Impact of glucagon-like peptide receptor agonists on endoscopy and its preoperative management: Guidelines, challenges, and future directions.

Glucagon-like peptide receptor agonists (GLP-1RA) are used to treat type 2 diabetes mellitus and, more recently, have garnered attention for their effectiveness in promoting weight loss. They have been associated with several gastrointestinal adverse effects, including nausea and vomiting. These side effects are presumed to be due to increased residual gastric contents. Given the potential risk of aspiration and based on limited data, the American Society of Anesthesiologists updated the guidelines concerning the preoperative management of patients on GLP-1RA in 2023. They included the duration of mandated cessation of GLP-1RA before sedation and usage of "full stomach" precautions if these medications were not appropriately held before the procedure. This has led to additional challenges, such as extended waiting time, higher costs, and increased risk for patients. In this editorial, we review the current societal guidelines, clinical practice, and future directions regarding the usage of GLP-1RA in patients undergoing an endoscopic procedure.

Tetanus management in a high-resource emergency department: A case report.

Any patient presenting with trismus should have tetanus considered as a differential diagnosis. Early recognition, timely treatment and supportive care can improve patient outcomes. Treatment with tetanus immunoglobulin to neutralize the toxin, antimicrobials to treat the infection and sedation in the intensive care unit are key therapeutic options.

Corrigendum: Tracheal intubation in patients with Pierre Robin sequence: development, application, and clinical value based on a 3-dimensional printed simulator.

[This corrects the article DOI: 10.3389/fphys.2023.1292523.].

The impact of hysterectomy on subsequent colonoscopy in women with Lynch Syndrome.

BACKGROUND AND AIMS: Women with Lynch Syndrome (LS) have a high risk of colorectal and endometrial cancer. They are recommended regular colonoscopies, and some choose prophylactic hysterectomy. The aim of this study was to determine the impact of hysterectomy on subsequent colonoscopy in these women. MATERIALS AND METHODS: A total of 219 LS women >30 years of age registered in the clinical registry at Section for Hereditary Cancer, Oslo University Hospital, were included. Data included hysterectomy status, other abdominal surgeries, and time of surgery. For colonoscopies, data were collected on cecal intubation rate, challenges, and level of pain. Observations in women with and without hysterectomy, and pre- and post-hysterectomy were compared. RESULTS: Cecal intubation rate was lower in women with hysterectomy than in those without (119/126 = 94.4% vs 88/88 = 100%, p = 0.025). Multivariate regression analysis showed an increased risk of challenging colonoscopies (OR,3.58; CI: 1.52-8.43; p = 0.003), and indicated a higher risk of painful colonoscopy (OR, 3.00; 95%CI: 0.99-17.44, p = 0.052), in women with hysterectomy compared with no hysterectomy. Comparing colonoscopy before and after hysterectomy, we also found higher rates of reported challenging colonoscopies post-hysterectomy (6/69 = 8.7% vs 23/69 = 33.3%, p < 0.001). CONCLUSIONS: Women with hysterectomy had a lower cecal intubation rate and a higher number of reported challenging colonoscopy than women with no hysterectomy. However, completion rate in the hysterectomy group was still as high as 94.4%. Thus, LS women who consider hysterectomy should not be advised against it.

Impact of universal use of a hyperangulated videolaryngoscope as the first option for all intubations in the ICU: A prospective before-after study.

