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Taboada M, Estany-Gestal A, Fernández J, Vazquez O, Pajares A, Ramasco F, Martínez S, Vallejo I, Pérez A, Rama-Maceiras P, Bermúdez M, Power M, García-Álvarez R, Fernández-Villa I, Aguilera JL, Carrió M, Cabadas R, Rubín A, Williams MM, Fernández-García R, Becerra A, Giné M, García FJ, Iglesias MC, Santamarina RM, Del Valle S, Charco LM, Alonso MC, Rodríguez IM, Varela M, Hermoso JI, Vives M, Cabaleiro T. Hyperangulated versus Macintosh blades for intubation with videolaryngoscopy in ICU: the randomised multicentre INVIBLADE-ICU trial study protocol. BMJ Open 2024; 14:e086691. [PMID: 39237284 PMCID: PMC11381729 DOI: 10.1136/bmjopen-2024-086691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/07/2024] Open
Abstract
INTRODUCTION Compared with the operating room, tracheal intubations in the intensive care unit (ICU) are associated with worsened glottic view, decreased first-time success rate and increase in the technical difficulty of intubation and incidence of complications. Videolaryngoscopes (VLs) have been proposed to improve airway management, and while recent studies have confirmed that VLs improve intubation conditions in this patient population, there remains a lack of clarity regarding the selection between a standard Macintosh blade or a hyperangulated one, to determine which yields the best outcomes. The purpose of this study was to compare successful intubation on the first attempt with the Macintosh VL versus the hyperangulated VL during tracheal intubation in ICU patients. We hypothesise that tracheal intubation using the hyperangulated VL will improve the frequency of successful intubation on the first attempt. METHODS AND ANALYSIS The INtubation VIdeolaryngoscopy BLADE-ICU trial is a prospective, multicentre, open-label, interventional, randomised, controlled superiority study conducted in 29 ICUs in Spain. Patients will be randomly assigned in a 1:1 ratio to undergo intubation using a Macintosh VL (control group) or a hyperangulated VL (experimental group) for the first intubation attempt. The primary outcome is successful intubation on the first attempt. The secondary outcomes include the time to intubation, attempts for successful intubation, laryngoscopic vision assessed with the modified Cormack-Lehane scale, the need for adjuvant airway devices for intubation, difficulty assessed by the anaesthesiologist and complications during tracheal intubation. Enrolment began on 1 May 2024 and is expected to be completed in 2025. ETHICS AND DISSEMINATION The study protocol was approved on 29 February 2024, by the Ethics Committee of Galicia (CEImG, code No. 2024-031).The results will be submitted for publication in a peer-reviewed journal. TRIAL REGISTRATION NUMBER NCT06322719.
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Affiliation(s)
- Manuel Taboada
- Anaesthesiology, Clinical University Hospital of Santiago, Teo, Spain
| | - Ana Estany-Gestal
- Fundación Instituto de Investigaciones Sanitarias (FIDIS), Santiago, Spain
| | - Jorge Fernández
- Anaesthesiology, Clinical University Hospital of Santiago, Teo, Spain
| | - Olalla Vazquez
- Preventive Medicine, Clinical University Hospital of Santiago, Teo, Spain
| | - Azucena Pajares
- Anaesthesiology, Hospital Universitario La Fe de Valencia, Valencia, Spain
| | - Fernando Ramasco
- Anaesthesiology, Hospital Universitario de la Princesa, Madrid, Spain
| | - Sara Martínez
- Anaesthesiology, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - Irene Vallejo
- Anaesthesiology, La Paz University Hospital, Madrid, Spain
| | - Ana Pérez
- Anesthesiology and Critical Care, Hospital General Universitario de Elche, Alicante, Spain
| | - Pablo Rama-Maceiras
- Department of Anaesthesiology, University Clinical Hospital, A Coruña, Spain
| | - María Bermúdez
- Department of Anaesthesiology, University Clinical Hospital Lucus Augusti, Lugo, Spain
| | - Mercedes Power
- Anaesthesiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Raquel García-Álvarez
- Department of Anesthesia and Intensive Care, Hospital Universitario 12 de Octubre, Madrid, Spain
| | | | - Jose Luis Aguilera
- Anaesthesiology, Hospital Universitario Virgen de las Nieves, Granada, Spain
| | | | | | - Anxo Rubín
- Anaesthesiology, Hospital de Donostia, San Sebastian, Spain
| | | | | | - Angel Becerra
- Hospital Universitario de Gran Canaria Dr Negrin, Las Palmas de Gran Canaria, Spain
| | - Marta Giné
- Anaesthesiology, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | | | | | | | - Sara Del Valle
- Anaesthesiology, Puerta de Hierro University Hospital, Majadahonda, Spain
| | | | | | | | - Marina Varela
- Anaesthesiology, Complexo Hospitalario de Pontevedra, Pontevedra, Spain
| | | | - Marc Vives
- Anaesthesiology, Clinica Universitaria de Navarra, Pamplona, Spain
| | - Teresa Cabaleiro
- Pharmacology, Pharmacy and Pharmaceutical Technology Department, University of Santiago de Compostela (USC), Santiago de Compostela, Spain
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Taboada M, Cariñena A, García F, Alonso S, Iraburu R, De Miguel M, Barreiro L, Dos Santos L, Caruezo V, Muniategui I, Aneiros F, Otero P, Álvarez J, Seoane-Pillado T. Impact of universal use of a hyperangulated videolaryngoscope as the first option for all intubations in the ICU: A prospective before-after study. Anaesth Crit Care Pain Med 2024; 43:101402. [PMID: 38964608 DOI: 10.1016/j.accpm.2024.101402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2024] [Revised: 04/10/2024] [Accepted: 05/05/2024] [Indexed: 07/06/2024]
Abstract
BACKGROUND Tracheal intubation in ICU is associated with high incidence of difficult intubations. The study aimed to investigate whether the "universal" use of a hyperangulated videolaryngoscope would increase the frequency of "easy intubation" in ICU patients compared to direct laryngoscopy. METHODS A prospective before-after study was conducted. The pre-interventional period (36 months) involved tracheal intubations using direct laryngoscopy as the first intubation option. In the interventional period (18 months) a hyperangulated videolaryngoscope was the first intubation option. The primary outcome was the percentage of patients with "easy intubation" defined as intubation on the first attempt and easy laryngoscopy (modified Cormack-Lehane glottic view of I-IIa). Secondary outcomes included difficult laryngoscopy, operator technical difficulty, and complications. RESULTS We enrolled 407 patients, 273 in non-interventional period, and 134 in interventional period. Tracheal intubation in the interventional period was associated with higher incidence of "easy intubation" (92.5%) compared with the non-interventional period (75.8%); P < 0.001)). Glottic visualization improved in the interventional period, with a reduced incidence of difficult laryngoscopy (1.5% vs. 22.5%; P < 0.001). The proportion of first-success rate intubation was 92.5% in the interventional period, and 87.8% in the non-interventional period (P = 0.147). Moderate and severe technical difficulty of intubation reported decreased in the interventional period (6% vs. 17.6%; P < 0.001). There was no significant difference between both periods in the incidence of complications. CONCLUSION "Universal" use of hyperangulated videolaryngoscopy for tracheal intubation in patients admitted in ICU improves the percentage of easy intubation compared to direct laryngoscopy.
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Affiliation(s)
- Manuel Taboada
- Department of Anesthesiology and Intensive Care Medicine, Clinical University Hospital of Santiago, Sanitary Research Institute of Santiago (IDIS), Spain.
| | - Agustín Cariñena
- Department of Anesthesiology and Intensive Care Medicine, Clinical University Hospital of Santiago, Sanitary Research Institute of Santiago (IDIS), Spain
| | - Fátima García
- Department of Anesthesiology and Intensive Care Medicine, Clinical University Hospital of Santiago, Sanitary Research Institute of Santiago (IDIS), Spain
| | - Sara Alonso
- Department of Anesthesiology and Intensive Care Medicine, Clinical University Hospital of Santiago, Sanitary Research Institute of Santiago (IDIS), Spain
| | - Rocío Iraburu
- Department of Anesthesiology and Intensive Care Medicine, Clinical University Hospital of Santiago, Sanitary Research Institute of Santiago (IDIS), Spain
| | - Manuela De Miguel
- Department of Anesthesiology and Intensive Care Medicine, Clinical University Hospital of Santiago, Sanitary Research Institute of Santiago (IDIS), Spain
| | - Laura Barreiro
- Department of Anesthesiology and Intensive Care Medicine, Clinical University Hospital of Santiago, Sanitary Research Institute of Santiago (IDIS), Spain
| | - Laura Dos Santos
- Department of Anesthesiology and Intensive Care Medicine, Clinical University Hospital of Santiago, Sanitary Research Institute of Santiago (IDIS), Spain
| | - Valentín Caruezo
- Department of Anesthesiology and Intensive Care Medicine, Clinical University Hospital of Santiago, Sanitary Research Institute of Santiago (IDIS), Spain
| | - Ignacio Muniategui
- Department of Anesthesiology and Intensive Care Medicine, Clinical University Hospital of Santiago, Sanitary Research Institute of Santiago (IDIS), Spain
| | - Francisco Aneiros
- Department of Anesthesiology and Intensive Care Medicine, Clinical University Hospital of Santiago, Sanitary Research Institute of Santiago (IDIS), Spain
| | - Pablo Otero
- Department of Anesthesiology and Intensive Care Medicine, Clinical University Hospital of Santiago, Sanitary Research Institute of Santiago (IDIS), Spain
| | - Julián Álvarez
- Department of Anesthesiology and Intensive Care Medicine, Clinical University Hospital of Santiago, Sanitary Research Institute of Santiago (IDIS), Spain
| | - Teresa Seoane-Pillado
- Department of Anesthesiology and Intensive Care Medicine, Clinical University Hospital of Santiago, Sanitary Research Institute of Santiago (IDIS), Spain; Preventive Medicine and Public Health Unit, Department of Health Sciences, University of A Coruña-INIBIC, A Coruña, Spain
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Taboada M, Estany-Gestal A, Rial M, Cariñena A, Martínez A, Selas S, Eiras M, Veiras S, Ferreiroa E, Cardalda B, López C, Calvo A, Fernández J, Álvarez J, Alcántara JM, Seoane-Pillado T. Impact of Universal Use of the McGrath Videolaryngoscope as a Device for All Intubations in the Cardiac Operating Room. A Prospective Before-After VIDEOLAR-CAR Study. J Cardiothorac Vasc Anesth 2024; 38:1499-1505. [PMID: 38580479 DOI: 10.1053/j.jvca.2024.03.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Revised: 03/02/2024] [Accepted: 03/11/2024] [Indexed: 04/07/2024]
Abstract
OBJECTIVE Tracheal intubation in cardiac surgery patients has a higher incidence of difficult laryngoscopic views compared with patients undergoing other types of surgery. The authors hypothesized that using the McGrath Mac videolaryngoscope as the first intubation option for cardiac surgery patients improves the percentage of patients with "easy intubation" compared with using a direct Macintosh laryngoscope. DESIGN A prospective, observational, before-after study. SETTING At a tertiary-care hospital. PARTICIPANTS One thousand one hundred nine patients undergoing cardiac surgery. INTERVENTION Consecutive patients undergoing cardiac surgery were intubated using, as the first option, a Macintosh laryngoscope (preinterventional phase) or a McGrath Mac videolaryngoscope (interventional phase). MEASUREMENTS AND MAIN RESULTS The main objective was to assess whether the use of the McGrath videolaryngoscope, as the first intubation option, improves the percentage of patients with "easy intubation," defined as successful intubation on the first attempt, modified Cormack-Lehane grades of I or IIa, and the absence of the need for adjuvant airway devices. A total of 1,109 patients were included, 801 in the noninterventional phase and 308 in the interventional phase. The incidence of "easy intubation" was 93% in the interventional phase versus 78% in the noninterventional phase (p < 0.001). First-success-rate intubation was higher in the interventional phase (304/308; 98.7%) compared with the noninterventional phase (754/801, 94.1%; p = 0.005). Intubation in the interventional phase showed decreases in the incidence of difficult laryngoscopy (12/308 [3.9%] v 157/801 [19.6%]; p < 0.001), as well as moderate or difficult intubation (5/308 [1.6%] v 57/801 [7.1%]; p < 0.001). CONCLUSIONS The use of the McGrath videolaryngoscope as the first intubation option for tracheal intubation in cardiac surgery improves the percentage of patients with "easy" intubation," increasing glottic view and first-success-rate intubation and decreasing the incidence of moderate or difficult intubation.
