1
|
Del Santo T, DI Filippo A, Romagnoli S. Rapid sequence induction of anesthesia: works in progress and steps forward with focus to oxygenation and monitoring techniques. Minerva Anestesiol 2024; 90:181-190. [PMID: 37851418 DOI: 10.23736/s0375-9393.23.17569-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2023]
Abstract
The description of the main scientifically consolidated innovations in recent years on Rapid Sequence Induction have been the subject of this narrative review. Data sources were PubMed, EMBASE, Web of Science, the Cochrane Central Register of Controlled Trials, and ClinicaTrials.gov, searched up to March 21st, 2023; rapid sequence induction and anesthesia were used as key word for the research. In recent years at least three significant innovations which have improved the procedure: firstly the possibility of using drugs which rapidly reverse the action of the myorelaxants and which have made it possible to give up the use of succinylcholine, replaced by rocuronium; secondly, the possibility of using much more effective pre-oxygenation methods than in the past, also through apneic oxygenation techniques which allow longer apnea time, and finally new monitoring systems much more effective than pulse oximetry in identifying and predicting periprocedural hypoxemia and indicating the need for ventilation in patients at risk of hypoxemia and preventing it. The description of three main scientifically consolidated innovations in recent years, in pharmacology, oxygen method of administration and monitoring, have been the subject of this narrative review.
Collapse
Affiliation(s)
- Tommaso Del Santo
- Department of Health Sciences, University of Florence, Florence, Italy
| | | | - Stefano Romagnoli
- Department of Health Sciences, University of Florence, Florence, Italy
| |
Collapse
|
2
|
Gómez-Ríos MÁ, Sastre JA, Onrubia-Fuertes X, López T, Abad-Gurumeta A, Casans-Francés R, Gómez-Ríos D, Garzón JC, Martínez-Pons V, Casalderrey-Rivas M, Fernández-Vaquero MÁ, Martínez-Hurtado E, Martín-Larrauri R, Reviriego-Agudo L, Gutierrez-Couto U, García-Fernández J, Serrano-Moraza A, Rodríguez Martín LJ, Camacho Leis C, Espinosa Ramírez S, Fandiño Orgeira JM, Vázquez Lima MJ, Mayo-Yáñez M, Parente-Arias P, Sistiaga-Suárez JA, Bernal-Sprekelsen M, Charco-Mora P. Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR), Spanish Society of Emergency and Emergency Medicine (SEMES) and Spanish Society of Otolaryngology, Head and Neck Surgery (SEORL-CCC) Guideline for difficult airway management. Part I. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2024; 71:171-206. [PMID: 38340791 DOI: 10.1016/j.redare.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 08/28/2023] [Indexed: 02/12/2024]
Abstract
The Airway Management section of the Spanish Society of Anesthesiology, Resuscitation, and Pain Therapy (SEDAR), the Spanish Society of Emergency Medicine (SEMES), and the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) present the Guide for the comprehensive management of difficult airway in adult patients. Its principles are focused on the human factors, cognitive processes for decision-making in critical situations, and optimization in the progression of strategies application to preserve adequate alveolar oxygenation in order to enhance safety and the quality of care. The document provides evidence-based recommendations, theoretical-educational tools, and implementation tools, mainly cognitive aids, applicable to airway management in the fields of anesthesiology, critical care, emergencies, and prehospital medicine. For this purpose, an extensive literature search was conducted following PRISMA-R guidelines and was analyzed using the GRADE methodology. Recommendations were formulated according to the GRADE methodology. Recommendations for sections with low-quality evidence were based on expert opinion through consensus reached via a Delphi questionnaire.
Collapse
Affiliation(s)
- M Á Gómez-Ríos
- Anesthesiology and Perioperative Medicine. Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain.
| | - J A Sastre
- Anesthesiology and Perioperative Medicine. Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - X Onrubia-Fuertes
- Department of Anesthesiology, Hospital Universitari Dr Peset, Valencia, Spain
| | - T López
- Anesthesiology and Perioperative Medicine. Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - A Abad-Gurumeta
- Department of Anesthesiology, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - R Casans-Francés
- Department of Anesthesiology. Hospital Universitario Infanta Elena, Valdemoro, Madrid, Spain
| | | | - J C Garzón
- Anesthesiology and Perioperative Medicine. Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - V Martínez-Pons
- Department of Anesthesiology, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - M Casalderrey-Rivas
- Department of Anesthesiology, Complejo Hospitalario Universitario de Ourense, Ourense, Spain
| | - M Á Fernández-Vaquero
- Department of Anesthesiology, Hospital Clínica Universitaria de Navarra, Madrid, Spain
| | - E Martínez-Hurtado
- Department of Anesthesiology, Hospital Universitario Infanta Leonor, Madrid, Spain
| | | | - L Reviriego-Agudo
- Department of Anesthesiology. Hospital Clínico Universitario, Valencia, Spain
| | - U Gutierrez-Couto
- Biblioteca, Complejo Hospitalario Universitario de Ferrol (CHUF), Ferrol, A Coruña, Spain
| | - J García-Fernández
- Department of Anesthesiology, Hospital Universitario Puerta de Hierro-Majadahonda, Majadahonda, Madrid, Spain; President of the Spanish Society of Anesthesiology, Resuscitation and Pain Therapy (SEDAR), Spain
| | | | | | | | | | - J M Fandiño Orgeira
- Servicio de Urgencias, Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain
| | - M J Vázquez Lima
- Emergency Department, Hospital do Salnes, Vilagarcía de Arousa, Pontevedra, Spain; President of the Spanish Emergency Medicine Society (SEMES), Spain
| | - M Mayo-Yáñez
- Department of Otorhinolaryngology/Head Neck Surgery, Complexo Hospitalario Universitario A Coruña, A Coruña, Spain
| | - P Parente-Arias
- Department of Otorhinolaryngology/Head Neck Surgery, Complexo Hospitalario Universitario A Coruña, A Coruña, Spain
| | - J A Sistiaga-Suárez
- Department of Otorhinolaryngology, Hospital Universitario Donostia, Donostia, Gipuzkoa, Spain
| | - M Bernal-Sprekelsen
- Department of Otorhinolaryngology, Hospital Clínic Barcelona, University of Barcelona, Barcelona, Spain; President of the Spanish Society for Otorhinolaryngology Head & Neck Surgery (SEORL-CCC), Spain
| | - P Charco-Mora
- Department of Anesthesiology, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| |
Collapse
|
3
|
Araújo B, Rivera A, Martins S, Abreu R, Cassa P, Silva M, Gallo de Moraes A. Video versus direct laryngoscopy in critically ill patients: an updated systematic review and meta-analysis of randomized controlled trials. Crit Care 2024; 28:1. [PMID: 38167459 PMCID: PMC10759602 DOI: 10.1186/s13054-023-04727-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 11/08/2023] [Indexed: 01/05/2024] Open
Abstract
BACKGROUND The utilization of video laryngoscopy (VL) has demonstrated superiority over direct laryngoscopy (DL) for intubation in surgical settings. However, its effectiveness in the intensive care unit and emergency department settings remains uncertain. METHODS We systematically searched PubMed, Embase, Cochrane, and ClinicalTrials.gov databases for randomized controlled trials (RCTs) comparing VL versus DL in critically ill patients. Critical setting was defined as emergency department and intensive care unit. This systematic review and meta-analysis followed Cochrane and PRISMA recommendations. R version 4.3.1 was used for statistical analysis and heterogeneity was examined with I2 statistics. All outcomes were submitted to random-effect models. RESULTS Our meta-analysis of 14 RCTs, compromising 3981 patients assigned to VL (n = 2002) or DL (n = 1979). Compared with DL, VL significantly increased successful intubations on the first attempt (RR 1.12; 95% CI 1.04-1.20; p < 0.01; I2 = 82%). Regarding adverse events, VL reduced the number of esophageal intubations (RR 0.44; 95% CI 0.24-0.80; p < 0.01; I2 = 0%) and incidence of aspiration episodes (RR 0.63; 95% CI 0.41-0.96; p = 0.03; I2 = 0%) compared to DL. CONCLUSION VL is a more effective and safer strategy compared with DL for increasing successful intubations on the first attempt and reducing esophageal intubations in critically ill patients. Our findings support the routine use of VL in critically ill patients. Registration CRD42023439685 https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42023439685 . Registered 6 July 2023.
Collapse
Affiliation(s)
- Beatriz Araújo
- Department of Medicine, Nove de Julho University, 90 Dom Jaime de Barros Câmara Avenue, São Bernardo do Campo, São Paulo, Brazil
| | - André Rivera
- Department of Medicine, Nove de Julho University, 90 Dom Jaime de Barros Câmara Avenue, São Bernardo do Campo, São Paulo, Brazil
| | - Suzany Martins
- Department of Medicine, Nove de Julho University, 90 Dom Jaime de Barros Câmara Avenue, São Bernardo do Campo, São Paulo, Brazil
| | - Renatha Abreu
- Department of Medicine, Nove de Julho University, 90 Dom Jaime de Barros Câmara Avenue, São Bernardo do Campo, São Paulo, Brazil
| | - Paula Cassa
- Department of Medicine, Nove de Julho University, 90 Dom Jaime de Barros Câmara Avenue, São Bernardo do Campo, São Paulo, Brazil
| | - Maicon Silva
- Department of Medicine, Nove de Julho University, 90 Dom Jaime de Barros Câmara Avenue, São Bernardo do Campo, São Paulo, Brazil
| | | |
Collapse
|
4
|
Ismath M, Black H, Hrymak C, Rosychuk RJ, Archambault P, Fok PT, Audet T, Dufault B, Hohl C, Leeies M. Characterizing intubation practices in response to the COVID-19 pandemic: a survey of the Canadian COVID-19 Emergency Department Rapid Response Network (CCEDRRN) sites. BMC Emerg Med 2023; 23:139. [PMID: 38001415 PMCID: PMC10675858 DOI: 10.1186/s12873-023-00911-w] [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: 03/19/2023] [Accepted: 11/20/2023] [Indexed: 11/26/2023] Open
Abstract
OBJECTIVE The risk of occupational exposure during endotracheal intubation has required the global Emergency Medicine (EM), Anesthesia, and Critical Care communities to institute new COVID- protected intubation guidelines, checklists, and protocols. This survey aimed to deepen the understanding of the changes in intubation practices across Canada by evaluating the pre-COVID-19, early-COVID-19, and present-day periods, elucidating facilitators and barriers to implementation, and understanding provider impressions of the effectiveness and safety of the changes made. METHODS We conducted an electronic, self-administered, cross-sectional survey of EM physician site leads within the Canadian COVID-19 Emergency Department Rapid Response Network (CCEDRRN) to characterize and compare airway management practices in the pre-COVID-19, early-COVID-19, and present-day periods. Ethics approval for this study was obtained from the University of Manitoba Health Research Ethics Board. The electronic platform SurveyMonkey ( www.surveymonkey.com ) was used to collect and store survey tool responses. Categorical item responses, including the primary outcome, are reported as numbers and proportions. Variations in intubation practices over time were evaluated through mixed-effects logistic regression models. RESULTS Invitations were sent to 33 emergency department (ED) physician site leads in the CCEDRRN. We collected 27 survey responses, 4 were excluded, and 23 analysed. Responses were collected in English (87%) and French (13%), from across Canada and included mainly physicians practicing in mainly Academic and tertiary sites (83%). All respondents reported that the intubation protocols used in their EDs changed in response to the COVID-19 pandemic (100%, n = 23, 95% CI 0.86-1.00). CONCLUSIONS This study provides a novel summary of changes to airway management practices in response to the evolving COVID-19 pandemic in Canada. Information from this study could help inform a consensus on safe and effective emergent intubation of persons with communicable respiratory infections in the future.
