Effects of supervision by attending anesthesiologists on complications of emergency tracheal intubation

The impact of residency training level on early postoperative desaturation: A retrospective multicenter cohort study

OBJECTIVE

We studied the primary hypothesis that the training level of anesthesiology residents (first clinical anesthesia year, CA1 vs CA2/3 residents) is associated with early postoperative desaturation (oxygen saturation < 90%). We also analyzed the change in the rate (trajectory) of desaturation during the resident's development from CA1 to CA2/3 resident, and its effects on postoperative respiratory complications.

DESIGN

Retrospective hospital registry study.

SETTING

Two university-affiliated hospitals networks (MA and NY, USA).

PATIENTS

140,818 adults undergoing non-cardiac surgery under general anesthesia and extubation in the operating room by residents (n = 378) between 2005 and 2021.

MEASUREMENTS

Multivariate logistic and quantile regression were used in the analyses. The secondary outcome was major respiratory complication within 7 days after surgery.

MAIN RESULTS

In 6.5% and 1.6% of cases, early postoperative desaturation to < 90% and 80% occurred. Compared to CA2/3 residents, CA1 residents had higher odds of experiencing early postoperative desaturation to < 90% and 80% (adjusted odds ratio [ORadj], 1.07; 95%CI 1.03-1.12; p = 0.002, and ORadj 1.10; 95%CI 1.01-1.20; p = 0.037, respectively). The change in postoperative desaturation rate during the transition from CA1 to CA2/3 status varied substantially from ORadj 0.80 (decreased risk) to 1.33 (increased risk). Major respiratory complication did not differ between experience levels (p = 0.52). However, a strong decline in improvement regarding the rate of postoperative desaturation during the transition from CA1 to CA2/3, was paralleled by an increased odds of major respiratory complication for CA2/3 residents (ORadj 1.20; 95%CI 1.02-1.42; p = 0.026, p-for-interaction = 0.056).

CONCLUSION

Patients treated by CA1 residents have an increased risk of postoperative desaturation. Some residents show an improvement and others a decline in postoperative desaturation rate. Our secondary analysis suggests that there should be more focus on those residents who had a declining performance in postoperative desaturation despite becoming more experienced.

Obesity is Unlikely to be an Impediment to First-Pass Success During the Intubation of Critically Ill Patients

Background: Obesity has been described as a potential risk factor for difficult intubation among critically ill patients. Our primary aim was to further elucidate the association between obesity and first-pass success. Our secondary aim was to determine whether the use of hyper-angulated video laryngoscopy improves first-pass success compared to direct laryngoscopy when utilized for the intubation of critically ill obese patients. Study Design and Methods: A retrospective cohort study of adult patients undergoing endotracheal intubation outside of the operating room or emergency department between January 30, 2016 and May 1, 2020 at 3 campuses of an academic hospital system in the Bronx, NY. Our primary outcome was first-pass success of intubation. A multivariate logistic analysis was utilized to compare obesity status with first-pass success. Results: We identified 3791 critically ill patients who underwent endotracheal intubation of which 1417 were obese (body mass index [BMI] ≥ 30). The incidence of hyper-angulated video laryngoscopy increased over the study period. A total of 46.6% of obese patients underwent intubation with hyper-angulated video laryngoscopy as compared to 35.1% of the nonobese group. First-pass success was 79.2% among the entire cohort. Obesity status did not appear to be associated with first-pass success (adjusted odds ratio [OR] 1.07, 95% confidence interval [CI]: 090-1.27; P = .47). Hyper-angulated video laryngoscopy did not seem to improve first-pass success among obese patients as compared to nonobese patients (adjusted OR 1.21, 95% CI: 0.85-1.71; P = .29). These findings persisted even after redefining the obesity cutoff as BMI ≥ 40 and excluding patients intubated during cardiac arrests. Conclusion: We did not detect an association between obesity and first-pass success. Hyper-angulated video laryngoscopy did not appear offer additional benefit over direct laryngoscopy during the intubation of critically ill obese patients.

A Comparison of Intubation and Airway Complications Between COVID-19 and Non-COVID-19 Critically Ill Subjects

Introduction The number of subjects infected with the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) throughout the western hemisphere increased exponentially in the later months of 2020. With this increase in infection, the number of subjects requiring advanced ventilatory support increased concomitantly. We decided to compare the survival rates between coronavirus disease 2019 (COVID-19) subjects versus non-COVID-19 subjects undergoing intubation in the intensive care unit (ICU). We hypothesized that COVID-19 subjects would have lower rates of survival post-intubation. Methods We screened all subjects admitted to the adult critical care unit between January 2020 and June 2020 to determine if they met the inclusion criteria. These subjects were required to be spontaneously ventilating upon admission and eventually required intubation. Subjects were selected from our electronic health record (EHR) system EPIC© (Epic Systems, Verona, WI) through a retrospective ICU admission analysis. We identified and included 267 non-COVID-19 subjects and 56 COVID-19 subjects. Our primary outcome of interest was intubation-related mortality. We defined intubation mortality as unexpected death (within 48 hours of intubation). Our secondary outcomes were the length of stay in the ICU, length of time requiring ventilator support, and proportion of subjects requiring tracheostomy placement. Results Compared to non-coronavirus disease (COVID) subjects, COVID subjects were more likely to be intubated for acute respiratory distress. COVID subjects had longer stays in the ICU and longer ventilator duration than non-COVID subjects. COVID-positive subjects had a decreased hazard ratio for mortality (HR = 0.42, 95% CI: 0.20-0.87, P < 0.05) and increased chances of survival compared to non-COVID subjects. Conclusions We showed the rates of intubation survival were no different between the COVID and non-COVID groups. We attribute this finding to intubation preparation, a multidisciplinary team approach, and having the most experienced provider lead the intubation process.

A Cross-Sectional Study on Hyomental Distance Ratio (HMDR) as a New Predictor of Difficult Laryngoscopy in ICU Patients

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. 

