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Gómez-Ríos MÁ, Sastre JA, Onrubia-Fuertes X, López T, Abad-Gurumeta A, Casans-Francés R, Gómez-Ríos D, Garzón JC, Martínez-Pons V, Casalderrey-Rivas M, Fernández-Vaquero MÁ, Martínez-Hurtado E, Martín-Larrauri R, Reviriego-Agudo L, Gutierrez-Couto U, García-Fernández J, Serrano-Moraza A, Rodríguez Martín LJ, Camacho Leis C, Espinosa Ramírez S, Fandiño Orgeira JM, Vázquez Lima MJ, Mayo-Yáñez M, Parente-Arias P, Sistiaga-Suárez JA, Bernal-Sprekelsen M, Charco-Mora P. Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR), Spanish Society of Emergency and Emergency Medicine (SEMES) and Spanish Society of Otolaryngology, Head and Neck Surgery (SEORL-CCC) Guideline for difficult airway management. Part I. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2024; 71:171-206. [PMID: 38340791 DOI: 10.1016/j.redare.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 08/28/2023] [Indexed: 02/12/2024]
Abstract
The Airway Management section of the Spanish Society of Anesthesiology, Resuscitation, and Pain Therapy (SEDAR), the Spanish Society of Emergency Medicine (SEMES), and the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) present the Guide for the comprehensive management of difficult airway in adult patients. Its principles are focused on the human factors, cognitive processes for decision-making in critical situations, and optimization in the progression of strategies application to preserve adequate alveolar oxygenation in order to enhance safety and the quality of care. The document provides evidence-based recommendations, theoretical-educational tools, and implementation tools, mainly cognitive aids, applicable to airway management in the fields of anesthesiology, critical care, emergencies, and prehospital medicine. For this purpose, an extensive literature search was conducted following PRISMA-R guidelines and was analyzed using the GRADE methodology. Recommendations were formulated according to the GRADE methodology. Recommendations for sections with low-quality evidence were based on expert opinion through consensus reached via a Delphi questionnaire.
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Affiliation(s)
- M Á Gómez-Ríos
- Anesthesiology and Perioperative Medicine. Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain.
| | - J A Sastre
- Anesthesiology and Perioperative Medicine. Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - X Onrubia-Fuertes
- Department of Anesthesiology, Hospital Universitari Dr Peset, Valencia, Spain
| | - T López
- Anesthesiology and Perioperative Medicine. Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - A Abad-Gurumeta
- Department of Anesthesiology, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - R Casans-Francés
- Department of Anesthesiology. Hospital Universitario Infanta Elena, Valdemoro, Madrid, Spain
| | | | - J C Garzón
- Anesthesiology and Perioperative Medicine. Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - V Martínez-Pons
- Department of Anesthesiology, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - M Casalderrey-Rivas
- Department of Anesthesiology, Complejo Hospitalario Universitario de Ourense, Ourense, Spain
| | - M Á Fernández-Vaquero
- Department of Anesthesiology, Hospital Clínica Universitaria de Navarra, Madrid, Spain
| | - E Martínez-Hurtado
- Department of Anesthesiology, Hospital Universitario Infanta Leonor, Madrid, Spain
| | | | - L Reviriego-Agudo
- Department of Anesthesiology. Hospital Clínico Universitario, Valencia, Spain
| | - U Gutierrez-Couto
- Biblioteca, Complejo Hospitalario Universitario de Ferrol (CHUF), Ferrol, A Coruña, Spain
| | - J García-Fernández
- Department of Anesthesiology, Hospital Universitario Puerta de Hierro-Majadahonda, Majadahonda, Madrid, Spain; President of the Spanish Society of Anesthesiology, Resuscitation and Pain Therapy (SEDAR), Spain
| | | | | | | | | | - J M Fandiño Orgeira
- Servicio de Urgencias, Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain
| | - M J Vázquez Lima
- Emergency Department, Hospital do Salnes, Vilagarcía de Arousa, Pontevedra, Spain; President of the Spanish Emergency Medicine Society (SEMES), Spain
| | - M Mayo-Yáñez
- Department of Otorhinolaryngology/Head Neck Surgery, Complexo Hospitalario Universitario A Coruña, A Coruña, Spain
| | - P Parente-Arias
- Department of Otorhinolaryngology/Head Neck Surgery, Complexo Hospitalario Universitario A Coruña, A Coruña, Spain
| | - J A Sistiaga-Suárez
