/- 2 versus 140 +/- 50, p < 0.02). CONCLUSIONS: These data suggest that pentoxifylline prevented reperfusion injury by decreasing neutrophil lung sequestration.

Evaluation of a new preservation solution: Celsior in the isolated rat lung. Paris-Sud University Lung Transplatation Group.

BACKGROUND: We compared Celsior solution, a new and original extracellular preservation solution, with blood-based Wallwork's solution. METHODS: In two groups of isolated rat lungs submitted to 4 hours of cold ischemia, pulmonary arterial and venous resistances, coefficient of filtration, and wet-to-dry lung weight ratio were determined at baseline and after 90 minutes of reperfusion. RESULTS: After ischemia-reperfusion, percentage of increases above the respective baseline coefficient of filtration values were 93% +/- 7% in the Wallwork group and 7% +/- 3% in the Celsior group (p < 0.001 versus Wallwork's solution). CONCLUSIONS: These results show that Celsior consistently prevented the ischemia-reperfusion-induced increase in pulmonary microvascular permeability as compared with Wallwork's solution.

Pentoxifylline and lung ischemia-reperfusion injury: application to lung transplantation. Université Paris-Sud Lung Transplant Group.

Pentoxifylline (PTX) attenuates neutrophil-mediated lung injury in several models of acute lung inflammation. Because pulmonary neutrophil sequestration is the main determinant of ischemia-reperfusion (IR) injury in lung transplantation, we sought to determine whether or not PTX prevented IR injury in isolated perfused rat and rabbit lungs submitted to IR, and in pigs after left lung allotransplantation. In rat lungs after IR, the coefficient of lung endothelial permeability (Kfc) increased by 112 +/- 12% in controls and by 27 +/- 8% (p < 0.001) in PTX-treated lungs. After IR, lung myeloperoxidase and blood neutrophil count decrease were lower with PTX than in controls, and the changes in Kfc were correlated with the percentage decrease in blood neutrophils during reperfusion. In rabbit lungs, endothelium-dependent relaxation in isolated pulmonary arterial rings was decreased in the control group and normal in the PTX group. In pigs ventilated with pure oxygen, the PaO2 was greater in the PTX group than in the control group (423 +/- 49 vs. 265 +/- 43 mm Hg; p < 0.05), whereas the total pulmonary vascular resistance was lower (15 +/- 1 vs. 30 +/- 9 mm Hg/L/min; p < 0.02). After reperfusion, the decrease in circulating leukocyte count fell by 35 +/- 3% in the control group and remained unchanged in the PTX group, and the leukocyte count per microscopic field in the transplanted lung was lower in the PTX group than in the control group (p < 0.02). In conclusion, PTX prevented IR lung endothelium injury and improved post-IR lung function by decreasing neutrophil lung sequestration, and this agent might be useful in clinical lung transplantation.

Lung preservation with Euro-Collins, University of Wisconsin, Wallwork, and low-potassium-dextran solution. Université++ Paris-Sud Lung Transplant Group.

Using isolated rat lungs, we compared prevention of ischemia-reperfusion injury provided by flushing the lungs with modified Euro-Collins solution (EC), University of Wisconsin solution (UW), low-potassium-dextran solution (LPD), or Wallwork solution (WA). After 4 hours' and 6 hours' cold ischemia, reperfusion injury was assessed on the basis of changes in filtration coefficients (Kfc) and pressure-flow curves, characterized by the slope of the curves (incremental resistance) and the extrapolation of this slope to zero flow (pulmonary pressure intercept [Ppi]). After 4 hours, Kfc and Ppi were higher with EC than with UW, LPD, and WA, and the incremental resistance was higher with EC and UW. After 6 hours, Kfc and incremental resistance Ppi were higher with LPD than with WA. Because ischemia-reperfusion injury is associated with decreased endothelial synthesis of prostacyclin and nitric oxide, we tested whether the addition of prostacyclin or the nitric oxide precursor L-arginine to WA would improve preservation. The Kfc and Ppi were lower with both treatments. In conclusion, ischemia-reperfusion injury was best prevented by using WA. The favorable effect of prostacyclin or L-arginine emphasizes the role played by endothelial dysfunction in ischemia-reperfusion injury.

Reduction of ischemia-reperfusion injury by pentoxifylline in the isolated rat lung. Paris-Sud University Lung Transplantation Group.

Inhibition of pulmonary neutrophil sequestration attenuates ischemia-reperfusion (IR) lung injury. Pentoxifylline (PTX) reduced pulmonary sequestration of neutrophils and neutrophil-dependent lung injury in several experimental settings but has never been tested in IR models. We hypothesized that PTX may have a beneficial effect on IR lung injury as measured by the coefficient of filtration (Kfc) and may reduce IR-associated sequestration of neutrophils as assessed by lung myeloperoxidase (MPO) activity and by blood neutrophil count decrease during reperfusion. Three groups of isolated blood perfused rat lungs were studied: a time control group (n = 6) was perfused for 3 h, and two groups (n = 10) subjected to 1 h ischemia were treated with PTX or saline before a 2 h reperfusion. The increase in Kfc induced by IR was reduced fivefold by PTX compared with saline (+27 +/- 8% versus +112 +/- 12%, respectively; p < 0.001), and was similar to time controls (+9 +/- 9%). After IR, MPO and blood neutrophil count decrease were lower with PTX than with saline. Changes in Kfc were correlated to the percentage decrease in blood neutrophils during reperfusion. We conclude that PTX reduced rat lung IR microvascular injury. This effect may be mainly caused by decrease in lung sequestration of neutrophils during reperfusion.

Soft tissue augmentation as a method of reducing the liability to pressure sores in spinal injured patients.

The development of a procedure designed to reduce the liability to pressure sores over bony prominences is described. This employs the properties of a particular type of carbon fibre pad implanted surgically over the bony prominence. The mechanical response of the pad to loading has been examined. The host tissue response to the pad involves penetration of the interstices between the carbon fibres with organised fibrous tissue. The host-tissue--carbon fibre pad complex has been found to be highly vascular. An 'ischiobarograph' has been developed and used in order to evaluate the alteration in pressure profile produced by the presence of the implanted prosthesis (the patient being in a sitting position).