Jerzy Robert Ladny

C-MAC compared with direct laryngoscopy for intubation in patients with cervical spine immobilization: A manikin trial

Introduction The aim of this study was to compare C‐MAC videolaryngoscopy with direct laryngoscopy for intubation in simulated cervical spine immobilization conditions. Methods The study was designed as a prospective randomized crossover manikin trial. 70 paramedics with < 5 years of medical experience participated in the study. The paramedics attempted to intubate manikins in 3 airway scenarios: normal airway without cervical immobilization (Scenario A); manual inline cervical immobilization (Scenario B); cervical immobilization using cervical extraction collar (Scenario C). Results Scenario A: Nearly all participants performed successful intubations with both MAC and C‐MAC on the first attempt (95.7% MAC vs. 100% C‐MAC), with similar intubation times (16.5 s MAC vs. 18 s C‐MAC). Scenario B: The results with C‐MAC were significantly better than those with MAC (p < 0.05) for the time of intubation (23 s MAC vs. 19 s C‐MAC), success of the first intubation attempt (88.6% MAC vs. 100% C‐MAC), Cormack‐Lehane grade, POGO score, severity of dental compression, device difficulty score, and preferred airway device. Scenario C: The results with C‐MAC were significantly better than those with MAC (p < 0.05) for all the analysed variables: success of the first attempt (51.4% MAC vs. 100% C‐MAC), overall success rate, intubation time (27 s MAC vs. 20.5 s C‐MAC), Cormack‐Lehane grade, POGO score, dental compression, device difficulty score and the preferred airway device. Conclusion The C‐MAC videolaryngoscope is an excellent alternative to the MAC laryngoscope for intubating manikins with cervical spine immobilization.

Comparison of the Trachway video intubating stylet and Macintosh laryngoscope for endotracheal intubation. Preliminary data

Sir, The ability to perform airway management and maintain adequate ventilation of the patient are the key elements during cardiopulmonary resuscitation. Current European Resuscitation Council guidelines indicate the endotracheal intubation are the gold standard for airway control in adults during CPR [1]. However, as indicated by numerous scientific studies, the effectiveness of endotracheal intubation with direct laryngoscopy performed during resuscitation is inadequate [2,3, 4]. Therefore, it seems reasonable to search for alternative methods of endotracheal intubation, which are likely to increase the intubation effectiveness and reduce the total time of the procedure. The aim of the study was to compare two methods of endotracheal intubation performed by novice physicians during simulated CPR. Before the study, all the participants took part in a 10-minute training on the correct use of Trachway video intubating stylet (TVI, TVI4000, Markstein Sichtec Medical Corp., Taichung, Taiwan) and Macintosh laryngoscope (MACMercuryMedical, Clearwater, FL, USA). Intubation was performed on MegaCode KellyTM advanced life support manikin (Laerdal Medical, Stavanger, Norway), which was situated on a flat floor in a bright room. Intubation was performed during uninterrupted chest compressions. Due to the fact that the quality of chest compressions varies among medical staff [5,6], in order to standardize the difficulties arising from intubation duringuninterrupted chest compressions we used mechanical chest compression device Lifeline ARM (Defibtech, USA). In the main study, both the order of participants and the study methods were random. Participants had up to three endotracheal intubation attempts, after the procedure had a 10-minute break, and then performed endotracheal intubation using other method. The

A randomized comparison of three chest compression techniques and associated hemodynamic effect during infant CPR: A randomized manikin study