Airway management in the operating room setting: An analysis of reported safety events

Adverse event reporting systems are important tools for identifying areas of risk and opportunities quality improvement. Perioperative airway management (PAM) carries patient risk. We examine the nature of PAM incident reports at an academic tertiary care center. In this retrospective data review, perioperative safety reports filed under "Airway Management" between 2015 and 2020 were analyzed. Data analyzed included severity level (patient harm) and specific event type. There was a total of 7827 safety reports filed from January 2015 to July 2020, with 67 reports related to "Airway Management" (0.85%). The most common specific event type in this safety reporting database was "Intubation Injury (Mouth, Tooth, Airway)" (35.8%). The most common severity level of all reported events was level 2 (temporary or minor harm, 57%). Our safety reporting data demonstrates that adverse events related to PAM are likely to reach the patient and can cause significant harm. Data from our findings can help providers and risk managers to focus efforts on reducing patient harm. Strategies include continued education in technical skills and crisis management, preparation for the difficult airway, increased availability of video laryngoscopes, ongoing safety reporting and collaborative review of adverse events with implementation of quality improvement measures.

Association of Number of Physician Postgraduate Years With Patient Intubation Outcomes in the Emergency Department

This cohort study examines the association between the number of physician postgraduate years and intubation outcomes among patients undergoing airway management in the emergency department.

A surgical needs assessment for airway rapid responses: A retrospective observational study

BACKGROUND

Airway rapid response (ARR) teams can be compiled of anesthesiologists, intensivists, otolaryngologists, general and thoracic surgeons, respiratory therapists, and nurses. The optimal composition of an ARR team is unknown but considered to be resource intensive. We sought to determine the type of technical procedures performed during an ARR activation to inform team composition.

METHODS

A large urban quaternary academic medical center retrospective review (2016-2019) of adult ARR patients was performed. Analysis included ARR demographics, patient characteristics, characteristics of preexisting tracheostomies, incidence of concomitant conditions, and procedures completed during an ARR event.

RESULTS

A total of 345 ARR patients with a median age of 60 years (interquartile range, 47-69 years) and a median time to ARR conclusion of 28 minutes (interquartile range, 14-47 minutes) were included. About 41.7% of the ARR had a preexisting tracheostomy. Overall, there were 130 procedures completed that can be performed by a general surgeon in addition to the 122 difficult intubations. These procedures included recannulation of a tracheostomy, operative intervention, new emergent tracheostomy or cricothyroidotomy, thoracostomy tube placement, initiation of extracorporeal membrane oxygenation, and pericardiocentesis.

CONCLUSION

Highly technical procedures are common during an ARR, including procedures related to tracheostomies. Surgeons possess a comprehensive skill set that is unique and comprehensive with respect to airway emergencies. This distinctive skill set creates an important role within the ARR team to perform these urgent technical procedures.

LEVEL OF EVIDENCE

Epidemiologic/prognostic, level III.

Risk Factors for Postoperative Sore Throat After Nasotracheal Intubation

OBJECTIVE

Postoperative sore throat is relatively frequent complication after orotracheal intubation. However, there are few reports about postoperative sore throat in nasotracheal intubation. In this retrospective study, we investigated the risk factors of postoperative sore throat in nasotracheal intubation.

METHODS

Anesthesia records of patients 16 to 80 years of age who underwent nasotracheal intubation were included. Patients underwent oral and maxillofacial surgery from February 2015 until September 2018. Airway device (Macintosh laryngoscope, Pentax-AWS, or McGRATH video laryngoscope, or fiberoptic scope), sex, age, height, weight, American Society of Anesthesiologists classification, intubation attempts, duration of intubation, intubation time, tube size, and fentanyl and remifentanil dose were investigated. Fisher exact test, Wilcoxon rank sum test, Welch t test, and Steel-Dwass multiple test were used, and a multivariable analysis was performed using stepwise logistic regression to determine the risk factors of postoperative sore throat.

RESULTS

A total of 169 cases were analyzed, and 126 patients (74.6%) had a postoperative sore throat. Based on the univariate analysis of the data, 12 factors were determined to be potentially related to the occurrence of a postoperative sore throat. However, after evaluation using stepwise logistic regression analysis, the 2 remaining variables that correlated with postoperative sore throat were airway device (P &lt; .05) and intubation attempts (P = .04). In the model using logistic regression analysis, the fiberoptic scope had the strongest influence on the incidence of sore throat with reference to Pentax-AWS (odds ratio = 5.25; 95% CI = 1.54-17.92; P &lt; .05).

CONCLUSION

Use of a fiberoptic scope was identified as an independent risk factor for postoperative throat discomfort. Compared with direct laryngoscopy and other video laryngoscopes, the use of a fiberoptic scope had a significantly higher incidence of sore throat.

What it takes to become an orthopaedic surgeon: A comparison of orthopaedic surgical training programmes in 10 countries focusing on structure and fellowship requirements

BACKGROUND

The quality of surgical training has been highlighted as one of the most important patient safety issues in the future. Training surgeons and supporting them to do their best should be considered integral in providing optimum and safe care for the individual patient and the best possible return on investment in training medical professionals. In 2011, an international consensus statement defined fundamental principles for surgical training.

PURPOSE

This study examines orthopaedic surgical training to explore the similarities and differences in the requirements for trainees to obtain board certification in ten countries.

METHODS

Countries of the Commonwealth Health Care Comparison: Canada, the United Kingdom, the United States of America, Australia, New Zealand, Germany, France, the Netherlands, Norway and Switzerland were chosen to be compared. The relevant information was extracted from official information from authorities and administrative bodies.

RESULTS

The study revealed significant differences in duration, organisation and assessment of training. So-called "competency-based" training is not featured in every country, and the manner of its implementation is variable. In particular, the numbers in surgical cases required to be accredited varies by country ranging from 1260 (UK) to 340 (Norway).

CONCLUSION

Despite the recommendation in 2011 for some degree of uniformity across surgical training in industrialised countries, evidence suggests wide variation in the training programmes which is likely to be a concern in both quality of training as well as present and future patient safety.

Rapid Intubation Sequence: 4-Year Experience in an Emergency Department

Background

The rapid intubation sequence is advanced airway management that effectively ensures an adequate supply of oxygen in critically ill patients. The medical personnel in the emergency department performed this procedure.

Objective

To describe the main characteristics of the rapid intubation sequence in an emergency department of a high complexity hospital.

Methods

This is a descriptive, cross-sectional, retrospective study. We included all older patients with a rapid intubation sequence requirement in the emergency department from 2014 to 2017. We used central tendency measures for numerical variables and proportions for categorical variables.

