Pilot multicenter study to determine the utility of point-of-care ultrasound to predict difficulty of tracheal intubation using videolaryngoscopy with the McGrath™ Mac videolaryngoscope.

Background: Clinical airway screening tests used to predict difficulties during airway management have low sensitivity and specificity. Point-of-care airway ultrasound has described measurements related to problems with difficult direct laryngoscopy. Nevertheless, the correlation between ultrasound parameters and videolaryngoscopy has not been published yet. The aim of this multicenter, prospective observational pilot study was to evaluate the applicability of clinical parameters and ultrasound measurements to find potential tracheal intubation difficulties when videolaryngoscopy is used. Methods: Preoperatively, six clinical airway assessments were performed: (1) modified Mallampati score, (2) thyromental distance, (3) sternomental distance, (4) interincisal distance, (5) upper lip bite test, and (6) neck circumference. Six ultrasound parameters were measured in awake patients: (1) distance from skin to hyoid bone, (2) distance from skin to epiglottis, (3) hyomental distance in neutral head position, (4) hyomental distance in head-extended position, (5) distance from skin to the deepest part of the palate, and (6) sagittal tongue area. And finally, there was one ultrasound measure obtained in anesthetized patients, the compressed sagittal tongue area during videolaryngoscopy. The difficulty for tracheal intubation using a McGrath™ Mac videolaryngoscope, the percentage of glottic opening, and Cormack-Lehane grade were also assessed. Results: In this cohort of 119 subjects, tongue dimensions, particularly the sagittal tongue area, showed a robust association with increased intubation difficulty using videolaryngoscopy. A multiparametric model combining the following three ultrasound variables in awake patients: (a) the distance from skin to epiglottis, (b) the distance from skin to the deepest part of the palate, and (c) the sagittal tongue area, yielded a sensitivity of 92.3%, specificity of 94.5%, positive predictive value of 82.8%, and negative predictive value of 97.8% (p < 0.001). Conclusion: Point-of-care airway ultrasound emerges as a more useful tool compared to traditional clinical scales to anticipate possible challenges during videolaryngoscopic intubation.

Tracheal intubation in critically ill adults with a physiologically difficult airway. An international Delphi study.

PURPOSE: Our study aimed to provide consensus and expert clinical practice statements related to airway management in critically ill adults with a physiologically difficult airway (PDA). METHODS: An international Steering Committee involving seven intensivists and one Delphi methodology expert was convened by the Society of Critical Care Anaesthesiologists (SOCCA) Physiologically Difficult Airway Task Force. The committee selected an international panel of 35 expert clinician-researchers with expertise in airway management in critically ill adults. A Delphi process based on an iterative approach was used to obtain the final consensus statements. RESULTS: The Delphi process included seven survey rounds. A stable consensus was achieved for 53 (87%) out of 61 statements. The experts agreed that in addition to pathophysiological conditions, physiological alterations associated with pregnancy and obesity also constitute a physiologically difficult airway. They suggested having an intubation team consisting of at least three healthcare providers including two airway operators, implementing an appropriately designed checklist, and optimizing hemodynamics prior to tracheal intubation. Similarly, the experts agreed on the head elevated laryngoscopic position, routine use of videolaryngoscopy during the first attempt, preoxygenation with non-invasive ventilation, careful mask ventilation during the apneic phase, and attention to cardiorespiratory status for post-intubation care. CONCLUSION: Using a Delphi method, agreement among a panel of international experts was reached for 53 statements providing guidance to clinicians worldwide on safe tracheal intubation practices in patients with a physiologically difficult airway to help improve patient outcomes. Well-designed studies are needed to assess the effects of these practice statements and address the remaining uncertainties.

International facets of the 'chain of survival' for out-of-hospital and in-hospital cardiac arrest - A scoping review.