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Affiliation(s)
- Manuel Taboada
- Department of Anaesthesiology, University Clinical Hospital of Santiago, Santiago de Compostela, Spain.
| | - Ana Estany-Gestal
- Research Methodology Unit. Fundación Instituto de Investigaciones Sanitarias (FIDIS), Santiago, Spain
| | - María Rial
- Department of Anaesthesiology, University Clinical Hospital of Santiago, Santiago de Compostela, Spain
| | - Agustín Cariñena
- Department of Anaesthesiology, University Clinical Hospital of Santiago, Santiago de Compostela, Spain
| | - Adrián Martínez
- Department of Anaesthesiology, University Clinical Hospital of Santiago, Santiago de Compostela, Spain
| | - Salomé Selas
- Department of Anaesthesiology, University Clinical Hospital of Santiago, Santiago de Compostela, Spain
| | - María Eiras
- Department of Anaesthesiology, University Clinical Hospital of Santiago, Santiago de Compostela, Spain
| | - Sonia Veiras
- Department of Anaesthesiology, University Clinical Hospital of Santiago, Santiago de Compostela, Spain
| | - Esteban Ferreiroa
- Department of Anaesthesiology, University Clinical Hospital of Santiago, Santiago de Compostela, Spain
| | - Borja Cardalda
- Department of Anaesthesiology, University Clinical Hospital of Santiago, Santiago de Compostela, Spain
| | - Carmen López
- Department of Anaesthesiology, University Clinical Hospital of Santiago, Santiago de Compostela, Spain
| | - Andrea Calvo
- Department of Anaesthesiology, University Clinical Hospital of Santiago, Santiago de Compostela, Spain
| | - Jorge Fernández
- Department of Anaesthesiology, University Clinical Hospital of Santiago, Santiago de Compostela, Spain
| | - Julián Álvarez
- Department of Anaesthesiology, University Clinical Hospital of Santiago, Santiago de Compostela, Spain
| | - Jorge Miguel Alcántara
- Research Methodology Unit. Fundación Instituto de Investigaciones Sanitarias (FIDIS), Santiago, Spain
| | - Teresa Seoane-Pillado
- Preventive Medicine and Public Health Unit, Department of Health Sciences, University of A Coruña-INIBIC, A Coruña, Spain
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Taboada M, Cariñena A, De Miguel M, García F, Alonso S, Iraburu R, Barreiro L, Dos Santos L, Tubio A, Diaz-Vieito M, Álvarez J, Seoane-Pillado T. Comparison of tracheal intubation conditions between the operating room and intensive care unit: impact of universal videolaryngoscopy. Br J Anaesth 2024; 132:984-986. [PMID: 38448268 DOI: 10.1016/j.bja.2024.01.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 12/14/2023] [Accepted: 01/27/2024] [Indexed: 03/08/2024] Open
Affiliation(s)
- Manuel Taboada
- Department of Anesthesiology and Intensive Care Medicine, Clinical University Hospital of Santiago, Sanitary Research Institute of Santiago (IDIS), Santiago, Spain.
| | - Agustín Cariñena
- Department of Anesthesiology and Intensive Care Medicine, Clinical University Hospital of Santiago, Sanitary Research Institute of Santiago (IDIS), Santiago, Spain
| | - Manuela De Miguel
- Department of Anesthesiology and Intensive Care Medicine, Clinical University Hospital of Santiago, Sanitary Research Institute of Santiago (IDIS), Santiago, Spain
| | - Fátima García
- Department of Anesthesiology and Intensive Care Medicine, Clinical University Hospital of Santiago, Sanitary Research Institute of Santiago (IDIS), Santiago, Spain
| | - Sara Alonso
- Department of Anesthesiology and Intensive Care Medicine, Clinical University Hospital of Santiago, Sanitary Research Institute of Santiago (IDIS), Santiago, Spain
| | - Rocío Iraburu
- Department of Anesthesiology and Intensive Care Medicine, Clinical University Hospital of Santiago, Sanitary Research Institute of Santiago (IDIS), Santiago, Spain
| | - Laura Barreiro
- Department of Anesthesiology and Intensive Care Medicine, Clinical University Hospital of Santiago, Sanitary Research Institute of Santiago (IDIS), Santiago, Spain
| | - Laura Dos Santos
- Department of Anesthesiology and Intensive Care Medicine, Clinical University Hospital of Santiago, Sanitary Research Institute of Santiago (IDIS), Santiago, Spain
| | - Ana Tubio
- Department of Anesthesiology and Intensive Care Medicine, Clinical University Hospital of Santiago, Sanitary Research Institute of Santiago (IDIS), Santiago, Spain
| | - María Diaz-Vieito
- Department of Anesthesiology and Intensive Care Medicine, Clinical University Hospital of Santiago, Sanitary Research Institute of Santiago (IDIS), Santiago, Spain
| | - Julián Álvarez
- Department of Anesthesiology and Intensive Care Medicine, Clinical University Hospital of Santiago, Sanitary Research Institute of Santiago (IDIS), Santiago, Spain
| | - Teresa Seoane-Pillado
- Preventive Medicine and Public Health Unit, Department of Health Sciences, University of A Coruña-INIBIC, A Coruña, Spain
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Taboada M, Almeida X, Cariñena A, Costa J, Carmona-Monge J, Agilda A, Barreiro L, Castillo J, Williams K, Segurola J, Álvarez J, Seoane-Pillado T. Complications and degree of difficulty of orotracheal intubation in the Intensive Care Unit before and after the establishment of an intubation protocol for critically ill patients: a prospective, observational study. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2024; 71:17-27. [PMID: 38104962 DOI: 10.1016/j.redare.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 07/17/2023] [Indexed: 12/19/2023]
Abstract
OBJECTIVE The objective of our study was to compare the degree of difficulty and complications related to tracheal intubation in an Intensive Care Unit (ICU) before and after the introduction of an intubation protocol based on the Difficult Airway Society guidelines for the management of tracheal intubation in critically ill adults, published in 2018. METHODS Prospective, observational study comparing all intubations performed in our ICU over 2 periods: pre-protocol (January 2015-January 2019) and post-protocol (February 2019-July 2022). The material used for intubation, the degree of difficulty, and intubation-related complications were recorded. RESULTS During the study period, 661 patients were intubated - 437 in the pre-protocol period (96% by direct laryngoscopy) and 224 in the post-protocol period (53% with direct laryngoscopy, 46% with video laryngoscopy). We observed an improvement in laryngeal view in the post-protocol period compared to the pre-protocol period (Cormack-Lehane ≥ 2b in 7.6% vs. 29.8%, p < 0.001), and a decrease in the number of moderate-to-severely difficult intubations (6.7% vs. 17.4%, p < 0.001). The first-pass success rate was 92.8% in the post-protocol period compared to 90.2% pre-protocol (p = 0.508). We did not find significant differences in complications between the periods studied. CONCLUSIONS Intubations performed in the post-protocol period were associated with improved laryngeal view and fewer cases of difficult intubation compared with the pre-protocol period.
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Affiliation(s)
- M Taboada
- Unidad de Cuidados Intensivos, Servicio de Anestesia y Reanimación, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain; Fundación Instituto de Investigaciones Sanitarias (FIDIS), Santiago de Compostela, La Coruña, Spain.
| | - X Almeida
- Unidad de Cuidados Intensivos, Servicio de Anestesia y Reanimación, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain; Fundación Instituto de Investigaciones Sanitarias (FIDIS), Santiago de Compostela, La Coruña, Spain
| | - A Cariñena
- Unidad de Cuidados Intensivos, Servicio de Anestesia y Reanimación, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain; Fundación Instituto de Investigaciones Sanitarias (FIDIS), Santiago de Compostela, La Coruña, Spain
| | - J Costa
- Unidad de Cuidados Intensivos, Servicio de Anestesia y Reanimación, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain; Fundación Instituto de Investigaciones Sanitarias (FIDIS), Santiago de Compostela, La Coruña, Spain
| | - J Carmona-Monge
- Unidad de Cuidados Intensivos, Servicio de Anestesia y Reanimación, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain; Fundación Instituto de Investigaciones Sanitarias (FIDIS), Santiago de Compostela, La Coruña, Spain
| | - A Agilda
- Unidad de Cuidados Intensivos, Servicio de Anestesia y Reanimación, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain; Fundación Instituto de Investigaciones Sanitarias (FIDIS), Santiago de Compostela, La Coruña, Spain
| | - L Barreiro
- Unidad de Cuidados Intensivos, Servicio de Anestesia y Reanimación, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain; Fundación Instituto de Investigaciones Sanitarias (FIDIS), Santiago de Compostela, La Coruña, Spain
| | - J Castillo
- Unidad de Cuidados Intensivos, Servicio de Anestesia y Reanimación, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain; Fundación Instituto de Investigaciones Sanitarias (FIDIS), Santiago de Compostela, La Coruña, Spain
| | - K Williams
- Unidad de Cuidados Intensivos, Servicio de Anestesia y Reanimación, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain; Fundación Instituto de Investigaciones Sanitarias (FIDIS), Santiago de Compostela, La Coruña, Spain
| | - J Segurola
- Unidad de Cuidados Intensivos, Servicio de Anestesia y Reanimación, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain; Fundación Instituto de Investigaciones Sanitarias (FIDIS), Santiago de Compostela, La Coruña, Spain
| | - J Álvarez
- Unidad de Cuidados Intensivos, Servicio de Anestesia y Reanimación, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain; Fundación Instituto de Investigaciones Sanitarias (FIDIS), Santiago de Compostela, La Coruña, Spain
| | - T Seoane-Pillado
- Preventive Medicine and Public Health Unit, Department of Health Sciences, University of A Coruña-INIBIC, La Coruña, Spain
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Taboada M, Cariñena A, Regueira J, Francisco C, Rodríguez M, Seoane-Pillado T. Use of a flexible tip bougie (FlexTip) in the management of the first-attempt failure intubation with the C-MAC D-Blade videolaryngoscope in the intensive care unit: A prospective, case series. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2024; 71:58-63. [PMID: 37666451 DOI: 10.1016/j.redare.2023.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 02/23/2023] [Indexed: 09/06/2023]
Abstract
We describe a series of 11 cases in which we used the new flexible tip (FlexTip) bougie as a rescue device following first-attempt failure at intubation with the C-MAC D-Blade video laryngoscope in our UCI. We collected data from all intubations performed using the C-MAC D-Blade video laryngoscope over a 16-month period. Ninety six patients were included in the study: 79 (86.8%) were intubated at the first attempt; 11 (12.1%) required 2 attempts; and 1 patient required 3 attempts. The Frova Intubating Introducer was used in 1 of the 12 patients requiring more than 1 intubation attempt, and the FlexTip was used in the remaining 11. This study shows that the new FlexTip bougie is a good rescue device when the first attempt at video laryngoscope intubation fails.
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Affiliation(s)
- M Taboada
- Unidad de Cuidados Intensivos de Anestesia, Servicio de Anestesia y Reanimación, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain.
| | - A Cariñena
- Unidad de Cuidados Intensivos de Anestesia, Servicio de Anestesia y Reanimación, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain
| | - J Regueira
- Unidad de Cuidados Intensivos de Anestesia, Servicio de Anestesia y Reanimación, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain
| | - C Francisco
- Unidad de Cuidados Intensivos de Anestesia, Servicio de Anestesia y Reanimación, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain
| | - M Rodríguez
- Unidad de Cuidados Intensivos de Anestesia, Servicio de Anestesia y Reanimación, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, A Coruña, Spain
| | - T Seoane-Pillado
- Preventive Medicine and Public Health Unit, Department of Health Sciences, University of A Coruña-INIBIC, A Coruña, Spain
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Hirano Y, Konishi T, Kaneko H, Itoh H, Matsuda S, Kawakubo H, Uda K, Matsui H, Fushimi K, Daiko H, Itano O, Yasunaga H, Kitagawa Y. Proportion of early extubation and short-term outcomes after esophagectomy: a retrospective cohort study. Int J Surg 2023; 109:3097-3106. [PMID: 37352519 PMCID: PMC10583926 DOI: 10.1097/js9.0000000000000568] [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: 02/13/2023] [Accepted: 06/11/2023] [Indexed: 06/25/2023]
Abstract
BACKGROUND The proportion of early extubation after esophagectomy varies among hospitals; however, the impact on clinical outcomes is unclear. The aim of this retrospective study was to evaluate associations between the proportion of early extubation in hospitals and short-term outcomes after esophagectomy. Because there is no consensus regarding the optimal timing for extubation, the authors considered that hospitals' early extubation proportion reflects the hospital-level extubation strategy. MATERIALS AND METHODS Data of patients who underwent oncologic esophagectomy (July 2010-March 2019) were extracted from a Japanese nationwide inpatient database. The proportion of patients who underwent early extubation (extubation on the day of surgery) at each hospital was assessed and grouped by quartiles: very low- (<11%), low- (11-37%), medium- (38-83%), and high-proportion (≥84%) hospitals. The primary outcome was respiratory complications; secondary outcomes included reintubation, anastomotic leakage, other major complications, and hospitalization costs. Multivariable regression analyses were performed, adjusting for patient demographics, cancer treatments, and hospital characteristics. A restricted cubic spline analysis was also performed for the primary outcome. RESULTS Among 37 983 eligible patients across 545 hospitals, early extubation was performed in 17 931 (47%) patients. Early extubation proportions ranged from 0-100% across hospitals. Respiratory complications occurred in 10 270 patients (27%). Multivariable regression analyses showed that high- and medium-proportion hospitals were significantly associated with decreased respiratory complications [odds ratio, 0.46 (95% CI, 0.36-0.58) and 0.43 (0.31-0.60), respectively], reintubation, and hospitalization costs when compared with very low-proportion hospitals. The risk of anastomotic leakage and other major complications did not differ among groups. The restricted cubic spline analysis demonstrated a significant inverse dose-dependent association between the early extubation proportion and the risk of respiratory complications. CONCLUSION A higher proportion of early extubation in a hospital was associated with a lower occurrence of respiratory complications, highlighting a potential benefit of early extubation after esophagectomy.
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Affiliation(s)
- Yuki Hirano
- Department of Hepatobiliary–Pancreatic and Gastrointestinal Surgery, International University of Health and Welfare School of Medicine, Chiba
| | - Takaaki Konishi
- Department of Clinical Epidemiology and Health Economics, School of Public Health
| | - Hidehiro Kaneko
- Department of Cardiovascular Medicine, The University of Tokyo, Bunkyo-ku
| | - Hidetaka Itoh
- Department of Cardiovascular Medicine, The University of Tokyo, Bunkyo-ku
| | - Satoru Matsuda
- Department of Surgery, Keio University School of Medicine, Shinjyuku-ku
| | - Hirofumi Kawakubo
- Department of Surgery, Keio University School of Medicine, Shinjyuku-ku
| | - Kazuaki Uda
- Department of Clinical Epidemiology and Health Economics, School of Public Health
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health
| | - Kiyohide Fushimi
- Department of Health Policy and Informatics, Tokyo Medical and Dental University Graduate School, Bunkyo-ku
| | - Hiroyuki Daiko
- Division of Esophageal Surgery, National Cancer Center Hospital, Chuo-ku, Tokyo, Japan
| | - Osamu Itano
- Department of Hepatobiliary–Pancreatic and Gastrointestinal Surgery, International University of Health and Welfare School of Medicine, Chiba
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health
| | - Yuko Kitagawa
- Department of Surgery, Keio University School of Medicine, Shinjyuku-ku
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8
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Grass A, Riemer E, Zimran A, Revel-Vilk S, Freundlich A, Lebel E, Ioscovich A. Anesthetic Approaches and Perioperative Complications of Total Hip Arthroplasty in Gaucher Disease: A Control-Matched Retrospective-Cohort Study. Life (Basel) 2023; 13:1716. [PMID: 37629573 PMCID: PMC10455665 DOI: 10.3390/life13081716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 08/06/2023] [Accepted: 08/08/2023] [Indexed: 08/27/2023] Open
Abstract
OBJECTIVES Gaucher disease's (GD) pathophysiology generates anesthetic concerns in total hip joint arthroplasty (THA), and due to its rareness, data on perioperative risks are scarce. This 22-year study at a large reference center addresses anesthetic management and perioperative outcomes in GD. METHODS This retrospective-cohort study assessed anesthetic success and safety in 30 THA patients, comparing them with a control-matched group. Data on clinical characteristics, perioperative events, and outcomes were collected. The primary outcome was the success rate of anesthesia induction performance at first attempt. Secondary outcomes were difficult intraoperative course and hemodynamic management, and the development of postoperative complications. The age, sex, weight, body mass index, and primary-to-revision hip arthroplasty ratio were similar in both groups. RESULTS There was no significant difference at all-type anesthesia first initiation attempt success. No particular preference by staff anesthetists for general anesthesia or neuraxial procedures was observed. The GD group showed a significantly higher mean of intraoperative packed Red Blood Cell units administered ((0.73 vs. 0.18); (p = 0.038)), higher intraoperative and postoperative platelet transfusion incidence ((5/30 [16.7%] vs. 0/56 [0.00%]; p = 0.004) and (3/30 [10%] vs. 0/56 [0%]; p = 0.040)), and longer mean recovery room length of stay (426 ± 412 vs. 175 ± 140; p = 0.004). Postoperative complications were not significantly different.