Results

A total of 401 patients were eligible for this analysis. The main indication for intubation was the Glasgow Coma Scale = <8 in 170 patients (42.4%), followed by hypoxemia in 142 patients (35.4%). In 36 patients, at least one complication occurred. RSI was performed in 54.4% by emergency physician. RSI was successful on the first attempt in 90.5%. Only 36 patients (9%) presented complications.

Conclusion

In this study, we found that the rapid intubation sequence was not related to a high proportion of complications. Perhaps, this is attributed to the degree of medical training and the use of emergency department protocols in our hospital.

Rapid Expansion of the Airway Response Team to Meet the Needs of the COVID-19 Pandemic

INTRODUCTION

The COVID-19 pandemic has brought unprecedented numbers of patients with acute respiratory distress to medical centers. Hospital systems require rapid adaptation to respond to the increased demand for airway management while ensuring high quality patient care and provider safety. There is limited literature detailing successful system-level approaches to adapt to the surge of COVID-19 patients requiring airway management.

METHODS

A deliberate system-level approach was used to expand a preexisting airway response service. Through a needs analysis (taking into account both existing resources and anticipated demands), we established priorities and solutions for the airway management challenges encountered during the pandemic.

RESULTS

During our COVID-19 surge (March 10, 2020, through May 26, 2020), there were 619 airway consults, and the COVID airway response team (CART) performed 341 intubations. Despite a 4-fold increase in intubations during the surge, there was no increase in cardiac arrests or surgical airways and no documented COVID-19 infections among the CART.

CONCLUSIONS

Our system-level approach successfully met the sudden escalation in demand in airway management incurred by the COVID-19 surge. The approach that addressed staffing needs prioritized provider protection and enhanced quality and safety monitoring may be adaptable to other institutions.

Complications during repeated tracheal intubation in the Intensive Care Unit. A prospective, observational study comparing the first intubation and the reintubation

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.

Head-neck movement may predispose to the development of arytenoid dislocation in the intubated patient: a 5-year retrospective single-center study

Background

Arytenoid dislocation is a rare laryngeal injury that may follow endotracheal intubation. We aimed to determine the incidence and risk factors for arytenoid dislocation after surgery under general anaesthesia.

Methods

We reviewed the medical records of patients who underwent operation under general anaesthesia with endotracheal intubation from January 2014 to December 2018. Patients were divided into the non-dislocation and dislocation groups depending on the presence or absence of arytenoid dislocation. Patient, anaesthetic, and surgical factors associated with arytenoid dislocation were determined using Poisson regression analysis.

Results

Among the 25,538 patients enrolled, 33 (0.13%) had arytenoid dislocation, with higher incidence after anterior neck and brain surgery. Patients in the dislocation group were younger (52.6 ± 14.4 vs 58.2 ± 14.2 yrs, P = 0.025), more likely to be female (78.8 vs 56.5%, P = 0.014), and more likely to be intubated by a first-year anaesthesia resident (33.3 vs 18.5%, P = 0.048) compared to those in the non-dislocation group. Patient positions during surgery were significantly different between the groups (P = 0.000). Multivariable Poisson regression identified head-neck positioning (incidence rate ratio [IRR], 3.10; 95% confidence interval [CI], 1.50–6.25, P = 0.002), endotracheal intubation by a first-year anaesthesia resident (IRR, 2.30; 95% CI, 1.07–4.64, P = 0.024), and female (IRR, 3.05; 95% CI, 1.38–7.73, P = 0.010) as risk factors for arytenoid dislocation.

Conclusion

This study showed that the incidence of arytenoid dislocation was 0.13%, and that head-neck positioning during surgery, less anaesthetist experience, and female were significantly associated with arytenoid dislocation in patients who underwent surgeries under general anaesthesia with endotracheal intubation.

Practice, Outcomes, and Complications of Emergent Endotracheal Intubation by Critical Care Practitioners During the COVID-19 Pandemic

Background

For patients with COVID-19 who undergo emergency endotracheal intubation, data are limited regarding the practice, outcomes, and complications of this procedure.

Research Question

For patients with COVID-19 requiring emergency endotracheal intubation, how do the procedural techniques, the incidence of first-pass success, and the complications associated with the procedure compare with intubations of critically ill patients before the COVID-19 pandemic?

Study Design and Methods

We conducted a retrospective study of adult patients with COVID-19 at Montefiore Medical Center who underwent first-time endotracheal intubation by critical care physicians between July 19, 2019, and May 1, 2020. The first COVID-19 patient was admitted to our institution on March 11, 2020; patients admitted before this date are designated the prepandemic cohort. Descriptive statistics were used to compare groups. A Fisher exact test was used to compare categorical variables. For continuous variables, a two-tailed Student t test was used for parametric variables or a Wilcoxon rank-sum test was used for nonparametric variables.

Results

One thousand two hundred sixty intubations met inclusion criteria (782 prepandemic cohort, 478 pandemic cohort). Patients during the pandemic were more likely to be intubated for hypoxemic respiratory failure (72.6% vs 28.1%; P < .01). During the pandemic, operators were more likely to use video laryngoscopy (89.4% vs 53.3%; P < .01) and neuromuscular blocking agents (86.0% vs 46.2%; P < .01). First-pass success was higher during the pandemic period (94.6% vs 82.9%; P < .01). The rate of associated complications was higher during the pandemic (29.5% vs 15.2%; P < .01), a finding driven by a higher rate of hypoxemia during or immediately after the procedure (25.7% vs 8.2%; P < .01).

Interpretation

Video laryngoscopy and neuromuscular blockade were used increasingly during the COVID-19 pandemic. Despite a higher rate of first-pass success during the pandemic, the incidence of complications associated with the procedure was higher.

The Impact of Nighttime on First Pass Success During the Emergent Endotracheal Intubation of Critically Ill Patients

BACKGROUND

While numerous investigations have described worse outcomes for patients undergoing emergent procedures at night, few studies have investigated the impact of nighttime on the outcomes of emergent endotracheal intubation (EEI). We hypothesized that for patients requiring EEI at night, the outcome of first pass success would be lower as compared to during the day.

METHODS

We performed a retrospective cohort study of all patients admitted to our institution between January 1st, 2016 and July 17st, 2019 who underwent EEI outside of an emergency department or operating room. Nighttime was defined as between 7:00 pm and 6:59 am. The primary outcome was the rate of first pass success. Logistic regression was utilized with adjustment for demographic, morbidity and procedure related covariables.

