Daily Anesthesiology Research Analysis

BACKGROUND: Airway management is a critical component of the care of patients experiencing cardiac arrest, but data from randomized trials on the use of video vs direct laryngoscopy for intubation in the setting of cardiac arrest are limited. Current American Heart Association guidelines recommend placement of an endotracheal tube either during CPR or shortly after return of spontaneous circulation, but do not provide guidance around intubation methods, including the choice of laryngoscope. RESEARCH QUESTION: Does use of video laryngoscopy improve the incidence of successful intubation on the first attempt, compared with use of direct laryngoscopy, among adults undergoing tracheal intubation after experiencing cardiac arrest? STUDY DESIGN AND METHODS: This secondary analysis of the Direct vs Video Laryngoscope (DEVICE) trial compared video laryngoscopy vs direct laryngoscopy in the subgroup of patients who were intubated after cardiac arrest. The primary outcome was the incidence of successful intubation on the first attempt. Additional outcomes included the duration of laryngoscopy. RESULTS: Among the 1,417 patients in the DEVICE trial, 113 patients (7.9%) experienced cardiac arrest before intubation, of whom 48 patients were randomized to the video laryngoscopy group and 65 patients were randomized to the direct laryngoscopy group. Successful intubation on the first attempt occurred in 40 of 48 patients (83.3%) in the video laryngoscopy group and in 42 of 65 patients (64.6%) in the direct laryngoscopy group (absolute risk difference, 18.7 percentage points; 95% CI, 1.2-36.2 percentage points; P = .03). The mean duration of laryngoscopy was 48.0 seconds (SD, 37.3 seconds) in the video laryngoscope group and 98.0 seconds (SD, 122.4 seconds) in the direct laryngoscopy group (mean difference, -50.0 seconds; 95% CI, -86.8 to -13.3 seconds; P = .004). INTERPRETATION: Among adults undergoing tracheal intubation after experiencing cardiac arrest, use of video laryngoscopy was associated with increased incidence of successful intubation on the first attempt and shortened duration of laryngoscopy, compared with use of direct laryngoscopy.

BACKGROUND: Ventilator-associated pneumonia (VAP) rates are higher in low- and middle-income countries (LMICs) than in high-income countries (HICs). RESEARCH QUESTION: Could differences in ventilator bundle adherence, ventilation practices, and critical care staffing be driving variations in VAP risk between LMICs and HICs? STUDY DESIGN AND METHODS: This secondary analysis of the multicenter, international Checklist for Early Recognition and Treatment of Acute Illness and Injury (CERTAIN) study included mechanically ventilated patients at risk for VAP from 11 LMICs and 5 HICs. We included oral care, head-of-bed elevation, spontaneous breathing assessments, and sedation breaks in the ventilator bundle. Staffing was assessed by the number of physicians and nurses per bed. Multivariable analyses were adjusted for severity, baseline characteristics, and checklist implementation. The primary outcome was VAP development. RESULTS: Among 2,253 patients, 1,755 were from LMICs and 498 from HICs. Compared with HICs, patients from LMICs were younger, had lower comorbidity burden, and were less severely ill. Lower country income level was independently associated with VAP development (adjusted OR [aOR], 2.11; 95% CI, 1.37-3.24). Ventilator bundle adherence was not significantly associated with VAP. Increased total duration of ventilation was associated with an increased risk of VAP (aOR, 1.04; 95% CI, 1.03-1.05), whereas higher nursing (aOR, 0.88; 95% CI, 0.79-0.98) and physician staffing ratios (aOR, 0.69; 95% CI, 0.50-0.87) were associated with lower VAP rates. INTERPRETATION: Our results show that patients in LMICs have a 2-fold higher risk of VAP, independent of bundle adherence. Prolonged mechanical ventilation was an independent predictor of VAP, whereas higher staffing ratios were associated with decreased risk for VAP development. Unmeasured factors (eg, infrastructure, infection control practices) may explain the higher VAP rates in LMICs.

BACKGROUND: The general anaesthesia or awake-regional anaesthesia in infancy (GAS) trial demonstrated evidence that most neurodevelopmental outcomes at 2 and 5 yr of age in infants who received a single general anesthetic for elective inguinal herniorrhaphy were clinically equivalent when compared to infants who did not receive general anesthesia. More than 20% of the children in the trial had at least one subsequent anesthetic exposure after their initial surgery. Using the GAS database, this study aimed to address whether multiple (two or more) general anesthetic exposures compared to one or no general anesthetic exposure in early childhood were associated with worse neurodevelopmental outcomes at 5 yr. METHODS: Children with multiple general anesthetic exposures and children with one or no general anesthetic exposure were identified from the GAS database. The primary outcome was the full-scale intelligence quotient on the Wechsler Preschool and Primary Scale of Intelligence (third edition) at 5 yr of age. Secondary outcomes included neurocognitive tests addressing all major developmental domains and caregiver-reported questionnaires assessing emotional and behavioral problems. RESULTS: Complete assessment was available from a total of 90 children in the multiple general anesthetic group and 141 children in the no or one general anesthetic group. Compared with children with a single or no general anesthetic exposure, multiply exposed children scored on average almost 6 points lower (mean, -5.8; 95% CI, -10.2 to -1.4; P = 0.011) in the Wechsler Preschool and Primary Scale of Intelligence full-scale intelligence quotient. They also demonstrated lower verbal and performance IQ scores and more emotional, behavioral, and executive function difficulties. However, significant residual confounding cannot be excluded from the results due to the observational nature of this study. CONCLUSIONS: Multiple general anesthetic exposures before 5 yr of age were associated with reduced performance in general intelligence score and some domains of neurodevelopmental assessments. The clinical significance of this study's results must be cautiously interpreted in light of several sources of limitations including small sample size and unadjusted residual confounding. This study illustrates the limitations of trial data sets that may not be fit for the purpose for the secondary analysis.