Introduction: Pediatric cardiac arrest is an uncommon but critical life‐threatening event requiring effective cardiopulmonary resuscitation. High‐quality cardio‐pulmonary resuscitation (CPR) is essential, but is poorly performed, even by highly skilled healthcare providers. The recently described two‐thumb chest compression technique (nTTT) consists of the two thumbs directed at the angle of 90° to the chest while having the fingers fist‐clenched. This technique might facilitate adequate chest‐compression depth, chest‐compression rate and rate of full chest‐pressure relief. Methods: 42 paramedics from the national Emergency Medical Service of Poland performed three single‐rescuer CPR sessions for 10 minutes each. Each session was randomly assigned to the conventional two‐thumb (TTHT), the conventional two‐finger (TFT) or the nTTT. The manikin used for this study was connected with an arterial blood pressure measurement device and blood measurements were documented on a 10‐seconds cycle. Results: The nTTT provided significant higher systolic (82 vs. 30 vs. 41 mmHg). A statistically significant difference was noticed between nTTT and TFT (p<.001), nTTT and TTHT (p < 0.001), TFT and TTHT (p = 0.003). The median diastolic preassure using nTTT was 16 mmHg compared with 9 mmHg for TFT (p < 0.001), and 9.5 mmHg for TTHT (p < 0.001). Mean arterial pressure using distinct methods varied and amounted to 40 vs. 22. vs. 26 mmHg (nTTT vs. TFT vs. TTHT, respectively). A statistically significant difference was noticed between nTTT and TFT (p < 0.001), nTTT and TTEHT (p < 0.001), and TFT and TTHT (p < 0.001). The highest median pulse pressure was obtained by the nTTT 67.5 mmHg. Pulse pressure was 31.5 mmHg in the TTHT and 24 mmHg in the TFT. The difference between TFT and TTHT (p = 0.025), TFT and nTTT (p < 0.001), as well as between TTHT and nTTT (p < 0.001) were statistically significant. Conclusions: The new nTTT technique generated higher arterial blood pressures compared to established chest compression techniques using an infant manikin model, suggesting a more effective chest compression. Our results have important clinical implications as nTTT was simple to perform and could be widely taught to both healthcare professionals and bystanders. Whether this technique translates to improved outcomes over existing techniques needs further animal studies and subsequent human trials.

Comparison of Macintosh and Intubrite laryngoscopes for intubation performed by novice physicians in a difficult airway scenario

Introduction: In the difficult airway, the intubation skills are critically important. In selected cases, particularly in airway edema, laryngeal or tongue edema, endotracheal intubation can turn out very difficult, and repeated attempts may even worsen the airway edema, causing trauma and bleeding, and finally leading to complete airway obstruction and inability to ventilate the patient. Aim of the study: The aim of the study was to compare the efficacy of endotracheal intubation performed by novice physicians using a standard Macintosh laryngoscope and an Intubrite videolaryngoscope. Material and methods: The study was designed as a prospective, randomized, crossover, simulation study and continues our research assessing the effectiveness of selected endotracheal intubation techniques in prehospital settings. All participants were experienced with the Macintosh direct laryngoscope but remained novice to videolaryngoscopy. Instructions on the correct use of the Macintosh and Intubrite laryngoscopes were given before the procedure, and all the 30 novice physicians were allowed to practice at least 10 times before the study on manikin with normal airways. We employed an airway manikin (Trucorp Airsim Bronchi; Trucorp Ltd., Belfast, Northern Ireland) to simulate difficult airway, with was obtained by inflating the tongue with 50 mL of air. The participants were asked to perform tracheal intubation using an endotracheal tube with 7.5 mm of internal diameter (Portex; Smiths Medical, Hythe, UK) through the vocal cords, applying either a conventional Macintosh laryngoscope with a size 3 blade (MAC; Mercury Medical, Clearwater, FL, USA) or the Intubrite videolaryngoscope, also with a Macintosh No. 3 blade (INT; Intubrite Llc, Vista, CA, USA). In both intubation techniques, a guide stylet (Rusch Inc., Duluth, GA, USA) was introduced into the endotracheal tube in order to obtain a C‐shape curve to facilitate tracheal intubation. Each participating physician was randomly assigned to three attempts of tracheal intubation with each device. Results: The effectiveness of the first intubation attempt using MAC and INT was 63.6% and 53.4%, respectively (p = 0.023), and the total percentage of intubation was 100% for both methods. The median time to intubation was 29.5 (interquartile range [IQR], 27–35.5) s with MAC, and 229 (IQR, 25.5–37) s with INT. The total of 24 physicians out of all study participants would choose MAC as a device to intubate with in real terms, while only 6 physicians would choose INT. Conclusions: During the simulation study, the novice physicians were able to perform endotracheal intubation at the same time using both the Macintosh and Intubrite videolaryngoscope. However, the efficacy of the first intubation attempt was higher for MAC. Further studies are needed to confirm the results.