RESULTS

The final examined cohort included 1,674 EEI during the day and 1,229 EEI at night. The unadjusted rate of first pass success was not different between the day and night (77.5% vs. 74.6%, unadjusted odds ratio (OR): 0.85; 95% confidence interval (CI): 0.72, 1.0; P = 0.073 though following adjustment for prespecified covariables the odds of first pass success was lower at night (adjusted OR: 0.83, 95% CI: 0.69, 0.99; P = 0.042. Obesity was found to be an effect modifier on first pass success rate for day vs. night intubations. In obese patients, nighttime intubations had significantly lower odds of first pass success (adjusted OR: 0.71, 95% CI: 0.52, 0.98; P = 0.037).

DISCUSSION

After adjustment for patient and procedure related factors, we have found that the odds of first pass success is lower at night as compared to the day. This finding was, to some degree, driven by obesity which was found to be a significant effect modifier in this relationship.

Mortality Related to Intubation in Adult General ICUs: A Systematic Review and Meta-Analysis

Context: Mortality related to intubation occurs as a result of multiple factors such as patient's condition, operator's skills, equipment use, intubation time, duration of laryngoscopy and intubation, and drugs and dosage used for endotracheal intubation (ETI). Objectives: This systematic review and meta-analysis aimed to determine mortality related to intubation and the overall intensive care unit (ICU) mortality rate in adult general ICUs. Methods: We performed a systematic review and meta-analysis on randomized clinical trials and cohort and cross-sectional research from three electronic databases with hand searching. The studies reported mortality related to intubation and the overall ICU mortality rate in adult general ICUs. Our search resulted in 28 published articles without any restriction on date and language. The systematic review and meta-analysis was performed to examine mortality related to intubation and the overall ICU mortality rate. Results: We found 7,866 articles in the literature review from the three databases based on our keywords, of which 28 studies were eligible to include in the study. We observed that mortality related to intubation and the overall ICU mortality rate in intubated patients were 1% and 30%, respectively. Conclusions: This was the first comprehensive systematic review on mortality related to intubation and the overall ICU mortality rate in adult general ICUs, which showed the current care of ETI. However, it was associated with increased complications, which may increase mortality.

In-hospital airway management of COVID-19 patients

Those involved in the airway management of COVID-19 patients are particularly at risk. Here, we describe a practical, stepwise protocol for safe in-hospital airway management in patients with suspected or confirmed COVID-19 infection.

Examining the Learning Practice of Emergency Airway Management Within an Academic Medical Center: Implications for Training and Improving Outcomes

Emergency airway management (EAM) is a "high stakes" clinical practice, associated with a significant risk of procedure-related complications and patient mortality. Learning within the EAM team practice is complex and challenging for trainees. Increasing concern for patient safety and changes in the structure of medical education have resulted in educational challenges and opportunities for improvement within the EAM team practice. This paper is divided into 3 sections that describe the past, present, and future of the EAM team learning practice within a large academic institution. Section 1 provides a brief overview of the evolution of the existing practice of EAM. Key features, goals, and challenges of the practice are outlined and a recently performed needs analysis to identify areas for improvement is described. Section 2 examines the underlying assumptions regarding learning within the existing practice and explores how these assumptions fit into major theories of learning. Section 3 proposes an idealized learning practice for the EAM team which includes the assumptions regarding learners, design of the learning environment, use of technology to enhance learning, and the means of assessment and measuring success. It is hoped that through this systematic exploration of the EAM team practice, learning efficacy and efficiency will be improved and remain adaptable for challenges in the future.

Impact of a Critical Care Specialist Intervention on First Pass Success for Emergency Airway Management Outside the ICU

BACKGROUND

There has been limited investigation into the procedural outcomes of patients undergoing emergent endotracheal intubation (EEI) by a critical care medicine (CCM) specialist outside the intensive care unit (ICU). We hypothesized that EEI outside an ICU would be associated with lower rates of first pass success (FPS) as compared to inside an ICU.

METHODS

We performed a retrospective cohort study of all adult patients admitted to our academic medical center between January 1, 2016, and July 31, 2018, who underwent EEI by a CCM practitioner. The primary outcome of FPS was identified in the EEI procedure note. Secondary outcomes included difficult intubation (> 2 attempts at laryngoscopy) and mortality following EEI.

RESULTS

In total, 1958 patients (1035 [52.9%] inside ICU and 923 [47.1%]) outside an ICU) were included in the final cohort. Unadjusted rate of FPS was not different between patients intubated out of the ICU and patients intubated inside of the ICU (689 [74.7%] vs 775 [74.9%]; P = .91). There was also no difference in FPS between groups after adjusting for predictors of difficult intubation and baseline covariates (odds ratio: 0.95; 95% confidence interval, 0.75-1.2, P = .65). Mortality of patients undergoing EEI out of the ICU was higher at each examined time interval following EEI.

DISCUSSION

For EEI done by CCM practitioners, rate of FPS is not different between patients undergoing EEI outside an ICU as compared to inside an ICU. Despite the lack of difference between rates of procedural success, patient mortality following EEI outside an ICU is higher than EEI inside an ICU at all examined time points during hospitalization.

Comparison of three video laryngoscopes and direct laryngoscopy for emergency endotracheal intubation: a retrospective cohort study

OBJECTIVE

Video laryngoscopes are used for managing difficult airways. This study compared three video laryngoscopes' (Pentax-Airway Scope [Pentax], King Vision[King] and McGrath MAC [McGrath]) performances with the Macintosh direct laryngoscope (Macintosh) as emergency tracheal intubations (TIs) reference.

DESIGN

Retrospective cohort study.

SETTING

The emergency department (ED) and the intensive care unit (ICU) of two Japanese tertiary-level hospitals.

PARTICIPANTS

All consecutive video-recorded emergency TI cases in EDs and ICUs between December 2013 and June 2015.

PRIMARY OUTCOME MEASURES

The primary study endpoint was first-pass intubation success. A subgroup analysis examined the first-pass intubation success of expert versus non-expert operators. A logistic regression analysis was performed to identify the predictors of first-pass intubation success.