BACKGROUND: Tracheal intubation in ICU is associated with high incidence of difficult intubations. The study aimed to investigate whether the "universal" use of a hyperangulated videolaryngoscope would increase the frequency of "easy intubation" in ICU patients compared to direct laryngoscopy. METHODS: A prospective before-after study was conducted. The pre-interventional period (36 months) involved tracheal intubations using direct laryngoscopy as the first intubation option. In the interventional period (18 months) a hyperangulated videolaryngoscope was the first intubation option. The primary outcome was the percentage of patients with "easy intubation" defined as intubation on the first attempt and easy laryngoscopy (modified Cormack-Lehane glottic view of I-IIa). Secondary outcomes included difficult laryngoscopy, operator technical difficulty, and complications. RESULTS: We enrolled 407 patients, 273 in non-interventional period, and 134 in interventional period. Tracheal intubation in the interventional period was associated with higher incidence of "easy intubation" (92.5%) compared with the non-interventional period (75.8%); P < 0.001)). Glottic visualization improved in the interventional period, with a reduced incidence of difficult laryngoscopy (1.5% vs. 22.5%; P < 0.001). The proportion of first-success rate intubation was 92.5% in the interventional period, and 87.8% in the non-interventional period (P = 0.147). Moderate and severe technical difficulty of intubation reported decreased in the interventional period (6% vs. 17.6%; P < 0.001). There was no significant difference between both periods in the incidence of complications. CONCLUSION: "Universal" use of hyperangulated videolaryngoscopy for tracheal intubation in patients admitted in ICU improves the percentage of easy intubation compared to direct laryngoscopy.

Intubation of critically ill patients: A pilot study of minute-by-minute physiological changes within an Australian tertiary intensive care unit.

BACKGROUND: There are no published minute-by-minute physiological assessment data for endotracheal intubation (ETT) performed in the intensive care unit (ICU). The majority of physiological data is available from Europe and North America where etomidate is the induction agent administered most commonly. AIMS: The aim of this study was to describe the feasibility of obtaining minute-by-minute physiological and medication data surrounding ETT in an Australian tertiary ICU and to assess its associated outcomes. METHODS: We performed a single-centre feasibility observational study. We obtained minute-by-minute data on physiological variables and medications for 15 min before and 30 min after ETT. We assessed feasibility as enrolled to screened patient ratio and completeness of data collection in enrolled patients. Severe hypotension (systolic blood pressure < 65 mmHg) and severe hypoxaemia (pulse oximetry saturation < 80%) were the secondary clinical outcomes. RESULTS: We screened 43 patients and studied 30 patients. The median age was 58.5 (interquartile range: 49-70) years, and 18 (60%) were male. Near-complete (97%) physiological and medication data were obtained in all patients at all times. Overall, 15 (50%) ETTs occurred after hours (17:30-08:00) and 90% were by video laryngoscopy with a 90% first-pass success rate. Prophylactic vasopressors were used in 50% of ETTs. Fentanyl was used in all except one ETT at a median dose of 2.5 mcg/kg. Propofol (63%) or midazolam (50%) were used as adjuncts at low dose. Rocuronium was used in all but one patient. There were no episodes of severe hypotension and only one episode of short-lived severe hypoxaemia. CONCLUSION: Minute-by-minute recording of ETT-associated physiological changes in the ICU was feasible but only fully available in two-thirds of the screened patients. ETT was based on fentanyl induction, low-dose adjunctive sedation, and frequent prophylactic vasopressor therapy and was associated with no severe hypotension and a single short-lived episode of severe hypoxaemia.

Glottis Recognition Software Development Using Artificial Intelligence.

The use of video laryngoscopes has enhanced the visualization of the vocal cords, thereby improving the accessibility of tracheal intubation. Employing artificial intelligence (AI) to recognize images obtained through video laryngoscopy, particularly when marking the epiglottis and vocal cords, may elucidate anatomical structures and enhance anatomical comprehension of anatomy. This study investigates the ability of an AI model to accurately identify the glottis in video laryngoscope images captured from a manikin. Tracheal intubation was conducted on a manikin using a bronchoscope with recording capabilities, and image data of the glottis was gathered for creating an AI model. Data preprocessing and annotation of the vocal cords, epiglottis, and glottis were performed, and human annotation of the vocal cords, epiglottis, and glottis was carried out. Based on the AI's determinations, anatomical structures were color-coded for identification. The recognition accuracy of the epiglottis and vocal cords recognized by the AI model was 0.9516, which was over 95%. The AI successfully marked the glottis, epiglottis, and vocal cords during the tracheal intubation process. These markings significantly aided in the visual identification of the respective structures with an accuracy of more than 95%. The AI demonstrated the ability to recognize the epiglottis, vocal cords, and glottis using an image recognition model of a manikin.

Retromolar intubation for the general anesthesia of maxillofacial fracture patients.

