Background: Delirium is a common problem among intensive care patients and can contribute to non-invasive ventilation (NIV) failure. Prevention of delirium may improve the outcome and success rate of NIV. The aim of the current study was to compare the effects of using dexmedetomidine and haloperidol for prevention of delirium during NIV. Patients and methods: Ninety adult intensive care patients of ASA physical status III and IV on NIV were randomly allocated to three equal groups. Group D (30 patients) received dexmedetomidine continuous intravenous infusion of 0.2-0.7 lg/kg/h preceded by a loading dose of 1.0 lg/kg intravenously over 10 min if needed, group H (30 patients) received haloperidol continuous intravenous infusion of 0.5-2 mg/h preceded by a loading dose of 2.5 mg intravenously if needed and group P (30 patients) received normal saline infusion. Supplementary sedation or analgesia was given when needed. Our primary outcome measure was the incidence of delirium. Duration of non-invasive mechanical ventilation, incidence of endotracheal intubation during NIV, length of ICU stay, and length of hospital stay, adverse events and mortality were recorded. Delirium was diagnosed using the Confusion Assessment Method for the ICU (CAM-ICU). Hemodynamic parameters and respiratory rate were recorded. Results: The incidence of delirium was significantly lower in dexmedetomidine group 3/30 (10%) than haloperidol 10/30 (33.3%) and placebo groups 13/30 (43.3%) groups. Duration of NIV was significantly shorter in dexmedetomidine group than in placebo group and shorter than haloperidol group. The incidence of endotracheal intubation was significantly less in dexmedetomidine group compared to placebo and haloperidol groups. The length of ICU and hospital stay was significantly shorter in dexmedetomidine group compared to haloperidol and placebo groups Bradycardia occurred significantly more in dexmedetomidine group while prolonged corrected QT (QTc) interval occurred only in haloperidol group (2 patients). A significantly lower incidence of respiratory

Background: Rapid shallow breathing index (RSBI) is a well-known weaning index. However; its diagnostic performance is less than satisfactory. Recently, diaphragmatic rapid shallow breathing index (DRSBI) is proposed as a promising tool in weaning outcome prediction. The aim of this study was to evaluate if DRSBI is more accurate than RSBI for weaning outcome prediction.Patients and methods: This prospective, randomized clinical trial was carried out on 106 mechanically ventilated patients for more than 48 h and ready to wean at their first spontaneous breathing trial (SBT). After one minute of SBT, RSBI and DRSBI were calculated. According to the decision to continue SBT patients were divided into: Group I (53 patients) the decision depends on the RSBI. Group II (53 patients) the decision based on DRSBI. 30 min later, patients were reevaluated for tolerance of SBT then RSBI and DRSBI were calculated. Outcome of the weaning attempt was recorded and ROC analysis was done to evaluate the diagnostic accuracy.Results: 106 patients were enrolled. Trauma was the commonest diagnosis on ICU admission and traumatic brain injury was the main indication for initiation of mechanical ventilation in the two groups. 33 patients (31.1%) failed to wean (19 patients in group I and 14 patients in group II). RSBI at 1 min and 30 min as well as DRSBI at 1 min and 30 min were highly statistical significant higher in weaning failure patients. RSBI and DRSBI at 30 min were highly statistical significant increased compared to at 1 min. DRSBI at 30 min was the parameter with the best diagnostic accuracy for predicting weaning success with a cutoff value <1.6 breaths/ min/mm.Conclusion: DRSBI has a better diagnostic accuracy than the traditional RSBI in predicting weaning outcome specially when monitored at 30 min from the start of SBT.Trial registration: this clinical trial was registered with ClinicalTrials.gov (NCT03561792) KEYWORDSWeaning; Rapid shallow breathing index; Diaphragmatic rapid shallow breathing index;

