Obesity is Unlikely to be an Impediment to First-Pass Success During the Intubation of Critically Ill Patients.

Background: Obesity has been described as a potential risk factor for difficult intubation among critically ill patients. Our primary aim was to further elucidate the association between obesity and first-pass success. Our secondary aim was to determine whether the use of hyper-angulated video laryngoscopy improves first-pass success compared to direct laryngoscopy when utilized for the intubation of critically ill obese patients. Study Design and Methods: A retrospective cohort study of adult patients undergoing endotracheal intubation outside of the operating room or emergency department between January 30, 2016 and May 1, 2020 at 3 campuses of an academic hospital system in the Bronx, NY. Our primary outcome was first-pass success of intubation. A multivariate logistic analysis was utilized to compare obesity status with first-pass success. Results: We identified 3791 critically ill patients who underwent endotracheal intubation of which 1417 were obese (body mass index [BMI] ≥ 30). The incidence of hyper-angulated video laryngoscopy increased over the study period. A total of 46.6% of obese patients underwent intubation with hyper-angulated video laryngoscopy as compared to 35.1% of the nonobese group. First-pass success was 79.2% among the entire cohort. Obesity status did not appear to be associated with first-pass success (adjusted odds ratio [OR] 1.07, 95% confidence interval [CI]: 090-1.27; P = .47). Hyper-angulated video laryngoscopy did not seem to improve first-pass success among obese patients as compared to nonobese patients (adjusted OR 1.21, 95% CI: 0.85-1.71; P = .29). These findings persisted even after redefining the obesity cutoff as BMI ≥ 40 and excluding patients intubated during cardiac arrests. Conclusion: We did not detect an association between obesity and first-pass success. Hyper-angulated video laryngoscopy did not appear offer additional benefit over direct laryngoscopy during the intubation of critically ill obese patients.

Thoracic Ultrasound in COVID-19: Use of Lung and Diaphragm Ultrasound in Evaluating Dyspnea in Survivors of Acute Respiratory Distress Syndrome from COVID-19 Pneumonia in a Post-ICU Clinic.

INTRODUCTION: Dyspnea is a common symptom in survivors of severe COVID-19 pneumonia. While frequently employed in hospital settings, the use of point-of-care ultrasound in ambulatory clinics for dyspnea evaluation has rarely been explored. We aimed to determine how lung ultrasound score (LUS) and inspiratory diaphragm excursion (DE) correlate with patient-reported dyspnea during a 6-min walk test (6MWT) in survivors of COVID-19 acute respiratory distress syndrome (ARDS). We hypothesize higher LUS and lower DE will correlate with dyspnea severity. STUDY DESIGN AND METHODS: Single-center cross-sectional study of survivors of critically ill COVID-19 pneumonia (requiring high-flow nasal cannula, invasive, or non-invasive mechanical ventilation) seen in our Post-ICU clinic. All patients underwent standardized scanning protocols to compute LUS and DE. Pearson correlations were performed to detect an association between LUS and DE with dyspnea at rest and exertion during 6MWT. RESULTS: We enrolled 45 patients. Average age was 61.5 years (57.7% male), with average BMI of 32.3 Higher LUS correlated significantly with dyspnea, at rest (r = + 0.41, p = < 0.01) and at exertion (r = + 0.40, p = < 0.01). Higher LUS correlated significantly with lower oxygen saturation during 6MWT (r = -0.55, p = < 0.01) and lower 6MWT distance (r = -0.44, p = < 0.01). DE correlated significantly with 6MWT distance but did not correlate with dyspnea at rest or exertion. CONCLUSION: Higher LUS correlated significantly with patient-reported dyspnea at rest and exertion. Higher LUS significantly correlated with more exertional oxygen desaturation during 6MWT and lower 6MWT distance. DE did not correlate with dyspnea.

The Impact of Nighttime on First Pass Success During the Emergent Endotracheal Intubation of Critically Ill Patients.