BACKGROUND: Evaluate the possibility of retromolar intubation for general anesthesia in patients with maxillofacial fractures. METHODS: The medical records of 54 patients with maxillofacial fractures who visited the Oral and Maxillofacial Surgery Department of Nantong First People's Hospital from January 2020 to August 2022 were collected. The retromolar areas of each patient were measured from the coronal CT images, and correlated with the patient's age, sex, type of fracture (i.e., maxillary fracture, mandibular fracture, or complex fracture of multiple maxillofacial bones), and the presence of the third molar (verified from 3D CT). The dimensions of the retromolar areas were finally compared with the outer diameter (OD) of standard endotracheal tubes (ETTs), most importantly the size 7.5 ETT (OD 10.3 mm) for male and the size 7.0 ETT (OD 9.8 mm) for female. RESULTS: The survey included 38 male and 16 female patients, with an average age of 44.1 and 54.3 years, respectively. The dimensions of the retromolar area (height × width) were as follows: male, (9.39 ± 1.77) mm × (12.08 ± 0.98) mm on the left and (9.81 ± 2.23) mm × (11.77 ± 1.08) mm on the right; female, (8.82 ± 1.53) mm × (10.51 ± 1.00) mm on the left and (9.73 ± 1.60) mm × (10.63 ± 1.58) mm on the right. The width was always larger than the OD of the routinely used ETT, but the height could be smaller by less than 1 mm. However, the oral mucosa can be compressed to allow the ETT to fit in the retromolar area. CONCLUSIONS: The retromolar area provided appropriate space to place a reinforced ETT for patients with maxillofacial fractures needing general anesthesia that must not interfere with intermaxillary ligation. Retromolar intubation can help maxillofacial fracture surgeries that focus on occlusal restoration.

Effect of noninvasive ventilation on mortality and clinical outcomes among patients with severe hypoxemic COVID-19 pneumonia after high-flow nasal oxygen failure: a multicenter retrospective French cohort with propensity score analysis.

BACKGROUND: We assessed the effect of noninvasive ventilation (NIV) on mortality and length of stay after high flow nasal oxygenation (HFNO) failure among patients with severe hypoxemic COVID-19 pneumonia. METHODS: In this multicenter, retrospective study, we enrolled COVID-19 patients admitted in intensive care unit (ICU) for severe COVID-19 pneumonia with a HFNO failure from December 2020 to January 2022. The primary outcome was to compare the 90-day mortality between patients who required a straight intubation after HFNO failure and patients who received NIV after HFNO failure. Secondary outcomes included ICU and hospital length of stay. A propensity score analysis was performed to control for confounding factors between groups. Exploratory outcomes included a subgroup analysis for 90-day mortality. RESULTS: We included 461 patients with HFNO failure in the analysis, 233 patients in the straight intubation group and 228 in the NIV group. The 90-day mortality did not significantly differ between groups, 58/228 (25.4%) int the NIV group compared with 59/233 (25.3%) in the straight intubation group, with an adjusted hazard ratio (HR) after propensity score weighting of 0.82 [95%CI, 0.50-1.35] (p = 0.434). ICU length of stay was significantly shorter in the NIV group compared to the straight intubation group, 10.0 days [IQR, 7.0-19.8] versus 18.0 days [IQR,11.0-31.0] with a propensity score weighted HR of 1.77 [95%CI, 1.29-2.43] (p < 0.001). A subgroup analysis showed a significant increase in mortality rate for intubated patients in the NIV group with 56/122 (45.9%), compared to 59/233 (25.3%) for patients in the straight intubation group (p < 0.001). CONCLUSIONS: In severely hypoxemic COVID-19 patients, no significant differences were observed on 90-day mortality between patients receiving straight intubation and those receiving NIV after HFNO failure. NIV strategy was associated with a significant reduction in ICU length of stay, despite an increase in mortality in the subgroup of patients finally intubated.

Evaluation of preoperative difficult airway prediction methods for adult patients without obvious airway abnormalities: a systematic review and meta-analysis.

