The effect of body mass index on intubation success rates and complications during emergency airway management

Flexible endoscopic intubation in emergency medicine: A mixed-methods needs assessment

Objectives

This needs assessment aimed to improve understanding of flexible endoscopic intubation training and practice in emergency medicine (EM), providing insights to educators and practice leaders seeking to improve education and practices.

Methods

We conducted a multicenter, mixed-methods needs assessment of emergency physicians (EPs) incorporating focus groups and a survey. Focus groups comprised community EPs, academic EPs, and resident EPs. We analyzed focus group transcripts using grounded theory, qualitatively describing EM endoscopic intubation. The qualitative analysis shaped our survey instrument, which we deployed in cross-sectional fashion. We report survey data with descriptive statistics.

Results

Focus groups with 13 EPs identified three themes: indications for use of endoscopic intubation, factors impacting a physician's decision to endoscopically intubate, and attaining and maintaining endoscopic intubation competency. Of 257 surveyed EPs (33% response rate), 79% had received endoscopic intubation training during residency, though 82% had performed this procedure 10 or fewer times in their career. Despite 97% acknowledging the necessity of competency, only 23% felt highly confident in their ability to perform endoscopic intubation. Participants (93%) reported scarce opportunities to perform the procedure and identified factors believed to facilitate competency acquisition and maintenance, including opportunities to perform endoscopic intubation in practice (98%), local champions (93%), and performing nasopharyngoscopy (87%).

Conclusions

While most EPs acknowledged the importance of competency in endoscopic intubation, they reported scarce procedural opportunities and commonly expressed low confidence. Further research is needed on this topic, and we propose avenues to enhance education and practices related to endoscopic intubation. These include development of robust procedural curricula, support of local champions, and incorporating nasopharyngoscopy into EM practice.

Airway management and pulmonary aspiration during surgical interventions in pregnant women in the 2nd/3rd trimester and immediate postpartum - a retrospective study in a tertiary care university hospital

BACKGROUND

Pregnancy is associated with an increased risk of pulmonary aspiration during general anaesthesia, but the incidence of this complication is not well defined.

METHODS

We performed a retrospective database review in a tertiary care university hospital to determine the incidence of pulmonary aspiration in pregnant patients undergoing endotracheal intubation, with and without Rapid Sequence Induction (RSI), as well as face-mask ventilation and supraglottic airway devices. We included Patients in the 2nd or 3rd trimester of pregnancy and immediate postpartum undergoing surgical procedures. The primary endpoint was the occurrence of pulmonary aspiration.

RESULTS

Data from 2,390 patients undergoing general anaesthesia for cerclage of cervix uteri, manual removal of retained placenta, repair of obstetric laceration, or postpartum bleeding were retrospectively evaluated. A supraglottic airway device or face-mask ventilation was used in 1,425/2,390 (60%) of patients, while 638/2,390 (27%) were intubated. RSI was used in 522/638 (82%) of patients undergoing tracheal intubation, or 522/2,390 (22%) of the entire cohort. In-depth review of the charts, including 54 patients who had been initially classified as "possible pulmonary aspiration" by anaesthetists, revealed that this adverse event did not occur in the cohort.

CONCLUSIONS

In conclusion, in this obstetric surgery patient population at risk for pulmonary aspiration, supraglottic airway devices were used in approximately 60% of cases. Yet, no aspiration event was detected with either a supraglottic airway or endotracheal intubation.

Influence of Patient Weight on Prehospital Advanced Airway Procedure Success Rates

OBJECTIVE

Previous investigations of the relationship between obesity and difficult airway management have provided mixed results. Almost universally, these studies were conducted in the hospital setting, and the influence of patient body weight on successful prehospital airway management remains unclear. Because patient weight could be one readily identifiable risk factor for problematic airway interventions, we sought to evaluate this relationship.

METHODS

We conducted a retrospective analysis using the 2020 ESO Data Collaborative dataset. The inclusion criteria consisted of adult patients weighing >30kg with an attempted orotracheal intubation (OTI) and/or blind insertion airway device (BIAD) placement. Separate logistic regression models were developed to determine the influence of weight (dichotomized at 100 kg) on cumulative procedure success for OTI and BIAD, and linear regression models were used to identify trends for each across weight strata.

