Effectiveness of Early Tracheostomy compared with Late Tracheostomy Or Prolonged Orotracheal Intubation in Traumatic Brain Injury: Protocol of Systematic Review

Review question / Objective: What is the effectiveness of Early Tracheostomy compared with Late Tracheostomy Or Prolonged Orotracheal Intubation in Traumatic Brain Injury? Condition being studied: Traumatic Brain Injury (TBI) is every traumatic anatomical ou functional injury that affects brain, skull and/or vessels related to them. TBI is a public health problem that involves over 50 million people per year in Worldwide. Information sources: PUBLISHED DATABASES (Medline by PUBMED, Lilacs, Central-Cochrane, Scopus by Elsevier, Web Of Science e Embase by Elsevier) NON-PUBLISHED (Open Grey by Sigle; Clinical Trial Register at the International Clinical Trials Registry Platform) (Referencies of the selected studies).

A Meta-Analysis on the Effectiveness of Video Laryngoscopy versus Laryngoscopy for Emergency Orotracheal Intubation

Background. Video laryngoscopy has been associated with some orotracheal intubations and enhances the glottic view at time of laryngoscopy and the success rate of the intubation in patients from the emergency department and the intensive care unit. In usual cases, direct laryngoscopy is performed among the patients from the emergency department or the intensive care unit. In this systematic review and meta-analysis, we draw the comparison between the video laryngoscopy and direct laryngoscopy for the emergency orotracheal intubation. Objective. The objective of the study was to identify the clinical efficacy of video laryngoscopy versus laryngoscopy for emergency orotracheal intubation. Materials and Methods. MEDLINE, CENTRAL, EMBASE, and Web of Science databases were analyzed from 2003 to 2020. Keywords used for searching the studies were “laryngoscopy,” “video laryngoscopy,” “direct laryngoscopy,” “emergency department,” “intensive care unit,” “orotracheal,” “video laryngoscope,” “glidescope,” “airway scope,” “airway,” “Macintosh laryngoscopy,” “airway management,” “tracheal intubation,” “orotracheal intubation,” and “intubation.” Results. The first-pass intubation success rates in the intensive care unit were low in video laryngoscopy with 95% CI 1.21 (1.13–1.30) and heterogeneity I2 = 78% favoring direct laryngoscopy nonsignificantly with low heterogeneity. Odds ratio for airway trauma or dental damage was 0.67, 95% CI (0.18–2.54), reported higher in video laryngoscopy. Complications with oesophageal laryngoscopy were higher in video laryngoscopy with risk ratio 0.16, 95% CI (0.09–0.29), odds ratio 0.88, 95% CI (0.65–1.18) for sever hypoxemia, risk ratio 1.53, 95% CI (1.02–2.28) for cardiovascular collapse, risk ratio with 95% CI 1.11 (0.59–2.07) for aspiration complications, and odds ratio 1.32, 95% CI (0.95, 1.85) for Inexperienced medical staff handling laryngoscopy. Conclusion. No significant efficiency was noticed in using video laryngoscopy when compared with direct laryngoscopy with the available data. The data reported in studies are not enough for efficient clinical analysis of the benefits of using video laryngoscopy over direct laryngoscopy. Thus, information such as length of stay, mortality, sever complications, and length of hospital stay must be reported.