BACKGROUND: This systematic review aims to assist clinical decision-making in selecting appropriate preoperative prediction methods for difficult tracheal intubation by identifying and synthesizing literature on these methods in adult patients undergoing all types of surgery. METHODS: A systematic review and meta-analysis were conducted following PRISMA guidelines. Comprehensive electronic searches across multiple databases were completed on March 28, 2023. Two researchers independently screened, selected studies, and extracted data. A total of 227 articles representing 526 studies were included and evaluated for bias using the QUADAS-2 tool. Meta-Disc software computed pooled sensitivity (SEN), specificity (SPC), positive likelihood ratio (PLR), negative likelihood ratio (NLR), and diagnostic odds ratio (DOR). Heterogeneity was assessed using the Spearman correlation coefficient, Cochran's-Q, and I2 index, with meta-regression exploring sources of heterogeneity. Publication bias was evaluated using Deeks' funnel plot. RESULTS: Out of 2906 articles retrieved, 227 met the inclusion criteria, encompassing a total of 686,089 patients. The review examined 11 methods for predicting difficult tracheal intubation, categorized into physical examination, multivariate scoring system, and imaging test. The modified Mallampati test (MMT) showed a SEN of 0.39 and SPC of 0.86, while the thyromental distance (TMD) had a SEN of 0.38 and SPC of 0.83. The upper lip bite test (ULBT) presented a SEN of 0.52 and SPC of 0.84. Multivariate scoring systems like LEMON and Wilson's risk score demonstrated moderate sensitivity and specificity. Imaging tests, particularly ultrasound-based methods such as the distance from the skin to the epiglottis (US-DSE), exhibited higher sensitivity (0.80) and specificity (0.77). Significant heterogeneity was identified across studies, influenced by factors such as sample size and study design. CONCLUSION: No single preoperative prediction method shows clear superiority for predicting difficult tracheal intubation. The evidence supports a combined approach using multiple methods tailored to specific patient demographics and clinical contexts. Future research should focus on integrating advanced technologies like artificial intelligence and deep learning to improve predictive models. Standardizing testing procedures and establishing clear cut-off values are essential for enhancing prediction reliability and accuracy. Implementing a multi-modal predictive approach may reduce unanticipated difficult intubations, improving patient safety and outcomes.

Conquering the obstacles during the intervention of a proximal chronic total occlusion of right coronary artery with a concurrent significant ostial stenosis: a case report.

Percutaneous coronary intervention (PCI) on a proximal chronic total occlusion (CTO) of the right coronary artery (RCA) with concurrent ostial stenosis can be challenging because of the significant difficulty in properly engaging the catheter and providing stable support during the procedure. We report the case of a 57-year-old man with chronic coronary syndrome who underwent an elective PCI at the Dr. Soetomo General Hospital in Surabaya, on April 13th, 2022. At the beginning of the procedure, there was difficulty in intubating the RCA, which required the guide catheter replacement. The angiography revealed a significant lesion at the ostium, a CTO at proximal to mid- RCA with bridging collaterals, and a significant distal lesion. Several strategies to improve guiding catheter support during PCI are using large and supportive shape guide catheters, deep guide catheter intubation, extra support wire, microcatheter and guide catheter extension. The risk of pressure dampening and ischaemia upon engagement should always be kept under consideration.

National survey on the current status of airway management in China.

Apparently, understanding airway management status may help to reduce risk and improve clinical practice. Given these facts, our team conducted a second survey on the current status of airway management for mainland China following our 2016 national airway survey. The national survey was conducted from November 7 to November 28, 2022. An electronic survey was sent to the New Youth Anesthesia Forum, where Chinese anesthesiologists completed the questionnaire via WeChat. A total of 3783 respondents completed the survey, with a response rate of 72.14%. So far, in 2022, 34.84% of anesthesiologists canceled or delayed surgery at least once due to difficult airway. For the anticipated difficult airway management, 66.11% of physicians would choose awake intubation under sedation and topical anesthesia, while the percentage seeking help has decreased compared to the 2016 survey. When encountering an emergency, 74.20% of respondents prefer to use the needle cricothyrotomy, albeit less than a quarter have actually performed it. Anesthesiologists with difficult airway training experience reached 72.96%, with a significant difference in participation between participants in Tier 3 hospitals and those in other levels of hospitals (P < 0.001). The videolaryngoscope, laryngeal mask, and flexible intubation scope were equipped at 97.18%, 95.96%, and 62.89%, respectively. Additionally, the percentage of brain damage or death caused by difficult airways was significantly decreased. The study may be the best reference for understanding the current status of airway management in China, revealing the current advancements and deficiencies. The future focus of airway management remains on training and education.

