Intubation Practices and Adverse Peri-intubation Events in Critically Ill Patients From 29 Countries

Efficacy and safety of esketamine for emergency endotracheal intubation in ICU patients: a double-blind, randomized controlled clinical trial

Emergency endotracheal intubation in critically ill patients are dangerous procedures with a greater risk of severe hypotension The efficacy and safety of esketamine with sympathoexcitatory effects for rapid sequence induction in critically ill patients remain unclear. In this prospective double-blinded randomized controlled trial, adult patients were randomly assigned to receive either esketamine or midazolam/sufentanil admixture for induction. The primary outcomes were the effects of induction with esketamine or midazolam/sufentanil admixture on hemodynamic responses (heart rate (HR) and mean arterial pressure (MAP) during and after induction). Secondary outcomes were the duration of ventilation support, length of intensive care unit (ICU) stay, 28-day mortality. We enrolled 80 patients, of whom 38 were assigned to the esketamine group and 42 to the midazolam/sufentanil admixture group. The MAP in group esketamine was significantly higher than that in group midazolam/sufentanil admixture during the induction, and at 1 min, 5 min and 10 min after intubation. No significant differences in HR between groups were observed. The duration of ventilation support [105.3 (interquartile range (IQR) 40.9 - 248.3) hours vs. 211.5 (IQR 122.1 - 542.1) hours, P = 0.002] and the length of ICU stay [7.0 (IQR 4.0 - 16.3) days vs. 15.0 (IQR 8.0 - 26.0) days, P = 0.002] were significantly decreased in group esketamine, compared to that in group midazolam/sufentanil admixture. In group esketamine, less norepinephrine [0.00 (IQR 0.00 - 0.10) µg/kg/min vs. 0.09 (IQR 0.00 - 0.29) µg/kg/min, P = 0.016] was needed. There was no significant difference in 28-day mortality between the two groups. No serious adverse events occurred. In conclusion, esketamine is a hemodynamically stable induction agent in critically ill patients, which could reduce the length of ICU stay and the duration of ventilation support.Trial registration: clinicaltrials.gov (19/07/2022; NCT05464979).

Did intubation procedures for critically ill patients without SARS-CoV-2 infection change during the pandemic? Secondary analysis of the INTUPROS multicenter study

OBJECTIVE

To determine the changes in intubation procedures of critically ill patients without SARS-CoV-2 infection induced during the COVID-19 pandemic.

DESIGN

Secondary Analysis of the INTUPROS Prospective Multicenter Observational Study on Intubation in Intensive Care Units (ICUs).

SETTING

43 Spanish ICUs between April 2019 and October 2020.

PATIENTS

1515 Non-COVID-19 patients intubated before and during the pandemic.

INTERVENTIONS

None.

MAIN VARIABLES OF INTEREST

Intubation procedures and medication, first-pass success rate, complications, and mortality.

RESULTS

1199 patients intubated before the pandemic and 316 during the pandemic were analyzed. During the pandemic, there were fewer days until intubation (OR 0.95 95% CI [0.92-0.98]), reduced resuscitation bag (OR 0.43 95% CI [0.29-0.63]) and non-invasive ventilation oxygenation (OR 0.51 95% CI [0.34-0.76]), reduced use of capnography (OR 0.55 95% CI [0.33-0.92]) and fentanyl (OR 0.47 95% CI [0.34-0.63]). On the other hand, there was an increase in oxygenation with non-HFNC devices (OR 2.21 95% CI [1.23-3.96]), in use of videolaryngoscopy on the first-pass (OR 2.74 95% CI [1.76-4.24]), and greater use of midazolam (OR 1.95 95% CI [1.39-2.72]), etomidate (OR 1.78 95% CI [1.28-2.47]) and succinylcholine (OR 2.55 95% CI [1.82-3.58]). The first-pass success was higher (68.5% vs. 74.7%; P=.033). There were no pre-post differences in major complications (34.7% vs. 34.8%; P=.970) and in-hospital mortality (42.7% vs. 38.6%; P=.137).

CONCLUSIONS

The COVID-19 pandemic modified intubation procedures in non-COVID-19 patients, changing the oxygenation strategy, the medication and the use of videolaryngoscopy, with no impact on complications or mortality.

The Future of Artificial Intelligence Using Images and Clinical Assessment for Difficult Airway Management

Artificial intelligence (AI) algorithms, particularly deep learning, are automatic and sophisticated methods that recognize complex patterns in imaging data providing high qualitative assessments. Several machine-learning and deep-learning models using imaging techniques have been recently developed and validated to predict difficult airways. Despite advances in AI modeling. In this review article, we describe the advantages of using AI models. We explore how these methods could impact clinical practice. Finally, we discuss predictive modeling for difficult laryngoscopy using machine-learning and the future approach with intelligent intubation devices.

Clinical Decision-Making and Process Complications During Anticipated Difficult Airway Management for Elective Surgery

BACKGROUND

Difficult airway management (DAM) is a challenging aspect of anesthetic care. Although nearly all DAM episodes result in successful intubation, complications are common and clinical decision-making may be complex. In adults with anticipated DAM scheduled for nonemergent surgery, we prospectively observed clinical decisions made during DAM such as awake/sedated versus anesthetized, choice of initial and subsequent devices, case cancellation/postponement, conversions between awake and anesthetized approaches, and process complications such as multiple intubation/supraglottic airway (SGA) insertion attempts, difficult bag-mask ventilation (BMV), hypoxemia, and cardiovascular destabilization.

METHODS

From 2009 to 2014, we prospectively observed 1295 episodes of anticipated DAM in a convenience sample of 1245 adults scheduled for nonemergent surgery. Trained observers recorded airway management decisions and process complications during DAM. We described clinical decisions made during DAM and outcomes including number of attempts, need for BMV, hypoxemia, and cardiovascular destabilization.

RESULTS

No cases were canceled/postponed for airway management failure and all intubations were eventually successful. Of the 1295 episodes of airway management in our study cohort, 166 (13%) were intubated awake. Patients intubated awake had more difficult airway indicators than those intubated anesthetized, their first-pass success rate was 49%, 30% required ≥3 attempts, 4% required a device change, 50% experienced hypoxemia, and 29% experienced cardiovascular destabilization. Among the 1129 patients intubated while anesthetized, first-pass success rate was 64% and 20% required ≥3 attempts, 11% required a device change, hypoxemia occurred in 30%, and cardiovascular destabilization in 20%. One patient (0.08%) was converted from an anesthetized to an awake approach. Patients with a failed anesthetized intubation attempt and difficult BMV between attempts were at high risk for multiple attempts (67%) and hypoxemia (100%).

CONCLUSIONS

Airway management was successful in all patients and the incidence of process complications was higher than in routine airway management. Despite a high risk of DAM, 87% of patients were intubated anesthetized and conversions between awake and anesthetized approaches were rare. That patients intubated awake had more difficult airway indicators implies that clinicians reserve awake intubation for particularly difficult airways. The high incidence of multiple attempts, hypoxemia, and cardiovascular destabilization in patients intubated awake suggests that awake airway management remains challenging. We found no clear pattern in device choices after a first failed attempt. Patients with a first failed anesthetized intubation attempt and difficult BMV were at particularly high risk for hypoxemia.

Protocol and Statistical Analysis Plan for the Randomized Trial of Sedative Choice for Intubation (RSI)

Background

Emergency tracheal intubation is a common and high-risk procedure. Ketamine and etomidate are sedative medicines commonly used to induce anesthesia for emergency tracheal intubation, but whether the induction medication used affects patient outcomes is uncertain.

Research Question

Does the use of ketamine for induction of anesthesia decrease the incidence of death among adults undergoing emergency tracheal intubation, compared to the use of etomidate?

Study Design and Methods

The Randomized trial of Sedative choice for Intubation (RSI) is a pragmatic, multicenter, unblinded, parallel-group, randomized trial being conducted in 14 sites (6 emergency departments and 8 intensive care units) in the United States. The trial compares ketamine vs etomidate for induction of anesthesia among 2,364 critically ill adults undergoing emergency tracheal intubation. The primary outcome is all-cause, 28-day in-hospital mortality. The secondary outcome is the incidence of cardiovascular collapse during intubation, a composite of hypotension, receipt of vasopressors, and cardiac arrest. Enrollment began on April 6, 2022, and is expected to conclude in 2025.

