BACKGROUND:Emergency tracheal intubation is associated with a risk of clinical adverse events, including the risk of first-attempt failure. Induction agents usually include a sedative and a neuromuscular blocking agent (i.e., paralytic). Whether the order of administration (i.e., sedative vs. paralytic given first) is associated with first-attempt failure or adverse events is unknown. METHODS:This study analyzed data from a single-center prospective cohort collected from 2021 to 2024 at Hennepin County Medical Center, which included all patients undergoing orotracheal intubation in the emergency department. Patients with no detail on administration sequence order were excluded. A Bayesian logistic regression analysis was used to measure the effect of drug sequence order (sedative first vs. paralytic first). The primary outcome was first-attempt failure. The key secondary outcome was peri-intubation hypoxemia (SpO2 < 90%). We estimated the odds ratio (OR), 95% credible interval (CrI), and the probability that the OR was inferior to 1 (existence of an effect) and inferior to 0.9 (significant effect). Frequentist analysis and reanalysis with various priors were performed as sensitivity analyses. RESULTS:A total of 2216 patients were included for analysis. The most frequently used sedative and paralytic agents were etomidate (88.9%) and rocuronium (77.8%), respectively. The paralytic was given first to 56.6% of the patients. After adjustment for age, sex, body mass index, and sedative and paralytic agents, the OR for a paralytic-first strategy for first-attempt failure was 0.73 (95% CrI 0.46-1.02). The probability that the OR was less than 1 was estimated at 95.7% and less than 0.9 at 87.6%. There was a 33.5% and 8.0% probability that administering the paralytic first resulted in an OR < 1 and OR < 0.9 for the risk of hypoxemia, respectively. Sensitivity analyses were consistent with the main results. CONCLUSIONS:In this Bayesian analysis a paralytic-first drug sequence was associated with reduced first-attempt failure during emergency tracheal intubation.

INTRODUCTION:Among critically ill patients undergoing orotracheal intubation in the emergency department (ED) or intensive care unit (ICU), failure to visualise the vocal cords and intubate the trachea on the first attempt is associated with an increased risk of complications. Two types of laryngoscopes are commonly available: direct laryngoscopes and video laryngoscopes. For critically ill adults undergoing emergency tracheal intubation, it remains uncertain whether the use of a video laryngoscope increases the incidence of successful intubation on the first attempt compared with the use of a direct laryngoscope. METHODS AND ANALYSIS:The DirEct versus VIdeo LaryngosCopE (DEVICE) trial is a prospective, multicentre, non-blinded, randomised trial being conducted in 7 EDs and 10 ICUs in the USA. The trial plans to enrol up to 2000 critically ill adults undergoing orotracheal intubation with a laryngoscope. Eligible patients are randomised 1:1 to the use of a video laryngoscope or a direct laryngoscope for the first intubation attempt. The primary outcome is successful intubation on the first attempt. The secondary outcome is the incidence of severe complications between induction and 2 min after intubation, defined as the occurrence of one or more of the following: severe hypoxaemia (lowest oxygen saturation <80%); severe hypotension (systolic blood pressure <65 mm Hg or new or increased vasopressor administration); cardiac arrest or death. Enrolment began on 19 March 2022 and is expected to be completed in 2023. ETHICS AND DISSEMINATION:The trial protocol was approved with waiver of informed consent by the single institutional review board at Vanderbilt University Medical Center and the Human Research Protection Office of the Department of Defense. The results will be presented at scientific conferences and submitted for publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER:ClinicalTrials.gov Registry (NCT05239195).

Rationale. Ketamine can provide dissociative sedation and analgesia for mechanically ventilated ICU patients, yet it has been utilized less than other drugs for this purpose. Methods. We reviewed the electronic medical record of critically ill adults who received a continuous infusion of ketamine for ≥24 hours during invasive mechanical ventilation in three hospitals over a two-year period. We captured data including ketamine indication, dose, unintended effects, and adjustments to coadministered sedatives or opioids. We analyzed these data to determine the incidence of reported unintended effects of ketamine infusion (primary outcome) and changes in exposure to coadministered sedatives or opioids during ketamine use (secondary outcome). Results. 95 mechanically ventilated adults received a ketamine infusion for a median duration of 75 hours (interquartile range [IQR] 44–115) at a mean ± standard deviation (SD) infusion rate of 1.3 ± 0.5 mg/kg/hour for the first 24 hours. At least one unintended effect attributed to ketamine was documented in 24% of cases, most frequently tachycardia (6%) and sialorrhea (6%). Other sedative or opioid infusions were administered with ketamine in 76% and 92% of cases, respectively. Comparing the total amount of sedative or opioid administered in the 24 hours prior to ketamine infusion with the total amount administered during the first 24 hours on ketamine, there were no significant differences in propofol, midazolam, or dexmedetomidine exposure, but the average fentanyl exposure was higher after ketamine (2740 ± 1812 mcg) than before (1975 ± 1860 mcg) (absolute difference 766 mcg, 95% confidence interval [CI] 442 to 1089 mcg). Conclusions. In this multicenter cohort of critically ill, mechanically ventilated adults, ketamine infusion was primarily used as an adjunct to conventional sedative and opioid infusions, with noticeable but unintended effects potentially related to ketamine in nearly one-quarter of cases.