- Department of Otorhinolaryngology, Hospital Universitario Donostia, Donostia, Gipuzkoa, Spain
| | - M Bernal-Sprekelsen
- Department of Otorhinolaryngology, Hospital Clínic Barcelona, University of Barcelona, Barcelona, Spain; President of the Spanish Society for Otorhinolaryngology Head & Neck Surgery (SEORL-CCC), Spain
| | - P Charco-Mora
- Department of Anesthesiology, Hospital Universitari i Politècnic La Fe, Valencia, Spain
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Steinberg I, Nabecker S, Greif R, Cortese G. Teaching airway teachers: a post-course quantitative and qualitative survey. BMC MEDICAL EDUCATION 2024; 24:123. [PMID: 38326744 PMCID: PMC10848376 DOI: 10.1186/s12909-023-04912-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 11/28/2023] [Indexed: 02/09/2024]
Abstract
BACKGROUND Airway management is a crucial skill for many clinicians. Besides mastering the technical skills of establishing a patent airway, human factors including leadership and team collaboration are essential. Teaching these human factors is often challenging for instructors who lack dedicated training. Therefore, the European Airway Management Society (EAMS) developed the Teach-the-Airway-Teacher (TAT) course. METHODS This online post-course survey of TAT-course participants 2013-2021 investigated the impact of the TAT-course and the status of airway management teaching in Europe. Twenty-eight questions e-mailed to participants (using SurveyMonkey) assessed the courses' strengths and possible improvements. It covered participants' and workplace details; after TAT-course considerations; and specifics of local airway teaching. Data were assessed using Excel and R. RESULTS Fifty-six percent (119/213) of TAT-participants answered the survey. Most were anaesthetists (84%), working in university level hospitals (76%). Seventy-five percent changed their airway teaching in some way, but 20% changed it entirely. The major identified limitation to airway teaching in their departments was "lack of dedicated resources" (63%), and the most important educational topic was "Teaching non-technical skills" (70%). "Lecturing " was considered less important (37%). Most surveyed anaesthesia departments lack a standardized airway teaching rotation. Twenty-one percent of TAT-participants rated their departmental level of airway teaching overall as inadequate. CONCLUSIONS This survey shows that the TAT-course purpose was successfully fulfilled, as most TAT-course participants changed their airway teaching approach and did obtain the EAMS-certificate. The feedback provided will guide future TAT-course improvements to advance and promote a comprehensive approach to teaching airway management.
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Affiliation(s)
- Irene Steinberg
- Department of Surgical Sciences, University of Turin, Turin, Italy
| | - Sabine Nabecker
- Department of Anesthesiology and Pain Management, Sinai Health System, University of Toronto, 600 University Avenue, Toronto, ON, M5G 1X5, Canada.
| | - Robert Greif
- School of Medicine, Sigmund Freud University Vienna, Vienna, Austria
| | - Gerardo Cortese
- Department of Anesthesia, Intensive Care and Emergency, 'Città Della Salute E Della Scienza', Turin, Italy
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Al-Saadi MA, Heidari B, Donahue KR, Shipman EM, Kinariwala KN, Masud FN. Pre-Existing Right Ventricular Dysfunction as an Independent Risk Factor for Post Intubation Cardiac Arrest and Hemodynamic Instability in Critically Ill Patients: A Retrospective Observational Study. J Intensive Care Med 2023; 38:169-178. [PMID: 35786053 DOI: 10.1177/08850666221111776] [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: 12/13/2022]
Abstract
BACKGROUND Post intubation cardiac arrest and hemodynamic instability are serious adverse events encountered in critically ill patients. The association of pre-existing right ventricular (RV) dysfunction with post intubation cardiac arrest and hemodynamic instability in critically ill patients is unknown. METHODS This is a retrospective matched cohort study of adult critically ill patients who underwent intubation from July 2016 to December 2019. The study was conducted at a quaternary medical center in Houston, Texas. A total of 340 critically ill patients who underwent intubation in the intensive care units, wards, and the emergency room were included. The study cohort was categorized into 4 groups based on the pre-existing RV function: normal function, mild dysfunction, moderate dysfunction, and severe