RESULTS

A total of 45,344 patients met inclusionary criteria, among which 40,668(89.7%) suffered from a medical emergency, followed by 3,130(6.9%) with traumatic injuries, and 1,546(3.4%) attributable to a combined medical-trauma etiology. Cardiac arrest occurred either prior to EMS arrival or at some point during EMS care in 38,210(84.3%) patients. OTI was attempted in 18,153(40.0%) patients, while 21,597(47.6%) had a BIAD attempt and 5,594(12.3%) had both airway types attempted. The overall cumulative insertion success rates for OTI and BIAD were 79.5% and 92.7%, respectively. Altogether, 2,711(6.0%) had no advanced airway of any type successfully placed, which represents the overall failed advanced airway rate. After controlling for patient age, sex, minority status, and call type (medical vs. trauma), weight >100kg was associated with decreased likelihood of cumulative OTI success (OR = 0.64, p < 0.001), but higher likelihood of cumulative BIAD success (OR = 1.31, p < 0.001). Cumulative OTI success was associated with a negative 0.6% linear trend per 5 kg of body weight (p < 0.001) while cumulative BIAD success had a 0.2% positive trend (p < 0.001).

CONCLUSION

This retrospective analysis of a national EMS database revealed that increasing patient weight was negatively associated with intubation success. A positive, but smaller, linear trend was observed for BIAD placement. Patient weight may be an easily identifiable predictor of difficult oral intubation and may be a consideration when selecting an airway management strategy.

Improvement in intubation success during COVID-19 pandemic with a simple and low-cost intervention: A quasi-experimental study

OBJECTIVES

primary objective: to improve the FPS rates after an educational intervention.

SECONDARY OBJECTIVE

to describe variables related to FPS in an ED and determine which ones were related to the highest number of attempts.

DESIGN

it was a prospective quasi-experimental study.

SETTING

done in an ED in a public Hospital in Argentina.

PATIENTS

there were patients of all ages with intubation in ED.

INTERVENTIONS

in the middle of the study, an educational intervention was done to improve FPS. Cognitive aids and pre- intubation Checklists were implemented.

MAIN VARIABLES OF INTEREST

the operator experience, the number of intubation attempts, intubation judgment, predictors of a difficult airway, Cormack score, assist devices, complications, blood pressure, heart rate, and pulse oximetry before and after intubation All the intubations were done by direct laryngoscopy (DL).

RESULTS

data from 266 patients were included of which 123 belonged to the basal period and 143 belonged to the post-intervention period. FPS percentage of the pre-intervention group was 69.9% (IC95%: 60.89-77.68) whereas the post-intervention group was 85.3% (IC95%: 78.20-90.48). The difference between these groups was statistically significant (p=0.002). Factors related to the highest number of attempts were low operator experience, Cormack-Lehane 3 score and no training.

CONCLUSIONS

a low-cost and simple educational intervention in airway management was significantly associated with improvement in FPS, reaching the same rate of FPS than in high income countries.

Safety, Efficacy, and Ease of Insertion of Gnana Laryngeal Airway (GLA-4): A Prospective Clinical Study Utilizing the Unique Laryngeal Mask Airway With a Suction Tubing

INTRODUCTION

Utilizing laryngeal mask airways to maintain patients' airways is advantageous because it enables the anesthesiologist to keep the patient spontaneously inhaling and is less traumatic to the airway than intubation. Newer designs such as the Gnana laryngeal mask airway design permit real-time suctioning while the mask is on a patient.

METHODS

This is a prospective observational study of the efficacy of Gnana laryngeal airway 4 (GLA-4) in 50 patients undergoing colonoscopy. Induction and maintenance of anesthesia were provided with propofol; GLA-4 was applied to secure the airway; and correct placement was verified.

RESULTS

Fifty patients were included in the study (44% female, 56% male, mean age: 56.5 years, mean BMI: 33.3). Twelve patients were assigned American Society of Anesthesiologists (ASA) class 2, and 38 were assigned ASA class 3. The first attempt of GLA-4 insertion was successful in 47 patients, and two attempts were required for the successful placement of the GLA-4 in two patients. The successful placement was not achieved in one patient. The average time to successful insertion was 27.1 ± 3.9s. The average volume of oropharyngeal secretions suctioned through the suction catheter was 9.96 ± 2.31 mL. No intraoperative or postoperative complications occurred in the 50 patients. There were no reports of sore throat, hoarseness, dysphagia, or cough immediately postop.