Interpretation

The RSI trial will provide important data on the effects of ketamine vs etomidate on death and other outcomes for critically ill adults undergoing emergency tracheal intubation. Specifying the protocol and statistical analysis plan before the conclusion of enrollment increases the rigor, reproducibility, and interpretability of the trial.

Trial Registry

ClinicalTrials.gov ; No.: NCT05277896 ; URL: www.clinicaltrials.gov.

Take-Home Points

Study Question: Does use of ketamine for induction of anesthesia during emergency tracheal intubation decrease the incidence of death, compared with use of etomidate?Results: This manuscript describes the protocol and statistical analysis plan for the Randomized trial of Sedative choice for Intubation (RSI) comparing ketamine vs etomidate for induction of anesthesia for emergency tracheal intubation.Interpretation: Prespecifying the full statistical analysis plan before completion of enrollment increases rigor, reproducibility, and transparency of the trial results.

Impact of Country Income Level on Outcomes in Patients with Acute Brain Injury Requiring Invasive Mechanical Ventilation: A Secondary Analysis of the ENIO Study

BACKGROUND

Invasive mechanical ventilation can present complex challenges for patients with acute brain injury (ABI) in middle-income countries (MICs). We characterized the impact of country income level on weaning strategies and outcomes in patients with ABI.

METHODS

A secondary analysis was performed on a registry of critically ill patients with ABI admitted to 73 intensive care units (ICUs) in 18 countries from 2018 to 2020. Patients were classified as high-income country (HIC) or MIC. The primary outcome was ICU mortality. Secondary outcomes were days to first extubation, tracheostomy, extubation failure, ICU length of stay, and hospital mortality. Multivariable analyses were adjusted for clinically preselected covariates such as age, sex, body mass index, neurological severity, comorbidities, and ICU management. Extubation and tracheostomy outcomes were also adjusted for arterial blood gas values and ventilatory settings.

RESULTS

Of 1512 patients (median age = 54 years, 66% male), 1170 (77%) were from HICs, and 342 (23%) were from MICs. Median age was significantly lower in MICs [35 (range 26-52) vs. 58 (range 45-68) years in HICs]. Neurosurgical procedures (47.7% vs. 38.2%) and decompressive craniectomy (30.7% vs. 15.9%) were more common in MICs, whereas intracranial pressure monitoring (12.0% vs. 51.5%) and external ventricular drain (7.6% vs. 35.6%) were less common. Compared with HICs, patients from MICs had 2.27 times the odds of ICU mortality [p = 0.009, 95% confidence interval (CI) 1.22-4.21]. Frequency of extubation failure was lower in MICs but not significant after adjustment. Patients from MICs had 3.38 times the odds of tracheostomy (p ≤ 0.001, 95% CI 2.28-5.01), 5.59 days shorter mean ICU stay (p < 0.001, 95% CI - 7.82 to - 3.36), and 1.96 times the odds of hospital mortality (p = 0.011, 95% CI 1.17-3.30).

CONCLUSIONS

In an international registry of patients with ABI requiring invasive mechanical ventilation, MICs had higher odds of ICU mortality, tracheostomy placement, and hospital mortality compared with HICs, which may be due to difference in neurocritical care resources and management.

Ventilation distribution during spontaneous breathing trials predicts liberation from mechanical ventilation: the VISION study

BACKGROUND

Predicting complete liberation from mechanical ventilation (MV) is still challenging. Electrical impedance tomography (EIT) offers a non-invasive measure of regional ventilation distribution and could bring additional information.

RESEARCH QUESTION

Whether the display of regional ventilation distribution during a Spontaneous Breathing Trial (SBT) could help at predicting early and successful liberation from MV.

STUDY DESIGN AND METHODS

Patients were monitored with EIT during the SBT. The tidal image was divided into ventral and dorsal regions and displayed simultaneously. We explored the ventral-to-dorsal ventilation difference in percentage, and its association with clinical outcomes. Liberation success was defined pragmatically as passing SBT followed by extubation within 24 h without reintubation for 7 days. Failure included use of rescue therapy, reintubation within 7 days, tracheostomy, and not being extubated within 24 h after succesful SBT. A training cohort was used for discovery, followed by a validation cohort.

RESULTS

Among a total of 98 patients analyzed, 85 passed SBT (87%), but rapid liberation success occurred only in 40; 13.5% of extubated patients required reintubation. From the first minutes to the entire SBT duration, the absolute ventral-to-dorsal difference was consistently smaller in liberation success compared to all subgroups of failure (p < 0.0001). An absolute difference at 5 min of SBT > 20% was associated with failure of liberation, with sensitivity and specificity of 71% and 78% and positive predictive value 81% in a validation cohort.

CONCLUSION

During SBT, a large ventral-to-dorsal difference in ventilation indicated by EIT may help to rapidly identify patients at risk of liberation failure.

Induction Agents for Tracheal Intubation in Critically Ill Patients

OBJECTIVES

Concise definitive review of the use of induction agents in critically ill patients undergoing tracheal intubation and their association with outcomes.

DATA SOURCES

Original publications were retrieved through a PubMed search with search terms related to induction agents for tracheal intubation in critically ill patients.

STUDY SELECTION

We included randomized controlled trials and observational studies that reported patient outcomes.

DATA EXTRACTION

Data from included studies, including choice of induction agents and clinically relevant outcomes, were extracted.

DATA SYNTHESIS

Etomidate and ketamine have been the most studied induction agents in critical care during last years. Recent studies on etomidate investigated the clinical impact of its recognized adrenal suppression in terms of morbidity and mortality. Etomidate may carry a non-negligible mortality risk without definitive hemodynamic benefits compared with ketamine. Available data then support the use of ketamine over etomidate, since the difference in the hemodynamic profile seems to be of minor clinical relevance. No multicenter randomized studies are available comparing propofol to other induction agents but evidence from a large observational study identified an association of propofol with post-intubation cardiovascular instability in critically ill patients. Despite the observational nature of these findings cannot exclude the role of confounders, the association of propofol with post-induction cardiovascular instability is pharmacologically plausible, justifying its avoidance in favor of drugs with a better safety profile in critical care such as ketamine.

CONCLUSIONS

Although no definitive conclusions can be drawn based on the available evidence, recent evidence pointed out the potential negative effect of etomidate on survival and the association of propofol with cardiovascular instability. Ketamine may be considered the drug with a safer profile, widespread availability and low cost but future research should provide definitive data on optimal drug selection, its dosage in the context of critical illness and concomitant interventions to minimize the risk of peri-intubation complications.

An International Factorial Vignette-Based Survey of Intubation Decisions in Acute Hypoxemic Respiratory Failure

OBJECTIVES

Intubation is a common procedure in acute hypoxemic respiratory failure (AHRF), with minimal evidence to guide decision-making. We conducted a survey of when to intubate patients with AHRF to measure the influence of clinical variables on intubation decision-making and quantify variability.

DESIGN

Factorial vignette-based survey asking "Would you recommend intubation?" Respondents selected an ordinal recommendation from a 5-point scale ranging from "Definite no" to "Definite yes" for up to ten randomly allocated vignettes. We used Bayesian proportional odds modeling, with clustering by individual, country, and region, to calculate mean odds ratios (ORs) with 95% credible intervals (CrIs).

SETTING

Anonymous web-based survey.

SUBJECTS

Clinicians involved in the decision to intubate.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Between September 2023 and January 2024, 2,294 respondents entered 17,235 vignette responses in 74 countries (most common: Canada [29%], United States [26%], France [9%], Japan [8%], and Thailand [5%]). Respondents were attending physicians (63%), nurses (13%), trainee physicians (9%), respiratory therapists (9%), and other (6%). Lower oxygen saturation, higher F io2 , noninvasive ventilation compared with high-flow, tachypnea, neck muscle use, abdominal paradox, drowsiness, and inability to obey were associated with increased odds of intubation; diagnosis, vasopressors, and duration of symptoms were not. Nurses were less likely than physicians to recommend intubation. Within a country, the odds of recommending intubation changed between clinicians by an average factor of 2.60; within a region, the same odds changed between countries by 1.56. Respondents from Canada (OR, 0.53; CrI, 0.40-0.70) and the United States (OR, 0.63; CrI, 0.48-0.84) were less likely to recommend intubation than respondents from most other countries.

CONCLUSIONS

In this international, multiprofessional survey of 2294 clinicians, intubation for patients with AHRF was mostly decided based on oxygenation, breathing pattern, and consciousness, but there was important variation across individuals and countries.