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Affiliation(s)
- Ariel Grass
- Department of Anesthesia, Shaare Zedek Medical Center, 12 Shmuel Bait St., P.O. Box 3235, Jerusalem 9103102, Israel; (A.F.); (A.I.)
- Faculty of Medicine, The Hebrew University of Jerusalem, Ein Kerem. P.O. Box 12271, Jerusalem 9112102, Israel (E.L.)
| | - Eyal Riemer
- Faculty of Medicine, The Hebrew University of Jerusalem, Ein Kerem. P.O. Box 12271, Jerusalem 9112102, Israel (E.L.)
| | - Ari Zimran
- Faculty of Medicine, The Hebrew University of Jerusalem, Ein Kerem. P.O. Box 12271, Jerusalem 9112102, Israel (E.L.)
- Gaucher Disease Unit, Shaare Zedek Medical Center, 12 Shmuel Bait St., P.O. Box 3235, Jerusalem 9103102, Israel
| | - Shoshana Revel-Vilk
- Faculty of Medicine, The Hebrew University of Jerusalem, Ein Kerem. P.O. Box 12271, Jerusalem 9112102, Israel (E.L.)
- Gaucher Disease Unit, Shaare Zedek Medical Center, 12 Shmuel Bait St., P.O. Box 3235, Jerusalem 9103102, Israel
| | - Andres Freundlich
- Department of Anesthesia, Shaare Zedek Medical Center, 12 Shmuel Bait St., P.O. Box 3235, Jerusalem 9103102, Israel; (A.F.); (A.I.)
- Faculty of Medicine, The Hebrew University of Jerusalem, Ein Kerem. P.O. Box 12271, Jerusalem 9112102, Israel (E.L.)
| | - Ehud Lebel
- Faculty of Medicine, The Hebrew University of Jerusalem, Ein Kerem. P.O. Box 12271, Jerusalem 9112102, Israel (E.L.)
- Gaucher Disease Unit, Shaare Zedek Medical Center, 12 Shmuel Bait St., P.O. Box 3235, Jerusalem 9103102, Israel
- Department of Orthopedic-Surgery, Shaare Zedek Medical Center, 12 Shmuel Bait St., P.O. Box 3235, Jerusalem 9103102, Israel
| | - Alexander Ioscovich
- Department of Anesthesia, Shaare Zedek Medical Center, 12 Shmuel Bait St., P.O. Box 3235, Jerusalem 9103102, Israel; (A.F.); (A.I.)
- Faculty of Medicine, The Hebrew University of Jerusalem, Ein Kerem. P.O. Box 12271, Jerusalem 9112102, Israel (E.L.)
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9
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Hughes KE, Islam MT, Co B, Lopido M, McNinch NL, Biffar D, Subbian V, Son YJ, Mosier JM. Comparison of Force During the Endotracheal Intubation of Commercial Simulation Manikins. Cureus 2023; 15:e43808. [PMID: 37731426 PMCID: PMC10508868 DOI: 10.7759/cureus.43808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/20/2023] [Indexed: 09/22/2023] Open
Abstract
Background Medical simulation allows clinicians to safely practice the procedural skill of endotracheal intubation. Applied force to oropharyngeal structures increases the risk of patient harm, and video laryngoscopy (VL) requires less force to obtain a glottic view. It is unknown how much force is required to obtain a glottic view using commercially available simulation manikins and if variability exists. This study compares laryngoscopy force for a modified Cormack-Lehane (CL) grade I view in both normal and difficult airway scenarios between three commercially available simulation manikins. Methods Experienced clinicians (≥2 years experience) were recruited to participate from critical care, emergency medicine, and anesthesia specialties. A C-MAC size 3 VL blade was equipped with five force resistor reading (FSR) sensors (four concave surfaces, one convex), measuring resistance (Ohms) in response to applied pressure (1-100 Newtons). The study occurred in a university simulation lab. Using a randomized sequence, 49 physicians performed intubations on three manikins (Laerdal SimMan 3GPlus, Gaumard Hal S3201, CAE Apollo) in normal and difficult airway scenarios. The outcomes were sensor mean pressure, peak force, and CL grade. Summary statistics were calculated. Generalized estimating equations (GEEs) conducted for both scenarios assessed changes in pressure measured in three manikins while accounting for correlated responses of individuals assigned in random order. Paired t-test assessed for the in-manikin difference between scenarios. STATA/BE v17 (R) was used for analysis; results interpreted at type I error alpha is 0.05. Results Participants included 49 experienced clinicians. Mean years' experience was 4(±6.6); median prior intubations were 80 (IQR 50-400). Mean individual sensor pressure varied within scenarios depending on manikin (p<0.001). Higher mean forces were used in difficult scenarios (603.4±128.9, 611.1±101.4, 467.5±72.4 FSR) than normal (462.5±121.9, 596.0±90.5, 290.6±63.2 FSR) for each manikin (p<0.001). All manikins required more peak force in the difficult scenario (p<0.03). The highest mean forces (Laerdal, CAE, difficult scenario) were associated with the higher frequency of grade 2A views (p<0.001). The Gaumard manikin was rated most realistic in terms of force required to intubate. Conclusion Commercially available high-fidelity manikins had significant variability in laryngoscopy force in both normal and difficult airway scenarios. In difficult airway scenarios, significant variability existed in CL grade between manikin brands. Experienced clinicians rated Gaumard Hal as the most realistic force applied during endotracheal intubation.
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Affiliation(s)
- Kate E Hughes
- Emergency Medicine, University of Arizona, Tucson, USA
| | | | - Benjamin Co
- Emergency Medicine, University of Arizona, Tucson, USA
| | | | - Neil L McNinch
- Biostatistics, McNinch Biostats, LLC (Limited Liability Company), Kent, USA
| | - David Biffar
- Health Sciences, University of Arizona, Tucson, USA
| | - Vignesh Subbian
- Systems and Industrial Engineering, University of Arizona, Tucson, USA
| | - Young-Jun Son
- Industrial Engineering, Purdue University, West Lafayette, USA
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10
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Chaves-Cardona HE, Fouda EA, Hernandez-Torres V, Torp KD, Logvinov II, Heckman MG, Renew JR. Comparison of onset of neuromuscular blockade with electromyographic and acceleromyographic monitoring: a prospective clinical trial. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2023; 73:393-400. [PMID: 37137388 PMCID: PMC10362458 DOI: 10.1016/j.bjane.2023.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 04/20/2023] [Accepted: 04/24/2023] [Indexed: 05/05/2023]
Abstract
BACKGROUND Reliable devices that quantitatively monitor the level of neuromuscular blockade after neuromuscular blocking agents' administration are crucial. Electromyography and acceleromyography are two monitoring modalities commonly used in clinical practice. The primary outcome of this study is to compare the onset of neuromuscular blockade, defined as a Train-Of-Four Count (TOFC) equal to 0, as measured by an electromyography-based device (TetraGraph) and an acceleromyography-based device (TOFscan). The secondary outcome was to compare intubating conditions when one of these two devices reached a TOFC equal to 0. METHODS One hundred adult patients scheduled for elective surgery requiring neuromuscular blockade were enrolled. Prior to induction of anesthesia, TetraGraph electrodes were placed over the forearm of patients' dominant/non-dominant hand based on randomization and TOFscan electrodes placed on the contralateral forearm. Intraoperative neuromuscular blocking agent dose was standardized to 0.5 mg.kg-1 of rocuronium. After baseline values were obtained, objective measurements were recorded every 20 seconds and intubation was performed using video laryngoscopy once either device displayed a TOFC = 0. The anesthesia provider was then surveyed about intubating conditions. RESULTS Baseline TetraGraph train-of-four ratios were higher than those obtained with TOFscan (Median: 1.02 [0.88, 1.20] vs. 1.00 [0.64, 1.01], respectively, p < 0.001). The time to reach a TOFC = 0 was significantly longer when measured with TetraGraph compared to TOFscan (Median: 160 [40, 900] vs. 120 [60, 300] seconds, respectively, p < 0.001). There was no significant difference in intubating conditions when either device was used to determine the timing of endotracheal intubation. CONCLUSIONS The onset of neuromuscular blockade was longer when measured with TetraGraph than TOFscan, and a train-of-four count of zero in either device was a useful indicator for adequate intubating conditions. CLINICAL TRIAL NUMBER AND REGISTRY URL NCT05120999, https://clinicaltrials.gov/ct2/show/NCT05120999.
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Affiliation(s)
- Harold E Chaves-Cardona
- Mayo Clinic Jacksonville, Department of Anesthesiology and Perioperative Medicine, Florida, USA
| | - Eslam A Fouda
- Mayo Clinic Jacksonville, Department of Anesthesiology and Perioperative Medicine, Florida, USA
| | - Vivian Hernandez-Torres
- Mayo Clinic Jacksonville, Department of Anesthesiology and Perioperative Medicine, Florida, USA
| | - Klaus D Torp
- Mayo Clinic Jacksonville, Department of Anesthesiology and Perioperative Medicine, Florida, USA
| | - Ilana I Logvinov
- Mayo Clinic Jacksonville, Department of Anesthesiology and Perioperative Medicine, Florida, USA
| | - Michael G Heckman
- Mayo Clinic Jacksonville, Division of Clinical Trials and Biostatistics, Florida, USA
| | - Johnathan Ross Renew
- Mayo Clinic Jacksonville, Department of Anesthesiology and Perioperative Medicine, Florida, USA.
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11
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Fuchita M, Pattee J, Russell DW, Driver BE, Prekker ME, Barnes CR, Brewer JM, Doerschug KC, Gaillard JP, Gandotra S, Ghamande S, Gibbs KW, Hughes CG, Janz DR, Khan A, Mitchell SH, Page DB, Rice TW, Self WH, Smith LM, Stempek SB, Trent SA, Vonderhaar DJ, West JR, Whitson MR, Williamson K, Semler MW, Casey JD, Ginde AA. Prophylactic Administration of Vasopressors Prior to Emergency Intubation in Critically Ill Patients: A Secondary Analysis of Two Multicenter Clinical Trials. Crit Care Explor 2023; 5:e0946. [PMID: 37457916 PMCID: PMC10344527 DOI: 10.1097/cce.0000000000000946] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023] Open
Abstract
Hypotension affects approximately 40% of critically ill patients undergoing emergency intubation and is associated with an increased risk of death. The objective of this study was to examine the association between prophylactic vasopressor administration and the incidence of peri-intubation hypotension and other clinical outcomes. DESIGN A secondary analysis of two multicenter randomized clinical trials. The clinical effect of prophylactic vasopressor administration was estimated using a one-to-one propensity-matched cohort of patients with and without prophylactic vasopressors. SETTING Seven emergency departments and 17 ICUs across the United States. PATIENTS One thousand seven hundred ninety-eight critically ill patients who underwent emergency intubation at the study sites between February 1, 2019, and May 24, 2021. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The primary outcome was peri-intubation hypotension defined as a systolic blood pressure less than 90 mm Hg occurring between induction and 2 minutes after tracheal intubation. A total of 187 patients (10%) received prophylactic vasopressors prior to intubation. Compared with patients who did not receive prophylactic vasopressors, those who did were older, had higher Acute Physiology and Chronic Health Evaluation II scores, were more likely to have a diagnosis of sepsis, had lower pre-induction systolic blood pressures, and were more likely to be on continuous vasopressor infusions prior to intubation. In our propensity-matched cohort, prophylactic vasopressor administration was not associated with reduced risk of peri-intubation hypotension (41% vs 32%; p = 0.08) or change in systolic blood pressure from baseline (-12 vs -11 mm Hg; p = 0.66). CONCLUSIONS The administration of prophylactic vasopressors was not associated with a lower incidence of peri-intubation hypotension in our propensity-matched analysis. To address potential residual confounding, randomized clinical trials should examine the effect of prophylactic vasopressor administration on peri-intubation outcomes.