CONCLUSION

GLA-4 can be inserted safely with adequate periglottic occlusion. This laryngeal mask is unique and desirable due to its ability to evacuate oropharyngeal secretions while in place to prevent laryngospasm. To establish the role of GLA-4 in broader clinical situations, additional clinical trials and studies are required.

Obesity is Unlikely to be an Impediment to First-Pass Success During the Intubation of Critically Ill Patients

Background: Obesity has been described as a potential risk factor for difficult intubation among critically ill patients. Our primary aim was to further elucidate the association between obesity and first-pass success. Our secondary aim was to determine whether the use of hyper-angulated video laryngoscopy improves first-pass success compared to direct laryngoscopy when utilized for the intubation of critically ill obese patients. Study Design and Methods: A retrospective cohort study of adult patients undergoing endotracheal intubation outside of the operating room or emergency department between January 30, 2016 and May 1, 2020 at 3 campuses of an academic hospital system in the Bronx, NY. Our primary outcome was first-pass success of intubation. A multivariate logistic analysis was utilized to compare obesity status with first-pass success. Results: We identified 3791 critically ill patients who underwent endotracheal intubation of which 1417 were obese (body mass index [BMI] ≥ 30). The incidence of hyper-angulated video laryngoscopy increased over the study period. A total of 46.6% of obese patients underwent intubation with hyper-angulated video laryngoscopy as compared to 35.1% of the nonobese group. First-pass success was 79.2% among the entire cohort. Obesity status did not appear to be associated with first-pass success (adjusted odds ratio [OR] 1.07, 95% confidence interval [CI]: 090-1.27; P = .47). Hyper-angulated video laryngoscopy did not seem to improve first-pass success among obese patients as compared to nonobese patients (adjusted OR 1.21, 95% CI: 0.85-1.71; P = .29). These findings persisted even after redefining the obesity cutoff as BMI ≥ 40 and excluding patients intubated during cardiac arrests. Conclusion: We did not detect an association between obesity and first-pass success. Hyper-angulated video laryngoscopy did not appear offer additional benefit over direct laryngoscopy during the intubation of critically ill obese patients.

Comparison of Intubation Conditions Between Airtraq, McGrath Video Laryngoscopes, and Macintosh Under Conditions of Simulated Trauma Airway and Rapid Sequence Induction Intubation

BACKGROUND

Patients arriving at the emergency department with a potential cervical spine injury and immobilized in a rigid cervical collar often require emergency airway management and rapid sequence induction intubation (RSII). There have been several advances in airway management with the advent of channeled (Airtraq^Ⓡ; Prodol Meditec) and nonchanneled (McGrath^Ⓡ; Meditronics) video laryngoscopes, which enable intubation without the removal of the cervical collar, but their efficacy and superiority over conventional laryngoscopy (Macintosh) in the presence of a rigid cervical collar and cricoid pressure have not been evaluated.

OBJECTIVE

Our aim was to compare the channeled (Airtraq [group A]) and nonchanneled (McGrath [Group M]) video laryngoscopes with a conventional laryngoscope (Macintosh [Group C]) in a simulated trauma airway.

METHODS

A prospective randomized controlled study was conducted in a tertiary care center. Participants were 300 patients requiring general anesthesia (American Society of Anesthesiologists class I or II), of both sexes, and aged 18-60 years. Airway management was simulated without removal of a rigid cervical collar and using cricoid pressure during intubation. After RSI, patients were intubated with one of the study techniques according to randomization. Intubation time and intubation difficulty scale (IDS) score were noted.

RESULTS

Mean intubation time was 42.2 s in group C, 35.7 s in group M, and 21.8 s in group A (p = 0.001). Intubation was easy in group M and group A (median IDS score of 0; interquartile range [IQR] 0-1 for group M and median IDS score of 1; IQR 0-2 for group A and group C; p < 0.001). A higher proportion (95.1%) of patients had an IDS score of < 1 in group A.

CONCLUSIONS

The performance of RSII with cricoid pressure in the presence of a cervical collar was easier and more rapid with channeled video laryngoscope than with other techniques.

2022 American Society of Anesthesiologists Practice Guidelines for Management of the Difficult Airway

The American Society of Anesthesiologists; All India Difficult Airway Association; European Airway Management Society; European Society of Anaesthesiology and Intensive Care; Italian Society of Anesthesiology, Analgesia, Resuscitation and Intensive Care; Learning, Teaching and Investigation Difficult Airway Group; Society for Airway Management; Society for Ambulatory Anesthesia; Society for Head and Neck Anesthesia; Society for Pediatric Anesthesia; Society of Critical Care Anesthesiologists; and the Trauma Anesthesiology Society present an updated report of the Practice Guidelines for Management of the Difficult Airway.

