for the COVID-ICU Gemelli Study Group IMPORTANCE High-flow nasal oxygen is recommended as initial treatment for acute hypoxemic respiratory failure and is widely applied in patients with COVID-19.OBJECTIVE To assess whether helmet noninvasive ventilation can increase the days free of respiratory support in patients with COVID-19 compared with high-flow nasal oxygen alone. DESIGN, SETTING, AND PARTICIPANTSMulticenter randomized clinical trial in 4 intensive care units (ICUs) in Italy between October and December 2020, end of follow-up February 11, 2021, including 109 patients with COVID-19 and moderate to severe hypoxemic respiratory failure (ratio of partial pressure of arterial oxygen to fraction of inspired oxygen Յ200).INTERVENTIONS Participants were randomly assigned to receive continuous treatment with helmet noninvasive ventilation (positive end-expiratory pressure, 10-12 cm H 2 O; pressure support, 10-12 cm H 2 O) for at least 48 hours eventually followed by high-flow nasal oxygen (n = 54) or high-flow oxygen alone (60 L/min) (n = 55). MAIN OUTCOMES AND MEASURESThe primary outcome was the number of days free of respiratory support within 28 days after enrollment. Secondary outcomes included the proportion of patients who required endotracheal intubation within 28 days from study enrollment, the number of days free of invasive mechanical ventilation at day 28, the number of days free of invasive mechanical ventilation at day 60, in-ICU mortality, in-hospital mortality, 28-day mortality, 60-day mortality, ICU length of stay, and hospital length of stay. RESULTS Among 110 patients who were randomized, 109 (99%) completed the trial (median age, 65 years [interquartile range {IQR}, 55-70]; 21 women [19%]). The median days free of respiratory support within 28 days after randomization were 20 (IQR, 0-25) in the helmet group and 18 (IQR, 0-22) in the high-flow nasal oxygen group, a difference that was not statistically significant (mean difference, 2 days [95% CI, −2 to 6]; P = .26). Of 9 prespecified secondary outcomes reported, 7 showed no significant difference. The rate of endotracheal intubation was significantly lower in the helmet group than in the high-flow nasal oxygen group (30% vs 51%; difference, −21% [95% CI, −38% to −3%]; P = .03). The median number of days free of invasive mechanical ventilation within 28 days was significantly higher in the helmet group than in the high-flow nasal oxygen group (28 [IQR,[13][14][15][16][17][18][19][20][21][22][23][24][25][26][27][28] vs 25 ; mean difference, 3 days [95% CI, 0-7]; P = .04). The rate of in-hospital mortality was 24% in the helmet group and 25% in the high-flow nasal oxygen group (absolute difference, −1% [95% CI, −17% to 15%]; P > .99).CONCLUSIONS AND RELEVANCE Among patients with COVID-19 and moderate to severe hypoxemia, treatment with helmet noninvasive ventilation, compared with high-flow nasal oxygen, resulted in no significant difference in the number of days free of respiratory support within 28 days. Further research is warranted to determine...

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Introduction: Eye tracking is the process of measuring an individual's eye movements to register their attentional behavior by using a device called an eye-tracker. Studies conducted using eye-tracking techniques have demonstrated a number of differences in eye movement parameters and patterns between experts and novices. The aim of this preliminary study was to evaluate if there are any differences in eye-tracking metrics between novice and expert anesthesiologists during the performance of an epidural block using an epidural simulator. Methods: Seven experts and seven novices who gave their consent to this preliminary study were asked to perform an epidural technique using an epidural simulator while wearing a pair of Tobii Pro glasses. Number of fixations, fixation duration, heat maps and scan-paths were examined by Tobii Pro Lab Software. Duration of the procedure was also recorded. Results: The observation of the attentional heat map and gaze plot showed different gaze dispersion between experts and novices. The mean total duration of fixations during needle insertion and advancement and catheter introduction was lower in experts than trainees (respectively, 0.18 vs 3.56 sec; P<0.05 and 0.73 vs 2.48 sec; P<0.05). The mean fixation count was greater in experts vs trainees (5 vs 2; P<0.05). The mean duration of the epidural procedure was 104.16 (41) (trainees) vs 65.3 (32.6) seconds (experts) (P<0.05). Expert anesthesiologists spent more time fixating a more specific target location (eg, the point of the epidural needle rather than the syringe's barrel) whilst novices split their attention between tracking their tools and the target location. Discussion: Eye tracking may have interesting implications for the creation of assessment programs, which distinguish skill level through the use of gaze behavior, and may be a promising tool for monitoring training progress towards the development of expertise.

