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Acquisto NM, Mosier JM, Bittner EA, Patanwala AE, Hirsch KG, Hargwood P, Oropello JM, Bodkin RP, Groth CM, Kaucher KA, Slampak-Cindric AA, Manno EM, Mayer SA, Peterson LKN, Fulmer J, Galton C, Bleck TP, Chase K, Heffner AC, Gunnerson KJ, Boling B, Murray MJ. Society of Critical Care Medicine Clinical Practice Guidelines for Rapid Sequence Intubation in the Critically Ill Adult Patient. Crit Care Med 2023; 51:1411-1430. [PMID: 37707379 DOI: 10.1097/ccm.0000000000006000] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
Abstract
RATIONALE Controversies and practice variations exist related to the pharmacologic and nonpharmacologic management of the airway during rapid sequence intubation (RSI). OBJECTIVES To develop evidence-based recommendations on pharmacologic and nonpharmacologic topics related to RSI. DESIGN A guideline panel of 20 Society of Critical Care Medicine members with experience with RSI and emergency airway management met virtually at least monthly from the panel's inception in 2018 through 2020 and face-to-face at the 2020 Critical Care Congress. The guideline panel included pharmacists, physicians, a nurse practitioner, and a respiratory therapist with experience in emergency medicine, critical care medicine, anesthesiology, and prehospital medicine; consultation with a methodologist and librarian was available. A formal conflict of interest policy was followed and enforced throughout the guidelines-development process. METHODS Panelists created Population, Intervention, Comparison, and Outcome (PICO) questions and voted to select the most clinically relevant questions for inclusion in the guideline. Each question was assigned to a pair of panelists, who refined the PICO wording and reviewed the best available evidence using predetermined search terms. The Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) framework was used throughout and recommendations of "strong" or "conditional" were made for each PICO question based on quality of evidence and panel consensus. Recommendations were provided when evidence was actionable; suggestions, when evidence was equivocal; and best practice statements, when the benefits of the intervention outweighed the risks, but direct evidence to support the intervention did not exist. RESULTS From the original 35 proposed PICO questions, 10 were selected. The RSI guideline panel issued one recommendation (strong, low-quality evidence), seven suggestions (all conditional recommendations with moderate-, low-, or very low-quality evidence), and two best practice statements. The panel made two suggestions for a single PICO question and did not make any suggestions for one PICO question due to lack of evidence. CONCLUSIONS Using GRADE principles, the interdisciplinary panel found substantial agreement with respect to the evidence supporting recommendations for RSI. The panel also identified literature gaps that might be addressed by future research.
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Affiliation(s)
- Nicole M Acquisto
- Department of Pharmacy and Emergency Medicine, University of Rochester Medical Center, Rochester, New York, NY
| | - Jarrod M Mosier
- Department of Emergency Medicine and Medicine, University of Arizona College of Medicine, Tucson, AZ
| | - Edward A Bittner
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA
| | - Asad E Patanwala
- Faculty of Medicine and Health, Sydney School of Pharmacy, The University of Sydney, Sydney, Australia
| | - Karen G Hirsch
- Department of Neurology and Neurological Sciences and Neurosurgery, Stanford University, Stanford, CA
| | - Pamela Hargwood
- Robert Wood Johnson Library of the Health Sciences, Rutgers University, New Brunswick, NJ
| | - John M Oropello
- Institute for Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ryan P Bodkin
- Department of Emergency Medicine, University of Rochester Medical Center, Rochester, New York, NY
| | - Christine M Groth
- Department of Pharmacy, University of Rochester Medical Center, Rochester, New York, NY
| | - Kevin A Kaucher
- Department of Pharmacy, University of New Mexico Hospital, Albuquerque, NM
| | | | - Edward M Manno
- Department of Neurology, Northwestern University, Feinberg School of Medicine, Chicago, IL
| | - Stephen A Mayer
- Departments of Neurology and Neurosurgery Westchester Medical Center, New York Medical College, New York, NY
| | - Lars-Kristofer N Peterson
- Departments of Critical Care Medicine and Emergency Medicine, Cooper University Health Care, Camden, NJ
| | - Jeremy Fulmer
- Respiratory Care Services, Geisinger Medical Center, Danville, PA
| | - Christopher Galton
- Departments of Anesthesiology and Perioperative Medicine and Emergency Medicine, University of Rochester Medical Center, Rochester, NY
| | - Thomas P Bleck
- Department of Neurology, Northwestern University, Feinberg School of Medicine, Chicago, IL
| | - Karin Chase
- Departments of Surgery and Emergency Medicine, University of Rochester Medical Center, Rochester, NY
| | - Alan C Heffner
- Departments of Critical Care and Emergency Medicine, Atrium Healthcare System, Charlotte, NC
| | - Kyle J Gunnerson
- Department of Emergency Medicine, University of Michigan Health System, Ann Arbor, MI
| | - Bryan Boling
- Department of Anesthesiology, Division or Critical Care Medicine, University of Kentucky, Lexington, KY
| | - Michael J Murray
- Departments of Anesthesiology and Internal Medicine/Cardiology, University of Arizona College of Medicine, Phoenix, AZ
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2
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Lowe JB, Yoo MJ, Patrick JO, Bridwell RE. Facilitated Intubation: Time to Re-examine an Old Technique With Its Associated Risks Mitigated by New Technology. Cureus 2023; 15:e43364. [PMID: 37701008 PMCID: PMC10494483 DOI: 10.7759/cureus.43364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/11/2023] [Indexed: 09/14/2023] Open
Abstract
BACKGROUND Facilitated intubation (FI) refers to intubation performed using a sedative or anesthetic drug as an induction agent, without the use of a paralytic (neuromuscular blocking agent). In comparison, rapid sequence intubation (RSI) employs both an induction agent and a paralytic drug. RSI has been seen to outperform FI in terms of first-pass success when performing direct laryngoscopy and was quickly adopted as the gold standard in all situations. Recently, ketamine-only intubation has been used in situations where there is distorted anatomy or apnea intolerance (physically and physiologically difficult airways) resulting in an increased risk of a can't intubate/can't oxygenate scenario or significant hypoxemia. Frequent and recurring national ketamine shortages have resulted in renewed interest in whether or not other forms of FI are feasible in an era where other factors that mitigate complictions in achieving first-pass success (video laryngoscopy, bougie use, semi-Fowler positioning) are commonly used. We present a case series with outcomes for profoundly hypoxic patients with coronavirus disease 2019 (COVID-19) (physiologically difficult airways) undergoing FI during a time of national ketamine shortage, using modern techniques and technology to maximize first-pass success and minimize peri-intubation complication. METHODS We included patients with COVID-19 pneumonia with pre-intubation oxygen saturations of less than 80% (significant hypoxemia) requiring intubation who presented to a tertiary care center in southern United States between August 25, 2021, and October 22, 2021. In this specific cohort, patients underwent endotracheal intubation with midazolam for induction without the use of paralytic agents. We used video-assisted laryngoscopy to increase the success of the first-pass attempt as well as placing the patients in a semi-Fowler position (head of bed elevation 30-45°) and bilevel positive pressure pre-oxygenation to minimize peri-intubation complications. RESULTS Our case series included 29 consecutive patients that met the inclusion criteria. The mean ± standard deviation (SD) age of the patients was 49.5±15.0 years. The mean±SD pre-intubation oxygenation of our cohort was 73.1±5.9%. All 29 intubations were successful on the first-pass attempt. Only one patient (3.4%) required a rescue paralytic to facilitate oral opening. Of note, 27/29 (93%) of the patients did not receive any immunizations (including partial) for COVID-19. There were no incidents of peri-intubation arrest (cardiac arrest within 30 minutes of induction) or aspiration. CONCLUSIONS In 29 physiologically difficult patients with acute respiratory failure, in whom the physician determined that RSI posed a higher than normal risk, FI assisted by VL, semi-Fowler positioning, and bilevel positive pressure pre-oxygenation resulted in excellent successful first-pass intubation rates without any incidences of peri-intubation arrest or aspiration. While this cohort was small, our study reveals that FI with midazolam does not likely pose a higher risk than ketamine-only intubation and warrants further study.
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Affiliation(s)
- Joshua B Lowe
- Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, USA
| | - Michael J Yoo
- Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, USA
| | - John O Patrick
- Emergency Medicine, Royal Air Force (RAF) Lakenhealth Medical Center, RAF Lakenheath, GBR
| | - Rachel E Bridwell
- Emergency Medicine, Madigan Army Medical Center, Joint Base Lewis-McChord, USA
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3
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Turner JS, Hunter BR, Haseltine ID, Motzkus CA, DeLuna HM, Cooper DD, Ellender TJ, Sarmiento EJ, Menard LM, Kirschner JM. Effect of inclined positioning on first-pass success during endotracheal intubation: a systematic review and meta-analysis. Emerg Med J 2023; 40:293-299. [PMID: 35393346 DOI: 10.1136/emermed-2021-211968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 03/24/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Endotracheal intubation is a high-risk procedure. Optimisation of all aspects of the procedure, including patient positioning, is important to facilitate success and minimise complications. The objective of this systematic review was to determine the association between inclined patient positioning and first-pass success and other clinically important outcomes among patients undergoing endotracheal intubation. METHODS A search of PubMed, CINAHL, SCOPUS, EMBASE and Cochrane, from inception through October 2020 was conducted. Studies were assessed independently by two authors to determine eligibility for inclusion. Included studies were any randomised or observational study that compared supine to inclined patient positioning for endotracheal intubation and assessed one of our predefined outcomes. Simulation studies were excluded. Study results were meta-analysed using a random effects model. The quality of the evidence for outcomes of interest was assessed using the Grading of Recommendations, Assessment, Development and Evaluations approach. RESULTS A total of 5113 studies were identified, of which 10 studies representing 18 371 intubations were included for meta-analysis. There was no statistically significant difference in the primary outcome of first-pass success rate (relative risk 1.02, 95% CI 0.98 to 1.05) or secondary outcomes of oesophageal intubation, glottic view, hypotension, hypoxaemia, mortality or peri-intubation arrest. Likewise, there were no statistically significant differences in any of the outcomes in predefined subgroup analyses of randomised controlled trials, intubations in acute settings or intubations performed with >45 degrees of incline. Overall quality of evidence was rated as low or very low for most outcomes. CONCLUSIONS This systematic review and meta-analysis found no evidence of benefit or harm with inclined versus supine patient positioning during endotracheal intubation in any setting.
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Affiliation(s)
- Joseph S Turner
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Benton R Hunter
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Ian D Haseltine
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Christine A Motzkus
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Hannah M DeLuna
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Dylan D Cooper
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Timothy J Ellender
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Elisa J Sarmiento
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Laura M Menard
- Ruth Lilly Medical Library, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Jonathan M Kirschner
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
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4
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Shires P, Harlow G, Holecova A. Fifteen-minute consultation: Airway management in the acutely unwell child requiring intubation for the general paediatrician. Arch Dis Child Educ Pract Ed 2023; 108:29-37. [PMID: 34510012 DOI: 10.1136/archdischild-2021-322200] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 08/19/2021] [Indexed: 02/05/2023]
Abstract
Emergency endotracheal intubation is a high risk procedure in acutely unwell children and is commonly jointly managed by paediatricians and anaesthetists. This article aims to develop a shared understanding of the practicalities and language around the risk factors for difficult intubation and management of failed intubation, including the approach to situations where you cannot intubate and or cannot ventilate, to improve communication and team working between these dynamic interdisciplinary teams.
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Affiliation(s)
- Peter Shires
- PCCU, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Georgina Harlow
- PCCU, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Agata Holecova
- PCCU, Nottingham University Hospitals NHS Trust, Nottingham, UK
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5
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Martin-Flores M, Sakai DM, Muto RM, Burns CC, Araos JD, de Miguel Garcia C, Campoy L. A flexible endotracheal tube introducer improves first-attempt success of intubation in cats by novice anesthetists. J Am Vet Med Assoc 2022; 260:1324-1329. [DOI: 10.2460/javma.22.01.0040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Abstract
OBJECTIVE
To test whether the use of a flexible endotracheal tube introducer (ETI) facilitates intubation of cats by veterinary students with little or no experience.
ANIMALS
125 healthy cats.
PROCEDURES
Cats were sedated with dexmedetomidine and morphine IM, and anesthesia was induced with propofol. They were randomly assigned to be intubated by supervised veterinary students using an ETI within a tracheal tube or an endotracheal tube alone (3.0, 3.5, or 4.0 internal diameter sizes). Success rate at first attempt, number of attempts to intubate (up to 3), and time to intubate were recorded. Multivariate logistic regression was used to test associations between several factors such as use of an ETI, cat’s weight, endotracheal tube size, administration of ketamine for sedation, and first-attempt success. Significance was considered when P < 0.05.
RESULTS
Success rate for the first attempt was higher with an ETI (79% [51/64) than without it (46% [28/61]), and attempts to intubate were fewer when an ETI was used (both P < 0.001). Time to intubate did not differ between groups (ETI, 30 seconds [4 to 143 seconds]; endotracheal tube, 28 seconds [5 to 180 seconds]). Use of an ETI was positively associated with improved first-attempt success, and the 3.0-mm internal diameter of the tube was negatively associated (both P ≤ 0.001).
CLINICAL RELEVANCE
The use of a flexible ETI improved the success of first-attempt intubation of cats by veterinary students. This technique may help minimize the number of attempts during intubation and incidence of complications that could arise from multiple attempts.
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Affiliation(s)
- Manuel Martin-Flores
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY
| | - Daniel M. Sakai
- Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, University of Georgia, Athens, GA
| | - Richard Marra Muto
- Cornell University Hospital for Animals, College of Veterinary Medicine, Cornell University, Ithaca, NY
| | - Charlotte C. Burns
- Department of Large Animal Medicine, College of Veterinary Medicine, University of Georgia, Athens, GA
| | - Joaquin D. Araos
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY
| | | | - Luis Campoy
- Department of Clinical Sciences, College of Veterinary Medicine, Cornell University, Ithaca, NY
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6
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Vaughan EM, Seitz KP, Janz DR, Russell DW, Dargin J, Vonderhaar DJ, Joffe AM, West JR, Self WH, Rice TW, Semler MW, Casey JD. Bag-Mask Ventilation Versus Apneic Oxygenation During Tracheal Intubation in Critically Ill Adults: A Secondary Analysis of 2 Randomized Trials. J Intensive Care Med 2021; 37:899-907. [PMID: 34898310 DOI: 10.1177/08850666211058646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Hypoxemia is common during tracheal intubation in intensive care units. To prevent hypoxemia during intubation, 2 methods of delivering oxygen between induction and laryngoscopy have been proposed: bag-mask ventilation and supplemental oxygen delivered by nasal cannula without ventilation (apneic oxygenation). Whether one of these approaches is more effective for preventing hypoxemia during intubation of critically ill patients is unknown. Methods: We performed a secondary analysis of data from 138 patients enrolled in 2, consecutive randomized trials of airway management in an academic intensive care unit. A total of 61 patients were randomized to receive bag-mask ventilation in a trial comparing bag-mask ventilation to none, and 77 patients were randomized to receive 100% oxygen at 15 L/min by nasal cannula in a trial comparing apneic oxygenation to none. Using multivariable linear regression accounting for age, body mass index, severity of illness, and oxygen saturation at induction, we compared patients assigned to bag-mask ventilation with those assigned to apneic oxygenation regarding lowest oxygen saturations from induction to 2 min after intubation. Results: Patients assigned to bag-mask ventilation and apneic oxygenation were similar at baseline. The median lowest oxygen saturation was 96% (interquartile range [IQR] 89%-100%) in the bag-mask ventilation group and 92% (IQR 84%-99%) in the apneic oxygenation group. After adjustment for prespecified confounders, bag-mask ventilation was associated with a higher lowest oxygen saturation compared to apneic oxygenation (mean difference, 4.2%; 95% confidence interval, 0.7%-7.8%; P = .02). The incidence of severe hypoxemia (oxygen saturation<80%) was 6.6% in the bag-mask ventilation group and 15.6% in the apneic oxygenation group (adjusted odds ratio, 0.33; P = .09). Conclusions: This secondary analysis of patients assigned to bag-mask ventilation and apneic oxygenation during 2 clinical trials suggests that bag-mask ventilation is associated with higher oxygen saturation during intubation compared to apneic oxygenation.