Collapse
Affiliation(s)
- Muzeen Ismath
- Department of Emergency Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Holly Black
- Department of Emergency Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Carmen Hrymak
- Department of Emergency Medicine, University of Manitoba, Winnipeg, MB, Canada
- George & Fay Yee Centre for Healthcare Innovation, Winnipeg, MB, Canada
| | - Rhonda J Rosychuk
- Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Patrick Archambault
- Department of Family Medicine and Emergency Medicine, Department of Anesthesiology and Intensive Care, Université Laval, Québec, QC, Canada
| | - Patrick T Fok
- Department of Emergency Medicine, Dalhousie University, Halifax, NS, Canada
| | - Thomas Audet
- Department of Internal Medicine, Université Laval, Québec, QC, Canada
| | - Brenden Dufault
- George & Fay Yee Centre for Healthcare Innovation, Winnipeg, MB, Canada
- Department of Community Health Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Corinne Hohl
- Deparment of Emergency Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Murdoch Leeies
- Department of Emergency Medicine, University of Manitoba, Winnipeg, MB, Canada.
- Rady Faculty of Health Sciences, Section of Critical Care Medicine, University of Manitoba, Winnipeg, MB, Canada.
| |
Collapse
|
5
|
Acquisto NM, Mosier JM, Bittner EA, Patanwala AE, Hirsch KG, Hargwood P, Oropello JM, Bodkin RP, Groth CM, Kaucher KA, Slampak-Cindric AA, Manno EM, Mayer SA, Peterson LKN, Fulmer J, Galton C, Bleck TP, Chase K, Heffner AC, Gunnerson KJ, Boling B, Murray MJ. Society of Critical Care Medicine Clinical Practice Guidelines for Rapid Sequence Intubation in the Critically Ill Adult Patient. Crit Care Med 2023; 51:1411-1430. [PMID: 37707379 DOI: 10.1097/ccm.0000000000006000] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
Abstract
RATIONALE Controversies and practice variations exist related to the pharmacologic and nonpharmacologic management of the airway during rapid sequence intubation (RSI). OBJECTIVES To develop evidence-based recommendations on pharmacologic and nonpharmacologic topics related to RSI. DESIGN A guideline panel of 20 Society of Critical Care Medicine members with experience with RSI and emergency airway management met virtually at least monthly from the panel's inception in 2018 through 2020 and face-to-face at the 2020 Critical Care Congress. The guideline panel included pharmacists, physicians, a nurse practitioner, and a respiratory therapist with experience in emergency medicine, critical care medicine, anesthesiology, and prehospital medicine; consultation with a methodologist and librarian was available. A formal conflict of interest policy was followed and enforced throughout the guidelines-development process. METHODS Panelists created Population, Intervention, Comparison, and Outcome (PICO) questions and voted to select the most clinically relevant questions for inclusion in the guideline. Each question was assigned to a pair of panelists, who refined the PICO wording and reviewed the best available evidence using predetermined search terms. The Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) framework was used throughout and recommendations of "strong" or "conditional" were made for each PICO question based on quality of evidence and panel consensus. Recommendations were provided when evidence was actionable; suggestions, when evidence was equivocal; and best practice statements, when the benefits of the intervention outweighed the risks, but direct evidence to support the intervention did not exist. RESULTS From the original 35 proposed PICO questions, 10 were selected. The RSI guideline panel issued one recommendation (strong, low-quality evidence), seven suggestions (all conditional recommendations with moderate-, low-, or very low-quality evidence), and two best practice statements. The panel made two suggestions for a single PICO question and did not make any suggestions for one PICO question due to lack of evidence. CONCLUSIONS Using GRADE principles, the interdisciplinary panel found substantial agreement with respect to the evidence supporting recommendations for RSI. The panel also identified literature gaps that might be addressed by future research.
Collapse
Affiliation(s)
- Nicole M Acquisto
- Department of Pharmacy and Emergency Medicine, University of Rochester Medical Center, Rochester, New York, NY
| | - Jarrod M Mosier
- Department of Emergency Medicine and Medicine, University of Arizona College of Medicine, Tucson, AZ
| | - Edward A Bittner
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA
| | - Asad E Patanwala
- Faculty of Medicine and Health, Sydney School of Pharmacy, The University of Sydney, Sydney, Australia
| | - Karen G Hirsch
- Department of Neurology and Neurological Sciences and Neurosurgery, Stanford University, Stanford, CA
| | - Pamela Hargwood
- Robert Wood Johnson Library of the Health Sciences, Rutgers University, New Brunswick, NJ
| | - John M Oropello
- Institute for Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ryan P Bodkin
- Department of Emergency Medicine, University of Rochester Medical Center, Rochester, New York, NY
| | - Christine M Groth
- Department of Pharmacy, University of Rochester Medical Center, Rochester, New York, NY
| | - Kevin A Kaucher
- Department of Pharmacy, University of New Mexico Hospital, Albuquerque, NM
| | | | - Edward M Manno
- Department of Neurology, Northwestern University, Feinberg School of Medicine, Chicago, IL
| | - Stephen A Mayer
- Departments of Neurology and Neurosurgery Westchester Medical Center, New York Medical College, New York, NY
| | - Lars-Kristofer N Peterson
- Departments of Critical Care Medicine and Emergency Medicine, Cooper University Health Care, Camden, NJ
| | - Jeremy Fulmer
- Respiratory Care Services, Geisinger Medical Center, Danville, PA
| | - Christopher Galton
- Departments of Anesthesiology and Perioperative Medicine and Emergency Medicine, University of Rochester Medical Center, Rochester, NY
| | - Thomas P Bleck
- Department of Neurology, Northwestern University, Feinberg School of Medicine, Chicago, IL
| | - Karin Chase
- Departments of Surgery and Emergency Medicine, University of Rochester Medical Center, Rochester, NY
| | - Alan C Heffner
- Departments of Critical Care and Emergency Medicine, Atrium Healthcare System, Charlotte, NC
| | - Kyle J Gunnerson
- Department of Emergency Medicine, University of Michigan Health System, Ann Arbor, MI
| | - Bryan Boling
- Department of Anesthesiology, Division or Critical Care Medicine, University of Kentucky, Lexington, KY
| | - Michael J Murray
- Departments of Anesthesiology and Internal Medicine/Cardiology, University of Arizona College of Medicine, Phoenix, AZ
| |
Collapse
|
6
|
Khara B, Tobias JD. Perioperative Care of the Pediatric Patient and an Algorithm for the Treatment of Intraoperative Bronchospasm. J Asthma Allergy 2023; 16:649-660. [PMID: 37384067 PMCID: PMC10295469 DOI: 10.2147/jaa.s414026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 06/17/2023] [Indexed: 06/30/2023] Open
Abstract
Asthma remains a common comorbid condition in patients presenting for anesthetic care. As a chronic inflammatory disease of the airway, asthma is known to increase the risk of intraoperative bronchospasm. As the incidence and severity of asthma and other chronic respiratory conditions that alter airway reactivity is increasing, a greater number of patients at risk for perioperative bronchospasm are presenting for anesthetic care. As bronchospasm remains one of the more common intraoperative adverse events, recognizing and mitigating preoperative risk factors and having a pre-determined treatment algorithm for acute events are essential to ensuring effective resolution of this intraoperative emergency. The following article reviews the perioperative care of pediatric patients with asthma, discusses modifiable risk factors for intraoperative bronchospasm, and outlines the differential diagnosis of intraoperative wheezing. Additionally, a treatment algorithm for intraoperative bronchospasm is suggested.
Collapse
Affiliation(s)
- Birva Khara
- Department of Anesthesiology, Shree Krishna Hospital, Pramukhswami Medical College and Bhaikaka University, Karamsad, Gujarat, India
| | - Joseph D Tobias
- Department of Anesthesiology & Pain Medicine, Nationwide Children’s Hospital, Columbus, OH, USA
- The Ohio State University College of Medicine, Columbus, OH, USA
| |
Collapse
|
7
|
von Vopelius-Feldt J, Peddle M, Lockwood J, Mal S, Sawadsky B, Diamond W, Williams T, Baumber B, Van Houwelingen R, Nolan B. The effect of a multi-faceted quality improvement program on paramedic intubation success in the critical care transport environment: a before-and-after study. Scand J Trauma Resusc Emerg Med 2023; 31:9. [PMID: 36814266 PMCID: PMC9945597 DOI: 10.1186/s13049-023-01074-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 02/13/2023] [Indexed: 02/24/2023] Open
Abstract
INTRODUCTION Endotracheal intubation (ETI) is an infrequent but key component of prehospital and retrieval medicine. Common measures of quality of ETI are the first pass success rates (FPS) and ETI on the first attempt without occurrence of hypoxia or hypotension (DASH-1A). We present the results of a multi-faceted quality improvement program (QIP) on paramedic FPS and DASH-1A rates in a large regional critical care transport organization. METHODS We conducted a retrospective database analysis, comparing FPS and DASH-1A rates before and after implementation of the QIP. We included all patients undergoing advanced airway management with a first strategy of ETI during the time period from January 2016 to December 2021. RESULTS 484 patients met the inclusion criteria during the study period. Overall, the first pass intubation success (FPS) rate was 72% (350/484). There was an increase in FPS from the pre-intervention period (60%, 86/144) to the post-intervention period (86%, 148/173), p < 0.001. DASH-1A success rates improved from 45% (55/122) during the pre-intervention period to 55% (84/153) but this difference did not meet pre-defined statistical significance (p = 0.1). On univariate analysis, factors associated with improved FPS rates were the use of video-laryngoscope (VL), neuromuscular blockage, and intubation inside a healthcare facility. CONCLUSIONS A multi-faceted advanced airway management QIP resulted in increased FPS intubation rates and a non-significant improvement in DASH-1A rates. A combination of modern equipment, targeted training, standardization and ongoing clinical governance is required to achieve and maintain safe intubation by paramedics in the prehospital and retrieval environment.
