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Garcia SI, Finch AS, Ridgeway JL, Beckman TJ, Montori VM, Rivera M, Gajic O, Kennedy CC, Kelm DJ. Understanding Team Dynamics and Culture of Safety Using Video Reflexive Ethnography during Real-Time Emergent Intubation. Ann Am Thorac Soc 2024; 21:1065-1073. [PMID: 38470228 DOI: 10.1513/annalsats.202310-901oc] [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: 10/23/2023] [Accepted: 03/08/2024] [Indexed: 03/13/2024] Open
Abstract
Rationale: Endotracheal intubation is the third most common bedside procedure in U.S. hospitals. In over 40% of intubations, preventable complications attributable to human factors occur. A better understanding of team dynamics during intubation may improve patient safety. Objectives: To explore team dynamics and safety-related actions during emergent endotracheal intubations in the emergency department and intensive care unit and to engage members of the care team in reflection for process improvement through a novel video-based team debriefing technique. Methods: Video-reflexive ethnography involves in situ video recording and reflexive discussions with practitioners to scrutinize behaviors and to identify opportunities for improvement. In this study, real-time intubations were recorded in the emergency department and intensive care unit at Mayo Clinic Rochester, and facilitated video-reflexive sessions were conducted with the multidisciplinary procedural teams. Themes about team dynamics and safety-related action were identified inductively from transcriptions of recorded sessions. Results: Between December 2022 and January 2023, eight video-reflexive sessions were conducted with a total of 78 participants. Multidisciplinary members included nurses (n = 23), respiratory therapists (n = 16), pharmacists (n = 7), advanced practitioners (n = 5), and physicians (n = 26). In video-reflexive discussions, major safety gaps were identified and several solutions were proposed related to the use of a multidisciplinary intubation checklist, standardized communication and team positioning, developing a culture of safety, and routinely debriefing after the procedure. Conclusions: The findings of this study may inform the development of a team supervision model for emergent endotracheal intubations. This approach could integrate key components such as a multidisciplinary intubation checklist, standardized communication and team positioning, a culture of safety, and debriefing as part of the procedure itself.
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Affiliation(s)
| | | | - Jennifer L Ridgeway
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | | | | | | | - Ognjen Gajic
- Division of Pulmonary, Critical Care, and Sleep Medicine
| | - Cassie C Kennedy
- Division of Pulmonary, Critical Care, and Sleep Medicine
- Division of Healthcare Delivery Research, Mayo Clinic College of Medicine and Science, Rochester, Minnesota; and
| | - Diana J Kelm
- Division of Pulmonary, Critical Care, and Sleep Medicine
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Yi Y, Kim DH, Choi EJ, Hong SB, Oh DK. The effect of a dedicated intensivist staffing to a medical emergency team on airway management in general wards. Medicine (Baltimore) 2024; 103:e38571. [PMID: 38905417 PMCID: PMC11191976 DOI: 10.1097/md.0000000000038571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 05/23/2024] [Indexed: 06/23/2024] Open
Abstract
Although medical emergency teams (METs) have been widely introduced, studies on the importance of a dedicated intensivist staffing to METs are lacking. A single-center retrospective before-and-after study was performed. Deteriorating patients who required emergency airway management in general wards by MET were included in this study. We divided the study period according to the presence of a dedicated intensivist staff in MET: (1) non-staffed period (from January 2016 to February 2018, n = 971) and (2) staffed period (from March 2018 to December 2019, n = 651), and compared emergency airway management-related variables and outcomes between the periods. Among 1622 patients included, mean age was 63.0 years and male patients were 64.2% (n = 1042). The first-pass success rate was significantly increased in the staffed period (85.9% in the non-staffed vs 89.2% in the staffed; P = .047). Compliance to rapid sequence intubation was increased (9.4% vs 34.4%; P < .001) and vocal cords were more clearly open (P < .001) in the staffed period. The SpO2/FiO2 ratio (median [interquartile range], 125 [113-218] vs 136 [116-234]; P = .007) and the ROX index (4.6 [3.4-7.6] vs 5.1 [3.6-8.5]; P = .013) at the time of intubation was higher in the staffed period, suggesting the decision on intubation was made earlier. The post-intubation hypoxemia was less commonly occurred in the staffed period (7.2% vs 4.2%, P = .018). In multivariate analysis, the rank of operator was a strong predictor of the first-pass success (adjusted OR [95% CI], 2.280 [1.639-3.172]; P < .001 for fellow and 5.066 [1.740-14.747]; P < .001 for staff, relative to resident). In our hospital, a dedicated intensivist staffing to MET was associated with improved emergency airway management in general wards. Staffing an intensivist to MET needs to be encouraged to improve the performance of MET and the patient safety.
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Affiliation(s)
- Yehyeon Yi
- Department of Pulmonology, Seoul Medical Center, Seoul, Republic of Korea
| | - Da-Hye Kim
- Medical Emergency Team, Asan Medical Center, Seoul, Republic of Korea
| | - Eun-Joo Choi
- Medical Emergency Team, Asan Medical Center, Seoul, Republic of Korea
| | - Sang-Bum Hong
- Medical Emergency Team, Asan Medical Center, Seoul, Republic of Korea
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Dong Kyu Oh
- Department of Pulmonology, Dongkang General Hospital, Ulsan, Republic of Korea
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Shukairy MK, Chadwick L, LaPorte CM, Pudwill J, Syslo JA, Fitzgerald J, Bier-Laning CM. Implementing an Interprofessional Difficult Airway Response Team to Identify and Manage High-Risk Airways. Otolaryngol Head Neck Surg 2023. [PMID: 37130509 DOI: 10.1002/ohn.357] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 03/16/2023] [Accepted: 04/01/2023] [Indexed: 05/04/2023]
Abstract
OBJECTIVE To describe a multidisciplinary approach to and results from the creation of a difficult airway response team (DART) to address the management of inpatient loss of airway events. METHODS Description of an interprofessional process to establish and sustain a DART program at a tertiary care hospital. An Institutional Review Board-approved retrospective review of the quantitative results was conducted from November 2019 through March 2021. RESULTS After establishing the existing processes for difficult airway management, a focus on "work as imagined" identified 4 pillars to address the goal for the project of bringing the right providers with the right equipment to the right patients at the right time through DART equipment carts, an expanded DART code team, a screening tool to identify patients with at-risk airways and unique messaging for DART code alerts. "Work as done" was assessed through simulations. Educational efforts included further simulations and group teaching. Sustainability was achieved through ongoing e-learning and bidirectional feedback. During the period of study, there were 40,752 patients admitted and 28,013 (69%) screens completed. At-risk airways were identified in 4282 admissions (11%), most commonly due to a history of a difficult airway (19%) and elevated body mass index (16%). The DART responded to 126 codes. There were no airway-related deaths or serious adverse events. DISCUSSION A successful DART program was created, optimized, and sustained using components of interprofessional meetings, simulation, bidirectional feedback, and quantitative analysis. IMPLICATIONS FOR PRACTICE The techniques described can serve to guide groups who identify a quality improvement project that involves interactions between multiple stakeholders.
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Affiliation(s)
| | - Lexia Chadwick
- Department of Anesthesiology, University of Illinois, Chicago, Illinois, USA
| | - Cinthia M LaPorte
- Department of Nursing, Loyola University Medical Center, Maywood, Illinois, USA
| | - Josephine Pudwill
- Department of Nursing, Loyola University Medical Center, Maywood, Illinois, USA
| | - Jennifer A Syslo
- Office of Patient Safety, Loyola University Medical Center, Maywood, Illinois, USA
| | - Julie Fitzgerald
- Department of Pediatrics, Ronald McDonald's Children's Hospital, Loyola University Medical Center, Maywood, Illinois, USA
| | - Carol M Bier-Laning
- Department of Otolaryngology, Loyola University Medical Center, Maywood, Illinois, USA
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Viola M, Braun RT, Luth EA, Pan CX, Lief L, Gang J, Adamou Z, Dodd P, Prigerson HG. Associations of Intellectual Disability with Cardiopulmonary Resuscitation and Endotracheal Intubation at End of Life. J Palliat Med 2022; 25:1268-1272. [PMID: 35442779 PMCID: PMC9347372 DOI: 10.1089/jpm.2021.0584] [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] [Accepted: 03/15/2022] [Indexed: 11/13/2022] Open
Abstract
Background: Little is known about end-of-life intensive care provided to patients with intellectual disabilities (ID). Objectives: To identify differences in receipt of end-of-life cardiopulmonary resuscitation (CPR) and endotracheal intubation among adult patients with and without ID and examine whether do-not-resuscitate orders (DNRs) mediate associations between ID and CPR. Design: Exploratory matched cohort study using medical records of inpatient decedents treated between 2012 and 2018. Results: Patients with ID (n = 37) more frequently received CPR (37.8% vs. 21.6%) and intubation (78.4% vs. 47.8%) than patients without ID (n = 74). In multivariable models, ID was associated with receiving CPR (relative risk [RR] = 2.92, 95% confidence interval = 1.26-6.78, p = 0.012), but not intubation. Patients with ID less frequently had a DNR placed (67.6% vs. 91.9%), mediating associations between ID and CPR. Conclusions: In this pilot study, ID was associated with increased likelihood of receiving end-of-life CPR, likely due to lower utilization of DNRs among patients with ID. Further research is needed to confirm these results.
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Affiliation(s)
- Martin Viola
- Center for Research on End-of-Life Care and Weill Cornell Medicine, New York, New York, USA
| | - Robert Tyler Braun
- Department of Population Health Sciences, Weill Cornell Medicine, New York, New York, USA
| | - Elizabeth A. Luth
- Department of Family Medicine and Community Health, Institute for Health, Healthcare Policy and Aging Research, Rutgers University, New Brunswick, New Jersey, USA
| | - Cynthia X. Pan
- Division of Palliative Medicine and Geriatrics, New York Presbyterian Queens Hospital, Flushing, New York, USA
- Department of Medicine, Weill Cornell Medical College, New York, New York, USA
| | - Lindsay Lief
- Department of Medicine, Weill Cornell Medical College, New York, New York, USA
| | - James Gang
- Department of Medicine, Weill Cornell Medical College, New York, New York, USA
| | - Zara Adamou
- Department of Medicine, Weill Cornell Medical College, New York, New York, USA
| | - Philip Dodd
- University of Dublin, Trinity College, Dublin, Ireland
- Department of Psychiatry, St Michael's House Intellectual Disability Services
| | - Holly G. Prigerson
- Center for Research on End-of-Life Care and Weill Cornell Medicine, New York, New York, USA
- Department of Medicine, Weill Cornell Medical College, New York, New York, USA
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Stone AB, Dasani SS, Grant MC, Nascimben L, Bader AM. Understanding the Economic Impact of an Essential Service: Applying Time-Driven Activity-Based Costing to the Hospital Airway Response Team. Anesth Analg 2022; 134:445-453. [PMID: 35180159 DOI: 10.1213/ane.0000000000005838] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND As the United States moves toward value-based care metrics, it will become essential for anesthesia groups nationwide to understand the costs of their services. Time-driven activity-based costing (TDABC) estimates the amount of time it takes to perform a clinical activity by dividing complex tasks into process steps and mapping each step and has historically been used to estimate the costs of various health care services. TDABC is a tool that can be adapted for variable staffing models and the volume of service provided. Anesthesia departments often provide staffing for airway response teams (ART). The economic implications of staffing ART have not been well described. We present a TDABC model for ART activation in a tertiary-care center to estimate the cost incurred by an anesthesiology department to staff an ART. METHODS Pages received by the Brigham and Women's Hospital ART over a 24-month time period (January 2019 to December 2020) were analyzed and categorized. The local administrative database was queried for the Current Procedural Terminology (CPT) code used to bill for emergency airway placements. Sessions were held by multiple members of the ART to create process maps for the different types of ART activations. We estimated the staffing costs using the estimated time it took for each type of ART activation as well as the data collected for local ART activations. RESULTS From the paging records, we analyzed 3368 activations of the ART. During the study period, 1044 airways were billed for with emergency airway CPT code. The average revenue collected per airway was $198.45 (95% CI, $190-$207). For STAT/Emergency airway team activations, process maps and non-STAT airway team activations were created, and third subprocess map was created for performing endotracheal intubation. Using the TDABC, the total staffing costs are estimated to be $218,601 for the 2-year study period. The ART generated $207,181 in revenue during the study period. CONCLUSIONS Our analysis of ART-activation pages suggests that while the revenue generated may cover the cost of staffing the team during ART activations, it does not cover consumable equipment costs. Additionally, the current fee-for-service model relies on the team being able to perform other clinical duties in addition to covering the airway pager and would be impossible to capture using traditional top-down costing methods. By using TDABC, anesthesia groups can demonstrate how certain services, such as ART, are not fully covered by current reimbursement models and how to negotiate for subsidy agreements.As the transition from traditional fee-for-service payments to value-based care models continues in the United States, improving the understanding and communication of medical care costs will be essential. In the United States, it is common for anesthesia groups to receive direct revenue from hospitals to preserve financial viability, and therefore, knowledge of true cost is essential regardless of payer model.1 With traditional payment models, what is billable and nonbillable may not reflect either the need for or the cost of providing the service. As anesthesia departments navigate the transition of care from volume to value, actual costs will be essential to understand for negotiations with hospitals for support when services are nonbillable, when revenue from payers does not cover anesthesia costs, and when calculating the appropriate share for anesthesia departments when bundled payments are distributed.
