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: Ultrasound facilitates neuraxial puncture in obese parturients. Unfortunately, the widespread adoption of neuraxial ultrasound may be limited by the lack of technical expertise or the limited availability of the equipment. A wireless portable ultrasound device (Accuro, Rivanna Medical, Charlottesville, VA) with automated pattern recognition software (Spi-neNav3DTM technology) has been introduced to obtain the automated real-time identification of interspaces and epidural depth. The primary objective of this study was to assess the accuracy of the SpineNav3DTM ultrasound technology (Accuro) in estimating the epidural space depth compared to the standard ultrasound examination in pregnant obese patients. The secondary aim was to compare the ultrasound measurements with the measured needle depth during epidural and spinal insertion. Methods: The study was conducted at S Gerardo Hospital, Monza, Italy from March 2021 to April 2021. Obese laboring women requesting epidural analgesia or undergoing elective cesarean delivery under spinal anesthesia were recruited. All the subjects had their lumbar area scanned for the measurements of the depth of the epidural space by the SpineNav3DTM ultrasound technology and by the standard US and then both compared with the needle insertion depth in a double-blind fashion. Results: Forty-eight women were enrolled in the study. There was agreement (±0.25 cm) between the epidural depth (in cm) measured with the Accuro, versus the standard ultrasound. There was a significant difference between the mean depth of epidural space s measured by Accuro or Standard US and needle insertion depth (P < 0.001). Conclusions: The handheld ultrasound system with 3D spine navigation technology can automatically

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.

Background: Pulsatile waveforms originating from the spinal cord and transmitted through the dura in synchrony with heart rate have been used to confirm the epidural location of the catheter. Lumbar epidural space identification using the CompuFlo ® instrument has been reported and validated. The aim of this preliminary study was to evaluate the new CompuFlo instrument which allows the identification of pulsatile waveform recordings. Methods: We tested 30 epidural catheters previously successfully used for post cesarean analgesia and about to be removed. All patients were given 5 mL 2% lidocaine to test the catheter before its removal. After priming with 5 mL saline, the catheter was connected to CompuFlo ® to record the occurrence of pulsatile waveforms and/or their disappearance during its removal. Results: Pulsatile waveforms were observed in all the catheters properly located in the epidural space and disappeared when the catheter was extracted from the epidural space. No waveforms were recorded in 2 cases in which no sensory block occurred after the test dose (catheter dislodgement). The pressure waveform analysis through the epidural catheter had a sensitivity of 100%, a positive predictive value of 100%, a specificity of 100% and a negative predictive value of 100%. Conclusions: In this preliminary trial pulsatile pressure waveform recording with CompuFlo ® CathCheck™ System through the epidural catheter resulted in high sensitivity and positive predictive value.