Collapse
Affiliation(s)
- Johannes von Vopelius-Feldt
- Ornge, 5310 Explorer Drive, Mississauga, ON, L4W 5H8, Canada. .,Department of Emergency Medicine, St. Michael's Hospital Toronto, 36 Queen St East, Toronto, ON, M5B 1W8, Canada.
| | - Michael Peddle
- Ornge, 5310 Explorer Drive, Mississauga, ON L4W 5H8 Canada ,grid.412745.10000 0000 9132 1600Department of Emergency Medicine, London Health Sciences Centre, 800 Commissioners Drive, London, ON N6A 5W9 Canada
| | - Joel Lockwood
- Ornge, 5310 Explorer Drive, Mississauga, ON L4W 5H8 Canada ,grid.415502.7Department of Emergency Medicine, St. Michael’s Hospital Toronto, 36 Queen St East, Toronto, ON M5B 1W8 Canada
| | - Sameer Mal
- Ornge, 5310 Explorer Drive, Mississauga, ON L4W 5H8 Canada ,grid.412745.10000 0000 9132 1600Department of Emergency Medicine, London Health Sciences Centre, 800 Commissioners Drive, London, ON N6A 5W9 Canada
| | - Bruce Sawadsky
- Ornge, 5310 Explorer Drive, Mississauga, ON L4W 5H8 Canada ,grid.413104.30000 0000 9743 1587Department of Emergency Medicine, Sunnybrook Health Sciences Centre, 2075 Bayview Ave, Toronto, ON M4N 3M5 Canada
| | - Wayde Diamond
- Ornge, 5310 Explorer Drive, Mississauga, ON L4W 5H8 Canada
| | - Tara Williams
- Ornge, 5310 Explorer Drive, Mississauga, ON L4W 5H8 Canada
| | - Brad Baumber
- Ornge, 5310 Explorer Drive, Mississauga, ON L4W 5H8 Canada
| | | | - Brodie Nolan
- Ornge, 5310 Explorer Drive, Mississauga, ON L4W 5H8 Canada ,grid.415502.7Department of Emergency Medicine, St. Michael’s Hospital Toronto, 36 Queen St East, Toronto, ON M5B 1W8 Canada
| |
Collapse
|
8
|
Snavely C, Chan C. Resuscitation of the Obstetric Patient. Emerg Med Clin North Am 2023; 41:323-335. [PMID: 37024167 DOI: 10.1016/j.emc.2022.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
Pregnancy is a time of tremendous physiologic change and vulnerability. At any point, symptoms and complications can prompt the need for emergency care, and these can range from minor to life-threatening. Emergency physicians must be prepared to treat any of these complications, in addition to rescucitating the critically ill and injured pregnant patient. To optimally care for these patients, it is paramount to be aware of the unique physiologic changes that occur during pregnancy. The focus of this review is to discuss illnesses unique to pregnancy and additional aspects of resuscitation that must be considered when caring for a critically ill pregnant patient.
Collapse
Affiliation(s)
- Cheyenne Snavely
- Department of Medicine, University of Maryland Medical Center, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA.
| | - Caleb Chan
- Department of Medicine, University of Maryland Medical Center, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA; Department of Emergency Medicine, University of Maryland School of Medicine, 110 South Paca Street, 6th Floor, Suite 200, Baltimore, MD 21201, USA
| |
Collapse
|
9
|
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] [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.
Collapse
Affiliation(s)
- Holly Black
- Department of Emergency Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada.
| | - Thomas Hall
- grid.21613.370000 0004 1936 9609Department of Anaesthesia, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB Canada
| | - Carmen Hrymak
- grid.21613.370000 0004 1936 9609Department of Emergency Medicine, Department of Internal Medicine Section of Critical Care, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB Canada
| | - Duane Funk
- grid.21613.370000 0004 1936 9609Department of Anaesthesia, Department of Internal Medicine Section of Critical Care, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB Canada
| | - Faisal Siddiqui
- grid.21613.370000 0004 1936 9609Department of Anaesthesia, Department of Internal Medicine Section of Critical Care, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB Canada
| | - John Sokal
- grid.21613.370000 0004 1936 9609Department of Emergency Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB Canada
| | - Jaime Satoudian
- grid.413899.e0000 0004 0633 2743Department of Respiratory Therapy, Health Sciences Center, Winnipeg, MB Canada
| | - Kendra Foster
- grid.413899.e0000 0004 0633 2743Department of Respiratory Therapy, Health Sciences Center, Winnipeg, MB Canada
| | - Stephen Kowalski
- grid.21613.370000 0004 1936 9609Department 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
- grid.21613.370000 0004 1936 9609Department of Emergency Medicine, Department of Internal Medicine Section of Critical Care, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB Canada
| |
Collapse
|
10
|
Hampton JP, Hommer K, Musselman M, Bilhimer M. Rapid sequence intubation and the role of the emergency medicine pharmacist: 2022 update. Am J Health Syst Pharm 2022; 80:182-195. [PMID: 36306474 PMCID: PMC9620375 DOI: 10.1093/ajhp/zxac326] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Indexed: 12/05/2022] Open
Abstract
PURPOSE The dosing, potential adverse effects, and clinical outcomes of the most commonly utilized pharmacologic agents for rapid sequence intubation (RSI) are reviewed for the practicing emergency medicine pharmacist (EMP). SUMMARY RSI is the process of establishing a safe, functional respiratory system in patients unable to effectively breathe on their own. Various medications are chosen to sedate and even paralyze the patient to facilitate an efficient endotracheal intubation. The mechanism of action and pharmacokinetic/pharmacodynamic profiles of these agents were described in a 2011 review. Since then, the role of the EMP as well as the published evidence regarding RSI agents, including dosing, adverse effects, and clinical outcomes, has grown. It is necessary for the practicing EMP to update previous practice patterns in order to continue to provide optimal patient care. CONCLUSION While the agents used in RSI have changed little, knowledge regarding optimal dosing, appropriate patient selection, and possible adverse effects continues to be gained. The EMP is a key member of the bedside care team and uniquely positioned to communicate this evolving data.
Collapse
Affiliation(s)
- Jeremy P Hampton
- University of Missouri-Kansas City School of Pharmacy, Kansas City, MO, and University Health Kansas City, Kansas City, MO, USA
| | | | | | | |
Collapse
|
11
|
Jain K, Jafra A, Sravani MV, Yaddanapudi L, Kumar P. Tracheal intubation practices and adverse events in trauma victims on arrival to trauma triage: A single centre prospective observational study. Indian J Anaesth 2022; 66:180-186. [PMID: 35497704 PMCID: PMC9053886 DOI: 10.4103/ija.ija_919_21] [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: 10/12/2021] [Revised: 02/09/2022] [Accepted: 02/16/2022] [Indexed: 11/24/2022] Open
Abstract
Background and Aims: Trauma is one of the leading causes of global disease burden. Data on airway management in trauma patients from developing countries, particularly India is sparse. Hence, we planned a prospective observational study to assess the airway management practice patterns and associated complications. Methods: The study was conducted in trauma triage of a tertiary care hospital. Data was collected on all tracheal intubations occurring in trauma victims requiring definitive airway control, a detailed proforma including patient details, mode of injury, drugs used, intubation procedure, and complications were filled out for each patient. Results: We observed that the airway in trauma patients was primarily managed by non-anaesthesia speciality residents (426 patients); anaesthesia residents were primarily called for deferred or difficult intubations. The first attempt success rate of intubation by anaesthesia residents was significantly higher than speciality residents (P = 0.0001; 95% CI 9.02-24.66). Non-anaesthesia residents used midazolam in varying doses (3-12 mg) for intubation, whereas, rapid sequence intubation was the most common technique used by anaesthesia residents. Airway injuries were the most frequent complication observed in 32.8% of patients intubated by specialty residents compared to 5.9% of patients intubated by anaesthesia residents. Conclusion: The trauma triage is a high-volume area for frequent tracheal intubations which are manned by non-anaesthesia speciality teams. A number of factors related to the patient, staff, availability of airway equipment and unfavourable surroundings impact airway management and may explain the high incidence of airway complications, such as airway injuries in these trauma victims.
Collapse
|
12
|
Meier NM, Gibbs KW. Evolving Tracheal Intubation Practice Patterns in the Pandemic Era. Chest 2021; 160:1993-1994. [PMID: 34872660 PMCID: PMC8640235 DOI: 10.1016/j.chest.2021.07.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 07/04/2021] [Indexed: 10/31/2022] Open
Affiliation(s)
- Nathan M Meier
- Section of Pulmonary, Critical Care, Allergy and Immunology, Wake Forest School of Medicine, Winston-Salem, NC
| | - Kevin W Gibbs
- Section of Pulmonary, Critical Care, Allergy and Immunology, Wake Forest School of Medicine, Winston-Salem, NC.
| |
Collapse
|
13
|
Abstract
Backgrounds: Since its first definition and publication on 1970, Rapid Sequence Induction / Intubation (RSI) technique has been accepted globally as the “standard” for doing rapid intubation after induction of anesthesia for patients with high risk of aspiration, especially in emergency situation. However, this technique is not so much a “standard” as there are numerous variations on its practice based on national surveys. Anesthesia providers have their own opinions on the practice of RSI components which need to be discussed to assess their advantages and disadvantages, while there has been no review article which discussed these controversies in the last ten years. Objectives: To review the technique differences within RSI protocols. Methods: Online databases were searched, including MEDLINE and COCHRANE for each step in the original RSI protocol using keywords such as: “rapid sequence induction” or “rapid sequence intubation” or “RSI” and “controversies” or “head position” or “cricoid pressure” or “neuromuscular blocking agent” or “NMBA” or positive pressure ventilation” or “PPV”; and so on. Articles were then sorted out based on relevancy. Results and conclusion: Supported by new evidence, RSI practices may differ in: the positioning of patient, choices of induction agent, application of cricoid pressure, choices of neuromuscular blocking agent, and the use of positive pressure ventilation. A more updated and standardized guideline should be established by referring and evaluating to these controversies.