Assessment of Tracheostomy Tube Placement and Late Change Practices in an Academic Tertiary Care Center.

Introduction The optimal time for tracheostomy changes is unknown. Most surgeons opt to wait until five to seven days postoperatively, while more recent studies suggest that changes occurring as early as two to three days postoperatively are also safe. Objective To evaluate the safety of changing the tracheostomy tube later than 14 days postoperatively. Methods The charts of patients who underwent tracheostomy placement and change at a tertiary care center from 2015 to 2019 were retrospectively reviewed, and the subjects were divided into 2 cohorts (late and very late), depending on the time of the first tracheostomy change. Results The study included 198 patients, 53 of whom aged between 0 and 18 years, and 145, aged > 18 years. The time until the first tracheostomy change was on average of 131.1 days. The most common indication for tracheostomy tube placement was prolonged intubation. Adverse events were observed in 30.8% of the cases (the most common being the formation of granulation tissue), a rate that does not differ much from the incidence reported in the literature (of 34% to 77%) when tracheostomy tubes are changed as early as 3 to 7 days postoperatively. There was no significant difference in the incidence of complications between patients undergoing late and very late changes ( p = 0.688), or between pediatric and adult subjects ( p = 0.36). There were no significant correlations regarding the time of the first or second change and the incidence of complications (r = -0.014; p = 0.84 for the first change; and r = -0.57; p = 0.64 for the second change). Conclusion The late first tracheostomy tube change was safe and could save resources and decrease the financial burden of frequent changes. It is always crucial to provide adequate information about home tracheostomy care for patients.

Sarcopenia, sarcopenic obesity and the clinical outcome of the older inpatients with COVID-19 infection: a prospective observational study.

OBJECTIVE: We aimed to investigate the impact of sarcopenia and sarcopenic obesity (SO) on the clinical outcome in older patients with COVID-19 infection and chronic disease. METHODS: We prospectively collected data from patients admitted to Huadong Hospital for COVID-19 infection between November 1, 2022, and January 31, 2023. These patients were included from a previously established comprehensive geriatric assessment (CGA) cohort. We collected information on their pre-admission condition regarding sarcopenia, SO, and malnutrition, as well as their medical treatment. The primary endpoint was the incidence of intubation, while secondary endpoints included in-hospital mortality rates. We then utilized Kaplan-Meier (K-M) survival curves and the log-rank tests to compare the clinical outcomes related to intubation or death, assessing the impact of sarcopenia and SO on patient clinical outcomes. RESULTS: A total of 113 patients (age 89.6 ± 7.0 years) were included in the study. Among them, 51 patients had sarcopenia and 39 had SO prior to hospitalization. Intubation was required for 6 patients without sarcopenia (9.7%) and for 18 sarcopenia patients (35.3%), with 16 of these being SO patients (41%). Mortality occurred in 2 patients without sarcopenia (3.3%) and in 13 sarcopenia patients (25.5%), of which 11 were SO patients (28%). Upon further analysis, patients with SO exhibited significantly elevated risks for both intubation (Hazard Ratio [HR] 7.43, 95% Confidence Interval [CI] 1.26-43.90, P < 0.001) and mortality (HR 6.54, 95% CI 1.09-39.38, P < 0.001) after adjusting for confounding factors. CONCLUSIONS: The prevalence of sarcopenia or SO was high among senior inpatients, and both conditions were found to have a significant negative impact on the clinical outcomes of COVID-19 infection. Therefore, it is essential to regularly assess and intervene in these conditions at the earliest stage possible.

Outcome of Guillain-Barré Syndrome with bulbar palsy.

