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Jarvis JL, Panchal AR, Lyng JW, Bosson N, Donofrio-Odmann JJ, Braude DA, Browne LR, Arinder M, Bolleter S, Gross T, Levy M, Lindbeck G, Maloney LM, Mattera CJ, Wang CT, Crowe RP, Gage CB, Lang ES, Sholl JM. Evidence-Based Guideline for Prehospital Airway Management. PREHOSP EMERG CARE 2023; 28:545-557. [PMID: 38133523 DOI: 10.1080/10903127.2023.2281363] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 11/05/2023] [Indexed: 12/23/2023]
Abstract
Airway management is a cornerstone of emergency medical care. This project aimed to create evidence-based guidelines based on the systematic review recently conducted by the Agency for Healthcare Research and Quality (AHRQ). A technical expert panel was assembled to review the evidence using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology. The panel made specific recommendations on the different PICO (population, intervention, comparison, outcome) questions reviewed in the AHRQ review and created good practice statements that summarize and operationalize these recommendations. The recommendations address the use of ventilation with bag-valve mask ventilation alone vs. supraglottic airways vs. endotracheal intubation for adults and children with cardiac arrest, medical emergencies, and trauma. Additional recommendations address the use of video laryngoscopy and drug-assisted airway management. These recommendations, and the associated good practice statements, offer EMS agencies and clinicians an opportunity to review the available evidence and incorporate it into their airway management strategies.
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Affiliation(s)
- Jeffrey L Jarvis
- Office of the Medical Director, Metropolitan Area EMS Authority, Fort Worth, Texas
| | - Ashish R Panchal
- National Registry of Emergency Medical Technicians, Columbus, Ohio
| | - John W Lyng
- Emergency Medicine, North Memorial Health Hospital Level 1 trauma center, Minneapolis, Minnesota
| | - Nichole Bosson
- EMS, Los Angeles County Department of Health Services, Los Angeles, California
| | | | - Darren A Braude
- Department of Emergency Medicine, The University of New Mexico, Albuquerque, New Mexico
| | - Lorin R Browne
- Department of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Michael Arinder
- EMS, Global Medical Response Inc., Greenwood Village, Colorado
| | - Scott Bolleter
- EMS, Healthcare Innovation & Sciences Centre, Spring Branch, Texas
| | - Toni Gross
- Department of Emergency Medicine, LCMC Health, New Orleans, Louisiana
| | | | - George Lindbeck
- National Registry of Emergency Medical Technicians, Columbus, Ohio
| | - Lauren M Maloney
- Department of Emergency Medicine, Stony Brook Medicine, Stony Brook, New York
| | | | - Cheng-Teng Wang
- Department of Emergency Medicine, Robert Wood Johnson University Hospital, New Brunswick, New Jersey
| | | | - Christopher B Gage
- Research, National Registry of Emergency Medical Technicians, Columbus, Ohio
| | - Eddy S Lang
- Department of Emergency Medicine, Alberta Health Services, Edmonton, Canada
| | - J Matthew Sholl
- National Registry of Emergency Medical Technicians, Columbus, Ohio
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2
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Chiang C, Teng WN, Chiang TY, Huang CL, Lin SP, Chang WK, Ting CK. True intratracheal oxygen concentration delivered by SentriO Oxy™ masks under various respiratory conditions: a bench study. J Clin Monit Comput 2023; 37:1489-1495. [PMID: 37828296 PMCID: PMC10651707 DOI: 10.1007/s10877-023-01076-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Accepted: 09/03/2023] [Indexed: 10/14/2023]
Abstract
SentriO Oxy™ is a newly available, Food and Drug Administration-approved oxygenation mask system that provides high oxygenation, even on low-flow (5-10 L/min) oxygen. This study aimed to accurately measure the intratracheal fraction of inspired oxygen (FiO2) using SentriO Oxy™ masks under relatively low oxygen flow rates. A manikin-ventilator-test lung simulation system was used. We measured FiO2 at the level of the carina, 5 minutes after applying 45 different respiratory parameter combinations using SentriO Oxy™ masks. Tidal volume (TV) was set to 300, 500, and 700 mL; respiratory rate (RR) was set to 8, 12, 16, 20, and 24 breaths per minute; and oxygen flow rate was set to 6, 8, and 10 L/min. Our hypothesis was that FiO2 would be proportional to the difference between oxygen flow rate and minute ventilation. FiO2 measured by smaller TV, lower RR, or higher oxygen flows revealed a significantly higher value, confirming our hypothesis. In addition, using linear regression analysis, we found that TV, RR, and oxygen flow were all significant factors influencing the measured FiO2. Our experiment proposed two prediction equations considering the oxygen flow rate, TV, and RR. The results of our study may provide information and prediction of FiO2 for clinicians to use SentriO Oxy™ masks during sedative anesthetic procedures under low oxygen flow rates.
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Affiliation(s)
- Cheng Chiang
- Department of Anesthesiology, Taipei Veterans General Hospital and National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Wei-Nung Teng
- Department of Anesthesiology, Taipei Veterans General Hospital and National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Ting-Yun Chiang
- Department of Anesthesiology, Taipei Veterans General Hospital and National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chao-Lan Huang
- Department of Anesthesiology, Taipei Veterans General Hospital and National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Shi-Pin Lin
- Department of Anesthesiology, Taipei Veterans General Hospital and National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Wen-Kuei Chang
- Department of Anesthesiology, Taipei Veterans General Hospital and National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Chien-Kun Ting
- Department of Anesthesiology, Taipei Veterans General Hospital and National Yang Ming Chiao Tung University, Taipei, Taiwan.