Collapse
Affiliation(s)
- Prihatma Kriswidyatomo
- Department of Anaesthesiology and Reanimation, Faculty of Medicine, Universitas Airlangga, Dr. Soetomo General Hospital, Surabaya, Indonesia
| | - Maharani Pradnya Paramitha
- Department of Anaesthesiology and Reanimation, Faculty of Medicine, Universitas Airlangga, Dr. Soetomo General Hospital, Surabaya, Indonesia
| |
Collapse
|
14
|
Mendes PV, Besen BAMP, Lacerda FH, Ramos JGR, Taniguchi LU. Neuromuscular blockade and airway management during endotracheal intubation in Brazilian intensive care units: a national survey. Rev Bras Ter Intensiva 2021; 32:433-438. [PMID: 33053034 PMCID: PMC7595723 DOI: 10.5935/0103-507x.20200073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Accepted: 03/23/2020] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE To describe the use of neuromuscular blockade as well as other practices among Brazilian physicians in adult intensive care units. METHODS An online national survey was designed and administered to Brazilian intensivists. Questions were selected using the Delphi method and assessed physicians' demographic data, intensive care unit characteristics, practices regarding airway management, use of neuromuscular blockade and sedation during endotracheal intubation in the intensive care unit. As a secondary outcome, we applied a multivariate analysis to evaluate factors associated with the use of neuromuscular blockade. RESULTS Five hundred sixty-five intensivists from all Brazilian regions responded to the questionnaire. The majority of respondents were male (65%), with a mean age of 38 ( 8.4 years, and 58.5% had a board certification in critical care. Only 40.7% of the intensivists reported the use of neuromuscular blockade during all or in more than 75% of endotracheal intubations. In the multivariate analysis, the number of intubations performed monthly and physician specialization in anesthesiology were directly associated with frequent use of neuromuscular blockade. Etomidate and ketamine were more commonly used in the clinical situation of hypotension and shock, while propofol and midazolam were more commonly prescribed in the situation of clinical stability. CONCLUSION The reported use of neuromuscular blockade was low among intensivists, and sedative drugs were chosen in accordance with patient hemodynamic stability. These results may help the design of future studies regarding airway management in Brazil.
Collapse
Affiliation(s)
- Pedro Vitale Mendes
- Disciplina de Emergências Clínicas, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil.,Unidade de Terapia Intensiva Oncológica, Hospital São Luiz Rede D'Or - São Paulo (SP), Brasil
| | - Bruno Adler Maccagnan Pinheiro Besen
- Disciplina de Emergências Clínicas, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil.,Unidade de Terapia Intensiva, Hospital da Luz - São Paulo (SP), Brasil
| | - Fabio Holanda Lacerda
- Disciplina de Emergências Clínicas, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil
| | | | - Leandro Utino Taniguchi
- Disciplina de Emergências Clínicas, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil.,Hospital Sírio-Libanês - São Paulo (SP), Brasil
| |
Collapse
|
15
|
Jiang Y, Bash LD, Saager L. A Clinical and Budgetary Impact Analysis of Introducing Sugammadex for Routine Reversal of Neuromuscular Blockade in a Hypothetical Cohort in the US. Adv Ther 2021; 38:2689-2708. [PMID: 33871823 PMCID: PMC8107065 DOI: 10.1007/s12325-021-01701-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 03/10/2021] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Sugammadex rapidly reverses the effects of rocuronium- and vecuronium-induced neuromuscular blockade (NMB), offering a more complete and predictable NMB recovery than cholinesterase inhibitors. Despite clinical benefits, cost pressures on hospital budgets influence the choice of the NMB reversal method. This study evaluated clinical and healthcare system payer's budget impacts associated with sugammadex in the US for routine reversal of moderate or deep rocuronium- or vecuronium-induced NMB in adults undergoing surgery. METHODS A 1-year decision analytic model was constructed reflecting a set of procedures using rocuronium or vecuronium that resulted in moderate or deep NMB at the end of surgery. Two scenarios were considered for a hypothetical cohort of 100,000 patients: without sugammadex versus with sugammadex. Comparators included neostigmine (+glycopyrrolate) and no neuromuscular blocking agents (NMBAs). Total costs (in 2019 US dollars) to a healthcare system [net of costs of reversal agents and overall cost offsets via reduction in postoperative pulmonary complications (PPC)] were compared. RESULTS A total of 9971 surgical procedures utilized rocuronium or vecuronium, resulting in moderate (91.0% of cases) or deep (9.0%) blockade at the end of surgeries. In the with sugammadex scenario, sugammadex replaced neostigmine in 4156 of 9585 procedures versus the without sugammadex scenario that used only neostigmine for NMB reversal. Introducing sugammadex reduced PPC events by 12% (58 cases) among the modeled procedures, leading to a budget impact of -$3,079,703 (-$309 per modeled procedure, or a 10.9% reduction in total costs). The results did not vary qualitatively in one-way sensitivity analyses. CONCLUSIONS The additional costs of sugammadex for the reversal of rocuronium- or vecuronium-induced NMB could be offset by improved outcomes (i.e., reduced PPC events), and potentially lead to overall healthcare budgetary savings versus reversal with neostigmine or spontaneous recovery. This study provides insights into savings that can be obtained beyond the anesthesia budget, reducing the broader clinical and budgetary burden on the hospital.
Collapse
Affiliation(s)
- Yiling Jiang
- Center for Observational and Real-world Evidence (CORE), Merck Sharp & Dohme (UK) Ltd., 120 Moorgate, London, EC2Y 9AL, UK.
| | - Lori D Bash
- Center for Observational and Real-world Evidence (CORE), Merck & Co., Inc., Kenilworth, NJ, USA
| | - Leif Saager
- Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA
- Klinik fuer Anaesthesiologie Universitaetsmedizin Goettingen, Goettingen, Germany
| |
Collapse
|
16
|
Krebs W, Werman H, Jackson J, Swecker KA, Hutchison H, Rodgers M, Fulton S, Brenna CC, Stausmire J, Buderer N, Paplaskas AM. Prehospital Ketamine Use for Rapid Sequence Intubation: Are Higher Doses Associated With Adverse Events? Air Med J 2021; 40:36-40. [PMID: 33455623 DOI: 10.1016/j.amj.2020.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 10/16/2020] [Accepted: 11/18/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Ketamine for rapid sequence intubation (RSI) is typically dosed at 1 to 2 mg/kg intravenously. The need to ensure dissociation during RSI led some to administer ketamine at doses greater than 2 mg/kg. This study assessed associations between ketamine dose and adverse events. METHODS This multisite, retrospective study included adult subjects undergoing RSI with intravenous ketamine. Subjects were categorized into 2 groups: a standard ketamine dose (≤ 2 mg/kg intravenously) or a high dose (> 2 mg/kg intravenously). Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated for adverse events. RESULTS Eighty subjects received standard-dose ketamine, and 50 received high-dose ketamine. The high-dose group had a significantly (P < .05) higher proportion of trauma patients, were younger, and had higher predose blood pressure compared with the standard-dose group. High-dose ketamine was associated with greater odds of adverse events including hypotension (OR = 7.0; 95% CI, 3.0-16.6), laryngospasm (OR = 10.8; 95% CI, 1.3-93.4), bradycardia (OR = 7.5; 95% CI, 1.5-36.6), repeat medications (OR = 12.9; 95% CI, 1.5-107.9), oxygen desaturation (OR = 6.0; 95% CI, 1.8-19.9), multiple attempts (OR = 3.2; 95% CI, 1.5-6.8%), and failed airway (OR = 3.6; 95% CI, 1.0-12.7). CONCLUSION Ketamine at higher doses was associated with increased odds of adverse events. Studies assessing adverse events of ketamine at lower than standard doses in shock patients are needed.
Collapse
Affiliation(s)
- William Krebs
- Mercy Health St. Vincent Medical Center, Toledo, OH; Ohio State University, Columbus, OH.
| | | | | | | | | | | | - Scott Fulton
- Mercy Health St. Vincent Medical Center, Toledo, OH
| | | | | | | | | |
Collapse
|
17
|
|
18
|
Suttapanit K, Yuksen C, Aramvanitch K, Meemongkol T, Chandech A, Songkathee B, Nuanprom P. Comparison of the effectiveness of endotracheal tube holder with the conventional method in a manikin model. Turk J Emerg Med 2020; 20:175-179. [PMID: 33089025 PMCID: PMC7549516 DOI: 10.4103/2452-2473.297470] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 05/09/2020] [Accepted: 07/13/2020] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES: Endotracheal tube (ETT) displacement occurs by improper fixation. To fix an ETT, many types of fixation tools are employed. Thomas tube holder is one of the fixation tools widely used in many countries. This study aims to compare the ETT fixation using the Thomas tube holder with the conventional method (adhesive tape) in a mannequin model. METHODS: The fixation tools were random, using the box of six randomizes to Thomas tube holder and conventional method. After fixation, the mannequin model was being logged roll, chest compression by automated chest compression machine, and transported by the paramedic. The time to ETT fixation and displacements were recorded. RESULTS: The mean time (standard deviation) to fixate an ETT was shorter (33.0 s [7.3]) with a Thomas tube holder compared to adhesive tape (52.6 s [7.3], P < 0.001). The number and proportion of the ETT displacements were significantly less with Thomas tube holder compared to adhesive tape during log roll (16, 35.6% vs. 29, 64.4%, P = 0.011), chest compression with automated machine (23, 51.1% vs. 37, 82.2%, P = 0.003), and transport (26, 57.8% vs. 40, 88.9%, P = 0.002). CONCLUSION: The Thomas tube holder is more effective than adhesive tape in preventing ETT displacement in a mannequin subjected to log roll, chest compressions, and transportation.
Collapse
Affiliation(s)
- Karn Suttapanit
- Department of Emergency Medicine, Mahidol University, Bangkok, Thailand
| | - Chaiyaporn Yuksen
- Department of Emergency Medicine, Mahidol University, Bangkok, Thailand
| | | | | | - Arnon Chandech
- Department of Emergency Medicine, Mahidol University, Bangkok, Thailand
| | | | - Promphet Nuanprom
- Department of Emergency Medicine, Mahidol University, Bangkok, Thailand
| |
Collapse
|
19
|
Schaefer MS, Hammer M, Santer P, Grabitz SD, Patrocinio M, Althoff FC, Houle TT, Eikermann M, Kienbaum P. Succinylcholine and postoperative pulmonary complications: a retrospective cohort study using registry data from two hospital networks. Br J Anaesth 2020; 125:629-636. [DOI: 10.1016/j.bja.2020.05.059] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 05/18/2020] [Accepted: 05/19/2020] [Indexed: 12/12/2022] Open
|
20
|
Use of the intubating laryngeal mask airway in the emergency department: A ten-year retrospective review. Am J Emerg Med 2020; 38:1367-1372. [DOI: 10.1016/j.ajem.2019.11.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 11/11/2019] [Accepted: 11/12/2019] [Indexed: 12/20/2022] Open
|
21
|
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: 19] [Impact Index Per Article: 4.8] [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.