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Affiliation(s)
- Alexander B Stone
- From the Department of Anesthesiology, Pain and Perioperative Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Anesthesiology, Hospital for Special Surgery, New York, New York
| | - Serena S Dasani
- From the Department of Anesthesiology, Pain and Perioperative Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Michael C Grant
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Maryland
| | - Luigino Nascimben
- From the Department of Anesthesiology, Pain and Perioperative Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Angela M Bader
- From the Department of Anesthesiology, Pain and Perioperative Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
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Costa LGVD, Monteiro FDLJ, Souza JKD, Queiroz VNF, Papa FDV. Risk factors for SARS-CoV-2 infection and epidemiological profile of Brazilian anesthesiologists during the COVID-19 pandemic: cross-sectional study. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2022; 72:176-184. [PMID: 34371059 PMCID: PMC8349390 DOI: 10.1016/j.bjane.2021.07.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 06/19/2021] [Accepted: 07/03/2021] [Indexed: 12/15/2022]
Abstract
INTRODUCTION The devasting effects of COVID-19 have caused economic and health impacts worldwide. Anesthesiologists were one of the key professionals fighting the pandemic and have been highly exposed at their multiple sites of clinical practice. Thus, the importance of determining the nature of the infection in this population that provides care to SARS-CoV-2 patients. METHOD We conducted a cross-sectional study administering an online questionnaire to examine the demographic and epidemiological profile of these professionals in Brazil, and to describe the risk factors for viral infection during the pandemic. RESULTS A total of 1,127 anesthesiologists answered the questionnaire, 55.2% were men, more than 90% with age below 60 years, with infection and reinfection rates of 14.7% and 0.5%, respectively, and 47.2% reported a significant income reduction. The predictors of COVID-19 contamination were practicing in operating rooms (OR = 0.42; 95% CI 0.23-0.78), direct contact with infected patients (OR = 5.74; 95% CI 3.05-11.57), indirect contact with infected patients (OR = 2.43; 95% CI 1.13-5.33), working in a pre-hospital setting (OR = 2.36; 95% CI 1.04-5.03), and presence of immunosuppression, except for cancer (OR = 4.89; 95% CI 1.16-19.01). CONCLUSION COVID-19 had enormous consequences on Brazilian anesthesiologists regarding sociodemographic aspects and contamination rates (5.57 times higher than in the general population). These are alarming and unprecedented findings for this professional group, as they reveal the considerable risk of infection and its independent predictor variables.
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Affiliation(s)
| | | | - Júlia Koerich de Souza
- Hospital Israelita Albert Einstein, Departamento de Anestesiologia, São Paulo, SP, Brazil
| | | | - Fábio de Vasconcelos Papa
- Hospital Israelita Albert Einstein, Departamento de Anestesiologia, São Paulo, SP, Brazil; University of Toronto, Department of Anesthesia, St. Michael's Hospital, Toronto, Ontario, Canada
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Bai M, Zhao B, Liu Z, Zheng Z, Wei X, Li L, Li K, Song X, Xu J, Li Z. Mucosa-Like Conformal Hydrogel Coating for Aqueous Lubrication. ADVANCED MATERIALS (DEERFIELD BEACH, FLA.) 2022; 34:e2108848. [PMID: 35075678 DOI: 10.1002/adma.202108848] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 01/09/2022] [Indexed: 02/05/2023]
Abstract
Mucosa is a protective and lubricating barrier in biological tissue, which has a great clinical inspiration because of its slippery, soft, and hydrophilic surface. However, mimicking mucosal traits on complex surface remains an enormous challenge. Herein, a novel approach to create mucosa-like conformal hydrogel coating is developed. A thin conformal hydrogel layer mimicking the epithelial layer is obtained by first absorbing micelles, followed by forming covalent interlinks with the polymer substrate via interface-initiated hydrogel polymerization. The resulting coating exhibits uniform thickness (≈15 µm), mucosa-matched compliance (Young's modulus = 1.1 ± 0.1 kPa) and lubrication (coefficients of friction = 0.018 ± 0.003), robust interfacial bonding against peeling (peeling strength = 1218.0 ± 187.9 J m-2 ), as well as high water absorption capacity. It effectively resists adhesion of proteins and bacteria without compromising biocompatibility. As demonstrated by an in vivo cynomolgus monkey model and clinical trial, applications of the mucosa-like conformal hydrogel coating on the endotracheal tube significantly reduce intubation-related complications, such as invasive stimuli, mucosal lesions, laryngeal edema, inflammation, and postoperative pain. This work offers a promising prototype for surface decoration of biomedical devices and holds great prospects for clinical translation to enable interventional operations with minimally invasive impacts.
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Affiliation(s)
- Meng‐Han Bai
- College of Polymer Science and Engineering State Key Laboratory of Polymer Materials Engineering Sichuan University Chengdu 610065 China
| | - Baisong Zhao
- Department of Anesthesiology Guangzhou Women and Children's Medical Center Guangzhou Medical University Guangzhou 510623 China
| | - Zhou‐Yun‐Tong Liu
- College of Polymer Science and Engineering State Key Laboratory of Polymer Materials Engineering Sichuan University Chengdu 610065 China
| | - Zi‐Li Zheng
- College of Polymer Science and Engineering State Key Laboratory of Polymer Materials Engineering Sichuan University Chengdu 610065 China
| | - Xin Wei
- College of Polymer Science and Engineering State Key Laboratory of Polymer Materials Engineering Sichuan University Chengdu 610065 China
| | - Lingli Li
- West China School of Nursing Sichuan University/West China Hospital Sichuan University Chengdu 610041 China
| | - Ka Li
- West China School of Nursing Sichuan University/West China Hospital Sichuan University Chengdu 610041 China
| | - Xingrong Song
- Department of Anesthesiology Guangzhou Women and Children's Medical Center Guangzhou Medical University Guangzhou 510623 China
| | - Jia‐Zhuang Xu
- College of Polymer Science and Engineering State Key Laboratory of Polymer Materials Engineering Sichuan University Chengdu 610065 China
- West China School of Nursing Sichuan University/West China Hospital Sichuan University Chengdu 610041 China
| | - Zhong‐Ming Li
- College of Polymer Science and Engineering State Key Laboratory of Polymer Materials Engineering Sichuan University Chengdu 610065 China
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Hynes AM, Lambe LD, Scantling DR, Bormann BC, Atkins JH, Rassekh CH, Seamon MJ, Martin ND. A surgical needs assessment for airway rapid responses: A retrospective observational study. J Trauma Acute Care Surg 2022; 92:126-134. [PMID: 34252060 DOI: 10.1097/ta.0000000000003348] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Airway rapid response (ARR) teams can be compiled of anesthesiologists, intensivists, otolaryngologists, general and thoracic surgeons, respiratory therapists, and nurses. The optimal composition of an ARR team is unknown but considered to be resource intensive. We sought to determine the type of technical procedures performed during an ARR activation to inform team composition. METHODS A large urban quaternary academic medical center retrospective review (2016-2019) of adult ARR patients was performed. Analysis included ARR demographics, patient characteristics, characteristics of preexisting tracheostomies, incidence of concomitant conditions, and procedures completed during an ARR event. RESULTS A total of 345 ARR patients with a median age of 60 years (interquartile range, 47-69 years) and a median time to ARR conclusion of 28 minutes (interquartile range, 14-47 minutes) were included. About 41.7% of the ARR had a preexisting tracheostomy. Overall, there were 130 procedures completed that can be performed by a general surgeon in addition to the 122 difficult intubations. These procedures included recannulation of a tracheostomy, operative intervention, new emergent tracheostomy or cricothyroidotomy, thoracostomy tube placement, initiation of extracorporeal membrane oxygenation, and pericardiocentesis. CONCLUSION Highly technical procedures are common during an ARR, including procedures related to tracheostomies. Surgeons possess a comprehensive skill set that is unique and comprehensive with respect to airway emergencies. This distinctive skill set creates an important role within the ARR team to perform these urgent technical procedures. LEVEL OF EVIDENCE Epidemiologic/prognostic, level III.
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Affiliation(s)
- Allyson M Hynes
- From the Division of Traumatology, Surgical Critical Care and Emergency Surgery (A.M.H., D.R.S., B.C.B., M.J.S., N.D.M.), Nursing Rapid Response Team (L.D.L.), Department of Anesthesiology and Critical Care (J.H.A.), and Department of Otorhinolaryngology: Head and Neck Surgery (C.H.R.), Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
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9
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Muñoz ÁM, Estrada M, Quintero JA, Umaña M. Rapid Intubation Sequence: 4-Year Experience in an Emergency Department. Open Access Emerg Med 2021; 13:449-455. [PMID: 34703330 PMCID: PMC8524177 DOI: 10.2147/oaem.s321365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 07/16/2021] [Indexed: 11/23/2022] Open
Abstract
Background The rapid intubation sequence is advanced airway management that effectively ensures an adequate supply of oxygen in critically ill patients. The medical personnel in the emergency department performed this procedure. Objective To describe the main characteristics of the rapid intubation sequence in an emergency department of a high complexity hospital. Methods This is a descriptive, cross-sectional, retrospective study. We included all older patients with a rapid intubation sequence requirement in the emergency department from 2014 to 2017. We used central tendency measures for numerical variables and proportions for categorical variables. Results A total of 401 patients were eligible for this analysis. The main indication for intubation was the Glasgow Coma Scale = <8 in 170 patients (42.4%), followed by hypoxemia in 142 patients (35.4%). In 36 patients, at least one complication occurred. RSI was performed in 54.4% by emergency physician. RSI was successful on the first attempt in 90.5%. Only 36 patients (9%) presented complications. Conclusion In this study, we found that the rapid intubation sequence was not related to a high proportion of complications. Perhaps, this is attributed to the degree of medical training and the use of emergency department protocols in our hospital.
