Noninvasive Ventilation for Critically Ill Subjects With Acute Respiratory Failure in the Emergency Department.

BACKGROUND: We aimed to investigate the association between noninvasive ventilation (NIV) initiated in the emergency department and patient outcomes for those requiring invasive mechanical ventilation so that we could understand the effect of extended NIV use (ie, > 4 h) prior to invasive mechanical ventilation on patient outcomes. METHODS: We conducted a retrospective single-center cohort study at an academic tertiary care hospital center. All emergency department patients with acute respiratory failure requiring invasive mechanical ventilation and admission to the ICU within 48 h of initial presentation over a 24-month period were included. RESULTS: Subject characteristics, ventilator parameters, and clinical course were captured via electronic query, respiratory billing data, and standardized chart abstraction. A total of 431 subjects with acute respiratory failure requiring invasive mechanical ventilation within 48 h of arrival were identified, of whom 115 (26.7%) were exposed to NIV prior to invasive mechanical ventilation, with a median duration of 4 h (interquartile range 1.9-9.3). Based on a multivariable model controlling for covariates, any NIV exposure prior to invasive mechanical ventilation was not associated with an increased odds of persistent organ dysfunction or death. However, in the subset of subjects exposed to NIV, extended NIV use (ie, > 4 h) prior to invasive mechanical ventilation was associated with increased odds of persistent organ dysfunction or death (odds ratio 4.11, 95% CI 1.51-11.19). Extended NIV use was also associated with increased odds of in-hospital mortality (odds ratio 4.02, 95% CI 1.51-10.74). CONCLUSIONS: Although any exposure to NIV prior to invasive mechanical ventilation did not appear to affect morbidity and mortality, extended NIV use prior to invasive mechanical ventilation was associated with worse patient outcomes, suggesting a need for additional study to better understand the ramifications of duration of NIV use prior to failure on outcomes. Given this early timeframe for intervention, future studies should be collaborations between the emergency department and ICU.

Determination of legal responsibility in shared airway management between anesthesiology and otolaryngology.

BACKGROUND: Malpractice litigation remains an important point of contention in the United States. Airway management often sees multidisciplinary teams of anesthesiologists and otolaryngologists. This report analyzes lawsuits affecting both teams in airway management. METHODS: The Westlaw legal database (West Publishing Co., St. Paul, MN) was used to search for malpractice cases involving failed airway management, where both anesthesiology and otolaryngology were involved. RESULTS: Among the 28 cases analyzed, otolaryngology and anesthesiology were most commonly sued together (46.4%). When sued together, defendants were less likely to win and average award amounts ($4, 558 716) were higher. These cases most commonly occurred in the operating room (78.6%), involved a difficult/improper intubation (39.3%), alleged a failure to follow standard of care (57%), and resulted in death (60.7%). CONCLUSION: These cases primarily cited failure to follow standard of care and communication failures. Efforts should be directed toward multidisciplinary airway management protocols and effective communication.

Association Between Outdoor Air Pollution Levels and Inpatient Outcomes in Pediatric Pneumonia Hospitalizations, 2007 to 2008.

OBJECTIVE: Pneumonia is a leading cause of pediatric admissions. Although air pollutants are associated with poor outcomes, few national studies have examined associations between pollutant levels and inpatient pediatric pneumonia outcomes. We examined the relationship between ozone (O3) and fine particulate matter with a diameter ≤2.5 µm (PM2.5) and outcomes related to disease severity. METHODS: In this cross-sectional study, we obtained discharge data from the 2007 to 2008 Nationwide Inpatient Sample and pollution data from the Air Quality System. Patients ≤18years with a principal diagnosis of pneumonia were included. Discharge data were linked to O3 and PM2.5 levels (predictors) from the patient's ZIP Code (not publicly available) from day of admission. Outcomes were mortality, intubation, length of stay (LOS), and total costs. We calculated weighted national estimates and performed multivariable analyses adjusting for sociodemographic and hospital factors. RESULTS: There were a total of 57,972 (278,871 weighted) subjects. Median PM2.5 level was 9.5 (interquartile range [IQR] 6.8-13.4) µg/m3. Median O3 level was 35.6 (IQR 28.2-45.2) parts per billion. Mortality was 0.1%; 0.75% of patients were intubated. Median LOS was 2 (IQR 2-4) days. Median costs were $3089 (IQR $2023-$5177). Greater levels of PM2.5 and O3 were associated with mortality, longer LOS, and greater costs. Greater O3 levels were associated with increased odds of intubation. CONCLUSIONS: Greater levels of O3 and PM2.5 were associated with more severe presentations of pneumonia. Future work should examine these relationships in more recent years and over a longer time period.