INTRODUCTION:Individuals with cystic fibrosis (CF) may be at increased risk of pulmonary embolism (PE). Symptoms of PE overlap substantially with those of CF respiratory exacerbations. CF patients commonly undergo chest computed tomography (CT) angiograms (CTPA) to evaluate for PE, but little is known about the clinical presentation and diagnosis of PE in this population.OBJECTIVES:The objectives of this study are to determine the diagnostic yield of CTPA for PE in adult patients with CF and assess the utility of the Revised Geneva Score (RGS) in this population.METHODS:Retrospective review of all CTPA results was performed on CF patients with suspected PE at a large CF center from 1 January 2011 through 31 March 2017. Patient demographics, medical history, and presenting signs and symptoms were abstracted by chart review.RESULTS:A total of 103 unique CTPA studies were performed in 68 patients. Most were hospitalized at the time of CTPA, predominantly for respiratory manifestations of CF. CTPA identified four patients with PE. The small number of positive studies precluded analysis of predictors of PE. Fewer PE were diagnosed than predicted by the Revised Geneva Score, which was intermediate probability in 77/103 (75%) patients.CONCLUSION:The prevalence of PE in CF patients undergoing CTPA for suspected PE was 4%, which is lower than predicted by the Revised Geneva Score. This may be due to a large overlap in the signs and symptoms of PE and exacerbations of CF lung disease.

Rationale: Positive pressure ventilation (PPV) during tracheal intubation of critically ill adults reduces the risk of peri-procedural hypoxemia. Patients with COVID-19 are at increased risk of hypoxemia during tracheal intubation, but expert guidelines have recommended against the use of PPV for patients with suspected or known COVID-19 based on a concern that PPV may increase aerosolization and the risk of infection of healthcare providers. Evidence informing the impact of these recommendations on the airway management practices for patients with COVID-19 is currently limited. Methods: We conducted a survey of perceived intubation practices in 21 emergency departments (EDs) and intensive care units (ICUs) participating in either of two randomized trials (clinicaltrials.gov identifiers: NCT03928925 and NCT03787732) within the Pragmatic Critical Care Research Group between 9-3-2020 and 10-21-2020. At each site, the site investigator provided information on perceived airway management practices among patients intubated prior to the COVID-19 pandemic and during the pandemic. The primary outcome for this analysis was the use of any PPV, either bag-mask ventilation (BMV) or non-invasive ventilation (NIV), between induction and laryngoscopy. Results: We received responses from 19 of 21 sites (90%). Use of BMV was reported in a median of 35% of intubations [IQR: 0-67%] prior to the pandemic compared with a median of 0% of intubations [IQR: 0-20%] performed among patients with known or suspected COVID-19 (p=0.004). Investigators reported using NIV in a median of 10% of intubations [IQR: 0-25%] prior to the pandemic, compared to 10% [IQR 0-30%] of intubations among patients with known or suspected COVID-19 (p=0.20). Receipt of any positive pressure was reported in 50% [IQR: 0-85%] of intubations prior to the pandemic, compared to 30% [IQR: 0-55%] of intubations among patients with known or suspected COVID-19 (p=0.06) (Figure 1). Conclusions: Based on reported practices at 19 EDs and ICUs participating in either of two ongoing clinical trials, we found that the perceived use of BMV between induction and laryngoscopy decreased in patients with known or suspected COVID-19 while the perceived use of NIV did not change. Despite recommendations to avoid its use, perceived use of PPV remains common among patients with suspected or known COVID-19. This reflects the tension between balancing risk to providers and patients for a condition that places both groups at high risk of peri-procedural complications.