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Affiliation(s)
- Ángela María Muñoz
- Emergency Department, Fundación Valle del Lili, Cali, 760032, Colombia.,Universidad ICESI, Emergency Medicine Residency, Cali, Colombia
| | - Manuela Estrada
- Emergency Department, Fundación Valle del Lili, Cali, 760032, Colombia
| | - Jaime A Quintero
- Emergency Department, Fundación Valle del Lili, Cali, 760032, Colombia.,Universidad ICESI, Emergency Medicine Residency, Cali, Colombia.,Centro de Investigaciones Clínicas (CIC), Fundación Valle del Lili, Cali, 760032, Colombia
| | - Mauricio Umaña
- Emergency Department, Fundación Valle del Lili, Cali, 760032, Colombia
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Ghaffar S, Blankenstein TN, Patel D, Theodosiou C, Griffith D. Quantification of the effect of body mass index on cricothyroid membrane depth: a cross-sectional analysis of clinical CT images. Emerg Med J 2021; 38:355-358. [PMID: 33627374 DOI: 10.1136/emermed-2019-209046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 01/19/2021] [Accepted: 02/07/2021] [Indexed: 01/25/2023]
Abstract
OBJECTIVES The recommended front of neck access procedure in can't intubate, can't oxygenate scenarios relies on palpation of the cricothyroid membrane (CTM), or dissection of the neck down to the larynx if CTM is impalpable. CTM palpation is particularly challenging in obese patients, most likely due to an increased distance between the skin and the CTM (CTM depth). The aims of this study were to measure the CTM depth in a representative clinical sample, and to quantify the relationship between body mass index (BMI) and CTM depth. METHODS This is a retrospective analysis of 355 clinical CT scans performed at a teaching hospital over an 8-month period. CTM depth was measured by two radiologists, and mean CTM depth calculated. Age, gender, height and weight were recorded, and BMI calculated. Linear relationships between patient characteristics and CTM depth were assessed in order to derive a predictive equation for calculating CTM depth. The variables included for this model were those with a strong association with CTM depth, that is, a p value of 0.10 or less. RESULTS Mean CTM depth was 8.12 mm (IQR 6.36-11.70). There was no association between CTM depth and sex (β -0.33, 95% CI -1.33 to 0.68, p=0.53), height (cm) (β 0.01, 95% CI -0.05 to 0.06, p=0.79) or age (years) (β -0.01, 95% CI 0.10 to 0.15, p=0.62). Increasing weight (kg) (β 0.12, 95% CI 0.10 to 0.15, p<0.001) and BMI (kg/m3) (β 0.52, 95% CI 0.44 to 0.60, p<0.001) were strongly associated with CTM depth. Predicted CTM depth increased from 6.4 mm (95% CI 4.9 to 8.1) at a BMI of 20 kg/m2 to 16.8 (95% CI 13.7 to 20.1) at BMI 40 kg/m2. CONCLUSION CTM depth was strongly associated with BMI in a retrospective analysis of patients having clinical CT scans.
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Affiliation(s)
- Sadia Ghaffar
- Department of Anaesthesia, Edinburgh Royal Infirmary, Edinburgh, UK
| | - Tom Nicholas Blankenstein
- HQ Army Medical Directorate, Army Medical Services, Camberley, Surrey, UK.,Clinical Radiology, South- East Scotland Deanery, Edinburgh, UK
| | - Dilip Patel
- Department of Radiology, Royal Infirmary of Edinburgh, Edinburgh, UK
| | | | - David Griffith
- Division of Medical and Radiological Sciences, University of Edinburgh, Edinburgh, UK
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Hsiao YJ, Chen CY, Hung HT, Lee CH, Su YY, Ng CJ, Chou AH. Comparison of the outcome of emergency endotracheal intubation in the general ward, intensive care unit and emergency department. Biomed J 2020; 44:S110-S118. [PMID: 35735080 PMCID: PMC9038942 DOI: 10.1016/j.bj.2020.07.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2019] [Revised: 07/08/2020] [Accepted: 07/22/2020] [Indexed: 12/20/2022] Open
Abstract
Background Emergency endotracheal intubations outside the operating room (OR) are associated with high complications. We compare the outcome of emergency endotracheal intubation in the general ward, the intensive care unit (ICU) and the emergency department (ED). Methods We retrospectively analyzed adult patients requiring emergency endotracheal intubation that called for anesthesiologists at our tertiary care institution from January 1, 2015 to December 31, 2016. We evaluated the outcomes, including aspiration, hemodynamic collapse, pneumothorax, emergency tracheostomy, and survival to hospital discharge in the general ward, ICU, and ED. Results There were 416 non-OR emergency endotracheal intubation calls for the anesthesiologist. Among these areas, the ED had the highest proportion of difficult endotracheal (DET) intubation (n = 144 [80.4%]), followed by the general ward (n = 85 [66.4%]), and then the ICU (n = 65 [59.6%]). The incidence of hemodynamic collapse was higher in the general ward (n = 44 [34.4%]) than the ICU (n = 18 [16.5%]) or the ED (n = 16 [9.0%]). We reported the survival rate of the general ward (55.5%), which was lower than the ICU (63.3%) and the ED (80.4%). Among these locations, the ED had the highest rate of neurologically intact (91%) to hospital discharge, compared to the ICU (56.6%) and the general ward (55%). As for the ED, although there was no difference in survival between non-preventive and preventive intubations, preventive intubations was associated with high neurological intact with hospital discharge. Conclusion Emergency and DET intubation in the general ward and ICU resulted in a higher incidence of hemodynamic collapse and mortality than those performed in the ED. Early calls for the anesthesiologist for DET intubation without medications in the ED resulted in a higher rate of neurologically intact survival to hospital discharge.
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Abstract
BACKGROUND Anaesthesia teams are temporarily assembled to cooperate with teams in emergency departments in the immediate management of events compromising patients’ airway, ventilation and circulation. PURPOSE The aim was to describe a temporary ad-hoc anaesthesia team’s performance. DESIGN An observational study was conducted. METHODS Data, collected with 12 non-participatory observations, were analysed using both an thematic method, and a validated assessment tool, the Team Emergency Assessment Measure. RESULTS Three themes were identified: (1) flexibility in assuming varying roles, (2) expertise in verbal and non-verbal communication and (3) skills dealing with the challenges of working in unfamiliar dynamic environments. Ninety per cent of anaesthesia teams scored 7.6 (0–10) on the overall assessment according to the Team Emergency Assessment Measure rating. CONCLUSION Ad-hoc anaesthesia team members communicated in various ways and the anaesthesia team adapted well to the unpredictable environment in the emergency department.
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Affiliation(s)
| | - Caisa Öster
- Department of Neuroscience, Uppsala University, Uppsala, Sweden
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Bittner EA, Schmidt U. Examining the Learning Practice of Emergency Airway Management Within an Academic Medical Center: Implications for Training and Improving Outcomes. JOURNAL OF MEDICAL EDUCATION AND CURRICULAR DEVELOPMENT 2020; 7:2382120520965257. [PMID: 33134549 PMCID: PMC7576904 DOI: 10.1177/2382120520965257] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Accepted: 09/17/2020] [Indexed: 06/11/2023]
Abstract
Emergency airway management (EAM) is a "high stakes" clinical practice, associated with a significant risk of procedure-related complications and patient mortality. Learning within the EAM team practice is complex and challenging for trainees. Increasing concern for patient safety and changes in the structure of medical education have resulted in educational challenges and opportunities for improvement within the EAM team practice. This paper is divided into 3 sections that describe the past, present, and future of the EAM team learning practice within a large academic institution. Section 1 provides a brief overview of the evolution of the existing practice of EAM. Key features, goals, and challenges of the practice are outlined and a recently performed needs analysis to identify areas for improvement is described. Section 2 examines the underlying assumptions regarding learning within the existing practice and explores how these assumptions fit into major theories of learning. Section 3 proposes an idealized learning practice for the EAM team which includes the assumptions regarding learners, design of the learning environment, use of technology to enhance learning, and the means of assessment and measuring success. It is hoped that through this systematic exploration of the EAM team practice, learning efficacy and efficiency will be improved and remain adaptable for challenges in the future.
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Affiliation(s)
- Edward A Bittner
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital; Harvard Medical School, Boston, MA
| | - Ulrich Schmidt
- Department of Anesthesiology, University of California San Diego Medical Center, San Diego, CA, USA
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Hung KC, Yu TS, Sun CK, Chang YJ, Chen IW, Lin CM. Characteristics and outcomes of patients requiring airway rescue by the difficult airway response team in the emergency department and wards: A retrospective study. Tzu Chi Med J 2020; 32:53-57. [PMID: 32110521 PMCID: PMC7015017 DOI: 10.4103/tcmj.tcmj_184_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Revised: 09/10/2018] [Accepted: 10/02/2018] [Indexed: 11/05/2022] Open
Abstract
Objective: In this retrospective cohort study, we aimed to determine the characteristics and outcomes of patients in the emergency department (ED) and wards who required emergency tracheal intubation by the difficult airway response team (DART). Materials and Methods: All patients between 18 and 80 years old receiving emergency tracheal intubation by the DART at a single tertiary referral hospital from January 2014 to December 2016 were reviewed and divided into ward and ED groups. Patient characteristics, comorbidities, indications for intubation, airway maintenance technique, and survival-to-discharge rates were analyzed and compared. Results: Totally, 192 patients (ward, n = 135; ED, n = 57) were eligible for the current study. Compared with the ward group, patients in the ED group were younger (58.9 ± 13 vs. 51.5 ± 15.6 years, P = 0.001), male-predominant (71.1% vs. 87.7%, P = 0.014), and had a higher incidence of trauma (6.7% vs. 22.8%, P = 0.001). The most common indications for tracheal intubation were respiratory distress (52.6%) and cardiac arrest (17.8%) in the ward group, and respiratory distress (31.6%) and airway protection (28.1%) in the ED group. Patients in the ED group received more fiberoptic intubations (42.1% vs. 17.8%, P = 0.039) and had a higher survival-to-discharge rate (87.7% vs. 44.4%, P < 0.001) than those in the ward group. Conclusions: Better recognition of differences in patient characteristics and indications for intubation in different units of the hospital may enable the DART to customize specialized equipment to improve efficiency and implement appropriate strategies for airway rescue to improve patient outcomes.
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Emergent airway management outside of the operating room - a retrospective review of patient characteristics, complications and ICU stay. BMC Anesthesiol 2019; 19:220. [PMID: 31795993 PMCID: PMC6889440 DOI: 10.1186/s12871-019-0894-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Accepted: 11/26/2019] [Indexed: 11/24/2022] Open
Abstract
Background Emergent airway management outside of the operating room is a high-risk procedure. Limited data exists about the indication and physiologic state of the patient at the time of intubation, the location in which it occurs, or patient outcomes afterward. Methods We retrospectively collected data on all emergent airway management interventions performed outside of the operating room over a 6-month period. Documentation included intubation performance, and intubation related complications and mortality. Additional information including demographics, ASA-classification, comorbidities, hospital-stay, ICU-stay, and 30-day in-hospital mortality was obtained. Results 336 intubations were performed in 275 patients during the six-month period. The majority of intubations (n = 196, 58%) occurred in an ICU setting, and the rest 140 (42%) occurred on a normal floor or in a remote location. The mean admission ASA status was 3.6 ± 0.5, age 60 ± 16 years, and BMI 30 ± 9 kg/m2. Chest X-rays performed immediately after intubation showed main stem intubation in 3.3% (n = 9). Two immediate (within 20 min after intubation) intubation related cardiac arrest/mortality events were identified. The 30-day in-hospital mortality was 31.6% (n = 87), the overall in-hospital mortality was 37.1% (n = 102), the mean hospital stay was 22 ± 20 days, and the mean ICU-stay was 14 days (13.9 ± 0.9, CI 12.1–15.8) with a 7.3% ICU-readmission rate. Conclusion Patients requiring emergent airway management are a high-risk patient population with multiple comorbidities and high ASA scores on admission. Only a small number of intubation-related complications were reported but ICU length of stay was high.