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Affiliation(s)
- Mikita Fuchita
- Department of Anesthesiology, Division of Critical Care, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Jack Pattee
- Department of Biostatistics & Informatics, Center for Innovative Design & Analysis, Colorado School of Public Health, Aurora, CO
| | - Derek W Russell
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL
- Pulmonary Section, Birmingham Veterans Affairs Medical Center, Birmingham, AL
| | - Brian E Driver
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - Matthew E Prekker
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - Christopher R Barnes
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA
| | - Joseph M Brewer
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Mississippi Medical Center, Jackson, MS
| | | | - John P Gaillard
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC
- Department of Anesthesiology, Section on Critical Care, Wake Forest School of Medicine, Winston-Salem, NC
| | - Sheetal Gandotra
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Shekhar Ghamande
- Department of Medicine, Division of Pulmonary Disease and Critical Care Medicine, Baylor Scott & White Medical Center, Temple, TX
| | - Kevin W Gibbs
- Department of Medicine, Section of Pulmonary, Critical Care, Allergy and Immunologic Disease, Wake Forest School of Medicine, Winston-Salem, NC
| | - Christopher G Hughes
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
| | - David R Janz
- University Medical Center New Orleans, New Orleans, LA
- Department of Medicine, Section of Pulmonary/Critical Care Medicine and Allergy/Immunology, Louisiana State University School of Medicine, New Orleans, LA
| | - Akram Khan
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Oregon Health & Science University School of Medicine, Portland, OR
| | - Steven H Mitchell
- Department of Emergency Medicine, University of Washington, Seattle, WA
| | - David B Page
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL
- Department of Emergency Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Todd W Rice
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN
| | - Wesley H Self
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, TN
| | - Lane M Smith
- Department of Internal Medicine, University of Iowa, Iowa City, IA
| | - Susan B Stempek
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Lahey Hospital and Medical Center, Burlington, MA
| | - Stacy A Trent
- Department of Emergency Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
- Department of Emergency Medicine, Denver Health Medical Center, Denver, CO
| | - Derek J Vonderhaar
- Department of Pulmonary and Critical Care Medicine, Ochsner Health System, New Orleans, LA
| | - Jason R West
- Department of Emergency Medicine, NYC Health + Hospitals | Lincoln, Bronx, NY
| | - Micah R Whitson
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Kayla Williamson
- Department of Biostatistics & Informatics, Center for Innovative Design & Analysis, Colorado School of Public Health, Aurora, CO
| | - Matthew W Semler
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN
| | - Jonathan D Casey
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN
| | - Adit A Ginde
- Department of Emergency Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
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12
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Khorsand S, Chin J, Rice J, Bughrara N, Myatra SN, Karamchandani K. Role of Point-of-Care Ultrasound in Emergency Airway Management Outside the Operating Room. Anesth Analg 2023; 137:124-136. [PMID: 36693019 DOI: 10.1213/ane.0000000000006371] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Tracheal intubation is one of the most frequently performed procedures in critically ill patients, and is associated with significant morbidity and mortality. Hemodynamic instability and cardiovascular collapse are common complications associated with the procedure, and are likely in patients with a physiologically difficult airway. Bedside point-of-care ultrasound (POCUS) can help identify patients with high risk of cardiovascular collapse, provide opportunity for hemodynamic and respiratory optimization, and help tailor airway management plans to meet individual patient needs. This review discusses the role of POCUS in emergency airway management, provides an algorithm to facilitate its incorporation into existing practice, and provides a framework for future studies.
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Affiliation(s)
- Sarah Khorsand
- From the Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jeanette Chin
- From the Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jake Rice
- From the Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Nibras Bughrara
- Department of Anesthesiology and Critical Care Medicine, Albany Medical College, Albany, New York
| | - Sheila N Myatra
- Department of Anesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi-Bhabha National Institute, Mumbai, India
| | - Kunal Karamchandani
- From the Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
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13
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Schechtman SA, Healy DW, Shah NJ, Almendras EG, Flori HR, Luther CK, Klumpner TT. Optimising difficult airway documentation: implementation of an automated update in the electronic health record. Br J Anaesth 2023:S0007-0912(23)00176-9. [PMID: 37149478 DOI: 10.1016/j.bja.2023.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 04/02/2023] [Accepted: 04/04/2023] [Indexed: 05/08/2023] Open
Affiliation(s)
- Samuel A Schechtman
- Department of Anesthesiology, University of Michigan Medical School, Michigan Medicine, Ann Arbor, MI, USA.
| | - David W Healy
- Department of Anesthesiology, University of Michigan Medical School, Michigan Medicine, Ann Arbor, MI, USA
| | - Nirav J Shah
- Department of Anesthesiology, University of Michigan Medical School, Michigan Medicine, Ann Arbor, MI, USA
| | - Emmeline G Almendras
- Department of Anesthesiology, University of Michigan Medical School, Michigan Medicine, Ann Arbor, MI, USA
| | - Heidi R Flori
- Department of Pediatric Critical Care Medicine, University of Michigan Medical School, Michigan Medicine, Ann Arbor, MI, USA
| | - Christopher K Luther
- Department of Anesthesiology, University of Michigan Medical School, Michigan Medicine, Ann Arbor, MI, USA
| | - Thomas T Klumpner
- Department of Anesthesiology, University of Michigan Medical School, Michigan Medicine, Ann Arbor, MI, USA
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14
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Abstract
This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2023. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2023 . Further information about the Annual Update in Intensive Care and Emergency Medicine is available from https://link.springer.com/bookseries/8901 .
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Affiliation(s)
- Craig Steven Jabaley
- Department of Anesthesiology, Emory University, Atlanta, GA, USA.
- Emory Critical Care Center, Atlanta, GA, USA.
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15
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Hall T, Leeies M, Funk D, Hrymak C, Siddiqui F, Black H, Webster K, Tkach J, Waskin M, Dufault B, Kowalski S. Emergency airway management in a tertiary trauma centre (AIRMAN): a one-year prospective longitudinal study. Can J Anaesth 2023; 70:351-358. [PMID: 36670315 PMCID: PMC9857903 DOI: 10.1007/s12630-022-02390-2] [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: 01/11/2022] [Revised: 07/08/2022] [Accepted: 09/20/2022] [Indexed: 01/21/2023] Open
Abstract
PURPOSE Emergency airway management can be associated with a range of complications including long-term neurologic injury and death. We studied the first-pass success rate with emergency airway management in a tertiary care trauma centre. Secondary outcomes were to identify factors associated with first-pass success and factors associated with adverse events peri-intubation. METHODS We performed a single-centre, prospective, observational study of patients ≥ 17 yr old who were intubated in the emergency department (ED), surgical intensive care unit (SICU), medical intensive care unit (MICU), and inpatient wards at our institution. Ethics approval was obtained from the local research ethics board. RESULTS In a seven-month period, there were 416 emergency intubations and a first-pass success rate of 73.1%. The first-pass success rates were 57.5% on the ward, 66.1% in the intensive care units (ICUs) and 84.3% in the ED. Equipment also varied by location; videolaryngoscopy use was 65.1% in the ED and only 10.6% on wards. A multivariate regression model using the least absolute shrinkage and selection algorithm (LASSO) showed that the odds ratios for factors associated with two or more intubation attempts were location (wards, 1.23; MICU, 1.24; SICU, 1.19; reference group, ED), physiologic instability (1.19), an anatomically difficult airway (1.05), hypoxemia (1.98), lack of neuromuscular blocker use (2.28), and intubator inexperience (1.41). CONCLUSIONS First-pass success rates varied widely between locations within the hospital and were less than those published from similar institutions, except for the ED. We are revamping ICU protocols to improve the first-pass success rate.
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Affiliation(s)
- Thomas Hall
- Department of Anesthesiology, Perioperative and Pain Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.
| | - Murdoch Leeies
- Department of Emergency Medicine, Section of Critical Care, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Duane Funk
- Department of Anesthesiology, Perioperative and Pain Medicine, Section of Critical Care, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Carmen Hrymak
- Department of Emergency Medicine, Section of Critical Care, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Faisal Siddiqui
- Department of Anesthesiology, Perioperative and Pain Medicine, Section of Critical Care, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Holly Black
- Department of Emergency Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Kim Webster
- Health Sciences Centre, Winnipeg, MB, Canada
| | - Jenn Tkach
- Health Sciences Centre, Winnipeg, MB, Canada
| | - Matt Waskin
- Health Sciences Centre, Winnipeg, MB, Canada
| | - Brenden Dufault
- George and Fay Yee Centre for Health Care Innovation, University of Manitoba, Winnipeg, MB, Canada
| | - Stephen Kowalski
- Department of Anesthesiology, Perioperative and Pain Medicine, Section of Critical Care, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
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16
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Black H, Hall T, Hrymak C, Funk D, Siddiqui F, Sokal J, Satoudian J, Foster K, Kowalski S, Dufault B, Leeies M. A prospective observational study comparing outcomes before and after the introduction of an intubation protocol during the COVID-19 pandemic. CAN J EMERG MED 2023; 25:123-133. [PMID: 36542309 PMCID: PMC9768405 DOI: 10.1007/s43678-022-00422-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Accepted: 11/19/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Orotracheal intubation is a life-saving procedure commonly performed in the Intensive Care unit and Emergency Department as a part of emergency airway management. Prior to the COVID-19 pandemic, our center undertook a prospective observational study to characterize emergency intubation performed in the emergency department and critical care settings at Manitoba's largest tertiary hospital. During this study, a natural experiment emerged when a standardized "COVID-Protected Rapid Sequence Intubation Protocol" was implemented in response to the pandemic. The resultant study aimed to answer the question; in adult ED patients undergoing emergent intubation by EM and CCM teams, does the use of a "COVID-Protected Rapid Sequence Intubation Protocol" impact first-pass success or other intubation-related outcomes? METHODS A single-center prospective quasi-experimental before and after study was conducted. Data were prospectively collected on consecutive emergent intubations. The primary outcome was the difference in first-pass success rates. Secondary outcomes included best Modified Cormack-Lehane view, hypoxemia, hypotension, esophageal intubation, cannot intubate cannot oxygenate scenarios, CPR post intubation, vasopressors required post intubation, Intensive Care Unit (ICU) mortality, ICU length of stay (LOS), and mechanical ventilation days. RESULTS Data were collected on 630 patients, 416 in the pre-protocol period and 214 in the post-protocol period. First-pass success rates in the pre-protocol period were found to be 73.1% (n = 304). Following the introduction of the protocol, first-pass success rates increased to 82.2% (n = 176, p = 0.0105). There was a statistically significant difference in Modified Cormack-Lehane view favoring the protocol (p = 0.0191). Esophageal intubation rates were found to be 5.1% pre-protocol introduction versus 0.5% following the introduction of the protocol (p = 0.0172). CONCLUSION A "COVID-Protected Protocol" implemented by Emergency Medicine and Critical Care teams in response to the COVID-19 pandemic was associated with increased first-pass success rates and decreases in adverse events.
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Affiliation(s)
- Holly Black
- Department of Emergency Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada.
| | - Thomas Hall
- Department of Anaesthesia, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Carmen Hrymak
- Department of Emergency Medicine, Department of Internal Medicine Section of Critical Care, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Duane Funk
- Department of Anaesthesia, Department of Internal Medicine Section of Critical Care, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Faisal Siddiqui
- Department of Anaesthesia, Department of Internal Medicine Section of Critical Care, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - John Sokal
- Department of Emergency Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Jaime Satoudian
- Department of Respiratory Therapy, Health Sciences Center, Winnipeg, MB, Canada
| | - Kendra Foster
- Department of Respiratory Therapy, Health Sciences Center, Winnipeg, MB, Canada
| | - Stephen Kowalski
- Department of Anaesthesia, Department of Internal Medicine Section of Critical Care, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Brenden Dufault
- George & Fay Yee Center for Healthcare Innovation, Winnipeg, MB, Canada
| | - Murdoch Leeies
- Department of Emergency Medicine, Department of Internal Medicine Section of Critical Care, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
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Videolaryngoscopy as a first-intention technique for tracheal intubation in unselected surgical patients: a before and after observational study. Br J Anaesth 2022; 129:624-634. [PMID: 35811139 DOI: 10.1016/j.bja.2022.05.030] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Revised: 05/21/2022] [Accepted: 05/22/2022] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Using a Macintosh-style videolaryngoscope as a first-intention device for tracheal intubation of unselected patients in the operating room has not often been studied. We hypothesised that using a Macintosh-style videolaryngoscope as a first-intention device is associated with an increased proportion of easy tracheal intubation. METHODS In a quality improvement project for airway management aimed at implementing a Macintosh-style videolaryngoscope as a first-intention device, we included all consecutive tracheal intubations in adults from March, 2017 to September, 2020 in two French teaching hospitals. We divided the cohort into three temporal cohorts: the pre-intervention, implementation, and post-intervention periods. The primary outcome was the proportion of easy airway management. The secondary outcomes were the rescue technique, Cormack-Lehane III or IV view, and operator-reported difficulty of intubation. Data from one hospital compliant with the quality improvement project were compared with data from a non-compliant hospital. RESULTS A total of 26 692 tracheal intubations were performed. Among 11 938 intubations included in the compliant hospital, 5487 were included in the pre-intervention, 1845 in the implementation, and 4606 in the post-intervention periods. In comparison to the pre-intervention period, the proportions of easy tracheal intubation increased from 94.3% (5177 of 5487) to 98.7% (4547 of 4606)) in the post-intervention period (+4.4% [95% confidence interval 3.7-5.1%], P<0.001). In comparison to the pre-intervention period, all secondary outcome proportions were significantly lower in the post-intervention period. No significant changes were noted in the non-compliant hospital between the pre- and post-intervention periods. CONCLUSIONS Using a Macintosh-style videolaryngoscope as a first-intention device for tracheal intubation in the operating room was associated with a significant increase in the proportion of easy tracheal intubation, compared with use of the standard Macintosh laryngoscope.
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Godet T, De Jong A, Garin C, Guérin R, Rieu B, Borao L, Pereira B, Molinari N, Bazin JE, Jabaudon M, Chanques G, Futier E, Jaber S. Impact of Macintosh blade size on endotracheal intubation success in intensive care units: a retrospective multicenter observational MacSize-ICU study. Intensive Care Med 2022; 48:1176-1184. [PMID: 35974189 PMCID: PMC9463307 DOI: 10.1007/s00134-022-06832-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 07/18/2022] [Indexed: 12/19/2022]
Abstract
Purpose To investigate the impact of Macintosh blade size used during direct laryngoscopy (DL) on first-attempt intubation success of orotracheal intubation in French intensive care units (ICUs). We hypothesized that success rate would be higher with Macintosh blade size No3 than with No4. Methods Multicenter retrospective observational study based on data from prospective trials conducted in 48 French ICUs of university, and general and private hospitals. After each intubation using Macintosh DL, patients’ and operators’ characteristics, Macintosh blade size, results of first DL and alternative techniques used, as well as the need of a second operator were collected. Complications rates associated with intubation were investigated. Primary outcome was success rate of first DL using Macintosh blade. Results A total of 2139 intubations were collected, 629 with a Macintosh blade No3 and 1510 with a No4. Incidence of first-pass intubation after first DL was significantly higher with Macintosh blade No3 (79.5 vs 73.3%, p = 0.0025), despite equivalent Cormack–Lehane scores (p = 0.48). Complications rates were equivalent between groups. Multivariate analysis concluded to a significant impact of Macintosh blade size on first DL success in favor of blade No3 (OR 1.44 [95% CI 1.14–1.84]; p = 0.0025) without any significant center effect on the primary outcome (p = 0.18). Propensity scores and adjustment analyses concluded to equivalent results. Conclusion In the present study, Macintosh blade No3 was associated with improved first-passed DL in French ICUs. However, study design requires the conduct of a nationwide prospective multicenter randomized trial in different settings to confirm these results. Supplementary Information The online version contains supplementary material available at 10.1007/s00134-022-06832-9.