- Institute of Emergency and intensive care medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.
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3
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Di Pumpo F, Meloni G, Paganini M, Cialoni D, Garetto G, Cipriano A, Giacon TA, Martani L, Camporesi E, Bosco G. Comparison between Arterial Blood Gases and Oxygen Reserve Index™ in a SCUBA Diver: A Case Report. Healthcare (Basel) 2023; 11:healthcare11081102. [PMID: 37107936 PMCID: PMC10138174 DOI: 10.3390/healthcare11081102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 04/08/2023] [Accepted: 04/10/2023] [Indexed: 04/29/2023] Open
Abstract
Hypoxia and hyperoxia are both worrisome issues potentially affecting SCUBA divers, but validated methods to monitor these two conditions underwater are still lacking. In this experiment, a volunteer SCUBA diver was equipped with a pulse oximeter to detect peripheral oxygen saturation (SpO2) and a device to monitor the oxygen reserve index (ORi™). ORi™ values were compared with arterial blood oxygen saturation (SaO2) and the partial pressure of oxygen (PaO2) obtained from the cannulated right radial artery at three steps: at rest out of water; at -15 m underwater after pedaling on a submerged bike; after resurfacing. SpO2 and ORi™ mirrored the changes in SaO2 and PaO2, confirming the expected hyperoxia at depth. To confirm the potential usefulness of an integrated SpO2 and ORi™ device, further studies are needed on a broader sample with different underwater conditions and diving techniques.
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Affiliation(s)
- Fabio Di Pumpo
- Department of Biomedical Sciences, University of Padova, 35131 Padova, Italy
- ComSubIn, Italian Navy, 19025 Varignano-Le Grazie, Italy
| | | | - Matteo Paganini
- Department of Biomedical Sciences, University of Padova, 35131 Padova, Italy
| | - Danilo Cialoni
- Department of Biomedical Sciences, University of Padova, 35131 Padova, Italy
| | | | - Alessandro Cipriano
- Emergency Medicine Unit and Emergency Department, Nuovo Santa Chiara Hospital, Azienda Ospedaliero-Universitaria of Pisa, 56126 Pisa, Italy
| | | | - Luca Martani
- Department of Biomedical Sciences, University of Padova, 35131 Padova, Italy
| | - Enrico Camporesi
- Department of Biomedical Sciences, University of Padova, 35131 Padova, Italy
| | - Gerardo Bosco
- Department of Biomedical Sciences, University of Padova, 35131 Padova, Italy
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Dodds JM, Appelqvist DI, Paleologos MS, Downey RG. Variability in oxygen delivery with bag-valve-mask devices: An observational laboratory simulation study. Anaesth Intensive Care 2023; 51:130-140. [PMID: 36722019 DOI: 10.1177/0310057x221119824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
A bag-valve-mask (BVM) is a portable handheld medical device commonly used in airway management and manual ventilation. Outside of the operating theatre, BVM devices are often used to pre-oxygenate spontaneously breathing patients before intubation to reduce the risk of hypoxaemia. Pre-oxygenation is considered adequate when the end-tidal expiratory fraction of oxygen is greater than 0.85. There are reports that some BVM devices fail to deliver a satisfactory inspired oxygen (FiO2) in spontaneously breathing patients due to variability in design. The primary aim of this study was to evaluate the efficacy of oxygen delivery of a broad range of adult and paediatric BVM devices at increasing tidal volumes using a mechanical lung to simulate spontaneous ventilation. The secondary aim was to evaluate the effect of BVM design on performance.Forty BVM devices were evaluated in a laboratory setting as part of a safety assessment requested by HealthShare New South Wales. The oxygen inlet of each BVM device was primed with 100% oxygen (15 l/min) for two min. The BVM device was then attached to the mechanical lung and commenced spontaneous breathing at a fixed respiratory rate of 12 breaths/min with an inspiratory: expiratory ratio of 1:2. For each device FiO2 was measured after two min of spontaneous breathing. This process was repeated with small (250 ml), medium (500 ml) and large (750 ml) tidal volumes simulating adult breathing in adult BVM devices, and small (150 ml), medium (300 ml) and large (450 ml) tidal volumes simulating paediatric breathing in paediatric BVM devices. The test was repeated using up to five BVM devices of the same model (where supplied) at each tidal volume as a manufacturing quality control measure.Eight of the 40 devices tested failed to deliver a FiO2 above 0.85 for at least one tidal volume, and five models failed to achieve this at any measured tidal volume. Concerningly, three of these devices delivered a FiO2 below 0.55. Six of the eight poorly performing devices delivered reducing concentrations of inspired oxygen with increasing tidal volumes. Devices which performed the worst were those with a duckbill non-rebreather valve and without a dedicated expiratory valve.Several BVM devices available for clinical use in Australia did not deliver sufficient oxygen for reliable pre-oxygenation in a spontaneously breathing in vitro model. Devices with a duckbill non-rebreather valve and without a dedicated expiratory valve performed the worst. It is imperative that clinicians using BVM devices to deliver oxygen to spontaneously breathing patients are aware of the characteristics and limitations of the BVM devices, and that the standards for manufacture are updated to require safe performance in all clinical circumstances.