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Chen C, Hei Z, Xing J, Zhu Q, Qiu R, Liu J, Gong C, Cheng N, Zhou S, Shen N. Laryngoscopic techniques modulate anaesthesiologists' perception of halitosis in patients: A randomised controlled trial. Eur J Anaesthesiol 2019; 36:918-923. [PMID: 31644511 PMCID: PMC6855315 DOI: 10.1097/eja.0000000000001115] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Perception of halitosis in patients during intubation is a common and additional stressor for anaesthesiologists and may lead to potential health risks. OBJECTIVES We hypothesised that intubation with videolaryngoscopy could help reduce the anaesthesiologists' perception of patients' oral malodor during intubation. DESIGN A single-blinded, randomised controlled trial. SETTING Single centre general hospital, Guangdong Province, China. PARTICIPANTS A total of 440 patients who underwent intubation under general anaesthesia for elective surgery, aged 18 to 60 years old, American Society of Anaesthesiologists class I to III, without upper airway abnormality or airway infection were enrolled. INTERVENTION Patients were randomly assigned to receive either UE videolaryngoscopy (UE) or Macintosh's direct laryngoscopy (Macintosh) group. All intubations were performed by one of six very experienced anaesthesiologists. MAIN OUTCOME MEASURES The patient's oral odour score was measured prior to induction of anaesthesia. The anaesthesiologists' perception of the patient's oral malodor during intubation was recorded. The shortest distance from patient's mouth to the anaesthesiologist's nose (MN distance), the exertion rating and discomfort were also measured. RESULTS The oral malodor score did not differ in the UE and Macintosh groups prior to the induction of anaesthesia. However, the incidence of the anaesthesiologists' perception of halitosis during intubation was significantly lower in the UE group compared with the Macintosh group (P < 0.001). Similarly, the MN distance was significantly greater in the UE group compared with the Macintosh group (P < 0.001). The first-attempt success rate was higher in the UE group compared to the Macintosh group (P < 0.001). However, the exertion scores were considerably higher in the Macintosh group. After intubation, anaesthesiologists experienced more waist and shoulder discomfort with the Macintosh than the UE technique of intubation. CONCLUSION Compared with direct laryngoscopy, videolaryngoscopy might reduce the anaesthesiologists' perception of the patients' oral malodor, help improve first-attempt success rate, as well as alleviate the anaesthesiologists' waist and shoulder discomfort. TRIAL REGISTRATION Clinicaltrials.gov (ChiCTR-IOR-15007038).
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Fein DG, Mastroianni F, Murphy CG, Aboodi M, Malik R, Emami N, Abramowitz M, Shiloh AL, Eisen L. Impact of a Critical Care Specialist Intervention on First Pass Success for Emergency Airway Management Outside the ICU. J Intensive Care Med 2019; 36:80-88. [PMID: 31707906 DOI: 10.1177/0885066619886816] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND There has been limited investigation into the procedural outcomes of patients undergoing emergent endotracheal intubation (EEI) by a critical care medicine (CCM) specialist outside the intensive care unit (ICU). We hypothesized that EEI outside an ICU would be associated with lower rates of first pass success (FPS) as compared to inside an ICU. METHODS We performed a retrospective cohort study of all adult patients admitted to our academic medical center between January 1, 2016, and July 31, 2018, who underwent EEI by a CCM practitioner. The primary outcome of FPS was identified in the EEI procedure note. Secondary outcomes included difficult intubation (> 2 attempts at laryngoscopy) and mortality following EEI. RESULTS In total, 1958 patients (1035 [52.9%] inside ICU and 923 [47.1%]) outside an ICU) were included in the final cohort. Unadjusted rate of FPS was not different between patients intubated out of the ICU and patients intubated inside of the ICU (689 [74.7%] vs 775 [74.9%]; P = .91). There was also no difference in FPS between groups after adjusting for predictors of difficult intubation and baseline covariates (odds ratio: 0.95; 95% confidence interval, 0.75-1.2, P = .65). Mortality of patients undergoing EEI out of the ICU was higher at each examined time interval following EEI. DISCUSSION For EEI done by CCM practitioners, rate of FPS is not different between patients undergoing EEI outside an ICU as compared to inside an ICU. Despite the lack of difference between rates of procedural success, patient mortality following EEI outside an ICU is higher than EEI inside an ICU at all examined time points during hospitalization.
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Affiliation(s)
- Daniel G Fein
- Division of Pulmonary Medicine, 2013Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Fiore Mastroianni
- Division of Pulmonary, Critical Care and Sleep Medicine Division, 232890Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Charles G Murphy
- Department of Internal Medicine, 2013Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Michael Aboodi
- Division of Critical Care Medicine, 2013Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Ryan Malik
- Division of Critical Care Medicine, 2013Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Nader Emami
- Division of Critical Care Medicine, 2013Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Matthew Abramowitz
- Division of Nephrology, 2013Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Ariel L Shiloh
- Division of Critical Care Medicine, 2013Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Lewis Eisen
- Division of Critical Care Medicine, 2013Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
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Lukannek C, Shaefi S, Platzbecker K, Raub D, Santer P, Nabel S, Lecamwasam HS, Houle TT, Eikermann M. The development and validation of the Score for the Prediction of Postoperative Respiratory Complications (SPORC-2) to predict the requirement for early postoperative tracheal re-intubation: a hospital registry study. Anaesthesia 2019; 74:1165-1174. [PMID: 31222727 DOI: 10.1111/anae.14742] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/22/2019] [Indexed: 01/24/2023]
Abstract
Postoperative pulmonary complications are associated with an increase in mortality, morbidity and healthcare utilisation. The Agency for Healthcare Research and Quality recommends risk assessment for postoperative respiratory complications in patients undergoing surgery. In this hospital registry study of adult patients undergoing non-cardiac surgery between 2005 and 2017 at two independent healthcare networks, a prediction instrument for early postoperative tracheal re-intubation was developed and externally validated. This was based on the development of the Score for Prediction Of Postoperative Respiratory Complications. For predictor selection, stepwise backward logistic regression and bootstrap resampling were applied. Development and validation cohorts were represented by 90,893 patients at Partners Healthcare and 67,046 patients at Beth Israel Deaconess Medical Center, of whom 699 (0.8%) and 587 (0.9%) patients, respectively, had their tracheas re-intubated. In addition to five pre-operative predictors identified in the Score for Prediction Of Postoperative Respiratory Complications, the final model included seven additional intra-operative predictors: early post-tracheal intubation desaturation; prolonged duration of surgery; high fraction of inspired oxygen; high vasopressor dose; blood transfusion; the absence of volatile anaesthetic use; and the absence of lung-protective ventilation. The area under the receiver operating characteristic curve for the new score was significantly greater than that of the original Score for Prediction Of Postoperative Respiratory Complications (0.84 [95%CI 0.82-0.85] vs. 0.76 [95%CI 0.75-0.78], respectively; p < 0.001). This may allow clinicians to develop and implement strategies to decrease the risk of early postoperative tracheal re-intubation.
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Affiliation(s)
- C Lukannek
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.,Anesthesia Information Systems, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - S Shaefi
- Anesthesia Information Systems, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - K Platzbecker
- Anesthesia Information Systems, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - D Raub
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.,Anesthesia Information Systems, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - P Santer
- Anesthesia Information Systems, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - S Nabel
- Anesthesia Information Systems, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
| | - H S Lecamwasam
- Department of Anesthesia, Rhode Island Hospital and Warren Alpert Medical School of Brown University, Providence, RI, USA.,Talis Clinical, LLC, USA
| | - T T Houle
- Department of Anaesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - M Eikermann
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA.,Duisburg-Essen University, Essen, Germany
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Suzuki K, Kusunoki S, Tanigawa K, Shime N. Comparison of three video laryngoscopes and direct laryngoscopy for emergency endotracheal intubation: a retrospective cohort study. BMJ Open 2019; 9:e024927. [PMID: 30928937 PMCID: PMC6475241 DOI: 10.1136/bmjopen-2018-024927] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE Video laryngoscopes are used for managing difficult airways. This study compared three video laryngoscopes' (Pentax-Airway Scope [Pentax], King Vision[King] and McGrath MAC [McGrath]) performances with the Macintosh direct laryngoscope (Macintosh) as emergency tracheal intubations (TIs) reference. DESIGN Retrospective cohort study. SETTING The emergency department (ED) and the intensive care unit (ICU) of two Japanese tertiary-level hospitals. PARTICIPANTS All consecutive video-recorded emergency TI cases in EDs and ICUs between December 2013 and June 2015. PRIMARY OUTCOME MEASURES The primary study endpoint was first-pass intubation success. A subgroup analysis examined the first-pass intubation success of expert versus non-expert operators. A logistic regression analysis was performed to identify the predictors of first-pass intubation success. RESULTS A total of 287 emergency TIs were included. The first-pass intubation success rates were 78%, 58%, 78% and 58% for the Pentax, King, McGrath and Macintosh instruments, respectively (p=0.004, Fisher's exact test). The non-expert operators' success rates were significantly higher (p=0.00004, Fisher's exact test) for the Pentax (87%) and McGrath (78%) instruments than that for the King (50%) and Macintosh (46%) instruments, unlike that of the experts (67%, 67%, 78% and 78% for Pentax, McGrath, King and Macintosh, respectively; p=0.556, Fisher's exact test). After TI indication, difficult airway characteristics, and expert versus non-expert operator parameters adjustments, the Pentax (OR=3.422, 95% CI 1.551 to 7.550; p=0.002) and McGrath (OR= 3.758, CI 1.640 to 8.612; p=0.002) instruments showed significantly higher first-pass intubation success odds when compared with the Macintosh laryngoscope (reference, OR=1). The King instrument, however, (OR=1.056; 95% CI 0.487 to 2.289, p=0.889) failed to show any significant superiority. CONCLUSION The Pentax and McGrath laryngoscopes showed significantly higher emergency TI first-pass intubation success rates than the King laryngoscope when compared with the Macintosh laryngoscope, especially for non-expert operators. TRIAL REGISTRATION NUMBER UMIN000027925; Results.
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Affiliation(s)
- Kei Suzuki
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Shinji Kusunoki
- Critical Care Medical Center, Hiroshima Prefectural Hospital, Hiroshima, Japan
| | - Koichi Tanigawa
- Fukushima Global Medical Science Center, Fukushima Medical University, Fukushima, Japan
| | - Nobuaki Shime
- Department of Emergency and Critical Care Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
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Leeper WR, Haut ER, Pandian V, Nakka S, Dodd-O J, Bhatti N, Hunt EA, Saheed M, Dalesio N, Schiavi A, Miller C, Kirsch TD, Berkow L. Multidisciplinary Difficult Airway Course: An Essential Educational Component of a Hospital-Wide Difficult Airway Response Program. JOURNAL OF SURGICAL EDUCATION 2018; 75:1264-1275. [PMID: 29628333 DOI: 10.1016/j.jsurg.2018.03.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 01/30/2018] [Accepted: 03/05/2018] [Indexed: 06/08/2023]
Abstract
OBJECTIVE A hospital-wide difficult airway response team was developed in 2008 at The Johns Hopkins Hospital with three central pillars: operations, safety monitoring, and education. The objective of this study was to assess the outcomes of the educational pillar of the difficult airway response team program, known as the multidisciplinary difficult airway course (MDAC). DESIGN The comprehensive, full-day MDAC involves trainees and staff from all provider groups who participate in airway management. The MDAC occurs within the Johns Hopkins Medicine Simulation Center approximately four times per year and uses a combination of didactic lectures, hands-on sessions, and high-fidelity simulation training. Participation in MDAC is the main intervention being investigated in this study. Data were collected prospectively using course evaluation survey with quantitative and qualitative components, and prepost course knowledge assessment multiple choice questions (MCQ). Outcomes include course evaluation scores and themes derived from qualitative assessments, and prepost course knowledge assessment MCQ scores. SETTING Tertiary care academic hospital center PARTICIPANTS: Students, residents, fellows, and practicing physicians from the departments of Surgery, Otolaryngology Head and Neck Surgery, Anesthesiology/Critical Care Medicine, and Emergency Medicine; advanced practice providers (nurse practitioners and physician assistants), nurse anesthetists, nurses, and respiratory therapists. RESULTS Totally, 23 MDACs have been conducted, including 499 participants. Course evaluations were uniformly positive with mean score of 86.9 of 95 points. Qualitative responses suggest major value from high-fidelity simulation, the hands-on skill stations, and teamwork practice. MCQ scores demonstrated significant improvement: median (interquartile range) pre: 69% (60%-81%) vs post: 81% (72%-89%), p < 0.001. CONCLUSIONS Implementation of a MDAC successfully disseminated principles and protocols to all airway providers. Demonstrable improvement in prepost course knowledge assessment and overwhelmingly positive course evaluations (quantitative and qualitative) suggest a critical and ongoing role for the MDAC course.