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Affiliation(s)
- Erin M Vaughan
- 12230Georgetown University School of Medicine, Washington, DC, USA
| | - Kevin P Seitz
- 12328Vanderbilt University Medical Center, Nashville, TN, USA
| | - David R Janz
- 473408University Medical Center New Orleans, New Orleans, LA, USA.,12258Louisiana State University School of Medicine New Orleans, New Orleans, LA, USA
| | | | - James Dargin
- 2094Lahey Hospital and Medical Center, Burlington, MA, USA
| | - Derek J Vonderhaar
- 12258Louisiana State University School of Medicine New Orleans, New Orleans, LA, USA.,12309Ochsner Health System New Orleans, New Orleans, LA, USA
| | - Aaron M Joffe
- 228464University of Washington School of Medicine, Seattle, WA, USA
| | | | - Wesley H Self
- 12328Vanderbilt University Medical Center, Nashville, TN, USA.,460460Vanderbilt Institute for Clinical and Translational Research, 5718Vanderbilt University Medical Center, Nashville, TN, USA
| | - Todd W Rice
- 12328Vanderbilt University Medical Center, Nashville, TN, USA
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7
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Mendes PV, Besen BAMP, Lacerda FH, Ramos JGR, Taniguchi LU. Neuromuscular blockade and airway management during endotracheal intubation in Brazilian intensive care units: a national survey. Rev Bras Ter Intensiva 2021; 32:433-438. [PMID: 33053034 PMCID: PMC7595723 DOI: 10.5935/0103-507x.20200073] [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: 02/16/2020] [Accepted: 03/23/2020] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE To describe the use of neuromuscular blockade as well as other practices among Brazilian physicians in adult intensive care units. METHODS An online national survey was designed and administered to Brazilian intensivists. Questions were selected using the Delphi method and assessed physicians' demographic data, intensive care unit characteristics, practices regarding airway management, use of neuromuscular blockade and sedation during endotracheal intubation in the intensive care unit. As a secondary outcome, we applied a multivariate analysis to evaluate factors associated with the use of neuromuscular blockade. RESULTS Five hundred sixty-five intensivists from all Brazilian regions responded to the questionnaire. The majority of respondents were male (65%), with a mean age of 38 ( 8.4 years, and 58.5% had a board certification in critical care. Only 40.7% of the intensivists reported the use of neuromuscular blockade during all or in more than 75% of endotracheal intubations. In the multivariate analysis, the number of intubations performed monthly and physician specialization in anesthesiology were directly associated with frequent use of neuromuscular blockade. Etomidate and ketamine were more commonly used in the clinical situation of hypotension and shock, while propofol and midazolam were more commonly prescribed in the situation of clinical stability. CONCLUSION The reported use of neuromuscular blockade was low among intensivists, and sedative drugs were chosen in accordance with patient hemodynamic stability. These results may help the design of future studies regarding airway management in Brazil.
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Affiliation(s)
- Pedro Vitale Mendes
- Disciplina de Emergências Clínicas, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil.,Unidade de Terapia Intensiva Oncológica, Hospital São Luiz Rede D'Or - São Paulo (SP), Brasil
| | - Bruno Adler Maccagnan Pinheiro Besen
- Disciplina de Emergências Clínicas, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil.,Unidade de Terapia Intensiva, Hospital da Luz - São Paulo (SP), Brasil
| | - Fabio Holanda Lacerda
- Disciplina de Emergências Clínicas, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil
| | | | - Leandro Utino Taniguchi
- Disciplina de Emergências Clínicas, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil.,Hospital Sírio-Libanês - São Paulo (SP), Brasil
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8
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Success and Complications of the Ketamine-Only Intubation Method in the Emergency Department. J Emerg Med 2020; 60:265-272. [PMID: 33308912 DOI: 10.1016/j.jemermed.2020.10.042] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 09/28/2020] [Accepted: 10/19/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND Rapid sequence intubation (RSI), defined as near-simultaneous administration of a sedative and neuromuscular blocking agent, is the most common and successful method of tracheal intubation in the emergency department. However, RSI is sometimes avoided when the physician believes there is a risk of a can't intubate/can't oxygenate scenario or critical hypoxemia because of distorted anatomy or apnea intolerance. Traditionally, topical anesthesia alone or in combination with low-dose sedation are used when physicians deem RSI too risky. Recently, a ketamine-only strategy has been suggested as an alternative approach. OBJECTIVE We compared first attempt success and complications between ketamine-only, topical anesthesia alone or with low-dose sedation, and RSI approaches. METHODS We analyzed registry data from the National Emergency Airway Registry, comprising emergency department intubation data from 25 centers from January 2016 to December 2018. We excluded pediatric patients (<14 years of age), those in cardiac and respiratory arrest, or those with an alternate pharmacologic approach (i.e., neuromuscular blocking agent only or nonketamine sedative alone). We analyzed first attempt intubation success and adverse events across the 3 intubation approaches. We calculated differences in outcomes between the ketamine-only and topical anesthesia groups. RESULTS During the study period, 12,511 of 19,071 intubation encounters met inclusion criteria, including 102 (0.8%) intubated with ketamine alone, 80 (0.6%) who had intubation facilitated by topical anesthesia, and 12,329 (98.5%) who underwent RSI. Unadjusted first attempt success was 61%, 85%, and 90% for the 3 groups, respectively. Hypoxemia (defined as oxygen saturation <90%) occurred in 16%, 13%, and 8% of patients during the first attempt, respectively. At least 1 adverse event occurred in 32%, 19%, and 14% of the courses of intubation for the 3 groups, respectively. In comparing the ketamine-only and topical anesthesia groups, the difference in first pass success was -24% (95% confidence interval -37% to -12%), and the difference in number of cases with ≥1 adverse event was 13% (95% confidence interval 0-25%), both favoring the topical anesthesia group. CONCLUSION Although sometimes advocated, the ketamine-only intubation approach is uncommon and is associated with lower success and higher complications compared with topical anesthesia and RSI approaches.
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9
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Rakhit S, Nordness MF, Lombardo SR, Cook M, Smith L, Patel MB. Management and Challenges of Severe Traumatic Brain Injury. Semin Respir Crit Care Med 2020; 42:127-144. [PMID: 32916746 DOI: 10.1055/s-0040-1716493] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Traumatic brain injury (TBI) is the leading cause of death and disability in trauma patients, and can be classified into mild, moderate, and severe by the Glasgow coma scale (GCS). Prehospital, initial emergency department, and subsequent intensive care unit (ICU) management of severe TBI should focus on avoiding secondary brain injury from hypotension and hypoxia, with appropriate reversal of anticoagulation and surgical evacuation of mass lesions as indicated. Utilizing principles based on the Monro-Kellie doctrine and cerebral perfusion pressure (CPP), a surrogate for cerebral blood flow (CBF) should be maintained by optimizing mean arterial pressure (MAP), through fluids and vasopressors, and/or decreasing intracranial pressure (ICP), through bedside maneuvers, sedation, hyperosmolar therapy, cerebrospinal fluid (CSF) drainage, and, in refractory cases, barbiturate coma or decompressive craniectomy (DC). While controversial, direct ICP monitoring, in conjunction with clinical examination and imaging as indicated, should help guide severe TBI therapy, although new modalities, such as brain tissue oxygen (PbtO2) monitoring, show great promise in providing strategies to optimize CBF. Optimization of the acute care of severe TBI should include recognition and treatment of paroxysmal sympathetic hyperactivity (PSH), early seizure prophylaxis, venous thromboembolism (VTE) prophylaxis, and nutrition optimization. Despite this, severe TBI remains a devastating injury and palliative care principles should be applied early. To better affect the challenging long-term outcomes of severe TBI, more and continued high quality research is required.
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Affiliation(s)
- Shayan Rakhit
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee.,Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mina F Nordness
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee.,Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sarah R Lombardo
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Madison Cook
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee.,Meharry Medical College, Nashville, Tennessee
| | - Laney Smith
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee.,Washington and Lee University, Lexington, Virginia
| | - Mayur B Patel
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee.,Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Neurosurgery and Hearing and Speech Sciences, Vanderbilt Brain Institute, Vanderbilt University Medical Center, Nashville, Tennessee.,Surgical Service, Nashville VA Medical Center, Tennessee Valley Healthcare System, US Department of Veterans Affairs, Nashville, Tennessee.,Geriatric Research, Education, and Clinical Center Service, Nashville VA Medical Center, Tennessee Valley Healthcare System, US Department of Veterans Affairs, Nashville, Tennessee
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10
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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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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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Benmelouka A, Shamseldin LS, Nourelden AZ, Negida A. A Review on the Etiology and Management of Pediatric Traumatic Spinal Cord Injuries. ADVANCED JOURNAL OF EMERGENCY MEDICINE 2019; 4:e28. [PMID: 32322796 PMCID: PMC7163256 DOI: 10.22114/ajem.v0i0.256] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
CONTEXT Pediatric traumatic spinal cord injury (SCI) is an uncommon presentation in the emergency department. Severe injuries are associated with devastating outcomes and complications, resulting in high costs to both the society and the economic system. EVIDENCE ACQUISITION The data on pediatric traumatic spinal cord injuries has been narratively reviewed. RESULTS Pediatric SCI is a life-threatening emergency leading to serious outcomes and high mortality in children if not managed promptly. Pediatric SCI can impose many challenges to neurosurgeons and caregivers because of the lack of large studies with high evidence level and specific guidelines in terms of diagnosis, initial management and of in-hospital treatment options. Several novel potential treatment options for SCI have been developed and are currently under investigation. However, research studies into this field have been limited by the ethical and methodological challenges. CONCLUSION Future research is needed to investigate the safety and efficacy of the recent uprising neurodegenerative techniques in SCI population. Owing to the current limitations, there is a need to develop novel trial methodologies that can overcome the current methodological and ethical limitations.
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Affiliation(s)
| | | | | | - Ahmed Negida
- Medical Research Group of Egypt, Egypt
- Faculty of Medicine, Zagazig University, Zagazig, Egypt
- Neurosurgery Department, Bahçeşehir University, Istanbul, Turkey
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Driver BE, Klein LR, Prekker ME, Cole JB, Satpathy R, Kartha G, Robinson A, Miner JR, Reardon RF. Drug Order in Rapid Sequence Intubation. Acad Emerg Med 2019; 26:1014-1021. [PMID: 30834639 DOI: 10.1111/acem.13723] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 02/04/2019] [Accepted: 02/06/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND The optimal order of drug administration (sedative first vs. neuromuscular blocking agent first) in rapid sequence intubation (RSI) is debated. OBJECTIVE We sought to determine if RSI drug order was associated with the time elapsed from administration of the first RSI drug to the end of a successful first intubation attempt. METHODS We conducted a planned secondary analysis of a randomized trial of adult ED patients undergoing emergency orotracheal intubation that demonstrated higher first-attempt success with bougie use compared to a tracheal tube + stylet. Drug choice, dose, and the order of sedative and neuromuscular blocking agent were not stipulated. We analyzed trial patients who received both a sedative and a neuromuscular blocking agent within 30 seconds of each other who were intubated successfully on the first attempt. The primary outcome was the time elapsed from complete administration of the first RSI drug to the end of the first intubation attempt, a surrogate outcome for apnea time. We performed a multivariable analysis using a mixed-effects generalized linear model. RESULTS Of 757 original trial patients, 562 patients (74%) met criteria for analysis; 153 received the sedative agent first, and 409 received the neuromuscular blocking agent first. Administration of the neuromuscular blocking agent before the sedative agent was associated with a reduction in time from RSI administration to the end of intubation attempt of 6 seconds (95% confidence interval = 0 to 11 sec). CONCLUSION Administration of either the neuromuscular blocking or the sedative agent first are both acceptable. Administering the neuromuscular blocking agent first may result in modestly faster time to intubation. For now, it is reasonable for physicians to continue performing RSI in the way they are most comfortable with. If future research determines that the order of medication administration is not associated with awareness of neuromuscular blockade, administration of the neuromuscular blocking agent first may be a logical default administration method to attempt to minimize apnea time during intubation.
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Affiliation(s)
- Brian E. Driver
- Department of Emergency Medicine Hennepin County Medical Center Minneapolis MN
| | - Lauren R. Klein
- Department of Emergency Medicine Hennepin County Medical Center Minneapolis MN
| | - Matthew E. Prekker
- Department of Emergency Medicine Hennepin County Medical Center Minneapolis MN
- Division of Pulmonary/Critical Care Department of Medicine Hennepin County Medical Center Minneapolis MN
| | - Jon B. Cole
- Department of Emergency Medicine Hennepin County Medical Center Minneapolis MN
| | - Rajesh Satpathy
- Department of Emergency Medicine Hennepin County Medical Center Minneapolis MN
| | - Gautham Kartha
- Department of Emergency Medicine Hennepin County Medical Center Minneapolis MN
| | - Aaron Robinson
- Department of Emergency Medicine Hennepin County Medical Center Minneapolis MN
| | - James R. Miner
- Department of Emergency Medicine Hennepin County Medical Center Minneapolis MN
| | - Robert F. Reardon
- Department of Emergency Medicine Hennepin County Medical Center Minneapolis MN
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14
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Casey JD, Janz DR, Russell DW, Vonderhaar DJ, Joffe AM, Dischert KM, Brown RM, Zouk AN, Gulati S, Heideman BE, Lester MG, Toporek AH, Bentov I, Self WH, Rice TW, Semler MW. Bag-Mask Ventilation during Tracheal Intubation of Critically Ill Adults. N Engl J Med 2019; 380:811-821. [PMID: 30779528 PMCID: PMC6423976 DOI: 10.1056/nejmoa1812405] [Citation(s) in RCA: 115] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Hypoxemia is the most common complication during tracheal intubation of critically ill adults and may increase the risk of cardiac arrest and death. Whether positive-pressure ventilation with a bag-mask device (bag-mask ventilation) during tracheal intubation of critically ill adults prevents hypoxemia without increasing the risk of aspiration remains controversial. METHODS In a multicenter, randomized trial conducted in seven intensive care units in the United States, we randomly assigned adults undergoing tracheal intubation to receive either ventilation with a bag-mask device or no ventilation between induction and laryngoscopy. The primary outcome was the lowest oxygen saturation observed during the interval between induction and 2 minutes after tracheal intubation. The secondary outcome was the incidence of severe hypoxemia, defined as an oxygen saturation of less than 80%. RESULTS Among the 401 patients enrolled, the median lowest oxygen saturation was 96% (interquartile range, 87 to 99) in the bag-mask ventilation group and 93% (interquartile range, 81 to 99) in the no-ventilation group (P = 0.01). A total of 21 patients (10.9%) in the bag-mask ventilation group had severe hypoxemia, as compared with 45 patients (22.8%) in the no-ventilation group (relative risk, 0.48; 95% confidence interval [CI], 0.30 to 0.77). Operator-reported aspiration occurred during 2.5% of intubations in the bag-mask ventilation group and during 4.0% in the no-ventilation group (P = 0.41). The incidence of new opacity on chest radiography in the 48 hours after tracheal intubation was 16.4% and 14.8%, respectively (P = 0.73). CONCLUSIONS Among critically ill adults undergoing tracheal intubation, patients receiving bag-mask ventilation had higher oxygen saturations and a lower incidence of severe hypoxemia than those receiving no ventilation. (Funded by Vanderbilt Institute for Clinical and Translational Research and others; PreVent ClinicalTrials.gov number, NCT03026322.).