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Affiliation(s)
- Jarron M Dodds
- Department of Anaesthesia and Acute Pain Medicine, St Vincent's Hospital, Melbourne, Australia
| | | | - Michael S Paleologos
- Department of Anaesthesia, Royal Prince Alfred Hospital, Sydney, Australia.,Sydney Medical School, University of Sydney, Sydney, Australia
| | - Ryan G Downey
- Department of Anaesthesia, Royal Prince Alfred Hospital, Sydney, Australia.,Sydney Medical School, University of Sydney, Sydney, Australia
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George S, Wilson M, Humphreys S, Gibbons K, Long E, Schibler A. Apnoeic oxygenation during paediatric intubation: A systematic review. Front Pediatr 2022; 10:918148. [PMID: 36479287 PMCID: PMC9720125 DOI: 10.3389/fped.2022.918148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 10/20/2022] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE This review assesses the effect of apnoeic oxygenation during paediatric intubation on rates of hypoxaemia, successful intubation on the first attempt and other adverse events. DATA SOURCES The databases searched included PubMed, Medline, CINAHL, EMBASE and The Cochrane Library. An electronic search for unpublished studies was also performed. STUDY SELECTION We screened studies that include children undergoing intubation, studies that evaluate the use of apnoeic oxygenation by any method or device with outcomes of hypoxaemia, intubation outcome and adverse events were eligible for inclusion. DATA EXTRACTION Screening, risk of bias, quality of evidence and data extraction was performed by two independent reviewers, with conflicts resolved by a third reviewer where consensus could not be reached. DATA SYNTHESIS From 362 screened studies, fourteen studies (N = 2442) met the eligibility criteria. Randomised controlled trials (N = 482) and studies performed in the operating theatre (N = 835) favoured the use of apnoeic oxygenation with a reduced incidence of hypoxaemia (RR: 0.34, 95% CI: 0.24 to 0.47, p < 0.001, I 2 = 0% and RR: 0.27, 95% CI: 0.11 to 0.68, p = 0.005, I 2 = 68% respectively). Studies in the ED and PICU were of lower methodological quality, displaying heterogeneity in their results and were unsuitable for meta-analysis. Among the studies reporting first attempt intubation success, there were inconsistent effects reported and data were not suitable for meta-analysis. CONCLUSION There is a growing body of evidence to support the use of apnoeic oxygenation during the intubation of children. Further research is required to determine optimal flow rates and delivery technique. The use of humidified high-flow oxygen shows promise as an effective technique based on data in the operating theatre, however its efficacy has not been shown to be superior to low flow oxygen in either the elective anesthetic or emergency intubation situations Systematic Review Registration: This review was prospectively registered in the PROSPERO international register of systematic reviews (Reference: CRD42020170884, registered April 28, 2020).
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Affiliation(s)
- Shane George
- Departments of Emergency Medicine and Children's Critical Care, Gold Coast University Hospital, Southport, QLD, Australia.,School of Medicine and Menzies Health Institute Queensland, Griffith University, Southport, QLD, Australia.,Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
| | - Megan Wilson
- Emergency Department, Tweed Heads Hospital, Tweed Heads, NSW, Australia.,Emergency Department, Lismore Base Hospital, Lismore, NSW, Australia
| | - Susan Humphreys
- Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia.,Department of Anaesthesia, Queensland Children's Hospital, Brisbane, QLD, Australia
| | - Kristen Gibbons
- Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
| | - Elliot Long
- Department of Emergency Medicine, The Royal Children's Hospital, Melbourne, VIC, Australia.,Clinical Sciences, Murdoch Children's Research Institute, VIC, Australia.,Department of Critical Care, University of Melbourne, VIC, Australia
| | - Andreas Schibler
- Critical Care Research Group, Intensive Care Unit, St Andrews War Memorial Hospital, Brisbane, QLD, Australia.,Wesley Medical Research, Auchenflower, QLD, Australia
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Grauman S, Johansson J, Drevhammar T. Large variations of oxygen delivery in self-inflating resuscitation bags used for preoxygenation - a mechanical simulation. Scand J Trauma Resusc Emerg Med 2021; 29:98. [PMID: 34281616 PMCID: PMC8290536 DOI: 10.1186/s13049-021-00885-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 05/11/2021] [Indexed: 11/23/2022] Open
Abstract
Background Self-Inflating Resuscitation Bags (SIRB) are common and essential tools in airway management and ventilation. They are often used in resuscitation and emergency anaesthesia outside the operating theatre. There is a common notion that all SIRBs applied with a tight sealed mask will deliver close to 100 % oxygen during spontaneous breathing. The aim of the study was to measure the oxygen delivery of six commonly used SIRBs in a mechanical spontaneous breathing adult in vitro model. Methods Three SIRBs of each of the six models were evaluated for oxygen delivery during simulated breathing with an adult mechanical lung. The test was repeated three times per device (54 tests in total). The breathing profile was fixed to a minute volume of 10 L/min, a tidal volume of 500 mL and the SIRBs supplied with an oxygen fresh gas flow of 15 L/min. The fraction of delivered oxygen (FDO2) was measured over a three-minute period. Average FDO2 was calculated and compared at 30, 60 and 90 s. Results At 90 s all models had reached a stable FDO2. Average FDO2 at 90 s; Ambu Oval Plus 99,5 %; Ambu Spur II 99,8 %; Intersurgical BVM Resuscitator 76,7 %; Laerdal Silicone 97,3 %; Laerdal The Bag II 94,5 % and the O-Two Smart Bag 39,0 %. All differences in FDO2 were significant apart from the two Ambu models. Conclusions In simulated spontaneous breathing, four out of six (by Ambu and Laerdal) Self-Inflating Resuscitation Bags delivered a high fraction of oxygen while two (Intersurgical and O-two) underperformed in oxygen delivery. These large variations confirm results reported in other studies. It is our opinion that underperforming Self-Inflating Resuscitation Bags might pose a serious threat to patients’ health if used in resuscitation and anaesthesia. Manufacturers of Self-Inflating Resuscitation Bags rarely provide information on performance for spontaneous breathing. This poses a challenge to all organizations that need their devices to deliver adequate oxygen during spontaneous breathing.