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Affiliation(s)
- Thomas Godet
- Département Anesthésie Réanimation, Centre Hospitalier Universitaire (CHU) Clermont-Ferrand, 63000, Clermont-Ferrand, France. .,Département Anesthésie Réanimation B (DAR B), Hôpital Saint-Eloi, and Inserm U-1046, Centre Hospitalier Universitaire (CHU) Montpellier, 34295, Montpellier, France. .,Département Anesthésie Réanimation, Pôle de Médecine Périopératoire (MPO), Hôpital Estaing, Centre Hospitalier Universitaire (CHU) de Clermont-Ferrand, 1 place Lucie et Raymond Aubrac, 63001, Clermont-Ferrand cedex 1, France.
| | - Audrey De Jong
- Département Anesthésie Réanimation B (DAR B), Hôpital Saint-Eloi, and Inserm U-1046, Centre Hospitalier Universitaire (CHU) Montpellier, 34295, Montpellier, France
| | - Côme Garin
- Département Anesthésie Réanimation, Centre Hospitalier Universitaire (CHU) Clermont-Ferrand, 63000, Clermont-Ferrand, France
| | - Renaud Guérin
- Département Anesthésie Réanimation, Centre Hospitalier Universitaire (CHU) Clermont-Ferrand, 63000, Clermont-Ferrand, France
| | - Benjamin Rieu
- Département Anesthésie Réanimation, Centre Hospitalier Universitaire (CHU) Clermont-Ferrand, 63000, Clermont-Ferrand, France
| | - Lucile Borao
- Département Anesthésie Réanimation, Centre Hospitalier Universitaire (CHU) Clermont-Ferrand, 63000, Clermont-Ferrand, France
| | - Bruno Pereira
- Délégation à la Recherche Clinique et à l'Innovation (DRCI), Centre Hospitalier Universitaire (CHU) de Clermont-Ferrand, 63000, Clermont-Ferrand, France
| | - Nicolas Molinari
- Clinical Research Department, Centre Hospitalier Universitaire (CHU) Montpellier, 34295, Montpellier, France
| | - Jean-Etienne Bazin
- Département Anesthésie Réanimation, Centre Hospitalier Universitaire (CHU) Clermont-Ferrand, 63000, Clermont-Ferrand, France
| | - Matthieu Jabaudon
- Département Anesthésie Réanimation, Centre Hospitalier Universitaire (CHU) Clermont-Ferrand, 63000, Clermont-Ferrand, France.,iGReD, Université Clermont Auvergne, CNRS, INSERM, 63003, Clermont-Ferrand, France
| | - Gérald Chanques
- Département Anesthésie Réanimation B (DAR B), Hôpital Saint-Eloi, and Inserm U-1046, Centre Hospitalier Universitaire (CHU) Montpellier, 34295, Montpellier, France
| | - Emmanuel Futier
- Département Anesthésie Réanimation, Centre Hospitalier Universitaire (CHU) Clermont-Ferrand, 63000, Clermont-Ferrand, France.,iGReD, Université Clermont Auvergne, CNRS, INSERM, 63003, Clermont-Ferrand, France
| | - Samir Jaber
- Département Anesthésie Réanimation B (DAR B), Hôpital Saint-Eloi, and Inserm U-1046, Centre Hospitalier Universitaire (CHU) Montpellier, 34295, Montpellier, France
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Diaz-Tormo C, Rodriguez-Martinez E, Galarza L. Airway Ultrasound in Critically Ill Patients: A Narrative Review. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2022; 41:1317-1327. [PMID: 34427949 DOI: 10.1002/jum.15817] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 08/05/2021] [Accepted: 08/08/2021] [Indexed: 06/13/2023]
Abstract
Airway assessment and management have a central role in critical care medicine. Airway ultrasound can help us evaluate the anatomy, facilitate interventions such as intubation in difficult airways and tracheostomy, prevent post-extubation complications, and diagnose dysphagia. In this review, we will summarize the current use of ultrasound in airway assessment and management in critically ill patients.
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Affiliation(s)
- Carmen Diaz-Tormo
- Department of Intensive Care, Hospital General Universitario de Castellon, Castellon de la Plana, Spain
| | - Enver Rodriguez-Martinez
- Department of Intensive Care, Hospital General Universitario de Castellon, Castellon de la Plana, Spain
| | - Laura Galarza
- Department of Intensive Care, Hospital General Universitario de Castellon, Castellon de la Plana, Spain
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Hrithma D, K R, Mahadevaiah DT, K N V. A Cross-Sectional Study on Hyomental Distance Ratio (HMDR) as a New Predictor of Difficult Laryngoscopy in ICU Patients. Cureus 2022; 14:e25435. [PMID: 35774688 PMCID: PMC9239289 DOI: 10.7759/cureus.25435] [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: 05/13/2022] [Accepted: 05/28/2022] [Indexed: 12/02/2022] Open
Abstract
Background: Intubation in the ICU is sometimes unpredictable unlike in an operation theatre, where pre-anesthetic assessment for airway has been done. This study has been done to evaluate the usefulness of hyomental distance ratio (HMDR) in accurately predicting difficult laryngoscopy in ICU patients. Methods: In this study, 104 critically ill patients in the age group 18-70 years, undergoing tracheal intubation in ICU were included. A hard plastic ruler was pressed on the skin surface just above the hyoid bone and the distance to the tip of the anterior-most part of the mentum measured was defined as hyomental distance (HMD). HMD was assessed in neutral and extended head positions, and the HMDR was calculated. All patients were sedated, pre-oxygenated, induced, and relaxed prior to glottic visualization by direct laryngoscopy, which was performed by an experienced anesthetist. Cormack-Lehane's (CL's) grade was assessed without external laryngeal manipulation. Further management was as per ICU protocol. Results: Using the Chi-Square test for statistical analysis, a p-value of HMDR in assessing difficult laryngoscopy was found to be <0.001 suggesting strong significance. HMD in the extended head position (HDMe) showed moderate significance with a p-value of 0.047. HMDR <1.2 can be considered a clinically reliable individual predictor of difficult laryngoscopy in ICU patients. Conclusion: HMDR <1.2 can be used as a simple, easy, and reliable bedside test to predict difficult laryngoscopy amongst ICU patients. An optimal combination of tests is suggested if feasible for better accuracy.
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21
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Bian L, Li J, Li W, Hu X, Dai M. Analysis of the Effect of Holistic Nursing in the Operating Room Based on PDCA and Evidence-Based Nursing in the Otorhinolaryngology Operating Room: Based on a Retrospective Case-Control Study. CONTRAST MEDIA & MOLECULAR IMAGING 2022; 2022:4514669. [PMID: 35655719 PMCID: PMC9148231 DOI: 10.1155/2022/4514669] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 03/26/2022] [Accepted: 04/15/2022] [Indexed: 11/20/2022]
Abstract
Objective Based on a retrospective case-control study, this study aims to explore the effect of holistic nursing in operating room based on PDCA (plan, do, check, and action) process and evidence-based nursing (EBN) in a ear, nose, and throat operating room. Methods About 200 patients who underwent otorhinolaryngology surgery in our hospital from January 2019 to September 2021 were enrolled. According to the difference of nursing mode, patients were assigned into a control group and study group; holistic nursing in operating room was included in control group, and holistic nursing in the operating room based on PDCA and EBN was included in study group. Nursing satisfaction, hypothermia, chills, restlessness, related indexes of operating room, nursing quality scores of operating room, and individual quality control scores were compared. Results First of all, we compared the nursing satisfaction, the study group was very satisfied in 69 cases, satisfactory in 30 cases, general in 1 case, the satisfaction rate was 100.00%, while in the control group, 46 cases were very satisfied, 34 cases were satisfied, 13 cases were general, and 7 cases were dissatisfied, the satisfaction rate was 93.00%. The nursing satisfaction of the study group was higher compared to the control group (P < 0.05). Second, we compared the incidence of hypothermia, chills and restlessness. The incidence of hypothermia, chills, and restlessness in the study group was lower compared to the control group (P < 0.05). The time of tracheal tube extubation, PACU stay time, postoperative hospitalization time, hospitalization cost, and operation time in the study group was significantly lower compared to the control group (P < 0.05). In terms of the scores of nursing quality in the operating room, the instruments and equipment management, equipment preparation, nurses' cooperation skills, disinfection and isolation quality, and total score in the study group were higher compared to the control group (P < 0.05). Finally, we compared the scores of individual quality control examination. The scores of ward management, rescue, therapeutic articles, drug management, first-level nursing, nursing documents, and head nurse management in the study group were higher compared to the control group (P < 0.05). Conclusion Incorporating the concepts of PDCA and EBN into the overall care of the operating theatre is effective for patients in the ENT operating theatre. Our results show that this care can be effective in improving patients' surgical indicators, reducing the incidence of postoperative infections, shortening postoperative resuscitation and length of stay, reducing hospital costs, and promoting surgical patient satisfaction. While further multicenter studies are necessary, this series of nursing interventions remains worthy of replication in the clinical setting.
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Affiliation(s)
- Leina Bian
- First People's Hospital Through the Operation Room, 222000 Lianyungang, China
| | - Jianhua Li
- First People's Hospital Through the Operation Room, 222000 Lianyungang, China
| | - Wang Li
- First People's Hospital Through the Operation Room, 222000 Lianyungang, China
| | - Xiaoyan Hu
- First People's Hospital Conduit Room, 222000 Lianyungang, China
| | - Ming Dai
- First People's Hospital Through the Operation Room, 222000 Lianyungang, China
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Jarzebowski M, Estime S, Russotto V, Karamchandani K. Challenges and outcomes in airway management outside the operating room. Curr Opin Anaesthesiol 2022; 35:109-114. [PMID: 35102045 DOI: 10.1097/aco.0000000000001100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW Airway management outside the operating room poses unique challenges that every clinician should recognize. These include anatomic, physiologic, and logistic challenges, each of which can contribute to complications and lead to poor outcomes. Recognizing these challenges and highlighting known outcome data may better prepare the team, making this otherwise daunting procedure safer and potentially improving patient outcomes. RECENT FINDINGS Newer intubating techniques and devices have made navigating anatomic airway challenges easier. However, physiological challenges during emergency airway management remain a cause of poor patient outcomes. Hemodynamic collapse has been identified as the most common peri-intubation adverse event and a leading cause of morbidity and mortality associated with the procedure. SUMMARY Emergency airway management outside the operating room remains a high-risk procedure, associated with poor outcomes. Pre-intubation hemodynamic optimization may mitigate some of the risks, and future research should focus on identification of best strategies for hemodynamic optimization prior to and during this procedure.
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Affiliation(s)
- Mary Jarzebowski
- Department of Anesthesiology, University of Michigan Medicine, Ann Arbor, Michigan
| | - Stephen Estime
- Department of Anesthesia & Critical Care University of Chicago Medicine, Chicago, Illinois, USA
| | - Vincenzo Russotto
- Department of Anesthesia & Critical Care, University Hospital San Luigi Gonzaga, University of Turin, Italy
| | - Kunal Karamchandani
- Department of Anesthesiology and Pain Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
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R NP, Chaudhari HK, Kulkarni AP, Dangi MS, Bhagat V, Siddiqui SS, Maheswarappa HM, Myatra SN, Divatia JV. Compliance with intubation bundle and complications in critically ill patients: A need to revisit the bundle components! TRENDS IN ANAESTHESIA AND CRITICAL CARE 2022. [DOI: 10.1016/j.tacc.2021.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Tarwade P, Smischney NJ. Endotracheal intubation sedation in the intensive care unit. World J Crit Care Med 2022; 11:33-39. [PMID: 35433310 PMCID: PMC8788207 DOI: 10.5492/wjccm.v11.i1.33] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 06/21/2021] [Accepted: 11/04/2021] [Indexed: 02/06/2023] Open
Abstract
Endotracheal intubation is one of the most common, yet most dangerous procedure performed in the intensive care unit (ICU). Complications of ICU intubations include severe hypotension, hypoxemia, and cardiac arrest. Multiple observational studies have evaluated risk factors associated with these complications. Among the risk factors identified, the choice of sedative agents administered, a modifiable risk factor, has been reported to affect these complications (hypotension). Propofol, etomidate, and ketamine or in combination with benzodiazepines and opioids are commonly used sedative agents administered for endotracheal intubation. Propofol demonstrates rapid onset and offset, however, has drawbacks of profound vasodilation and associated cardiac depression. Etomidate is commonly used in the critically ill population. However, it is known to cause reversible inhibition of 11 β-hydroxylase which suppresses the adrenal production of cortisol for at least 24 h. This added organ impairment with the use of etomidate has been a potential contributing factor for the associated increased morbidity and mortality observed with its use. Ketamine is known to provide analgesia with sedation and has minimal respiratory and cardiovascular effects. However, its use can lead to tachycardia and hypertension which may be deleterious in a patient with heart disease or cause unpleasant hallucinations. Moreover, unlike propofol or etomidate, ketamine requires organ dependent elimination by the liver and kidney which may be problematic in the critically ill. Lately, a combination of ketamine and propofol, “Ketofol”, has been increasingly used as it provides a balancing effect on hemodynamics without any of the side effects known to be associated with the parent drugs. Furthermore, the doses of both drugs are reduced. In situations where a difficult airway is anticipated, awake intubation with the help of a fiberoptic scope or video laryngoscope is considered. Dexmedetomidine is a commonly used sedative agent for these procedures.