BACKGROUND: Elective intubation is advocated in Guillain-Barré syndrome (GBS) with bulbar palsy to prevent aspiration pneumonia and lung collapse. We evaluate the outcome of GBS patients with bulbar palsy, and also compare the risks and benefits of intubation and MV in them. METHODS: 187 GBS patients with bulbar palsy from a cohort of 547 GBS registry were analyzed. Detailed clinical records and peak disability on a 0-6 GBS Disability Scale (GBSDS) were noted. The patients were intubated if arterial blood gas (ABG) analysis revealed hypoxia, hypercarbia or acidosis. The patients with normal ABG parameters were fed by nasogastric tube, and nursed in lateral position. Occurrence of pneumonia, in-hospital death and outcomes at 6-months were classified as complete (GBSDS <2), partial (GBSDS 2-3) and poor (GBSDS >3). RESULTS: 76/187(40.6%) patients required MV, and they had a shorter duration of illness (p = 0.007), higher peak disability (p < 0.001), autonomic dysfunction (p < 0.001) and more frequently received IVIg (p = 0.02). Pneumonia (63% vs 10.8%; p < 0.001) and in-hospital deaths (7.9% vs 1.8%; p = 0.06) were more frequent in MV group compared to nasogastric fed group. At 6-months,104 (55.6%) patients recovered completely. On multivariate analysis, the independent predictors of poor outcome were peak disability [Adjusted Odds Ratio (AOR) 9.84, 95% Confidence Interval (CI) 3.15-30.74, p < 0.0001], day of hospitalization from disease onset (AOR 1.09, 95% Cl 1.01-1.01; p=0.009) and requirement of MV (AOR 0.10; 95% 0.02-0.50; p = 0.005). CONCLUSION: GBS patients with bulbar palsy may be managed by nasogastric feeding and nursing in lateral position without increasing the risk of pneumonia. Mechanical ventilation based on ABG does not worsen outcomes of GBS with bulbar palsy.

Alternative Hybrid Technique of Intubation Using C-MAC and Yankauer Suction Catheter: Case of A Floppy Supraglottic Mass.

Supraglottic masses can be an anaesthesiologist's nightmare due to the difficult airway scenario and bleeding risk during airway manipulation. Awake fibreoptic intubation is the primary method to secure the airway in such cases. However, most practising anaesthesiologists are not experts at handling the fibreoptic scope, especially in cases with a floppy supraglottic mass where it becomes difficult to displace the mask with the thin flexible bronchoscope. A hybrid technique of intubation in supraglottic masses using Bonfils rigid scope and C-MAC is often described but frequently not available. Here we describe a case of an elderly patient in their 80s presenting with a floppy supraglottic mass where an awake fibreoptic bronchoscope failed to secure the airway. Without access to a rigid Bonfils scope, we intuitively used a C-MAC to visualize the larynx and a yankauer suction catheter to displace the mass and perform a bougie-guided endotracheal intubation.

Right trace wrong place: a normal capnography trace despite the tip of the tracheal tube existing outside the airway.

Head and neck trauma can result in difficult airway management. A 25-year-old male required emergency tracheal intubation on arrival to the emergency department following a motorbike accident. Despite the presence of a normal capnography a computed tomography scan demonstrated a tracheal opening, an extra-tracheal position of the distal end of the tracheal tube, and extensive subcutaneous emphysema. The tube was re-directed into the trachea and the tracheal injury was surgically repaired. This case highlights that the presence of a normal capnograph does not necessarily mean that the distal end of the tracheal tube resides within the airway.

Explainable artificial intelligence (XAI) for predicting the need for intubation in methanol-poisoned patients: a study comparing deep and machine learning models.