Diabetes Mellitus Is Not a Risk Factor for Difficult Intubation Among Critically Ill Adults: A Secondary Analysis of Multicenter Trials

OBJECTIVES

Diabetes mellitus has been associated with greater difficulty of tracheal intubation in the operating room. This relationship has not been examined for tracheal intubation of critically ill adults. We examined whether diabetes mellitus was independently associated with the time from induction of anesthesia to intubation of the trachea among critically ill adults.

DESIGN

A secondary analysis of data from five randomized trials completed by the Pragmatic Critical Care Research Group (PCCRG).

SETTING

Emergency departments (EDs) or ICUs at 11 centers across the United States that enrolled in randomized trials of a pre-intubation checklist, fluid bolus administration, bag-mask ventilation between induction and laryngoscopy, and intubation using a bougie vs. stylet.

PATIENTS

Critically ill adults undergoing tracheal intubation with a laryngoscope in an ED or an ICU.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A total of 2654 patients were included in this analysis, of whom 638 (24.0%) had diabetes mellitus. The mean time from induction of anesthesia to intubation of the trachea was 169 seconds (sd, 137s). Complications occurred during intubation in 1007 patients (37.9%). Diabetes mellitus was not associated with the time from induction of anesthesia to intubation of the trachea (-4.4 s compared with nondiabetes; 95% CI, -17.2 to 8.3 s; p = 0.50). Use of a video vs. direct laryngoscope did not modify the association between diabetes mellitus and the time from induction to intubation (p for interaction = 0.064). Diabetes mellitus was not associated with the probability of successful intubation on the first attempt (85.6% vs. 84.3%; p = 0.46) or complications during intubation (39.8% vs. 37.4%; p = 0.52).

CONCLUSIONS

Among 2654 critically ill patients undergoing tracheal intubation in an ED or an ICU, diabetes mellitus was not independently associated with the time from induction to intubation, the probability of successful intubation on the first attempt, or the rate of complications during intubation.

Evaluation of Point-of-care Ultrasound of Airway to Predict Difficult Laryngoscopy and Intubation in Intensive Care Unit Patients

Background

To evaluate the role of ultrasound (US) in the assessment of the airway and to determine whether US has the potential to serve as effective, noninvasive and less time-consuming method for the diagnosis of difficult intubation in ICU patients.

Patients and methods

This cross-sectional study was carried in 152 critically ill patients who underwent intubation in the ICU from December 2022 to April 2024. Prior to intubation thyromental height (TMH) and hyomental distance ratio (HMD-R) was measured using a scale and distance from skin to hyoid bone (SHB) and distance from skin to thyrohyoid membrane (STM) was measured using a US. Direct laryngoscopy was performed using a Macintosh blade, and the Cormack-Lehane (CL) grade was noted without external laryngeal manipulation. The laryngoscopy was classified as easy (CL Grade I and II) or difficult (CL Grade III and IV). The number of attempts at intubation, need for alternative difficult intubation approaches or inability to secure the airway was also noted.

Results

The incidence of difficult airway was 17.76%. The success rate for first-attempt intubation was 96.7%. Based on the receiver operating characteristic (ROC) curve analysis cut-off value of 1.97 cm [95% confidence interval (CI), 0.949-0.996, area under the curve (AUC), 0.972] for anterior soft tissue thickness from the skin to thyrohyoid membrane distinguished the difficult intubation group from the easy intubation group, with a sensitivity of 96.3% and specificity of 86.4%. For the hyoid bone level, a cut-off value of 0.905 cm (95% CI, 0.706-0.887, AUC, 0.797) had a sensitivity of 74.1% and specificity of 74.4%. Anterior soft tissue thickness from the skin to thyrohyoid membrane was a better predictor of a difficult airway. There was a significant correlation between clinical airway assessments and US airway assessments.

Conclusion

Point-of-care US can serve as an independent tool for assessing the airway in intensive care unit (ICU) patients, with anterior soft tissue thickness from skin to thyrohyoid membrane being a superior predictor. Combined models of sonographic and clinical tests could enhance the diagnostic value for identifying difficult intubation cases in ICU patients.

How to cite this article

Mallick S, Das S, Pradhan S, Kar S. Evaluation of Point-of-care Ultrasound of Airway to Predict Difficult Laryngoscopy and Intubation in Intensive Care Unit Patients. Indian J Crit Care Med 2025;29(1):14-20.

Evaluation of Reduced-Dose Induction Agents During Endotracheal Intubation in Critical Care Transport

OBJECTIVE

Induction agent selection and dose are potentially modifiable risk factors to mitigate postintubation hypotension and hemodynamic collapse. Despite it being a common practice, minimal literature exists to support induction agent dose reduction. Our objective was to evaluate the rate of postintubation hemodynamic collapse with reduced-dose compared to full dose induction agents.

METHODS

This is a retrospective chart review of adult patients who were endotracheally intubated by a critical care transport team and received etomidate or ketamine for induction. The primary outcome was association of reduced-dose induction agent use (etomidate <0.2 mg/kg or ketamine <1 mg/kg) with postintubation hemodynamic collapse.

RESULTS

A total of 304 patients were included; 187 (61.5%) received etomidate and 117 (38.5%) received ketamine. Of these 304 patients, 64 (21.1%) received reduced-dose agents and 240 (78.9%) received full-dose agents. The initial systolic blood pressure and mean arterial blood pressure levels were lower in the reduced-dose arm. Shock index, hemodynamic collapse, and life-threatening hemodynamic collapse did not differ between the groups.

CONCLUSION

In this analysis, there was no difference in rates of postintubation hemodynamic collapse with reduced-dose induction agents when compared with full-dose agents.

Intubation of critically ill patients: A pilot study of minute-by-minute physiological changes within an Australian tertiary intensive care unit

BACKGROUND

There are no published minute-by-minute physiological assessment data for endotracheal intubation (ETT) performed in the intensive care unit (ICU). The majority of physiological data is available from Europe and North America where etomidate is the induction agent administered most commonly.

AIMS

The aim of this study was to describe the feasibility of obtaining minute-by-minute physiological and medication data surrounding ETT in an Australian tertiary ICU and to assess its associated outcomes.

METHODS

We performed a single-centre feasibility observational study. We obtained minute-by-minute data on physiological variables and medications for 15 min before and 30 min after ETT. We assessed feasibility as enrolled to screened patient ratio and completeness of data collection in enrolled patients. Severe hypotension (systolic blood pressure < 65 mmHg) and severe hypoxaemia (pulse oximetry saturation < 80%) were the secondary clinical outcomes.

RESULTS

We screened 43 patients and studied 30 patients. The median age was 58.5 (interquartile range: 49-70) years, and 18 (60%) were male. Near-complete (97%) physiological and medication data were obtained in all patients at all times. Overall, 15 (50%) ETTs occurred after hours (17:30-08:00) and 90% were by video laryngoscopy with a 90% first-pass success rate. Prophylactic vasopressors were used in 50% of ETTs. Fentanyl was used in all except one ETT at a median dose of 2.5 mcg/kg. Propofol (63%) or midazolam (50%) were used as adjuncts at low dose. Rocuronium was used in all but one patient. There were no episodes of severe hypotension and only one episode of short-lived severe hypoxaemia.

CONCLUSION

Minute-by-minute recording of ETT-associated physiological changes in the ICU was feasible but only fully available in two-thirds of the screened patients. ETT was based on fentanyl induction, low-dose adjunctive sedation, and frequent prophylactic vasopressor therapy and was associated with no severe hypotension and a single short-lived episode of severe hypoxaemia.

A Systematic Review and Meta-Analysis of Prophylactic Vasopressors for the Prevention of Peri-Intubation Hypotension

BACKGROUND/OBJECTIVES

Peri-intubation hypotension is a known complication of endotracheal intubation. In the hospital setting, peri-intubation hypotension has been shown to increase hospital mortality and length of stay. The use of prophylactic vasopressors at the time of sedation induction to prevent peri-intubation hypotension has been raised. This systematic review and meta-analysis aims to review the safety and efficacy of this practice.

METHODS

The study was fully registered with PROSPERO on 13 October 2022, and screening for eligibility was initiated on 20 September 2024. Randomized controlled trials, along with retrospective or prospective cohort studies, were included in the search. The terms "peri-intubation hypotension", "vasopressors", "intubation", and "anesthesia induced hypotension" were used to search the title/summary in PubMed, Cochrane Library, and Google Scholar databases. An assessment of bias for each study was conducted using the Newcastle-Ottawa Quality Assessment Scale. The primary outcome was the rate of hypotension peri-intubation. Any complications secondary to hypotension or vasopressors were the secondary outcome.