Comparison of efficacies of the self-expandable metallic stent versus transanal drainage tube and emergency surgery for malignant left-sided colon obstruction.

BACKGROUND/OBJECTIVE: Patients with left-sided malignant colorectal obstruction require emergency treatment. Emergency stoma surgery has traditionally been recommended, however many stomas became permanent, decreasing patient quality of life. Recently, self-expandable metallic stents (SEMS) and transanal decompression tubes (TDT) have become widely used decompression methods to avoid stoma surgery. In this study, we evaluated: 1) the efficacy of SEMS compared with TDT and emergency surgery (ES) to avoid permanent stomas; and 2) the safety and success rate of each treatment. METHODS: We retrospectively reviewed data from 56 patients who underwent SEMS, TDT, or emergency surgery for malignant left-sided colon obstruction. We compared the permanent stoma rate of each group, and assessed whether or not each treatment was an independent risk factor for permanent stomas. We compared morbidity and mortality for each treatment group (SEMS, TDT, ES), and the success rate of the decompression procedures (SEMS and TDT). RESULTS: The permanent stoma rates in the SEMS, TDT, and ES groups were 5.3%, 50.0%, and 56.0%, respectively. Emergency surgery (vs. SEMS) and TDT (vs. SEMS) were independent risk factors for permanent stomas, as was age ≥ 75 years. Operative morbidity, mortality, and hospital stay were not different between groups. The success rate of SEMS was significantly higher than TDT; however, two deaths, including one perforation, occurred in the former group. CONCLUSION: SEMS seems to be effective in avoiding permanent stomas, but caution should be taken to avoid complications.

Risk factors for mortality in septic patients who received etomidate.

PURPOSE: To characterize risk factors for mortality in septic patients who received etomidate for rapid sequence intubation. MATERIALS AND METHODS: This study was a retrospective cohort conducted at a large, tertiary, urban, academic medical center that included patients with severe sepsis or septic shock who received etomidate between January 1, 2010, and December 31, 2012. RESULTS: A total of 169 patients were included with similar baseline characteristics. There were more men in the nonsurvivor group than in the survivor group (67.1% vs 50.6%, P=.03). Septic shock occurred in 91.5% of nonsurvivors and 69% of survivors (P<.01). Nonsurvivors also had a higher initial lactate of (5.1±4.3 mmol/L vs 3.6±3.4 mmol/L, P=.02) and more vasopressor therapy (91.5% vs 69%, P<.01), required a higher number of vasopressors (2.2±1.1 vs 1.3±1, P<.01), and were administered hydrocortisone (53.7% vs 34.5%, P=.01). Abdominal source of sepsis (P=.048) and number of vasopressors (P=.01) were predictive of 30-day mortality. CONCLUSION: An alternative sedative induction agent may be considered for use in rapid sequence intubation in patients on multiple vasopressors or with abdominal source of infection.

Intubación monocanalicular autoajustable para la obstrucción lagrimal congénita / Self-adjusting monocanalicular intubation for congenital lacrimal obstruction

OBJETIVO: Presentar nuestra experiencia con la intubación monocanalicular autoestable Masterka, sin recuperación nasal, en la obstrucción lagrimal congénita en niños mayores de un año. MÉTODOS: Un total de 40 niños con edad media de 2,6 años (rango 1-7 años) fueron intervenidos de forma consecutiva. La sonda de Masterka incluye una guía metálica flexible dentro del tubo de silicona que la cubre totalmente hasta su extremo distal. El extremo proximal se ancla a punto lagrimal tras presionarlo con el terminal de un dilatador o pinza. Hubo monitorización y comprobación visual endoscópica de su correcta ubicación en tiempo real en todos los casos. RESULTADOS: El tiempo medio de maniobras quirúrgicas, excluyendo el tiempo anestésico, fue 1,56 min (rango 1,05-4). Los éxitos finales fueron un 97,5%, entendiéndolos como ausencia de epífora, la desaparición del colorante en menisco lagrimal y de secreción mucopurulenta. El tiempo medio de seguimiento fue 15 meses (rango 7-21). CONCLUSIONES: La intubación con Masterka es un tratamiento primario efectivo. No ofrece más dificultad que el sondaje simple, puesto que la técnica quirúrgica es similar, sin embargo sus resultados funcionales son mejores, evita la posibilidad de tener que repetir el sondaje y es más fácil de realizar que la intubación bicanalicular clásica, al no precisar manipulaciones repetidas ni tener que introducir instrumental quirúrgico en el meato inferior, simplificando el proceso