Background: The "chain of survival" was first systematically addressed in 1991, and its sequence still forms the cornerstone of current resuscitation guidelines. The term "chain of survival" is widely used around the world in literature, education, and awareness campaigns, but growing heterogeneity in the components of the chain has led to confusion. It is unclear which of these emerging chains is most suitable, or if adaptations are needed in particular contexts to depict key actions of resuscitation in the 21st century. This scoping review provides an overview of the variety of chains of survival described. Objectives: To identify published facets of the chain of survival, to assess views and strategies about adapting the chain, and to identify reports on how the chain of survival affects teaching, implementation, or patient outcomes. Methods eligibility criteria and sources of evidence: A scoping review as part of the continuous evidence evaluation process of the International Liaison Committee on Resuscitation (ILCOR) was conducted. MEDLINE(R) ALL (Ovid), Embase (Ovid), APA PsycINFO (Ovid), CINAHL (Ebscohost), ERIC (Ebscohost), Web of Science (Clarivate), Scopus (Elsevier), and Cochrane Library (Wiley Online) were searched. All publications in all languages describing chains of survival were eligible, without time restrictions. Due to the heterogeneity and publication types of the relevant studies, we did not pursue a systematic review or meta-analysis. Results: A primary search yielded 1713 studies and after screening we included 43 publications. Modified versions of the chain of survival for specific contexts were found (e.g., in-hospital cardiac arrest or paediatric resuscitation). There were also numerous versions with minor adaptations of the existing chain. Three publications suggested an impact of the use of the chain of survival on patient outcomes. No educational or implementation outcomes were reported. Conclusion: There is a vast heterogeneity of chain of survival concepts published. Future research is warranted, especially into the concept's importance concerning educational, implementation, and clinical outcomes.

Teaching team competencies within resuscitation training: A systematic review.

Objectives: To evaluate the effectiveness of life support training with specific emphasis on team competencies on clinical and educational outcomes. Methods: This systematic review was prospectively registered (PROSPERO CRD42023473154) and followed the PICOST (population, intervention, comparison, outcome, study design, timeframe) format. All randomized controlled trials and non-randomized studies evaluating learners undertaking life support training with specific emphasis on team competencies in any setting (actual and simulated resuscitations) were included. Unpublished studies were excluded. Medline, Embase and Cochrane databases as well as trial registries were searched from inception to August 2023 (updated January 18, 2024). Two researchers performed title and abstract screening, full-text screening, data extraction, assessment of risk of bias (using RoB2 and ROBINS-I) and certainty of evidence (using GRADE). PRISMA reporting checklist was used to report the results. No funding was obtained to perform this systematic review. Results: The literature search identified 5470 manuscripts. After the removal of 2073 duplicates, reviewing the remaining articles' titles and abstracts yielded 31 articles for full-text review. Of these, 17 studies were finally included. The studies involved the following training levels: basic life support, adult advanced life support, paediatric and neonatal resuscitations. Most studies (n = 16) evaluated outcomes in simulated, and only one study in actual resuscitations. Studies included in all training contexts showed either neutrality and/or benefits of life support training with specific emphasis on team competencies. Team competencies training improved CPR skill performance and CPR quality. Specific team competencies that improved included leadership, communication, decision-making and task management. No undesirable effects were observed. Meta-analysis was not possible due to significant methodological heterogeneity. Sub-group analysis was impossible due to lack of data. Risk of bias assessment ranged from some concerns to serious. Overall certainty of evidence was rated as low to very low due to risk of bias and imprecision. Conclusion: This systematic review identified very low and low certainty evidence, almost entirely derived from simulation studies. The studies and their findings were heterogenous but suggest that teaching team competencies can improve resuscitation skills performance and CPR quality, as well as improve team competencies, specifically leadership, communication, decision-making, and task management. Further research is required to understand optimal configuration of team competencies training interventions and to understand the effect on clinical outcomes and cost-effectiveness.

Tailored Basic Life Support Training for Specific Layperson Populations-A Scoping Review.