RESULTS

A total of 287 emergency TIs were included. The first-pass intubation success rates were 78%, 58%, 78% and 58% for the Pentax, King, McGrath and Macintosh instruments, respectively (p=0.004, Fisher's exact test). The non-expert operators' success rates were significantly higher (p=0.00004, Fisher's exact test) for the Pentax (87%) and McGrath (78%) instruments than that for the King (50%) and Macintosh (46%) instruments, unlike that of the experts (67%, 67%, 78% and 78% for Pentax, McGrath, King and Macintosh, respectively; p=0.556, Fisher's exact test). After TI indication, difficult airway characteristics, and expert versus non-expert operator parameters adjustments, the Pentax (OR=3.422, 95% CI 1.551 to 7.550; p=0.002) and McGrath (OR= 3.758, CI 1.640 to 8.612; p=0.002) instruments showed significantly higher first-pass intubation success odds when compared with the Macintosh laryngoscope (reference, OR=1). The King instrument, however, (OR=1.056; 95% CI 0.487 to 2.289, p=0.889) failed to show any significant superiority.

CONCLUSION

The Pentax and McGrath laryngoscopes showed significantly higher emergency TI first-pass intubation success rates than the King laryngoscope when compared with the Macintosh laryngoscope, especially for non-expert operators.

TRIAL REGISTRATION NUMBER

UMIN000027925; Results.

Evaluation of the laryngoscopy view using the modified Cormack-Lehane scale during tracheal intubation in an intensive care unit. A prospective observational study

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.

Evaluation of Anesthesiology Residents' Supervision Skills: A Tool to Assess Transition Towards Independent Practice

Problem

Anesthesiologists are often expected to supervise residents, nurse anesthetists, and anesthesiologist assistants in their practice. Development of a supervisory skill set is important during anesthesiology training and has a potential impact on the quality of patient care. During anesthesiology residency training, residents develop different competencies through direct supervision by a staff anesthesiologist. However, there is significant variability among anesthesia residency programs in the United States in terms of the opportunity residents have to supervise other anesthesia providers. The supervisory competency is not routinely evaluated during residency training.

Intervention

This study aimed at evaluating an educational seminar to foster the competency of supervision in anesthesiology. The 90-minute seminar included a live lecture and a series of workshops. The lecture had a duration of 45 minutes followed by three workshops of 15 minutes each. The workshops consisted of different simulated case scenarios with the participation of actors and a manikin as a patient. A debriefing session took place after the scenarios. Every resident included in the study participated in the workshops. The workshops were aligned with the learning objectives of the educational strategy.

Context

The study included 12 junior anesthesiology residents supervised by 24 senior residents during simulated clinical encounters. Quality of supervision, using the nine-item Quality of Supervision Questionnaire validated by De Oliveira Filho, and self-perception were evaluated before and after the educational intervention consisting of a face-to-face seminar and individual workshops administered during each encounter.

Impact

There was a significant difference between the overall means among senior residents for the quality of supervision measured by a nine-item quality of supervision questionnaire before and after the educational intervention program (3.11 ± 0.29 vs 3.96 ± 0.17, p < 0.01). There was no significant difference between the overall means for the self-perception of the senior residents before and after the intervention program (3.51 ± 0.54 vs. 3.48 ± 0.20).

Lessons learned

A bimodal educational intervention combining face-to-face seminars and workshops is effective to improve the quality of supervision in senior residents; however, it does not change the self-perception of the supervisory process. Addition of this type of educational intervention to the anesthesiology residency curriculum would add to the development of the supervisory competency and warrants further research in clinical situations.

Comparison of Tracheal Intubation Conditions in Operating Room and Intensive Care Unit: A Prospective, Observational Study

WHAT WE ALREADY KNOW ABOUT THIS TOPIC

WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: Tracheal intubation is a common intervention in the operating room and in the intensive care unit. The authors hypothesized that tracheal intubation using direct laryngoscopy would be associated with worse intubation conditions and more complications in the intensive care unit compared with the operating room.

METHODS

The authors prospectively evaluated during 33 months patients who were tracheally intubated with direct laryngoscopy in the operating room, and subsequently in the intensive care unit (within a 1-month time frame). The primary outcome was to compare the difference in glottic visualization using the modified Cormack-Lehane grade between intubations performed on the same patient in an intensive care unit and previously in an operating room. Secondary outcomes were to compare first-time success rate, technical difficulty (number of attempts, operator-reported difficulty, need for adjuncts), and the incidence of complications.

RESULTS

A total of 208 patients met inclusion criteria. Tracheal intubations in the intensive care unit were associated with worse glottic visualization (Cormack-Lehane grade I/IIa/IIb/III/IV: 116/24/47/19/2) compared with the operating room (Cormack-Lehane grade I/IIa/IIb/III/IV: 159/21/16/12/0; P < 0.001). First-time intubation success rate was lower in the intensive care unit (185/208; 89%) compared with the operating room (201/208; 97%; P = 0.002). Tracheal intubations in the intensive care unit had an increased incidence of moderate and difficult intubation (33/208 [16%] vs. 18/208 [9%]; P < 0.001), and need for adjuncts to direct laryngoscopy (40/208 [19%] vs. 21/208 [10%]; P = 0.002), compared with the operating room. Complications were more common during tracheal intubations in the intensive care unit (76/208; 37%) compared with the operating room (13/208; 6%; P < 0.001).

CONCLUSIONS

Compared with the operating room, tracheal intubations in the intensive care unit were associated with worse intubation conditions and an increase of complications.

Team-based model for non-operating room airway management: validation using a simulation-based study

BACKGROUND

Non-operating room (non-OR) airway management has previously been identified as an area of concern because it carries a significant risk for complications. One reason for this could be attributed to the independent practice of residents in these situations. The aim of the present study was to ascertain whether differences in performance exist between residents working alone vs with a resident partner when encountering simulated non-OR airway management scenarios.

METHODS

Thirty-six anaesthesia residents were randomized into two groups. Each group experienced three separate scenarios (two scenarios initially and then a third 6 weeks later). The scenarios consisted of one control scenario and two critical event scenarios [i.e. asystole during laryngoscopy and pulseless electrical activity (PEA) upon post-intubation institution of positive pressure ventilation]. One group experienced the simulated non-OR scenarios alone (Solo group). The other group consisted of resident pairs, participating in the same three scenarios (Team group).