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Affiliation(s)
- Sven Grauman
- Department of Anaesthesia and Intensive Care, Östersund Hospital, Region of Jämtland Härjedalen, 83183, Östersund, Sweden
| | - Joakim Johansson
- Department of Anaesthesia and Intensive Care, Östersund Hospital, Region of Jämtland Härjedalen, 83183, Östersund, Sweden.,Department of Surgical and Perioperative Sciences, Umeå University, 90187, Umeå, Sweden
| | - Thomas Drevhammar
- Department of Anaesthesia and Intensive Care, Östersund Hospital, Region of Jämtland Härjedalen, 83183, Östersund, Sweden. .,Department of Surgical and Perioperative Sciences, Umeå University, 90187, Umeå, Sweden. .,Department of Women's and Children's Health, Karolinska Institutet. Tomtebodavägen 18A, 17177, Stockholm, Sweden.
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Canadian Airway Focus Group updated consensus-based recommendations for management of the difficult airway: part 2. Planning and implementing safe management of the patient with an anticipated difficult airway. Can J Anaesth 2021; 68:1405-1436. [PMID: 34105065 PMCID: PMC8186352 DOI: 10.1007/s12630-021-02008-z] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 03/11/2021] [Accepted: 03/14/2021] [Indexed: 01/15/2023] Open
Abstract
PURPOSE Since the last Canadian Airway Focus Group (CAFG) guidelines were published in 2013, the published airway management literature has expanded substantially. The CAFG therefore re-convened to examine this literature and update practice recommendations. This second of two articles addresses airway evaluation, decision-making, and safe implementation of an airway management strategy when difficulty is anticipated. SOURCE Canadian Airway Focus Group members, including anesthesia, emergency medicine, and critical care physicians were assigned topics to search. Searches were run in the Medline, EMBASE, Cochrane Central Register of Controlled Trials, and CINAHL databases. Results were presented to the group and discussed during video conferences every two weeks from April 2018 to July 2020. These CAFG recommendations are based on the best available published evidence. Where high-quality evidence is lacking, statements are based on group consensus. FINDINGS AND KEY RECOMMENDATIONS Prior to airway management, a documented strategy should be formulated for every patient, based on airway evaluation. Bedside examination should seek predictors of difficulty with face-mask ventilation (FMV), tracheal intubation using video- or direct laryngoscopy (VL or DL), supraglottic airway use, as well as emergency front of neck airway access. Patient physiology and contextual issues should also be assessed. Predicted difficulty should prompt careful decision-making on how most safely to proceed with airway management. Awake tracheal intubation may provide an extra margin of safety when impossible VL or DL is predicted, when difficulty is predicted with more than one mode of airway management (e.g., tracheal intubation and FMV), or when predicted difficulty coincides with significant physiologic or contextual issues. If managing the patient after the induction of general anesthesia despite predicted difficulty, team briefing should include triggers for moving from one technique to the next, expert assistance should be sourced, and required equipment should be present. Unanticipated difficulty with airway management can always occur, so the airway manager should have a strategy for difficulty occurring in every patient, and the institution must make difficult airway equipment readily available. Tracheal extubation of the at-risk patient must also be carefully planned, including assessment of the patient's tolerance for withdrawal of airway support and whether re-intubation might be difficult.