Multivariate Analysis of the Failure Risk of First Tracheal Intubation Attempt in a Population of Patients Scheduled for Bariatric Surgery

BACKGROUND

Airway management during the administration of anesthesia to patients undergoing bariatric surgery is challenging. The goal is to avoid multiple intubation attempts because the risk of complications increases with the number of attempts. The objective of this study was to determine the failed first intubation attempt rate, as well as variables associated with this failure, in patients undergoing bariatric surgery.

METHODS

We enrolled patients scheduled for bariatric surgery in this prospective, observational, single-center study. We determined predictive criteria for difficult intubation at the preoperative anesthesia consultation. All patients were evaluated for obstructive sleep apnea by polygraphy. The primary study endpoint was a failed first intubation attempt.

RESULTS

We enrolled 519 patients between December 2012 and January 2015. The cohort consisted of 425 women (82%), with a median (interquartile range [IQR]) age of 39 (30-50) years and a body mass index of 42 (39-46) kg/m². The first intubation attempt failed in 60 patients, with an incidence rate of 11.5% (95% confidence interval [CI], 8.8-14.2%). We included nine variables in the final multivariate model. Two variables were associated with failed first intubation attempt: male sex (odds ratio [OR] [95% CI], 6.9% [2.5-18.7%]) and Mallampati score 3-4 (OR [95% CI], 2.2% [1.0-4.7%]).

CONCLUSIONS

In this morbidly obese population, the first intubation attempt failed in 11.5% of patients, and the risk factors for failure were male sex and a high Mallampati score.

Evaluating the Safety and Efficacy of Intraoperative Enteral Nutrition in Critically Ill Burn Patients: A Systematic Review and Meta-analysis

Major burn injuries incite a hypermetabolic response, and the initiation of early enteral nutrition is the standard of care in patients with large burns and contributes to improved outcomes. Perioperative fasting is a common cause of caloric deficits in burn patients and can be obviated with intraoperative enteral nutrition. However, the risks and benefits of this practice are unknown, and there is a concern for aspiration. We conducted a systematic review and meta-analysis to evaluate the safety and efficacy of intraoperative enteral nutrition. We performed a systematic literature search using PubMed, Scopus, and OvidSP MEDLINE databases. We identified studies that evaluated the effects of intraoperative enteral nutrition in adult burn patients compared to those undergoing routine perioperative fasting. We performed a meta-analysis on the incidence of mortality, pneumonia, wound infections, and aspiration in burn patients receiving intraoperative enteral nutrition. We identified seven articles for qualitative review and four for quantitative review (N = 83 patients). There were no statistically significant increases in the risk of mortality (odds ratio [OR] = 1.28, 95% confidence interval [CI]: 0.49, 3.31), wound infections (OR = 0.71, 95% CI: 0.16, 3.24), pneumonia (OR = 2.1, 95% CI: 0.7, 6.1), and aspiration (OR = 1.14, 95% CI: 0.07, 18.75) in patients receiving intraoperative enteral nutrition. Within individual studies, intraoperative enteral nutrition patients received significantly more calories than standard fasting patients. Intraoperative enteral nutrition may increase nutritional intake in burn patients without an increase in complications; however, this is based on limited studies. Randomized controlled trials are needed before recommendations on intraoperative enteral nutrition practice can be made.

Tracheal Ultrasound for the Accurate Confirmation of the Endotracheal Tube Position in Obese Patients

OBJECTIVES

Obesity is a serious disorder that may lead to numerous difficulties in endotracheal tube (ETT) management. This study investigated the potential of tracheal ultrasound (TUS) for the accurate confirmation of the ETT position in obese patients.

METHODS

A total of 68 obese patients undergoing tracheal intubation were enrolled in this study from January 2017 to June 2018. All patients received auscultation and TUS to evaluate the ETT position, which was ultimately verified by bronchoscopy. A correct position of the ETT was defined as placement at the trachea, whereas placement at the right/left main bronchus was classified as an incorrect position.