Evaluation of a newly developed infant chest compression technique: A randomized crossover manikin trial

Background: Providing adequate chest compression is essential during infant cardio-pulmonary-resuscitation (CPR) but was reported to be performed poor. The “new 2-thumb technique” (nTTT), which consists in using 2 thumbs directed at the angle of 90° to the chest while closing the fingers of both hands in a fist, was recently introduced. Therefore, the aim of this study was to compare 3 chest compression techniques, namely, the 2-finger-technique (TFT), the 2-thumb-technique (TTHT), and the nTTT in an randomized infant-CPR manikin setting. Methods: A total of 73 paramedics with at least 1 year of clinical experience performed 3 CPR settings with a chest compression:ventilation ratio of 15:2, according to current guidelines. Chest compression was performed with 1 out of the 3 chest compression techniques in a randomized sequence. Chest compression rate and depth, chest decompression, and adequate ventilation after chest compression served as outcome parameters. Results: The chest compression depth was 29 (IQR, 28–29) mm in the TFT group, 42 (40–43) mm in the TTHT group, and 40 (39–40) mm in the nTTT group (TFT vs TTHT, P < 0.001; TFT vs nTTT, P < 0.001; TTHT vs nTTT, P < 0.01). The median compression rate with TFT, TTHT, and nTTT varied and amounted to 136 (IQR, 133–144) min–1 versus 117 (115–121) min–1 versus 111 (109–113) min–1. There was a statistically significant difference in the compression rate between TFT and TTHT (P < 0.001), TFT and nTTT (P < 0.001), as well as TTHT and nTTT (P < 0.001). Incorrect decompressions after CC were significantly increased in the TTHT group compared with the TFT (P < 0.001) and the nTTT (P < 0.001) group. Conclusions: The nTTT provides adequate chest compression depth and rate and was associated with adequate chest decompression and possibility to adequately ventilate the infant manikin. Further clinical studies are necessary to confirm these initial findings.

The LMA Fastrach® as a conduit for endotracheal intubation during simulated cardiopulmonary resuscitation ☆

Securing a clear airway is one of the priorities during CPR. Endotracheal intubation remains the gold standard for airway management [1,2]; however, when carried out by inexperienced persons, it may be associated with many complications, including teeth injury, soft tissue damage and bleeding, or edema causing inability to ventilate the patient [3]. Therefore, it is reasonable to search for alternativemethods of direct laryngoscopy intubation. One of such methods is using supraglottic devices as a guide for the endotracheal tube. An example of such a device may be the laryngeal mask airway LMA Fastrach (Teleflex San Diego, San Diego, CA, USA). A number of studies point at the usefulness of the laryngeal mask in difficult airwaymanagement. Baskett et al. on the basis of a multicenter study conducted in the United Kingdom, stated that the effectiveness of the first intubation attempt with LMA equaled 80%, 4% of cases required intubation with three attempts, and 4% were failures [4]. The high efficiency of the use of LMA as a guide for the endotracheal tube refers not only to intubation in operating theaters, but also in the prehospital settings [5]. The aim of the study was to evaluate the effectiveness of intubation with the use of LMA Fastrach as a guide for endotracheal tube during simulated cardiopulmonary resuscitation. The study involved 32 novice physicians. Their median age was 25.7 (interquartile range [IQR], 25–27) years, and the median work

Quinapril decreases antifibrinolytic and prooxidative potential of propofol in arterial thrombosis in hypertensive rats.

Angiotensin converting enzyme inhibitors and propofol both exert hypotensive action and may affect hemostasis. We investigated the influence of quinapril and propofol on hemodynamics and hemostasis in renal-hypertensive rats with induced arterial thrombosis. Two-kidney, one clip hypertensive rats were treated with quinapril (3.0 mg/kg for 10 days), and then received propofol infusion (15 mg/kg/h) during ongoing arterial thrombosis. The hemodynamic and hemostatic parameters were assayed. Quinapril exerted a hypotensive effect increasing after propofol infusion. Quinapril showed an antithrombotic effect with the platelet adhesion reduction, fibrinolysis enhancement and oxidative stress reduction. Propofol did not influence thrombosis; however, it inhibited fibrinolysis and showed prooxidative action. The effect of propofol on fibrinolysis and oxidative stress was significantly lower in quinapril-pretreated rats. Mortality was increased among rats treated with both drugs together. Our study demonstrates that pretreatment with quinapril reduced the adverse effects of propofol on hemostasis. Unfortunately, co-administration of both drugs potentiated hypotension in rats, which corresponds to higher mortality.