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Jarvis JL, King T. Is adequate preoxygenation about more than just 3 minutes? J Am Coll Emerg Physicians Open 2020; 1:714-715. [PMID: 33145510 PMCID: PMC7593438 DOI: 10.1002/emp2.12291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 10/01/2020] [Accepted: 10/01/2020] [Indexed: 12/02/2022] Open
Affiliation(s)
- Jeffrey L. Jarvis
- Williamson County EMSGeorgetownTexasUSA
- University of Texas Health Science Center at HoustonHoustonTexasUSA
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Lee BA, Shin WJ, Jeong D, Choi JM, Gwak M, Song IK. Use of a High-Flow Nasal Cannula in a Child With a Functional Single Ventricle and Difficult Airway. J Cardiothorac Vasc Anesth 2020; 35:2128-2131. [PMID: 32888801 DOI: 10.1053/j.jvca.2020.08.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Revised: 08/04/2020] [Accepted: 08/05/2020] [Indexed: 11/11/2022]
Abstract
Inducing anesthesia and securing the airway without disrupting the patient's hemodynamic state are challenging in pediatric patients with a functional single ventricle (FSV). Here, the authors report effective use of a high-flow nasal cannula (HFNC) as a tool in providing oxygen supplementation for airway management in pediatric FSV patients with a history of a difficult airway. A female patient, aged 5 years 7 months, was admitted for extracardiac conduit Fontan procedure. The patient had a history of multiple failed attempts at endotracheal intubation and was diagnosed with retrognathia and severe oral trismus of less than 1 finger width. The patient had another event of mask ventilation failure after propofol sedation during the preoperative computed tomography scan a day before the surgery. The patient's preoperative cardiac catheterization report revealed that the Qp/Qs ratio of 0.82 at room air, and the patient's peripheral oxygen saturation (SpO2) ranged from 70% to 80% at room air. On entering the operating room, the preoxygenation process began with HFNC at an oxygen flow of 16 L/min, with a fraction of inspired oxygen (FIO2) set at 95% after light sedation with an intravenous bolus of midazolam, 0.1 mg/kg. After 4 minutes of applying HFNC, with SpO2 rising from 76% to 98%, anesthetic medications were administered intravenously without a neuromuscular blocking agent to preserve spontaneous breathing. The patient was not ventilated with a facemask but instead left with HFNC in place for continuous supplemental oxygenation. The patient's airway was secured in a single attempt in 80 seconds. HFNC is an ideal option for oxygen supplementation during airway management of pediatric FSV patients, as their balance of pulmonary and systemic flow is perturbed easily by subtle physiologic alteration and therapeutic maneuvers during the induction of general anesthesia and highly susceptible to rapid desaturation and cardiovascular collapse, and should be considered as having a physiologically difficult airway.
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Affiliation(s)
- Byungdoo Andrew Lee
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Won-Jung Shin
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, Seoul, Republic of Korea; Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - DaUn Jeong
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Jae Moon Choi
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, Seoul, Republic of Korea
| | - Mijeung Gwak
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, Seoul, Republic of Korea; Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - In-Kyung Song
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, Seoul, Republic of Korea; Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea.
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10
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Difficult Intubation due to Penetrating Trauma from a Crossbow Bolt. Air Med J 2020; 39:300-302. [PMID: 32690309 DOI: 10.1016/j.amj.2020.03.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Accepted: 03/26/2020] [Indexed: 12/11/2022]
Abstract
We present the case of a patient with penetrating neck and craniofacial trauma from a self-inflicted crossbow bolt injury. This case highlights the challenges involved in prehospital airway management related to an in situ foreign object penetrating the oral cavity. We review the complications associated with such injuries and considerations for effective prehospital airway management.
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11
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Stoecklein HH, Kelly C, Kaji AH, Fantegrossi A, Carlson M, Fix ML, Madsen T, Walls RM, Brown CA. Multicenter Comparison of Nonsupine Versus Supine Positioning During Intubation in the Emergency Department: A National Emergency Airway Registry (NEAR) Study. Acad Emerg Med 2019; 26:1144-1151. [PMID: 31116893 DOI: 10.1111/acem.13805] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 05/11/2019] [Accepted: 05/18/2019] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
| | | | - Amy H. Kaji
- Department of Emergency Medicine Harbor–UCLA Torrance CA
| | | | - Margaret Carlson
- Division of Emergency Medicine University of Utah Salt Lake City UT
| | - Megan L. Fix
- Division of Emergency Medicine University of Utah Salt Lake City UT
| | - Troy Madsen
- Division of Emergency Medicine University of Utah Salt Lake City UT
| | - Ron M. Walls
- Department of Emergency Medicine Brigham and Women's Hospital Boston MA
| | - Calvin A. Brown
- Department of Emergency Medicine Brigham and Women's Hospital Boston MA
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13
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Caputo ND, Oliver M, West JR, Hackett R, Sakles JC. Use of End Tidal Oxygen Monitoring to Assess Preoxygenation During Rapid Sequence Intubation in the Emergency Department. Ann Emerg Med 2019; 74:410-415. [DOI: 10.1016/j.annemergmed.2019.01.038] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2018] [Revised: 01/21/2019] [Accepted: 01/22/2019] [Indexed: 12/20/2022]
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Kim HJ, Asai T. High-flow nasal oxygenation for anesthetic management. Korean J Anesthesiol 2019; 72:527-547. [PMID: 31163107 PMCID: PMC6900423 DOI: 10.4097/kja.19174] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 05/20/2019] [Indexed: 12/12/2022] Open
Abstract
High-flow nasal oxygenation (HFNO) is a promising new technique for anesthesiologists. The use of HFNO during the induction of anesthesia and during upper airway surgeries has been initiated, and its applications have been rapidly growing ever since. The advantages of this technique include its easy set-up, high tolerability, and its abilities to produce positive airway pressure and a high fraction of inspired oxygen and to influence the clearance of carbon dioxide to some extent. HFNO, via a nasal cannula, can provide oxygen both to patients who can breathe spontaneously and to those who are apneic; further, this technique does not interfere with bag-mask ventilation, attempts at laryngoscopy for tracheal intubation, and surgical procedures conducted in the airway. In this review, we describe the techniques associated with HFNO and the advantages and disadvantages of HFNO based on the current state of knowledge.