RESULTS

We identified 13 studies, which were all randomized controlled studies, to include in the final analysis. The risk ratio for preventing peri-intubation hypotension was 1.6 (95% CI, 1.2-2.14) with the use of prophylactic phenylephrine while giving propofol versus no prophylactic vasopressors and 1.28 (95% CI 1.03-1.60) with the use of ephedrine.

CONCLUSIONS

These findings suggest that in patients undergoing intubation in the operating room with propofol, prophylactic vasopressors given with induction for intubation decrease the odds of hypotension.

Bridging the procedures skill gap from medical school to residency: a simulation-based mastery learning curriculum

BACKGROUND

The transition from medical student to intern is a recognized educational gap. To help address this, the Association of American Medical Colleges developed the Core Entrustable Professional Activities for entering residency. As these metrics outline expectations for all graduating students regardless of specialty, the described procedural expectations are appropriately basic. However, in procedure-heavy specialties such as emergency medicine, the ability to perform advanced procedures continues to contribute to the disconnect between undergraduate and graduate medical education. To prepare our graduating students for their internship in emergency medicine, we developed a simulation-based mastery learning curriculum housed within a specialty-specific program. Our overall goal was to develop the students' procedural competency for central venous catheter placement and endotracheal intubation before graduation from medical school.

METHODS

Twenty-five students participated in a simulation-based mastery learning procedures curriculum for ultrasound-guided internal jugular central venous catheter placement and endotracheal intubation. Students underwent baseline assessment, deliberate practice, and post-test assessments. Both the baseline and post-test assessments used the same internally developed checklists with pre-established minimum passing scores.

RESULTS

Despite completing an emergency medicine rotation and a critical care rotation, none of the students met the competency standard during their baseline assessments. All twenty-five students demonstrated competency on both procedures by the end of the curriculum. A second post-test was required to demonstrate achievement of the central venous catheter and endotracheal intubation minimum passing scores by 16% and 28% of students, respectively.

CONCLUSIONS

Students demonstrated procedural competency for central venous catheter placement and endotracheal intubation by engaging in simulation-based mastery learning procedures curriculum as they completed their medical school training. With three instructional hours, students were able to achieve basic procedural competence for two common, high-risk procedures they will need to perform during emergency medicine residency training.

Acute kidney injury in elderly patients receiving invasive mechanical ventilation: early versus late onset

BACKGROUND

Acute kidney injury (AKI) is a severe complication in critical patients receiving invasive mechanical ventilation (MV). However, AKI which occurs in the first 48 h after MV (early AKI) and thus likely associated with the MV settings is probably different from AKI occurring following 48 h (late AKI). This study is aimed at exploring the incidence of early and late AKI in elderly patients receiving MV and identifying their different risk factors and outcomes.

METHODS

This retrospective, observational, multicenter cohort study consecutively included 3271 elderly patients (≥ 75 years) receiving invasive MV at four medical centers of Chinese PLA General Hospital from 2008 to 2020. The diagnosis of AKI was made following the 2012 KDIGO criteria and categorized into early (≤ 48 h) or late (> 48 h-7 days) according to the time from MV.

RESULTS

There were totally 1292 cases enrolled for the final analysis. Among them, 376 patients (29.1%) developed early AKI versus 132 (10.2%) developed late AKI. The 28-day mortality rates of the non-AKI, early AKI, and late AKI patients were 14.4, 46.8, and 61.4%, respectively. After 90 days, mortality rates of three groups were 33.2, 60.6, and 72.7%, respectively. Risk factors for early AKI included PaO2/FIO2, serum creatinine, hemoglobin, and positive end-expiratory pressure at the beginning of MV, while those for late AKI were PaO2/FIO2, serum creatinine, and hemoglobin. In the multivariable adjusted analysis, both early AKI (HR = 4.035; 95% CI = 3.166-5.142; P < 0.001) and late AKI (HR = 6.272; 95% CI = 4.654-8.453; P < 0.001) were related to the increased 28-day mortality relative to non-AKI. AKI was significantly related to 90-day mortality: early AKI (HR = 2.569; 95% CI = 2.142-3.082; P < 0.001) and late AKI (HR = 3.692; 95% CI = 2.890-4.716; P < 0.001).

CONCLUSIONS

AKI mostly develops in the initial 48 h following MV, which is related to the health and MV settings; while AKI occurring following 48 h is not associated with MV settings. Therefore, a strategy for kidney protection in patients with MV should take these differences into consideration.

Association between metabolic acidosis and post-intubation hypotension in airway management performed in the emergency department

Introduction

Post-intubation hypotension (PIH) is a common complication of intubations performed in the emergency department (ED). Identification of patients at high-risk for PIH is a major challenge. We aimed to determine whether pre-intubation metabolic acidosis affects the incidence of PIH in the ED.

Methods

This was a single-center, retrospective, observational study of consecutive patients requiring emergent endotracheal intubation (ETI) from November 1, 2016 to March 31, 2022 at Hyogo Emergency Medical Center, an urban ED. The primary outcome was PIH, defined as a decreased systolic blood pressure (sBP) of <90 mmHg, required initiation of any vasopressor, or a decrease in sBP by ≥ 20 % within 30 min following intubation. Patients were divided into two groups: those with pre-intubation metabolic acidosis (metabolic acidosis group), defined as pH < 7.3 and base excess (BE) < -4 mmol/L on arterial blood gas analysis, and those with no metabolic acidosis (without-metabolic acidosis group). The association between PIH and pre-intubation metabolic acidosis was examined using multivariable logistic regression models. A receiver operating characteristic (ROC) curve was produced to assess the predictive value of pre-intubation BE for PIH.

Results

The study included 311 patients. PIH occurred in 65.5 % (74/113) of patients in the metabolic acidosis group and 29.3 % (58/198) of patients in the without-metabolic acidosis group. Multivariable logistic regression demonstrated that metabolic acidosis was associated with PIH (odds ratio 4.06, 95 % confidence interval 2.31-7.11). In the ROC analysis, the optimal cut-off point for BE was -4.1 (sensitivity = 71 %, specificity = 70 %), with the area under the ROC curve 0.74.

Conclusion

Pre-intubation metabolic acidosis was significantly associated with PIH. Physicians.

Failed/difficult Intubation comparing between pre-COVID-19 and COVID-19 pandemic period using a national insurance claims database and information system of a university hospital

INTRODUCTION

Endotracheal intubation can be difficult or even fail under certain patient and anaesthesiologist conditions. During the COVID-19 pandemic a country-wide lockdown policy was enforced in Thailand which stipulated that anaesthesiologists wear personal protective equipment, powered air purifying respirator, or goggles and surgical/N95 mask during the intubation procedure. Thus, an anaesthesiologist's vision is restricted and grip on the equipment less sure. Under these conditions, the incidence of difficult intubation was expected to increase.

METHODS

This time-series study was based on the aggregated age- and sex-standardized monthly incidence of difficult intubation among all intubated patients whose data were recorded in the national insurance claims database and among patients recorded in the records of a university hospital from January 2018 to September 2022. Changes in incidence of difficult intubation following the implementation of a lockdown policy from 26 March 2020 during the COVID-19 pandemic were explored using negative binomial regression and interrupted linear regression time-series analysis.

RESULTS

Data of 922,274 individuals in the national database and 95,457 individuals in the university database were retrieved. The overall incidence of difficult intubation in both settings dropped by 25% following lockdown, significantly so in the national database (p < 0.001). At the point of interruption, a significant drop in level was evident in the national data (of 1.682 per thousand per month, P = 0.003) and a non-significant drop at the university level (of 1.118 per thousand per month, P = 0.304).

DISCUSSION

The decreased incidence of difficult intubation during the lockdown period was contrary to expectation but might be related to the deployment solely of anaesthesiologists and more experienced anaesthetic staff using videolaryngoscopes during lockdown following the recommendation for intubation during respiratory disease pandemics.

Effective Use of a Combined Video Laryngoscope and Bronchoscope System in the Emergency Department for a Patient With Severe Upper Airway Obstruction Due to Angioedema: A Case Report

Management of difficult airways in the emergency department is challenging. Herein, we report a case of successful management of severe upper airway obstruction caused by angioedema, where intubation was achieved using a dual-function video laryngoscope and bronchoscope system in the emergency department for a patient with severe upper airway stenosis due to angioedema. A 74-year-old obese man with dyspnea presented to our emergency department. Despite initial attempts using a conventional intubation technique, the patient's airway remained difficult to manage because of marked enlargement of the tongue. The anesthesiologists decided to apply the dual-function video laryngoscope and bronchoscope system (GlideScope Core System™, Verathon Inc., Bothell, WA, USA). Finally, nasotracheal intubation was successfully performed using a bronchoscope switched from a video laryngoscope. The patient's respiratory status improved post-intubation. Subsequent management proceeded uneventfully. The patient was transferred to the ICU, where he was diagnosed with angioedema after admission.