Collapse
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
| |
Collapse
|
22
|
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
| |
Collapse
|
23
|
Scott JA, Heard SO, Zayaruzny M, Walz JM. Airway Management in Critical Illness. Chest 2020; 157:877-887. [DOI: 10.1016/j.chest.2019.10.026] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 10/05/2019] [Accepted: 10/09/2019] [Indexed: 11/25/2022] Open
|
24
|
|
25
|
Fein DG, Mastroianni F, Murphy CG, Aboodi M, Malik R, Emami N, Abramowitz M, Shiloh AL, Eisen L. Impact of a Critical Care Specialist Intervention on First Pass Success for Emergency Airway Management Outside the ICU. J Intensive Care Med 2019; 36:80-88. [PMID: 31707906 DOI: 10.1177/0885066619886816] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND There has been limited investigation into the procedural outcomes of patients undergoing emergent endotracheal intubation (EEI) by a critical care medicine (CCM) specialist outside the intensive care unit (ICU). We hypothesized that EEI outside an ICU would be associated with lower rates of first pass success (FPS) as compared to inside an ICU. METHODS We performed a retrospective cohort study of all adult patients admitted to our academic medical center between January 1, 2016, and July 31, 2018, who underwent EEI by a CCM practitioner. The primary outcome of FPS was identified in the EEI procedure note. Secondary outcomes included difficult intubation (> 2 attempts at laryngoscopy) and mortality following EEI. RESULTS In total, 1958 patients (1035 [52.9%] inside ICU and 923 [47.1%]) outside an ICU) were included in the final cohort. Unadjusted rate of FPS was not different between patients intubated out of the ICU and patients intubated inside of the ICU (689 [74.7%] vs 775 [74.9%]; P = .91). There was also no difference in FPS between groups after adjusting for predictors of difficult intubation and baseline covariates (odds ratio: 0.95; 95% confidence interval, 0.75-1.2, P = .65). Mortality of patients undergoing EEI out of the ICU was higher at each examined time interval following EEI. DISCUSSION For EEI done by CCM practitioners, rate of FPS is not different between patients undergoing EEI outside an ICU as compared to inside an ICU. Despite the lack of difference between rates of procedural success, patient mortality following EEI outside an ICU is higher than EEI inside an ICU at all examined time points during hospitalization.
Collapse
Affiliation(s)
- Daniel G Fein
- Division of Pulmonary Medicine, 2013Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Fiore Mastroianni
- Division of Pulmonary, Critical Care and Sleep Medicine Division, 232890Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Charles G Murphy
- Department of Internal Medicine, 2013Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Michael Aboodi
- Division of Critical Care Medicine, 2013Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Ryan Malik
- Division of Critical Care Medicine, 2013Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Nader Emami
- Division of Critical Care Medicine, 2013Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Matthew Abramowitz
- Division of Nephrology, 2013Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Ariel L Shiloh
- Division of Critical Care Medicine, 2013Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Lewis Eisen
- Division of Critical Care Medicine, 2013Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| |
Collapse
|
26
|
Driver BE, Klein LR, Prekker ME, Cole JB, Satpathy R, Kartha G, Robinson A, Miner JR, Reardon RF. Drug Order in Rapid Sequence Intubation. Acad Emerg Med 2019; 26:1014-1021. [PMID: 30834639 DOI: 10.1111/acem.13723] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 02/04/2019] [Accepted: 02/06/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND The optimal order of drug administration (sedative first vs. neuromuscular blocking agent first) in rapid sequence intubation (RSI) is debated. OBJECTIVE We sought to determine if RSI drug order was associated with the time elapsed from administration of the first RSI drug to the end of a successful first intubation attempt. METHODS We conducted a planned secondary analysis of a randomized trial of adult ED patients undergoing emergency orotracheal intubation that demonstrated higher first-attempt success with bougie use compared to a tracheal tube + stylet. Drug choice, dose, and the order of sedative and neuromuscular blocking agent were not stipulated. We analyzed trial patients who received both a sedative and a neuromuscular blocking agent within 30 seconds of each other who were intubated successfully on the first attempt. The primary outcome was the time elapsed from complete administration of the first RSI drug to the end of the first intubation attempt, a surrogate outcome for apnea time. We performed a multivariable analysis using a mixed-effects generalized linear model. RESULTS Of 757 original trial patients, 562 patients (74%) met criteria for analysis; 153 received the sedative agent first, and 409 received the neuromuscular blocking agent first. Administration of the neuromuscular blocking agent before the sedative agent was associated with a reduction in time from RSI administration to the end of intubation attempt of 6 seconds (95% confidence interval = 0 to 11 sec). CONCLUSION Administration of either the neuromuscular blocking or the sedative agent first are both acceptable. Administering the neuromuscular blocking agent first may result in modestly faster time to intubation. For now, it is reasonable for physicians to continue performing RSI in the way they are most comfortable with. If future research determines that the order of medication administration is not associated with awareness of neuromuscular blockade, administration of the neuromuscular blocking agent first may be a logical default administration method to attempt to minimize apnea time during intubation.
Collapse
Affiliation(s)
- Brian E. Driver
- Department of Emergency Medicine Hennepin County Medical Center Minneapolis MN
| | - Lauren R. Klein
- Department of Emergency Medicine Hennepin County Medical Center Minneapolis MN
| | - Matthew E. Prekker
- Department of Emergency Medicine Hennepin County Medical Center Minneapolis MN
- Division of Pulmonary/Critical Care Department of Medicine Hennepin County Medical Center Minneapolis MN
| | - Jon B. Cole
- Department of Emergency Medicine Hennepin County Medical Center Minneapolis MN
| | - Rajesh Satpathy
- Department of Emergency Medicine Hennepin County Medical Center Minneapolis MN
| | - Gautham Kartha
- Department of Emergency Medicine Hennepin County Medical Center Minneapolis MN
| | - Aaron Robinson
- Department of Emergency Medicine Hennepin County Medical Center Minneapolis MN
| | - James R. Miner
- Department of Emergency Medicine Hennepin County Medical Center Minneapolis MN
| | - Robert F. Reardon
- Department of Emergency Medicine Hennepin County Medical Center Minneapolis MN
| |
Collapse
|
27
|
Tezcan B, Turan S, Özgök A. Current Use of Neuromuscular Blocking Agents in Intensive Care Units. Turk J Anaesthesiol Reanim 2019; 47:273-281. [PMID: 31380507 DOI: 10.5152/tjar.2019.33269] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Accepted: 10/08/2018] [Indexed: 11/22/2022] Open
Abstract
Neuromuscular blocking agents can be used for purposes such as eliminating ventilator-patient dyssynchrony, facilitating gas exchange by reducing intra-abdominal pressure and improving chest wall compliance, reducing risk of lung barotrauma, decreasing contribution of muscles to oxygen consumption by preventing shivering and limiting elevations in intracranial pressure caused by airway stimulation in patients supported with mechanical ventilation in intensive care units. Adult Respiratory Distress Syndrome (ARDS), status asthmaticus, increased intracranial pressure and therapeutic hypothermia following ventricular fibrillation-associated cardiac arrest are some of clinical conditions that can be sustained by neuromuscular blockade. Appropriate indication and clinical practice have gained importance considering side effects such as ICU-acquired weakness, masking seizure activity and longer durations of hospital and ICU stays. We mainly aimed to review the current literature regarding neuromuscular blockade in up-to-date clinical conditions such as improving oxygenation in early ARDS and preventing shivering in the therapeutic hypothermia along with summarising the clinical practice in adult ICU in this report.
Collapse
Affiliation(s)
- Büşra Tezcan
- Clinic of Anaesthesiology and Reanimation, Department of Intensive Care, Türkiye Yüksek İhtisas Training and Research Hospital, Ankara, Turkey
| | - Sema Turan
- Clinic of Anaesthesiology and Reanimation, Department of Intensive Care, Türkiye Yüksek İhtisas Training and Research Hospital, Ankara, Turkey
| | - Ayşegül Özgök
- Clinic of Anaesthesiology and Reanimation, Türkiye Yüksek İhtisas Training and Research Hospital, Ankara, Turkey
| |
Collapse
|
28
|
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.
Collapse
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
| |
Collapse
|
29
|
Comparison of Tracheal Intubation Conditions in Operating Room and Intensive Care Unit: A Prospective, Observational Study. Anesthesiology 2019; 129:321-328. [PMID: 29787386 DOI: 10.1097/aln.0000000000002269] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
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.
Collapse
|
30
|
Trauma Airway Management: Induction Agents, Rapid Versus Slower Sequence Intubations, and Special Considerations. Anesthesiol Clin 2018; 37:33-50. [PMID: 30711232 DOI: 10.1016/j.anclin.2018.09.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Trauma patients who require intubation are at higher risk for aspiration, agitation/combativeness, distorted anatomy, hemodynamic instability, an unstable cervical spine, and complicated injuries. Although rapid-sequence intubation is the most common technique in trauma, slow-sequence intubation may reduce the risk for failed intubation and cardiovascular collapse. Providers often choose plans with which they are most comfortable. However, developing a flexible team-based approach, through recognition of complicating factors in trauma patients, improves airway management success.
Collapse
|
31
|
Dodd KW, Prekker ME, Robinson AE, Buckley R, Reardon RF, Driver BE. Video screen viewing and first intubation attempt success with standard geometry video laryngoscope use. Am J Emerg Med 2018; 37:1336-1339. [PMID: 30528054 DOI: 10.1016/j.ajem.2018.10.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2018] [Revised: 10/15/2018] [Accepted: 10/15/2018] [Indexed: 10/28/2022] Open
Abstract
STUDY OBJECTIVES Direct laryngoscopy (DL) is the traditional approach for emergency intubation but video laryngoscopy (VL) is gaining popularity. Some studies have demonstrated higher first-attempt success with VL, particularly in difficult airways. In real-world settings, physicians choose whether or not to view the video screen when utilizing VL devices for tracheal intubation. Therefore, we sought to determine whether screen viewing is associated with higher intubation first-attempt success in clinical practice. METHODS In this retrospective, observational investigation, we studied consecutive adult emergency department intubations at an urban, academic medical center during the calendar year 2013. Cases were identified from the electronic medical record and analyzed using standard video review methodology. We compared first-attempt success rates when standard geometry Macintosh VL was used, stratified by whether the screen was viewed or not. RESULTS Of the 593 cases with videos available for review, 515 (87%) were performed with a standard geometry Macintosh video laryngoscope. First-attempt success was not significantly different when the screen was viewed (195/207; 94% [95%CI 91-97]) compared to when the screen was not viewed (284/301; 94% [95%CI 92-97]). The median first-attempt duration was longer when the screen was viewed compared to when the screen was not viewed (45 versus 33 s; median difference 12 s [95%CI 10-15 s]). CONCLUSION In this study of orotracheal intubations performed by emergency physicians with Macintosh-style VL, the first-attempt success rate was high. The success rate was similar whether or not the intubating physician chose to view the video screen.