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Affiliation(s)
- Hyun Joo Kim
- Department of Anesthesiology and Pain Medicine, Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea
| | - Takashi Asai
- Department of Anesthesiology, Dokkyo Medical University Saitama Medical Center, Koshigaya, Japan
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15
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Goto T, Goto Y, Hagiwara Y, Okamoto H, Watase H, Hasegawa K. Advancing emergency airway management practice and research. Acute Med Surg 2019; 6:336-351. [PMID: 31592072 PMCID: PMC6773646 DOI: 10.1002/ams2.428] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Accepted: 04/11/2019] [Indexed: 12/11/2022] Open
Abstract
Emergency airway management is one of the vital resuscitative procedures undertaken in the emergency department (ED). Despite its clinical and research importance in the care of critically ill and injured patients, earlier studies have documented suboptimal intubation performance and high adverse event rates with a wide variation across the EDs. The optimal emergency airway management strategies remain to be established and their dissemination to the entire nation is a challenging task. This article reviews the current published works on emergency airway management with a focus on the use of airway management algorithms as well as the importance of first‐pass success and systematic use of rescue intubation strategies. Additionally, the review summarizes the current evidence for each of the important airway management processes, such as assessment of the difficult airway, preparation (e.g., positioning and oxygenation), intubation methods (e.g., rapid sequence intubation), medications (e.g., premedications, sedatives, and neuromuscular blockades), devices (e.g., direct and video laryngoscopy and supraglottic devises), and rescue intubation strategies (e.g., airway adjuncts and rescue intubators), as well as the airway management in distinct patient populations (i.e., trauma, cardiac arrest, and pediatric patients). Well‐designed, rigorously conducted, multicenter studies that prospectively and comprehensively characterize emergency airway management should provide clinicians with important opportunities for improving the quality and safety of airway management practice. Such data will not only advance research into the determination of optimal airway management strategies but also facilitate the development of clinical guidelines, which will, in turn, improve the outcomes of critically ill and injured patients in the ED.
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Affiliation(s)
- Tadahiro Goto
- Graduate School of Medical Sciences University of Fukui Fukui Japan
| | - Yukari Goto
- Department of Emergency and Critical Care Nagoya University Hospital Nagoya Aichi Japan
| | - Yusuke Hagiwara
- Department of Pediatric Emergency and Critical Care Medicine Tokyo Metropolitan Children's Medical Centre Fuchu Tokyo Japan
| | - Hiroshi Okamoto
- Department of Critical Care Medicine St. Luke's International Hospital Tokyo Japan
| | - Hiroko Watase
- Department of Surgery University of Washington Seattle Washington
| | - Kohei Hasegawa
- Department of Emergency Medicine Massachusetts General Hospital Harvard Medical School Boston Massachusetts
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16
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George S, Humphreys S, Williams T, Gelbart B, Chavan A, Rasmussen K, Ganeshalingham A, Erickson S, Ganu SS, Singhal N, Foster K, Gannon B, Gibbons K, Schlapbach LJ, Festa M, Dalziel S, Schibler A. Transnasal Humidified Rapid Insufflation Ventilatory Exchange in children requiring emergent intubation (Kids THRIVE): a protocol for a randomised controlled trial. BMJ Open 2019; 9:e025997. [PMID: 30787094 PMCID: PMC6398737 DOI: 10.1136/bmjopen-2018-025997] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Emergency intubation of children with abnormal respiratory or cardiac physiology is a high-risk procedure and associated with a high incidence of adverse events including hypoxemia. Successful emergency intubation is dependent on inter-related patient and operator factors. Preoxygenation has been used to maximise oxygen reserves in the patient and to prolong the safe apnoeic time during the intubation phase. Transnasal Humidified Rapid Insufflation Ventilatory Exchange (THRIVE) prolongs the safe apnoeic window for a safe intubation during elective intubation. We designed a clinical trial to test the hypothesis that THRIVE reduces the frequency of adverse and hypoxemic events during emergency intubation in children and to test the hypothesis that this treatment is cost-effective compared with standard care. METHODS AND ANALYSIS The Kids THRIVE trial is a multicentre randomised controlled trial performed in participating emergency departments and paediatric intensive care units. 960 infants and children aged 0-16 years requiring emergency intubation for all reasons will be enrolled and allocated to THRIVE or control in a 1:1 allocation with stratification by site, age (<1, 1-7 and >7 years) and operator (junior and senior). Children allocated to THRIVE will receive weight appropriate transnasal flow rates with 100% oxygen, whereas children in the control arm will not receive any transnasal oxygen insufflation. The primary outcomes are defined as follows: (1) hypoxemic event during the intubation phase defined as SpO2 <90% (patient-dependent variable) and (2) first intubation attempt success without hypoxemia (operator-dependent variable). Analyses will be conducted on an intention-to-treat basis. ETHICS AND DISSEMINATION Ethics approval for the protocol and consent process has been obtained (HREC/16/QRCH/81). The trial has been actively recruiting since May 2017. The study findings will be submitted for publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER ACTRN12617000147381.