Management Strategies for Acute Pulmonary Embolism in the ICU

TOPIC IMPORTANCE

Acute pulmonary embolism (PE) is a common disease encountered by pulmonologists, cardiologists, and critical care physicians throughout the world. For patients with high-risk acute PE (defined by systemic hypotension) and intermediate high-risk acute PE (defined by the absence of systemic hypotension, but the presence of numerous other concerning clinical and imaging features), intensive care often is necessary. Initial management strategies should focus on optimization of right ventricle (RV) function while decisions about advanced interventions are being considered.

REVIEW FINDINGS

We reviewed the existing literature of various vasoactive agents, IV fluids and diuretics, and pulmonary vasodilators in both animal models and human trials of acute PE. We also reviewed the potential complications of endotracheal intubation and positive pressure ventilation in acute PE. Finally, we reviewed the data of venoarterial extracorporeal membrane oxygenation use in acute PE. The above interventions are discussed in the context of the underlying pathophysiologic features of acute RV failure in acute PE with corresponding illustrations.

SUMMARY

Norepinephrine is a reasonable first choice for hemodynamic support with vasopressin as an adjunct. IV loop diuretics may be useful if evidence of RV dysfunction or volume overload is present. Fluids should be given only if concern exists for hypovolemia and absence of RV dilatation. Supplemental oxygen administration should be considered even without hypoxemia. Positive pressure ventilation should be avoided if possible. Venoarterial extracorporeal membrane oxygenation cannulation should be implemented early if ongoing deterioration occurs despite these interventions.

Fluid infusion prior to intubation or anesthesia: A meta-analysis of randomized controlled trials

BACKGROUND

The results of current randomized controlled trials (RCTs) vary regarding the effectiveness of rehydration prior to anesthesia induction. Our objective was to determine the effectiveness of pre-induction rehydration in patients undergoing tracheal intubation or surgical procedures.

METHODS

This meta-analysis followed PRISMA guidelines and was registered in the INPLASY database (registration number: INPLASY2022100099). Two reviewers independently searched PubMed, Embase, The Cochrane Database of Systematic Reviews, and Clinical Trials databases until October 2022, without any restrictions on date. Any randomized controlled trial investigating the administration of intravenous fluids to patients undergoing tracheal intubation or pre-surgical anesthesia induction was considered eligible. Exclusion criteria were applied to exclude certain literature. Data were analyzed using RevMan (5.4.1) software after independent extraction. The primary objective of this study was to determine if intravenous rehydration could reduce the occurrence of hypotensive events and the use of vasoactive drugs following anesthesia induction.

RESULTS

This meta-analysis included seven studies with a total of 2850 patients, including 1430 patients who received rehydration and 1420 control patients. Patients who received early rehydration had a lower incidence of hypotensive events compared to those who did not (RR 0.78, 95% CI 0.66-0.92, P = 0.004). No heterogeneity was observed (p = 0.31, I2 = 16%). However, subgroup analysis showed that rehydration before tracheal intubation did not reduce hypotensive events in critically ill patients (RR 0.99, 95% CI 0.61-1.60, P = 0.96). There were no significant differences in the use of vasoactive medications between the two study groups (RR 0.96, 95% CI 0.80-1.16, P = 0.69). No heterogeneity was observed (p = 0.26, I2 = 23%). The funnel plot indicated no evidence of publication bias.

CONCLUSIONS

Pre-induction rehydration can reduce the occurrence of hypotensive events, but only in pre-surgical patients, and does not decrease the use of vasoactive medications.

Propofol administration for induction is associated with peri-intubation instability in trauma critical care unit patients

INTRODUCTION

Peri-intubation hypotension is associated with increased hospital length of stay and morbidity. Propofol is associated with alterations in hemodynamics. We hypothesize that using propofol for induction leads to peri-intubation hypotension in trauma critical care patients.

METHODS

Patients that underwent unplanned intubation in the trauma intensive care unit (TICU) were prospectively enrolled. Peri-intubation vitals and medications were recorded to assess hypotension within 10 ​min of intubation. Patients were divided into propofol (PROP) or other medication (OTR) groups.

RESULTS

Data was complete for 69 patients; 31 PROP and 38 OTR. In OTR there was an 8.8-point (-21.1, 3.6) SBP decrease (p ​= ​0.159) and in PROP there was a 30.8-point (-45.6, -16.0) SBP decrease (p ​= ​0.0002) with significant increases in heart rate (HR) and shock index (SI) (HR p ​= ​0.001, SI p ​< ​0.0001).

CONCLUSION

In patients without hypotension prior to intubation, we observed a statistically significant drop in the patients' SBP with use of propofol. In trauma critical care unit patients, we recommend considering an induction medication for unplanned intubation other than propofol.

Comparing the hemodynamic effects of ketamine versus fentanyl bolus in patients with septic shock: a randomized controlled trial

BACKGROUND

Ketamine and fentanyl are commonly used for sedation and induction of anesthesia in critically ill patients. This study aimed to compare the hemodynamic effects of ketamine versus fentanyl bolus in patients with septic shock.

METHODS

This randomized controlled trial included mechanically ventilated adults with septic shock receiving sedation. Patients were randomized to receive either 1 mg/kg ketamine bolus or 1 mcg/kg fentanyl bolus. Cardiac output (CO), stroke volume (SV), heart rate (HR), and mean arterial pressure (MAP) were measured at the baseline, 3, 6, 10, and 15 min after the intervention. Delta CO was calculated as the change in CO at each time point in relation to baseline measurement. The primary outcome was delta CO 6 min after administration of the study drug. Other outcomes included CO, SV, HR, and MAP.

RESULTS

Eighty-six patients were analyzed. The median (quartiles) delta CO 6 min after drug injection was 71(37, 116)% in the ketamine group versus - 31(- 43, - 12)% in the fentanyl group, P value < 0.001. The CO, SV, HR, and MAP increased in the ketamine group and decreased in the fentanyl group in relation to the baseline reading; and all were higher in the ketamine group than the fentanyl group.

CONCLUSION

In patients with septic shock, ketamine bolus was associated with higher CO and SV compared to fentanyl bolus.

CLINICAL TRIAL REGISTRATION

Date of registration: 24/07/2023.

CLINICALTRIALS

gov Identifier: NCT05957302. URL: https://clinicaltrials.gov/study/NCT05957302 .

Evaluation of Etomidate Use and Association with Mortality Compared with Ketamine among Critically Ill Patients

Rationale: Uncertainty remains regarding the risks associated with single-dose use of etomidate. Objectives: To assess the use of etomidate in critically ill patients and compare outcomes for patients who received etomidate versus ketamine. Methods: We assessed patients who received invasive mechanical ventilation (IMV) and were admitted to an ICU in the Premier Healthcare Database between 2008 and 2021. The exposure was receipt of etomidate on the day of IMV initiation, and the main outcome was hospital mortality. Using multivariable regression, we compared patients who received IMV within the first 2 days of hospitalization who received etomidate with propensity score-matched patients who received ketamine. We also assessed whether receipt of corticosteroids in the days after intubation modified the association between etomidate and mortality. Measurements and Main Results: Of 1,689,945 patients who received IMV, nearly half (738,855; 43.7%) received etomidate. Among those who received IMV in the first 2 days of hospitalization, we established 22,273 matched pairs administered either etomidate or ketamine. In the primary analysis, receipt of etomidate was associated with greater hospital mortality relative to ketamine (21.6% vs. 18.7%; absolute risk difference, 2.8%; 95% confidence interval, 2.1%, 3.6%; adjusted odds ratio, 1.28, 95% confidence interval, 1.21,1.34). This was consistent across subgroups and sensitivity analyses. We found no attenuation of the association with mortality with receipt of corticosteroids in the days after etomidate use. Conclusions: Use of etomidate on the day of IMV initiation is common and associated with a higher odds of hospital mortality than use of ketamine. This finding is independent of subsequent treatment with corticosteroids.