dysfunction. Cardiac arrest and/or hemodynamic instability within one hour post intubation were the primary study outcomes. Secondary outcomes included in hospital and 60-day mortality. RESULTS Study patients were of mean age of 61.95 ± 14.28 years, including 132 (39%) females and 208 (61%) males. The primary outcomes were significantly worse in mild, moderate, and severe RV dysfunction groups compared to the normal RV function group (34.12%-P = 0.014, 47.06%-P < 0.001, 51.67%-P < 0.001, vs. 17.56%). In a multivariable logistic regression analysis, pre-existing moderate (OR = 2.65, P = 0.013) and severe RV dysfunction groups (OR = 2.66, P = 0.015) were associated with statistically significant higher cardiac arrest and hemodynamic instability post intubation. Pre-existing severe RV dysfunction was associated with statistically significant higher in hospital mortality (62.35%-P < 0.001). The multivariable Cox-regression analysis showed that pre-existing severe RV dysfunction was associated with a statistically significant higher 60-day mortality (HR = 2.57, P = 0.001). CONCLUSIONS Pre-existing moderate and severe RV dysfunctions were independently associated with significantly higher cardiac arrest and/or hemodynamic instability post intubation in critically ill patients. Pre-existing RV function may serve as a mortality predictor in critically ill patients undergoing endotracheal intubation.
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Affiliation(s)
- Mukhtar A Al-Saadi
- Department of Medicine, 23534Houston Methodist Hospital, Houston, Texas, USA
| | - Behnam Heidari
- Department of Medicine, 23534Houston Methodist Hospital, Houston, Texas, USA
| | - Kevin R Donahue
- Department of Pharmacy, 23534Houston Methodist Hospital, Houston, Texas, USA
| | - Emily M Shipman
- Department of Medicine, 23534Houston Methodist Hospital, Houston, Texas, USA
| | - Kush N Kinariwala
- Department of Medicine, 23534Houston Methodist Hospital, Houston, Texas, USA
| | - Faisal N Masud
- Department of Anesthesiology, 23534Houston Methodist Hospital, Houston, Texas, USA
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Deng J, Huang S, Zou D, Liu W, He M, Xiong J, Wang H. Investigation of the airway management practice of emergency department ward nurses: a nationwide survey in China. BMJ Open 2021; 11:e049869. [PMID: 34921074 PMCID: PMC8689174 DOI: 10.1136/bmjopen-2021-049869] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES To investigate the airway management equipment and clinical practice in emergency department wards in China, and to explore the factors that influenced the nurses' airway management practice. DESIGN Cross-sectional study. SETTING A nationwide survey covering the seven administrative regions of China (North China, Northeast China, East China, Central China, South China, Southwest China and Northwest China). PARTICIPANTS The nurses had to be registered nurses who worked in adult emergency department wards of the selected hospitals. MEASURES An online survey was designed, piloted and distributed to the members of the Emergency Medicine Committee of the Chinese Nursing Association, and the nurses from the members' hospitals were invited to participate. The questionnaire was used to determine nurses' clinical practice scores of airway management in emergency wards. RESULTS Finally, we collected 995 valid questionnaires from 31 provinces and 143 districts in China. Among them, 361 (36.28%) nurses responded that their departments used open suction system (OSS) in clinical work, the major barrier for closed suction system (CSS) reported by 630 respondents (63.32%) was cost. Significant differences in all three scores were found in age, nursing experience years, technical title, airway management training experience and nursing specialist (all p<0.05). Correlations were found among airway management attitude, practice of sputum aspiration and practice of ventilator care bundles (r=0.655, r=0.543 and r=0.763, all p<0.001). CONCLUSIONS Chinese emergency department managers need to identify better methods for assessing equipment availability in OSS. CSS can be a choice when costs, status of the individual patient and severity of disease are comprehensively considered. Emergency department nurses' scores of airway management practice were affected by demographic and job-related characteristics; regular training should be encouraged, and equipment and resources should be guaranteed to improve airway management quality and optimise patient outcomes.