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Affiliation(s)
- W Robert Leeper
- Department of Surgery, Western University, Schulich School of Medicine and Dentistry, London, Ontario, Canada.
| | - Elliott R Haut
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland; Department of Emergency Medicine, Johns Hopkins School of Medicine, Baltimore Maryland; The Armstrong Institute for Patient Safety and Quality, Johns Hopkins School of Medicine, Baltimore Maryland
| | - Vinciya Pandian
- Department of Acute and Chronic Care, Johns Hopkins School of Nursing, Baltimore, Maryland
| | - Sajan Nakka
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Jeffrey Dodd-O
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Nasir Bhatti
- Department of Otolaryngology, Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Elizabeth A Hunt
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland; Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Mustapha Saheed
- Department of Emergency Medicine, Johns Hopkins School of Medicine, Baltimore Maryland
| | - Nicholas Dalesio
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Adam Schiavi
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Christina Miller
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Thomas D Kirsch
- Department of Emergency Medicine, Johns Hopkins School of Medicine, Baltimore Maryland
| | - Lauren Berkow
- Department of Anesthesiology, University of Florida College of Medicine, Gainesville, Florida
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DeMaria S, Berman DJ, Goldberg A, Lin HM, Khelemsky Y, Levine AI. Team-based model for non-operating room airway management: validation using a simulation-based study. Br J Anaesth 2018; 117:103-8. [PMID: 27317709 DOI: 10.1093/bja/aew121] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2016] [Indexed: 01/23/2023] Open
Abstract
BACKGROUND Non-operating room (non-OR) airway management has previously been identified as an area of concern because it carries a significant risk for complications. One reason for this could be attributed to the independent practice of residents in these situations. The aim of the present study was to ascertain whether differences in performance exist between residents working alone vs with a resident partner when encountering simulated non-OR airway management scenarios. METHODS Thirty-six anaesthesia residents were randomized into two groups. Each group experienced three separate scenarios (two scenarios initially and then a third 6 weeks later). The scenarios consisted of one control scenario and two critical event scenarios [i.e. asystole during laryngoscopy and pulseless electrical activity (PEA) upon post-intubation institution of positive pressure ventilation]. One group experienced the simulated non-OR scenarios alone (Solo group). The other group consisted of resident pairs, participating in the same three scenarios (Team group). RESULTS Although the time to intubation did not differ between the Solo and Team groups, there were several differences in performance. The Team group received better overall performance ratings for the asystole (8.5 vs 5.5 out of 10; P<0.001) and PEA (8.5 vs 5.8 out of 10; P<0.001) scenarios. The Team group was also able to recognize asystole and PEA conditions faster than the Solo group [10.1 vs 23.5 s (P<0.001) and 13.3 vs 36.0 s (P<0.001), respectively]. CONCLUSIONS Residents who performed a simulated intubation with a second trained provider had better overall performance than those who practised independently. The residents who practised in a group were also faster to diagnose serious complications, including peri-intubation asystole and PEA. Given these data, it is reasonable that training programmes consider performing all non-OR airway management with a team-based method.
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Affiliation(s)
- S DeMaria
- Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place Box 1010, New York, NY 10029, USA
| | - D J Berman
- Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place Box 1010, New York, NY 10029, USA
| | - A Goldberg
- Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place Box 1010, New York, NY 10029, USA
| | - H-M Lin
- Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place Box 1010, New York, NY 10029, USA
| | - Y Khelemsky
- Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place Box 1010, New York, NY 10029, USA
| | - A I Levine
- Department of Anesthesiology, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place Box 1010, New York, NY 10029, USA
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Corl KA, Dado C, Agarwal A, Azab N, Amass T, Marks SJ, Levy MM, Merchant RC, Aliotta J. A modified Montpellier protocol for intubating intensive care unit patients is associated with an increase in first-pass intubation success and fewer complications. J Crit Care 2018; 44:191-195. [PMID: 29149690 PMCID: PMC10184499 DOI: 10.1016/j.jcrc.2017.11.014] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 11/06/2017] [Accepted: 11/09/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND The Montpellier protocol for intubating patients in the intensive care unit (ICU) is associated with a decrease in intubation-related complications. We sought to determine if implementation of a simplified version of the Montpellier protocol that removed selected components and allowed for a variety of pre-oxygenation modalities increased first-pass intubation success and reduced intubation-related complications. METHODS A prospective pre/post-comparison of a modified Montpellier protocol in two medical and one medical/surgical/cardiac ICU within a hospital system. The modified eight-point protocol included: fluid administration, ordering sedation, two intubation trained providers, pre-oxygenation with non-invasive positive pressure ventilation, nasal high flow cannula or non-rebreather mask, rapid sequence intubation, capnography, sedation administration, and vasopressors for shock. RESULTS Patient characteristics and indications for intubation were similar for the 275 intubations in the control (137) and intervention (138) periods. In the intervention vs. control periods, the modified Montpellier protocol was associated with a significant 16.2% [95% CI: 5.1-30.0%] increase in first-pass intubation success and a 12.6% [95% CI: 1.2-23.6%] reduction in all intubation-related complications. CONCLUSION A simplified version of the Montpellier intubation protocol for intubating ICU patients was associated with an improvement in first-pass intubation success rates and a reduction in the rate of intubation-related complications.
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Affiliation(s)
- Keith A Corl
- The Department of Medicine, Division of Pulmonary Critical Care & Sleep, United States; The Department of Emergency Medicine, Alpert Medical School of Brown University, United States; The Brown University School of Public Health, Providence, RI, United States.
| | - Christopher Dado
- The Department of Medicine, Division of Pulmonary Critical Care & Sleep, United States
| | - Ankita Agarwal
- The Department of Medicine, Division of Pulmonary Critical Care & Sleep, United States.
| | - Nader Azab
- The Department of Medicine, Division of Pulmonary Critical Care & Sleep, United States.
| | - Tim Amass
- The Department of Medicine, Division of Pulmonary Critical Care & Sleep, United States; The Brown University School of Public Health, Providence, RI, United States
| | - Sarah J Marks
- The Department of Emergency Medicine, Alpert Medical School of Brown University, United States.
| | - Mitchell M Levy
- The Department of Medicine, Division of Pulmonary Critical Care & Sleep, United States.
| | - Roland C Merchant
- The Department of Emergency Medicine, Alpert Medical School of Brown University, United States; The Brown University School of Public Health, Providence, RI, United States.
| | - Jason Aliotta
- The Department of Medicine, Division of Pulmonary Critical Care & Sleep, United States.
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Arulkumaran N, McLaren CS, Arulkumaran K, Philips BJ, Cecconi M. An analysis of emergency tracheal intubations in critically ill patients by critical care trainees. J Intensive Care Soc 2018; 19:180-187. [PMID: 30159008 DOI: 10.1177/1751143717749686] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Introduction We evaluated intensive care medicine trainees' practice of emergency intubations in the United Kingdom. Methods Retrospective analysis of 881 in-hospital emergency intubations over a three-year period using an online trainee logbook. Results Emergency intubations out-of-hours were less frequent than in-hours, both on weekdays and weekends. Complications occurred in 9% of cases, with no association with time of day/day of week (p = 0.860). Complications were associated with higher Cormack and Lehane grades (p=0.004) and number of intubation attempts (p < 0.001), but not American Society of Anesthesiologist grade. Capnography usage was ≥99% in all locations except in wards (85%; p = 0.001). Ward patients were the oldest (p < 0.001), had higher American Society of Anesthesiologist grades (p < 0.001) and lowest Glasgow Coma Scale (p < 0.001). Conclusions Complications of intubations are associated with higher Cormack and Lehane grades and number of attempts, but not time of day/day of week. The uptake of capnography is reassuring, although there is scope for improvement on the ward.
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Affiliation(s)
- Nishkantha Arulkumaran
- General Intensive Care Unit, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Charles S McLaren
- Intensive Care Medicine, Hillingdon Hospital Foundation Trust, London, UK
| | | | - Barbara J Philips
- General Intensive Care Unit, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Maurizio Cecconi
- General Intensive Care Unit, St George's University Hospitals NHS Foundation Trust, London, UK
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Effects of training on resident physician emergency airway management skills. Can J Anaesth 2017; 64:777-779. [PMID: 28247240 DOI: 10.1007/s12630-017-0856-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Revised: 02/12/2017] [Accepted: 02/21/2017] [Indexed: 10/20/2022] Open
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25
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Trainee experience and success of urgent airway management. J Clin Anesth 2016; 35:536-542. [DOI: 10.1016/j.jclinane.2016.07.041] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Revised: 07/11/2016] [Accepted: 07/25/2016] [Indexed: 11/17/2022]
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Natt B, Malo J, Hypes C, Sakles J, Mosier J. Strategies to improve first attempt success at intubation in critically ill patients. Br J Anaesth 2016; 117 Suppl 1:i60-i68. [DOI: 10.1093/bja/aew061] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
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Wang CH, Chen WJ, Chang WT, Tsai MS, Yu PH, Wu YW, Huang CH. The association between timing of tracheal intubation and outcomes of adult in-hospital cardiac arrest: A retrospective cohort study. Resuscitation 2016; 105:59-65. [DOI: 10.1016/j.resuscitation.2016.05.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Revised: 04/29/2016] [Accepted: 05/20/2016] [Indexed: 01/02/2023]
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28
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Inoue S. Achieving both patient safety and developing trainees' airway skills. Br J Anaesth 2016; 117:138-9. [DOI: 10.1093/bja/aew168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Acute respiratory compromise on inpatient wards in the United States: Incidence, outcomes, and factors associated with in-hospital mortality. Resuscitation 2016; 105:123-9. [PMID: 27255952 DOI: 10.1016/j.resuscitation.2016.05.014] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Revised: 05/15/2016] [Accepted: 05/17/2016] [Indexed: 11/23/2022]
Abstract
AIM To estimate the United States' incidence and in-hospital mortality of acute respiratory events on inpatient wards and to identify factors associated with mortality. METHODS This is an analysis of prospectively collected data from the Get With the Guidelines(®) - Resuscitation registry. We included adult patients with index acute respiratory events on inpatient wards from January 2005 to December 2013. A negative binomial regression model was used to estimate the 2012 United States incidence and a multivariable logistic regression model was used to examine time trends and characteristics associated with in-hospital mortality. RESULTS There were 13,086 index events from 320 hospitals included in the analysis. Using 2012 data, the estimated number of events in the United States was 44,551 (95%CI: 25,170-95,371). The in-hospital mortality for the entire cohort was 39.4% (95%CI: 38.5, 40.2) and rose to 82.6% (95%CI: 79.9, 85.2) for events leading to cardiac arrest. There was a decrease in in-hospital mortality over time (48.3% in 2005 to 34.5% in 2013, p<0.001). Characteristics associated with mortality included agonal breathing, hypotension and septicemia. CONCLUSIONS Acute respiratory events on inpatient wards in the US is common with an associated in-hospital mortality of approximately 40% that has been decreasing over the past decade. Multiple factors were associated with in-hospital mortality.