Background: Emergency endotracheal intubation in intensive care is a major challenge that can be associated with life-threatening complications. The aim of this study was to evaluate the success of the first attempt of endotracheal intubation and incidence of complications using Macintosh laryngoscopy, Airtraq or Glidescope during emergency intubation in intensive care. Patients and methods: One hundred twenty adult intensive care patients of ASA physical status III and IV who required emergency endotracheal intubation were randomly allocated into 3 groups. Group M (40 patients) were intubated using Macintosh laryngoscopy. Group G (40 patients) were intubated using Glidescope. Group A (40 patients) were intubated using Airtraq. The primary outcome was the success of the first attempt of endotracheal intubation. Secondary outcomes included the number of intubation attempts, duration of intubation, glottic view as assessed by Cormack-Lehane grade (C&L grade) and incidence of complications. Results: Success of the first attempt of endotracheal intubation was significantly higher in both groups G and A compared to group M (p < 0.05). The number of intubation attempts was significantly higher in group M compared to both groups G and A (p < 0.05). The duration of endotracheal intubation was 28.80 ± 10.27 s in group M compared to 31.45 ± 12.17 s in group G and 32.25 ± 11.96 s in group A (p > 0.05). The C&L grade was significantly better in both groups G and A compared to group M (p < 0.05). No statistically significant difference between the three groups in HR or MAP. The incidence of oxygen desaturation was significantly more in group M compared to groups G and A. No statistically significant difference between the 3 studied groups regarding the incidence of other complications. Conclusion: Both Glidescope and Airtraq have higher first attempt success rate with a better glottic view and less incidence of oxygen desaturation than Macintosh laryngoscopy during emergency intubation in intensive care.

Background: The aim of this study was to evaluate the efficacy of intravenous infusion of clevidipine or esmolol for producing controlled hypotension during endoscopic repair of cerebrospinal fluid (CSF) rhinorrhea. Patients and methods: Fifty adult ASA I and II patients scheduled for endoscopic repair of CSF rhinorrhea were randomized into one of two groups. Group C (25 patients) received clevidipine 0.5 mcg/kg/min increased by 0.5 mcg/kg/min every 3-5 min to achieve the target mean arterial pressure (MAP) of 55-65 mmHg. Group E (25 patients) received esmolol infusion 50 mcg/kg/min increased by 50 mcg/kg/min every 3-5 min to achieve the target MAP. Surgical field Quality, blood loss, haemodynamic parameters, surgeons' satisfaction and adverse events were recorded. Results: Time to reach target MAP was significantly shorter in group C compared to group E. Number of patients needed nitroglycerine was significantly higher in group E compared to group C (8 versus 2 respectively). The nitroglycerine dose needed/patient in group E was significantly more compared to group C. Surgeon satisfaction score was significantly higher in group C compared to group E. More patients in group E developed bradycardia compared to group C. Mean arterial pressure was significantly lower in group C compared to group E after 5 and 10 min from the start of the studied drugs infusion while it was significantly higher in group C after 25 min from the start of the studied drugs. The heart rate (HR) was significantly lower in group E compared to group C 10 min after starting drugs infusion till the end of surgery. Conclusion: Both clevidipine and esmolol are effective for inducing controlled hypotension during endoscopic repair of CSF rhinorrhea. Clevidipine has the advantage of having shorter time to reach target MAP with less need of additional hypotensive agent and better surgeon satisfaction.

Background: The aim of this study was to evaluate if the addition of dexmedetomidine to propofol could improve the success and reduce the complications during drug induced sleep endoscopy in obstructive sleep apnea patients. Patient and methods: Fifty adult patients scheduled for drug induced sleep endoscopy were randomly allocated to one of two groups. Group P (25 patients) received propofol loading dose of 0.5 mg/kg over 3 min then continuous infusion in a dose of 25-75 mcg/kg/min. Group PD (25 patients) received propofol infusion as group P and dexmedetomidine intravenous infusion with a loading dose of 0.5 mcg/kg over 5 min then continuous infusion in a dose of 0.2-0.7 mcg/kg/h. The primary outcome was successful completion of the procedure. The secondary outcomes included the time to start endoscopy, procedure duration, the incidence of adverse events and surgeons and patients satisfaction. Results: Successful completion of the procedure was significantly higher in group PD (96%) compared to group P (72%). The total propofol dose needed/patient (mg) was significantly more in group P compared to group PD (173.5 ± 41.6 versus98.4 ± 19.8 with shorter recovery time in group PD. Both surgeons and patients satisfaction were significantly higher in group PD compared to group P. The incidence of cough and gag reflexes were significantly higher in group P compared to group PD. Heart rate (HR) was significantly lower in group PD compared to group P at 5, 10, 15, 20, 25 and 30 min from the start of the studied drugs. Respiratory rate (RR) was significantly lower in group P compared to group PD at 5, 10, 15 and 20 min from the start of the studied drugs (p < 0.05). Conclusion: Addition of dexmedetomidine to propofol is associated with higher incidence of successful completion of the procedure with faster recovery. Cough and gag reflexes were significantly lower with the addition of dexmedetomidine with higher surgeons and patients satisfaction.