RESULTS

We found 58 correct placements of the ETT at the trachea, 8 incorrect placements at the right main bronchus, and 2 incorrect placements at the left main bronchus. Compared with auscultation, TUS showed higher accuracy (85.29% versus 67.65%; P = .005), sensitivity (84.48% versus 67.24%; P = .005), and specificity (90.00% versus 70.00%; P < .001), as well as lower rates of false-positive (10.00% versus 30.00%; P < .001) and false-negative (15.52% versus 32.76%; P = .005) results for detecting the correct placement of the ETT, defined as placement at the trachea.

CONCLUSIONS

Tracheal ultrasound is highly sensitive and specific in confirming the ETT position in obese patients.

Utilization of Resources by Patients Who Are Morbid and Super Obese Admitted to a Tertiary Care Center

OBJECTIVES

Data regarding the characteristics of patients who are morbidly and super obese, and the resources they use in nonbariatric hospital settings are limited. The aims of our study were to explore the frequency of inpatient admissions of patients who are morbid (body mass index [BMI] ≥ 40 kg/m) and super obese (BMI ≥ 50 kg/m), their specific characteristics, and to identify their utilization of hospital services and resources, 30-day readmission rates, safe patient handling equipment, and patient clinical outcomes.

METHODS

We conducted a retrospective chart review of adult patients hospitalized at our institution (n = 1670) who are morbidly obese or super obese. We collected and compared data regarding the characteristics of patients, the services and resources used, the use of any special handling equipment, and patient clinical outcomes.

RESULTS

After accounting for confounding variables, wound care and occupational therapy services were more likely to be required for the patients who are super obese (odds ratio [OR] = 1.49, P = 0.04) than for those who are morbidly obese (odds ratio [OR] = 1.36, P = 0.02). Use of safe patient handling devices was twice as likely for the super obese group (OR = 2.09, P < 0.01). There was no difference in mortality rates between the two patient groups (P = 0.81); patients who are super obese had higher odds of prolonged hospital stay by 32% (P = 0.009).

CONCLUSIONS

This study provides an understanding of the characteristics of patients with BMI of 40 kg/m or greater who are admitted to the hospital, the resources and services use, and their clinical outcomes. There is also a need to develop an organizational protocol to ensure safe handling using the right devices and activation of appropriate consult services.

Multicenter Comparison of Nonsupine Versus Supine Positioning During Intubation in the Emergency Department: A National Emergency Airway Registry (NEAR) Study

OBJECTIVE

Head-up positioning for preoxygenation and ramping for morbidly obese patients are well-accepted techniques, but the effect of head-up positioning with full torso elevation for all intubations is controversial. We compared first-pass success, adverse events, and glottic view between supine (SP) and nonsupine (NSP) positioning for emergency department (ED) patients undergoing orotracheal intubation.

METHODS

We performed a retrospective analysis of prospectively collected data for ED intubations over a 2-year period from 25 participating centers in the National Emergency Airway Registry (NEAR). We compared characteristics and outcomes for adult patients intubated orotracheally in SP and NSP positions with either a direct or video laryngoscope. We report odds ratios (OR) with 95% confidence interval (CI) for categorical variables and interquartile ranges with 95% CI for continuous variables. Our primary outcome was first-attempt intubation success and secondary outcomes were glottic views and peri-intubation adverse events.

RESULTS

Of 11,480 total intubations, 5.8% were performed in NSP. The NSP group included significantly more obese patients (OR = 2.2 [95% CI = 1.9-2.6]) and patients with a suspected difficult airway (OR = 1.8 [95% CI = 1.6-2.2]). First-pass success (adjusted OR = 1.1 [95% CI = 0.9-1.4]) and overall rate of grade I glottic views (OR = 1.1 [95% CI = 0.9-1.2]) were similar between groups while NSP had a significantly higher rate of grade I views when direct laryngoscopy was employed (OR = 1.27 [95% CI = 1.04-1.54]). NSP was associated with higher odds of any adverse event (OR = 1.4 [95% CI = 1.1-1.7]).

CONCLUSIONS

ED providers utilized SP in most ED intubations but were more likely to use NSP for patients who were obese or in whom they predicted a difficult airway. We found no differences in first-pass success between groups but total adverse events were more likely in NSP. A randomized trial comparing patient positioning during intubation in the ED is warranted.

The association of body mass index with difficult tracheal intubation management by direct laryngoscopy: a meta-analysis

BACKGROUND

Obesity is a serious disorder and may bring about many difficulties of perioperative management. A systematic review was conducted to assess the association between obesity and difficult intubation.