The need for intubation in methanol-poisoned patients, if not predicted in time, can lead to irreparable complications and even death. Artificial intelligence (AI) techniques like machine learning (ML) and deep learning (DL) greatly aid in accurately predicting intubation needs for methanol-poisoned patients. So, our study aims to assess Explainable Artificial Intelligence (XAI) for predicting intubation necessity in methanol-poisoned patients, comparing deep learning and machine learning models. This study analyzed a dataset of 897 patient records from Loghman Hakim Hospital in Tehran, Iran, encompassing cases of methanol poisoning, including those requiring intubation (202 cases) and those not requiring it (695 cases). Eight established ML (SVM, XGB, DT, RF) and DL (DNN, FNN, LSTM, CNN) models were used. Techniques such as tenfold cross-validation and hyperparameter tuning were applied to prevent overfitting. The study also focused on interpretability through SHAP and LIME methods. Model performance was evaluated based on accuracy, specificity, sensitivity, F1-score, and ROC curve metrics. Among DL models, LSTM showed superior performance in accuracy (94.0%), sensitivity (99.0%), specificity (94.0%), and F1-score (97.0%). CNN led in ROC with 78.0%. For ML models, RF excelled in accuracy (97.0%) and specificity (100%), followed by XGB with sensitivity (99.37%), F1-score (98.27%), and ROC (96.08%). Overall, RF and XGB outperformed other models, with accuracy (97.0%) and specificity (100%) for RF, and sensitivity (99.37%), F1-score (98.27%), and ROC (96.08%) for XGB. ML models surpassed DL models across all metrics, with accuracies from 93.0% to 97.0% for DL and 93.0% to 99.0% for ML. Sensitivities ranged from 98.0% to 99.37% for DL and 93.0% to 99.0% for ML. DL models achieved specificities from 78.0% to 94.0%, while ML models ranged from 93.0% to 100%. F1-scores for DL were between 93.0% and 97.0%, and for ML between 96.0% and 98.27%. DL models scored ROC between 68.0% and 78.0%, while ML models ranged from 84.0% to 96.08%. Key features for predicting intubation necessity include GCS at admission, ICU admission, age, longer folic acid therapy duration, elevated BUN and AST levels, VBG_HCO3 at initial record, and hemodialysis presence. This study as the showcases XAI's effectiveness in predicting intubation necessity in methanol-poisoned patients. ML models, particularly RF and XGB, outperform DL counterparts, underscoring their potential for clinical decision-making.

Universal paediatric videolaryngoscopy and glottic view grading: a prospective observational study.

BACKGROUND: Although videolaryngoscopy has been proposed as a default technique for tracheal intubation in children, published evidence on universal videolaryngoscopy implementation programmes is scarce. We aimed to determine if universal, first-choice videolaryngoscopy reduces the incidence of restricted glottic views and to determine the diagnostic performance of the Cormack and Lehane classification to discriminate between easy and difficult videolaryngoscopic tracheal intubations in children. METHODS: We conducted a prospective observational study within a structured universal videolaryngoscopy implementation programme. We used C-MAC™ (Karl Storz, Tuttlingen, Germany) videolaryngoscopes in all anaesthetised children undergoing elective tracheal intubation for surgical procedures. The direct and videolaryngoscopic glottic views were classified using a six-stage grading system. RESULTS: There were 904 tracheal intubations in 809 children over a 16-month period. First attempt and overall success occurred in 607 (67%) and 903 (> 99%) tracheal intubations, respectively. Difficult videolaryngoscopic tracheal intubation occurred in 47 (5%) and airway-related adverse events in 42 (5%) tracheal intubations. Direct glottic view during laryngoscopy was restricted in 117 (13%) and the videolaryngoscopic view in 32 (4%) tracheal intubations (p < 0.001). Videolaryngoscopy improved the glottic view in 57/69 (83%) tracheal intubations where the vocal cords were only just visible, and in 44/48 (92%) where the vocal cords were not visible by direct view. The Cormack and Lehane classification discriminated poorly between easy and difficult videolaryngoscopic tracheal intubations with a mean area under the receiver operating characteristic curve of 0.68 (95%CI 0.59-0.78) for the videolaryngoscopic view compared with 0.80 (95%CI 0.73-0.87) for the direct glottic view during laryngoscopy (p = 0.005). CONCLUSIONS: Universal, first-choice videolaryngoscopy reduced substantially the incidence of restricted glottic views. The Cormack and Lehane classification was not a useful tool for grading videolaryngoscopic tracheal intubation in children.