Collapse
Affiliation(s)
- Kenneth W Dodd
- Department of Emergency Medicine, Hennepin County Medical Center, 701 Park Avenue, Minneapolis, MN 55415, United States of America; Division of Pulmonary and Critical Care Medicine, Hennepin County Medical Center, 701 Park Avenue, Minneapolis, MN 55415, United States of America.
| | - Matthew E Prekker
- Department of Emergency Medicine, Hennepin County Medical Center, 701 Park Avenue, Minneapolis, MN 55415, United States of America; Division of Pulmonary and Critical Care Medicine, Hennepin County Medical Center, 701 Park Avenue, Minneapolis, MN 55415, United States of America; Department of Emergency Medicine, University of Minnesota Medical School, 717 Delaware Street SE, Suite 508, Minneapolis, MN 55414, United States of America.
| | - Aaron E Robinson
- Department of Emergency Medicine, Hennepin County Medical Center, 701 Park Avenue, Minneapolis, MN 55415, United States of America.
| | - Ryan Buckley
- Department of Emergency Medicine, Hennepin County Medical Center, 701 Park Avenue, Minneapolis, MN 55415, United States of America.
| | - Robert F Reardon
- Department of Emergency Medicine, Hennepin County Medical Center, 701 Park Avenue, Minneapolis, MN 55415, United States of America; Department of Emergency Medicine, University of Minnesota Medical School, 717 Delaware Street SE, Suite 508, Minneapolis, MN 55414, United States of America.
| | - Brian E Driver
- Department of Emergency Medicine, Hennepin County Medical Center, 701 Park Avenue, Minneapolis, MN 55415, United States of America; Department of Emergency Medicine, University of Minnesota Medical School, 717 Delaware Street SE, Suite 508, Minneapolis, MN 55414, United States of America.
| |
Collapse
|
32
|
Baek MS, Han M, Huh JW, Lim CM, Koh Y, Hong SB. Video laryngoscopy versus direct laryngoscopy for first-attempt tracheal intubation in the general ward. Ann Intensive Care 2018; 8:83. [PMID: 30105607 PMCID: PMC6089856 DOI: 10.1186/s13613-018-0428-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 08/02/2018] [Indexed: 01/14/2023] Open
Abstract
Background Recent trials showed that video laryngoscopy (VL) did not yield higher first-attempt tracheal intubation success rate than direct laryngoscopy (DL) and was associated with higher rates of complications. Tracheal intubation can be more challenging in the general ward than in the intensive care unit. This study aimed to investigate which laryngoscopy mode is associated with higher first-attempt intubation success in a general ward. Methods This is a retrospective study of tracheal intubations conducted at a tertiary academic hospital. This analysis included all intubations performed by the medical emergency team in the general ward during a 48-month period. Results For the 958 included patients, the initial laryngoscopy mode was video laryngoscopy in 493 (52%) and direct laryngoscopy in 465 patients (48%). The overall first-attempt success rate was 69% (664 patients). The first-attempt success rate was higher with VL (79%; 391/493) than with DL (59%; 273/465, p < 0.001). The first-attempt intubation success rate was higher among experienced operators (83%; 266/319) than among inexperienced operators (62%; 398/639, p < 0.001). In multivariate logistic regression analyses, VL, pre-intubation heart rate, pre-intubation SpO2 > 80%, a non-predicted difficult airway, experienced operator, and Cormack–Lehane grade were associated with first-attempt intubation success in the general ward. Over all intubation-related complications were not different between two groups (27% for VL vs. 25% for DL). However, incidence of a post-intubation SpO2 < 80% was higher with VL than with DL (4% vs. 1%, p = 0.005), and in-hospital mortality was also higher (53.8% vs. 43%, p = 0.001). Conclusion In a general ward setting, the first-attempt intubation success rate was higher with video laryngoscopy than with direct laryngoscopy. However, video laryngoscopy did not reduce intubation-related complications. Furthers trials on best way to perform intubation in the emergency settings are required. Electronic supplementary material The online version of this article (10.1186/s13613-018-0428-0) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Moon Seong Baek
- Department of Pulmonary and Critical Care Medicine, Asan Medical Centre, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - MyongJa Han
- Medical Emergency Team, Asan Medical Centre, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jin Won Huh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Centre, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Chae-Man Lim
- Department of Pulmonary and Critical Care Medicine, Asan Medical Centre, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Younsuck Koh
- Department of Pulmonary and Critical Care Medicine, Asan Medical Centre, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea
| | - Sang-Bum Hong
- Department of Pulmonary and Critical Care Medicine, Asan Medical Centre, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul, 05505, Republic of Korea.
| |
Collapse
|
33
|
Zafirova Z, Dalton A. Neuromuscular blockers and reversal agents and their impact on anesthesia practice. Best Pract Res Clin Anaesthesiol 2018; 32:203-211. [PMID: 30322460 DOI: 10.1016/j.bpa.2018.06.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2018] [Accepted: 06/22/2018] [Indexed: 12/17/2022]
Abstract
Neuromuscular blockers have long been an intricate part of the anesthesia regimen. The scientific progress in pharmacology and physiology has strengthened their clinical relevance, has helped to delineate with precision their medical role, and has enhanced the safety and effectiveness of their use. New frontiers in research will define further the role of these agents in modern anesthesia practice and guide their expanding and discrete clinical applications.
Collapse
Affiliation(s)
- Zdravka Zafirova
- Department of Cardiovascular Surgery, Icahn School of Medicine, Mount Sinai Hospital System, 321 West 37 St, ap. 5A, New York, NY, 10018, USA.
| | - Allison Dalton
- Department of Anesthesiology and Critical Care, The University of Chicago, Chicago, USA.
| |
Collapse
|
34
|
Driver B, Dodd K, Klein LR, Buckley R, Robinson A, McGill JW, Reardon RF, Prekker ME. The Bougie and First-Pass Success in the Emergency Department. Ann Emerg Med 2017; 70:473-478.e1. [PMID: 28601269 DOI: 10.1016/j.annemergmed.2017.04.033] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Revised: 04/14/2017] [Accepted: 04/19/2017] [Indexed: 11/19/2022]
Abstract
STUDY OBJECTIVE The bougie may improve first-pass intubation success in operating room patients. We seek to determine whether bougie use is associated with emergency department (ED) first-pass intubation success. METHODS We studied consecutive adult ED intubations at an urban, academic medical center during 2013. Intubation events were identified by motion-activated video recording. We determined the association between bougie use and first-pass intubation success, adjusting for neuromuscular blockade, video laryngoscopy, abnormal airway anatomy, and whether the patient was placed in the sniffing position or the head was lifted off the bed during intubation. RESULTS Intubation with a Macintosh blade was attempted in 543 cases; a bougie was used on the majority of initial attempts (80%; n=435). First-pass success was greater with than without bougie use (95% versus 86%; absolute difference 9% [95% confidence interval {CI} 2% to 16%]). The median first-attempt duration was higher with than without bougie (40 versus 27 seconds; difference 14 seconds [95% CI 11 to 16 seconds]). Bougie use was independently associated with greater first-pass success (adjusted odds ratio 2.83 [95% CI 1.35 to 5.92]). CONCLUSION Bougie was associated with increased first-pass intubation success. Bougie use may be helpful in ED intubation.
Collapse
Affiliation(s)
- Brian Driver
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN.
| | - Kenneth Dodd
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - Lauren R Klein
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - Ryan Buckley
- University of Minnesota School of Medicine, Minneapolis, MN
| | - Aaron Robinson
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - John W McGill
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - Robert F Reardon
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - Matthew E Prekker
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN; Division of Pulmonary/Critical Care, Department of Medicine, Hennepin County Medical Center, Minneapolis, MN
| |
Collapse
|
35
|
Jiang J, Ma D, Li B, Yue Y, Xue F. Video laryngoscopy does not improve the intubation outcomes in emergency and critical patients - a systematic review and meta-analysis of randomized controlled trials. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:288. [PMID: 29178953 PMCID: PMC5702235 DOI: 10.1186/s13054-017-1885-9] [Citation(s) in RCA: 61] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Accepted: 11/06/2017] [Indexed: 01/12/2023]
Abstract
Background There is significant controversy regarding the influence of video laryngoscopy on the intubation outcomes in emergency and critical patients. This systematic review and meta-analysis was designed to determine whether video laryngoscopy could improve the intubation outcomes in emergency and critical patients. Methods We searched the Cochrane Central Register of Controlled Trials, PubMed, Embase, and Scopus databases from database inception until 15 February 2017. Only randomized controlled trials comparing video and direct laryngoscopy for tracheal intubation in emergency department, intensive care unit, and prehospital settings were selected. The primary outcome was the first-attempt success rate. Review Manager 5.3 software was used to perform the pooled analysis and assess the risk of bias for each eligible study. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) system was used to assess the quality of evidence for all outcomes. Results Twelve studies (2583 patients) were included in the review for data extraction. Pooled analysis did not show an improved first-attempt success rate using video laryngoscopy (relative risk [RR], 0.93; P = 0.28; low-quality evidence). There was significant heterogeneity among studies (I2 = 91%). Subgroup analyses showed that, in the prehospital setting, video laryngoscopy decreased the first-attempt success rate (RR, 0.57; P < 0.01; high-quality evidence) and overall success rate (RR, 0.58; 95% CI, 0.48–0.69; moderate-quality evidence) by experienced operators, whereas in the in-hospital setting, no significant difference between two devices was identified for the first-attempt success rate (RR, 1.06; P = 0.14; moderate-quality evidence), regardless of the experience of the operators or the types of video laryngoscopes used (P > 0.05), although a slightly higher overall success rate was shown (RR, 1.11; P = 0.03; moderate-quality evidence). There were no differences between devices for other outcomes (P > 0.05), except for a lower rate of esophageal intubation (P = 0.01) and a higher rate of Cormack and Lehane grade 1 (P < 0.01) when using video laryngoscopy. Conclusions On the basis of the results of this study, we conclude that, compared with direct laryngoscopy, video laryngoscopy does not improve intubation outcomes in emergency and critical patients. Prehospital intubation is even worsened by use of video laryngoscopy when performed by experienced operators. Electronic supplementary material The online version of this article (doi:10.1186/s13054-017-1885-9) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Jia Jiang
- Department of Anesthesiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, 100020, China
| | - Danxu Ma
- Department of Anesthesiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, 100020, China
| | - Bo Li
- Beijing Hospital of Traditional Chinese Medicine, affiliated with Capital Medical University, Beijing Institute of Traditional Chinese Medicine, Beijing, 100010, China
| | - Yun Yue
- Department of Anesthesiology, Beijing Chaoyang Hospital, Capital Medical University, Beijing, 100020, China.
| | - Fushan Xue
- Department of Anesthesiology, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, 100144, China.
