Evaluation of emotional excitation during standardized endotracheal intubation in simulated conditions.

OBJECTIVE: To assess how stressful conditions in endotracheal intubation could induct emotional excitation in a population of acute care physicians. MATERIALS AND METHODS: Two situations were randomly tested: one in standard and easy intubation conditions the other under difficult conditions presumed to induce stress (monitoring alarms, manikin lying on the floor, difficult intubation). Emotional excitation was assessed using several physiological (cardiac patterns, electrodermal activity and eye-tracking) and psycho-cognitive patterns. Auto-evaluations of video recordings and mental workload were performed immediately after simulation. RESULTS: Significant physiological parameter modifications were observed under the stressful intubation conditions (SDNN 35 ± 15 vs. 42 ± 21; p = 0.035-AVNN 514 ± 94 vs. 548 ± 110; p < 0.0001). Emotional excitation was demonstrated to lead a higher mental workload (NASA-TLX = 39 ± 18 vs. 63 ± 15; p = 0.001), frustration and effort dimensions being its determinant components (p < 0.01). Video recording auto-evaluations depicted significant emotional excitation occurrence under the difficult conditions, with few differences according to the operator's experience. CONCLUSION: This study highlights the fact that a stress condition during ETI on a simulation model leads to an important emotional excitation as compared to the neutral condition.

Pulmonary embolism rule-out criteria (PERC) rule in European patients with low implicit clinical probability (PERCEPIC): a multicentre, prospective, observational study.

BACKGROUND: The ability of the pulmonary embolism rule-out criteria (PERC) to exclude pulmonary embolism without further testing remains debated outside the USA, especially in the population with suspected pulmonary embolism who have a high prevalence of the condition. Our main objective was to prospectively assess the predictive value of negative PERC to rule out pulmonary embolism among European patients with low implicit clinical probability. METHODS: We did a multicentre, prospective, observational study in 12 emergency departments in France and Belgium. We included consecutive patients aged 18 years or older with suspected pulmonary embolism. Patients were excluded if they had already been hospitalised for more than 2 days, had curative anticoagulant therapy in progress for more than 48 h, or had a diagnosis of thromboembolic disease documented before admission to emergency department. Physicians completed a standardised case report form comprising implicit clinical probability assessment (low, moderate, or high) and a list of risk factors including criteria of the PERC rule. They were asked to follow international recommendations for diagnostic strategy, masked to PERC assessment. The primary endpoint was the proportion of patients with low implicit clinical probability and negative PERC who had venous thromboembolic events, diagnosed during initial diagnostic work-up or during 3-month follow-up, as externally adjudicated by an independent committee masked to the PERC and clinical probability assessment. The upper limit of the 95% CI around the 3-month thromboembolic risk was set at 3%. We did all analyses by intention to treat, including all patients with complete follow-up. This trial is registered with ClinicalTrials.gov, number NCT02360540. FINDINGS: Between May 1, 2015, and April 30, 2016, 1773 consecutive patients with suspected pulmonary embolism were prospectively assessed for inclusion, of whom 1757 were included. 1052 (60%) patients were classed as having low clinical probability, 49 (4·7%, 95% CI 3·5-6·1) of whom had a venous thromboembolic event. In patients with a low implicit clinical probability, 337 (32%) patients had negative PERC, of whom four (1·2%; 95% CI 0·4-2·9) went on to have a pulmonary embolism. INTERPRETATION: In European patients with low implicit clinical probability, PERC can exclude pulmonary embolism with a low percentage of false-negative results. The results of our prospective, observational study allow and justify an implementation study of the PERC rule in Europe. FUNDING: French Ministry of Health.

A new global and comprehensive model for ICU ventilator performances evaluation.

BACKGROUND: This study aimed to provide a new global and comprehensive evaluation of recent ICU ventilators taking into account both technical performances and ergonomics. METHODS: Six recent ICU ventilators were evaluated. Technical performances were assessed under two FIO2 levels (100%, 50%), three respiratory mechanics combinations (Normal: compliance [C] = 70 mL cmH2O-1/resistance [R] = 5 cmH2O L-1 s-1; Restrictive: C = 30/R = 10; Obstructive: C = 120/R = 20), four exponential levels of leaks (from 0 to 12.5 L min-1) and three levels of inspiratory effort (P0.1 = 2, 4 and 8 cmH2O), using an automated test lung. Ergonomics were evaluated by 20 ICU physicians using a global and comprehensive model involving physiological response to stress measurements (heart rate, respiratory rate, tidal volume variability and eye tracking), psycho-cognitive scales (SUS and NASA-TLX) and objective tasks completion. RESULTS: Few differences in terms of technical performance were observed between devices. Non-invasive ventilation modes had a huge influence on asynchrony occurrence. Using our global model, either objective tasks completion, psycho-cognitive scales and/or physiological measurements were able to depict significant differences in terms of devices' usability. The level of failure that was observed with some devices depicted the lack of adaptation of device's development to end users' requests. CONCLUSIONS: Despite similar technical performance, some ICU ventilators exhibit low ergonomics performance and a high risk of misusage.