Development and external validation of an interpretable machine learning model for the prediction of intubation in the intensive care unit

Given the limited capacity to accurately determine the necessity for intubation in intensive care unit settings, this study aimed to develop and externally validate an interpretable machine learning model capable of predicting the need for intubation among ICU patients. Seven widely used machine learning (ML) algorithms were employed to construct the prediction models. Adult patients from the Medical Information Mart for Intensive Care IV database who stayed in the ICU for longer than 24 h were included in the development and internal validation. The model was subsequently externally validated using the eICU-CRD database. In addition, the SHapley Additive exPlanations method was employed to interpret the influence of individual parameters on the predictions made by the model. A total of 11,988 patients were included in the final cohort for this study. The CatBoost model demonstrated the best performance (AUC: 0.881). In the external validation set, the efficacy of our model was also confirmed (AUC: 0.750), which suggests robust generalization capabilities. The Glasgow Coma Scale (GCS), body mass index (BMI), arterial partial pressure of oxygen (PaO2), respiratory rate (RR) and length of stay (LOS) before ICU were the top 5 features of the CatBoost model with the greatest impact. We developed an externally validated CatBoost model that accurately predicts the need for intubation in ICU patients within 24 to 96 h of admission, facilitating clinical decision-making and has the potential to improve patient outcomes. The prediction model utilizes readily obtainable monitoring parameters and integrates the SHAP method to enhance interpretability, providing clinicians with clear insights into the factors influencing predictions.

Direct Laryngoscopy Versus Video Laryngoscopy for Intubation in Critically Ill Patients: A Systematic Review, Meta-Analysis, and Trial Sequential Analysis of Randomized Trials

OBJECTIVES

Given the uncertainty regarding the optimal approach to laryngoscopy for the intubation of critically ill adult patients, we conducted a systematic review and meta-analysis to compare video laryngoscopy (VL) vs. direct laryngoscopy (DL) for intubation in emergency department and ICU patients.

DATA SOURCES

We searched MEDLINE, PubMed, Embase, Cochrane Library, and unpublished sources, from inception to February 27, 2024.

STUDY SELECTION

We included randomized controlled trials (RCTs) of critically ill adult patients randomized to VL compared with DL for endotracheal intubation.

DATA EXTRACTION

Reviewers screened abstracts, full texts, and extracted data independently and in duplicate. We pooled data using a random-effects model, assessed risk of bias using the modified Cochrane tool and certainty of evidence using the Grading Recommendations Assessment, Development, and Evaluation approach. We pre-registered the protocol on PROSPERO (CRD42023469945).

DATA SYNTHESIS

We included 20 RCTs ( n = 4569 patients). Compared with DL, VL probably increases first pass success (FPS) (relative risk [RR], 1.13; 95% CI, 1.06-1.21; moderate certainty) and probably decreases esophageal intubations (RR, 0.47; 95% CI, 0.27-0.82; moderate certainty). VL may result in fewer aspiration events (RR, 0.74; 95% CI, 0.51-1.09; low certainty) and dental injuries (RR, 0.46; 95% CI, 0.19-1.11; low certainty) and may have no effect on mortality (RR, 0.97; 95% CI, 0.88-1.07; low certainty) compared with DL.

CONCLUSIONS

In critically ill adult patients undergoing intubation, the use of VL, compared with DL, probably leads to higher rates of FPS and probably decreases esophageal intubations. VL may result in fewer dental injuries as well as aspiration events compared with DL with no effect on mortality.

The use of vasopressors to reduce post-intubation hypotension in critically ill adult patients undergoing emergent endotracheal intubation: a scoping review

INTRODUCTION

Patients requiring emergent endotracheal intubation are at higher risk of post-intubation hypotension due to altered physiology in critical illness. Post-intubation hypotension increases mortality and hospital length of stay, however, the impact of vasopressors on its incidence and outcomes is not known. This scoping review identified studies reporting hemodynamic data in patients undergoing emergent intubation to provide a literature overview on post-intubation hypotension in cohorts that did and did not receive vasopressors.

METHODS

A systematic search of CINAHL, Cochrane, EMBASE and PubMed-Medline was performed from database inception until September 28, 2023. Two independent reviewers completed the title and abstract screen, full text review and data extraction per PRISMA guidelines. Studies including patients < 18 years or intubations during cardiac arrest were excluded. Primary outcome was the presence of hypotension within 30 min of emergent intubation. Secondary outcomes included mortality at 1 h and in-hospital.

RESULTS

The systematic search yielded 13,126 articles, with 61 selected for final inclusion. There were 24,547 patients with a mean age of 57.2 years and a slight male predominance (63.8%). Respiratory failure was the most common intubation indication. Across 18 studies reporting on vasopressor use prior to intubation, 1171/7085 patients received vasopressors pre-intubation. Post-intubation hypotension occurred in 22.2% of patients across all studies, and in 34.3% of patients in studies where vasopressor administration pre-intubation was specifically reported. One-hour mortality of patients across all studies and within the vasopressor use studies was 1.2% and 1.6%, respectively. In-hospital mortality across studies was 21.5%, and 13.1% in studies which reported on vasopressor use pre-intubation.

CONCLUSION

Patients requiring emergent intubation have a high rate of post-intubation hypotension and in-hospital mortality. While there is an intuitive rationale for the use of vasopressors during emergent intubation, current evidence is limited to support a definitive change in clinical practice at this time.

The critical care literature 2023

The number of critically ill patients that present to emergency departments across the world continues to rise. In fact, the proportion of critically ill patients in emergency departments is now higher than pre-COVID-19 pandemic levels. [1] The emergency physician (EP) is typically the first physician to evaluate and resuscitate the critically ill patient. Given the continued shortage of intensive care unit (ICU) beds, persistent staff shortages, and overall inefficient hospital throughput, EPs are often tasked with providing intensive care to these patients long beyond the initial resuscitation phase. Prolonged boarding of critically ill patients in the ED is associated with increased ICU and hospital length of stay, increased adverse events, ED staff burnout, decreased patient and family satisfaction, and, most importantly, increased mortality. [2-5]. As such, it is imperative for the EP to be knowledgeable about recent literature in resuscitation and critical care medicine, so that critically ill ED patients can continue to receive the best, most up-to-date evidence-based care. This review summarizes important articles published in 2023 that pertain to the resuscitation and management of select critically ill ED patients. Topics included in this article include cardiac arrest, post-cardiac arrest care, septic shock, rapid sequence intubation, severe pneumonia, transfusions, trauma, and critical procedures.

Mortality Prediction of Biochemical Parameters in Patients Intubated in the Emergency Department

Introduction Tracheal intubation is a high-risk airway management protocol frequently applied in patients with critical illnesses. Numerous parameters have been suggested to predict mortality in these patients. Blood gas analysis, electrolyte levels, enzyme activities, and other biochemical measurements provide insights into a patient's metabolic status and organ functions. Accordingly, it is considered that these parameters have a significant potential for predicting the clinical outcomes of intubated patients. The study aimed to investigate the role of biochemical parameters in determining the 24-hour mortality risk of patients intubated in the emergency department and understand the potential significance of these parameters in predicting the clinical prognosis of these patients. Methods The present study was conducted on 1,236 patients who were intubated within a 1.5-year period at the Emergency Medicine Clinic of a tertiary Education and Research Hospital. Lactate, hemoglobin (Hgb), platelets (PLT), pH, HCO3, K, urea, creatinine, high-sensitivity troponin I (HS troponin I), and serum sodium levels were recorded for each patient in a data form. The 24-hour mortality rates were then analyzed based on these test results and comorbidities in the patients, and the data were recorded. Results The study included 702 patients after reviewing 1,236 cases. The median/mean values of HCO3, PLT, and pH were significantly higher in survivors compared to those who did not survive within 24 hours. Conversely, the median/mean values of lactate, creatinine, potassium, and HS troponin I were significantly higher in the patients who lost their lives within 24 hours than in the survivors. Epilepsy status, HCO3, lactate, potassium, and PLT values were statistically significant in the multivariate model in predicting 24-hour mortality. Conclusion The results of this study indicate that specific laboratory values, particularly blood gas analysis, play a significant role in predicting mortality among patients who present to the emergency department and undergo rapid sequence intubation. Patient prognosis can be predicted using these parameters, and treatment can be planned accordingly. Future multicenter prospective studies using standardized patient-specific intubation could provide further evidence for using the parameters in question in predicting mortality.

Emergency medicine updates: Endotracheal intubation

INTRODUCTION

Airway management including endotracheal intubation (ETI) is a key skill for emergency clinicians. Therefore, it is important for emergency clinicians to be aware of the current evidence regarding the identification and management of patients requiring ETI.