RESULTS

Although the time to intubation did not differ between the Solo and Team groups, there were several differences in performance. The Team group received better overall performance ratings for the asystole (8.5 vs 5.5 out of 10; P<0.001) and PEA (8.5 vs 5.8 out of 10; P<0.001) scenarios. The Team group was also able to recognize asystole and PEA conditions faster than the Solo group [10.1 vs 23.5 s (P<0.001) and 13.3 vs 36.0 s (P<0.001), respectively].

CONCLUSIONS

Residents who performed a simulated intubation with a second trained provider had better overall performance than those who practised independently. The residents who practised in a group were also faster to diagnose serious complications, including peri-intubation asystole and PEA. Given these data, it is reasonable that training programmes consider performing all non-OR airway management with a team-based method.

Emergency Neurological Life Support: Airway, Ventilation, and Sedation

Airway management and ventilation are central to the resuscitation of the neurologically ill. These patients often have evolving processes that threaten the airway and adequate ventilation. Furthermore, intubation, ventilation, and sedative choices directly affect brain perfusion. Therefore, Airway, Ventilation, and Sedation was chosen as an Emergency Neurological Life Support protocol. Topics include airway management, when and how to intubate with special attention to hemodynamics and preservation of cerebral blood flow, mechanical ventilation settings and the use of sedative agents based on the patient's neurological status.

Expert-Performed Endotracheal Intubation-Related Complications in Trauma Patients: Incidence, Possible Risk Factors, and Outcomes in the Prehospital Setting and Emergency Department

The aim of this study was to determine complication rates and possible risk factors of expert-performed endotracheal intubation (ETI) in patients with trauma, in both the prehospital setting and the emergency department. We also investigated how the occurrence of ETI-related complications affected the survival of trauma patients. This single-center retrospective observational study included all injured patients who underwent anesthesiologist-performed ETI from 2007 to 2017. ETI-related complications were defined as hypoxemia, unrecognized esophageal intubation, regurgitation, cardiac arrest, ETI failure rescued by emergency surgical airway, dental trauma, cuff leak, and mainstem bronchus intubation. Of the 537 patients included, 23.5% experienced at least one complication. Multivariable logistic regression analysis revealed that low Glasgow Coma Scale Score (adjusted odds ratio [AOR], 0.93; 95% confidence interval [CI], 0.88-0.98), elevated heart rate (AOR, 1.01; 95% CI, 1.00-1.02), and three or more ETI attempts (AOR, 15.71; 95% CI, 3.37-73.2) were independent predictors of ETI-related complications. We also found that ETI-related complications decreased the likelihood of survival of trauma patients (AOR, 0.60; 95% CI, 0.38-0.95), independently of age, male sex, Injury Severity Score, Glasgow Coma Scale Score, and off-hours presentation. Our results suggest that airway management in trauma patients carries a very high risk; this finding has implications for the practice of airway management in injured patients.

A modified Montpellier protocol for intubating intensive care unit patients is associated with an increase in first-pass intubation success and fewer complications

BACKGROUND

The Montpellier protocol for intubating patients in the intensive care unit (ICU) is associated with a decrease in intubation-related complications. We sought to determine if implementation of a simplified version of the Montpellier protocol that removed selected components and allowed for a variety of pre-oxygenation modalities increased first-pass intubation success and reduced intubation-related complications.

METHODS

A prospective pre/post-comparison of a modified Montpellier protocol in two medical and one medical/surgical/cardiac ICU within a hospital system. The modified eight-point protocol included: fluid administration, ordering sedation, two intubation trained providers, pre-oxygenation with non-invasive positive pressure ventilation, nasal high flow cannula or non-rebreather mask, rapid sequence intubation, capnography, sedation administration, and vasopressors for shock.

RESULTS

Patient characteristics and indications for intubation were similar for the 275 intubations in the control (137) and intervention (138) periods. In the intervention vs. control periods, the modified Montpellier protocol was associated with a significant 16.2% [95% CI: 5.1-30.0%] increase in first-pass intubation success and a 12.6% [95% CI: 1.2-23.6%] reduction in all intubation-related complications.

CONCLUSION

A simplified version of the Montpellier intubation protocol for intubating ICU patients was associated with an improvement in first-pass intubation success rates and a reduction in the rate of intubation-related complications.

An analysis of emergency tracheal intubations in critically ill patients by critical care trainees

Introduction

We evaluated intensive care medicine trainees' practice of emergency intubations in the United Kingdom.

Methods

Retrospective analysis of 881 in-hospital emergency intubations over a three-year period using an online trainee logbook.

Results

Emergency intubations out-of-hours were less frequent than in-hours, both on weekdays and weekends. Complications occurred in 9% of cases, with no association with time of day/day of week (p = 0.860). Complications were associated with higher Cormack and Lehane grades (p=0.004) and number of intubation attempts (p < 0.001), but not American Society of Anesthesiologist grade. Capnography usage was ≥99% in all locations except in wards (85%; p = 0.001). Ward patients were the oldest (p < 0.001), had higher American Society of Anesthesiologist grades (p < 0.001) and lowest Glasgow Coma Scale (p < 0.001).

Conclusions

Complications of intubations are associated with higher Cormack and Lehane grades and number of attempts, but not time of day/day of week. The uptake of capnography is reassuring, although there is scope for improvement on the ward.

Are «off hours» intubations a risk factor for complications during intubation? A prospective, observational study

OBJECTIVE

To compare the complications and the difficulty of orotracheal intubation procedures performed in the Intensive Care Unit during the off-hours period and the on-hours period.

DESIGN

A prospective, observational and non-interventional cohort study covering a period of 27 months was carried out. Working days between 8:00 a. m. and 7:59 p. m. were considered «on-hours», while the remaining shifts were regarded as «off-hours».

SCOPE

An 18-bed surgical in a Intensive Care Unit of a third-level hospital.

PATIENTS

All orotracheal intubation patients admitted to the ICU from January 2015 to March 2017 were included. Patients were stratified into 2groups according to whether intubation was performed on-hours or off-hours.

INTERVENTIONS

Non-interventional study.

VARIABLES OF INTEREST

The reason for intubation, time and day on which intubation was performed, degree of intubation difficulty (number of attempts, Cormack-Lehane laryngoscopic vision, need for accessory material) and complications during intubation.