Angiotensin-converting enzyme inhibitors attenuate propofol-induced pro-oxidative and antifibrinolytic effect in human endothelial cells.

Introduction: The aim of this study was to investigate the effects of plasma and tissue angiotensin-converting enzyme inhibitors (ACE-Is) against propofol-induced endothelial dysfunction and to elucidate the involved mechanisms in vitro. Materials and methods: We examined the effects of propofol (50 μM), quinaprilat and enalaprilat (10−5 M) on fibrinolysis (t-PA, PAI-1, TAFI antigen levels), oxidative stress parameters (H2O2 and MDA antigen levels and SOD and NADPH oxidase mRNA levels) and nitric oxide bioavailability (NO2/NO3 concentration and NOS expression at the level of mRNA) in human umbilical vein endothelial cells (HUVECs). Results: We found that both ACE-Is promoted similar endothelial fibrinolytic properties and decreased oxidative stress in vitro. Propofol alone increased the release of antifibrinolytic and pro-oxidative factors from the endothelium and increased mRNA iNOS expression. We also found that the incubation of HUVECs in the presence of propofol following ACE-Is pre-incubation caused weakness of the antifibrinolytic and pro-oxidative potential of propofol and this effect was similar after both ACE-Is. Conclusions: This observation suggests that the studied ACE-Is exerted protective effects against endothelial cell dysfunction caused by propofol, independently of hemodynamics.

ET-View compared to direct laryngoscopy in patients with immobilized cervical spine by unexperienced physicians: A randomized crossover manikin trial

BACKGROUND Immobilization of the cervical spine is indicated in all patients with the potential risk of any cervical spine injury. Airway management in these patients is challenging and direct laryngoscopy is the standard of care. Videolaryngoscopes like the ET-View were introduced into clinical practice to provide better airway visualization and ease intubation. The ET-View is essentially a conventional endotracheal tube, but is equipped with a miniature camera on the tip. The ET-View has not been investigated in patients with immobilized cervical spine so far. The aim was to evaluate the performance of the VivaSight SL compared with Macintosh when performed in patients with immobilized cervical spine by unexperienced physicians. METHODS This was prospective, randomized, cross-over manikin trial. 50 novice physicians were randomly assigned to intubate a manikin in three airway scenarios including a normal airway and two cervical immobilization techniques. Overall and first intubation attempt success rate, time to intubation, dental compression and airway visualization according to the Cormack&Lehane graduation were assessed. RESULTS All physicians were able to intubate the manikin in all scenarios using the ETView, whereas direct laryngoscopy failed in 16 % with immobilized cervical spine using the patriot cervical extraction collar. First intubation attempt success rate was higher and airway visualization was better in all three scenarios using the ET-View compared to direct laryngoscopy. CONCLUSION The ET-View offered much better 62 airway visualization and provided higher overall and first intubation attempt success rates. Therefore, the ET-View is a valuable alternative in patients with difficult intubation due to immobilized cervical spine. Further clinical trials are indicated to confirm these findings. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT02733536.

A Novel Method of Newborn Chest Compression: A Randomized Crossover Simulation Study

Objective: To compare a novel two-thumb chest compression technique with standard techniques during newborn resuscitation performed by novice physicians in terms of median depth of chest compressions, degree of full chest recoil, and effective compression efficacy. Patients and Methods: The total of 74 novice physicians with less than 1-year work experience participated in the study. They performed chest compressions using three techniques: (A) The new two-thumb technique (nTTT). The novel method of chest compressions in an infant consists in using two thumbs directed at the angle of 90° to the chest while closing the fingers of both hands in a fist. (B) TFT. With this method, the rescuer compresses the sternum with the tips of two fingers