METHODS

We searched electronic databases for related reviews and references of meta-analyses on August 14, 2017. The databases of PubMed, Embase, and the Cochrane controlled trials register were searched compared obese with non-obese patients in which difficult intubation rate of the adult population were retrieved. Patients with a BMI ≥ 30 kg·m- 2 were considered obese. The primary outcome was difficult tracheal intubation; secondary outcomes were the rates of difficult laryngoscopy and Mallampati score ≥ 3. This review included papers published from 1998 to 2015.

RESULTS

This review included 204,303 participants in 16 studies. There was a statistically significant association between obesity and risk of difficult tracheal intubation (pooled RR = 2.04, 95% CI: 1.16-3.59, p = 0.01; I2 = 71%, p = 0.008, Power = 1.0). It also showed significantly association between obesity and risk of difficult laryngoscopy (pooled RR = 1.54, 95% CI: 1.25-1.89, p < 0.0001; I2 = 45%, p = 0.07, Power = 1.0), obesity and risk of Mallampati score ≥ 3 (pooled RR = 1.83, 95% CI: 1.24-2.69, p = 0.002; I2 = 81%, p < 0.00001, Power = 0.93). However, there were no association of obesity and risks of difficult intubation compared with non-obesity in the cohort studies (pooled RR = 3.41, 95% CI: 0.88-13.23, p = 0.08; I2 = 50%, p = 0.14) and the elective tracheal intubation (pooled RR = 2.31, 95% CI: 0.76-6.99, p = 0.14; I2 = 73%, p = 0.01), no associated with an increased risk of difficult laryngoscopy in the sniffing position (pooled RR = 2.00, 95% CI: 0.97-4.15, p = 0.06; I2 = 67%, p = 0.03).

CONCLUSION

Obesity was associated with an increased risk of difficult intubation, difficult laryngoscopy and Mallampati score ≥ 3 in adults patients undergoing general surgical procedures. However, there were no association of obesity and risks of difficult intubation compared with non-obesity in the cohort studies and the elective tracheal intubation, no associated with an increased risk of difficult laryngoscopy in the sniffing position. Future analyses should explore the association of BMI and difficult airway.

Associations of obesity with tracheal intubation success on first attempt and adverse events in the emergency department: An analysis of the multicenter prospective observational study in Japan

Obesity is deemed to increase the risk of difficult tracheal intubation. However, there is a dearth of research that examines the relationship of obesity with intubation success and adverse events in the emergency department (ED). We analyzed the data from a prospective, observational, multicenter study—the Japanese Emergency Airway Network (JEAN) 2 study from 2012 through 2016. We included all adults (aged ≥18 years) who underwent tracheal intubation in the ED. Patients were categorized into three groups according to their body mass index (BMI): lean (<25.0 kg/m²), overweight (25.0–29.9 kg/m²), and obesity (≥30.0 kg/m²). Outcomes of interest were intubation success on the first attempt and intubation-related adverse events. Of 6,889 patients who are eligible for the analysis, 5,370 patients (77%) were lean, 1,177 (17%) were overweight, and 342 (4%) were obese. Compared to the lean patients, the intubation success rates were significantly lower in the overweight and obese patients (70.9% in lean, 66.4% in overweight, and 59.3% in obese patients; P<0.001). In the multivariable analysis, compared to the lean patients, overweight (adjusted odds ratio [OR], 0.85; 95%CI, 0.74–0.98) and obese (adjusted OR, 0.62; 95%CI, 0.49–0.79) patients had a significantly lower success rate on the first attempt. Additionally, obesity was significantly associated with a higher risk of adverse events (adjusted OR, 1.62; 95%CI, 1.23–2.13). Based on the data from a multicenter prospectively study, obesity was associated with a lower success rate on the first intubation attempt and a higher risk of adverse event in the ED.

Difficult Tracheal Intubation in Obese Gastric Bypass patients

BACKGROUND

Endotracheal intubation is commonly perceived to be more difficult in obese patients than in lean patients. Primarily, we investigated the association between difficult tracheal intubation (DTI) and obesity, and secondarily, the association between DTI and validated scoring systems used to assess the airways, the association between DTI and quantities of anesthetics used to induce general anesthesia, and the association between DTI and difficulties with venous and arterial cannulation.