RESULTS

A total of 252 patients were intubated; of these, 132 were included in the on-hours group and 120 patients in the off-hours group. In the off-hours group we observed a greater percentage of urgent and emergent intubations compared to the on-hours group. However, no differences were found between the 2groups in relation to the other variables studied.

CONCLUSIONS

During the off-hours period, orotracheal intubation was not associated to a greater number of complications or to greater difficulty of the technique in our Unit.

Predictors of arterial desaturation during intubation: a nested case-control study of airway management-part I

Background

Arterial desaturations experienced during endotracheal intubation (ETI) may lead to poor outcomes. Thus, our primary aim was to identify predictors of arterial desaturation (pulse oximetry <90%) during the peri-intubation period and to assess outcomes of those who developed arterial hypoxemia.

Methods

Adult patients admitted to a medical and/or surgical intensive care unit (ICU) over the time period of January 1st 2013 through December 31st 2014 who required ETI were included. Only the first intubation was captured. Arterial desaturation was defined as pulse oximetry readings of <90% (hypoxemia) in the immediate peri-intubation period. Patients were then grouped in cases (those who developed desaturation) and controls (those who did not develop this complication).

Results

The final cohort included 420 patients. Arterial desaturations occurred in 74 (18%) patients. When adjusting for significant predictors on univariate analysis and known predictors of a difficult airway, only acute respiratory failure (OR 2.38; 95% CI: 1.15-4.93; P=0.02) and provider training level (OR 7.12; 95% CI: 1.65-30.67; P=0.016) remained significant. Higher pulse oximetry readings prior to intubation was found to be protective on multivariate analysis (OR 0.92; 95% CI: 0.89-0.96; P<0.01; per one percent increase).

Conclusions

Patients who were intubated for acute respiratory failure and those who were intubated by junior level trainees had increased odds of experiencing arterial desaturation in the peri-intubation period. Patients experiencing arterial desaturation had lower pulse oximetry readings prior to intubation suggesting a possible delay at intubation.

Assessing anesthesiology residents' out-of-the-operating-room (OOOR) emergent airway management

BACKGROUND

At many academic institutions, anesthesiology residents are responsible for managing emergent intubations outside of the operating room (OOOR), with complications estimated to be as high as 39%. In order to create an OOOR training curriculum, we evaluated residents' familiarity with the content and correct adherence to the American Society of Anesthesiologists' Difficult Airway Algorithm (ASA DAA).

METHODS

Residents completed a pre-simulation multiple-choice survey measuring their understanding and use of the DAA. Residents then managed an emergent, difficult OOOR intubation in the simulation center, where two trained reviewers assessed performance using checklists. Post-simulation, the residents completed a survey rating their behaviors during the simulation. The primary outcome was comprehension and adherence to the DAA as assessed by survey responses and behavior in the simulation.

RESULTS

Sixty-three residents completed both surveys and the simulation. Post-survey responses indicated a shift toward decreased self-perceived familiarity with the DAA content compared to pre-survey responses. During the simulation, 22 (35%) residents were unsuccessful with intubation. Of these, 46% placed an LMA and 46% prepared for cricothyroidotomy. Nineteen residents did not attempt intubation. Of these, only 31% considered LMA placement, and 26% initiated cricothyroidotomy.

CONCLUSIONS

Many anesthesiology residency training programs permit resident autonomy in managing emergent intubations OOOR. Residents self-reported familiarity with the content of and adherence to the DAA was higher than that observed during the simulation. Curriculum focused on comprehension of the DAA, as well as improving communication with higher-level physicians and specialists, may improve outcomes during OOORs.

Republication: All India Difficult Airway Association 2016 Guidelines for Tracheal Intubation in the Intensive Care Unit

Tracheal intubation (TI) is a routine procedure in the Intensive Care Unit (ICU) and is often lifesaving. In contrast to the controlled conditions in the operating room, critically ill patients with respiratory failure and shock are physiologically unstable. These factors, along with under evaluation of the airway and suboptimal response to preoxygenation, are responsible for a high incidence of life-threatening complications such as severe hypoxemia and cardiovascular collapse during TI in the ICU. The All India Difficult Airway Association (AIDAA) proposes a stepwise plan for safe management of the airway in critically ill patients. These guidelines have been developed based on available evidence; Wherever, robust evidence was lacking, recommendations were arrived at by consensus opinion of airway experts, incorporating the responses to a questionnaire sent to members of the (AIDAA) and Indian Society of Anaesthesiologists. Noninvasive positive pressure ventilation for preoxygenation provides adequate oxygen stores during TI for patients with respiratory pathology. Nasal insufflation of oxygen at 15 L/min can increase the duration of apnea before hypoxemia sets in. High flow nasal cannula oxygenation at 60-70 L/min may also increase safety during intubation of critically ill patients. Stable hemodynamics and gas exchange must be maintained during rapid sequence induction. It is necessary to implement an intubation protocol during routine airway management in the ICU. Adherence to a plan for difficult airway management incorporating the use of intubation aids and airway rescue devices and strategies is useful.

The All India Difficult Airway Association 2016 guidelines for tracheal intubation in the Intensive Care Unit

Tracheal intubation (TI) is a routine procedure in the Intensive Care Unit (ICU) and is often life-saving. In contrast to the controlled conditions in the operating room, critically ill patients with respiratory failure and shock are physiologically unstable. These factors, along with a suboptimal evaluation of the airway and limited oxygen reserves despite adequate pre-oxygenation, are responsible for a high incidence of life-threatening complications such as severe hypoxaemia and cardiovascular collapse during TI in the ICU. The All India Difficult Airway Association (AIDAA) proposes a stepwise plan for safe management of the airway in critically ill patients. These guidelines have been developed based on available evidence; wherever robust evidence was lacking, recommendations were arrived at by consensus opinion of airway experts, incorporating the responses to a questionnaire sent to members of the AIDAA and the Indian Society of Anaesthesiologists. Non-invasive positive pressure ventilation during pre-oxygenation improves oxygen stores in patients with respiratory pathology. Nasal insufflation of oxygen at 15 L/min can increase the duration of apnoea before the occurrence of hypoxaemia. High-flow nasal cannula oxygenation at 60-70 L/min may also increase safety during TI in critically ill patients. Stable haemodynamics and gas exchange must be maintained during rapid sequence induction. It is necessary to implement an intubation protocol during routine airway management in the ICU. Adherence to a plan for difficult airway management incorporating the use of intubation aids and airway rescue devices and strategies is useful.