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Affiliation(s)
- Juan Deng
- Nursing department of Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
- Department of Emergency, Tongji Hospital,Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
- Department of Intensive Care Unit, Tongji Hospital,Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Sufang Huang
- Nursing department of Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
- Department of Emergency, Tongji Hospital,Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Dengxiu Zou
- Nursing department of Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
- Department of Emergency, Tongji Hospital,Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
- Department of Intensive Care Unit, Tongji Hospital,Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Weiquan Liu
- Nursing department of Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
- Department of Emergency, Tongji Hospital,Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
- Department of Intensive Care Unit, Tongji Hospital,Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Mei He
- Nursing department of Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
- Department of Emergency, Tongji Hospital,Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
- Department of Intensive Care Unit, Tongji Hospital,Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Jie Xiong
- Nursing department of Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
- Department of Emergency, Tongji Hospital,Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
- Department of Intensive Care Unit, Tongji Hospital,Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
| | - Hui Wang
- Nursing department of Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, Wuhan, China
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Scott JA, Heard SO, Zayaruzny M, Walz JM. Response. Chest 2021; 158:2712. [PMID: 33280766 DOI: 10.1016/j.chest.2020.07.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Accepted: 07/02/2020] [Indexed: 11/27/2022] Open
Affiliation(s)
- J Aaron Scott
- Department of Anesthesiology and Perioperative Medicine, Division of Critical Care Medicine, UMass Memorial Medical Center, Worcester, MA.
| | - Stephen O Heard
- Department of Anesthesiology and Perioperative Medicine, Division of Critical Care Medicine, UMass Memorial Medical Center, Worcester, MA
| | - Maksim Zayaruzny
- Department of Anesthesiology and Perioperative Medicine, Division of Critical Care Medicine, UMass Memorial Medical Center, Worcester, MA
| | - J Matthias Walz
- Department of Anesthesiology and Perioperative Medicine, Division of Critical Care Medicine, UMass Memorial Medical Center, Worcester, MA
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Gómez-Ríos MÁ, Casans-Francés R. Airway Management in Critically Ill Adults. Chest 2021; 158:2711-2712. [PMID: 33280765 DOI: 10.1016/j.chest.2020.06.086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 06/15/2020] [Accepted: 06/17/2020] [Indexed: 10/22/2022] Open
Affiliation(s)
- Manuel Ángel Gómez-Ríos
- Department of Anesthesia and Perioperative Medicine, Complejo Hospitalario Universitario de A Coruña, A Coruña.
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Affiliation(s)
- Thomas Heidegger
- From the Department of Anesthesia, Spital Grabs, Grabs, and the Department of Anesthesiology and Pain Medicine, Bern University Hospital, University of Bern, Bern - both in Switzerland; and the Private University of the Principality of Liechtenstein, Triesen, Liechtenstein
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Agrawal A, Sikachi RR, Koenig SJ. Response to Airway Management in Critically Ill Patients: Don't Forget the Bronchoscope! Chest 2021; 157:1685-1686. [PMID: 32505318 DOI: 10.1016/j.chest.2019.12.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Revised: 12/19/2019] [Accepted: 12/31/2019] [Indexed: 10/24/2022] Open
Affiliation(s)
- Abhinav Agrawal
- Interventional Pulmonology, Section of Pulmonary & Critical Care, The University of Chicago Medicine, Chicago, IL.
| | - Rutuja R Sikachi
- Department of Anesthesiology, Hofstra Northwell School of Medicine, New Hyde Park, NY
| | - Seth J Koenig
- Division of Pulmonary Medicine, Montefiore Medical Center, New York, NY
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Scott JA, Heard SO, Zayaruzny M, Walz JM. Response. Chest 2021; 157:1686-1687. [PMID: 32505319 DOI: 10.1016/j.chest.2020.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 01/22/2020] [Indexed: 10/24/2022] Open
Affiliation(s)
- J Aaron Scott
- Department of Anesthesiology and Perioperative Medicine, Division of Critical Care Medicine, UMass Memorial Medical Center, Worcester, MA.