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Neuromuscular blockade improves first-attempt success for intubation in the intensive care unit. A propensity matched analysis. Ann Am Thorac Soc 2016; 12:734-41. [PMID: 25719512 DOI: 10.1513/annalsats.201411-517oc] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
RATIONALE The use of neuromuscular blocking agents (NMBAs) has been shown to be valuable in improving successful tracheal intubation in the operating room and emergency department. However, data on NMBA use in critically ill intensive care unit (ICU) patients are lacking. Furthermore, there are no data on NMBA use with video laryngoscopy. OBJECTIVES To evaluate the effect of NMBA use on first-attempt success (FAS) with tracheal intubation in the ICU. METHODS Single-center observational study of 709 consecutive patients intubated in the medical ICU of a university medical center from January 1, 2012 to June 30, 2014. Data were collected prospectively through a continuous quality improvement program on all patients intubated in the ICU over the study period. Data relating to patient demographics, intubation, and complications were analyzed. We used propensity score (propensity to use an NMBA) matching to generate 5,000 data sets of cases (failed first intubation attempts) matched to controls (successful first attempts) and conditional logistic regression to analyze the results. MEASUREMENTS AND MAIN RESULTS There were no significant differences in patient demographics, except median total difficult airway characteristics were higher in the non-NMBA group (2 vs. 1, P < 0.001). There were significant differences in the sedative used between groups and the operator level of training. More patients who were given NMBAs received etomidate (83 vs. 35%) and more patients in the non-NMBA group received ketamine (39 vs. 9%) (P < 0.001). The FAS for NMBA use was 80.9% (401/496) compared with 69.6% (117/168) for non-NMBA use (P = 0.003). The summary odds ratio for FAS when an NMBA was used from the propensity matched analyses was 2.37 (95% confidence interval, 1.36-4.88). In the subgroup of patients intubated with a video laryngoscope, propensity-adjusted odds of FAS with the use of an NMBA was 2.50 (1.43-4.37; P < 0.001). There were no differences in procedurally related complications between groups. CONCLUSIONS After controlling for potential confounders, this propensity-adjusted analysis demonstrates improved odds of FAS at intubation in the ICU with the use of an NMBA. This improvement in FAS is seen even with the use of a video laryngoscope.
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The impact of a comprehensive airway management training program for pulmonary and critical care medicine fellows. A three-year experience. Ann Am Thorac Soc 2016; 12:539-48. [PMID: 25715227 DOI: 10.1513/annalsats.201501-023oc] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
RATIONALE Airway management in the intensive care unit (ICU) is challenging, as many patients have limited physiologic reserve and are at risk for clinical deterioration if the airway is not quickly secured. In academic medical centers, ICU intubations are often performed by trainees, making airway management education paramount for pulmonary and critical care trainees. OBJECTIVES To improve airway management education for our trainees, we developed a comprehensive training program including an 11-month simulation-based curriculum. The curriculum emphasizes recognition of and preparation for potentially difficult intubations and procedural skills to maximize patient safety and increase the likelihood of first-attempt success. METHODS Training is provided in small group sessions twice monthly using a high-fidelity simulation program under the guidance of a core group of two to three advanced providers. The curriculum is designed with progressively more difficult scenarios requiring critical planning and execution of airway management by the trainees. Trainees consider patient position, preoxygenation, optimization of hemodynamics, choice of induction agents, selection of appropriate devices for the scenario, anticipation of difficulties, back-up plans, and immediate postintubation management. Clinical performance is monitored through a continuous quality improvement program. MEASUREMENTS AND MAIN RESULTS Sixteen fellows have completed the program since July 1, 2013. In the 18 months since the start of the curriculum (July 1, 2013-December 31, 2014), first-attempt success has improved from 74% (358/487) to 82% (305/374) compared with the 18 months before implementation (P = 0.006). During that time there were no serious complications related to airway management. Desaturation rates decreased from 26 to 17% (P = 0.002). Other complication rates are low, including aspiration (2.1%), esophageal intubation (2.7%), dental trauma (0.8%), and hypotension (8.3%). First-attempt success in a 6-month period after implementation (July 1, 2014-December 31, 2014) was significantly higher (82.1 compared with 70.9%, P = 0.03) than during a similar 6-month period before implementation (July 1, 2012-December 31, 2012). CONCLUSIONS This comprehensive airway curriculum is associated with improved first-attempt success rate for intensive care unit intubations. Such a curriculum holds the potential to improve patient care.
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Mark LJ, Herzer KR, Cover R, Pandian V, Bhatti NI, Berkow LC, Haut ER, Hillel AT, Miller CR, Feller-Kopman DJ, Schiavi AJ, Xie YJ, Lim C, Holzmueller C, Ahmad M, Thomas P, Flint PW, Mirski MA. Difficult airway response team: a novel quality improvement program for managing hospital-wide airway emergencies. Anesth Analg 2015; 121:127-139. [PMID: 26086513 DOI: 10.1213/ane.0000000000000691] [Citation(s) in RCA: 75] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Difficult airway cases can quickly become emergencies, increasing the risk of life-threatening complications or death. Emergency airway management outside the operating room is particularly challenging. METHODS We developed a quality improvement program-the Difficult Airway Response Team (DART)-to improve emergency airway management outside the operating room. DART was implemented by a team of anesthesiologists, otolaryngologists, trauma surgeons, emergency medicine physicians, and risk managers in 2005 at The Johns Hopkins Hospital in Baltimore, Maryland. The DART program had 3 core components: operations, safety, and education. The operations component focused on developing a multidisciplinary difficult airway response team, standardizing the emergency response process, and deploying difficult airway equipment carts throughout the hospital. The safety component focused on real-time monitoring of DART activations and learning from past DART events to continuously improve system-level performance. This objective entailed monitoring the paging system, reporting difficult airway events and DART activations to a Web-based registry, and using in situ simulations to identify and mitigate defects in the emergency airway management process. The educational component included development of a multispecialty difficult airway curriculum encompassing case-based lectures, simulation, and team building/communication to ensure consistency of care. Educational materials were also developed for non-DART staff and patients to inform them about the needs of patients with difficult airways and ensure continuity of care with other providers after discharge. RESULTS Between July 2008 and June 2013, DART managed 360 adult difficult airway events comprising 8% of all code activations. Predisposing patient factors included body mass index >40, history of head and neck tumor, prior difficult intubation, cervical spine injury, airway edema, airway bleeding, and previous or current tracheostomy. Twenty-three patients (6%) required emergent surgical airways. Sixty-two patients (17%) were stabilized and transported to the operating room for definitive airway management. There were no airway management-related deaths, sentinel events, or malpractice claims in adult patients managed by DART. Five in situ simulations conducted in the first program year improved DART's teamwork, communication, and response times and increased the functionality of the difficult airway carts. Over the 5-year period, we conducted 18 airway courses, through which >200 providers were trained. CONCLUSIONS DART is a comprehensive program for improving difficult airway management. Future studies will examine the comparative effectiveness of the DART program and evaluate how DART has impacted patient outcomes, operational efficiency, and costs of care.
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Affiliation(s)
- Lynette J Mark
- From the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland; Medical Scientist Training Program, Johns Hopkins School of Medicine, Baltimore, Maryland; Legal Department, The Johns Hopkins Hospital, Baltimore, Maryland; Otolaryngology-Head and Neck Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland; Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland; Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland; MD Program, Johns Hopkins School of Medicine, Baltimore, Maryland; MD Program, University of Maryland School of Medicine, Baltimore, Maryland; Armstrong Institute for Patient Safety and Quality, Johns Hopkins Medicine, Baltimore, Maryland; and Otolaryngology/Head & Neck Surgery, Oregon Health & Science University, Portland, Oregon
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Mosier JM, Hypes C, Joshi R, Whitmore S, Parthasarathy S, Cairns CB. Ventilator Strategies and Rescue Therapies for Management of Acute Respiratory Failure in the Emergency Department. Ann Emerg Med 2015; 66:529-41. [PMID: 26014437 DOI: 10.1016/j.annemergmed.2015.04.030] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2015] [Revised: 04/08/2015] [Accepted: 04/20/2015] [Indexed: 01/19/2023]
Abstract
Acute respiratory failure is commonly encountered in the emergency department (ED), and early treatment can have effects on long-term outcome. Noninvasive ventilation is commonly used for patients with respiratory failure and has been demonstrated to improve outcomes in acute exacerbations of chronic obstructive lung disease and congestive heart failure, but should be used carefully, if at all, in the management of asthma, pneumonia, and acute respiratory distress syndrome. Lung-protective tidal volumes should be used for all patients receiving mechanical ventilation, and FiO2 should be reduced after intubation to achieve a goal of less than 60%. For refractory hypoxemia, new rescue therapies have emerged to help improve the oxygenation, and in some cases mortality, and should be considered in ED patients when necessary, as deferring until ICU admission may be deleterious. This review article summarizes the pathophysiology of acute respiratory failure, management options, and rescue therapies including airway pressure release ventilation, continuous neuromuscular blockade, inhaled nitric oxide, and extracorporeal membrane oxygenation.
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Affiliation(s)
- Jarrod M Mosier
- Division of Pulmonary, Critical Care, Allergy and Sleep, Department of Medicine, University of Arizona, Tucson, AZ; Department of Emergency Medicine, University of Arizona, Tucson, AZ.
| | - Cameron Hypes
- Division of Pulmonary, Critical Care, Allergy and Sleep, Department of Medicine, University of Arizona, Tucson, AZ; Department of Emergency Medicine, University of Arizona, Tucson, AZ
| | - Raj Joshi
- Division of Pulmonary, Critical Care, Allergy and Sleep, Department of Medicine, University of Arizona, Tucson, AZ; Department of Emergency Medicine, University of Arizona, Tucson, AZ
| | - Sage Whitmore
- Division of Emergency Critical Care, Department of Emergency Medicine, University of Michigan Health System, Ann Arbor, MI
| | - Sairam Parthasarathy
- Division of Pulmonary, Critical Care, Allergy and Sleep, Department of Medicine, University of Arizona, Tucson, AZ
| | - Charles B Cairns
- Department of Emergency Medicine, University of Arizona, Tucson, AZ
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Mosier JM, Sakles JC, Whitmore SP, Hypes CD, Hallett DK, Hawbaker KE, Snyder LS, Bloom JW. Failed noninvasive positive-pressure ventilation is associated with an increased risk of intubation-related complications. Ann Intensive Care 2015; 5:4. [PMID: 25852964 PMCID: PMC4385202 DOI: 10.1186/s13613-015-0044-1] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2014] [Accepted: 02/17/2015] [Indexed: 01/10/2023] Open
Abstract
BACKGROUND Noninvasive positive-pressure ventilation (NIPPV) use has increased in the treatment of patients with respiratory failure. However, despite decreasing the need for intubation in some patients, there are no data regarding the risk of intubation-related complications associated with delayed intubation in adult patients who fail NIPPV. The objective of this study is to evaluate the odds of a composite complication of intubation following failed NIPPV compared to patients intubated primarily in the medical intensive care unit (ICU). METHODS This is a single-center retrospective cohort study of 235 patients intubated between 1 January 2012 and 30 June 2013 in a medical ICU of a university medical center. A total of 125 patients were intubated after failing NIPPV, 110 patients were intubated without a trial of NIPPV. Intubation-related data were collected prospectively through a continuous quality improvement (CQI) program and retrospectively extracted from the medical record on all patients intubated on the medical ICU. A propensity adjustment for the factors expected to affect the decision to initially use NIPPV was used, and the adjusted multivariate regression analysis was performed to evaluate the odds of a composite complication (desaturation, hypotension, or aspiration) with intubation following failed NIPPV versus primary intubation. RESULTS A propensity-adjusted multivariate regression analysis revealed that the odds of a composite complication of intubation in patients who fail NIPPV was 2.20 (CI 1.14 to 4.25), when corrected for the presence of pneumonia or acute respiratory distress syndrome (ARDS), and adjusted for factors known to increase complications of intubation (total attempts and operator experience). When a composite complication occurred, the unadjusted odds of death in the ICU were 1.79 (95% CI 1.03 to 3.12). CONCLUSIONS After controlling for potential confounders, this propensity-adjusted analysis demonstrates an increased odds of a composite complication with intubation following failed NIPPV. Further, the presence of a composite complication during intubation is associated with an increased odds of death in the ICU.