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Affiliation(s)
- Pritee Tarwade
- Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN 55905, United States
| | - Nathan J Smischney
- Anesthesiology and Perioperative Medicine, Division of Critical Care Medicine, Mayo Clinic, Rochester, MN 55905, United States
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Bakhsh A, Alharbi A, Almehmadi R, Kamfar S, Aldhahri A, Aledeny A, Ashour Y, Khojah I. Improving first-pass success rates during emergency intubation at an academic emergency department: a quality improvement initiative. Int J Qual Health Care 2021; 33:6366349. [PMID: 34494654 DOI: 10.1093/intqhc/mzab132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 08/23/2021] [Accepted: 09/08/2021] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Airway management is a high-stakes procedure in emergency medicine. Continuously monitoring this procedure allows performance improvement while revealing safety issues. We instituted a quality improvement initiative in the emergency department to improve first-pass success rates in the emergency department. METHODS This was a quality improvement initiative at an academic emergency department from 2018 to 2020. We developed a rapid sequence intubation guideline for procedure standardization and introduced an intubation procedure note for performance monitoring. Data were entered directly by the primary physician and nurse during intubation. The quality improvement team thereafter collected the data retrospectively and entered into a local airway database. More importantly, we introduced a culture of quality improvement and safety in airway management via regular education and feedback. RESULTS We included a total of 146 intubations. The first-pass success rate started at 57.1% and increased to 80.0% during the study period (P < 0.01). Fifty-six percent were male, and the mean age (±SD) was 55.56 (±17.64). Video laryngoscopy was used in 101 (69.2%) patients, while direct laryngoscopy was used in only 44 (30.8%) patients. A logistic regression analysis was conducted to determine the independent factors associated with first-pass success. These factors included the use of video laryngoscopy (odds ratio (OR) 2.47 95% confidence interval (95% CI) [1.62-3.76]) (adjusted OR 3.87 [1.13-13.23]) and good Cormack-Lehane views (grades 1-2) (OR 2.71 95% CI [1.74-4.20]) (adjusted OR 7.88 [2.43-25.53]). CONCLUSION Our study shows that implementing and maintaining an airway quality improvement program improves first-pass intubation success. Moreover, the use of video laryngoscopy and obtaining good Cormack-Lehane views (grades 1-2) are independently associated with improved first-pass success.
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Affiliation(s)
- Abdullah Bakhsh
- Department of Emergency Medicine, King Abdulaziz University Hospital, P.O. Box 80215, Jeddah 21589, Saudi Arabia
| | - Ahd Alharbi
- Faculty of Medicine, King Abdulaziz University Hospital, P.O. 80215, Jeddah 21589, Saudi Arabia
| | - Raghad Almehmadi
- Faculty of Medicine, King Abdulaziz University Hospital, P.O. 80215, Jeddah 21589, Saudi Arabia
| | - Sara Kamfar
- Faculty of Medicine, King Abdulaziz University Hospital, P.O. 80215, Jeddah 21589, Saudi Arabia
| | - Arwa Aldhahri
- Faculty of Medicine, King Abdulaziz University Hospital, P.O. 80215, Jeddah 21589, Saudi Arabia
| | - Ahmed Aledeny
- Faculty of Medicine, King Abdulaziz University Hospital, P.O. 80215, Jeddah 21589, Saudi Arabia
| | - Yasmeen Ashour
- Department of Total Quality Management, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | - Imad Khojah
- Department of Emergency Medicine, King Abdulaziz University Hospital, P.O. Box 80215, Jeddah 21589, Saudi Arabia
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Taboada M, Baluja A, Park SH, Otero P, Gude C, Bolón A, Ferreiroa E, Tubio A, Cariñena A, Caruezo V, Alvarez J, Atanassoff PG. Complications during repeated tracheal intubation in the Intensive Care Unit. A prospective, observational study comparing the first intubation and the reintubation. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2021; 68:384-391. [PMID: 34353767 DOI: 10.1016/j.redare.2020.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Accepted: 11/02/2020] [Indexed: 06/13/2023]
Abstract
BACKGROUND AND GOAL OF THE STUDY The goal of the study was to compare the incidence of complications, technical difficulty of intubation and physiologic pre-intubation status between the first intubation and reintubation performed on the same patient in an ICU. MATERIALS AND METHODS The study was approved by the ethics committee of Galicia (Santiago-Lugo, code No. 2015-012). Due to the observational, noninterventional, and noninvasive design of this study, the need for written consent was waived by the ethics committee of Galicia. Patients requiring tracheal intubation and reintubation in the ICU were included in this prospective observational study. Main endpoint was to compare the incidence of complications, physiologic pre-intubation status, and the rate of technical difficulty of intubation between the first intubation and reintubation performed on the same patient in an ICU. RESULTS AND DISCUSSION 504 patients were intubated in our ICU during the study period, and 82 (16%) required reintubation. There was no difference between the first intubation and reintubation regarding number of total complication (35% vs 33%; P = ,86), hypotension (24% vs 24%; P = 1), hypoxia (26% vs 26%; P = 1), esophageal intubation (1% vs 1%; P = 1), and bronchoaspiration (2% vs 1%; P = ,86). Physiologic pre-intubation status and technical difficulty of intubation did not differ between the first intubation and reintubation. CONCLUSIONS In our ICU patients requiring tracheal reintubation, incidence of complications, physiologic pre-intubation status, and technical difficulty of intubation did not differ between the first intubation and reintubation.
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Affiliation(s)
- M Taboada
- Departamento de Anestesiología y Cuidados Intensivos, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain.
| | - A Baluja
- Departamento de Anestesiología y Cuidados Intensivos, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - S H Park
- Departamento de Anestesiología y Cuidados Intensivos, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - P Otero
- Departamento de Anestesiología y Cuidados Intensivos, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - C Gude
- Departamento de Anestesiología y Cuidados Intensivos, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - A Bolón
- Departamento de Anestesiología y Cuidados Intensivos, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - E Ferreiroa
- Departamento de Anestesiología y Cuidados Intensivos, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - A Tubio
- Departamento de Anestesiología y Cuidados Intensivos, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - A Cariñena
- Departamento de Anestesiología y Cuidados Intensivos, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - V Caruezo
- Departamento de Anestesiología y Cuidados Intensivos, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
| | - J Alvarez
- Departamento de Anestesiología y Cuidados Intensivos, Hospital Clínico Universitario de Santiago de Compostela, Santiago de Compostela, Spain
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Karamchandani K, Wheelwright J, Yang AL, Westphal ND, Khanna AK, Myatra SN. Emergency Airway Management Outside the Operating Room: Current Evidence and Management Strategies. Anesth Analg 2021; 133:648-662. [PMID: 34153007 DOI: 10.1213/ane.0000000000005644] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Emergency airway management outside the operating room (OR) is often associated with an increased risk of airway related, as well as cardiopulmonary, complications which can impact morbidity and mortality. These emergent airways may take place in the intensive care unit (ICU), where patients are critically ill with minimal physiological reserve, or other areas of the hospital where advanced equipment and personnel are often unavailable. As such, emergency airway management outside the OR requires expertise at manipulation of not only the anatomically difficult airway but also the physiologically and situationally difficult airway. Adequate preparation and appropriate use of airway management techniques are important to prevent complications. Judicious utilization of pre- and apneic oxygenation is important as is the choice of medications to facilitate intubation in this at-risk population. Recent study in critically ill patients has shown that postintubation hemodynamic and respiratory compromise is common, independently associated with poor outcomes and can be impacted by the choice of drugs and techniques used. In addition to adequately preparing for a physiologically difficult airway, enhancing the ability to predict an anatomically difficult airway is essential in reducing complication rates. The use of artificial intelligence in the identification of difficult airways has shown promising results and could be of significant advantage in uncooperative patients as well as those with a questionable airway examination. Incorporating this technology and understanding the physiological, anatomical, and logistical challenges may help providers better prepare for managing such precarious airways and lead to successful outcomes. This review discusses the various challenges associated with airway management outside the OR, provides guidance on appropriate preparation, airway management skills, medication use, and highlights the role of a coordinated multidisciplinary approach to out-of-OR airway management.
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Affiliation(s)
- Kunal Karamchandani
- From the Department of Anesthesiology and Pain Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Jonathan Wheelwright
- Department of Anesthesiology and Perioperative Medicine, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Ae Lim Yang
- Penn State College of Medicine, Hershey, Pennsylvania
| | - Nathaniel D Westphal
- Section on Critical Care Medicine, Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Ashish K Khanna
- Section on Critical Care Medicine, Department of Anesthesiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina.,Outcomes Research Consortium, Cleveland, Ohio
| | - Sheila N Myatra
- Department of Anesthesia, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, Maharashtra, India
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Hawkins A, Stapleton S, Rodriguez G, Gonzalez RM, Baker WE. Emergency Tracheal Intubation in Patients with COVID-19: A Single-center, Retrospective Cohort Study. West J Emerg Med 2021; 22:678-686. [PMID: 34125046 PMCID: PMC8203023 DOI: 10.5811/westjem.2020.2.49665] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 01/13/2021] [Accepted: 02/05/2021] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION The objective of this study was to compare airway management technique, performance, and peri-intubation complications during the novel coronavirus pandemic (COVID-19) using a single-center cohort of patients requiring emergent intubation. METHODS We retrospectively collected data on non-operating room (OR) intubations from February 1-April 23, 2020. All patients undergoing emergency intubation outside the OR were eligible for inclusion. Data were entered using an airway procedure note integrated within the electronic health record. Variables included level of training and specialty of the laryngoscopist, the patient's indication for intubation, methods of intubation, induction and paralytic agents, grade of view, use of video laryngoscopy, number of attempts, and adverse events. We performed a descriptive analysis comparing intubations with an available positive COVID-19 test result with cases that had either a negative or unavailable test result. RESULTS We obtained 406 independent procedure notes filed between February 1-April 23, 2020, and of these, 123 cases had a positive COVID-19 test result. Residents performed fewer tracheal intubations in COVID-19 cases when compared to nurse anesthetists (26.0% vs 37.4%). Video laryngoscopy was used significantly more in COVID-19 cases (91.1% vs 56.8%). No difference in first-pass success was observed between COVID-19 positive cases and controls (89.4% vs. 89.0%, p = 1.0). An increased rate of oxygen desaturation was observed in COVID-19 cases (20.3% vs. 9.9%) while there was no difference in the rate of other recorded complications and first-pass success. DISCUSSION An average twofold increase in the rate of tracheal intubation was observed after March 24, 2020, corresponding with an influx of COVID-19 positive cases. We observed adherence to society guidelines regarding performance of tracheal intubation by an expert laryngoscopist and the use of video laryngoscopy.
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Affiliation(s)
- Andrew Hawkins
- Boston University Medical Center, Department of Emergency Medicine, Boston, Massachusetts
| | - Stephanie Stapleton
- Boston University Medical Center, Department of Emergency Medicine, Boston, Massachusetts
| | - Gerardo Rodriguez
- Boston University, Department of Anesthesiology, Boston, Massachusetts
| | | | - William E. Baker
- Boston University Medical Center, Department of Emergency Medicine, Boston, Massachusetts
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Schechtman SA, Flori HR, Thatcher AL, Almendras G, Robell SE, Healy DW, Shah NJ. The Difficult Airway Navigator: Development and Implementation of a Health Care System's Approach to Difficult Airway Documentation Utilizing the Electronic Health Record. A A Pract 2021; 15:e01455. [PMID: 33950875 DOI: 10.1213/xaa.0000000000001455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Careful airway risk assessment and procedural planning are vital to ensure patients' safety during airway management. Patients with known procedural difficulty during previous airway management or new anatomical changes pose challenges and risks. To improve communication and the value of documented information regarding difficult airway management for future clinical encounters, we utilized existing electronic health record functions to develop a "difficult airway Navigator." We describe this tool's creation and implementation, which allows clinicians to readily review past airway information and efficiently create difficult airway notes, bedside signs, flags, and orders.
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Affiliation(s)
| | | | - Aaron L Thatcher
- Department of Otolaryngology-Head & Neck Surgery, Michigan Medicine-University of Michigan Medical School, Ann Arbor, Michigan
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Abstract
Purpose of Review This paper will evaluate the recent literature and best practices in airway management in critically ill patients. Recent Findings Cardiac arrest remains a common complication of intubation in these high-risk patients. Patients with desaturation or peri-intubation hypotension are at high risk of cardiac arrest, and each of these complications have been reported in up to half of all intubations in critically ill patient populations. Summary There have been significant advances in preoxygenation and devices available for performing laryngoscopy and rescue oxygenation. However, the risk of cardiovascular collapse remains concerningly high with few studies to guide therapeutic maneuvers to reduce this risk.
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31
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Song JA, Bae HB, Choi JI, Kang J, Jeong S. Difficult intubation and anesthetic management in an adult patient with undiagnosed congenital tracheal stenosis: a case report. J Int Med Res 2021; 48:300060520911267. [PMID: 32321342 PMCID: PMC7180306 DOI: 10.1177/0300060520911267] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
In the operating room, unanticipated difficult intubation can occur and anesthesiologists can experience challenging situations. Undiagnosed tracheal stenosis caused by congenital factors, trauma, tumors, or post-intubation injury, can make advancing the endotracheal tube difficult. We present an adult patient in whom we were unable to pass an endotracheal tube into the trachea. This was caused by undiagnosed congenital mid-tracheal stenosis with complete tracheal rings. When faced with an unanticipated difficult airway, the anesthesiologist needs to comprehend the results of preoperative evaluations. If an unusual situation (e.g., congenital tracheal stenosis) occurs, active cooperation with other departments should be considered.
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Affiliation(s)
- Ji-A Song
- Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School and Hospital, Gwangju, South Korea
| | - Hong-Beom Bae
- Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School and Hospital, Gwangju, South Korea
| | - Jeong-Il Choi
- Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School and Hospital, Gwangju, South Korea
| | - Jeonghyeon Kang
- Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School and Hospital, Gwangju, South Korea
| | - Seongtae Jeong
- Department of Anesthesiology and Pain Medicine, Chonnam National University Medical School and Hospital, Gwangju, South Korea
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Tsan SEH, Ng KT, Lau J, Viknaswaran NL, Wang CY. A comparison of ramping position and sniffing position during endotracheal intubation: a systematic review and meta-analysis. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ENGLISH EDITION) 2020. [PMID: 33288219 PMCID: PMC9373499 DOI: 10.1016/j.bjane.2020.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objectives Positioning during endotracheal intubation (ETI) is critical to ensure its success. We aimed to determine if the ramping position improved laryngeal exposure and first attempt success at intubation when compared to the sniffing position. Methods PubMed, EMBASE, and Cochrane CENTRAL databases were searched systematically from inception until January 2020. Our primary outcomes included laryngeal exposure as measured by Cormack-Lehane Grade 1 or 2 (CLG 1/2), CLG 3 or 4 (CLG 3/4), and first attempt success at intubation. Secondary outcomes were intubation time, use of airway adjuncts, ancillary maneuvers, and complications during ETI. Results Seven studies met our inclusion criteria, of which 4 were RCTs and 3 were cohort studies. The meta-analysis was conducted by pooling the effect estimates for all 4 included RCTs (n = 632). There were no differences found between ramping and sniffing positions for odds of CLG 1/2, CLG 3/4, first attempt success at intubation, intubation time, use of ancillary airway maneuvers, and use of airway adjuncts, with evidence of high heterogeneity across studies. However, the ramping position in surgical patients is associated with increased likelihood of CLG 1/2 (OR = 2.05, 95% CI 1.26 to 3.32, p = 0.004) and lower likelihood of CLG 3/4 (OR = 0.49, 95% CI 0.30 to 0.79, p = 0.004), moderate quality of evidence. Conclusion Our meta-analysis demonstrated that the ramping position may benefit surgical patients undergoing ETI by improving laryngeal exposure. Large scale well designed multicentre RCTs should be carried out to further elucidate the benefits of the ramping position in the surgical and intensive care unit patients.