OBJECTIVE

This paper evaluates key evidence-based updates concerning ETI for the emergency clinician.

DISCUSSION

ETI is commonly performed in the emergency department (ED) setting but has many nuanced components. There are several tools that have been used to predict a difficult airway which incorporate anatomic and physiologic features. While helpful, these tools should not be used in isolation. Preoxygenation and apneic oxygenation are recommended to reduce the risk of desaturation and patient decompensation, particularly with noninvasive ventilation in critically ill patients. Induction and neuromuscular blocking medications should be tailored to the clinical scenario. Video laryngoscopy is superior to direct laryngoscopy among novice users, while both techniques are reasonable among more experienced clinicians. Recent literature suggests using a bougie during the first attempt. Point-of-care ultrasound is helpful for confirming correct placement and depth of the endotracheal tube.

CONCLUSIONS

An understanding of literature updates can improve the ED care of patients requiring emergent intubation.

Video laryngoscopy may improve the intubation outcomes in critically ill patients: a systematic review and meta-analysis of randomised controlled trials

BACKGROUND

The role of video laryngoscopy in critically ill patients requiring emergency tracheal intubation remains controversial. This systematic review and meta-analysis aimed to evaluate whether video laryngoscopy could improve the clinical outcomes of emergency tracheal intubation.

METHODS

We searched the PubMed, Embase, Scopus and Cochrane databases up to 5 September 2024. Randomised controlled trials comparing video laryngoscopy with direct laryngoscopy for emergency tracheal intubation were analysed. The primary outcome was the first-attempt success rate, while secondary outcomes included intubation time, glottic visualisation, in-hospital mortality and complications.

RESULTS

Twenty-six studies (6 in prehospital settings and 20 in hospital settings) involving 5952 patients were analysed in this study. Fifteen studies had low risk of bias. Overall, there was no significant difference in first-attempt success rate between two groups (RR 1.05, 95% CI 0.97 to 1.13, p=0.24, I2=89%). However, video laryngoscopy was associated with a higher first-attempt success rate in hospital settings (emergency department: RR 1.13, 95% CI 1.03 to 1.23, p=0.007, I2=85%; intensive care unit: RR 1.16, 95% CI 1.05 to 1.29, p=0.003, I2=68%) and among inexperienced operators (RR 1.15, 95% CI 1.03 to 1.28, p=0.01, I2=72%). Conversely, the first-attempt success rate with video laryngoscopy was lower in prehospital settings (RR 0.75, 95% CI 0.57 to 0.99, p=0.04, I2=95%). There were no differences for other outcomes except for better glottic visualisation (RR 1.11, 95% CI 1.03 to 1.20, p=0.005, I2=91%) and a lower incidence of oesophageal intubation (RR 0.42, 95% CI 0.24 to 0.71, p=0.001, I2=0%) when using video laryngoscopy.

CONCLUSIONS

In hospital settings, video laryngoscopy improved first-attempt success rate of emergency intubation, provided superior glottic visualisation and reduced incidence of oesophageal intubation in critically ill patients. Our findings support the routine use of video laryngoscopy in the emergency department and intensive care units.

PROSPERO REGISTRATION NUMBER

CRD 42023461887.

Tracheal intubation in critically ill adults with a physiologically difficult airway. An international Delphi study

PURPOSE

Our study aimed to provide consensus and expert clinical practice statements related to airway management in critically ill adults with a physiologically difficult airway (PDA).

METHODS

An international Steering Committee involving seven intensivists and one Delphi methodology expert was convened by the Society of Critical Care Anaesthesiologists (SOCCA) Physiologically Difficult Airway Task Force. The committee selected an international panel of 35 expert clinician-researchers with expertise in airway management in critically ill adults. A Delphi process based on an iterative approach was used to obtain the final consensus statements.

RESULTS

The Delphi process included seven survey rounds. A stable consensus was achieved for 53 (87%) out of 61 statements. The experts agreed that in addition to pathophysiological conditions, physiological alterations associated with pregnancy and obesity also constitute a physiologically difficult airway. They suggested having an intubation team consisting of at least three healthcare providers including two airway operators, implementing an appropriately designed checklist, and optimizing hemodynamics prior to tracheal intubation. Similarly, the experts agreed on the head elevated laryngoscopic position, routine use of videolaryngoscopy during the first attempt, preoxygenation with non-invasive ventilation, careful mask ventilation during the apneic phase, and attention to cardiorespiratory status for post-intubation care.

CONCLUSION

Using a Delphi method, agreement among a panel of international experts was reached for 53 statements providing guidance to clinicians worldwide on safe tracheal intubation practices in patients with a physiologically difficult airway to help improve patient outcomes. Well-designed studies are needed to assess the effects of these practice statements and address the remaining uncertainties.

Effects of Oxygenation Targets on Mortality in Critically Ill Patients in Intensive Care Units: A Systematic Review and Meta-Analysis

BACKGROUND

The effects of oxygenation targets (partial pressure of arterial oxygen [Pa o2 ], arterial oxygen saturation [Sa o2 ]/peripheral oxygen saturation [Sp o2 ], or inspiratory oxygen concentration [Fi o2 ] on clinical outcomes in critically ill patients remains controversial. We reviewed the existing literature to assess the effects of lower and higher oxygenation targets on the mortality rates of critically ill intensive care unit (ICU) patients.

METHODS

MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and Web of Science databases were searched from their dates of inception to December 31, 2022, for randomized controlled trials (RCTs) comparing lower and higher oxygenation targets for critically ill patients ≥18 years of age undergoing mechanical ventilation, nasal cannula, oxygen mask, or high-flow oxygen therapy in the ICU. Data extraction was conducted independently, and RoB 2.0 software was used to evaluate the quality of each RCT. A random-effects model was used for the meta-analysis to calculate the relative risk (RR). We used the I 2 statistic as a measure of statistical heterogeneity. Certainty of evidence was assessed according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) guidelines.

RESULTS

We included 12 studies with a total of 7416 patients participating in RCTs. Oxygenation targets were extremely heterogeneous between studies. The meta-analysis found no differences in mortality between lower and higher oxygenation targets for critically ill ICU patients (relative risk [RR], 1.00; 95% confidence interval [CI], 0.93-1.09; moderate certainty). The incidence of serious adverse events (RR, 0.93; 95% CI, 0.85-1.00; high certainty), mechanical ventilation-free days through day 28 (mean difference [MD], -0.05; 95%CI, -1.23 to 1.13; low certainty), the number of patients requiring renal replacement therapy (RRT) (RR, 0.96; 95% CI, 0.84-1.10; low certainty), and ICU length of stay (MD, 1.05; 95% CI, -0.04 to 2.13; very low certainty) also did not differ among patients with lower or higher oxygenation targets.

CONCLUSIONS

Critically ill ICU patients ≥18 years of age managed with lower and higher oxygenation targets did not differ in terms of mortality, RRT need, mechanical ventilation-free days through day 28, or ICU length of stay. However, due to considerable heterogeneity between specific targets in individual studies, no conclusion can be drawn regarding the effect of oxygenation targets on ICU outcomes.

Extubation-Related Complications

Extubation represents an essential component of airway management. While being a common procedure in anesthesiology and critical care medicine, it is accompanied by a significant risk of morbidity and mortality. Safe extubation requires considerable skills, risk stratification and advanced planning. It is important to emphasize that intentional extubation is always an elective procedure, and as such should only be executed when conditions are optimal. The purpose of this review is to discuss the complications associated with planned extubation in the adult patient, including risk factors and management strategies, mainly focusing on the postoperative setting.

Alfentanil versus fentanyl for emergency department rapid sequence induction with ketamine: A-FAKT, a pilot randomized trial

BACKGROUND

Fentanyl is often administered during rapid sequence induction of anesthesia (RSI) in the emergency department (ED) to ameliorate the hypertensive response that may occur. Due to its more rapid onset, the use of alfentanil may be more consistent with both the onset time of the sedative and the commencement of laryngoscopy. As such, we compared the effect of alfentanil and fentanyl on post-induction hemodynamic changes when administered as part of a standardized induction regimen including ketamine and rocuronium in ED RSI.