BACKGROUND: While numerous investigations have described worse outcomes for patients undergoing emergent procedures at night, few studies have investigated the impact of nighttime on the outcomes of emergent endotracheal intubation (EEI). We hypothesized that for patients requiring EEI at night, the outcome of first pass success would be lower as compared to during the day. METHODS: We performed a retrospective cohort study of all patients admitted to our institution between January 1st, 2016 and July 17st, 2019 who underwent EEI outside of an emergency department or operating room. Nighttime was defined as between 7:00 pm and 6:59 am. The primary outcome was the rate of first pass success. Logistic regression was utilized with adjustment for demographic, morbidity and procedure related covariables. RESULTS: The final examined cohort included 1,674 EEI during the day and 1,229 EEI at night. The unadjusted rate of first pass success was not different between the day and night (77.5% vs. 74.6%, unadjusted odds ratio (OR): 0.85; 95% confidence interval (CI): 0.72, 1.0; P = 0.073 though following adjustment for prespecified covariables the odds of first pass success was lower at night (adjusted OR: 0.83, 95% CI: 0.69, 0.99; P = 0.042. Obesity was found to be an effect modifier on first pass success rate for day vs. night intubations. In obese patients, nighttime intubations had significantly lower odds of first pass success (adjusted OR: 0.71, 95% CI: 0.52, 0.98; P = 0.037). DISCUSSION: After adjustment for patient and procedure related factors, we have found that the odds of first pass success is lower at night as compared to the day. This finding was, to some degree, driven by obesity which was found to be a significant effect modifier in this relationship.

Impact of Drain Placement and Duration on Outcomes After Pancreaticoduodenectomy: A National Surgical Quality Improvement Program Analysis.

BACKGROUND: The decisions to routinely place a drain after pancreaticoduodenectomy and how long to leave the drain remain controversial due to conflicting evidence and significant variations in clinical practice. This study aims to address those questions by using a large national database and a rigorous analytical model. METHODS: The American College of Surgeons National Surgical Quality Improvement Program 2015-2016 Pancreatectomy Participant Use Data Files were used to identify patients who had undergone pancreaticoduodenectomy (n = 7583). Univariable and multivariable binomial regression analyses were performed to control for potential confounders and various preoperative risk factors. Cox regression with drain as a time-dependent covariate, conditional on having a drain placed, was used to examine the association between the drain remaining in place and morbidities. RESULTS: Of 7583 patients, drains were placed in 6666 (87.9%). Drain placement decreased the risk of developing serious morbidity (relative risk [RR] 0.73, 95% confidence interval [CI] 0.65-0.82), overall morbidity (RR 0.79, 95% CI 0.72-0.87), and organ space surgical site infection (RR 0.72, 95% CI 0.61-0.85). Drain placement did not change the risk of developing a clinically relevant postoperative pancreatic fistula (RR 0.96, 95% CI 0.78-1.19). However, for those with drains placed, length of drainage was independently associated with serious morbidity (hazard ratio [HR] 3.06, 95% CI 2.65-3.53), overall morbidity (HR 2.48, 95% CI 2.20-2.80), and organ space surgical site infection (HR 1.47, 95% CI 1.23-1.74). CONCLUSIONS: Routine drain placement following pancreaticoduodenectomy may decrease postoperative complications, including serious morbidity, overall morbidity, and organ space surgical site infections; however, length of drainage was associated with increased risk of the previously-named complications. These results support the routine placement and early removal of intraoperative surgical drains in pancreaticoduodenectomy.

Validation of Lipase and Systemic Inflammatory Response Syndrome as Prognostic Indicators in Pediatric Acute Pancreatitis: A Retrospective Analysis.

INTRODUCTION: Acute pancreatitis (AP) is understudied in the pediatric population despite increasing incidence. Although many cases are mild and resolve with supportive care, severe acute pancreatitis (SAP) can be associated with significant morbidity and mortality. There is a lack of pediatric-specific predictive tools to help stratify risk of SAP in children. METHODS: A retrospective cohort study of patients with AP or recurrent AP at Cohen Children's Medical Center between 2011 and 2016 was performed. Lipase level and the presence of pediatric systemic inflammatory response syndrome (SIRS) on admission were examined as potential predictors of SAP and length of stay (LOS). A multivariate logistic regression or analysis of covariance was used to conduct the multivariate analysis. RESULTS: Seventy-nine pediatric patients met inclusion criteria. Approximately 37% (29/79) had SIRS on admission, 22% (17/79) developed SAP, and there were no mortalities. In both the univariate and multivariate models, SIRS was a predictor of SAP. Mean (SD) LOS for patients with SIRS compared with without SIRS was 9.6 ±â€Š8.3 compared with 6.3 ±â€Š6.9 days (P < 0.05). The mean LOS of patients with one or more comorbidity (48%, 38/79) was 10.0 ±â€Š9.5 compared with 5.2 ±â€Š4.0 days (P < 0.01) for those patients without any comorbidities. Only the presence of comorbidities predicted length of time spent nil per os (NPO; P = 0.0022). Patients with comorbidities stayed an average of 5.6 ±â€Š7.6 days NPO, whereas those without comorbidities spent 2.8 ±â€Š2.4 days NPO. Lipase was not predictive of SAP, LOS, or length of time spent NPO. CONCLUSIONS: These results support the use of SIRS as a simple screening tool on admission to identify children at risk for the development of SAP. The presence of any comorbidity was predictive of LOS and length of NPO in the multivariate model. This may reflect that comorbidities prolong pancreatitis or influence disposition planning.