Background: Basic life support (BLS) is a life-saving link in the out-of-hospital cardiac arrest chain of survival. Most members of the public are capable of providing BLS but are more likely to do so confidently and effectively if they undertake BLS training. Lay members of the public comprise diverse and specific populations and may benefit from tailored BLS training. Data on this topic are scarce, and it is completely unknown if there are any benefits arising from tailored courses or for whom course adaptations should be developed. Methods: The primary objective of this scoping review was to identify and describe differences in patient, clinical, and educational outcomes when comparing tailored versus standard BLS courses for specific layperson populations. This review was undertaken as part of the continuous evidence evaluation process of the International Liaison Committee on Resuscitation. Results: A primary search identified 1307 studies and after title, abstract, and full-text screening, we included eight publications reporting on tailored courses for specific populations. There were no studies reporting direct comparisons between tailored and standardized training. Seven (88%) studies investigated courses tailored for individuals with a disability, and only one study covered another specific population group (refugees). Overall, the quality of evidence was low as the studies did not compare tailored vs. non-tailored approaches or consisted of observational or pre-post-designed investigations. Conclusions: Tailored BLS education for specific populations is likely feasible and can include such groups into the pool of potential bystander resuscitation providers. Research into comparing tailored vs. standard courses, their cost-to-benefit ratio, how to best adapt courses, and how to involve members of the respective communities should be conducted. Additionally, tailored courses for first responders with and without a duty to respond could be explored.

Termination of Resuscitation Rules and Survival Among Patients With Out-of-Hospital Cardiac Arrest: A Systematic Review and Meta-Analysis.

Importance: Termination of resuscitation (TOR) rules may help guide prehospital decisions to stop resuscitation, with potential effects on patient outcomes and health resource use. Rules with high sensitivity risk increasing inappropriate transport of nonsurvivors, while rules without excellent specificity risk missed survivors. Further examination of the performance of TOR rules in estimating survival of out-of-hospital cardiac arrest (OHCA) is needed. Objective: To determine whether TOR rules can accurately identify patients who will not survive an OHCA. Data Sources: For this systematic review and meta-analysis, the MEDLINE, Embase, CINAHL, Cochrane Library, and Web of Science databases were searched from database inception up to January 11, 2024. There were no restrictions on language, publication date, or time frame of the study. Study Selection: Two reviewers independently screened records, first by title and abstract and then by full text. Randomized clinical trials, case-control studies, cohort studies, cross-sectional studies, retrospective analyses, and modeling studies were included. Systematic reviews and meta-analyses were reviewed to identify primary studies. Studies predicting outcomes other than death, in-hospital studies, animal studies, and non-peer-reviewed studies were excluded. Data Extraction and Synthesis: Data were extracted by one reviewer and checked by a second. Two reviewers assessed risk of bias using the Revised Quality Assessment Tool for Diagnostic Accuracy Studies. Cochrane Screening and Diagnostic Tests Methods Group recommendations were followed when conducting a bivariate random-effects meta-analysis. This review followed the Preferred Reporting Items for a Systematic Review and Meta-Analysis of Diagnostic Test Accuracy Studies (PRISMA-DTA) statement and is registered with the International Prospective Register of Systematic Reviews (CRD42019131010). Main Outcomes and Measures: Sensitivity and specificity tables with 95% CIs and bivariate summary receiver operating characteristic (SROC) curves were produced. Estimates of effects at different prevalence levels were calculated. These estimates were used to evaluate the practical implications of TOR rule use at different prevalence levels. Results: This review included 43 nonrandomized studies published between 1993 and 2023, addressing 29 TOR rules and involving 1 125 587 cases. Fifteen studies reported the derivation of 20 TOR rules. Thirty-three studies reported external data validations of 17 TOR rules. Seven TOR rules had data to facilitate meta-analysis. One clinical study was identified. The universal termination of resuscitation rule had the best performance, with pooled sensitivity of 0.62 (95% CI, 0.54-0.71), pooled specificity of 0.88 (95% CI, 0.82-0.94), and a diagnostic odds ratio of 20.45 (95% CI, 13.15-31.83). Conclusions and Relevance: In this review, there was insufficient robust evidence to support widespread implementation of TOR rules in clinical practice. These findings suggest that adoption of TOR rules may lead to missed survivors and increased resource utilization.

Cognitive aids used in simulated resuscitation: A systematic review.