Association between off-hour presentation and endotracheal-intubation-related adverse events in trauma patients with a predicted difficult airway: A historical cohort study at a community emergency department in Japan

Background

A reduction in medical staff such as occurs in hospitals during nights and weekends (off hours) is associated with a worse outcome in patients with several unanticipated critical conditions. Although difficult airway management (DAM) requires the simultaneous assistance of several appropriately trained medical caregivers, data are scarce regarding the association between off-hour presentation and endotracheal intubation (ETI)-related adverse events, especially in the trauma population. The aim of this study was to determine whether off-hour presentation was associated with ETI complications in injured patients with a predicted difficult airway.

Methods

This historical cohort study was conducted at a Japanese community emergency department (ED). All patients with inhalation burn, comminuted facial trauma (Abbreviated Injury Scale Score Face ≥3), and penetrating neck injury who underwent ETI from January 2007 to January 2016 in our ED were included. Primary exposure was off-hour presentation, defined as the period from 6:01 PM to 8:00 AM weekdays plus the entire weekend. The primary outcome measure was the occurrence of an ETI-related adverse event, including hypoxemia, unrecognized esophageal intubation, regurgitation, cardiac arrest, ETI failure rescued by emergency surgical airway, cuff leak, and mainstem bronchus intubation.

Results

Of the 123 patients, 75 (61.0 %) were intubated during off hours. Crude analysis showed that off-hour presentation was significantly associated with an increased risk of ETI-related adverse events [odds ratio (OR), 2.5; 95 % confidence interval (CI), 1.1–5.6; p = 0.033]. The increased risk remained significant after adjusting for potential confounders, including operator being an anesthesiologist, use of a paralytic agent, and injury severity score (OR, 3.0; 95 % CI, 1.1–8.4; p = 0.034).

Conclusions

In this study, off-hour presentation was independently associated with ETI-related adverse events in trauma patients with a predicted difficult airway. These data imply the need for more attentive hospital care during nights and weekends.

Electronic supplementary material

The online version of this article (doi:10.1186/s13049-016-0296-2) contains supplementary material, which is available to authorized users.

Incidence Rate of Post-Intubation Tracheal Stenosis in Patients Admitted to Five Intensive Care Units in Iran

Background

Tracheal stenosis is one of the worst complications associated with endotracheal intubation and it is the most common reason for reconstructive airway surgeries. Due to various local risk factors, the incidence rate of tracheal stenosis may vary in different countries. In order to estimate the incidence rate of post-intubation tracheal stenosis (PITS) in patients admitted to an intensive care unit (ICU), a follow-up study was planned. As there was no similar methodological model in the literature, a feasibility step was also designed to examine the whole project and to enhance the follow-up rate.

Objectives

To estimate the PITS incidence rate in patients admitted to ICUs, as well as to evaluate the feasibility of the study.

Methods

This prospective cohort study was conducted in five hospitals in two provinces (Tehran and Arak) of Iran from November 2011 to March 2013. All patients admitted to ICUs who underwent more than 24 hours of endotracheal intubation were included. Upon their discharge from the ICUs, the patients received oral and written educational materials intended to ensure a more successful follow-up. The patients were asked to come back for follow-up three months after their extubation, or sooner in case of any symptoms developing. Those with dyspnea or stridor underwent a bronchoscopy. The asymptomatic patients were given a spirometry and then they underwent a bronchoscopy if the flow-volume loop suggested airway stenosis.

Results

Some seventy-three patients (70% men) were included in the study. Multiple trauma secondary to motor vehicle accidents (52%) was the most common cause of intubation. Follow-ups were completed in only 14 (19.2%, CI = 0.109 - 0.300) patients. One patient (7%, CI = 0.007 - 0.288) developed symptomatic tracheal stenosis that was confirmed by bronchoscopy. The barriers to a successful follow-up were assessed on three levels: ineffective oral education upon discharge, improper usage of educational materials, and difficulties to attending follow-up visits. There were also some important obstacles in terms of human, time, material, and cost resources, as well as data management.

Conclusions

To enhance the follow-up rate, three strategies were proposed: patient-focused strategies such as emphasizing patient education upon discharge and providing rewards; structural-focused strategies such as scheduling home visits and uploading questionnaires onto the research center’s website; and provider-focused strategies such as selecting coordinators with good communication skills. All necessary resources should also be re-arranged for a multicenter national study.

Airway management by physician-staffed Helicopter Emergency Medical Services - a prospective, multicentre, observational study of 2,327 patients

Background

Despite numerous studies on prehospital airway management, results are difficult to compare due to inconsistent or heterogeneous data. The objective of this study was to assess advanced airway management from international physician-staffed helicopter emergency medical services.

Methods

We collected airway data from 21 helicopter emergency medical services in Australia, England, Finland, Hungary, Norway and Switzerland over a 12-month period. A uniform Utstein-style airway template was used for collecting data.

Results

The participating services attended 14,703 patients on primary missions during the study period, and 2,327 (16 %) required advanced prehospital airway interventions. Of these, tracheal intubation was attempted in 92 % of the cases. The rest were managed with supraglottic airway devices (5 %), bag-valve-mask ventilation (2 %) or continuous positive airway pressure (0.2 %). Intubation failure rates were 14.5 % (first-attempt) and 1.2 % (overall). Cardiac arrest patients showed significantly higher first-attempt intubation failure rates (odds ratio: 2.0; 95 % CI: 1.5-2.6; p < 0.001) compared to non-cardiac arrest patients. Complications were recorded in 13 %, with recognised oesophageal intubation being the most frequent (25 % of all patients with complications). For non-cardiac arrest patients, important risk predictors for first-attempt failure were patient age (a non-linear association) and administration of sedatives (reduced failure risk). The patient’s sex, provider’s intubation experience, trauma type (patient category), indication for airway intervention and use of neuromuscular blocking agents were not risk factors for first-attempt intubation failure.

Conclusions

Advanced airway management in physician-staffed prehospital services was performed frequently, with high intubation success rates and low complication rates overall. However, cardiac arrest patients showed significantly higher first-attempt failure rates compared to non-cardiac arrest patients. All failed intubations were handled successfully with a rescue device or surgical airway.

Trial registration

Study registration: www.clinicaltrials.govNCT01502111. Registered 22 December 2011.