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Affiliation(s)
- Jonathan D. Casey
- Division of Allergy, Pulmonary, and Critical Care Medicine (J.D.C., R.M.B., B.E.H., M.G.L., A.H.T., T.W.R., M.W.S.), and the Department of Emergency Medicine (W.H.S.), Vanderbilt University Medical Center, Nashville; the Section of Pulmonary, Critical Care, and Allergy and Immunology (D.R.J.), and the Section of Emergency Medicine (D.J.V.), Louisiana State University School of Medicine– New Orleans, and the Department of Pulmonary and Critical Care Medicine, Ochsner Health System (D.J.V., K.M.D.) — both in New Orleans; the Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham (D.W.R., A.N.Z., S.G.); and the Department of Anesthesiology and Pain Medicine (A.M.J.) and the Division of Pulmonary and Critical Care (I.B.), University of Washington School of Medicine, Seattle. Address reprint requests to Dr. Casey at the Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, T-1210 MCN, 1161 21st Ave. S., Nashville, TN 37232-2650, or at
| | - David R. Janz
- Division of Allergy, Pulmonary, and Critical Care Medicine (J.D.C., R.M.B., B.E.H., M.G.L., A.H.T., T.W.R., M.W.S.), and the Department of Emergency Medicine (W.H.S.), Vanderbilt University Medical Center, Nashville; the Section of Pulmonary, Critical Care, and Allergy and Immunology (D.R.J.), and the Section of Emergency Medicine (D.J.V.), Louisiana State University School of Medicine– New Orleans, and the Department of Pulmonary and Critical Care Medicine, Ochsner Health System (D.J.V., K.M.D.) — both in New Orleans; the Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham (D.W.R., A.N.Z., S.G.); and the Department of Anesthesiology and Pain Medicine (A.M.J.) and the Division of Pulmonary and Critical Care (I.B.), University of Washington School of Medicine, Seattle. Address reprint requests to Dr. Casey at the Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, T-1210 MCN, 1161 21st Ave. S., Nashville, TN 37232-2650, or at
| | - Derek W. Russell
- Division of Allergy, Pulmonary, and Critical Care Medicine (J.D.C., R.M.B., B.E.H., M.G.L., A.H.T., T.W.R., M.W.S.), and the Department of Emergency Medicine (W.H.S.), Vanderbilt University Medical Center, Nashville; the Section of Pulmonary, Critical Care, and Allergy and Immunology (D.R.J.), and the Section of Emergency Medicine (D.J.V.), Louisiana State University School of Medicine– New Orleans, and the Department of Pulmonary and Critical Care Medicine, Ochsner Health System (D.J.V., K.M.D.) — both in New Orleans; the Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham (D.W.R., A.N.Z., S.G.); and the Department of Anesthesiology and Pain Medicine (A.M.J.) and the Division of Pulmonary and Critical Care (I.B.), University of Washington School of Medicine, Seattle. Address reprint requests to Dr. Casey at the Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, T-1210 MCN, 1161 21st Ave. S., Nashville, TN 37232-2650, or at
| | - Derek J. Vonderhaar
- Division of Allergy, Pulmonary, and Critical Care Medicine (J.D.C., R.M.B., B.E.H., M.G.L., A.H.T., T.W.R., M.W.S.), and the Department of Emergency Medicine (W.H.S.), Vanderbilt University Medical Center, Nashville; the Section of Pulmonary, Critical Care, and Allergy and Immunology (D.R.J.), and the Section of Emergency Medicine (D.J.V.), Louisiana State University School of Medicine– New Orleans, and the Department of Pulmonary and Critical Care Medicine, Ochsner Health System (D.J.V., K.M.D.) — both in New Orleans; the Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham (D.W.R., A.N.Z., S.G.); and the Department of Anesthesiology and Pain Medicine (A.M.J.) and the Division of Pulmonary and Critical Care (I.B.), University of Washington School of Medicine, Seattle. Address reprint requests to Dr. Casey at the Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, T-1210 MCN, 1161 21st Ave. S., Nashville, TN 37232-2650, or at
| | - Aaron M. Joffe
- Division of Allergy, Pulmonary, and Critical Care Medicine (J.D.C., R.M.B., B.E.H., M.G.L., A.H.T., T.W.R., M.W.S.), and the Department of Emergency Medicine (W.H.S.), Vanderbilt University Medical Center, Nashville; the Section of Pulmonary, Critical Care, and Allergy and Immunology (D.R.J.), and the Section of Emergency Medicine (D.J.V.), Louisiana State University School of Medicine– New Orleans, and the Department of Pulmonary and Critical Care Medicine, Ochsner Health System (D.J.V., K.M.D.) — both in New Orleans; the Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham (D.W.R., A.N.Z., S.G.); and the Department of Anesthesiology and Pain Medicine (A.M.J.) and the Division of Pulmonary and Critical Care (I.B.), University of Washington School of Medicine, Seattle. Address reprint requests to Dr. Casey at the Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, T-1210 MCN, 1161 21st Ave. S., Nashville, TN 37232-2650, or at
| | - Kevin M. Dischert
- Division of Allergy, Pulmonary, and Critical Care Medicine (J.D.C., R.M.B., B.E.H., M.G.L., A.H.T., T.W.R., M.W.S.), and the Department of Emergency Medicine (W.H.S.), Vanderbilt University Medical Center, Nashville; the Section of Pulmonary, Critical Care, and Allergy and Immunology (D.R.J.), and the Section of Emergency Medicine (D.J.V.), Louisiana State University School of Medicine– New Orleans, and the Department of Pulmonary and Critical Care Medicine, Ochsner Health System (D.J.V., K.M.D.) — both in New Orleans; the Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham (D.W.R., A.N.Z., S.G.); and the Department of Anesthesiology and Pain Medicine (A.M.J.) and the Division of Pulmonary and Critical Care (I.B.), University of Washington School of Medicine, Seattle. Address reprint requests to Dr. Casey at the Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, T-1210 MCN, 1161 21st Ave. S., Nashville, TN 37232-2650, or at
| | - Ryan M. Brown
- Division of Allergy, Pulmonary, and Critical Care Medicine (J.D.C., R.M.B., B.E.H., M.G.L., A.H.T., T.W.R., M.W.S.), and the Department of Emergency Medicine (W.H.S.), Vanderbilt University Medical Center, Nashville; the Section of Pulmonary, Critical Care, and Allergy and Immunology (D.R.J.), and the Section of Emergency Medicine (D.J.V.), Louisiana State University School of Medicine– New Orleans, and the Department of Pulmonary and Critical Care Medicine, Ochsner Health System (D.J.V., K.M.D.) — both in New Orleans; the Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham (D.W.R., A.N.Z., S.G.); and the Department of Anesthesiology and Pain Medicine (A.M.J.) and the Division of Pulmonary and Critical Care (I.B.), University of Washington School of Medicine, Seattle. Address reprint requests to Dr. Casey at the Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, T-1210 MCN, 1161 21st Ave. S., Nashville, TN 37232-2650, or at
| | - Aline N. Zouk
- Division of Allergy, Pulmonary, and Critical Care Medicine (J.D.C., R.M.B., B.E.H., M.G.L., A.H.T., T.W.R., M.W.S.), and the Department of Emergency Medicine (W.H.S.), Vanderbilt University Medical Center, Nashville; the Section of Pulmonary, Critical Care, and Allergy and Immunology (D.R.J.), and the Section of Emergency Medicine (D.J.V.), Louisiana State University School of Medicine– New Orleans, and the Department of Pulmonary and Critical Care Medicine, Ochsner Health System (D.J.V., K.M.D.) — both in New Orleans; the Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham (D.W.R., A.N.Z., S.G.); and the Department of Anesthesiology and Pain Medicine (A.M.J.) and the Division of Pulmonary and Critical Care (I.B.), University of Washington School of Medicine, Seattle. Address reprint requests to Dr. Casey at the Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, T-1210 MCN, 1161 21st Ave. S., Nashville, TN 37232-2650, or at
| | - Swati Gulati
- Division of Allergy, Pulmonary, and Critical Care Medicine (J.D.C., R.M.B., B.E.H., M.G.L., A.H.T., T.W.R., M.W.S.), and the Department of Emergency Medicine (W.H.S.), Vanderbilt University Medical Center, Nashville; the Section of Pulmonary, Critical Care, and Allergy and Immunology (D.R.J.), and the Section of Emergency Medicine (D.J.V.), Louisiana State University School of Medicine– New Orleans, and the Department of Pulmonary and Critical Care Medicine, Ochsner Health System (D.J.V., K.M.D.) — both in New Orleans; the Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham (D.W.R., A.N.Z., S.G.); and the Department of Anesthesiology and Pain Medicine (A.M.J.) and the Division of Pulmonary and Critical Care (I.B.), University of Washington School of Medicine, Seattle. Address reprint requests to Dr. Casey at the Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, T-1210 MCN, 1161 21st Ave. S., Nashville, TN 37232-2650, or at
| | - Brent E. Heideman
- Division of Allergy, Pulmonary, and Critical Care Medicine (J.D.C., R.M.B., B.E.H., M.G.L., A.H.T., T.W.R., M.W.S.), and the Department of Emergency Medicine (W.H.S.), Vanderbilt University Medical Center, Nashville; the Section of Pulmonary, Critical Care, and Allergy and Immunology (D.R.J.), and the Section of Emergency Medicine (D.J.V.), Louisiana State University School of Medicine– New Orleans, and the Department of Pulmonary and Critical Care Medicine, Ochsner Health System (D.J.V., K.M.D.) — both in New Orleans; the Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham (D.W.R., A.N.Z., S.G.); and the Department of Anesthesiology and Pain Medicine (A.M.J.) and the Division of Pulmonary and Critical Care (I.B.), University of Washington School of Medicine, Seattle. Address reprint requests to Dr. Casey at the Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, T-1210 MCN, 1161 21st Ave. S., Nashville, TN 37232-2650, or at
| | - Michael G. Lester
- Division of Allergy, Pulmonary, and Critical Care Medicine (J.D.C., R.M.B., B.E.H., M.G.L., A.H.T., T.W.R., M.W.S.), and the Department of Emergency Medicine (W.H.S.), Vanderbilt University Medical Center, Nashville; the Section of Pulmonary, Critical Care, and Allergy and Immunology (D.R.J.), and the Section of Emergency Medicine (D.J.V.), Louisiana State University School of Medicine– New Orleans, and the Department of Pulmonary and Critical Care Medicine, Ochsner Health System (D.J.V., K.M.D.) — both in New Orleans; the Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham (D.W.R., A.N.Z., S.G.); and the Department of Anesthesiology and Pain Medicine (A.M.J.) and the Division of Pulmonary and Critical Care (I.B.), University of Washington School of Medicine, Seattle. Address reprint requests to Dr. Casey at the Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, T-1210 MCN, 1161 21st Ave. S., Nashville, TN 37232-2650, or at
| | - Alexandra H. Toporek
- Division of Allergy, Pulmonary, and Critical Care Medicine (J.D.C., R.M.B., B.E.H., M.G.L., A.H.T., T.W.R., M.W.S.), and the Department of Emergency Medicine (W.H.S.), Vanderbilt University Medical Center, Nashville; the Section of Pulmonary, Critical Care, and Allergy and Immunology (D.R.J.), and the Section of Emergency Medicine (D.J.V.), Louisiana State University School of Medicine– New Orleans, and the Department of Pulmonary and Critical Care Medicine, Ochsner Health System (D.J.V., K.M.D.) — both in New Orleans; the Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham (D.W.R., A.N.Z., S.G.); and the Department of Anesthesiology and Pain Medicine (A.M.J.) and the Division of Pulmonary and Critical Care (I.B.), University of Washington School of Medicine, Seattle. Address reprint requests to Dr. Casey at the Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, T-1210 MCN, 1161 21st Ave. S., Nashville, TN 37232-2650, or at
| | - Itay Bentov
- Division of Allergy, Pulmonary, and Critical Care Medicine (J.D.C., R.M.B., B.E.H., M.G.L., A.H.T., T.W.R., M.W.S.), and the Department of Emergency Medicine (W.H.S.), Vanderbilt University Medical Center, Nashville; the Section of Pulmonary, Critical Care, and Allergy and Immunology (D.R.J.), and the Section of Emergency Medicine (D.J.V.), Louisiana State University School of Medicine– New Orleans, and the Department of Pulmonary and Critical Care Medicine, Ochsner Health System (D.J.V., K.M.D.) — both in New Orleans; the Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham (D.W.R., A.N.Z., S.G.); and the Department of Anesthesiology and Pain Medicine (A.M.J.) and the Division of Pulmonary and Critical Care (I.B.), University of Washington School of Medicine, Seattle. Address reprint requests to Dr. Casey at the Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, T-1210 MCN, 1161 21st Ave. S., Nashville, TN 37232-2650, or at
| | - Wesley H. Self
- Division of Allergy, Pulmonary, and Critical Care Medicine (J.D.C., R.M.B., B.E.H., M.G.L., A.H.T., T.W.R., M.W.S.), and the Department of Emergency Medicine (W.H.S.), Vanderbilt University Medical Center, Nashville; the Section of Pulmonary, Critical Care, and Allergy and Immunology (D.R.J.), and the Section of Emergency Medicine (D.J.V.), Louisiana State University School of Medicine– New Orleans, and the Department of Pulmonary and Critical Care Medicine, Ochsner Health System (D.J.V., K.M.D.) — both in New Orleans; the Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham (D.W.R., A.N.Z., S.G.); and the Department of Anesthesiology and Pain Medicine (A.M.J.) and the Division of Pulmonary and Critical Care (I.B.), University of Washington School of Medicine, Seattle. Address reprint requests to Dr. Casey at the Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, T-1210 MCN, 1161 21st Ave. S., Nashville, TN 37232-2650, or at
| | - Todd W. Rice
- Division of Allergy, Pulmonary, and Critical Care Medicine (J.D.C., R.M.B., B.E.H., M.G.L., A.H.T., T.W.R., M.W.S.), and the Department of Emergency Medicine (W.H.S.), Vanderbilt University Medical Center, Nashville; the Section of Pulmonary, Critical Care, and Allergy and Immunology (D.R.J.), and the Section of Emergency Medicine (D.J.V.), Louisiana State University School of Medicine– New Orleans, and the Department of Pulmonary and Critical Care Medicine, Ochsner Health System (D.J.V., K.M.D.) — both in New Orleans; the Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham (D.W.R., A.N.Z., S.G.); and the Department of Anesthesiology and Pain Medicine (A.M.J.) and the Division of Pulmonary and Critical Care (I.B.), University of Washington School of Medicine, Seattle. Address reprint requests to Dr. Casey at the Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, T-1210 MCN, 1161 21st Ave. S., Nashville, TN 37232-2650, or at
| | - Matthew W. Semler
- Division of Allergy, Pulmonary, and Critical Care Medicine (J.D.C., R.M.B., B.E.H., M.G.L., A.H.T., T.W.R., M.W.S.), and the Department of Emergency Medicine (W.H.S.), Vanderbilt University Medical Center, Nashville; the Section of Pulmonary, Critical Care, and Allergy and Immunology (D.R.J.), and the Section of Emergency Medicine (D.J.V.), Louisiana State University School of Medicine– New Orleans, and the Department of Pulmonary and Critical Care Medicine, Ochsner Health System (D.J.V., K.M.D.) — both in New Orleans; the Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham (D.W.R., A.N.Z., S.G.); and the Department of Anesthesiology and Pain Medicine (A.M.J.) and the Division of Pulmonary and Critical Care (I.B.), University of Washington School of Medicine, Seattle. Address reprint requests to Dr. Casey at the Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, T-1210 MCN, 1161 21st Ave. S., Nashville, TN 37232-2650, or at
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Trauma Airway Management: Induction Agents, Rapid Versus Slower Sequence Intubations, and Special Considerations. Anesthesiol Clin 2018; 37:33-50. [PMID: 30711232 DOI: 10.1016/j.anclin.2018.09.002] [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: 01/20/2023]
Abstract
Trauma patients who require intubation are at higher risk for aspiration, agitation/combativeness, distorted anatomy, hemodynamic instability, an unstable cervical spine, and complicated injuries. Although rapid-sequence intubation is the most common technique in trauma, slow-sequence intubation may reduce the risk for failed intubation and cardiovascular collapse. Providers often choose plans with which they are most comfortable. However, developing a flexible team-based approach, through recognition of complicating factors in trauma patients, improves airway management success.