Objectives: To compare the effectiveness of cognitive aid use during resuscitation with no use of cognitive aids on cardiopulmonary resuscitation quality and performance. Methods: This systematic review followed the PICOST format. All randomised controlled trials and non-randomised studies evaluating cognitive aid use during (simulated) resuscitation were included in any setting. Unpublished studies were excluded. We did not include studies that reported cognitive aid use during training for resuscitation alone. Medline, Embase and Cochrane databases were searched from inception until July 2019 (updated August 2022, November 2023, and 23 April 2024). We did not search trial registries. Title and abstract screening, full-text screening, data extraction, risk of bias assessment (using RoB2 and ROBINS-I), and certainty of evidence (using GRADE) were performed by two researchers. PRISMA reporting standards were followed, and registration (PROSPERO CRD42020159162, version 19 July 2022) was performed. No funding has been obtained. Results: The literature search identified 5029 citations. After removing 512 duplicates, reviewing the titles and abstracts of the remaining articles yielded 103 articles for full-text review. Hand-searching identified 3 more studies for full-text review. Of these, 29 studies were included in the final analysis. No clinical studies involving patients were identified. The review was limited to indirect evidence from simulation studies only. The results are presented in five different populations: healthcare professionals managing simulated resuscitations in neonates, children, adult advanced life support, and other emergencies; as well as lay providers managing resuscitations. Main outcomes were adherence to protocol or process, adherence to protocol or process assessed by performance score, CPR performance and retention, and feasibility of chatbot guidance. The risk of bias assessment ranged from low to high. Studies in neonatal, paediatric and adult life support delivered by healthcare professionals showed benefits of using cognitive aids, however, some studies evaluating resuscitations by lay providers reported undesirable effects. The performance of a meta-analysis was not possible due to significant methodological heterogeneity. The certainty of evidence was rated as moderate to very low due to serious indirectness, (very) serious risk of bias, serious inconsistency and (very) serious imprecision. Conclusion: Because of the very low certainty evidence from simulation studies, we suggest that cognitive aids should be used by healthcare professionals during resuscitation. In contrast, we do not suggest use of cognitive aids for lay providers, based on low certainty evidence.

Critical airway-related incidents and near misses in anaesthesia: a qualitative study of a critical incident reporting system.

BACKGROUND: Many serious adverse events in anaesthesia are retrospectively rated as preventable. Anonymous reporting of near misses to a critical incident reporting system (CIRS) can identify structural weaknesses and improve quality, but incidents are often underreported. METHODS: This prospective qualitative study aimed to identify conceptions of a CIRS and reasons for underreporting at a single Swiss centre. Anaesthesia cases were screened to identify critical airway-related incidents that qualified to be reported to the CIRS. Anaesthesia providers involved in these incidents were individually interviewed. Factors that prevented or encouraged reporting of critical incidents to the CIRS were evaluated. Interview data were analysed using the Framework method. RESULTS: Of 3668 screened airway management procedures, 101 cases (2.8%) involved a critical incident. Saturation was reached after interviewing 21 anaesthesia providers, who had been involved in 42/101 critical incidents (41.6%). Only one incident (1.0%) had been reported to the CIRS, demonstrating significant underreporting. Interviews revealed highly variable views on the aims of the CIRS with an overall high threshold for reporting a critical incident. Factors hindering reporting of cases included concerns regarding identifiability of the reported incident and involved healthcare providers. CONCLUSIONS: Methods to foster anonymity of reporting, such as by national rather than departmental critical incident reporting system databases, and a change in culture is required to enhance reporting of critical incidents. Institutions managing a critical incident reporting system need to ensure timely feedback to the team regarding lessons learned, consequences, and changes to standards of care owing to reported critical incidents. Consistent reporting and assessment of critical incidents is required to allow the full potential of a critical incident reporting system.

Rapid cycle deliberate practice approach on resuscitation training: A systematic review.

Aim: To evaluate the effectiveness of Rapid Cycle Deliberate Practice (RCDP) compared to traditional instruction or other forms of learning on resuscitation training outcomes and on clinical and/or patient-related outcomes. Methods: As part of the continuous evidence evaluation process of the International Liaison Committee on Resuscitation it was conducted this review and searched Medline, Embase and Cochrane from inception to Feb 12th, 2024. Risk of bias assessment was performed with the Risk of Bias in Non-randomized Studies of Interventions assessment tool and the Revised Cochrane risk-of-bias tool for randomized trials. The GRADE approach was used to evaluate the overall certainty of evidence for each outcome. Results: 4420 abstracts were retrieved by the initial search and 10 additional studies were identified through other resources. Sixty-five studies were selected for eligibility and nine simulated studies met the inclusion criteria. A meta-analysis was performed on three outcomes: time to chest compressions, time to defibrillation and time to first epinephrine given, which showed that RCDP had significantly shorter time to defibrillation and time to administration of epinephrine than controls. The overall certainty of evidence was very low across all outcomes due to risk of bias, inconsistency, indirectness, and imprecision. Conclusion: It may be reasonable to include RCDP as an instructional design feature of basic and advanced life support training. However, substantial variations of delivering RCDP exist and there is no uniform use of RCDP. Further research is necessary on medium/long-term effects of RCDP training, and on the effects on different target groups of training.