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Affiliation(s)
- Jarrod M Mosier
- Section of Pulmonary, Critical Care, Allergy and Sleep, Department of Medicine, University of Arizona, 1501 N Campbell Ave., Tucson, AZ 85721 USA ; Department of Emergency Medicine, University of Arizona, 1609 N. Warren Ave., Tucson, AZ 85724 USA ; University of Arizona, 1609N Warren, FOB 122C, Tucson, AZ 85719 USA
| | - John C Sakles
- Department of Emergency Medicine, University of Arizona, 1609 N. Warren Ave., Tucson, AZ 85724 USA
| | - Sage P Whitmore
- Division of Emergency Critical Care, Department of Emergency Medicine, University of Michigan Health System, 1500 E Medical Center Drive, Ann Arbor, MI 48109 USA
| | - Cameron D Hypes
- Section of Pulmonary, Critical Care, Allergy and Sleep, Department of Medicine, University of Arizona, 1501 N Campbell Ave., Tucson, AZ 85721 USA ; Department of Emergency Medicine, University of Arizona, 1609 N. Warren Ave., Tucson, AZ 85724 USA
| | - Danielle K Hallett
- Department of Emergency Medicine, University of Arizona, 1609 N. Warren Ave., Tucson, AZ 85724 USA
| | - Katharine E Hawbaker
- Department of Emergency Medicine, University of Arizona, 1609 N. Warren Ave., Tucson, AZ 85724 USA
| | - Linda S Snyder
- Section of Pulmonary, Critical Care, Allergy and Sleep, Department of Medicine, University of Arizona, 1501 N Campbell Ave., Tucson, AZ 85721 USA
| | - John W Bloom
- Section of Pulmonary, Critical Care, Allergy and Sleep, Department of Medicine, University of Arizona, 1501 N Campbell Ave., Tucson, AZ 85721 USA
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Kim GW, Koh Y, Lim CM, Han M, An J, Hong SB. Does medical emergency team intervention reduce the prevalence of emergency endotracheal intubation complications? Yonsei Med J 2014; 55:92-8. [PMID: 24339292 PMCID: PMC3874914 DOI: 10.3349/ymj.2014.55.1.92] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Abstract
PURPOSE Emergency endotracheal intubation (EEI) is a complex process that leads to various complications. Previous studies mainly demonstrated that the Medical Emergency Team (MET) intervention reduced the incidence of cardiac arrest, however, the impact of a MET on airway management has not been investigated in detail. Our purpose was to confirm the impact of a MET on airway management and compare the incidence of complications of EEI before and after MET intervention in a general ward. MATERIALS AND METHODS We performed an observational study and reviewed 318 patients intubated by a MET in a general ward. RESULTS The patients enrolled during the control (2007) and study (2009) periods were 103 and 215, respectively. Cardiopulmonary resuscitation requiring emergency intubation in a general ward was reduced after MET intervention at the Asan Medical Center (39.8% vs. 19.1%, p<0.001). Pre-intubation and post-intubation oxygen saturation levels were higher after MET intervention (pre-intubation, 80% before vs. 92% after MET, p<0.001; post-intubation, 95% before vs. 99% after MET, p<0.001). The use of vasopressors after intubation decreased as a result of MET intervention (62.1% before vs. 36.7% after MET, p<0.001). Hypotension was also reduced (34% before vs. 8.8% after MET, p<0.001). CONCLUSION Early interventions of a MET changed the causes of emergency intubation in a general ward from cardiopulmonary resuscitation to respiratory distress or shock and improved hypoxemia and hypotension related to emergency intubation. The MET intervention is safe and effective system for emergency intubation in a general ward.
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Affiliation(s)
- Go-Woon Kim
- Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 138-736, Korea.
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The difficult airway with recommendations for management--part 1--difficult tracheal intubation encountered in an unconscious/induced patient. Can J Anaesth 2013; 60:1089-118. [PMID: 24132407 PMCID: PMC3825644 DOI: 10.1007/s12630-013-0019-3] [Citation(s) in RCA: 222] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2013] [Accepted: 08/13/2013] [Indexed: 12/14/2022] Open
Abstract
Background Previously active in the mid-1990s, the Canadian Airway Focus Group (CAFG) studied the unanticipated difficult airway and made recommendations on management in a 1998 publication. The CAFG has since reconvened to examine more recent scientific literature on airway management. The Focus Group’s mandate for this article was to arrive at updated practice recommendations for management of the unconscious/induced patient in whom difficult or failed tracheal intubation is encountered.
Methods Nineteen clinicians with backgrounds in anesthesia, emergency medicine, and intensive care joined this iteration of the CAFG. Each member was assigned topics and conducted reviews of Medline, EMBASE, and Cochrane databases. Results were presented and discussed during multiple teleconferences and two face-to-face meetings. When appropriate, evidence- or consensus-based recommendations were made together with assigned levels of evidence modelled after previously published criteria. Conclusions The clinician must be aware of the potential for harm to the patient that can occur with multiple attempts at tracheal intubation. This likelihood can be minimized by moving early from an unsuccessful primary intubation technique to an alternative “Plan B” technique if oxygenation by face mask or ventilation using a supraglottic device is non-problematic. Irrespective of the technique(s) used, failure to achieve successful tracheal intubation in a maximum of three attempts defines failed tracheal intubation and signals the need to engage an exit strategy. Failure to oxygenate by face mask or supraglottic device ventilation occurring in conjunction with failed tracheal intubation defines a failed oxygenation, “cannot intubate, cannot oxygenate” situation. Cricothyrotomy must then be undertaken without delay, although if not already tried, an expedited and concurrent attempt can be made to place a supraglottic device.
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Development and Validation of a Score for Prediction of Postoperative Respiratory Complications. Anesthesiology 2013; 118:1276-85. [DOI: 10.1097/aln.0b013e318293065c] [Citation(s) in RCA: 153] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Abstract
Background:
Postoperative respiratory failure is associated with increased morbidity and mortality, as well as high costs of hospital care.
Methods:
Using electronic anesthesia records, billing data, and chart review, the authors developed and validated a score predicting reintubation in the hospital after primary extubation in the operating room, leading to unplanned mechanical ventilation within the first 3 postoperative days. Using multivariable logistic regression analysis, independent predictors were determined and a score postulated and validated.
Results:
In the entire cohort (n = 33,769 surgical cases within 29,924 patients), reintubation occurred in 137 cases (0.41%). Of those, 16%, (n = 22) died subsequently, whereas the mortality in patients who were not reintubated was 0.26% (P < 0.0001). Independent predictors for reintubation were: American Society of Anesthesiologist Score 3 or more, emergency surgery, high-risk surgical service, history of congestive heart failure, and chronic pulmonary disease. A point value of 3, 3, 2, 2, and 1 were assigned to these predictors, respectively, based on their β coefficient in the predictive model. The score yielded a calculated area under the curve of 0.81, whereas each point increment was associated with a 1.7-fold (odds ratio: 1.72 [95% CI, 1.55–1.91]) increase in the odds for reintubation in the training dataset. Using the validation dataset (n = 16,884), the score had an area under the curve of 0.80 and similar estimated probabilities for reintubation.
Conclusion:
The authors developed and validated a score for the prediction of postoperative respiratory complications, a simple, 11-point score that can be used preoperatively by anesthesiologists to predict severe postoperative respiratory complications.
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Kory P, Guevarra K, Mathew JP, Hegde A, Mayo PH. The impact of video laryngoscopy use during urgent endotracheal intubation in the critically ill. Anesth Analg 2013; 117:144-9. [PMID: 23687228 DOI: 10.1213/ane.0b013e3182917f2a] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND The video laryngoscope (VL) has been shown to improve laryngoscopic views and first-attempt success rates in elective operating room and simulated tracheal intubations compared with the direct laryngoscope (DL). However, there are limited data on the effectiveness of the VL compared with the DL in urgent endotracheal intubations (UEIs) in the critically ill. We assessed the effectiveness of using a VL as the primary intubating device during UEI in critically ill patients when performed by less experienced operators. METHODS We compared success rates of UEIs performed by Pulmonary and Critical Care Medicine (PCCM) fellows in the medical intensive care unit and medical or surgical wards. A cohort of PCCM fellows using GlideScope VL as the primary intubating device was compared with a historical cohort of PCCM fellows using a traditional Macintosh or Miller blade DL. The primary measured outcome was first-attempt intubation success rate. Secondary outcomes included total number of attempts required for successful tracheal intubation, rate of esophageal intubation, need for supervising attending intervention, duration of intubation sequence, and incidence of hypoxemia and hypotension. RESULTS There were 138 UEIs, with 78 using a VL and 50 using a DL as the primary intubating device. The rate of first-attempt success was superior with the VL as compared with the DL (91% vs 68%, P < 0.01). The rate of intubations requiring ≥3 attempts (4% vs 20%, P < 0.01), unintended esophageal intubations (0% vs 14%, P < 0.01), and the average number of attempts required for successful tracheal intubation (1.2 ± 0.56 vs 1.7 ± 1.1, P < 0.01) all improved significantly with use of the VL compared with the DL. CONCLUSIONS UEI using a VL as the primary device improved intubation success and decreased complications compared with a DL when PCCM fellows were the primary operators. These data suggest that the VL should be used as the primary device when urgent intubations are performed by less experienced operators.
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Affiliation(s)
- Pierre Kory
- Division of Pulmonary, Critical Care, and Sleep Medicine, Beth Israel Medical Center, 7th Floor Dazian Bldg., 16th St. and First Ave., New York, NY 10003, USA.
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Gray LD, Morris C. The principles and conduct of anaesthesia for emergency surgery. Anaesthesia 2012; 68 Suppl 1:14-29. [DOI: 10.1111/anae.12057] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Video-laryngoscopy versus direct laryngoscopy in critically ill patients: a pilot randomized trial. Can J Anaesth 2012; 59:1032-9. [PMID: 22932944 DOI: 10.1007/s12630-012-9775-8] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2012] [Accepted: 08/16/2012] [Indexed: 10/27/2022] Open
Abstract
PURPOSE Endotracheal intubation in critically ill patients is associated with a high risk of complications that tend to increase with multiple attempts at laryngoscopy. In this pilot study, we compared direct laryngoscopy (DL) with video-laryngoscopy (VL) with regard to the number of attempts and other clinical parameters during endotracheal intubation of critically ill patients performed by novice providers. METHODS Patients were randomized to either VL or DL for endotracheal intubation. Exclusion criteria for the study included: requirement for immediate endotracheal intubation, cervical spine precautions, anticipated difficult intubation, oxygen saturation < 90%, or systolic blood pressure < 80 mmHg despite resuscitation. The providers, predominantly non-anesthesiology residents in their first three years of postgraduate training, received a one-hour teaching and mannequin session prior to performing the procedures. RESULTS Forty patients, mean age 65 (standard deviation, 16) yr were randomized to VL (n = 20) or DL (n = 20). Sixty percent of the patients received endotracheal intubation for respiratory failure, and all patients received a neuromuscular blocker. Multiple attempts were required in 25/40 (63%) patients, and this did not differ with technique (P = 1.0) Video-laryngoscopy resulted in improved glottic visualization with 85% of patients having a Cormack-Lehane grade 1 view compared with 30% of patients in the DL group (P < 0.001). Total time-to-intubation for VL was 221 sec (interquartile range [IQR 103-291]) vs 156 sec [IQR 67-220] for DL (P = 0.15). Video-laryngoscopy resulted in a lower median SaO(2) (86%) during endotracheal intubation [IQR 75-93] compared with a median SaO(2) of 95% in the DL group [IQR 85-99] (P = 0.04). CONCLUSIONS Video-laryngoscopy resulted in improved glottic visualization compared with DL; however, this did not translate into improved clinical outcomes. The trial was registered on ClinicalTrials.gov number, NCT00911755.
