The Latest In Critical Care: May 23, 2025

Video laryngoscopy in severe obesity, CT scan cancer risk and more

Video laryngoscopy vs. direct laryngoscopy in severely obese patients

In the U.K., an ongoing national audit project surveilling intubations has provided invaluable information about airway complications from data that is hard to collect in the U.S.

Intubation rates have risen in the U.K. over the past 10 years, which has been partially attributed to rising obesity rates. The audit project identified an unsurprising increase in airway and respiratory complications among patients with more severe obesity.

In a review of 10 randomized trials (n=955), patients with severe obesity who were randomized to video laryngoscopy had an enormous decrease in complications, including failed intubations (relative risk 0.15 in 9 studies), hypoxemia (relative risk 0.21 in 7 studies), and first attempt failure (relative risk 0.44 in 7 studies), as compared to patients intubated with direct laryngoscopy.

These were small, mostly single-center studies (n~95 patients each on average). Even accounting for the likely bias that is present, it’s hard not to conclude that video laryngoscopy can dramatically reduce complication rates from intubation of patients with severe obesity.

(Goh et al, Anaesthesia 08 April 2025 https://doi.org/10.1111/anae.16578 )

More on Laryngoscopy:

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Prophylactic antibiotics for vented patients with “acute brain injury”

In 2024 the PROPHY-VAP trial suggested patients with “acute brain injury” (a lumping together of trauma, non-traumatic hemorrhage, and ischemic strokes) might have lower rates of ventilator-associated pneumonia if they received a single dose of prophylactic ceftriaxone.

More impressively, there was a large mortality benefit observed as well with ceftriaxone prophylaxis (absolute 10% reduction), a magnitude which has never been seen before or since.

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In a new systematic review and meta-analysis, authors identified 7 randomized trials (n=835) testing prophylactic antibiotics in brain-injured patients.

Pooled relative risks did favor a reduction in ventilator-associated pneumonia with prophylactic antibiotics (RR 0.56, 95% CI, 0.35-0.89).

Mortality was reduced by a relative 9% in those receiving prophylactic antibiotics (RR 0.91, 95% CI, 0.70-1.17; P = .39), which was not statistically significant.

ICU length of stay and duration of mechanical ventilation were similar in both pooled treatment groups.

Confidence intervals were wide, and the certainty of all the findings was considered low or very low.

(Hadley-Brown et al, Chest April 2025)

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Agency nursing and overtime associated with increased pressure ulcer risk

Reduced nursing staffing overall is associated with increased mortality, bloodstream infections, falls, and pressure ulcers. It hasn’t been clear whether increased use of contract (agency) nurses has an independent association with a decreased quality of care.

In a large database analysis of 70 U.S. hospitals (three-quarters in the southern U.S., all Premier-affiliated), both nurse overtime hours and nurse agency hours were associated with increased rates of pressure ulcers and perioperative hemorrhage or hematoma.

The Agency for Healthcare Research and Quality (AHRQ) tracks these and 8 other metrics; the other six (iatrogenic pneumothorax, in-hospital fall with hip fracture, postoperative acute kidney injury requiring dialysis, postoperative respiratory failure, perioperative thromboembolism, postoperative sepsis, postoperative wound dehiscence, and accidental puncture or laceration) did not show an association.

Much of the period covered was during the Covid-19 pandemic, during a boom in agency nursing that has since lessened substantially.

Premier, a ~$1.9 billion publicly traded company, has a stake in creating support for any policymaking that would tend to suppress agency nursing, which costs it and other large systems loads of money. An invited editorialist wrote that the “findings are intriguing, but raise a number of questions and have a number of methodological loose ends typical of similar studies.”

(Pittman et al, JAMA Network Open 2025)

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CT scans on track to cause 5% of future cancers

Ionizing radiation from CT scans causes cancer in a tiny fraction of patients undergoing the scans. On a population scale, the risk adds up.

Over 93 million CT scans were performed on 62 million people in the U.S. in 2023.

This staggeringly high number is predicted to cause approximately 103,000 future cancers over the expected lifetimes of scanned patients. According to modeling, this would represent 5% of cancers in the U.S. in future decades.

Abdomen and pelvis CT were predicted to cause the most cancers (37% of the total excess), along with chest CT (21%).

The model, using the University of California San Francisco International CT Dose Registry, assumes current radiation dosing and practice patterns continue. Tweaking the model produced estimates from 80,000 to 127,000 excess cancers.

(Smith-Bindman et al, JAMA Internal Medicine, April 2025)