| |
Collapse
|
36
|
Sakles JC. Maintenance of Oxygenation During Rapid Sequence Intubation in the Emergency Department. Acad Emerg Med 2017; 24:1395-1404. [PMID: 28791775 DOI: 10.1111/acem.13271] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- John C. Sakles
- Department of Emergency Medicine; University of Arizona College of Medicine; Tucson AZ
| |
Collapse
|
37
|
Huang HB, Peng JM, Xu B, Liu GY, Du B. Video Laryngoscopy for Endotracheal Intubation of Critically Ill Adults: A Systemic Review and Meta-Analysis. Chest 2017; 152:510-517. [PMID: 28629915 DOI: 10.1016/j.chest.2017.06.012] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Revised: 05/21/2017] [Accepted: 06/01/2017] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Endotracheal intubation (EI) in ICU patients is associated with an increased risk of life-threatening adverse events due to unstable conditions, rapid deterioration, limited preparation time, and variability in the expertise of operators. The goal of this study was to compare the effect of video laryngoscopy (VL) and direct laryngoscopy (DL) in ICU patients requiring EI. METHODS We searched for relevant studies in PubMed, Embase, and the Cochrane database from inception through January 30, 2017. Randomized controlled trials were included if they reported data on any of the predefined outcomes in ICU patients requiring EI and managed with VL or DL. Results were expressed as risk ratios (RRs) or mean differences (MDs) with accompanying 95% CIs. RESULTS Five randomized controlled trials with 1,301 patients were included. Despite better glottic visualization with VL (RR = 1.24; 95% CI, 1.07 to 1.43; P = .003), use of VL did not result in a significant increase in the first-attempt success rate (RR = 1.08; 95% CI, 0.92-1.26; P = .35) compared with DL. In addition, time to intubation (MD = 4.12 s; 95% CI, -15.86-24.09; P = .69), difficult intubation (RR = 0.72; 95% CI, 0.30-1.70; P = .45), mortality (RR = 1.02; 95% CI, 0.84-1.25; P = .83), and most other complications were similar between the VL and DL groups. CONCLUSIONS The VL technique did not increase the first-attempt success rate during EI in ICU patients compared with DL. These findings do not support routine use of VL in ICU patients.
Collapse
Affiliation(s)
- Hui-Bin Huang
- Medical ICU, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Peking, People's Republic of China; Department of Critical Care Medicine, the First Affiliated Hospital of Fujian Medical University, Fuzhou, People's Republic of China
| | - Jin-Min Peng
- Medical ICU, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Peking, People's Republic of China
| | - Biao Xu
- Critical Care Medicine Center, the PLA 302 Hospital, Fengtai District, Beijing, People's Republic of China
| | - Guang-Yun Liu
- Medical ICU, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Peking, People's Republic of China
| | - Bin Du
- Medical ICU, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Peking, People's Republic of China.
| |
Collapse
|
38
|
Randomized Trial of Video Laryngoscopy for Endotracheal Intubation of Critically Ill Adults. Crit Care Med 2017; 44:1980-1987. [PMID: 27355526 DOI: 10.1097/ccm.0000000000001841] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the effect of video laryngoscopy on the rate of endotracheal intubation on first laryngoscopy attempt among critically ill adults. DESIGN A randomized, parallel-group, pragmatic trial of video compared with direct laryngoscopy for 150 adults undergoing endotracheal intubation by Pulmonary and Critical Care Medicine fellows. SETTING Medical ICU in a tertiary, academic medical center. PATIENTS Critically ill patients 18 years old or older. INTERVENTIONS Patients were randomized 1:1 to video or direct laryngoscopy for the first attempt at endotracheal intubation. MEASUREMENTS AND MAIN RESULTS Patients assigned to video (n = 74) and direct (n = 76) laryngoscopy were similar at baseline. Despite better glottic visualization with video laryngoscopy, there was no difference in the primary outcome of intubation on the first laryngoscopy attempt (video 68.9% vs direct 65.8%; p = 0.68) in unadjusted analyses or after adjustment for the operator's previous experience with the assigned device (odds ratio for video laryngoscopy on intubation on first attempt 2.02; 95% CI, 0.82-5.02, p = 0.12). Secondary outcomes of time to intubation, lowest arterial oxygen saturation, complications, and in-hospital mortality were not different between video and direct laryngoscopy. CONCLUSIONS In critically ill adults undergoing endotracheal intubation, video laryngoscopy improves glottic visualization but does not appear to increase procedural success or decrease complications.
Collapse
|
39
|
Huh H, Lim HH, Kim JY, Shin HW, Lim HJ, Yoon SM, Yoon SZ, Lee HW. A Novel and Simple Method for Tracheal Intubation in a Swine Model: Preparing for the Era of Xenotransplantation. EXP CLIN TRANSPLANT 2017; 15:453-457. [PMID: 28447930 DOI: 10.6002/ect.2016.0123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES Organ transplant in humans is an established therapy for a variety of end-stage organ diseases. However, due to organ shortages and lack of donors, the need for xenotransplant has gradually increased. Xenotransplantation has great potential to solve many of the problems facing organ transplantation. Pigs are being developed as xenogeneic organ donors for use in humans. In this study, we propose a novel and simple method for tracheal intubation in a swine model using neuromuscular blocking agents and laryngeal mask airway. MATERIALS AND METHODS Eight Yorkshire pigs were used for the 2 separate experiments, which were conducted 1 week apart. In the first experiment, an anesthesiologist with no previous comparable experience performed endotracheal intubation of pigs. One week later, using the same pig, a second experiment was performed by an experienced anesthesiologist. Anesthesia was induced with intramuscular injection of a mixture of 1 mg/kg xylazine (Rompun, Bayer Korea Ltd., Seoul, Korea) and 7 mg/kg Zoletil (a mixture of tiletamine hydrochloride and zolazepam hydro-chloride, Virbac Laboratory, Carros, France). The laryngeal mask was then placed, and 0.15 mg/kg vecuronium bromide was injected intravenously. Tracheal intubation was attempted after mask removal. The duration and number of intubation attempts were recorded, and the degree of intubation difficulty was scored. RESULTS In all cases, the laryngeal mask was easily inserted, and endotracheal intubation was successfully completed. Oxygen saturation did not fall below 95%, and there were no hypoxemia episodes. Degree of intubation difficulty and duration were not significantly different between the 2 anesthesiologists. CONCLUSIONS Tracheal intubation in our swine model was successfully performed using neuromuscular blocking agents and laryngeal masks without resulting in hypoxemia, with even anesthesiologists who are unfamiliar with endotracheal intubation of pigs easily able to do so using our protocol. Therefore, our protocol will enable all investigators to perform successful tracheal intubation in swine models.
Collapse
Affiliation(s)
- Hyub Huh
- From the Department of Anesthesiology and Pain Medicine, College of Medicine, Korea University
| | | | | | | | | | | | | | | |
Collapse
|
40
|
Lemyze M, Durville E, Meddour M, Jonard M, Temime J, Barailler S, Thevenin D, Mallat J. Impact of fiber-optic laryngoscopy on the weaning process from mechanical ventilation in high-risk patients for postextubation stridor. Medicine (Baltimore) 2017; 96:e5971. [PMID: 28151886 PMCID: PMC5293449 DOI: 10.1097/md.0000000000005971] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
The objective of this study was to assess the impact of fiber-optic laryngoscopy (FOL) on the weaning process from mechanical ventilation in critically ill patients with a positive cuff leak test (CLT) as compared with the current recommended strategy based on corticosteroids.In this prospective observational pilot study conducted over a 1-year period in a 15-bed ICU, CLT was systematically performed before extubation in all intubated patients having passed a spontaneous breathing trial (SBT). After the endotracheal tube cuff was deflated, cuff leak volume (CLVol) was assessed during assisted controlled ventilation. When CLT was positive (CLVol < 110 mL), patients either were evaluated using FOL by our half-time FOL-practitioner when present, or received corticosteroids.Among the 233 patients included, 34 (14.6%) had a positive CLT that hampered extubation. Seventeen were treated by corticosteroids and 17 were evaluated by FOL. In the corticosteroids group, the CLVol was still <110 mL at 24 hours in 9 patients (53%). Corticosteroids strategy merely prolonged the total duration of mechanical ventilation (7 [4-11] vs 4 [2-6] days, P = 0.01) by increasing the time between successful SBT and the moment when extubation was effectively achieved (30 [24-60] vs 1.5 [1-2] hours, P < 0.001). This resulted in 2 self-extubations (12%) and 9 FOL-guided extubations (53%) in the corticosteroids group. Massive swelling of the arytenoids was the most common feature shown by FOL. The patients evaluated by FOL who exhibited the thin anterior V-shaped opening of the vocal cords-the V sign-(n = 26, 100%) were immediately extubated without any stridor or respiratory failure afterward.In this pilot study, a FOL-based extubation strategy was feasible and reliable, and significantly reduced the duration of mechanical ventilation in patients with a positive CLT. We describe the "V sign" of FOL that safely allows a successful prompt extubation in patients considered at high risk for postextubation stridor.
Collapse
Affiliation(s)
- Malcolm Lemyze
- Department of Respiratory and Critical Care Medicine, Schaffner Hospital, Lens
| | - Emmanuelle Durville
- Department of Respiratory and Critical Care Medicine, Schaffner Hospital, Lens
| | - Mehdi Meddour
- Department of Respiratory and Critical Care Medicine, Schaffner Hospital, Lens
| | - Marie Jonard
- Intensive Care Unit, Arras Hospital, Arras, France
| | - Johanna Temime
- Department of Respiratory and Critical Care Medicine, Schaffner Hospital, Lens
| | - Stéphanie Barailler
- Department of Respiratory and Critical Care Medicine, Schaffner Hospital, Lens
| | | | - Jihad Mallat
- Intensive Care Unit, Arras Hospital, Arras, France
| |
Collapse
|
41
|
deBacker J, Hart N, Fan E. Neuromuscular Blockade in the 21st Century Management of the Critically Ill Patient. Chest 2016; 151:697-706. [PMID: 27818334 DOI: 10.1016/j.chest.2016.10.040] [Citation(s) in RCA: 44] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Neuromuscular blockings agents (NMBAs) have a controversial role in the ventilatory and medical management of critical illness. The clinical concern surrounding NMBA-induced complications stems from evidence presented in the 2002 clinical practice guidelines, but new evidence from subsequent randomized trials and studies provides a more optimistic outlook about the application of NMBAs in the ICU. Furthermore, changes in the delivery of critical care, such as protocolized care pathways, minimizing or interrupting sedation, increased monitoring techniques, and overall improvements in reducing immobility, have created a modern, 21st century ICU environment whereby NMBAs may be administered safely. In this article we start with a review of the mechanism of action, side effects, and pharmacology of commonly used NMBAs. We then address the rationale for NMBA use for an expanding number of indications (endotracheal intubation, acute respiratory distress syndrome, status asthmaticus, increased intracranial and intra-abdominal pressure, and therapeutic hypothermia after cardiac arrest), with an emphasis on NMBA use in facilitating lung-protective ventilation for respiratory failure. We end with an appraisal over the importance of monitoring depth of paralysis and the concerns of complications, such as prolonged skeletal muscle weakness. In the context of adequate sedation and analgesia, monitored NMBA use (continuous or bolus administration) can be considered for the small number of clinical indications in critically ill patients for which evidence currently exists.