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Comparison of techniques for visualisation of the airway anatomy for ultrasound-assisted intubation: A prospective study of emergency department patients. Anaesth Crit Care Pain Med 2018; 37:545-549. [DOI: 10.1016/j.accpm.2018.01.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2017] [Revised: 11/21/2017] [Accepted: 01/21/2018] [Indexed: 12/29/2022]
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McKown AC, Casey JD, Russell DW, Joffe AM, Janz DR, Rice TW, Semler MW. Risk Factors for and Prediction of Hypoxemia during Tracheal Intubation of Critically Ill Adults. Ann Am Thorac Soc 2018; 15:1320-1327. [PMID: 30109943 PMCID: PMC6322012 DOI: 10.1513/annalsats.201802-118oc] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Accepted: 07/30/2018] [Indexed: 11/20/2022] Open
Abstract
RATIONALE Hypoxemia is a common complication during tracheal intubation of critically ill adults and is a frequently used endpoint in airway management research. Identifying patients likely to experience low oxygen saturations during tracheal intubation may be useful for clinical practice and clinical trials. OBJECTIVES To identify risk factors for lower oxygen saturations and severe hypoxemia during tracheal intubation of critically ill adults and develop prediction models for lowest oxygen saturation and hypoxemia. METHODS Using data on 433 intubations from two randomized trials, we developed linear and logistic regression models to identify preprocedural risk factors for lower arterial oxygen saturations and severe hypoxemia between induction and 2 minutes after intubation. Penalized regression was used to develop prediction models for lowest oxygen saturation after induction and severe hypoxemia. A simplified six-point score was derived to predict severe hypoxemia. RESULTS Among the 433 intubations, 426 had complete data and were included in the model. The mean (standard deviation) lowest oxygen saturation was 88% (14%); median (interquartile range) was 93% (83-98%). Independent predictors of severe hypoxemia included hypoxemic respiratory failure as the indication for intubation (odds ratio [OR], 2.70; 95% confidence interval [CI], 1.58-4.60), lower oxygen saturation at induction (OR, 0.92 per 1% increase; 95% CI, 0.89-0.96 per 1% increase), younger age (OR, 0.97 per 1-year increase; 95% CI, 0.95-0.99 per 1-year increase), higher body mass index (OR, 1.03 per 1 kg/m2; 95% CI, 1.00-1.06 per 1 kg/m2), race (OR, 4.58 for white vs. black; 95% CI, 1.97-10.67; OR, 4.47 for other vs. black; 95% CI, 1.19-16.84), and operator with fewer than 100 prior intubations (OR, 2.83; 95% CI, 1.37-5.85). A six-point score using the identified risk factors predicted severe hypoxemia with an area under the receiver operating curve of 0.714 (95% CI, 0.653 to 0.778). CONCLUSIONS Lowest oxygen saturation and severe hypoxemia during tracheal intubation in the intensive care unit can be accurately predicted using routinely available preprocedure clinical data, with saturation at induction and hypoxemic respiratory failure being the strongest predictors. A simple bedside score may identify patients at risk for hypoxemia during intubation to help target preventative interventions and facilitate enrichment in clinical trials.
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Affiliation(s)
- Andrew C McKown
- 1 Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jonathan D Casey
- 1 Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Derek W Russell
- 2 Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Aaron M Joffe
- 3 Department of Anesthesiology and Pain Medicine, University of Washington, Harborview Medical Center, Seattle, Washington; and
| | - David R Janz
- 4 Section of Pulmonary/Critical Care and Allergy/Immunology, Louisiana State University School of Medicine, New Orleans, Louisiana
| | - Todd W Rice
- 1 Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Matthew W Semler
- 1 Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
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Zitek T, Berkeley RP, Hodnick R, Davis K, Dadon N, Slattery DE. A novel technique to intubate patients without reliable pulse oximetry. Am J Emerg Med 2018; 36:2131.e1-2131.e2. [DOI: 10.1016/j.ajem.2018.07.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 07/18/2018] [Indexed: 11/16/2022] Open
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Dodd KW, Prekker ME, Robinson AE, Buckley R, Reardon RF, Driver BE. Video screen viewing and first intubation attempt success with standard geometry video laryngoscope use. Am J Emerg Med 2018; 37:1336-1339. [PMID: 30528054 DOI: 10.1016/j.ajem.2018.10.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Revised: 10/15/2018] [Accepted: 10/15/2018] [Indexed: 10/28/2022] Open
Abstract
STUDY OBJECTIVES Direct laryngoscopy (DL) is the traditional approach for emergency intubation but video laryngoscopy (VL) is gaining popularity. Some studies have demonstrated higher first-attempt success with VL, particularly in difficult airways. In real-world settings, physicians choose whether or not to view the video screen when utilizing VL devices for tracheal intubation. Therefore, we sought to determine whether screen viewing is associated with higher intubation first-attempt success in clinical practice. METHODS In this retrospective, observational investigation, we studied consecutive adult emergency department intubations at an urban, academic medical center during the calendar year 2013. Cases were identified from the electronic medical record and analyzed using standard video review methodology. We compared first-attempt success rates when standard geometry Macintosh VL was used, stratified by whether the screen was viewed or not. RESULTS Of the 593 cases with videos available for review, 515 (87%) were performed with a standard geometry Macintosh video laryngoscope. First-attempt success was not significantly different when the screen was viewed (195/207; 94% [95%CI 91-97]) compared to when the screen was not viewed (284/301; 94% [95%CI 92-97]). The median first-attempt duration was longer when the screen was viewed compared to when the screen was not viewed (45 versus 33 s; median difference 12 s [95%CI 10-15 s]). CONCLUSION In this study of orotracheal intubations performed by emergency physicians with Macintosh-style VL, the first-attempt success rate was high. The success rate was similar whether or not the intubating physician chose to view the video screen.
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Affiliation(s)
- Kenneth W Dodd
- Department of Emergency Medicine, Hennepin County Medical Center, 701 Park Avenue, Minneapolis, MN 55415, United States of America; Division of Pulmonary and Critical Care Medicine, Hennepin County Medical Center, 701 Park Avenue, Minneapolis, MN 55415, United States of America.
| | - Matthew E Prekker
- Department of Emergency Medicine, Hennepin County Medical Center, 701 Park Avenue, Minneapolis, MN 55415, United States of America; Division of Pulmonary and Critical Care Medicine, Hennepin County Medical Center, 701 Park Avenue, Minneapolis, MN 55415, United States of America; Department of Emergency Medicine, University of Minnesota Medical School, 717 Delaware Street SE, Suite 508, Minneapolis, MN 55414, United States of America.
| | - Aaron E Robinson
- Department of Emergency Medicine, Hennepin County Medical Center, 701 Park Avenue, Minneapolis, MN 55415, United States of America.
| | - Ryan Buckley
- Department of Emergency Medicine, Hennepin County Medical Center, 701 Park Avenue, Minneapolis, MN 55415, United States of America.
| | - Robert F Reardon
- Department of Emergency Medicine, Hennepin County Medical Center, 701 Park Avenue, Minneapolis, MN 55415, United States of America; Department of Emergency Medicine, University of Minnesota Medical School, 717 Delaware Street SE, Suite 508, Minneapolis, MN 55414, United States of America.
| | - Brian E Driver
- Department of Emergency Medicine, Hennepin County Medical Center, 701 Park Avenue, Minneapolis, MN 55415, United States of America; Department of Emergency Medicine, University of Minnesota Medical School, 717 Delaware Street SE, Suite 508, Minneapolis, MN 55414, United States of America.
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Kim JM, Shin TG, Hwang SY, Yoon H, Cha WC, Sim MS, Jo IJ, Song KJ, Rhee JE, Jeong YK. Sedative dose and patient variable impacts on postintubation hypotension in emergency airway management. Am J Emerg Med 2018; 37:1248-1253. [PMID: 30220641 DOI: 10.1016/j.ajem.2018.09.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 08/10/2018] [Accepted: 09/11/2018] [Indexed: 12/20/2022] Open
Abstract
PURPOSE Postintubation hypotension (PIH) is an adverse event associated with poor outcomes in emergency department (ED) endotracheal intubation. This study aimed to evaluate the association between sedative dose adjustment and PIH during emergency airway management. We also investigated the impact of patient and procedural factors on the incidence of PIH. MATERIALS AND METHODS This was a single-center, retrospective study that used a prospectively collected registry of airway management performed at the ED from April 2014 to February 2017. Adult patients who received emergency endotracheal intubation were included. Multivariable logistic regression models were used to evaluate the association of PIH with sedative dose, patient variables, and procedural variables. RESULTS Overall, 689 patients were included, and 233 (33.8%) patients developed PIH. In the patients overall, multivariable logistic regression demonstrated that age > 70 years, shock index >0.8, arterial acidosis (pH < 7.2), intubation indication, and use of non-depolarizing neuromuscular blocking agent were significantly related to PIH. In patients overall, the sedative dose was not related to PIH (overdose; OR: 1.09, 95%CI: 0.57-2.06), (reduction; OR: 0.93, 95%CI: 0.61-1.42), (none used; OR: 1.28, 95%CI: 0.64-2.53). In subgroup analysis, ketamine dose was not related to PIH (overdose; OR: 0.81, 95%CI: 0.27-2.38, reduction; OR: 1.41, 95%CI: 0.78-2.54). Reduction of etomidate dose was significantly associated with decreased PIH (reduction; OR: 0.46, 95%CI: 0.22-0.98, overdose; OR: 1.77, 95%CI: 0.79-3.93). CONCLUSIONS PIH was mainly related to predisposing patient-related factors. Only adjustment of etomidate dose was associated with the incidence of PIH.
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Affiliation(s)
- Jae Min Kim
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Tae Gun Shin
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea.
| | - Sung Yeon Hwang
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Hee Yoon
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Won Chul Cha
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Min Seob Sim
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Ik Joon Jo
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Keun Jeong Song
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Joong Eui Rhee
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Yeon Kwon Jeong
- Department of Emergency Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
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Casey JD, Janz DR, Russell DW, Vonderhaar DJ, Joffe AM, Dischert KM, Brown RM, Lester MG, Zouk AN, Gulati S, Stigler WS, Rice TW, Semler MW. Manual ventilation to prevent hypoxaemia during endotracheal intubation of critically ill adults: protocol and statistical analysis plan for a multicentre randomised trial. BMJ Open 2018; 8:e022139. [PMID: 30099400 PMCID: PMC6089322 DOI: 10.1136/bmjopen-2018-022139] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Hypoxaemia is the most common complication during endotracheal intubation of critically ill adults, and it increases the risk of cardiac arrest and death. Manual ventilation between induction and intubation has been hypothesised to decrease the incidence of hypoxaemia, but efficacy and safety data are lacking. METHODS AND ANALYSIS The Preventing Hypoxemia with Manual Ventilation during Endotracheal Intubation trial is a prospective, multicentre, non-blinded randomised clinical trial being conducted in seven intensive care units in the USA. A total of 400 critically ill adults undergoing endotracheal intubation will be randomised 1:1 to receive prophylactic manual ventilation between induction and endotracheal intubation using a bag-valve-mask device or no prophylactic ventilation. The primary outcome is the lowest arterial oxygen saturation between induction and 2 min after successful endotracheal intubation, which will be analysed as an unadjusted, intention-to-treat comparison of patients randomised to prophylactic ventilation versus patients randomised to no prophylactic ventilation. The secondary outcome is the incidence of severe hypoxaemia, defined as any arterial oxygen saturation of less than 80% between induction and 2 min after endotracheal intubation. Enrolment began on 2 February 2017 and is expected to be complete in May 2018. ETHICS AND DISSEMINATION The trial was approved by the institutional review boards or designees of all participating centres. The results will be submitted for publication in a peer-reviewed journal and presented at one or more scientific conferences. TRIAL REGISTRATION NUMBER NCT03026322; Pre-results.