Maximizing the Use of Scoring Systems in the Prediction of Outcomes in Acute Pancreatitis.

BACKGROUND/AIMS: No single classification system has so far effectively predicted the severity for Acute Pancreatitis (AP). This study compares the effectiveness of classification systems: Original Atlanta (OAC), Revised Atlanta (RAC), Determinant based classification (DBC), PANC 3, Harmless AP Score (HAPS), Japanese Severity Score (JSS), Symptoms Nutrition Necrosis Antibiotics and Pain (SNNAP), and Beside Index of Severity for AP (BISAP) in predicting outcomes in AP. METHODS: Scores for BISAP, Panc 3, HAPS, SNNAP, OAC, RAC, and DBC were calculated for 221 adult patients hospitalized for AP. Receiver Operating Characteristic curve analysis and Akaike Information Criteria were used to compare the effectiveness of predicting need for surgery, intensive care unit (ICU) admission, readmission within 30 days, and length of hospital stay. RESULTS: Both the RAC and the DBC strongly predict the length of hospital stay (p < 0.0001 for both) and ICU admission (p < 0.0001 for both). Additionally, both BISAP and PANC 3 showed weak predictive capacity at identifying length of stay and ICU admission. CONCLUSIONS: We suggest that BISAP and PANC3 be obtained within the initial 24 h of hospitalization to offer an early prediction of length of stay and ICU admission. Subsequently, RAC and DBC can offer further information later in the course of the disease.

Practice, Outcomes, and Complications of Emergent Endotracheal Intubation by Critical Care Practitioners During the COVID-19 Pandemic.

BACKGROUND: For patients with COVID-19 who undergo emergency endotracheal intubation, data are limited regarding the practice, outcomes, and complications of this procedure. RESEARCH QUESTION: For patients with COVID-19 requiring emergency endotracheal intubation, how do the procedural techniques, the incidence of first-pass success, and the complications associated with the procedure compare with intubations of critically ill patients before the COVID-19 pandemic? STUDY DESIGN AND METHODS: We conducted a retrospective study of adult patients with COVID-19 at Montefiore Medical Center who underwent first-time endotracheal intubation by critical care physicians between July 19, 2019, and May 1, 2020. The first COVID-19 patient was admitted to our institution on March 11, 2020; patients admitted before this date are designated the prepandemic cohort. Descriptive statistics were used to compare groups. A Fisher exact test was used to compare categorical variables. For continuous variables, a two-tailed Student t test was used for parametric variables or a Wilcoxon rank-sum test was used for nonparametric variables. RESULTS: One thousand two hundred sixty intubations met inclusion criteria (782 prepandemic cohort, 478 pandemic cohort). Patients during the pandemic were more likely to be intubated for hypoxemic respiratory failure (72.6% vs 28.1%; P < .01). During the pandemic, operators were more likely to use video laryngoscopy (89.4% vs 53.3%; P < .01) and neuromuscular blocking agents (86.0% vs 46.2%; P < .01). First-pass success was higher during the pandemic period (94.6% vs 82.9%; P < .01). The rate of associated complications was higher during the pandemic (29.5% vs 15.2%; P < .01), a finding driven by a higher rate of hypoxemia during or immediately after the procedure (25.7% vs 8.2%; P < .01). INTERPRETATION: Video laryngoscopy and neuromuscular blockade were used increasingly during the COVID-19 pandemic. Despite a higher rate of first-pass success during the pandemic, the incidence of complications associated with the procedure was higher.