Emergency medicine (EM) physicians (EPs) are sometimes called to perform tracheal intubation for critically ill patients outside of the emergency department (ED), for example as part of a hospital airway or medical emergency team. Differences in patient characteristics or intubation context in the inpatient units (ie, cognitive, team-based, or environmental challenges) may be associated with changes in the safety and success of tracheal intubation, as compared to intubations performed in the ED. Our objective was to characterize intubation performance for EPs in the ED compared to inpatient settings. We hypothesized that first-pass success rates for EPs in different settings would not be significantly different. We performed a retrospective, single center study of adult patients intubated at Hennepin County Medical Center in the ED, Intensive Care Units (ICU), and inpatient units between March 2019 and April 2021. Patients intubated in these settings by a non emergency physician were excluded. Clinical data and patient variables were collected from the electronic health record (EHR). Patient demographics, first attempt success rate, and hospital mortality were captured. The primary outcome, successful intubation on the first laryngoscopy attempt across settings, was evaluated using an unadjusted chi square test. The first attempt success rate for intubations performed by emergency physicians was 95.5% (1683/1763) in the ED, 94.8% (1072/1131) in the ICU, and 94.6% (156/165) in inpatient non-ICU settings. These differences did not reach statistical significance (p=0.66 by chi square test). Mean age was 47.1 years in the ED, 50.5 years in the ICU, and 46.8 years in inpatient non-ICU settings. The most common primary diagnoses for all settings were altered mental status, cardiac arrest, and sepsis. Hospital mortality was significantly different (p < 0.001) for patients intubated by emergency physicians in the different settings, with a rate of 15% for ED patients, 20% in the ICU, and 24% in inpatient non-ICU settings. Emergency physicians achieved >94% first pass intubation success among critically ill patients regardless of hospital setting, and the rates of first pass success in the ED, ICU, and non-ICU inpatient units were similar. The first attempt success rate in this study is similar to previous ED studies, however is higher than the rate in previous descriptions in the ICU setting. This suggests that EPs perform intubations outside of the emergency department with a high level of performance. Limitations of this study include the use of EHR procedural documentation to evaluate first attempt success rate. Further research should include data collection by trained observers and in multiple institutions.

Rationale: Significant variability exists in the use of direct versus video laryngoscopy for the intubation of critically ill adults. Concerns regarding risks of infection to healthcare providers have led many experts to recommend the use of video laryngoscopy for intubation of patients with COVID-19. This recommendation is based on the belief that using video laryngoscopy allows more physical distance between the operator and the patient, potentially decreasing the risk to providers. Information on the effect of the COVID-19 pandemic on intubation practices is currently limited. Methods: We conducted a survey of intubation practices in 21 emergency departments and intensive care units participating in either of two randomized trials (clinicaltrials.gov identifiers: NCT03928925 and NCT03787732) within the Pragmatic Critical Care Research Group. At each site, the site investigator estimated the prevalence of various airway practices among 3 groups of patients: 1) patients intubated prior to the COVID-19 pandemic, 2) patients intubated with known or suspected COVID-19, and 3) patients intubated during the pandemic without known or suspected COVID-19. The site investigator provided information on use of personal protective equipment, preintubation fluid bolus administration, preoxygenation, sedative choice, paralytic choice, approach to oxygenation from induction to intubation, approach to laryngoscopy, bougie use, primary operator, and ancillary staff present. The primary outcome was the proportion of intubations at a study site that was estimated to be performed using video laryngoscopy. Results: We received responses from 19 of 21 sites (90%). Investigators reported that video laryngoscopy was used in a median of 65% of intubations [IQR: 50-76%] at their site prior to the pandemic compared with a median of 100% of intubations [IQR: 76-100%] for patients with known or suspected COVID-19 (p= 0.0002). Prior to the pandemic only 2 sites (10.5%) reported using exclusively video laryngoscopy, compared to 10 sites (52.6%) that reported using exclusively video laryngoscopy for COVID-19 patients. For patients without known or suspected COVID-19, use of video versus direct laryngoscopy did not differ significantly between patients intubated before the pandemic and patients intubated during the pandemic. Conclusions: Among patients intubated at 19 emergency departments and intensive care units participating in two ongoing clinical trials, we found that the perceived use of video laryngoscopy was greater for patients with known or suspected COVID-19 compared to patients intubated prior to the pandemic, whereas perceived use of video laryngoscopy for patients without COVID-19 during the pandemic was similar to use prior to the pandemic.

Hyperactivation of Calcium Release-Activated Calcium (CRAC) channels results in excessive Ca2+ influx in acinar cells and plays a pivotal role in cellular injury and the progression of acute pancreatitis. Our purpose was to evaluate the efficacy of CM4620-IE, a potent selective CRAC channel inhibitor, to improve outcomes in ED patients with acute pancreatitis.

Cardiopulmonary resuscitation (CPR) guidelines place importance on achieving a chest compression fraction greater than 0.6, accompanied by a ventilation rate of 10 breaths per minute, to optimize perfusion during cardiac arrest and increase the likelihood of survival. We reviewed video of emergency department (ED) patients in cardiac arrest to evaluate the ability of the resuscitation team to adhere to these CPR targets.