Opioids in COVID-19: Two Sides of a Coin

Introduction: The treatment of most severe COVID-19 patients included the large-scale use of sedatives and analgesics–possibly in higher doses than usual–which was reported in the literature. The use of drugs that decrease mortality is necessary and opioids are important agents in procedures such as orotracheal intubation. However, these drugs seem to have been overestimated in the COVID-19 pandemic. We performed a review of the PubMed-Medline database to evaluate the use of opioids during this period. The following descriptors were used to enhance the search for papers: “Opioids”, “COVID-19,” “COVID-19 pandemic,” “SARS-CoV-2,” “Opioid use disorder,” “Opioid dependence” and the names of the drugs used. We also evaluated the distribution of COVID-19 patients in Brazil and the applicability of opioids in our country during the COVID-19 pandemic.Results: Several positive points were found in the use of opioids in the COVID-19 pandemic, for instance, they can be used for analgesia in orotracheal intubation, for chronic pain management, and as coadjutant in the management of acute intensification of pain. However, high doses of opioids might exacerbate the respiratory depression found in COVID-19 patients, their chronic use can trigger opioid tolerance and the higher doses used during the pandemic might result in greater adverse effects. Unfortunately, the pandemic also affected individuals with opioid use disorder, not only those individuals are at higher risk of mortality, hospitalization and need for ventilatory support, but measures taken to decrease the SARS-CoV-2 spread such as social isolation, might negatively affect the treatment for opioid use disorder. In Brazil, only morphine, remifentanil and fentanyl are available in the basic health care system for the treatment of COVID-19 patients. Out of the 5,273,598 opioid units used in this period all over the country, morphine, fentanyl, and remifentanil, accounted for, respectively, 559,270 (10.6%), 4,624,328 (87.6%), and 90,000 (1.8%) units. Many Brazilian regions with high number of confirmed cases of COVID-19 had few units of opioids available, as the Southeast region, with a 0.23 units of opioids per confirmed COVID-19 case, and the South region, with 0.05 units. In the COVID-19 pandemic scenario, positive points related to opioids were mainly the occurrence of analgesia, to facilitate intubation and their use as coadjutants in the management of acute intensification of pain, whereas the negative points were indiscriminate use, the presence of human immunosuppressor response and increased adverse effects due to higher doses of the drug.Conclusion: The importance of rational and individualized use of analgesic hypnotics and sedative anesthetics should be considered at all times, especially in situations of high demand such as the COVID-19 pandemic.

Hemodynamic Stress Response in Controlled Hypertensive Patients- A Randomized Comparison of I-Scope Video Laryngoscope and Macintosh Laryngoscope

Background: Laryngoscopy and intubation cause activation of the sympathetic nervous system and can results in tachycardia, arrhythmias and hypertension. Hypertensive patients demonstrate a relatively greater rise in catecholamine secretion and an increased sensitivity to them. Aim of the study is to compare the haemodynamic stress response associated with orotracheal intubation using videolaryngoscope or Macintosh laryngoscope in controlled hypertensive patients. Methods: Sixty hypertensive, American Society of Anesthesiologist’s class II, patients were randomly divided in to two groups. In group V (videolaryngoscope), intubation was done with i-scope videolaryngoscope. In group M (Macintosh), intubation was done using Macintosh laryngoscope. Primary objectives of the study pulse rate (PR), systolic blood pressure (SBP), diastolic blood pressure (DBP) and mean blood pressure (MBP) were noted immediately after and at 1, 2, 3, 5 and 10 minutes after intubation. Results: The demographic data were comparable in both groups. There was no significant difference at baseline for mean (SD) PR, SBP, DBP and MBP at baseline and after induction/before intubation (p>0.05). The mean (SD) PR, SBP, DBP and MBP were significantly higher in Macintosh laryngoscope group as compared to i-scope videolaryngoscope immediately after intubation, 1, 2, 3, 5 and 10 minutes after intubation (p<0.001). Conclusion: We found that intubation with the use of i-scope videolaryngoscope results in less haemodynamic stress response than Macintosh laryngoscope in controlled hypertensive patients.

Pneumoperitoneum Secondary to Pneumothorax Post-Intubation in a Patient with Difficult Airway

The use of mechanical ventilation can be performed in situations where patients need ventilatory support to maintain adequate oxygenation. Its inappropriate use can cause some complications, among them: pneumothorax and pneumoperitoneum. Our report describes a 28-year-old man admitted to the ICU with a diagnosis of Covid-19 requiring mechanical ventilation with orotracheal intubation due to acute respiratory failure. During the patient’s clinical evolution he presented bilateral pneumothorax with evolution and progression to secondary pneumoperitoneum, where we sought to understand the relationship between the two conditions.