Effects of a Serious Smartphone Game on Nursing Students' Theoretical Knowledge and Practical Skills in Adult Basic Life Support: Randomized Wait List-Controlled Trial.

BACKGROUND: Retention of adult basic life support (BLS) knowledge and skills after professional training declines over time. To combat this, the European Resuscitation Council and the American Heart Association recommend shorter, more frequent BLS sessions. Emphasizing technology-enhanced learning, such as mobile learning, aims to increase out-of-hospital cardiac arrest (OHCA) survival and is becoming more integral in nursing education. OBJECTIVE: The aim of this study was to investigate whether playing a serious smartphone game called MOBICPR at home can improve and retain nursing students' theoretical knowledge of and practical skills in adult BLS. METHODS: This study used a randomized wait list-controlled design. Nursing students were randomly assigned in a 1:1 ratio to either a MOBICPR intervention group (MOBICPR-IG) or a wait-list control group (WL-CG), where the latter received the MOBICPR game 2 weeks after the MOBICPR-IG. The aim of the MOBICPR game is to engage participants in using smartphone gestures (eg, tapping) and actions (eg, talking) to perform evidence-based adult BLS on a virtual patient with OHCA. The participants' theoretical knowledge of adult BLS was assessed using a questionnaire, while their practical skills were evaluated on cardiopulmonary resuscitation quality parameters using a manikin and a checklist. RESULTS: In total, 43 nursing students participated in the study, 22 (51%) in MOBICPR-IG and 21 (49%) in WL-CG. There were differences between the MOBICPR-IG and the WL-CG in theoretical knowledge (P=.04) but not in practical skills (P=.45) after MOBICPR game playing at home. No difference was noted in the retention of participants' theoretical knowledge and practical skills of adult BLS after a 2-week break from playing the MOBICPR game (P=.13). Key observations included challenges in response checks with a face-down manikin and a general neglect of safety protocols when using an automated external defibrillator. CONCLUSIONS: Playing the MOBICPR game at home has the greatest impact on improving the theoretical knowledge of adult BLS in nursing students but not their practical skills. Our findings underscore the importance of integrating diverse scenarios into adult BLS training. TRIAL REGISTRATION: ClinicalTrials.gov (NCT05784675); https://clinicaltrials.gov/study/NCT05784675.

Use of augmented and virtual reality in resuscitation training: A systematic review.

Objectives: To evaluate the effectiveness of augmented reality (AR) and virtual reality (VR), compared with other instructional methods, for basic and advanced life support training. Methods: This systematic review was part of the continuous evidence evaluation process of the International Liaison Committee on Resuscitation (ILCOR) and reported based on the Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA) guidelines and registered with PROSPERO (CRD42023376751). MEDLINE, EMBASE, and SCOPUS were searched from inception to January 16, 2024. We included all published studies comparing virtual or augmented reality to other methods of resuscitation training evaluating knowledge acquisition and retention, skills acquisition and retention, skill performance in real resuscitation, willingness to help, bystander CPR rate, and patients' survival. Results: Our initial literature search identified 1807 citations. After removing duplicates, reviewing the titles and abstracts of the remaining 1301 articles, full text review of 74 articles and searching references lists of relevant articles, 19 studies were identified for analysis. AR was used in 4 studies to provide real-time feedback during CPR, demonstrating improved CPR performance compared to groups trained with no feedback, but no difference when compared to other sources of CPR feedback. VR use in resuscitation training was explored in 15 studies, with the majority of studies that assessed CPR skills favoring other interventions over VR, or showing no difference between groups. Conclusion: Augmented and virtual reality can be used to support resuscitation training of lay people and healthcare professionals, however current evidence does not clearly demonstrate a consistent benefit when compared to other methods of training.