METHODS

This was a double-blind pilot randomized controlled trial of adult patients requiring RSI in the ED of three urban Australian hospitals. Patients were randomized to receive either alfentanil or fentanyl in addition to ketamine and rocuronium for RSI. Non-invasive blood pressure and heart rate were measured immediately before and at two, four, and six minutes after induction. The primary outcome was the occurrence of at least one post-induction systolic blood pressure outside the pre-specified range of 100-160mmHg (with adjustment for patients with baseline hypertension). Secondary outcomes included hypertension, hypotension, hypoxia, first-pass intubation success, 30-day mortality, and the pattern of hemodynamic changes.

RESULTS

A total of 61 patients were included in the final analysis (31 in the alfentanil group and 30 in the fentanyl group). The primary outcome was met in 58% of the alfentanil group and 50% of the fentanyl group (difference 8%, 95% confidence interval: -17% to 33%). The 30-day mortality rate, first-pass success rate, and incidences of hypertension, hypotension, and hypoxia were similar between the groups. There were no significant differences in systolic blood pressure or heart rate between the groups at any of the measured time-points.

CONCLUSION

Alfentanil and fentanyl produced comparable post-induction hemodynamic changes when used as adjuncts to ketamine in ED RSI. Future studies could consider comparing different dosages of these opioids.

Routine Use of Videolaryngoscopy in Airway Management

Tracheal intubation is a fundamental facet of airway management, for which the importance of achieving success at the first attempt is well recognized. Failure to do so can lead to significant morbidity and mortality if there is inadequate patient oxygenation by alternate means. The evidence supporting the benefits of a videolaryngoscope in attaining this objective is now overwhelming (in adults). This has led to its increasing recognition in international airway management guidelines and its promotion from an occasional airway rescue tool to the first-choice device during routine airway management. However, usage in clinical practice does not currently reflect the increased worldwide availability that followed the upsurge in videolaryngoscope purchasing during the coronavirus disease 2019 pandemic. There are a number of obstacles to widespread adoption, including lack of adequate training, fears over de-skilling at direct laryngoscopy, equipment and cleaning costs, and concerns over the environmental impact, among others. It is now clear that in order for patients to benefit maximally from the technology and for airway managers to fully appreciate its role in everyday practice, proper training and education are necessary. Recent research evidence has addressed some existing barriers to default usage, and the emergence of techniques such as awake videolaryngoscopy and video-assisted flexible (bronchoscopic) intubation has also increased the scope of clinical application. Future studies will likely further confirm the superiority of videolaryngoscopy over direct laryngoscopy, therefore, it is incumbent upon all airway managers (and their teams) to gain expertise in videolaryngoscopy and to use it routinely in their everyday practice..

Impact of non-invasive oxygen reserve index versus standard SpO2 monitoring on peripheral oxygen saturation during endotracheal intubation in the intensive care unit: Protocol for the randomized controlled trial NESOI2

In critically ill patients, endotracheal intubation (ETI) is lifesaving but carries a high risk of adverse events, notably hypoxemia. Preoxygenation is performed before introducing the tube to increase the safe apnea time. Oxygenation is monitored by pulse oximeter measurement of peripheral oxygen saturation (SpO2). However, SpO2 is unreliable at the high oxygenation levels produced by preoxygenation and, in the event of desaturation, may not decrease sufficiently early to allow preventive measures. The oxygen reserve index (ORI) is a dimensionless parameter that can also be measured continuously by a fingertip monitor and reflects oxygenation in the moderate hyperoxia range. The ORI ranges from 0 to 1 when arterial oxygen saturation (PaO2) varies between 100 to 200 mmHg, as occurs during preoxygenation. No trial has assessed the potential effects of ORI monitoring to guide preoxygenation for ETI in unstable patients. We designed a multicenter, two-arm, parallel-group, randomized, superiority, open trial in 950 critically ill adults requiring ETI. The intervention consists in monitoring ORI values and using an ORI target for preoxygenation of at least 0.6 for at least 1 minute. In the control group, preoxygenation is guided by SpO2 values recorded by a standard pulse oximeter, according to the standard of care, the goal being to obtain 100% SpO2 during preoxygenation, which lasts at least 3 minutes. The standard-of-care ETI technique is used in both arms. Baseline parameters, rapid-sequence induction medications, ETI devices, and physiological data are recorded. The primary outcome is the lowest SpO2 value from laryngoscopy to 2 minutes after successful ETI. Secondary outcomes include cognitive function on day 28. Assuming a 10% standard deviation for the lowest SpO2 value in the control group, no missing data, and crossover of 5% of patients, with the bilateral alpha risk set at 0.05, including 950 patients will provide 85% power for detecting a 2% between-group absolute difference in the lowest SpO2 value. Should ORI monitoring with a target of ≥0.6 be found to increase the lowest SpO2 value during ETI, then this trial may change current practice regarding preoxygenation for ETI. Trial registration: Registered on ClinicalTrials.gov (NCT05867875) on April 27, 2023.

Hyperangulated versus Macintosh blades for intubation with videolaryngoscopy in ICU: the randomised multicentre INVIBLADE-ICU trial study protocol

INTRODUCTION

Compared with the operating room, tracheal intubations in the intensive care unit (ICU) are associated with worsened glottic view, decreased first-time success rate and increase in the technical difficulty of intubation and incidence of complications. Videolaryngoscopes (VLs) have been proposed to improve airway management, and while recent studies have confirmed that VLs improve intubation conditions in this patient population, there remains a lack of clarity regarding the selection between a standard Macintosh blade or a hyperangulated one, to determine which yields the best outcomes. The purpose of this study was to compare successful intubation on the first attempt with the Macintosh VL versus the hyperangulated VL during tracheal intubation in ICU patients. We hypothesise that tracheal intubation using the hyperangulated VL will improve the frequency of successful intubation on the first attempt.

METHODS AND ANALYSIS

The INtubation VIdeolaryngoscopy BLADE-ICU trial is a prospective, multicentre, open-label, interventional, randomised, controlled superiority study conducted in 29 ICUs in Spain. Patients will be randomly assigned in a 1:1 ratio to undergo intubation using a Macintosh VL (control group) or a hyperangulated VL (experimental group) for the first intubation attempt. The primary outcome is successful intubation on the first attempt. The secondary outcomes include the time to intubation, attempts for successful intubation, laryngoscopic vision assessed with the modified Cormack-Lehane scale, the need for adjuvant airway devices for intubation, difficulty assessed by the anaesthesiologist and complications during tracheal intubation. Enrolment began on 1 May 2024 and is expected to be completed in 2025.

ETHICS AND DISSEMINATION

The study protocol was approved on 29 February 2024, by the Ethics Committee of Galicia (CEImG, code No. 2024-031).The results will be submitted for publication in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

NCT06322719.

Quality and safety in prehospital airway management - retrospective analysis of 18,000 cases from an air rescue database in Germany

BACKGROUND

Prehospital airway management remains crucial with regard to the quality and safety of emergency medical service (EMS) systems worldwide. In 2007, the benchmark study by Timmermann et al. hit the German EMS community hard by revealing a significant rate of undetected oesophageal intubations leading to an often-fatal outcome. Since then, much attention has been given to guideline development and training. This study evaluated the incidence and special circumstances of tube misplacement as an adverse peri-intubation event from a Helicopter Emergency Medical Services perspective.

METHODS

This was a retrospective analysis of a German helicopter-based EMS database from January 1, 2012, to December 31, 2020. All registered patients were included in the primary analysis. The results were analysed using SPSS 27.0.1.0.

RESULTS

Out of 227,459 emergency medical responses overall, a total of 18,087 (8.0%) involved invasive airway management. In 8141 (45.0%) of these patients, airway management devices were used by ground-based EMS staff, with an intubation rate of 96.6% (n = 7861), and alternative airways were used in 3.2% (n = 285). Overall, the rate of endotracheal intubation success was 94.7%, while adverse events in the form of tube misplacement were present in 5.3%, with a 1.2% rate of undetected oesophageal intubation. Overall tube misplacement and undetected oesophageal intubation occurred more often after intubation was carried out by paramedics (10.4% and 3.6%, respectively). In view of special circumstances, those errors occurred more often in the presence of trauma or cardiopulmonary resuscitation, with rates of 5.6% and 6.4%, respectively. Difficult airways with a Cormack 4 status were present in 2.1% (n = 213) of HEMS patients, accompanied by three or more intubation attempts in 5.2% (n = 11).

CONCLUSIONS

Prehospital airway management success has improved significantly in recent years. However, adverse peri-intubation events such as undetected oesophageal intubation remain a persistent threat to patient safety.

TRIAL REGISTRATION

The study was registered in the German Register for Clinical Studies (number DRKS00028068).