| | - Stephen O Heard
- Department of Anesthesiology and Perioperative Medicine, Division of Critical Care Medicine, UMass Memorial Medical Center, Worcester, MA
| | - Maksim Zayaruzny
- Department of Anesthesiology and Perioperative Medicine, Division of Critical Care Medicine, UMass Memorial Medical Center, Worcester, MA
| | - J Matthias Walz
- Department of Anesthesiology and Perioperative Medicine, Division of Critical Care Medicine, UMass Memorial Medical Center, Worcester, MA
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Russotto V, Myatra SN, Bellani G. Preoxygenation of Critically Ill Patients With Acute Hypoxemic Respiratory Failure. Chest 2021; 157:1684-1685. [PMID: 32505316 DOI: 10.1016/j.chest.2019.12.047] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2019] [Accepted: 12/31/2019] [Indexed: 11/15/2022] Open
Affiliation(s)
- Vincenzo Russotto
- Department of Emergency and Intensive Care, University Hospital San Gerardo, Monza, Italy; University of Milano - Bicocca, Milan, Italy.
| | - Sheila Nainan Myatra
- Department of Anaesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Giacomo Bellani
- Department of Emergency and Intensive Care, University Hospital San Gerardo, Monza, Italy; University of Milano - Bicocca, Milan, Italy
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Schechtman SA, Flori HR, Thatcher AL, Almendras G, Robell SE, Healy DW, Shah NJ. The Difficult Airway Navigator: Development and Implementation of a Health Care System's Approach to Difficult Airway Documentation Utilizing the Electronic Health Record. A A Pract 2021; 15:e01455. [PMID: 33950875 DOI: 10.1213/xaa.0000000000001455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Careful airway risk assessment and procedural planning are vital to ensure patients' safety during airway management. Patients with known procedural difficulty during previous airway management or new anatomical changes pose challenges and risks. To improve communication and the value of documented information regarding difficult airway management for future clinical encounters, we utilized existing electronic health record functions to develop a "difficult airway Navigator." We describe this tool's creation and implementation, which allows clinicians to readily review past airway information and efficiently create difficult airway notes, bedside signs, flags, and orders.
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Affiliation(s)
| | | | - Aaron L Thatcher
- Department of Otolaryngology-Head & Neck Surgery, Michigan Medicine-University of Michigan Medical School, Ann Arbor, Michigan
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Abstract
ZusammenfassungIm Rahmen des nichttraumatologischen Schockraummanagements zur Versorgung kritisch kranker Patienten werden akute Störungen der Vitalfunktionen rasch detektiert und interdisziplinär behandelt. Beim „primary survey“ dient das etablierte ABCDE-Schema der strukturierten Untersuchung aller relevanten Vitalparameter, Störungen werden hierbei sofort therapiert. „A-Probleme“ gehen mit einer drohenden Atemwegsverlegung und damit einer konsekutiven Hypoxie einher. Unterschiedlichste Pathologien können hier zugrunde liegen, meist ist aber zunächst eine symptomatische Therapie, also die Sicherung der Atemwege, die entscheidende Notfallmaßnahme. Ein strukturiertes Konzept zum Atemwegsmanagement unter Berücksichtigung lokaler Gegebenheiten sollte in jeder Notaufnahme etabliert sein und regelmäßig trainiert werden.
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de Carvalho CC, da Silva DM, de Athayde Regueira SLP, de Souza ABS, Rego CO, Ramos IB, Dos Santos Neto JM. Comparison between rocuronium and succinylcholine for rapid sequence induction: A systematic review and network meta-analysis of randomized clinical trials. J Clin Anesth 2021; 72:110265. [PMID: 33819827 DOI: 10.1016/j.jclinane.2021.110265] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 03/25/2021] [Accepted: 03/27/2021] [Indexed: 11/29/2022]
Affiliation(s)
- Clístenes Crístian de Carvalho
- Department of Post-graduation, Instituto de Medicina Integral Professor Fernando Figueira, Recife, Brazil; Department of Surgery, Universidade Federal de Campina Grande, Campina Grande, Brazil.