Collapse
Affiliation(s)
- Julian deBacker
- Cleveland Clinic Lerner College of Medicine, Cleveland, OH; Interdepartmental Division of Critical Care Medicine, Toronto, ON, Canada
| | - Nicholas Hart
- Lane Fox Respiratory Service, St. Thomas' Hospital, Guy's & St. Thomas' NHS Foundation Trust, London, UK
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, Toronto, ON, Canada.
| |
Collapse
|
42
|
First-Pass Intubation Success. Notf Rett Med 2016. [DOI: 10.1007/s10049-016-0168-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
43
|
Natt B, Malo J, Hypes C, Sakles J, Mosier J. Strategies to improve first attempt success at intubation in critically ill patients. Br J Anaesth 2016; 117 Suppl 1:i60-i68. [DOI: 10.1093/bja/aew061] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
|
44
|
Abstract
Although anesthesia-associated mortality has been significantly reduced down to 0.00068-0.00082% over the last decades, recent studies have revealed a high perioperative mortality of 0.8- 4%. Apart from anesthesia and surgery-induced major complications, perioperative mortality is primarily negatively influenced by individual patient comorbidities. These risk factors predispose for acute critical incidents (e.g., myocardial infarction); however, the majority of fatal complications are a result of slowly progressing conditions, particularly infections or the sequelae of systemic inflammation. This implicates a broad window of opportunity for the detection and treatment of slow-onset complications to improve the perioperative outcome. The term "failure to rescue" (FTR), i.e., the proportion of patients who die from major complications compared to the number of all patients with complications, has been introduced as a valid indicator for the quality of perioperative care. Growing evidence has already shown that FTR is an underestimated factor in perioperative medicine accounting for or at least being involved in the development of postoperative mortality. While the incidence of severe postoperative complications amazingly does not show much variation between hospitals, FTR shows significant differences implying a major potential for improvement. With 14 million surgical procedures per year in Germany, a postoperative mortality of approximately 1% and an avoidable FTR rate of 40% mean that there are an estimated 60,000 preventable deaths per year. Hence, in the future it will be imperative to (1) identify patients at risk, (2) to prevent the development of postoperative complications with the use of adequate adjunctive therapeutic strategies, (3) to establish surveillance and monitoring systems for the early detection of postoperative complications and (4) to treat postoperative complications efficiently and in time when they arise.
Collapse
Affiliation(s)
- O Boehm
- Klinik und Poliklinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Bonn, Sigmund-Freud-Str. 25, 53105, Bonn, Deutschland
| | - M K A Pfeiffer
- Klinik und Poliklinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Bonn, Sigmund-Freud-Str. 25, 53105, Bonn, Deutschland
| | - G Baumgarten
- Klinik und Poliklinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Bonn, Sigmund-Freud-Str. 25, 53105, Bonn, Deutschland
| | - A Hoeft
- Klinik und Poliklinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Bonn, Sigmund-Freud-Str. 25, 53105, Bonn, Deutschland.
| |
Collapse
|
45
|
Advanced airway management in an anaesthesiologist-staffed Helicopter Emergency Medical Service (HEMS): A retrospective analysis of 1047 out-of-hospital intubations. Resuscitation 2016; 105:66-9. [DOI: 10.1016/j.resuscitation.2016.04.020] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Revised: 04/13/2016] [Accepted: 04/15/2016] [Indexed: 01/23/2023]
|
46
|
Li LW, He L, Ai Y, Chu Q, Zhang W. Site-directed topical lidocaine spray attenuates perioperative respiratory adverse events in children undergoing elective surgery. J Surg Res 2016; 203:206-10. [DOI: 10.1016/j.jss.2016.03.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Revised: 02/03/2016] [Accepted: 03/07/2016] [Indexed: 11/29/2022]
|
47
|
|
48
|
Lee JH, Turner DA, Kamat P, Nett S, Shults J, Nadkarni VM, Nishisaki A. The number of tracheal intubation attempts matters! A prospective multi-institutional pediatric observational study. BMC Pediatr 2016; 16:58. [PMID: 27130327 PMCID: PMC4851769 DOI: 10.1186/s12887-016-0593-y] [Citation(s) in RCA: 90] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2015] [Accepted: 04/21/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The impact of multiple tracheal intubation (TI) attempts on outcomes in critically ill children with acute respiratory failure is not known. The objective of our study is to determine the association between number of TI attempts and severe desaturation (SpO2 < 70 %) and adverse TI associated events (TIAEs). METHODS We performed an analysis of a prospective multicenter TI database (National Emergency Airway Registry for Children: NEAR4KIDS). Primary exposure variable was number of TI attempts trichotomized as one, two, or ≥3 attempts. Estimates were adjusted for history of difficult airway, upper airway obstruction, and age. We included all children with initial TI performed with direct laryngoscopy for acute respiratory failure between 7/2010-3/2013. Our main outcome measures were desaturation (<80 % during TI attempt), severe desaturation (<70 %), adverse and severe TIAEs (e.g., cardiac arrest, hypotension requiring treatment). RESULTS Of 3382 TIs, 2080(65 %) were for acute respiratory failure. First attempt success was achieved in 1256/2080(60 %), second attempt in 503/2080(24 %), and ≥3 attempts in 321/2080(15 %). Higher number of attempts was associated with younger age, history of difficult airway, signs of upper airway obstruction, and first provider training level. The proportion of TIs with desaturation increased with increasing number of attempts (1 attempt:16 %, 2 attempts:36 %, ≥3 attempts:56 %, p < 0.001; adjusted OR for 2 attempts: 2.9[95 % CI:2.3-3.7]; ≥3 attempts: 6.5[95 % CI: 5.0-8.5], adjusted for patient factors). Proportion of TIs with severe desaturation also increased with increasing number of attempts (1 attempt:12 %, 2 attempts:30 %, ≥3 attempts:44 %, p < 0.001); adjusted OR for 2 attempts: 3.1[95 % CI:2.4-4.0]; ≥3 attempts: 5.7[95 % CI: 4.3-7.5] ). TIAE rates increased from 10 to 29 to 38 % with increasing number of attempts (p < 0.001); adjusted OR for 2 attempts: 3.7[95 % CI:2.9-4.9] ; ≥3 attempts: 5.5[95 % CI: 4.1-7.4]. Severe TIAE rates went from 5 to 8 to 9 % (p = 0.008); adjusted OR for 2 attempts: 1.6 [95 % CI:1.1-2.4]; ≥3 attempts: 1.8[95 % CI:1.1-2.8]. CONCLUSIONS Number of TI attempts was associated with desaturations and increased occurrence of TIAEs in critically ill children with acute respiratory failure. Thoughtful attention to initial provider as well as optimal setting/preparation is important to maximize the chance for first attempt success and to avoid desaturation.
Collapse
Affiliation(s)
- Jan Hau Lee
- Children's Intensive Care Unit, KK Women's and Children's Hospital, 100 Bukit Timah Road, Singapore, 229899, Singapore. .,Duke-NUS Medical School, Singapore, Singapore.
| | - David A Turner
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Duke Children's Hospital, Durham, NC, USA
| | - Pradip Kamat
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA, USA.,Critical Care Medicine, Children's Healthcare of Atlanta at Egleston, Atlanta, GA, USA
| | - Sholeen Nett
- Division of Pediatric Critical Care, Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA
| | - Justine Shults
- Department of Biostatistics and Epidemiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, USA
| | - Vinay M Nadkarni
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Akira Nishisaki
- Department of Anesthesiology and Critical Care Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | | |
Collapse
|
49
|
Haerter F, Eikermann M. Reversing neuromuscular blockade: inhibitors of the acetylcholinesterase versus the encapsulating agents sugammadex and calabadion. Expert Opin Pharmacother 2016; 17:819-33. [PMID: 26799963 DOI: 10.1517/14656566.2016.1145667] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
INTRODUCTION Acetylcholinesterase inhibitors (neostigmine, edrophonium) and encapsulating agents (sugammadex and calabadion) can be used to reverse residual neuromuscular blockade (NMB). AREAS COVERED This review provides information about efficacy, effectiveness, and side effects of drugs (acetylcholinesterase inhibitors and encapsulating agents) used to reverse neuromuscular blocking agents (NMBAs). EXPERT OPINION The therapeutic range of acetylcholinesterase-inhibitors is narrow and effectiveness studies demonstrate clinicians don't use these unspecific reversal agents effectively to increase postoperative respiratory safety. The encapsulating drugs sugammadex and calabadion reverse all levels of NMB, and complete recovery of muscle strength can be achieved almost immediately after administration. For this reason encapsulating agents can be used as a solution for "cannot intubate cannot ventilate"- situations. Poor binding selectivity of encapsulating agents carries the risk of displacement of the NMBA by a competitively binding drug, which may lead to recurarization. In order to avoid side-effects, related to unspecific binding of endogenous proteins and drugs administered perioperatively it is prudent to titrate the dose of reversal agents to the minimal effective dose, depending on the depth of neuromuscular transmission block identified by neuromuscular transmission monitoring. Calabadions provide a diversified (increased binding selectivity) and expanded (reversal of benzylisoquinolines) spectrum of possible indications.
Collapse
Affiliation(s)
- Friederike Haerter
- a Department of Anesthesia, Critical Care and Pain Medicine , Massachusetts General Hospital and Harvard Medical School , Boston , MA , USA
| | - Matthias Eikermann
- a Department of Anesthesia, Critical Care and Pain Medicine , Massachusetts General Hospital and Harvard Medical School , Boston , MA , USA.,b Department of Anesthesia and Critical Care Medicine , University Hospital Essen, University Duisburg-Essen , Essen , Germany
| |
Collapse
|
50
|
Courtright KR, Kerlin MP. Intensive care unit staffing and quality of care: challenges in times of an intensivist shortage. Rev Bras Ter Intensiva 2016; 26:205-7. [PMID: 25295814 PMCID: PMC4188456 DOI: 10.5935/0103-507x.20140031] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2014] [Accepted: 06/13/2014] [Indexed: 12/01/2022] Open
Affiliation(s)
- Katherine R Courtright
- Pulmonary, Allergy, and Critical Care Division, University of Pennsylvania, Philadelphia, PA, Estados Unidos
| | - Meeta Prasad Kerlin
- Pulmonary, Allergy, and Critical Care Division, University of Pennsylvania, Philadelphia, PA, Estados Unidos
| |
Collapse
|