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Affiliation(s)
- Jonathan D Casey
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - David R Janz
- School of Medicine, Section of Pulmonary/Critical Care & Allergy/Immunology, Louisiana State University, New Orleans, Louisiana, USA
| | - Derek W Russell
- Division of Pulmonary, Allergy, & Critical Care Medicine, University of Alabama at Birmingham, Birmingham, USA
| | - Derek J Vonderhaar
- School of Medicine, Section of Pulmonary/Critical Care & Allergy/Immunology, Louisiana State University, New Orleans, Louisiana, USA
| | - Aaron M Joffe
- Department of Anesthesiology and Pain Medicinex, University of Washington, Seattle, Washington, USA
| | - Kevin M Dischert
- Department of Anesthesiology and Pain Medicinex, University of Washington, Seattle, Washington, USA
| | - Ryan M Brown
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Michael G Lester
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Aline N Zouk
- Division of Pulmonary, Allergy, & Critical Care Medicine, University of Alabama at Birmingham, Birmingham, USA
| | - Swati Gulati
- Division of Pulmonary, Allergy, & Critical Care Medicine, University of Alabama at Birmingham, Birmingham, USA
| | - William S Stigler
- Division of Pulmonary, Allergy, & Critical Care Medicine, University of Alabama at Birmingham, Birmingham, USA
| | - Todd W Rice
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Matthew W Semler
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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Abstract
Airway management and ventilation are central to the resuscitation of the neurologically ill. These patients often have evolving processes that threaten the airway and adequate ventilation. Furthermore, intubation, ventilation, and sedative choices directly affect brain perfusion. Therefore, Airway, Ventilation, and Sedation was chosen as an Emergency Neurological Life Support protocol. Topics include airway management, when and how to intubate with special attention to hemodynamics and preservation of cerebral blood flow, mechanical ventilation settings and the use of sedative agents based on the patient's neurological status.
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Abstract
PURPOSE OF REVIEW Subdural hematomas (SDH) represent common neurosurgical problem associated with significant morbidity, mortality, and high recurrence rates. SDH incidence increases with age; numbers of patients affected by SDH continue to rise with our aging population and increasing number of people taking antiplatelet agents or anticoagulation. Medical and surgical SDH management remains a subject of investigation. RECENT FINDINGS Initial management of patients with concern for altered mental status with or without trauma starts with Emergency Neurological Life Support (ENLS) guidelines, with a focus on maintaining ICP < 22 mmHg, CPP > 60 mmHg, MAP 80-110 mmHg, and PaO2 > 60 mmHg, followed by rapid sequence intubation if necessary, and expedited acquisition of imaging to identify a space-occupying lesion. Patients are administered anti-seizure medications, and their antiplatelet medications or anticoagulation may be reversed if neurosurgical interventions are anticipated, or until hemorrhage is stabilized on imaging. Medical SDH care focuses on (a) management of intracranial hypertension; (b) maintenance of adequate cerebral perfusion; (c) seizure prevention and treatment; (d) maintenance of normothermia, eucarbia, euglycemia, and euvolemia; and (e) early initiation of enteral feeding, mobilization, and physical therapy. Post-operatively, SDH patients require ICU level care and are co-managed by neurointensivists with expertise in treating increased intracranial pressure, seizures, and status epilepticus, as well as medical complications of critical illness. Here, we review various aspects of medical management with a brief overview of pertinent literature and clinical trials for patients diagnosed with SDH.
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Expert-Performed Endotracheal Intubation-Related Complications in Trauma Patients: Incidence, Possible Risk Factors, and Outcomes in the Prehospital Setting and Emergency Department. Emerg Med Int 2018; 2018:5649476. [PMID: 29984001 PMCID: PMC6015695 DOI: 10.1155/2018/5649476] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 04/19/2018] [Accepted: 05/16/2018] [Indexed: 11/18/2022] Open
Abstract
The aim of this study was to determine complication rates and possible risk factors of expert-performed endotracheal intubation (ETI) in patients with trauma, in both the prehospital setting and the emergency department. We also investigated how the occurrence of ETI-related complications affected the survival of trauma patients. This single-center retrospective observational study included all injured patients who underwent anesthesiologist-performed ETI from 2007 to 2017. ETI-related complications were defined as hypoxemia, unrecognized esophageal intubation, regurgitation, cardiac arrest, ETI failure rescued by emergency surgical airway, dental trauma, cuff leak, and mainstem bronchus intubation. Of the 537 patients included, 23.5% experienced at least one complication. Multivariable logistic regression analysis revealed that low Glasgow Coma Scale Score (adjusted odds ratio [AOR], 0.93; 95% confidence interval [CI], 0.88-0.98), elevated heart rate (AOR, 1.01; 95% CI, 1.00-1.02), and three or more ETI attempts (AOR, 15.71; 95% CI, 3.37-73.2) were independent predictors of ETI-related complications. We also found that ETI-related complications decreased the likelihood of survival of trauma patients (AOR, 0.60; 95% CI, 0.38-0.95), independently of age, male sex, Injury Severity Score, Glasgow Coma Scale Score, and off-hours presentation. Our results suggest that airway management in trauma patients carries a very high risk; this finding has implications for the practice of airway management in injured patients.
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Bommiasamy AK, Opel D, McCallum R, Yonge JD, Perl VU, Connelly CR, Friess D, Schreiber MA, Mullins RJ. Conscious sedation versus rapid sequence intubation for the reduction of native traumatic hip dislocation. Am J Surg 2018. [PMID: 29534815 DOI: 10.1016/j.amjsurg.2018.02.023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND Traumatic hip dislocations (THD) are a medical emergency. There is debate whether the painful reduction of a dislocated hip should be first attempted using primary conscious sedation (PCS) or primary general anesthesia (PGA) METHODS: All cases of native THD from 2006 to 2015 in the trauma registry of a level 1 trauma center were reviewed. The primary outcome was successful reduction of the THD. RESULTS 67 patients had a native, meaning not a hip prosthesis, THD. 34 (50.7%) patients had successful PCS, 12 (17.9%) failed PCS and underwent reduction following PGA. 21 (31.3%) underwent PGA. Patients in the PGA group were more severely injured. Time to reduction greater than 6 h was associated with PCS failure (Odds ratio (95% confidence interval) 19.75 (2.06,189.10) p = 0.01). CONCLUSION Clinicians treating patients with a THD can utilize either PCS or PGA with many patients safely reduced under PCS. However, patients whose hip have been dislocated for more than 6 h are at risk for failure with PCS, and are good candidates for PGA.
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Affiliation(s)
- Aravind K Bommiasamy
- Department of Surgery, Oregon Health & Science University, 3181 S.W. Sam Jackson Park Rd, Mail Code: L223, Portland, OR, 97239, USA.
| | - Dayton Opel
- Department of Orthopedics and Rehabilitation, Oregon Health & Science University, 3181 S.W. Sam Jackson Park Road, Sam Jackson Hall Suite 2360, Portland, OR, 97239, USA
| | - Raluca McCallum
- Department of Surgery, Oregon Health & Science University, 3181 S.W. Sam Jackson Park Rd, Mail Code: L223, Portland, OR, 97239, USA
| | - John D Yonge
- Department of Surgery, Oregon Health & Science University, 3181 S.W. Sam Jackson Park Rd, Mail Code: L223, Portland, OR, 97239, USA
| | - Vicente Undurraga Perl
- Department of Surgery, Oregon Health & Science University, 3181 S.W. Sam Jackson Park Rd, Mail Code: L223, Portland, OR, 97239, USA
| | - Christopher R Connelly
- Department of Surgery, Oregon Health & Science University, 3181 S.W. Sam Jackson Park Rd, Mail Code: L223, Portland, OR, 97239, USA
| | - Darin Friess
- Department of Orthopedics and Rehabilitation, Oregon Health & Science University, 3181 S.W. Sam Jackson Park Road, Sam Jackson Hall Suite 2360, Portland, OR, 97239, USA
| | - Martin A Schreiber
- Department of Surgery, Oregon Health & Science University, 3181 S.W. Sam Jackson Park Rd, Mail Code: L223, Portland, OR, 97239, USA
| | - Richard J Mullins
- Department of Surgery, Oregon Health & Science University, 3181 S.W. Sam Jackson Park Rd, Mail Code: L223, Portland, OR, 97239, USA
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Driver B, Dodd K, Klein LR, Buckley R, Robinson A, McGill JW, Reardon RF, Prekker ME. The Bougie and First-Pass Success in the Emergency Department. Ann Emerg Med 2017; 70:473-478.e1. [PMID: 28601269 DOI: 10.1016/j.annemergmed.2017.04.033] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 04/14/2017] [Accepted: 04/19/2017] [Indexed: 11/19/2022]
Abstract
STUDY OBJECTIVE The bougie may improve first-pass intubation success in operating room patients. We seek to determine whether bougie use is associated with emergency department (ED) first-pass intubation success. METHODS We studied consecutive adult ED intubations at an urban, academic medical center during 2013. Intubation events were identified by motion-activated video recording. We determined the association between bougie use and first-pass intubation success, adjusting for neuromuscular blockade, video laryngoscopy, abnormal airway anatomy, and whether the patient was placed in the sniffing position or the head was lifted off the bed during intubation. RESULTS Intubation with a Macintosh blade was attempted in 543 cases; a bougie was used on the majority of initial attempts (80%; n=435). First-pass success was greater with than without bougie use (95% versus 86%; absolute difference 9% [95% confidence interval {CI} 2% to 16%]). The median first-attempt duration was higher with than without bougie (40 versus 27 seconds; difference 14 seconds [95% CI 11 to 16 seconds]). Bougie use was independently associated with greater first-pass success (adjusted odds ratio 2.83 [95% CI 1.35 to 5.92]). CONCLUSION Bougie was associated with increased first-pass intubation success. Bougie use may be helpful in ED intubation.
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Affiliation(s)
- Brian Driver
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN.
| | - Kenneth Dodd
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - Lauren R Klein
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - Ryan Buckley
- University of Minnesota School of Medicine, Minneapolis, MN
| | - Aaron Robinson
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - John W McGill
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - Robert F Reardon
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - Matthew E Prekker
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN; Division of Pulmonary/Critical Care, Department of Medicine, Hennepin County Medical Center, Minneapolis, MN
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Choi YF, Wong TW, Lau CC, Siu AYC, Lo CB, Yuen MC, Tung WK, Ng P, Kam CW, Mui TK, Yuen WL, Lim B, Lit ACH. A Study of Orotracheal Intubation in Emergency Departments of Five District Hospitals in Hong Kong. HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490790301000302] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Objective To study the success rates and complications of orotracheal intubation in emergency departments of five district hospitals in Hong Kong in order to identify ways for improvement. Method This was a prospective observational study. The emergency department doctors performing the intubation were asked to complete an intubation study form immediately after the procedure over a period of four months. Data collected included vital signs, experiences of intubators, method of intubation and complications. Results A total of 347 cases were collected and 93% of them were non-trauma cases. Fifty-two percent (52%) of the cases were in cardiac arrest before intubation. Rapid sequence intubation (RSI) was applied in 36% of the cases. Junior doctors first intubated about 72% of the patients. Successful intubation was achieved in 1 and 2 attempts in 70% and 89% of the cases respectively. In 10 cases (3%), secondary methods such as laryngeal mask airway, Combitube, Trachlight or cricothyroidotomy were needed. The overall complication rate was 7.8% and the complication rate in the RSI group was 15.3%. The complication rate was even higher (20%) if intubation without medication was used in non-cardiac arrest patients. Significant drop in blood pressure was the most common complication and it could be attributed to the use of midazolam as induction medication. The success rate was found to correlate with the experience of the first intubator (p<0.05) and the laryngeal view (p<0.001). The complication rate increased with repeated attempts (p<0.001) and was higher among junior doctors (p<0.05). Early use of elastic gum bougie was associated with lower complication and higher success rates. Conclusion Orotracheal intubation in the emergency department was associated with high complication rate. Many complications came from junior intubators. Hypotension was the most common complication. Potentially avoidable complications may be a result of failure to use RSI in non-cardiac arrest patients and failure to use bougie in cases of poor laryngeal view.
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Affiliation(s)
- YF Choi
- Pamela Youde Nethersole Eastern Hospital, Accident and Emergency Department, 3 Lok Man Road, Chaiwan, Hong Kong
| | - TW Wong
- Pamela Youde Nethersole Eastern Hospital, Accident and Emergency Department, 3 Lok Man Road, Chaiwan, Hong Kong
| | - CC Lau
- Pamela Youde Nethersole Eastern Hospital, Accident and Emergency Department, 3 Lok Man Road, Chaiwan, Hong Kong
| | - AYC Siu
- North District Hospital, Accident and Emergency Department, 9 Po Kin Road, Sheung Shui, N.T., Hong Kong
| | - CB Lo
- North District Hospital, Accident and Emergency Department, 9 Po Kin Road, Sheung Shui, N.T., Hong Kong
| | - MC Yuen
- Kwong Wah Hospital, Accident and Emergency Department, 25 Waterloo Road, Kowloon, Hong Kong
| | - WK Tung
- Kwong Wah Hospital, Accident and Emergency Department, 25 Waterloo Road, Kowloon, Hong Kong
| | - P Ng
- Tuen Mun Hospital, Accident and Emergency Department, Tsing Chung Koon Road, Tuen Mun, N.T., Hong Kong
| | - CW Kam
- Tuen Mun Hospital, Accident and Emergency Department, Tsing Chung Koon Road, Tuen Mun, N.T., Hong Kong
| | - TK Mui
- Caritas Medical Centre, Accident and Emergency Department, Shamshuipo, Kowloon, Hong Kong
| | - WL Yuen
- Caritas Medical Centre, Accident and Emergency Department, Shamshuipo, Kowloon, Hong Kong
| | - B Lim
- Yan Chai Hospital, Accident and Emergency Department, Tsuen Wan, N.T., Hong Kong
| | - ACH Lit
- Yan Chai Hospital, Accident and Emergency Department, Tsuen Wan, N.T., Hong Kong
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Lahham S, Baydoun J, Bailey J, Sandoval S, Wilson SP, Fox JC, Slattery DE. A Prospective Evaluation of Transverse Tracheal Sonography During Emergent Intubation by Emergency Medicine Resident Physicians. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2017; 36:2079-2085. [PMID: 28503749 DOI: 10.1002/jum.14231] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/27/2016] [Accepted: 01/13/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVES Establishing a definitive airway is often the first step in emergency department treatment of critically ill patients. Currently, there is no agreed upon consensus as to the most efficacious method of airway confirmation. Our objective was to determine the diagnostic accuracy of real-time sonography performed by resident physicians to confirm placement of the endotracheal tube during emergent intubation. METHODS We performed a prospective cohort study of adult patients in the emergency department undergoing emergent endotracheal intubation. Thirty emergency medicine residents, who were blinded to end-tidal carbon dioxide detection results, performed real-time transverse tracheal sonography during intubation to evaluate correct endotracheal tube placement. RESULTS Seventy-two patients were enrolled in the study. Sixty-eight instances (94.4%) were interpreted as correct placement in the trachea; 4 (5.6%) were interpreted as esophageal, of which 1 was a false-negative finding, therefore conferring sensitivity of 98.5% (95% confidence interval, 92.1%-99.9%) and specificity of 75.0% (95% confidence interval, 19.4%-99.4%) for correct placement. There was no significant difference in accuracy among resident sonographers with different levels of residency training. CONCLUSIONS A simple transverse tracheal sonographic examination performed by emergency medicine resident physicians can be used as an adjunct to help confirm correct endotracheal tube placement during intubation. In our cohort, the level of training did not appear to affect the ability of residents to correctly identify the endotracheal tube position.