OBJECTIVE: To present our work with the Masterka self-adjusting monocanalicular intubation without nasal recuperation in congenital lacrimal obstruction in children over 12-months old. METHODS: A total of 40 children between the ages of one and seven (average age 2.6 years) were consecutively operated on. The Masterka catheter has a flexible metal guide inside the silicone tube that covers it completely. The proximal end is fixed onto the lacrimal punctum by pushing it with a dilator or forceps. Its correct position was monitored and visually checked in real time during surgery in all cases. RESULTS: The average surgery time, excluding anaesthetic, was 1.56 min, ranging from 1.05 to 4 min. The final success was 97.5%, considering absence of epiphora, disappearance of colouring in lacrimal meniscus, and mucopurulent secretion. The average follow-up time was 15 months (ranging from 7 to 21 months). CONCLUSIONS: Masterka intubation is an effective primary treatment. It is no more difficult than a simple catheter, since the surgical technique is similar, but with better functional results. It avoids the possibility of having to repeat the catheterization and it is easier to carry out than bicanalicular intubation, since there is no need to manipulate repeatedly or use surgical instruments in the inferior meatus, thus simplifying the process

Fatal surgical or procedure-related complications: a Finnish registry-based study.

INTRODUCTION: In Finland, all healthcare personnel must be insured against causing patient injury. The Patient Insurance Centre (PIC) pays compensation in all cases of malpractice and in some cases of infection or other surgical complications. This study aimed to analyze all complaints relating to fatal surgical or other procedure-related errors in Finland during 2006-2010. MATERIALS AND METHODS: In total, 126 patients fulfilled the inclusion criteria. Details of patient care and decisions made by the PIC were reviewed, and the total national number of surgical procedures for the study period was obtained from the National Hospital Discharge Registry. RESULTS: Of the 94 patients who underwent surgery, most fatal surgical complications involved orthopedic or gastrointestinal surgery. Non-surgical procedures with fatal complications included deliveries (N = 10), upper gastrointestinal endoscopy or nasogastric tube insertion (N = 8), suprapubic catheter insertion (N = 4), lower intestinal endoscopy (N = 5), coronary angiogram (N = 1), pacemaker fitting (N = 1), percutaneous drainage of a hepatic abscess (N = 1), and chest tube insertion (N = 2). In 42 (33.3 %) cases, patient injury resulted from errors made during the procedure, including 24 technical errors and 15 errors of judgment. There were 19 (15.2 %) cases of inappropriate pre-operative assessment, 28 (22.4 %) errors made in postoperative follow-up, 23 (18.4 %) cases of fatal infection, and 11 (8.8 %) fatal complications not linked to treatment errors. CONCLUSION: Fatal surgical and procedure-related complications are rare in Finland. Complications are usually the result of errors of judgment, technical errors, and infections.

A randomized trial of conventional chest physical therapy versus high frequency chest wall compressions in intubated and non-intubated adults.

BACKGROUND: Conventional chest physical therapy (CCPT), applied by therapists using cupped hands to perform percussion, is commonly used in hospitalized adults. However, increased work load demands and occupational health concerns (eg, carpal tunnel syndrome) limit the overall utilization of this therapy. Therefore, we conducted a study to compare the overall effectiveness of CCPT to high-frequency chest wall compressions (HFCWC) applied via a vibratory vest. METHODS: A single-center, randomized trial among hospitalized intubated and non-intubated adult patients requiring chest physical therapy comparing CCPT and HFCWC. The primary outcome measure was hospital stay. RESULTS: A total of 280 per-protocol patients (out of an a priori estimated 320 patients required to demonstrate a 20% relative reduction in hospital stay) were randomly assigned to receive CCPT (no. = 146, 52.1%) or HFCWC (no. = 134, 47.9%). The hospital stay was 12.5 ± 8.8 days for patients randomized to CCPT and 13.0 ± 8.9 days for patients randomized to HFCWC (P = .62). Patient comfort was assessed using a visual analog scale (increasing score reflects greater discomfort) and was statistically greater for patients randomized to CCPT compared to HFCWC (2.2 ± 0.8 vs 1.9 ± 0.8, P = .009). The duration of time until radiographic resolution of lobar atelectasis trended less for CCPT compared to HFCWC (5.2 ± 4.3 d vs 6.5 ± 5.2 d, P = .051). All other secondary outcomes, including hospital mortality and nosocomial pneumonia, were similar for both treatment groups. CONCLUSIONS: This study was inadequately powered for the primary outcome of interest and hence we cannot make recommendations on the preferential use of HFCWC or CCPT for intubated and non-intubated adult patients. HFCWC was associated with statistically better comfort scores. (ClinicalTrials.gov registration NCT00717873.).