METHODS

This is a monocentric prospective observational clinical study of a consecutive series of 539 obese patients undergoing gastric bypass. Tracheal intubation was done preoperatively together with scoring of Intubation Score (IS), Mallampati (MLP), and Cormack-Lehane classification (CLC) and registration of the quantities of anesthetics and total attempts on cannulation.

RESULTS

The overall proportion of patients with DTI was 3.5 % and the patients with DTI were more frequently males, had higher CLC, higher American Society of Anesthesiologists physical status classification (ASA), and noticeably, a lower BMI compared to the patients with easy tracheal intubation. After adjustment with multivariable analyses body mass index (BMI) <40, CLC >2, ASA scores >2, and male gender were risk factors of DTI. Males generally had higher CLC, MLP, and ASA scores compared to females, but no difference in BMI. There was no difference in quantities of anesthetics used between the two groups with or without DTI. Intra-venous and intra-arterial cannulation was succeeded in first attempt in 85 and 86 % of the patients, respectively, and there were no association between BMI and difficult vascular access.

CONCLUSIONS

We found no association between increasing BMI and DTI.

The degree of intubation difficulties and the frequency of complications in obese patients at the Hospital Emergency Department and the Intensive Care Unit: Case-control study

The intubation difficulties in obese patients are not a new problem. They may result from an accumulation of fat in the oral cavity and cheeks. A thick tongue is also a significant factor. The literature reports that some tests to determine the intubation difficulties in obese people may be unreliable. The observed predictors of difficult intubation were the thyromental and sternomental distance and the intubation difficulty scale: FRONT score.The aim of this study was to assess the degree of difficult intubation in obese patients by the parameters such as the thyromental and sternomental distance. The authors also tried to evaluate the frequency of the guidewire usage and the number of intubation attempts in obese patients in the research sample.The study included the group of 153 patients intubated in prehospital conditions. The research was conducted in 3 clinical centers receiving patients from prehospital care. Among the members of the research sample, obese patients with body mass index >35 were selected and evaluated for various predictors of intubation difficulties. Quantitative analysis of differences in the incidence of the variables was assessed using the chi-squared test for P < 0.05. Analyses were performed in STATISTICA.Complications such as postintubation hematomas were more frequent in obese patients of the research sample. The frequency of the guidewire usage observed in that group was also higher. As anticipated by the adopted predictors, most of the obese patients were classified as difficult to intubate.There is a correlation between the occurrence of injuries and the prevalence of obesity in the research sample and the same dependency has been demonstrated in the issue concerning the use of the guidewire. Although the majority of predictors indicated patients with intubation difficulties, many predictors could show falsely positive results. The greater amount of intubation attempts was observed in obese patients. Further studies devoted to explain those correlations would be needed.

Outcomes of In-Hospital Cardiopulmonary Resuscitation in Morbidly Obese Patients

OBJECTIVES

This study sought to assess the impact of morbid obesity on outcomes in patients with in-hospital cardiac arrest (IHCA).

BACKGROUND

Obesity is associated with increased risk of out-of-hospital cardiac arrest; however, little is known about survival of morbidly obese patients with IHCA.

METHODS

Using the Nationwide Inpatient Sample database from 2001 to 2008, we identified adult patients undergoing resuscitation for IHCA, including those with morbid obesity (body mass index ≥40 kg/m²) by using International Classification of Diseases 9th edition codes and clinical outcomes. Outcomes including in-hospital mortality, length of stay, and discharge dispositions were identified. Logistic regression model was used to examine the independent association of morbid obesity with mortality.

RESULTS

Of 1,293,071 IHCA cases, 27,469 cases (2.1%) were morbidly obese. The overall mortality was significantly higher for the morbidly obese group than for the nonobese group experiencing in-hospital non-ventricular fibrillation (non-VF) (77% vs. 73%, respectively; p = 0.006) or VF (65% vs. 58%, respectively; p = 0.01) arrest particularly if cardiac arrest happened late (>7 days) after hospitalization. Discharge to home was significantly lower in the morbidly obese group (21% vs. 31%, respectively; p = 0.04). After we adjusted for baseline variables, morbid obesity remained an independent predictor of increased mortality. Other independent predictors of mortality were age and severe sepsis for non-VF and VF group and venous thromboembolism, cirrhosis, stroke, malignancy, and rheumatologic conditions for non-VF group.

CONCLUSIONS

The overall mortality of morbidly obese patients after IHCA is worse than that for nonobese patients, especially if IHCA occurs after 7 days of hospitalization and survivors are more likely to be transferred to a skilled nursing facility.