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Background. The occurrence of false losses of resistance may be one of the reasons for inadequate or failed epidural block. A CompuFlo® epidural instrument has been introduced to measure the pressure of human tissues in real time at the orifice of a needle and has been used as a tool to identify the epidural space. The aim of this study was to investigate the sensitivity and the specificity of the ability of CompuFlo® to differentiate the false loss of resistance from the true loss of resistance encountered during the epidural space identification procedure. Method. We performed epidural block with the CompuFlo® epidural instrument in 120 healthy women who requested labor epidural analgesia. The epidural needle was considered to have reached the epidural space when an increase in pressure (accompanied by an increase in the pitch of the audible tone) was followed by a sudden and sustained drop in pressure for more than 5 seconds accompanied by a sudden decrease in the pitch of the audible tone, resulting in the formation of a low and stable pressure plateau. We evaluate the sensitivity, specificity, and positive and negative predictive values of the ability of CompuFlo® recordings to correctly identify the true LOR from the false LOR. Results. The drop in pressure associated with the epidural space identification was significantly greater than that recorded after the false loss of resistance (73% vs 33%) (P=0.000001). The sensitivity was 0.83, and the AUC was 0.82. Discussion. We have confirmed the ability of CompuFlo® to differentiate the false loss of resistance from the true loss of resistance and established its specificity and sensitivity. Conclusion. An easier identification of dubious losses of resistance during the epidural procedure is essential to reduce the number of epidural attempts and/or needle reinsertions with the potential of a reduced risk of accidental dural puncture especially in difficult cases or when the procedure is performed by trainees.

Background The epidural pressure is pulsatile and synchronized with arterial pulsations. Monitoring the epidural waveform has been suggested as a technique to reliably confirm the appropriate localization of the epidural catheter. Objective The aim of this study was to evaluate the sensitivity and specificity of the Computer Controlled Drug Delivery System with continuous pressure and waveform sensing technology (CCDDS) (CompuFlo ® CathCheck™) as an instrument to assess the correct placement of the catheter in the epidural space in parturients who have received combined spinal-epidural technique (CSE) for labor analgesia. Methods We enrolled 40 consecutive healthy patients undergoing CSE labor analgesia with successful analgesia. All the cases in which pulsatile waveforms in synchrony with heart rate were detected were considered to be true positives; all the cases in which there was the absence of pulsatile waves were followed up. If these patients had to eventually relocate or manipulate the epidural catheter, they were considered to be true negative. If the absence of pulse waves was observed in the presence of successful analgesia during labor, the patients were considered to be false negatives. Results Pulsatile waveforms synchronous with heart rate were observed in 33 cases associated with adequate analgesia. In 5 cases, the pulsatile waveforms were absent due to unilateral analgesia or catheter occlusion (true negatives). In 2 cases, the patients had effective analgesia but we were not able to observe a distinct pulsatile waveform. The pressure waveform analysis through the epidural catheter had a sensitivity of 95%, a positive predictive value of 100%, a specificity of 100% and a negative predictive value of 60%. Conclusion Pulsatile pressure waveform recording with CCDDS through the epidural catheter resulted in high sensitivity and positive predictive value which can help the proper placement of the epidural catheter.

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Background The use of eye tracking in the simulated setting can help improve our understanding of what sources of information clinicians are using as they deliver routine patient care. The aim of this simulation study was to observe the differences, if any, between the eye tracking patterns of leaders who performed best in a simulated postpartum hemorrhage (PPH) high-fidelity scenario, in comparison with those who performed worst. Methods Forty anesthesia trainees from the University of Catania Medical School were divided into eight teams, to enact four times the same scenario of a patient with postpartum hemorrhage following vaginal delivery. Trainees who were assigned the leader’s role wore the eye tracking glasses during the scenario, and their behavioral skills were evaluated by two observers, who reviewed the video recordings of the scenarios using a standardized checklist. The leader’s eye tracking metrics, extracted from 27 selected areas of interest (AOI), were recorded by a Tobii Pro Glasses 50 Hz wearable wireless eye tracker. Team performance was evaluated using a PPH checklist. After completion of the study, the leaders were divided into two groups, based on the scores they had received (High-Performance Leader group, HPL, and Low-Performance Leader group, LPL). Results In the HPL group, the duration and number of fixations were greater, and the distribution of gaze was uniformly distributed among the various members of the team as compared with the LPL group (with the exception of the participant who performed the role of the obstetrician). The HPL group also looked both at the patient’s face and established eye contact with their team members more often and for longer (P < .05). The team performance (PPH checklist) score was greater in the HPL group (P < .001). The LPL group had more and/or longer fixations of technical areas of interest (P < .05). Conclusions Our findings suggest that the leaders who perform the best distribute their gaze across all members of their team and establish direct eye contact. They also look longer at the patient’s face and dwell less on areas that are more relevant to technical skills. In addition, the teams led by these best performing leaders fulfilled their clinical task better. The information provided by the eye behaviors of “better-performing physicians” may lay the foundation for the future development of both the assessment process and the educational tools used in simulation. Trial Registration Clinical.Trial.Gov ID n. NCT04395963.