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Affiliation(s)
- Shadi Lahham
- Department of Emergency Medicine, University of California, Irvine, Orange, California, USA
| | - Jamie Baydoun
- Department of Emergency Medicine, University of Nevada School of Medicine, Las Vegas, Nevada, USA
| | - James Bailey
- Department of Emergency Medicine, University of Nevada School of Medicine, Las Vegas, Nevada, USA
| | - Sandra Sandoval
- Department of Emergency Medicine, University of Nevada School of Medicine, Las Vegas, Nevada, USA
| | - Sean P Wilson
- Department of Emergency Medicine, University of California, Irvine, Orange, California, USA
| | - John C Fox
- Department of Emergency Medicine, University of California, Irvine, Orange, California, USA
| | - David E Slattery
- Department of Emergency Medicine, University of Nevada School of Medicine, Las Vegas, Nevada, USA
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Brinjikji W, Pasternak J, Murad MH, Cloft HJ, Welch TL, Kallmes DF, Rabinstein AA. Anesthesia-Related Outcomes for Endovascular Stroke Revascularization. Stroke 2017; 48:2784-2791. [DOI: 10.1161/strokeaha.117.017786] [Citation(s) in RCA: 107] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Revised: 08/08/2017] [Accepted: 08/11/2017] [Indexed: 01/02/2023]
Affiliation(s)
- Waleed Brinjikji
- From the Department of Radiology (W.B., H.J.C., D.F.K.), Department of Neurosurgery (W.B., D.F.K.), Department of Anesthesia (J.P., T.L.W.), Division of Preventive Medicine (M.H.M.), Knowledge and Evaluation Research Unit (M.H.M.), and Department of Neurology (A.A.R.), Mayo Clinic, Rochester, MN
| | - Jeffrey Pasternak
- From the Department of Radiology (W.B., H.J.C., D.F.K.), Department of Neurosurgery (W.B., D.F.K.), Department of Anesthesia (J.P., T.L.W.), Division of Preventive Medicine (M.H.M.), Knowledge and Evaluation Research Unit (M.H.M.), and Department of Neurology (A.A.R.), Mayo Clinic, Rochester, MN
| | - Mohammad H. Murad
- From the Department of Radiology (W.B., H.J.C., D.F.K.), Department of Neurosurgery (W.B., D.F.K.), Department of Anesthesia (J.P., T.L.W.), Division of Preventive Medicine (M.H.M.), Knowledge and Evaluation Research Unit (M.H.M.), and Department of Neurology (A.A.R.), Mayo Clinic, Rochester, MN
| | - Harry J. Cloft
- From the Department of Radiology (W.B., H.J.C., D.F.K.), Department of Neurosurgery (W.B., D.F.K.), Department of Anesthesia (J.P., T.L.W.), Division of Preventive Medicine (M.H.M.), Knowledge and Evaluation Research Unit (M.H.M.), and Department of Neurology (A.A.R.), Mayo Clinic, Rochester, MN
| | - Tasha L. Welch
- From the Department of Radiology (W.B., H.J.C., D.F.K.), Department of Neurosurgery (W.B., D.F.K.), Department of Anesthesia (J.P., T.L.W.), Division of Preventive Medicine (M.H.M.), Knowledge and Evaluation Research Unit (M.H.M.), and Department of Neurology (A.A.R.), Mayo Clinic, Rochester, MN
| | - David F. Kallmes
- From the Department of Radiology (W.B., H.J.C., D.F.K.), Department of Neurosurgery (W.B., D.F.K.), Department of Anesthesia (J.P., T.L.W.), Division of Preventive Medicine (M.H.M.), Knowledge and Evaluation Research Unit (M.H.M.), and Department of Neurology (A.A.R.), Mayo Clinic, Rochester, MN
| | - Alejandro A. Rabinstein
- From the Department of Radiology (W.B., H.J.C., D.F.K.), Department of Neurosurgery (W.B., D.F.K.), Department of Anesthesia (J.P., T.L.W.), Division of Preventive Medicine (M.H.M.), Knowledge and Evaluation Research Unit (M.H.M.), and Department of Neurology (A.A.R.), Mayo Clinic, Rochester, MN
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Feasibility of upright patient positioning and intubation success rates At two academic EDs. Am J Emerg Med 2017; 35:986-992. [DOI: 10.1016/j.ajem.2017.02.011] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Revised: 02/03/2017] [Accepted: 02/04/2017] [Indexed: 11/22/2022] Open
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Lin SH, Chi CH, Chuang CC, Chan TY. Tips to Improve Success Rate of Intubation: A Standardized Rapid Sequence Intubation Protocol Attached to the Resuscitation Cart. J Acute Med 2017; 7:67-74. [PMID: 32995174 PMCID: PMC7517902 DOI: 10.6705/j.jacme.2017.0702.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Revised: 10/13/2016] [Accepted: 11/21/2016] [Indexed: 06/11/2023]
Abstract
OBJECTIVES The purpose of this study was to determine whether the implementation of a standardized rapid sequence intubation (RSI) protocol easily accessed on the resuscitation cart increased the success rate of intubation and reduced intubation-related complications in the emergency department (ED). METHODS This work was a retrospective study of patients who were intubated in the ED between February 2006 and June 2007. The RSI protocol and a dosage cross-table were attached to the resuscitation cart beginning in January 2007. Intubated patients before and after application of the protocol were sorted into two groups: pre-intervention and post-intervention. RESULTS A total of 147 patients were enrolled in the study, including 72 patients in the pre-intervention group and 75 patients in the post-intervention group. After application of the standardized protocol prompted on the resuscitation cart. The adherence rates to pre-treatment agents (69% vs. 90%; p < 0.01) and neuromuscular blocking agents (NMBA) (72% vs. 90%; p < 0.01) significantly improved. The first-attempt success rate was 57 of 72 (79%) in the pre-intervention group versus 70 of 75 (93%) in the post-intervention group (p = 0.016). The time to intubation did not differ signifi cantly, but the preintervention group had a higher percentage of prolonged time to intubation (13% vs. 3%; p = 0.029). The implementation of a standardized RSI protocol did not induce signifi cant adverse effects. CONCLUSIONS Our study demonstrated implementation of a standardized RSI protocol, improved clinician adherence to the RSI, increased success of first-attempt ED intubation and led to a decline in the rate of prolonged time to intubation.
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Affiliation(s)
- Shih-Hao Lin
- National Cheng Kung University Hospital Department of Emergency Medicine Tainan Taiwan
| | - Chih-Hsien Chi
- National Cheng Kung University Hospital Department of Emergency Medicine Tainan Taiwan
| | - Chia-Chang Chuang
- National Cheng Kung University Hospital Department of Emergency Medicine Tainan Taiwan
| | - Tsung-Yu Chan
- National Cheng Kung University Hospital Department of Emergency Medicine Tainan Taiwan
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Slezak A, Kurmann R, Oppliger L, Broeg-Morvay A, Gralla J, Schroth G, Mattle HP, Arnold M, Fischer U, Jung S, Greif R, Neff F, Mordasini P, Mono ML. Impact of Anesthesia on the Outcome of Acute Ischemic Stroke after Endovascular Treatment with the Solitaire Stent Retriever. AJNR Am J Neuroradiol 2017; 38:1362-1367. [PMID: 28473340 DOI: 10.3174/ajnr.a5183] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Accepted: 02/14/2017] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE General anesthesia during endovascular treatment of acute ischemic stroke may have an adverse effect on outcome compared with conscious sedation. The aim of this study was to examine the impact of the type of anesthesia on the outcome of patients with acute ischemic stroke treated with the Solitaire stent retriever, accounting for confounding factors. MATERIALS AND METHODS Four-hundred one patients with consecutive acute anterior circulation stroke treated with a Solitaire stent retriever were included in this prospective analysis. Outcome was assessed after 3 months by the modified Rankin Scale. RESULTS One-hundred thirty-five patients (31%) underwent endovascular treatment with conscious sedation, and 266 patients (69%), with general anesthesia. Patients under general anesthesia had higher NIHSS scores on admission (17 versus 13, P < .001) and more internal carotid artery occlusions (44.6% versus 14.8%, P < .001) than patients under conscious sedation. Other baseline characteristics such as time from symptom onset to the start of endovascular treatment did not differ. Favorable outcome (mRS 0-2) was more frequent with conscious sedation (47.4% versus 32%; OR, 0.773; 95% CI, 0.646-0.925; P = .002) in univariable but not multivariable logistic regression analysis (P = .629). Mortality did not differ (P = .077). Independent predictors of outcome were age (OR, 0.95; 95% CI, 0.933-0.969; P < .001), NIHSS score (OR, 0.894; 95% CI, 0.855-0.933; P < .001), time from symptom onset to the start of endovascular treatment (OR, 0.998; 95% CI, 0.996-0.999; P = .011), diabetes mellitus (OR, 0.544; 95% CI, 0.305-0.927; P = .04), and symptomatic intracerebral hemorrhage (OR, 0.109; 95% CI, 0.028-0.428; P = .002). CONCLUSIONS In this single-center study, the anesthetic management during stent retriever thrombectomy with general anesthesia or conscious sedation had no impact on the outcome of patients with large-vessel occlusion in the anterior circulation.
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Affiliation(s)
- A Slezak
- From the Departments of Neurology (A.S., R.K., L.O., A.B.-M., H.P.M., M.A., U.F., S.J., M.-L.M.)
| | - R Kurmann
- From the Departments of Neurology (A.S., R.K., L.O., A.B.-M., H.P.M., M.A., U.F., S.J., M.-L.M.)
| | - L Oppliger
- From the Departments of Neurology (A.S., R.K., L.O., A.B.-M., H.P.M., M.A., U.F., S.J., M.-L.M.)
| | - A Broeg-Morvay
- From the Departments of Neurology (A.S., R.K., L.O., A.B.-M., H.P.M., M.A., U.F., S.J., M.-L.M.)
| | - J Gralla
- Diagnostic and Interventional Neuroradiology (J.G., G.S., P.M.)
| | - G Schroth
- Diagnostic and Interventional Neuroradiology (J.G., G.S., P.M.)
| | - H P Mattle
- From the Departments of Neurology (A.S., R.K., L.O., A.B.-M., H.P.M., M.A., U.F., S.J., M.-L.M.)
| | - M Arnold
- From the Departments of Neurology (A.S., R.K., L.O., A.B.-M., H.P.M., M.A., U.F., S.J., M.-L.M.)
| | - U Fischer
- From the Departments of Neurology (A.S., R.K., L.O., A.B.-M., H.P.M., M.A., U.F., S.J., M.-L.M.)
| | - S Jung
- From the Departments of Neurology (A.S., R.K., L.O., A.B.-M., H.P.M., M.A., U.F., S.J., M.-L.M.)
| | - R Greif
- Anesthesiology and Pain Medicine (R.G., F.N.), University Hospital Bern and University of Bern, Bern, Switzerland
| | - F Neff
- Anesthesiology and Pain Medicine (R.G., F.N.), University Hospital Bern and University of Bern, Bern, Switzerland
| | - P Mordasini
- Diagnostic and Interventional Neuroradiology (J.G., G.S., P.M.)
| | - M-L Mono
- From the Departments of Neurology (A.S., R.K., L.O., A.B.-M., H.P.M., M.A., U.F., S.J., M.-L.M.)
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Huh H, Lim HH, Kim JY, Shin HW, Lim HJ, Yoon SM, Yoon SZ, Lee HW. A Novel and Simple Method for Tracheal Intubation in a Swine Model: Preparing for the Era of Xenotransplantation. EXP CLIN TRANSPLANT 2017; 15:453-457. [PMID: 28447930 DOI: 10.6002/ect.2016.0123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Organ transplant in humans is an established therapy for a variety of end-stage organ diseases. However, due to organ shortages and lack of donors, the need for xenotransplant has gradually increased. Xenotransplantation has great potential to solve many of the problems facing organ transplantation. Pigs are being developed as xenogeneic organ donors for use in humans. In this study, we propose a novel and simple method for tracheal intubation in a swine model using neuromuscular blocking agents and laryngeal mask airway. MATERIALS AND METHODS Eight Yorkshire pigs were used for the 2 separate experiments, which were conducted 1 week apart. In the first experiment, an anesthesiologist with no previous comparable experience performed endotracheal intubation of pigs. One week later, using the same pig, a second experiment was performed by an experienced anesthesiologist. Anesthesia was induced with intramuscular injection of a mixture of 1 mg/kg xylazine (Rompun, Bayer Korea Ltd., Seoul, Korea) and 7 mg/kg Zoletil (a mixture of tiletamine hydrochloride and zolazepam hydro-chloride, Virbac Laboratory, Carros, France). The laryngeal mask was then placed, and 0.15 mg/kg vecuronium bromide was injected intravenously. Tracheal intubation was attempted after mask removal. The duration and number of intubation attempts were recorded, and the degree of intubation difficulty was scored. RESULTS In all cases, the laryngeal mask was easily inserted, and endotracheal intubation was successfully completed. Oxygen saturation did not fall below 95%, and there were no hypoxemia episodes. Degree of intubation difficulty and duration were not significantly different between the 2 anesthesiologists. CONCLUSIONS Tracheal intubation in our swine model was successfully performed using neuromuscular blocking agents and laryngeal masks without resulting in hypoxemia, with even anesthesiologists who are unfamiliar with endotracheal intubation of pigs easily able to do so using our protocol. Therefore, our protocol will enable all investigators to perform successful tracheal intubation in swine models.
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Affiliation(s)
- Hyub Huh
- From the Department of Anesthesiology and Pain Medicine, College of Medicine, Korea University
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Abstract
Abstract
Since cricoid pressure was introduced into clinical practice, controversial issues have arisen, including necessity, effectiveness in preventing aspiration, quantifying the cricoid force, and its reliability in certain clinical entities and in the presence of gastric tubes. Cricoid pressure–associated complications have also been alleged, such as airway obstruction leading to interference with manual ventilation, laryngeal visualization, tracheal intubation, placement of supraglottic devices, and relaxation of the lower esophageal sphincter. This review synthesizes available information to identify, address, and attempt to resolve the controversies related to cricoid pressure. The effective use of cricoid pressure requires that the applied force is sufficient to occlude the esophageal entrance while avoiding airway-related complications. Most of these complications are caused by excessive or inadequate force or by misapplication of cricoid pressure. Because a simple-to-use and reliable cricoid pressure device is not commercially available, regular training of personnel, using technology-enhanced cricoid pressure simulation, is required. The current status of cricoid pressure and objectives for future cricoid pressure–related research are also discussed.