Bronchoscopic intubation is an effective airway strategy in critically ill patients

PURPOSE

American Society of Anesthesiologists guidelines recommend the use of bronchoscopic intubation as a rescue technique in critically ill patients. We sought to assess the safety and efficacy of bronchoscopic intubation as an initial approach in critically ill patients.

METHODS

We performed a retrospective cohort study of patients who underwent endotracheal intubation in the medical intensive care unit of a tertiary urban referral center over 1 academic year. The primary outcome was first-pass success rate.

MEASUREMENTS AND MAIN RESULTS

We identified 219 patients who underwent either bronchoscopic (n=52) or laryngoscopic guided (n=167) intubation as the initial attempt. There was a higher first-pass success rate in the bronchoscopic intubation group than in the laryngoscopic group (96% vs 78%; P=.003). The bronchoscopic intubation group had a higher body mass index (28.4 vs 25.9; P=.027) and higher preintubation fraction of inspired oxygen requirement (0.73±0.27 vs 0.63±0.30; P=.044) than the laryngoscopic group. There were no cases of right mainstem intubation, esophageal intubation, or pneumothorax with bronchoscopic intubation. Rates of postintubation hypotension and hypoxemia were similar in both groups. The association with first-pass success remained with multivariate and propensity matched analysis.

CONCLUSIONS

Bronchoscopic intubation as an initial strategy in critically ill patients is associated with a higher first-pass success rate than laryngoscopic intubation, and is not associated with an increase in complications.

Reintubation in critically ill patients: procedural complications and implications for care

Introduction

In critically ill patients, re-intubation is common and may be a high-risk procedure. Anticipating a difficult airway and identifying high-risk patients can allow time for life-saving preparation. Unfortunately, prospective studies have not compared the difficulty or complication rates associated with reintubation in this population.

Methods

We performed a secondary analysis of a prospective registry of in-hospital emergency airway management, focusing on patients that underwent multiple out-of-operating room intubations during a single hospitalization. Our main outcomes of interest were technical difficulty of intubation (number of attempts, need for adjuncts to direct laryngoscopy, best Cormack-Lehane grade and training level of final intubator) and the frequency of procedural complications (aspiration, arrhythmia, airway trauma, new hypotension, new hypoxia, esophageal intubation and cardiac arrest). We compared the cohort of reintubated patients to a matched cohort of singly intubated patients and compared each repeatedly intubated patient’s first and last intubation.

Results

Our registry included 1053 patients, of which 151 patients (14%) were repeatedly intubated (median two per patient). Complications were significantly more common during last intubation compared to first (13% versus 5%, P = 0.02). The most common complications were hypotension (41%) and hypoxia (35%). These occurred despite no difference in any measure of technical difficultly across intubations.

Conclusion

In this cohort of reintubated patients, clinically important procedural complications were significantly more common on last intubation compared to first.

Incidence and factors associated with cardiac arrest complicating emergency airway management

OBJECTIVE

Cardiac arrest (CA) is a rare but recognized complication of emergency airway management. Our aim was to measure the incidence of peri-intubation CA during emergency intubation and identify factors associated with this complication.

METHODS

Retrospective cohort study of emergency endotracheal intubations performed in a large, urban emergency department over a one-year period. Patients were included if they were >18 years old and not in CA prior to intubation. Multiple logistic regression modeling was used to define factors independently associated with CA.

RESULTS

A total 542 patients underwent emergency intubation during the study period and 410 met inclusion criteria for this study. CA occurred in 17/410 (4.2%) at a median of 6 min post-intubation. Nearly two-thirds of CA events occurred within 10 min of drug induction; early peri-intubation CA rate 2.4% (95% CI: 1.3-4.5%). Pulseless electrical activity was the initial rhythm in the majority of cases. More than half of CA events were successfully resuscitated but CA was associated with increased odds of hospital death (OR 14.8; 95% CI: 4.2-52). Pre-intubation hemodynamic and oximetry variables were associated with CA. CA was more common in patients experiencing pre intubation hypotension (12% vs 3%; p<0.002). Pre RSI shock index (SI) and weight were independently associated with CA.

CONCLUSIONS

In this series, 1 in 25 emergency intubations was associated with the complication of CA. Peri-intubation CA is associated with increased mortality. Pre-intubation patient characteristics are associated with this complication.