A Case-Control Study of Prone Positioning in Awake and Nonintubated Hospitalized Coronavirus Disease 2019 Patients.

To determine the association between prone positioning in nonintubated patients with coronavirus disease 2019 and frequency of invasive mechanical ventilation or inhospital mortality. DESIGN: A nested case-matched control analysis. SETTING: Three hospital sites in Bronx, NY. PATIENTS: Adult coronavirus disease 2019 patients admitted between March 1, 2020, and April 1, 2020. We excluded patients with do-not-intubate orders. Cases were defined by invasive mechanical ventilation or inhospital mortality. Each case was matched with two controls based on age, gender, admission date, and hospital length of stay greater than index time of matched case via risk-set sampling. The presence of nonintubated proning was identified from provider documentation. INTERVENTION: Nonintubated proning documented prior to invasive mechanical ventilation or inhospital mortality for cases or prior to corresponding index time for matched controls. MEASUREMENTS AND MAIN RESULTS: We included 600 patients, 41 (6.8%) underwent nonintubated proning. Cases had lower Spo2/Fio2 ratios prior to invasive mechanical ventilation or inhospital mortality compared with controls (case median, 97 [interquartile range, 90-290] vs control median, 404 [interquartile range, 296-452]). Although most providers (58.5%) documented immediate improvement in oxygenation status after initiating nonintubated proning, there was no difference in worst Spo2/Fio2 ratios before and after nonintubated proning in both case and control (case median Spo2/Fio2 ratio difference, 3 [interquartile range, -3 to 8] vs control median Spo2/Fio2 ratio difference, 0 [interquartile range, -3 to 50]). In the univariate analysis, patients who underwent nonintubated proning were 2.57 times more likely to require invasive mechanical ventilation or experience inhospital mortality (hazard ratio, 2.57; 95% CI, 1.17-5.64; p = 0.02). Following adjustment for patient level differences, we found no association between nonintubated proning and invasive mechanical ventilation or inhospital mortality (adjusted hazard ratio, 0.92; 95% CI, 0.34-2.45; p = 0.86). CONCLUSIONS: There was no significant association with reduced risk of invasive mechanical ventilation or inhospital mortality after adjusting for baseline severity of illness and oxygenation status.

The Use of Point-of-Care Ultrasound (POCUS) in the Diagnosis of Deep Vein Thrombosis.

Acute lower extremity proximal deep venous thrombosis (DVT) requires accurate diagnosis and treatment in order to prevent embolization and other complications. Point-of-care ultrasound (POCUS), a clinician performed, and clinician interpreted bedside ultrasound examination has been increasingly used for DVT evaluation mainly in the urgent and critical care setting, but also in the ambulatory clinics and the medical wards. Studies have demonstrated that POCUS has excellent diagnostic accuracy for acute proximal DVT when performed by well-trained users. However, there is significant heterogeneity among studies on the necessary extent of training and universally acceptable standardized education protocols are needed. In this review, we summarize the evidence that supports the use of POCUS to diagnose acute proximal DVT and focus on methodology and current technology, sensitivity and specificity, pre-test probability and the role of D-dimer, time and resources, education, limitations, and future directions.

The Focused Assessment with Sonography in Cancer (FASC) Examination.

Malignant effusions occur frequently in patients with cancer and are important to diagnose and treat. In this report, we describe a novel point-of-care ultrasound (POCUS) protocol to rapidly identify pleural effusion, pericardial effusion, and ascites: The Focused Assessment with Sonography in Cancer (FASC). This protocol utilizes six standard sonographic positions to identify the presence of fluid in common anatomic spaces. The FASC examination is intended for widespread use by oncologists and other clinicians who treat patients with cancer.

Gel Rounds: Integrating Bedside Ultrasound Training for Third-Year Medical Students Into the Internal Medicine Clerkship.