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Neuromuscular blocking agent administration for emergent tracheal intubation is associated with decreased prevalence of procedure-related complications. Crit Care Med 2012; 40:1808-13. [PMID: 22610185 DOI: 10.1097/ccm.0b013e31824e0e67] [Citation(s) in RCA: 77] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Emergent intubation is associated with a high rate of complications. Neuromuscular blocking agents are routinely used in the operating room and emergency department to facilitate intubation. However, use of neuromuscular blocking agents during emergent airway management outside of the operating room and emergency department is controversial. We hypothesized that the use of neuromuscular blocking agents is associated with a decreased prevalence of hypoxemia and reduced rate of procedure-related complications. METHODS Five hundred sixty-six patients undergoing emergent intubations in two tertiary care centers, Massachusetts General Hospital, Boston, MA, and the University of California Los Angeles, Ronald Reagan Medical Center, Los Angeles, CA, were enrolled in a prospective, observational study. The 112 patients intubated during cardiopulmonary resuscitation were excluded, leaving 454 patients for analysis. All intubations were supervised by attendings trained in Critical Care Medicine. We measured intubating conditions, oxygen saturation during and 5 mins following intubation. We assessed the prevalence of procedure-related complications defined as esophageal intubation, traumatic intubation, aspiration, dental injury, and endobronchial intubation. RESULTS The use of neuromuscular blocking agents was associated with a lower prevalence of hypoxemia (10.1% vs. 17.4%, p = .022) and a lower prevalence of procedure-related complications (3.1% vs. 8.3%, p = .012). This association persisted in a multivariate analysis, which controlled for airway grade, sedation, and institution. Use of neuromuscular blocking agents was associated with significantly improved intubating conditions (laryngeal view, p = .014; number of intubation attempts, p = .049). After controlling for the number of intubation attempts and laryngoscopic view, muscle relaxant use is an independent predictor of complications associated with emergency intubation (p = .037), and there is a trend towards improvement of oxygenation (p = .07). CONCLUSION The use of neuromuscular blocking agents, when used by intensivists with a high level of training and experience, is associated with a decrease in procedure-related complications.
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Griesdale DEG, Liu D, McKinney J, Choi PT. Glidescope® video-laryngoscopy versus direct laryngoscopy for endotracheal intubation: a systematic review and meta-analysis. Can J Anaesth 2011; 59:41-52. [PMID: 22042705 PMCID: PMC3246588 DOI: 10.1007/s12630-011-9620-5] [Citation(s) in RCA: 236] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2011] [Accepted: 10/19/2011] [Indexed: 02/07/2023] Open
Abstract
Introduction The Glidescope® video-laryngoscopy appears to provide better glottic visualization than direct laryngoscopy. However, it remains unclear if it translates into increased success with intubation. Methods We systematically searched electronic databases, conference abstracts, and article references. We included trials in humans comparing Glidescope® video-laryngoscopy to direct laryngoscopy regarding the glottic view, successful first-attempt intubation, and time to intubation. We generated pooled risk ratios or weighted mean differences across studies. Meta-regression was used to explore heterogeneity based on operator expertise and intubation difficulty. Results We included 17 trials with a total of 1,998 patients. The pooled relative risk (RR) of grade 1 laryngoscopy (vs ≥ grade 2) for the Glidescope® was 2.0 [95% confidence interval (CI) 1.5 to 2.5]. Significant heterogeneity was partially explained by intubation difficulty using meta-regression analysis (P = 0.003). The pooled RR for nondifficult intubations of grade 1 laryngoscopy (vs ≥ grade 2) was 1.5 (95% CI 1.2 to 1.9), and for difficult intubations it was 3.5 (95% CI 2.3 to 5.5). There was no difference between the Glidescope® and the direct laryngoscope regarding successful first-attempt intubation or time to intubation, although there was significant heterogeneity in both of these outcomes. In the two studies examining nonexperts, successful first-attempt intubation (RR 1.8, 95% CI 1.4 to 2.4) and time to intubation (weighted mean difference −43 sec, 95% CI −72 to −14 sec) were improved using the Glidescope®. These benefits were not seen with experts. Conclusion Compared to direct laryngoscopy, Glidescope® video-laryngoscopy is associated with improved glottic visualization, particularly in patients with potential or simulated difficult airways.
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Affiliation(s)
- Donald E G Griesdale
- Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada.
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Griesdale DEG, Henderson WR, Green RS. Airway management in critically ill patients. Lung 2011; 189:181-92. [PMID: 21274550 DOI: 10.1007/s00408-011-9278-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2010] [Accepted: 01/10/2011] [Indexed: 12/19/2022]
Abstract
In critically ill patients, endotracheal intubation is associated with a high risk of complications, including severe hypoxemia and hypotension. The purpose of this review is to discuss the definitions, complications, airway assessment, and patient optimization with respect to these patients. In addition, we present different approaches and techniques to help secure the airway in critically ill patients. We also discuss strategies to help minimize the risk of a difficult or failed airway and to mitigate the severe life-threatening complications associated with this high-risk procedure.
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Affiliation(s)
- Donald E G Griesdale
- Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada.
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Krausz AA, El-Naaj IA, Barak M. Maxillofacial trauma patient: coping with the difficult airway. World J Emerg Surg 2009; 4:21. [PMID: 19473497 PMCID: PMC2693512 DOI: 10.1186/1749-7922-4-21] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2008] [Accepted: 05/27/2009] [Indexed: 12/12/2022] Open
Abstract
Establishing a secure airway in a trauma patient is one of the primary essentials of treatment. Any flaw in airway management may lead to grave morbidity and mortality. Maxillofacial trauma presents a complex problem with regard to the patient's airway. By definition, the injury compromises the patient's airway and it is, therefore, must be protected. In most cases, the patient undergoes surgery for maxillofacial trauma or for other, more severe, life-threatening injuries, and securing the airway is the first step in the introduction of general anaesthesia. In such patients, we anticipate difficult endotracheal intubation and, often, also difficult mask ventilation. In addition, the patient is usually regarded as having a "full stomach" and has not been cleared of a C-spine injury, which may complicate airway management furthermore. The time available to accomplish the task is short and the patient's condition may deteriorate rapidly. Both decision-making and performance are impaired in such circumstances. In this review, we discuss the complexity of the situation and present a treatment approach.
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Affiliation(s)
- Amir A Krausz
- Department of Oral and Maxillofacial Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Imad Abu El-Naaj
- Department of Oral and Maxillofacial Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Michal Barak
- Department of Anesthesiology, Rambam Health Care Campus, and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
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Chen WH, Su HP, Chiu YH, Tseng CC, Chung KC. A two-stage approach to positioning and identification of tracheal intubation using LED-based lightwand and acoustic models. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2009; 2008:4883-6. [PMID: 19163811 DOI: 10.1109/iembs.2008.4650308] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
This paper proposes a two-stage approach to positioning and identifying tracheal intubations by computer-assisted diagnosis system. First, an innovated LED-based lightwand is developed for positioning the opening of the trachea and inserting the endotracheal tube rapidly. The proposed LED-based lightwand instrument significantly reduces the effects of temperature reaction without changing transillumination through the tissue. After intubation, breath sound analysis instrumentation is developed and assists for identifying the accurate tube position. To overcome the fast and overstepped variations of amplitude, a high sensitivity omni dimensional microphone and an automatic gain control device with linear phase property are calibrated and conducted into experiments of operating intubations. User-friendly interface software is also developed to analyze and transcribe the physiological characteristics of the collected breath sound corpus. Several subjective and objective experiments are performed to examine the practicability of the proposed approach and systems. The preliminary results show that the proposed LED-based lightwand instrument outperformed in the tip temperature without the influence on transillumination. The proposed parameters of average vibration parameter variance (AVPV) and frequency-domain energy variance (FEV) revealed the potential for distinguishing between the tracheal and esophageal intubations.
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Affiliation(s)
- Wei-Hao Chen
- Institute of Biomedical Engineering, National Cheng Kung University, No. 1, Ta-Hsueh Road, Tainan, 701, Taiwan.
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Risk of cardiopulmonary arrest after acute respiratory compromise in hospitalized patients. Resuscitation 2008; 79:234-40. [DOI: 10.1016/j.resuscitation.2008.06.025] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2008] [Revised: 06/20/2008] [Accepted: 06/30/2008] [Indexed: 11/19/2022]
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Griesdale DEG, Bosma TL, Kurth T, Isac G, Chittock DR. Complications of endotracheal intubation in the critically ill. Intensive Care Med 2008; 34:1835-42. [PMID: 18604519 DOI: 10.1007/s00134-008-1205-6] [Citation(s) in RCA: 285] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2008] [Accepted: 06/10/2008] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Assess the risk of complications during endotracheal intubation (ETI) and their association with the skill level of the intubating physician. DESIGN Prospective cohort study of 136 patients intubated by the intensive care team during a 5-month period. Standardized data forms were used to collect detailed information on the intubating physicians, supervisors, techniques, medications and complications. SETTING Canadian academic intensive care unit. MEASUREMENTS AND RESULTS All intubations were successful and there were no deaths during intubation. Non-experts were supervised in 92% of procedures. Expert operators were successful within two attempts in 94%, compared to only 82% of non-experts (P = 0.03), with 13.2% of all intubations requiring > or =3 attempts. Furthermore, 10.3% of intubations required 10 or more minutes. Difficult intubation (3 or more attempts by an expert) occurred in 6.6%. Overall risk of complications was 39%, including: severe hypoxemia (19.1%), severe hypotension (9.6%), esophageal intubation (7.4%) and frank aspiration (5.9%). ICU and hospital mortality were 15.4 and 29.4%, respectively. Compared with non-expert intubating physicians, propensity score-adjusted odds ratios (95% confidence interval) for expert physicians were 0.92 (95% CI: 0.28, 3.05, P = 0.89) for any complication, 0.45 (95% CI: 0.09, 2.20, P = 0.32) for ICU mortality and 0.47 (95% CI: 0.13, 1.70, P = 0.25) for hospital mortality. Two or more attempts at ETI was independently associated with an increased risk of severe complications (OR 3.31, 95% CI: 1.30, 8.40, P = 0.01). CONCLUSIONS These prospective data show a high risk of serious complications, and difficult intubations, that are associated with ETI of the critically ill. DESCRIPTOR Artificial airways and complications.
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Affiliation(s)
- Donald E G Griesdale
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada.
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Bagheri SC, Stockmaster N, Delgado G, Kademani D, Carter TG, Ramzy A, Dierks EJ. Esophageal Rupture With the Use of the Combitube: Report of a Case and Review of the Literature. J Oral Maxillofac Surg 2008; 66:1041-4. [DOI: 10.1016/j.joms.2007.08.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2005] [Revised: 06/19/2007] [Accepted: 08/23/2007] [Indexed: 10/22/2022]
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