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Goto Y, Goto T, Hagiwara Y, Tsugawa Y, Watase H, Okamoto H, Hasegawa K. Techniques and outcomes of emergency airway management in Japan: An analysis of two multicentre prospective observational studies, 2010-2016. Resuscitation 2017; 114:14-20. [PMID: 28219617 DOI: 10.1016/j.resuscitation.2017.02.009] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2016] [Revised: 02/04/2017] [Accepted: 02/07/2017] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Continuous surveillance of emergency airway management practice is imperative in improving quality of care and patient safety. We aimed to investigate the changes in the practice of emergency airway management and the related outcomes in the emergency departments (EDs) in Japan. METHODS We conducted an analysis of the data from two prospective, observational, multicentre registries of emergency airway management-the Japanese Emergency Airway Network (JEAN)-1 and -2 Registries from April 2010 through May 2016. RESULTS We recorded 10,927 ED intubations (capture rate, 96%); 10,875 paediatric and adult patients were eligible for our analysis. The rate of rapid sequence intubation (RSI) use as the initial intubation method significantly increased from 28% in 2010 to 53% in 2016 (Ptrend=0.03). Likewise, the rate of video laryngoscope (VL) use as the first intubation device increased significantly from 2% in 2010 to 40% in 2016 (Ptrend<0.001), with a significant decrease in the rate of direct laryngoscope use from 97% in 2010 to 58% in 2016 (Ptrend<0.001). Concurrent with these changes, the overall first-attempt success rate also increased from 68% in 2010 to 74% in 2016 (Ptrend=0.02). By contrast, the rate of adverse events did not change significantly over time (Ptrend=0.06). CONCLUSION By using data from two large, multicentre, prospective registries, we characterised the current emergency airway management practice, and identified their changes in Japan. The data demonstrated significant increases in the rate of RSI and VL use on the first attempt and the first-attempt success rate over the 6-year study period.
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Affiliation(s)
- Yukari Goto
- Department of Emergency Medicine, Nagoya Ekisaikai Hospital, 4-66 Shonen, Nakagawa, Nagoya, Aichi 454-8502, Japan.
| | - Tadahiro Goto
- Department of Emergency Medicine, Massachusetts General Hospital, 125 Nashua Street Boston, Suite 920, Boston, MA 02114, USA
| | - Yusuke Hagiwara
- Department of Paediatric Emergency and Critical Care Medicine, Tokyo Metropolitan Children's Medical Centre, 2-8-29 Musashidai, Fuchu, Tokyo 183-8561, Japan
| | - Yusuke Tsugawa
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, 677 Huntington Avenue Boston, MA 02115, USA
| | - Hiroko Watase
- Department of Radiology, University of Washington, 850 Republican Street Seattle, WA 98006, USA
| | - Hiroshi Okamoto
- Centre for Clinical Epidemiology, Department of Emergency Medicine, St. Luke's International Hospital, 3-6 Tsukiji, Chuo, Tokyo 104-0045, Japan
| | - Kohei Hasegawa
- Department of Emergency Medicine, Massachusetts General Hospital, 125 Nashua Street Boston, Suite 920, Boston, MA 02114, USA; Harvard Medical School, Boston, MA, USA
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Abstract
Although urgent surgical hematoma evacuation is necessary for most patients with subdural hematoma (SDH), well-orchestrated, evidenced-based, multidisciplinary, postoperative critical care is essential to achieve the best possible outcome. Acute SDH complicates approximately 11% of mild to moderate traumatic brain injuries (TBIs) that require hospitalization, and approximately 20% of severe TBIs. Acute SDH usually is related to a clear traumatic event, but in some cases can occur spontaneously. Management of SDH in the setting of TBI typically conforms to the Advanced Trauma Life Support protocol with airway taking priority, and management breathing and circulation occurring in parallel rather than sequence.
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Affiliation(s)
- Fawaz Al-Mufti
- Endovascular Surgical Neuroradiology Program, Rutgers University-New Jersey Medical School, Newark, NJ, USA
| | - Stephan A Mayer
- Department of Neurology, Henry Ford Health System, 2799 W Grand Boulevard, Detroit, MI 48202, USA.
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Okubo M, Gibo K, Hagiwara Y, Nakayama Y, Hasegawa K. The effectiveness of rapid sequence intubation (RSI) versus non-RSI in emergency department: an analysis of multicenter prospective observational study. Int J Emerg Med 2017; 10:1. [PMID: 28124199 PMCID: PMC5267589 DOI: 10.1186/s12245-017-0129-8] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Accepted: 01/18/2017] [Indexed: 01/30/2023] Open
Abstract
Background Although rapid sequence intubation (RSI) is the method of choice in emergency department (ED) airway management, data to support the use of RSI remain scarce. We sought to compare the effectiveness of airway management between RSI and non-RSI (intubation with sedative agents only or without medications) in the ED. Methods Secondary analysis of the data from a multicenter prospective observational registry at 13 Japanese EDs. All non-cardiac-arrest patients who underwent intubation with RSI or non-RSI were included for the analysis. Outcomes of interest were the success rate of intubation and intubation-related complications. Results Of 2365 eligible patients, 761 (32%) underwent intubations with RSI and 1,604 (68%) with non-RSI. Intubations with RSI had a higher success rate on the first attempt compared to those with non-RSI (73 vs. 63%; P < 0.0001). By contrast, the complication rates did not differ significantly between RSI and non-RSI groups (12 vs. 13%; P = 0.59). After adjusting for age, sex, estimated weight, principal indication, device, specialties and training level of the intubator, and clustering of patients within EDs, intubation with RSI was associated with a significantly higher success rate on the first attempt (OR, 2.3; 95% CI, 1.8–2.9; P < 0.0001) while that with RSI was not associated with the risk of complications (OR, 0.9; 95% CI, 0.6–1.2; P = 0.31). Conclusions In this large multicenter study of ED airway management, we found that intubation with RSI was independently associated with a higher success rate on the first attempt but not with the risk of complications.
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Affiliation(s)
- Masashi Okubo
- Department of Emergency Medicine, University of Pittsburgh, Iroquois Building Suite 400 A, 3600 Forbes Avenue, Pittsburgh, PA, 15261, USA.
| | - Koichiro Gibo
- Biostatistics Center, Kurume University, 67 Asahimachi, Kurume, Fukuoka, 830-0011, Japan
| | - Yusuke Hagiwara
- Department of Pediatric Emergency and Critical Care Medicine, Tokyo Metropolitan Children's Medical Center, 2-8-29 Musashidai, Fuchu, Tokyo, 183-8561, Japan
| | - Yukiko Nakayama
- Department of Emergency Medicine, Okinawa Prefectural Chubu Hospital, 281 Miyazato, Uruma, Okinawa, 904-2293, Japan
| | - Kohei Hasegawa
- Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA
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Silvestri S, Ladde JG, Brown JF, Roa JV, Hunter C, Ralls GA, Papa L. Endotracheal tube placement confirmation: 100% sensitivity and specificity with sustained four-phase capnographic waveforms in a cadaveric experimental model. Resuscitation 2017; 115:192-198. [PMID: 28111195 DOI: 10.1016/j.resuscitation.2017.01.002] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Revised: 12/19/2016] [Accepted: 01/06/2017] [Indexed: 01/04/2023]
Abstract
BACKGROUND Waveform capnography is considered the gold standard for verification of proper endotracheal tube placement, but current guidelines caution that it is unreliable in low-perfusion states such as cardiac arrest. Recent case reports found that long-deceased cadavers can produce capnographic waveforms. The purpose of this study was to determine the predictive value of waveform capnography for endotracheal tube placement verification and detection of misplacement using a cadaveric experimental model. METHODS We conducted a controlled experiment with two intubated cadavers. Tubes were placed within the trachea, esophagus, and hypopharynx utilizing video laryngoscopy. We recorded observations of capnographic waveforms and quantitative end-tidal carbon dioxide (ETCO2) values during tracheal versus extratracheal (i.e., esophageal and hypopharyngeal) ventilations. RESULTS 106 and 89 tracheal ventilations delivered to cadavers one and two, respectively (n=195) all produced characteristic alveolar waveforms (positive) with ETCO2 values ranging 2-113mmHg. 42 esophageal ventilations (36 to cadaver one and 6 to cadaver two), and 6 hypopharyngeal ventilations (4 to cadaver one and 2 to cadaver two) all resulted in non-alveolar waveforms (negative) with ETCO2 values of 0mmHg. Esophageal and hypopharyngeal measurements were categorized as extratracheal (n=48). A binary classification test showed no false negatives or false positives, indicating 100% sensitivity (NPV 1.0, 95%CI 0.98-1.00) and 100% specificity (PPV 1.0, 95%CI 0.93-1.00). CONCLUSION Though current guidelines question the reliability of waveform capnography for verifying endotracheal tube location during low-perfusion states such as cardiac arrest, our findings suggest that it is highly sensitive and specific.
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Affiliation(s)
- Salvatore Silvestri
- Department of Emergency Medicine, Orlando Regional Medical Center, 86 West Underwood Street, Suite 200, Orlando, FL 32806, United States
| | - Jay G Ladde
- Department of Emergency Medicine, Orlando Regional Medical Center, 86 West Underwood Street, Suite 200, Orlando, FL 32806, United States
| | - James F Brown
- Department of Emergency Medicine, Orlando Regional Medical Center, 86 West Underwood Street, Suite 200, Orlando, FL 32806, United States.
| | - Jesus V Roa
- Department of Emergency Medicine, Orlando Regional Medical Center, 86 West Underwood Street, Suite 200, Orlando, FL 32806, United States
| | - Christopher Hunter
- Department of Emergency Medicine, Orlando Regional Medical Center, 86 West Underwood Street, Suite 200, Orlando, FL 32806, United States
| | - George A Ralls
- Department of Emergency Medicine, Orlando Regional Medical Center, 86 West Underwood Street, Suite 200, Orlando, FL 32806, United States
| | - Linda Papa
- Department of Emergency Medicine, Orlando Regional Medical Center, 86 West Underwood Street, Suite 200, Orlando, FL 32806, United States
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39
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First-Pass Intubation Success. Notf Rett Med 2016. [DOI: 10.1007/s10049-016-0168-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Abstract
Airway management and ventilation are central to the resuscitation of the neurologically ill. These patients often have evolving processes that threaten the airway and adequate ventilation. Furthermore, intubation, ventilation, and sedative choices directly affect brain perfusion. Therefore, airway, ventilation, and sedation was chosen as an emergency neurological life support protocol. Topics include airway management, when and how to intubate with special attention to hemodynamics and preservation of cerebral blood flow, mechanical ventilation settings, and the use of sedative agents based on the patient's neurological status.
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41
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Ono Y, Sugiyama T, Chida Y, Sato T, Kikuchi H, Suzuki D, Ikeda M, Tanigawa K, Shinohara K. Association between off-hour presentation and endotracheal-intubation-related adverse events in trauma patients with a predicted difficult airway: A historical cohort study at a community emergency department in Japan. Scand J Trauma Resusc Emerg Med 2016; 24:106. [PMID: 27576447 PMCID: PMC5006537 DOI: 10.1186/s13049-016-0296-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Accepted: 08/22/2016] [Indexed: 11/30/2022] Open
Abstract
Background A reduction in medical staff such as occurs in hospitals during nights and weekends (off hours) is associated with a worse outcome in patients with several unanticipated critical conditions. Although difficult airway management (DAM) requires the simultaneous assistance of several appropriately trained medical caregivers, data are scarce regarding the association between off-hour presentation and endotracheal intubation (ETI)-related adverse events, especially in the trauma population. The aim of this study was to determine whether off-hour presentation was associated with ETI complications in injured patients with a predicted difficult airway. Methods This historical cohort study was conducted at a Japanese community emergency department (ED). All patients with inhalation burn, comminuted facial trauma (Abbreviated Injury Scale Score Face ≥3), and penetrating neck injury who underwent ETI from January 2007 to January 2016 in our ED were included. Primary exposure was off-hour presentation, defined as the period from 6:01 PM to 8:00 AM weekdays plus the entire weekend. The primary outcome measure was the occurrence of an ETI-related adverse event, including hypoxemia, unrecognized esophageal intubation, regurgitation, cardiac arrest, ETI failure rescued by emergency surgical airway, cuff leak, and mainstem bronchus intubation. Results Of the 123 patients, 75 (61.0 %) were intubated during off hours. Crude analysis showed that off-hour presentation was significantly associated with an increased risk of ETI-related adverse events [odds ratio (OR), 2.5; 95 % confidence interval (CI), 1.1–5.6; p = 0.033]. The increased risk remained significant after adjusting for potential confounders, including operator being an anesthesiologist, use of a paralytic agent, and injury severity score (OR, 3.0; 95 % CI, 1.1–8.4; p = 0.034). Conclusions In this study, off-hour presentation was independently associated with ETI-related adverse events in trauma patients with a predicted difficult airway. These data imply the need for more attentive hospital care during nights and weekends. Electronic supplementary material The online version of this article (doi:10.1186/s13049-016-0296-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Yuko Ono
- Department of Anesthesiology, Ohta General Hospital Foundation, Ohta Nishinouchi Hospital, 2-5-20 Nishinouchi, Koriyama, Fukushima, 963-8558, Japan. .,Emergency and Critical Care Medical Center, Fukushima Medical University Hospital, 1 Hikarigaoka, Fukushima, 960-1295, Japan.
| | - Takuya Sugiyama
- Department of Anesthesiology, Ohta General Hospital Foundation, Ohta Nishinouchi Hospital, 2-5-20 Nishinouchi, Koriyama, Fukushima, 963-8558, Japan
| | - Yasuyuki Chida
- Department of Anesthesiology, Ohta General Hospital Foundation, Ohta Nishinouchi Hospital, 2-5-20 Nishinouchi, Koriyama, Fukushima, 963-8558, Japan
| | - Tetsuya Sato
- Department of Anesthesiology, Ohta General Hospital Foundation, Ohta Nishinouchi Hospital, 2-5-20 Nishinouchi, Koriyama, Fukushima, 963-8558, Japan
| | - Hiroaki Kikuchi
- Department of Anesthesiology, Ohta General Hospital Foundation, Ohta Nishinouchi Hospital, 2-5-20 Nishinouchi, Koriyama, Fukushima, 963-8558, Japan
| | - Daiji Suzuki
- Department of Head and Neck Surgery, Ohta General Hospital Foundation, Ohta Nishinouchi Hospital, 2-5-20 Nishinouchi, Koriyama, Fukushima, 963-8558, Japan
| | - Masakazu Ikeda
- Department of Otolaryngology, Fukushima Medical University, 1 Hikarigaoka, Fukushima, 960-1295, Japan
| | - Koichi Tanigawa
- Fukushima Medical University, 1 Hikarigaoka, Fukushima, 960-1295, Japan.,Fukushima Global Medical Science Center, 1 Hikarigaoka, Fukushima, 960-1295, Japan
| | - Kazuaki Shinohara
- Department of Anesthesiology, Ohta General Hospital Foundation, Ohta Nishinouchi Hospital, 2-5-20 Nishinouchi, Koriyama, Fukushima, 963-8558, Japan
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Little G, Kelly M, Glucksman E. Critical pitfalls in the immediate assessment of the trauma patient. TRAUMA-ENGLAND 2016. [DOI: 10.1177/146040860100300106] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
In the immediate assessment of trauma patients, critical pitfalls exist that may interfere with optimal clinical care. Failure to recognize the need for early anaesthesia and endotracheal intubation may put the patient at unnecessary risk and delay the assessment and treatment process. Pressure to clear the cervical spine may lead to inadequate imaging and premature removal of neck immobilization devices. The limitations of the initial chest X-ray in diagnosing pneumothoraces may not be appreciated and needle thoracentesis may be ineffective. ‘Springing’ the pelvis to assess for instability may cause life-threatening haemorrhage and should not be done prior to the initial pelvic X-ray. Log rolling may dislodge crucial clot formation and promote bleeding, and should only be used for diagnostic purposes. Applying clinical common sense to the assessment of trauma patients may avoid the pitfalls whilst allowing the clinician to operate within internationally agreed assessment and treatment frameworks.