Despite formal ultrasound training becoming prevalent in preclinical medical student education, significant barriers remain to the continuation of this training during clinical years. We sought to develop a program for third-year medical students to continue ultrasound training after an already robust preclinical ultrasound curriculum and evaluate their scanning confidence after participation. We developed a program to facilitate bedside ultrasound scanning of patients being cared for by third-year students. Students identified appropriate patients to be scanned, obtained consent for scanning, and determined which scans were most appropriate given the patient's clinical problems. Trained facilitators met with students at the bedside in 1-hour sessions called Gel Rounds to observe and direct the students' scans of their patients. Fifty-one students were surveyed after completing Gel Rounds. Students were significantly more likely to feel comfortable with independently acquiring and interpreting images after Gel Rounds than before completing the activity. Approximately 67% of students felt that ultrasound had utility in assisting bedside clinical reasoning, and this proportion did not change significantly after completing Gel Rounds. Gel Rounds was a positive continuation of the ultrasound curriculum into the third-year clerkship environment. A minority of students reported prior ultrasound exposure in their third year, reflecting difficulty with developing a longitudinal curriculum. The activity helped students to independently acquire and interpret images in patients. Because Gel Rounds can be performed at the discretion of students and faculty, it fits naturally in a variety of existing longitudinal curricula.

Systems Opportunities to Reduce ED Crowding From Nonemergency Referrals.

Emergency department (ED) crowding threatens patient safety and is associated with increased mortality. This study explored the role of nonurgent referrals to the ED in crowding and collaborated on a large quality initiative with the study institution's accountable care organization (ACO) to provide timely alternatives to such referrals. Fifty-two percent of nonemergent ED patients report contacting a medical provider prior to coming to the ED, with 70% of those providers directing the patient to go to the ED. Fifty-nine percent of patients indicated that they would have accepted a clinic appointment in lieu of going to the ED. The authors collaborated on a multidisciplinary ED alternatives quality improvement effort with leadership to address these nonemergent referrals. ED visits per 1000 ACO patients declined significantly following survey results and ACO implementation of increased alternative ambulatory resources.

Glucose-Responsive Trehalose Hydrogel for Insulin Stabilization and Delivery.

Effective delivery of therapeutic proteins is important for many biomedical applications. Yet, the stabilization of proteins during delivery and long-term storage remains a significant challenge. Herein, a trehalose-based hydrogel is reported that stabilizes insulin to elevated temperatures prior to glucose-triggered release. The hydrogel is synthesized using a polymer with trehalose side chains and a phenylboronic acid end-functionalized 8-arm poly(ethylene glycol) (PEG). The hydroxyls of the trehalose side chains form boronate ester linkages with the PEG boronic acid cross-linker to yield hydrogels without any further modification of the original trehalose polymer. Dissolution of the hydrogel is triggered upon addition of glucose as a stronger binder to boronic acid (Kb = 2.57 vs 0.48 m-1 for trehalose), allowing the insulin that is entrapped during gelation to be released in a glucose-responsive manner. Moreover, the trehalose hydrogel stabilizes the insulin as determined by immunobinding after heating up to 90 °C. After 30 min heating, 74% of insulin is detected by enzyme-linked immunosorbent assay in the presence of the trehalose hydrogel, whereas only 2% is detected without any additives.

Enhancing Conjugation Yield of Brush Polymer-Protein Conjugates by Increasing Linker Length at the Polymer End-Group.

Polymers with oligoethylene glycol side chains are promising in therapeutic protein-polymer conjugates as replacements for linear polyethylene glycol (PEG). Branched PEG polymers can confer additional stability and advantageous properties compared to linear PEGs. However, branched PEG polymers suffer from low conjugation yields to proteins, likely due to steric interactions between bulky side chains of the polymer and the protein. In an effort to increase yields, the linker length between the protein-reactive functional end-group of the polymer chain and branched PEG side chain was systematically increased. This was accomplished by synthesizing four well-defined poly(poly(ethylene glycol methyl ether) acrylates) (pPEGA) with pyridyl disulfide end-groups by reversible addition-fragmentation chain transfer (RAFT) polymerization mediated by chain transfer agents (CTAs) with different linker lengths. These, along with linear PEG and poly(N-isopropylacrylamide) (pNIPAAm), were conjugated to two model proteins, bovine serum albumin (BSA) and beta-lactoglobulin (ßLG). The conjugation yields were determined by gel electrophoresis. The length of the linker affected conjugation yield for both proteins. For BSA, the conjugation yield step increased from 10% to 24% when the linker was altered from 1 ethylene glycol (EG) unit to 3, with no additional increase for 4 and 6 EG units. In the case of ßLG, the yield gradually increased from 9% to the 33% when the linker length was increased from 1 to 6. PEG and pNIPAAm reacted with yields as high as 75% further emphasizing the effect of steric hindrance in lowering conjugation yields.