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Affiliation(s)
- Shane George
- Children’s Critical Care Service, Gold Coast University Hospital, Southport, Queensland, Australia
- School of Medicine, Griffith University, Southport, Queensland, Australia
- Paediatric Critical Care Research Group (PCCRG), Queensland Children’s Hospital and The University of Queensland, Brisbane, Queensland, Australia
- Paediatric Research in Emergency Departments International Collaborative (PREDICT), Parkville, Victoria, Australia
- Paediatric Study Group, Australia and New Zealand Intensive Care Society (ANZICS PSG), Melbourne, Victoria, Australia
| | - Susan Humphreys
- Paediatric Critical Care Research Group (PCCRG), Queensland Children’s Hospital and The University of Queensland, Brisbane, Queensland, Australia
| | - Tara Williams
- Paediatric Critical Care Research Group (PCCRG), Queensland Children’s Hospital and The University of Queensland, Brisbane, Queensland, Australia
| | - Ben Gelbart
- Paediatric Intensive Care Unit, Royal Children’s Hospital Melbourne, Parkville, Victoria, Australia
- Murdoch Children’s Research Institute, Parkville, Victoria, Australia
| | - Arjun Chavan
- Paediatric Intensive Care Unit, The Townsville Hospital, Townsville, Queensland, Australia
| | - Katie Rasmussen
- Critical Care Division, Queensland Children’s Hospital, Brisbane, Queensland, Australia
- Paediatric Emergency Research Unit, Centre for Children’s Health Research, Children’s Health Queensland, Brisbane, Queensland, Australia
| | | | - Simon Erickson
- Paediatric Critical Care, Perth Children’s Hospital, Perth, Western Australia, Australia
| | - Subodh Suhas Ganu
- Department of Paediatric Critical Care Medicine, Women’s and Children’s Hospital, North Adelaide, South Australia, Australia
| | - Nitesh Singhal
- Paediatric Intensive Care Unit, Royal Alexandra Hospital for Children, Westmead, New South Wales, Australia
| | - Kelly Foster
- Paediatric Research in Emergency Departments International Collaborative (PREDICT), Parkville, Victoria, Australia
- Paediatric Emergency Research Unit, Centre for Children’s Health Research, Children’s Health Queensland, Brisbane, Queensland, Australia
| | - Brenda Gannon
- Centre for the Business and Economics of Health, The University of Queensland, Brisbane, Queensland, Australia
| | - Kristen Gibbons
- Paediatric Critical Care Research Group (PCCRG), Queensland Children’s Hospital and The University of Queensland, Brisbane, Queensland, Australia
| | - Luregn J Schlapbach
- Paediatric Critical Care Research Group (PCCRG), Queensland Children’s Hospital and The University of Queensland, Brisbane, Queensland, Australia
| | - Marino Festa
- Paediatric Study Group, Australia and New Zealand Intensive Care Society (ANZICS PSG), Melbourne, Victoria, Australia
- Paediatric Intensive Care Unit, Royal Alexandra Hospital for Children, Westmead, New South Wales, Australia
| | - Stuart Dalziel
- Paediatric Research in Emergency Departments International Collaborative (PREDICT), Parkville, Victoria, Australia
- Starship Children’s Hospital, Auckland, Auckland, New Zealand
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Andreas Schibler
- Paediatric Critical Care Research Group (PCCRG), Queensland Children’s Hospital and The University of Queensland, Brisbane, Queensland, Australia
- Paediatric Study Group, Australia and New Zealand Intensive Care Society (ANZICS PSG), Melbourne, Victoria, Australia
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17
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McKown AC, Casey JD, Russell DW, Joffe AM, Janz DR, Rice TW, Semler MW. Risk Factors for and Prediction of Hypoxemia during Tracheal Intubation of Critically Ill Adults. Ann Am Thorac Soc 2018; 15:1320-1327. [PMID: 30109943 PMCID: PMC6322012 DOI: 10.1513/annalsats.201802-118oc] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Accepted: 07/30/2018] [Indexed: 11/20/2022] Open
Abstract
RATIONALE Hypoxemia is a common complication during tracheal intubation of critically ill adults and is a frequently used endpoint in airway management research. Identifying patients likely to experience low oxygen saturations during tracheal intubation may be useful for clinical practice and clinical trials. OBJECTIVES To identify risk factors for lower oxygen saturations and severe hypoxemia during tracheal intubation of critically ill adults and develop prediction models for lowest oxygen saturation and hypoxemia. METHODS Using data on 433 intubations from two randomized trials, we developed linear and logistic regression models to identify preprocedural risk factors for lower arterial oxygen saturations and severe hypoxemia between induction and 2 minutes after intubation. Penalized regression was used to develop prediction models for lowest oxygen saturation after induction and severe hypoxemia. A simplified six-point score was derived to predict severe hypoxemia. RESULTS Among the 433 intubations, 426 had complete data and were included in the model. The mean (standard deviation) lowest oxygen saturation was 88% (14%); median (interquartile range) was 93% (83-98%). Independent predictors of severe hypoxemia included hypoxemic respiratory failure as the indication for intubation (odds ratio [OR], 2.70; 95% confidence interval [CI], 1.58-4.60), lower oxygen saturation at induction (OR, 0.92 per 1% increase; 95% CI, 0.89-0.96 per 1% increase), younger age (OR, 0.97 per 1-year increase; 95% CI, 0.95-0.99 per 1-year increase), higher body mass index (OR, 1.03 per 1 kg/m2; 95% CI, 1.00-1.06 per 1 kg/m2), race (OR, 4.58 for white vs. black; 95% CI, 1.97-10.67; OR, 4.47 for other vs. black; 95% CI, 1.19-16.84), and operator with fewer than 100 prior intubations (OR, 2.83; 95% CI, 1.37-5.85). A six-point score using the identified risk factors predicted severe hypoxemia with an area under the receiver operating curve of 0.714 (95% CI, 0.653 to 0.778). CONCLUSIONS Lowest oxygen saturation and severe hypoxemia during tracheal intubation in the intensive care unit can be accurately predicted using routinely available preprocedure clinical data, with saturation at induction and hypoxemic respiratory failure being the strongest predictors. A simple bedside score may identify patients at risk for hypoxemia during intubation to help target preventative interventions and facilitate enrichment in clinical trials.