Evaluation of using distal part of endotracheal tube samples for SARS-COV-2 diagnosis by RT-PCR

Objective: The reverse transcription-polymerase chain reaction (RT-PCR) analyses method is the most important diagnostic method in the diagnosis of SARS-CoV-2 virus infection. In this research, we aimed to investigate the positivity of SARS-CoV-2 by RT-PCR from distal part of the endotracheal tube (DPET) samples, which have not been investigated in any study yet. Materials and Methods: A total of 48 patients with a diagnosis of COVID-19 hospitalized in the intensive care unit receiving mechanical ventilation and whose conditions resulted in death or extubation were included in the study. The distal 6 cm part of the orotracheal intubation tube was removed from the patient (including the cuff). DPET samples were mixed with viral transport medium and vortexed; then, it was centrifuged at 4500g for 4 minutes. RNA isolation was performed by taking 400 µl from the supernatant and then SARS-CoV-2 RT-PCR was studied. Results: In 15 patients (31.25 %) the swab samples were PCR positive, 42 patients (87.5 %) had positive computed tomography finding and 48 patients (100 %) had positive clinical findings. Among the patients whose oropharynx (OP)/nasopharynx (NP) combined swab sample was positive for RT-PCR, the rate of RT-PCR positivity detected in DPET samples was 26.7%. While OP/NP combined swab sample was negative, DPET RT-PCR positivity rate was found to be 9.09%. Conclusions: Patients with positive DPET RT-PCR are detected when the swab is negative. These findings suggest that DPET can be used as a good lower respiratory sample without the risk of particle spread and transmission to healthcare personnel.

Comparison of McGrath Videolaryngoscope and Macintosh Laryngoscope in Children with Torticollis: Randomized Controlled Trial

We investigated the efficacy of the McGrath videolaryngoscope compared with the Macintosh laryngoscope in children with torticollis. Thirty children aged 1–10 years who underwent surgical release of torticollis were randomly assigned into the McGrath and Macintosh groups. Orotracheal intubation was performed by a skilled anesthesiologist. The primary outcome was the intubation time. The Cormack–Lehane grade, lifting force, intubation difficulty scale (IDS), difficulty level, and intubation failure rate were also assessed. The intubation time was significantly longer in the McGrath group than in the Macintosh group (31.4 ± 6.7 s vs. 26.1 ± 5.4 s, p = 0.025). Additionally, the Cormack–Lehane grades were comparable between the groups (p = 0.101). The lifting force and IDS were significantly lower in the McGrath group than in the Macintosh group (p < 0.001 and p = 0.022, respectively). No significant differences were observed with respect to endotracheal intubation difficulty and intubation success rate. Intubation-related complications were also not observed. In conclusion, compared with the Macintosh laryngoscope, the McGrath videolaryngoscope extended the intubation time and did not improve glottic visualization in children with torticollis, despite having a lesser lifting force, lower intubation difficulty scale, and similar success rate.

Mid-Regional Pro-Adrenomedullin, Methemoglobin and Carboxyhemoglobin as Prognosis Biomarkers in Critically Ill Patients with COVID-19: An Observational Prospective Study

Mid-regional pro-adrenomedullin (MR-proADM), methemoglobin (MetHb), and carboxyhemoglobin (COHb) levels have been associated with sepsis. In this study, we assessed the role of this potential biomarkers in critically ill COVID-19 patients. Outcomes were mortality and a combined event (mortality, venous or arterial thrombosis, and orotracheal intubation (OTI)) during a 30-day follow-up. A total of 95 consecutive patients were included, 51.6% required OTI, 12.6% patients died, 8.4% developed VTE, and 3.1% developed arterial thrombosis. MetHb and COHb levels were not associated with mortality nor combined event. Higher MR-proADM levels were found in patients with mortality (median of 1.21 [interquartile range-IQR-0.84;2.33] nmol/L vs. 0.76 [IQR 0.60;1.03] nmol/L, p = 0.011) and combined event (median of 0.91 [IQR 0.66;1.39] nmol/L vs. 0.70 [IQR 0.51;0.82] nmol/L, p < 0.001); the positive likelihood ratio (LR+) and negative likelihood ratio (LR−) for mortality were 2.40 and 0.46, respectively. The LR+ and LR− for combined event were 3.16 and 0.63, respectively. MR-proADM ≥1 nmol/L was the optimal cut-off for mortality and combined event prediction. The predictive capacity of MR-proADM showed an area under the ROC curve of 0.73 (95% CI, 0.62–0.81) and 0.72 (95% CI, 0.62–0.81) for mortality and combined event, respectively. In conclusion, elevated on-admission MR-proADM levels were associated with higher risk of 30-day mortality and 30-day poor outcomes in a cohort of critically ill patients with COVID-19.