Anesthesiologists' skills in emergency cricothyroidotomy mandate a brush-up training after 3 months-A randomized controlled trial.

BACKGROUND: In the Difficult Airway Society's 2015 "cannot intubate, cannot oxygenate" guideline, the emergency cricothyroidotomy is the final option when managing an unanticipated difficult airway. How often training for maintenance of this skill is required for anesthesiologists remains unknown. We aimed to assess if specialist-trained anesthesiologists' skills improved from a brush-up intervention and if skills were retained after 3 months. METHODS: In this multicenter, randomized, controlled trial, participants were randomized to either a simulation-based brush-up or no brush-up. Both groups performed a mannequin-based technical skills emergency cricothyroidotomy test twice and were assessed by a blinded rater using a structured assessment tool that included time, positioning, palpation, appropriate employment of instruments, and stepwise progression. After 3 months of non-training, participants completed identical tests of retention. RESULTS: A total of 54 anesthesiologists were included from three hospitals in the Region of Southern Denmark. Thirty-seven percent of the participants had received skills training in emergency cricothyroidotomy in the prior 12 months. The intervention group (N = 27) performed better in the initial tests, with a mean time of 51.5 s (SD = 10.82), a total score per minute of 15.9 points (SD = 4.91), and 93% passing both initial tests compared to the control group (N = 27) with a mean time of 76.8 s (SD = 35.82), a total score per minute of 6.6 (SD = 4.68) and only 15% passing both initial tests. The intervention group managed to retain overall performance in retention tests in terms of performance time (48.9 s, p = .26), total score per minute (13.6 points, p = .094), and passing the tests (75%, p = .059). CONCLUSION: Exposure to simulation-based brush-up training in emergency cricothyroidotomy improved anesthesiologists' technical performance and was overall retained after 3 months. Some loss of skill concerning specific items was observed, highlighting the need for regular training in emergency cricothyroidotomy. Simulation-based training should be prioritized to improve and maintain technical skills in infrequent high-stakes procedures.

Considerations of organ donation among prehospital physicians.

INTRODUCTION: Moderate to severe respiratory distress among patients with COVID-19 is associated with a high mortality. This study evaluated ventilator support and mortality by Do Intubate (DI) or Do Not Intubate (DNI) orders. METHODS: This was a retrospective study of patients with COVID-19 and a supplemental oxygen requirement of ≥ 15 l/min. The patients were divided into two groups corresponding to the first and second wave of COVID-19 and were subsequently further divided according to DI and DNI orders and analysed regarding need of ventilator support and mortality. RESULTS: The study included 178 patients. The mortality was 24% for patients with DI orders (n = 115) and 81% for patients with DNI orders (n = 63) increasing to 98% (n = 46) for patients with DNI orders and very high flow oxygen requirements (≥ 30 l/min.). From the first to the second wave of COVID-19, the use of constant continuous positive airway pressure (cCPAP) increased from 71% to 91% (p less-than 0.001), whereas the use of mechanical ventilation decreased from 54% to 28% (odds ratio = 0.38 (95% confidence interval: 0.17-0.85)). CONCLUSION: The mortality was high for patients with DNI orders and respiratory distress with very high levels in supplemental oxygen in both the first and second wave of COVID-19 despite an increase in use of cCPAP and treatment with dexamethasone and remdesivir during the second wave. Hence, careful evaluation on transition to palliative care must be considered for these patients. FUNDING: none. TRIAL REGISTRATION: The study was approved by the Danish Patient Safety Authority (record no. 31-1521-309) and the Regional Data Protection Centre (record no. P-2020-492).

Prehospital triage of patients suffering severe dyspnoea using N-terminal pro-brain natriuretic peptide, the PreBNP trial: a randomised controlled clinical trial.

PURPOSE: The purpose of this study was to examine whether the addition of brain natriuretic peptide measurement to the routine diagnostic work-up by prehospital critical care team physicians improves triage in patients with severe dyspnoea. METHODS: Prehospital critical care team physicians randomly assigned patients older than 18 years with severe dyspnoea to routine diagnostic work-up or diagnostic work-up with incorporated point-of-care N-terminal pro-brain natriuretic peptide (NT-proBNP) measurement. The primary endpoint was the proportion of patients with dyspnoea of primary cardiac origin triaged directly to a department of cardiology. RESULTS: A total of 747 patients were randomly assigned and 711 patients consented to participate, 350 were randomly assigned to the NT-proBNP group and 361 to the routine work-up group. NT-proBNP was measured in 90% (315/350) of patients in the NT-proBNP group and in 19% (70/361) of patients in the routine work-up group. There was no difference in the proportion of patients with dyspnoea of primary cardiac origin triaged directly to a department of cardiology between the NT-proBNP group and the routine work-up group (75% vs. 69%, P=0.22) in the intention-to-treat analysis. Sensitivity analysis according to the de facto diagnostics performed showed results consistent with this. No differences in hospital length of stay, intensive care unit admission rates or mortality between the NT-proBNP group and the routine work-up group were observed. CONCLUSION: Routine supplementary point-of-care measurement of NT-proBNP in patients with severe dyspnoea did not improve triage of patients with dyspnoea primarily caused by heart disease. ClinicalTrials.gov identifier NCT02050282.