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Affiliation(s)
- Andrew C McKown
- 1 Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jonathan D Casey
- 1 Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Derek W Russell
- 2 Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Aaron M Joffe
- 3 Department of Anesthesiology and Pain Medicine, University of Washington, Harborview Medical Center, Seattle, Washington; and
| | - David R Janz
- 4 Section of Pulmonary/Critical Care and Allergy/Immunology, Louisiana State University School of Medicine, New Orleans, Louisiana
| | - Todd W Rice
- 1 Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Matthew W Semler
- 1 Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
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18
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Confounding biases in the association between fentanyl use and hypotension after rapid sequence intubation. Am J Emerg Med 2018; 36:1694-1695. [DOI: 10.1016/j.ajem.2018.07.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 07/07/2018] [Indexed: 11/19/2022] Open
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19
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El-Orbany M. Apneic oxygenation during emergency airway management. Can J Anaesth 2018; 66:121. [DOI: 10.1007/s12630-018-1188-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 05/16/2018] [Indexed: 11/25/2022] Open
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20
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Jarvis JL, Gonzales J, Johns D, Sager L. Implementation of a Clinical Bundle to Reduce Out-of-Hospital Peri-intubation Hypoxia. Ann Emerg Med 2018. [PMID: 29530653 DOI: 10.1016/j.annemergmed.2018.01.044] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
STUDY OBJECTIVE Peri-intubation hypoxia is an important adverse event of out-of-hospital rapid sequence intubation. The aim of this project is to determine whether a clinical bundle encompassing positioning, apneic oxygenation, delayed sequence intubation, and goal-directed preoxygenation is associated with decreased peri-intubation hypoxia compared with standard out-of-hospital rapid sequence intubation. METHODS We conducted a retrospective, before-after study using data from a suburban emergency medical services (EMS) system in central Texas. The study population included all adults undergoing out-of-hospital intubation efforts, excluding those in cardiac arrest. The before-period intervention was standard rapid sequence intubation using apneic oxygenation at flush flow, ketamine, and a paralytic. The after-period intervention was a care bundle including patient positioning (elevated head, sniffing position), apneic oxygenation, delayed sequence intubation (administration of ketamine to facilitate patient relaxation and preoxygenation with a delayed administration of paralytics), and goal-directed preoxygenation. The primary outcome was the rate of peri-intubation hypoxia, defined as the percentage of patients with a saturation less than 90% during the intubation attempt. RESULTS The before group (October 2, 2013, to December 13, 2015) included 104 patients and the after group (August 8, 2015, to July 14, 2017) included 87 patients. The 2 groups were similar in regard to sex, age, weight, ethnicity, rate of trauma, initial oxygen saturation, rates of initial hypoxia, peri-intubation peak SpO2, preintubation pulse rate and systolic blood pressure, peri-intubation cardiac arrest, and first-pass and overall success rates. Compared with the before group, the after group experienced less peri-intubation hypoxia (44.2% versus 3.5%; difference -40.7% [95% confidence interval -49.5% to -32.1%]) and higher peri-intubation nadir SpO2 values (100% versus 93%; difference 5% [95% confidence interval 2% to 10%]). CONCLUSION In this single EMS system, a care bundle encompassing patient positioning, apneic oxygenation, delayed sequence intubation, and goal-directed preoxygenation was associated with lower rates of peri-intubation hypoxia than standard out-of-hospital rapid sequence intubation.
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Affiliation(s)
- Jeffrey L Jarvis
- Williamson County EMS, Georgetown, TX; Department of Emergency Medicine, Baylor Scott & White Healthcare, Temple, TX.
| | | | | | - Lauren Sager
- Department of Biostatistics, Baylor Scott & White Healthcare, Temple, TX
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21
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Sakles JC. Maintenance of Oxygenation During Rapid Sequence Intubation in the Emergency Department. Acad Emerg Med 2017; 24:1395-1404. [PMID: 28791775 DOI: 10.1111/acem.13271] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- John C. Sakles
- Department of Emergency Medicine; University of Arizona College of Medicine; Tucson AZ
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