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Affiliation(s)
- George Little
- Accident and Emergency Department, King’s College Hospital, London, UK,
| | - Michael Kelly
- Accident and Emergency Department, King’s College Hospital, London, UK
| | - E Glucksman
- Accident and Emergency Department, King’s College Hospital, London, UK
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Przybysz TM, Heffner AC. Early Treatment of Severe Acute Respiratory Distress Syndrome. Emerg Med Clin North Am 2015; 34:1-14. [PMID: 26614238 DOI: 10.1016/j.emc.2015.08.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Acute respiratory distress syndrome (ARDS) is defined by acute diffuse inflammatory lung injury invoked by a variety of systemic or pulmonary insults. Despite medical progress in management, mortality remains 27% to 45%. Patients with ARDS should be managed with low tidal volume ventilation. Permissive hypercapnea is well tolerated. Conservative fluid strategy can reduce ventilator and hospital days in patients without shock. Prone positioning and neuromuscular blockers reduce mortality in some patients. Early management of ARDS is relevant to emergency medicine. Identifying ARDS patients who should be transferred to an extracorporeal membrane oxygenation center is an important task for emergency providers.
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Affiliation(s)
- Thomas M Przybysz
- Division of Critical Care Medicine, Department of Internal Medicine, Carolinas Medical Center, 1000 Blyth Boulevard, Charlotte, NC 28203, USA
| | - Alan C Heffner
- Division of Critical Care Medicine, Department of Internal Medicine, Carolinas Medical Center, 1000 Blyth Boulevard, Charlotte, NC 28203, USA; Medical ICU, Department of Emergency Medicine, Carolinas Medical Center, University of North Carolina, Charlotte Campus, 1000 Blyth Boulevard, Charlotte, NC 28203, USA.
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Incidence and Duration of Continuously Measured Oxygen Desaturation During Emergency Department Intubation. Ann Emerg Med 2015; 67:389-95. [PMID: 26164643 DOI: 10.1016/j.annemergmed.2015.06.006] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2013] [Revised: 03/23/2015] [Accepted: 06/05/2015] [Indexed: 11/22/2022]
Abstract
STUDY OBJECTIVE Desaturation during intubation has been associated with serious complications, including dysrhythmias, hemodynamic decompensation, hypoxic brain injury, and cardiac arrest. We seek to determine the incidence and duration of oxygen desaturation during emergency department (ED) rapid sequence intubation. METHODS This study included adult rapid sequence intubation cases conducted between September 2011 and July 2012 in an urban, academic, Level I trauma center ED. We obtained continuous vital signs with BedMasterEX data acquisition software. Start and completion times of rapid sequence intubation originated from nursing records. We defined oxygen desaturation as (1) cases exhibiting SpO2 reduction to less than 90% if the starting SpO2 was greater than or equal to 90%, or (2) a further reduction in SpO2 in cases in which starting SpO2 was less than 90%. We used multivariable logistic regression to predict oxygen desaturation during rapid sequence intubation. RESULTS During the study period, there were 265 rapid sequence intubation cases. The study excluded 99 cases for failure of electronic data acquisition, inadequate documentation, or poor SpO2 waveform during rapid sequence intubation, and excluded cases managed by anesthesia providers, leaving 166 patients in the analysis. After preoxygenation, starting SpO2 was greater than 93% in 124 of 166 cases (75%) and SpO2 was less than 93% in the remaining 46 cases. Oxygen desaturation occurred in 59 patients (35.5%). The median duration of desaturation was 80 seconds (interquartile range 40, 155). Multivariable analysis demonstrated that oxygen desaturation was associated with preintubation SpO2 less than 93% (odds ratio [OR] 5.1; 95% confidence interval (CI) 2.3 to 11.0), multiple intubation attempts (>1 attempt) (OR 3.4; 95% CI 1.4 to 6.1), and rapid sequence intubation duration greater than 3 minutes (OR 2.7; 95% CI 1.2 to 6.1). CONCLUSION In this series, 1 in 3 patients undergoing ED rapid sequence intubation experienced oxygen desaturation for a median duration of 80 seconds. Preintubation saturation less than 93%, multiple intubation attempts, and prolonged intubation time are independently associated with oxygen desaturation. Clinicians should use strategies to prevent oxygen desaturation during ED rapid sequence intubation.
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Jung JY. Airway management of patients with traumatic brain injury/C-spine injury. Korean J Anesthesiol 2015; 68:213-9. [PMID: 26045922 PMCID: PMC4452663 DOI: 10.4097/kjae.2015.68.3.213] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Revised: 12/08/2014] [Accepted: 12/09/2014] [Indexed: 11/26/2022] Open
Abstract
Traumatic brain injury (TBI) is usually combined with cervical spine (C-spine) injury. The possibility of C-spine injury is always considered when performing endotracheal intubation in these patients. Rapid sequence intubation is recommended with adequate sedative or analgesics and a muscle relaxant to prevent an increase in intracranial pressure during intubation in TBI patients. Normocapnia and mild hyperoxemia should be maintained to prevent secondary brain injury. The manual-in-line-stabilization (MILS) technique effectively lessens C-spine movement during intubation. However, the MILS technique can reduce mouth opening and lead to a poor laryngoscopic view. The newly introduced video laryngoscope can manage these problems. The AirWay Scope® (AWS) and AirTraq laryngoscope decreased the extension movement of C-spines at the occiput-C1 and C2-C4 levels, improving intubation conditions and shortening the time to complete tracheal intubation compared with a direct laryngoscope. The Glidescope® also decreased cervical movement in the C2-C5 levels during intubation and improved vocal cord visualization, but a longer duration was required to complete intubation compared with other devices. A lightwand also reduced cervical motion across all segments. A fiberoptic bronchoscope-guided nasal intubation is the best method to reduce cervical movement, but a skilled operator is required. In conclusion, a video laryngoscope assists airway management in TBI patients with C-spine injury.
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Affiliation(s)
- Jin Yong Jung
- Department of Anesthesiology and Pain Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea
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46
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Schönenberger S, Möhlenbruch M, Pfaff J, Mundiyanapurath S, Kieser M, Bendszus M, Hacke W, Bösel J. Sedation vs. Intubation for Endovascular Stroke TreAtment (SIESTA) – A Randomized Monocentric Trial. Int J Stroke 2015; 10:969-78. [DOI: 10.1111/ijs.12488] [Citation(s) in RCA: 64] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2014] [Accepted: 02/25/2015] [Indexed: 11/28/2022]
Abstract
Background The optimal peri-interventional management of sedation and airway for endovascular stroke treatment (EST) appears to be a crucial factor for treatment success. According to retrospective studies, the widely favored general anesthesia with intubation seems to be associated with poor functional outcome compared to a slightly sedated non-intubated condition (conscious sedation). Method SIESTA is a monocentric, prospective, randomized parallel-group, open-label treatment trial with blinded endpoint evaluation (PROBE design). The study compares the non-intubated with the intubated state in patients receiving endovascular treatment of acute ischemic anterior circulation stroke. The primary endpoint is early neurological improvement as by National Institutes of Health Stroke Scale (NIHSS) after 24 h (difference between NIHSS on admission and NIHSS after 24 h). Secondary endpoints include: functional outcome after three-months as by modified Rankin Scale (mRS), mortality, parameters of ventilation and critical care, feasibility, and safety, i.e. complications related to endovascular stroke treatment. Conclusion The aims of this study are to prospectively clarify whether the non-intubated state of conscious sedation is feasible, safe, and superior with regard to early neurological improvement compared to the intubated state of general anesthesia in patients receiving acute endovascular stroke treatment.
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Affiliation(s)
| | - Markus Möhlenbruch
- Department of Neuroradiology, University of Heidelberg, Heidelberg, Germany
| | - Johannes Pfaff
- Department of Neuroradiology, University of Heidelberg, Heidelberg, Germany
| | | | - Meinhard Kieser
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Martin Bendszus
- Department of Neuroradiology, University of Heidelberg, Heidelberg, Germany
| | - Werner Hacke
- Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - Julian Bösel
- Department of Neurology, University of Heidelberg, Heidelberg, Germany
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Emergency endotracheal intubation-related adverse events in bronchial asthma exacerbation: can anesthesiologists attenuate the risk? J Anesth 2015; 29:678-85. [PMID: 25801541 DOI: 10.1007/s00540-015-2003-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2014] [Accepted: 03/09/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE Airway management in severe bronchial asthma exacerbation (BAE) carries very high risk and should be performed by experienced providers. However, no objective data are available on the association between the laryngoscopist's specialty and endotracheal intubation (ETI)-related adverse events in patients with severe bronchial asthma. In this paper, we compare emergency ETI-related adverse events in patients with severe BAE between anesthesiologists and other specialists. METHODS This historical cohort study was conducted at a Japanese teaching hospital. We analyzed all BAE patients who underwent ETI in our emergency department from January 2002 to January 2014. Primary exposure was the specialty of the first laryngoscopist (anesthesiologist vs. other specialist). The primary outcome measure was the occurrence of an ETI-related adverse event, including severe bronchospasm after laryngoscopy, hypoxemia, regurgitation, unrecognized esophageal intubation, and ventricular tachycardia. RESULTS Of 39 patients, 21 (53.8 %) were intubated by an anesthesiologist and 18 (46.2 %) by other specialists. Crude analysis revealed that ETI performed by an anesthesiologist was significantly associated with attenuated risk of ETI-related adverse events [odds ratio (OR) 0.090, 95 % confidence interval (CI) 0.020-0.41, p = 0.001]. The benefit of attenuated risk remained significant after adjusting for potential confounders, including Glasgow Coma Score, age, and use of a neuromuscular blocking agent (OR 0.058, 95 % CI 0.010-0.35, p = 0.0020). CONCLUSIONS Anesthesiologist as first exposure was independently associated with attenuated risk of ETI-related adverse events in patients with severe BAE. The skill and knowledge of anesthesiologists should be applied to high-risk airway management whenever possible.
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Brinjikji W, Murad MH, Rabinstein AA, Cloft HJ, Lanzino G, Kallmes DF. Conscious sedation versus general anesthesia during endovascular acute ischemic stroke treatment: a systematic review and meta-analysis. AJNR Am J Neuroradiol 2015; 36:525-9. [PMID: 25395655 DOI: 10.3174/ajnr.a4159] [Citation(s) in RCA: 175] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE A number of studies have suggested that anesthesia type (conscious sedation versus general anesthesia) during intra-arterial treatment for acute ischemic stroke has implications for patient outcomes. We performed a systematic review and meta-analysis of studies comparing the clinical and angiographic outcomes of the 2 anesthesia types. MATERIALS AND METHODS In March 2014, we conducted a computerized search of MEDLINE and EMBASE for reports on anesthesia and endovascular treatment of acute ischemic stroke. Using random-effects meta-analysis, we evaluated the following outcomes: recanalization rate, good functional outcome (mRS ≤ 2), asymptomatic and symptomatic intracranial hemorrhage, death, vascular complications, respiratory complications, procedure time, time to groin, and time from symptom onset to recanalization. RESULTS Nine studies enrolling 1956 patients (814 with general anesthesia and 1142 with conscious sedation) were included. Compared with patients treated by using conscious sedation during stroke intervention, patients undergoing general anesthesia had higher odds of death (OR = 2.59; 95% CI, 1.87-3.58) and respiratory complications (OR = 2.09; 95% CI, 1.36-3.23) and lower odds of good functional outcome (OR = 0.43; 95% CI, 0.35-0.53) and successful angiographic outcome (OR = 0.54; 95% CI, 0.37-0.80). No difference in procedure time (P = .28) was seen between the groups. Preintervention NIHSS scores were available from 6 studies; in those, patients receiving general anesthesia had a higher average NIHSS score. CONCLUSIONS Patients with acute ischemic stroke undergoing intra-arterial therapy may have worse outcomes with general anesthesia compared with conscious sedation. However, the difference in stroke severity at the onset may confound the comparison in the available studies; thus, a randomized trial is necessary to confirm this association.
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Affiliation(s)
- W Brinjikji
- From the Departments of Radiology (W.B., H.J.C., G.L., D.F.K.)
| | - M H Murad
- Center for the Science of Healthcare Delivery and the Division of Preventive Medicine (M.H.M.), Mayo Clinic, Rochester, Minnesota
| | | | - H J Cloft
- From the Departments of Radiology (W.B., H.J.C., G.L., D.F.K.) Neurosurgery (H.J.C., G.L., D.F.K.)
| | - G Lanzino
- From the Departments of Radiology (W.B., H.J.C., G.L., D.F.K.) Neurosurgery (H.J.C., G.L., D.F.K.)
| | - D F Kallmes
- From the Departments of Radiology (W.B., H.J.C., G.L., D.F.K.) Neurosurgery (H.J.C., G.L., D.F.K.)
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Assessment of Emergency Airway Management Techniques in Korea Using an Online Registration System: A Multicenter Study. J Emerg Med 2015; 48:1-9. [DOI: 10.1016/j.jemermed.2014.06.044] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2013] [Revised: 04/15/2014] [Accepted: 06/30/2014] [Indexed: 11/21/2022]
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50
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Zettervall SL, Sirajuddin S, Akst S, Valdez C, Golshani C, Amdur RL, Sarani B, Dunne JR. Use of propofol as an induction agent in the acutely injured patient. Eur J Trauma Emerg Surg 2014; 41:405-11. [PMID: 26038005 DOI: 10.1007/s00068-014-0479-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2014] [Accepted: 11/06/2014] [Indexed: 12/19/2022]
Abstract
PURPOSE Etomidate is a commonly used agent for rapid sequence induction (RSI) in trauma due to its limited hemodynamic effects. Given a recent nationwide shortage of etomidate, alternative induction agents may be required. Propofol is a frequent substitute; however, concern exists regarding its potential hypotensive effects. The study attempts to determine the hemodynamic effects of propofol and etomidate following RSI in trauma bay. METHODS A retrospective study was performed on 76 consecutive trauma patients requiring RSI at a single academic medical center. Patients were stratified by age, gender, mechanism of injury, Injury Severity Score (ISS), and Glasgow Coma Scale (GCS). Pre-induction and post-induction hemodynamic parameters were evaluated, and a multivariate regression analysis was performed. RESULTS The mean age was 42, ISS was 13, and GCS was 9.8. The mean dose of propofol was 127 ± 5 mg and the mean dose of etomidate was 21 ± 6 mg. Patients who received propofol were younger and had a lower ISS. The etomidate group had significantly increased post-induction systolic blood pressure but no difference in mean arterial pressure or heart rate when compared to pre-induction parameters. The propofol group had no significant changes in any post-induction parameter compared to pre-induction parameter. CONCLUSION RSI with propofol did not result in hypotension in our patient population, suggesting that a reduced dose of propofol may represent a reasonable alternative to etomidate in hemodynamically stable trauma patient. Further research is warranted to assess the safety of propofol in the acutely injured patient.
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Affiliation(s)
- S L Zettervall
- Department of Surgery, George Washington University School of Medicine and Health Sciences, 2150 Pennsylvania Ave. NW, Suite 6B, Washington, DC, 20037, USA,
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