Gamified learning for resuscitation education: A systematic review.

Aim: To systematically review published literature to evaluate the impact of gamified learning on educational and clinical outcomes during life support education. Methods: This systematic review was conducted as part of the continuous evidence evaluation process of the International Liaison Committee on Resuscitation (ILCOR). A search of PubMed, Embase, and Cochrane was conducted from inception until February 12, 2024. Studies examining incorporation of gamified learning were eligible for inclusion. Reviewers independently extracted data on study design and outcomes; appropriate risk of bias assessment tools were used across all outcomes. Results: 2261 articles were identified and screened, yielding sixteen articles (seven randomized trials, nine observational studies) which comprised the final review. No meta-analyses were conducted due to significant heterogeneity of intervention, population, and outcome. Only one study was found to have a low risk of bias; the remaining studies were found to have moderate to high risk. Fourteen studies were in healthcare providers and two were in laypersons. Most studies (11 of 16) examined the impact of a digital platform (computer or smartphone). Most (15 of 16) studies found a positive effect on at least one educational domain; one study found no effect. No included study found a negative effect on any educational domain. Conclusion: This systematic review found a very heterogeneous group of studies with low certainty evidence, all but one of which demonstrated a positive effect on one or more educational domains. Future studies should examine the underlying causes of improved learning with gamification and assess the resource requirements with implementation and dissemination of gamified learning.

Emergency front-of-neck access in pediatric anesthesia: A narrative review.

BACKGROUND AND OBJECTIVES: Children undergoing airway management during general anesthesia may experience airway complications resulting in a rare but life-threatening situation known as "Can't Intubate, Can't Oxygenate". This situation requires immediate recognition, advanced airway management, and ultimately emergency front-of-neck access. The absence of standardized procedures, lack of readily available equipment, inadequate knowledge, and training often lead to failed emergency front-of-neck access, resulting in catastrophic outcomes. In this narrative review, we examined the latest evidence on emergency front-of-neck access in children. METHODS: A comprehensive literature was performed the use of emergency front-of-neck access (eFONA) in infants and children. RESULTS: Eighty-six papers were deemed relevant by abstract. Finally, eight studies regarding the eFONA technique and simulations in animal models were included. For all articles, their primary and secondary outcomes, their specific animal model, the experimental design, the target participants, and the equipment were reported. CONCLUSION: Based on the available evidence, we propose a general approach to the eFONA technique and a guide for implementing local protocols and training. Additionally, we introduce the application of innovative tools such as 3D models, ultrasound, and artificial intelligence, which can improve the precision, safety, and training of this rare but critical procedure.

The effect of scripted debriefing in resuscitation training: A scoping review.

Objectives: To evaluate the effectiveness of scripted debriefing relative to no use of script during debriefing in resuscitation training. Methods: This scoping review was undertaken as part of the continuous evidence evaluation process of the International Liaison Committee on Resuscitation (ILCOR) and based on the Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA) extension for scoping review. MEDLINE, EMBASE, and SCOPUS were searched from inception to January 2024. We included all published studies comparing scripted debriefing vs non-scripted debriefing evaluating patient outcomes, behaviour change of learners, learning outcomes for learners and cognitive load and teaching quality for instructors. Results: Our initial literature search identified 1238 citations. After removing 552 duplicates, reviewing the titles and abstracts of the remaining 686 articles yielded 11 for full-text review. Of these, six articles were selected for inclusion in the final analysis. The six studies described debriefing scripts varying in content, framework, scripted language and the integration of objective data. Scripted debriefing improved CPR performance, team leadership skills and knowledge acquisition, but showed no difference in teamwork performance compared to non-scripted debriefing. Scripted debriefing also improved debriefing quality and decreased cognitive load of the instructor during resuscitation training. Conclusion: The use of a debriefing script during resuscitation education can improve CPR performance, team leader performance, knowledge acquisition and reduce the debriefer's cognitive load. Future research should explore how debriefing scripts can be designed to optimize learning outcomes.