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Affiliation(s)
- Samuel Ern Hung Tsan
- Departamento de Anestesiologia, Faculty of Medicine and Health Sciences, University of Malaysia Sarawak, Sarawak, Malásia.
| | - Ka Ting Ng
- Departamento de Anestesiologia, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malásia
| | - Jiaying Lau
- Departamento de Anestesiologia, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malásia
| | - Navian Lee Viknaswaran
- Departamento de Anestesiologia, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malásia
| | - Chew Yin Wang
- Departamento de Anestesiologia, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malásia
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Tsan SEH, Ng KT, Lau J, Viknaswaran NL, Wang CY. [A comparison of ramping position and sniffing position during endotracheal intubation: a systematic review and meta-analysis]. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ELSEVIER) 2020; 70:667-677. [PMID: 33288219 PMCID: PMC9373499 DOI: 10.1016/j.bjan.2020.08.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/01/2019] [Revised: 07/11/2020] [Accepted: 08/01/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVES Positioning during endotracheal intubation (ETI) is critical to ensure its success. We aimed to determine if the ramping position improved laryngeal exposure and first attempt success at intubation when compared to the sniffing position. METHODS PubMed, EMBASE, and Cochrane CENTRAL databases were searched systematically from inception until January 2020. Our primary outcomes included laryngeal exposure as measured by Cormack-Lehane Grade 1 or 2 (CLG 1/2), CLG 3 or 4 (CLG 3/4), and first attempt success at intubation. Secondary outcomes were intubation time, use of airway adjuncts, ancillary maneuvers and complications during ETI. RESULTS Seven studies met our inclusion criteria, of which 4 were RCTs and 3 were cohort studies. The meta-analysis was conducted by pooling the effect estimates for all 4 included RCTs (n=632). There were no differences found between ramping and sniffing positions for odds of CLG 1/2, CLG 3/4, first attempt success at intubation, intubation time, use of ancillary airway maneuvers and use of airway adjuncts, with evidence of high heterogeneity across studies. However, the ramping position in surgical patients is associated with increased likelihood of CLG 1/2 (OR=2.05, 95% CI 1.26 to 3.32, p=0.004) and lower likelihood of CLG 3/4 (OR=0.49, 95% CI 0.30 to 0.79, p=0.004), moderate quality of evidence. CONCLUSION Our meta-analysis demonstrated that the ramping position may benefit surgical patients undergoing ETI by improving laryngeal exposure. Large-scale well-designed multicentre RCTs should be carried out to further elucidate the benefits of the ramping position in the surgical and intensive care unit patients.
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Affiliation(s)
- Samuel Ern Hung Tsan
- Departamento de Anestesiologia, Faculty of Medicine and Health Sciences, University of Malaysia Sarawak, Sarawak, Malásia.
| | - Ka Ting Ng
- Departamento de Anestesiologia, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malásia
| | - Jiaying Lau
- Departamento de Anestesiologia, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malásia
| | - Navian Lee Viknaswaran
- Departamento de Anestesiologia, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malásia
| | - Chew Yin Wang
- Departamento de Anestesiologia, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malásia
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The effect of cricoid pressure on tracheal intubation in adult patients: a systematic review and meta-analysis. Can J Anaesth 2020; 68:137-147. [PMID: 33089413 DOI: 10.1007/s12630-020-01830-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 07/10/2020] [Accepted: 07/21/2020] [Indexed: 10/23/2022] Open
Abstract
PURPOSE This meta-analysis aimed to assess the impact of cricoid pressure (CP) application on intubation outcomes. SOURCE Electronic databases (i.e., MEDLINE, PubMed, Embase, and Cochrane review) were searched from inception to 2 June 2020 for randomized-controlled trials that assessed the intubation outcomes in adult patients using laryngoscopic approaches with and without the application of CP (i.e., CP vs non-CP group). The primary outcome was the successful first-attempt intubation rate (SFAIR), and the secondary outcomes were intubation time, incidences of poor laryngoscopic views (i.e., Cormack and Lehane grade 3-4), airway complications, and pulmonary aspiration. PRINCIPAL FINDINGS A total of five trials (published from 2005 to 2018) were included, and all tracheal intubations were performed by anesthesiologists or nurse anesthetists with a video (n = 3) or Macintosh laryngoscope (n = 2) in the operating room. We found no significant difference in SFAIR (risk ratio [RR], 0.98; P = 0.37), incidence of poor laryngoscopic views (RR, 1.49; P = 0.21), and risk of sore throat (RR, 1.17; P = 0.73) between the two groups. Nevertheless, the intubation time on the first successful attempt was slightly longer (weighted mean difference = 4.40 sec, P = 0.002) and risk of hoarseness was higher (RR, 1.70; P = 0.03) in the CP group compared with in the non-CP group. The secondary outcome "pulmonary aspiration" was not analyzed because only one trial was available. CONCLUSION The application of CP did not have a negative impact on the SFAIR or laryngoscopic view. Nevertheless, this maneuver may slightly prolong intubation time and increase the risk of postoperative hoarseness.
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Brown W, Santhosh L, Brady AK, Denson JL, Niroula A, Pugh ME, Self WH, Joffe AM, O'Neal Maynord P, Carlos WG. A call for collaboration and consensus on training for endotracheal intubation in the medical intensive care unit. Crit Care 2020; 24:621. [PMID: 33092615 PMCID: PMC7583182 DOI: 10.1186/s13054-020-03317-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 09/30/2020] [Indexed: 11/10/2022] Open
Abstract
Endotracheal intubation (EI) is a potentially lifesaving but high-risk procedure in critically ill patients. While the ACGME mandates that trainees in pulmonary and critical care medicine (PCCM) achieve competence in this procedure, there is wide variation in EI training across the USA. One study suggests that 40% of the US PCCM trainees feel they would not be proficient in EI upon graduation. This article presents a review of the EI training literature; the recommendations of a national group of PCCM, anesthesiology, emergency medicine, and pediatric experts; and a call for further research, collaboration, and consensus guidelines.
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Affiliation(s)
- Wade Brown
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, T-1218 Medical Center North, 1211 Medical Center Drive, Nashville, TN, 37232, USA.
| | - Lekshmi Santhosh
- Division of Pulmonary and Critical Care Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Anna K Brady
- Division of Pulmonary and Critical Care Medicine, Oregon Health Science University, Portland, OR, USA
| | - Joshua L Denson
- Section of Pulmonary, Critical Care, and Environmental Medicine, Tulane University School of Medicine, New Orleans, LA, USA
| | - Abesh Niroula
- Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Meredith E Pugh
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, T-1218 Medical Center North, 1211 Medical Center Drive, Nashville, TN, 37232, USA
| | - Wesley H Self
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Aaron M Joffe
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, WA, USA
| | - P O'Neal Maynord
- Division of Pediatric Critical Care Medicine, Monroe Carell Jr. Children's Hospital at Vanderbilt and Vanderbilt University School of Medicine, Nashville, TN, USA
| | - W Graham Carlos
- Division of Pulmonary, Critical Care, Sleep and Occupational Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
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Austin DR, Chang MG, Bittner EA. Use of Handheld Point-of-Care Ultrasound in Emergency Airway Management. Chest 2020; 159:1155-1165. [PMID: 32971075 DOI: 10.1016/j.chest.2020.09.083] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 08/27/2020] [Accepted: 09/13/2020] [Indexed: 12/22/2022] Open
Abstract
Emergency airway management (EAM) is associated with a high rate of complications, morbidity, and mortality. Handheld point-of-care ultrasound shows promise as an emerging technology to facilitate rapid screening for difficult laryngoscopy, identify the cricothyroid membrane for potential cricothyroidotomy, and assess for increased aspiration risk, as well as provide confirmation of proper endotracheal tube positioning. This review summarizes the available evidence for the use of point-of-care ultrasound in EAM, provides an algorithm to facilitate its incorporation into existing EAM practice to improve patient safety, and serves as a framework for future validation studies.
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Affiliation(s)
- Daniel R Austin
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA
| | - Marvin G Chang
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA.
| | - Edward A Bittner
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA
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Tsan SEH, Lim SM, Abidin MFZ, Ganesh S, Wang CY. Comparison of Macintosh Laryngoscopy in Bed-up-Head-Elevated Position With GlideScope Laryngoscopy: A Randomized, Controlled, Noninferiority Trial. Anesth Analg 2020; 131:210-219. [PMID: 31348051 DOI: 10.1213/ane.0000000000004349] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Approximately half of all difficult tracheal intubations (DTIs) are unanticipated; hence, proper positioning during intubation is critical to increase the likelihood of success. The bed-up-head-elevated (BUHE) intubation position has been shown to improve laryngeal view, reduce airway complications, and prolong safe apneic time during intubation. In this study, we sought to determine whether the BUHE intubation position is noninferior to Glidescope (GLSC)-assisted intubation with regard to laryngeal exposure. METHODS A total of 138 American Society of Anesthesiologists (ASA) I to III patients were randomly assigned into 2 groups and underwent baseline laryngoscopy in the sniffing position. Group BUHE patients (n = 69) were then intubated in the BUHE position, while group GLSC patients (n = 69) were intubated using GLSC laryngoscopy. Laryngeal exposure was measured using Percentage of Glottic Opening (POGO) score and Cormack-Lehane (CL) grading, and noninferiority will be declared if the difference in mean POGO scores between both groups do not exceed -15% at the lower limit of a 98% confidence interval (CI). Secondary outcomes measured included time required for intubation (TRI), number of intubation attempts, use of airway adjuncts, effort during laryngoscopy, and complications during intubation. RESULTS Mean POGO score in group BUHE was 80.14% ± 22.03%, while in group GLSC it was 86.45% ± 18.83%, with a mean difference of -6.3% (98% CI, -13.2% to 0.6%). In both groups, there was a significant improvement in mean POGO scores when compared to baseline laryngoscopy in the sniffing position (group BUHE, 25.8% ± 4.7%; group GLSC, 30.7% ± 6.8%) (P < .0001). The mean TRI was 36.23 ± 14.41 seconds in group BUHE, while group GLSC had a mean TRI of 44.33 ± 11.53 seconds (P < .0001). In patients with baseline CL 3 grading, there was no significant difference between mean POGO scores in both groups (group BUHE, 49.2% ± 19.6% versus group GLSC, 70.5% ± 29.7%; P = .054). CONCLUSIONS In the general population, BUHE intubation position provides a noninferior laryngeal view to GLSC intubation. The laryngeal views obtained in both approaches were superior to the laryngeal view obtained in the sniffing position. In view of the many advantages of the BUHE position for intubation, the lack of proven adverse effects, the simplicity, and the cost-effectiveness, we propose that clinicians should consider the BUHE position as the standard intubation position for the general population.
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Affiliation(s)
- Samuel E H Tsan
- From the Department of Anaesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia.,Department of Anaesthesiology, Faculty of Medicine and Health Sciences, University of Malaysia Sarawak, Sarawak, Malaysia
| | - Siu M Lim
- From the Department of Anaesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Mohd F Z Abidin
- From the Department of Anaesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Shahmini Ganesh
- From the Department of Anaesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Chew Y Wang
- From the Department of Anaesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
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Reply to: reintubation in the ICU versus in the operating room in cardiac surgery patients. Eur J Anaesthesiol 2020; 37:818-819. [PMID: 32769508 DOI: 10.1097/eja.0000000000001226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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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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Groombridge C, Maini A, Olaussen A, Kim Y, Fitzgerald M, Mitra B, Smit DV. Impact of a targeted bundle of audit with tailored education and an intubation checklist to improve airway management in the emergency department: an integrated time series analysis. Emerg Med J 2020; 37:576-580. [PMID: 32554746 DOI: 10.1136/emermed-2019-208935] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 04/21/2020] [Accepted: 04/29/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND Endotracheal intubation (ETI) is a commonly performed but potentially high-risk procedure in the emergency department (ED). Requiring more than one attempt at intubation has been shown to increase adverse events and interventions improving first-attempt success rate should be identified to make ETI in the ED safer. We introduced and examined the effect of a targeted bundle of airway initiatives on first-attempt success and adverse events associated with ETI. METHODS This prospective, interventional cohort study was conducted over a 2-year period at an Australian Major Trauma Centre. An online airway registry was established at the inception of the study to collect information related to all intubations. After 6 months, we introduced a bundle of initiatives including monthly audit, monthly airway management education and an airway management checklist. A time series analysis model was used to compare standard practice (ie, first 6 months) to the postintervention period. RESULTS There were 526 patients, 369 in the intervention group and 157 in the preintervention comparator group. A total of 573 intubation attempts were performed. There was a significant improvement in first-attempt success rates between preintervention and postintervention groups (88.5% vs 94.6%, relative risk 1.07; 95% CI 1.00 to 1.14, p=0.014). After the introduction of the intervention the first-attempt success rate increased significantly, by 13.4% (p=0.006) in the first month, followed by a significant increase in the monthly trend (relative to the preintervention trend) of 1.71% (p<0.001). The rate of adverse events were similar preintervention and postintervention (hypoxia 8.3% vs 8.9% (p=0.81); hypotension 8.3% vs 7.0% (p=0.62); any complication 27.4% vs 23.6% (p=0.35)). CONCLUSIONS This bundle of airway management initiatives was associated with significant improvement in the first-attempt success rate of ETI. The introduction of a regular education programme based on the audit of a dedicated airway registry, combined with a periprocedure checklist is a worthwhile ED quality improvement initiative.