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Dean PN, Hoehn EF, Geis GL, Frey ME, Cabrera‐Thurman MK, Kerrey BT, Zhang Y, Stalets EL, Zackoff MW, Maxwell AR, Pham TM, Lautz AJ. Identification of the Physiologically Difficult Airway in the Pediatric Emergency Department. Acad Emerg Med 2020; 27:1241-1248. [PMID: 32896033 DOI: 10.1111/acem.14128] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 08/27/2020] [Accepted: 09/01/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND The risk factors for peri-intubation cardiac arrest in critically ill children are incompletely understood. The study objective was to derive physiologic risk factors for deterioration during tracheal intubation in a pediatric emergency department (PED). METHODS This was a retrospective cohort study of patients undergoing emergency tracheal intubation in a PED. Using the published literature and expert opinion, a multidisciplinary team developed high-risk criteria for peri-intubation arrest: 1) hypotension, 2) concern for cardiac dysfunction, 3) persistent hypoxemia, 4) severe metabolic acidosis (pH < 7.1), 5) post-return of spontaneous circulation (ROSC), and 6) status asthmaticus. We completed a structured review of the electronic health record for a historical cohort of patients intubated in the PED. The primary outcome was peri-intubation arrest. Secondary outcomes included tracheal intubation success rate, extracorporeal membrane oxygenation (ECMO) activation, and in-hospital mortality. We compared outcomes between patients meeting one or more versus no high-risk criteria. RESULTS Peri-intubation cardiac arrest occurred in 5.6% of patients who met at least one high-risk criterion compared to 0% in patients meeting none (5.6% difference, 95% confidence interval [CI] = 1.0 to 18.1, p = 0.028). Patients meeting at least one criterion had higher rates of any postintubation cardiac arrest in the PED (11.1% vs. 0%, 11.1% difference, 95% CI = 4.1 to 25.3, p = 0.0007), in-hospital mortality (25% vs. 2.3%, 22.7% difference, 95% CI = 11.0 to 38.9, p < 0.0001), ECMO activation (8.3% vs. 0%, 8.3% difference, 95% CI = 2.5 to 21.8, p = 0.004), and lower likelihood of first-pass intubation success (47.2% vs. 66.1%, -18.9% difference, 95% CI = -35.5 to -1.5, p = 0.038), respectively. CONCLUSIONS We have developed criteria that successfully identify physiologically difficult airways in the PED. Children with hypotension, persistent hypoxemia, concern for cardiac dysfunction, severe metabolic acidosis, status asthmaticus or who are post-ROSC are at higher risk for peri-intubation cardiac arrest and in-hospital mortality. Further multicenter investigation is needed to validate our findings.
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Affiliation(s)
- Preston N. Dean
- From the Division of Emergency Medicine Cincinnati Children's Hospital Medical Center CincinnatiOHUSA
- the Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OHUSA
| | - Erin F. Hoehn
- From the Division of Emergency Medicine Cincinnati Children's Hospital Medical Center CincinnatiOHUSA
- the Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OHUSA
- the Division of Emergency Medicine Children's Hospital of Pittsburgh of UPMC Pittsburgh PAUSA
| | - Gary L. Geis
- From the Division of Emergency Medicine Cincinnati Children's Hospital Medical Center CincinnatiOHUSA
- the Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OHUSA
| | - Mary E. Frey
- From the Division of Emergency Medicine Cincinnati Children's Hospital Medical Center CincinnatiOHUSA
| | - Mary K. Cabrera‐Thurman
- From the Division of Emergency Medicine Cincinnati Children's Hospital Medical Center CincinnatiOHUSA
| | - Benjamin T. Kerrey
- From the Division of Emergency Medicine Cincinnati Children's Hospital Medical Center CincinnatiOHUSA
- the Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OHUSA
| | - Yin Zhang
- the Division of Biostatistics and EpidemiologyCincinnati Children's Hospital Medical Center CincinnatiOHUSA
| | - Erika L. Stalets
- the Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OHUSA
- and the Division of Critical Care Medicine Cincinnati Children's Hospital Medical Center Cincinnati OHUSA
| | - Matthew W. Zackoff
- the Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OHUSA
- and the Division of Critical Care Medicine Cincinnati Children's Hospital Medical Center Cincinnati OHUSA
| | - Andrea R. Maxwell
- the Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OHUSA
- and the Division of Critical Care Medicine Cincinnati Children's Hospital Medical Center Cincinnati OHUSA
| | - Tena M. Pham
- and the Division of Critical Care Medicine Cincinnati Children's Hospital Medical Center Cincinnati OHUSA
| | - Andrew J. Lautz
- the Department of Pediatrics University of Cincinnati College of Medicine Cincinnati OHUSA
- and the Division of Critical Care Medicine Cincinnati Children's Hospital Medical Center Cincinnati OHUSA
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