ImportanceMany patients with severe stroke have impaired airway protective reflexes, resulting in prolonged invasive mechanical ventilation.ObjectiveTo test whether early vs standard tracheostomy improved functional outcome among patients with stroke receiving mechanical ventilation.Design, Setting, and ParticipantsIn this randomized clinical trial, 382 patients with severe acute ischemic or hemorrhagic stroke receiving invasive ventilation were randomly assigned (1:1) to early tracheostomy (≤5 days of intubation) or ongoing ventilator weaning with standard tracheostomy if needed from day 10. Patients were randomized between July 28, 2015, and January 24, 2020, at 26 US and German neurocritical care centers. The final date of follow-up was August 9, 2020.InterventionsPatients were assigned to an early tracheostomy strategy (n = 188) or to a standard tracheostomy (control group) strategy (n = 194).Main Outcomes and MeasuresThe primary outcome was functional outcome at 6 months, based on the modified Rankin Scale score (range, 0 [best] to 6 [worst]) dichotomized to a score of 0 (no disability) to 4 (moderately severe disability) vs 5 (severe disability) or 6 (death).ResultsAmong 382 patients randomized (median age, 59 years; 49.8% women), 366 (95.8%) completed the trial with available follow-up data on the primary outcome (177 patients [94.1%] in the early group; 189 patients [97.4%] in the standard group). A tracheostomy (predominantly percutaneously) was performed in 95.2% of the early tracheostomy group in a median of 4 days after intubation (IQR, 3-4 days) and in 67% of the control group in a median of 11 days after intubation (IQR, 10-12 days). The proportion without severe disability (modified Rankin Scale score, 0-4) at 6 months was not significantly different in the early tracheostomy vs the control group (43.5% vs 47.1%; difference, −3.6% [95% CI, −14.3% to 7.2%]; adjusted odds ratio, 0.93 [95% CI, 0.60-1.42]; P = .73). Of the serious adverse events, 5.0% (6 of 121 reported events) in the early tracheostomy group vs 3.4% (4 of 118 reported events) were related to tracheostomy.Conclusions and RelevanceAmong patients with severe stroke receiving mechanical ventilation, a strategy of early tracheostomy, compared with a standard approach to tracheostomy, did not significantly improve the rate of survival without severe disability at 6 months. However, the wide confidence intervals around the effect estimate may include a clinically important difference, so a clinically relevant benefit or harm from a strategy of early tracheostomy cannot be excluded.Trial RegistrationClinicalTrials.gov Identifier: NCT02377167

The Centers for Disease Control and Prevention guidelines for the prevention of catheter-related bloodstream infections suggest using "a subclavian site, rather than an internal jugular or a femoral site, in adult patients." This recommendation is based on evidence of lower rates of thrombosis and catheter-related bloodstream infections in patients with subclavian central venous catheters (CVCs) compared to femoral or internal jugular sites. However, preference toward a subclavian approach to CVC insertion is hindered by increased risk of mechanical complications, especially pneumothorax, when compared to other sites. This is largely related to the proximity of the subclavian vein to the pleural space and the traditional "blind" or anatomic landmark approach used in subclavian vein cannulation. We revisit a method that may provide increased safety and avoidance of pneumothorax during ultrasound-guided subclavian/axillary vein cannulation. This is achieved by directing the needle toward the subclavian vein at a point where it traverses over the second rib, providing a protective rib shield between the vessel and pleura as a safety net for operators. The technique also allows for increased compressibility of the subclavian/axillary vein in the event of bleeding complication.

Objectives: To determine the feasibility of a combination of tracheal and thoracic ultrasonography to confirm adequate positioning of endotracheal tube placement in a cohort of critically ill patients. Design: Prospective, multicenter, observational study from January 2019 to May 2020. Setting: Multicenter study conducted in multiple ICUs across four different academic tertiary and community hospitals. Patients: Eligible patients were adults (≥ 18 yr) requiring endotracheal intubation and intensive care. Intervention: Tracheal and thoracic ultrasonography were performed during intubation attempts to rule out esophageal intubations, to detect mainstem intubations, and to confirm and adjust endotracheal tube position. Measurements and Main Results: Among 118 patients, median age was 66 years (interquartile range 56–73 yr), body mass index 28 (interquartile range 25–34), and 63.6 % were males. Using the ultrasound protocol, one esophageal (0.9%) and five main stem intubations (4.2%) were detected. 97.5% of final endotracheal tube positions confirmed by ultrasound were in concordance with the next occurring chest radiograph, with only three (2.5%) requiring minor post-chest radiograph adjustments. Conclusions: A protocolized, systematic approach using tracheal and thoracic ultrasonography can be used to confirm endotracheal intubation, detect main stem intubations, and guide tube positioning in the critically ill. This ultrasonographic approach is easily applicable, safe, and comparable to chest radiography. This approach may serve as a potential alternative or adjunct when chest radiography is not available or ideal. This has the potential to be used for routine intensive care, out-of-hospital or resource-poor settings, or situations which require isolation precautions to mitigate the use of chest radiography.

No abstract

No abstract