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Affiliation(s)
- Christopher Groombridge
- National Trauma Research Institute, Melbourne, Victoria, Australia .,Emergency & Trauma Centre, Alfred Health, Melbourne, Victoria, Australia.,Monash University, Melbourne, Victoria, Australia.,Trauma Service, Alfred Hospital, Melbourne, Victoria, Australia
| | - Amit Maini
- National Trauma Research Institute, Melbourne, Victoria, Australia.,Emergency & Trauma Centre, Alfred Health, Melbourne, Victoria, Australia.,Monash University, Melbourne, Victoria, Australia
| | | | - Yen Kim
- National Trauma Research Institute, Melbourne, Victoria, Australia.,Monash University, Melbourne, Victoria, Australia
| | - Mark Fitzgerald
- National Trauma Research Institute, Melbourne, Victoria, Australia.,Monash University, Melbourne, Victoria, Australia.,Trauma Service, Alfred Hospital, Melbourne, Victoria, Australia
| | - Biswadev Mitra
- National Trauma Research Institute, Melbourne, Victoria, Australia.,Emergency & Trauma Centre, Alfred Health, Melbourne, Victoria, Australia.,Monash University, Melbourne, Victoria, Australia
| | - De Villiers Smit
- National Trauma Research Institute, Melbourne, Victoria, Australia.,Emergency & Trauma Centre, Alfred Health, Melbourne, Victoria, Australia.,Monash University, Melbourne, Victoria, Australia
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41
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Renew JR, Ratzlaff R, Hernandez-Torres V, Brull SJ, Prielipp RC. Neuromuscular blockade management in the critically Ill patient. J Intensive Care 2020; 8:37. [PMID: 32483489 PMCID: PMC7245849 DOI: 10.1186/s40560-020-00455-2] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Accepted: 05/13/2020] [Indexed: 12/16/2022] Open
Abstract
Neuromuscular blocking agents (NMBAs) can be an effective modality to address challenges that arise daily in the intensive care unit (ICU). These medications are often used to optimize mechanical ventilation, facilitate endotracheal intubation, stop overt shivering during therapeutic hypothermia following cardiac arrest, and may have a role in the management of life-threatening conditions such as elevated intracranial pressure and status asthmaticus (when deep sedation fails or is not tolerated). However, current NMBA use has decreased during the last decade due to concerns of potential adverse effects such as venous thrombosis, patient awareness during paralysis, development of critical illness myopathy, autonomic interactions, and even residual paralysis following cessation of NMBA use. It is therefore essential for clinicians to be familiar with evidence-based practices regarding appropriate NMBA use in order to select appropriate indications for their use and avoid complications. We believe that selecting the right NMBA, administering concomitant sedation and analgesic therapy, and using appropriate monitoring techniques mitigate these risks for critically ill patients. Therefore, we review the indications of NMBA use in the critical care setting and discuss the most appropriate use of NMBAs in the intensive care setting based on their structure, mechanism of action, side effects, and recognized clinical indications. Lastly, we highlight the available pharmacologic antagonists, strategies for sedation, newer neuromuscular monitoring techniques, and potential complications related to the use of NMBAs in the ICU setting.
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Affiliation(s)
- J Ross Renew
- 1Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL 32224 USA
| | - Robert Ratzlaff
- 2Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL USA
| | - Vivian Hernandez-Torres
- 1Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL 32224 USA
| | - Sorin J Brull
- 1Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL 32224 USA.,3Department of Anesthesiology, University of Minnesota Medical School, Minneapolis, MN USA
| | - Richard C Prielipp
- 3Department of Anesthesiology, University of Minnesota Medical School, Minneapolis, MN USA
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42
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Stieglitz S, Frohnhofen H, Netzer N, Haidl P, Orth M, Schlesinger A. [Recommendations for the Treatment of Elderly Patients with COVID-19 from the Taskforce for Gerontopneumology]. Pneumologie 2020; 74:505-508. [PMID: 32434253 PMCID: PMC7534603 DOI: 10.1055/a-1177-3588] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- S Stieglitz
- Medizinische Klinik I - Pneumologie, Allergologie, Schlaf- und Intensivmedizin, Wuppertaler Lungenzentrum, Petrus-Krankenhaus, Wuppertal
| | - H Frohnhofen
- Alfried Krupp Krankenhaus Rüttenscheid, Altersmedizin am Alfried Krupp von Bohlen und Halbach Krankenhaus gemeinnützige GmbH, Essen
| | - N Netzer
- Hermann Buhl Institut für Hypoxie und Schlafmedizinforschung der Universität Innsbruck, Bad Aibling und Eurac Research, Institut für alpine Notfallmedizin, Bozen
| | - P Haidl
- Fachkrankenhaus Kloster Grafschaft GmbH, Pneumologie II, Akademisches Lehrkrankenhaus der Philipps-Universität Marburg, Schmallenberg
| | - M Orth
- Pneumologie, Pneumologische Onkologie, Allergologie, Schlaf- und Beatmungsmedizin, Theresienkrankenhaus, Mannheim
| | - A Schlesinger
- Klinik für Innere Medizin/ Pneumologie und Beatmungsmedizin, Lungenklinik Köln-Nord, Betriebsteil St. Marien Hospital, Köln
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43
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Mosier JM, Sakles JC, Law JA, Brown CA, Brindley PG. Tracheal Intubation in the Critically Ill. Where We Came from and Where We Should Go. Am J Respir Crit Care Med 2020; 201:775-788. [DOI: 10.1164/rccm.201908-1636ci] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Jarrod M. Mosier
- Department of Emergency Medicine and
- Division of Pulmonary, Allergy, Critical Care, and Sleep, Department of Medicine, University of Arizona, Tucson, Arizona
| | | | - J. Adam Law
- Department of Anesthesiology and Department of Emergency Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Calvin A. Brown
- Department of Emergency Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts; and
| | - Peter G. Brindley
- Department of Critical Care Medicine, University of Alberta, Edmonton, Alberta, Canada
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44
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Intubation in Operating Room versus Intensive Care: Comment. Anesthesiology 2020; 130:1089-1090. [PMID: 31090620 DOI: 10.1097/aln.0000000000002721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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45
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46
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Intubation in Operating Room versus Intensive Care: Reply. Anesthesiology 2019; 130:1090-1091. [PMID: 31090621 DOI: 10.1097/aln.0000000000002722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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47
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Comparison of Tracheal Intubation Conditions in Operating Room and Intensive Care Unit: A Prospective, Observational Study: Erratum. Anesthesiology 2019; 131:222. [DOI: 10.1097/aln.0000000000002807] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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48
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[Is bag-mask ventilation before endotracheal intubation in intensive care patients useful?]. Med Klin Intensivmed Notfmed 2019; 114:749-751. [PMID: 30944944 DOI: 10.1007/s00063-019-0577-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Revised: 03/15/2019] [Accepted: 03/15/2019] [Indexed: 10/27/2022]
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49
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Morrison C, Avanis MC, Ritchie-McLean S, Woo C, Herod J, Nandi R, Thompson D. Retrospective audit of airway management practices in children with craniocervical pathology. Paediatr Anaesth 2019; 29:338-344. [PMID: 30710400 DOI: 10.1111/pan.13596] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Revised: 01/23/2019] [Accepted: 01/27/2019] [Indexed: 11/26/2022]
Abstract
BACKGROUND Craniocervical immobilization using halo body orthoses may be required in the management of children with craniocervical junction pathology. To date, the effect of such immobilization on perioperative anesthetic management has not been addressed in large series. AIMS The aim of this study was to review the airway management of children requiring halo body orthoses undergoing general anesthesia. METHODS The study was a retrospective case note review from a single institution. The neurosurgical database was interrogated to identify all patients less than 16 years of age that required a halo body orthosis from 1996 to 2015. We used the electronic patient record to identify all procedures performed under general anesthesia for these patients, either for halo application, or with the halo in situ. Details of techniques used for airway management were recorded, and paired data between individuals pre- and post-halo application were compared. Demographic data, diagnosis, and perioperative complications were also recorded. RESULTS We identified 90 children that underwent placement of a halo body orthosis. A total of 269 anesthetic records from these patients were analyzed and classified as pre-halo application, or halo in situ. Facemask ventilation was achieved in all patients, though some required simple airway adjuncts and may have been more difficult in the presence of the halo. Supraglottic airways were used successfully in many patients. There was a significant increase in the number of patients classed as Cormack and Lehane grades 3 or 4 on direct laryngoscopy with the halo in situ compared with before the halo was applied. The incidence of intubation using fiberoptic or videolaryngoscopy was higher with the halo in situ. Multiple intubation attempts were required in 3.4% (1/29) of patients undergoing anesthesia for halo placement compared with 15.1% (11/73) undergoing anesthesia with a halo in situ. CONCLUSION Airway management in children with cervical spine pathology should be anticipated to be more difficult than the general pediatric population. This is likely to be due to co-existing pathology associated with cervical spine disease in children, limitation of neck movement to prevent further neurological injury, and the halo itself limiting access to the head. We recommend advanced preparation, and ensuring the immediate availability of an anesthetist with skills in managing the pediatric difficult airway to avoid complications in this patient population.
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Affiliation(s)
- Christa Morrison
- Department of Anaesthesia, Great Ormond Street Hospital, London, UK
| | | | | | - Colleen Woo
- Department of Anaesthesia, Great Ormond Street Hospital, London, UK
| | - Jane Herod
- Department of Anaesthesia, Great Ormond Street Hospital, London, UK
| | - Reema Nandi
- Department of Anaesthesia, Great Ormond Street Hospital, London, UK
| | - Dominic Thompson
- Department of Neurosurgery, Great Ormond Street Hospital, London, UK
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50
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Taboada M, Soto-Jove R, Mirón P, Martínez S, Rey R, Ferreiroa E, Almeida X, Álvarez J, Baluja A. Evaluation of the laryngoscopy view using the modified Cormack-Lehane scale during tracheal intubation in an intensive care unit. A prospective observational study. ACTA ACUST UNITED AC 2019; 66:250-258. [PMID: 30862397 DOI: 10.1016/j.redar.2019.01.004] [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] [Received: 11/08/2018] [Revised: 12/17/2018] [Accepted: 01/08/2019] [Indexed: 01/06/2023]
Abstract
BACKGROUND AND OBJECTVIES Tracheal intubation in the Intensive Care Unit is associated with a high incidence of difficult intubation and complications. This may be due to a poor view of the glottis during direct laryngoscopy. The aim of this study is to determine if there is a relationship between laryngoscopy view using the modified Cormack-Lehane scale with the incidence of difficult intubation and complications. METHODS All patients who were subjected to tracheal intubated with direct laryngoscopy in the Intensive Care Unit over a 45 month period were included in the study. In all patients, an evaluation was made of the laryngoscopy view using the modified Cormack-Lehane scale, as well as the technical difficulty (number of intubations at first attempt, operator-reported difficulty, need for a Frova introducer), and the incidence of complications (hypotension, hypoxia, oesophageal intubation). RESULTS A total of 360 patients were included. When the grade of the modified Cormack-Lehane scale was increased from 1 to 4, the incidence of first success rate intubation decreased (1: 97%, 2a: 94%, 2b: 80%, 3: 60%, 4: 0%, p<.001), the incidence of moderate and severe difficulty intubation increased (1: 2%, 2a: 4%, 2b: 36%, 3: 77%, 4: 100%, p<.001.), as well as the need for a Frova guide (1: 7%, 2a: 8%, 2b: 45%, 3: 60%, 4: 100%, p<.001). When the grade of the modified Cormack-Lehane scale increased from 1 to 4, the incidence of hypoxia<90% increased (1: 20%, 2a: 20%, 2b: 28%, 3: 47%, 4: 100%, p=.0073), as well as hypoxia<80% (1: 11%, 2a: 10%, 2b: 12%, 3: 27%, 4: 100%, p=.00398). No relationship was observed between the incidence of hypotension and the grade of the modified Cormack-Lehane scale (p=ns). CONCLUSIONS During tracheal intubation in the Intensive Care Unit a close relationship was found between a poor laryngoscopy view using the modified Cormack-Lehane scale and a higher difficulty technique of intubation. A relationship was found between the incidence of hypoxia with a higher grade in the modified Cormack-Lehane scale. No relationship was found between hypotension and the modified Cormack-Lehane scale.
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Affiliation(s)
- M Taboada
- Grupo de Investigación Enfermo Crítico, Unidad de Cuidados Críticos, Servicio de Anestesiología, Hospital Clínico Universitario de Santiago de Compostela, Fundación Instituto de Investigación Sanitaria, Santiago de Compostela, A Coruña, España.
| | - R Soto-Jove
- Grupo de Investigación Enfermo Crítico, Unidad de Cuidados Críticos, Servicio de Anestesiología, Hospital Clínico Universitario de Santiago de Compostela, Fundación Instituto de Investigación Sanitaria, Santiago de Compostela, A Coruña, España
| | - P Mirón
- Grupo de Investigación Enfermo Crítico, Unidad de Cuidados Críticos, Servicio de Anestesiología, Hospital Clínico Universitario de Santiago de Compostela, Fundación Instituto de Investigación Sanitaria, Santiago de Compostela, A Coruña, España
| | - S Martínez
- Grupo de Investigación Enfermo Crítico, Unidad de Cuidados Críticos, Servicio de Anestesiología, Hospital Clínico Universitario de Santiago de Compostela, Fundación Instituto de Investigación Sanitaria, Santiago de Compostela, A Coruña, España
| | - R Rey
- Grupo de Investigación Enfermo Crítico, Unidad de Cuidados Críticos, Servicio de Anestesiología, Hospital Clínico Universitario de Santiago de Compostela, Fundación Instituto de Investigación Sanitaria, Santiago de Compostela, A Coruña, España
| | - E Ferreiroa
- Grupo de Investigación Enfermo Crítico, Unidad de Cuidados Críticos, Servicio de Anestesiología, Hospital Clínico Universitario de Santiago de Compostela, Fundación Instituto de Investigación Sanitaria, Santiago de Compostela, A Coruña, España
| | - X Almeida
- Grupo de Investigación Enfermo Crítico, Unidad de Cuidados Críticos, Servicio de Anestesiología, Hospital Clínico Universitario de Santiago de Compostela, Fundación Instituto de Investigación Sanitaria, Santiago de Compostela, A Coruña, España
| | - J Álvarez
- Grupo de Investigación Enfermo Crítico, Unidad de Cuidados Críticos, Servicio de Anestesiología, Hospital Clínico Universitario de Santiago de Compostela, Fundación Instituto de Investigación Sanitaria, Santiago de Compostela, A Coruña, España
| | - A Baluja
- Grupo de Investigación Enfermo Crítico, Unidad de Cuidados Críticos, Servicio de Anestesiología, Hospital Clínico Universitario de Santiago de Compostela, Fundación Instituto de Investigación Sanitaria, Santiago de Compostela, A Coruña, España
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