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Latona A, Pellatt R, Wedgwood D, Keijzers G, Grant S. Ventilator-assisted preoxygenation in an aeromedical retrieval setting. Emerg Med Australas 2024; 36:596-603. [PMID: 38504443 DOI: 10.1111/1742-6723.14404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 01/13/2024] [Accepted: 03/01/2024] [Indexed: 03/21/2024]
Abstract
OBJECTIVE Ventilator-assisted preoxygenation (VAPOX) is a method of preoxygenation and apnoeic ventilation which has been tried in hospital setting. We aimed to describe VAPOX during intubation of critically unwell patients in aeromedical retrieval setting. METHODS Retrospective observational study of VAPOX performed at LifeFlight Retrieval Medicine (LRM) between January 2018 and December 2022 across Queensland, Australia. Demographic and clinical data were recorded. Descriptive statistics and paired Student's t-tests were used to evaluate the efficacy of VAPOX on oxygen saturation (SpO2). RESULTS VAPOX was used in 40 patients. Diagnoses included pneumonia (n = 11), COPD (n = 6) and neurological (n = 7). Patients were intubated in hospital (n = 36), in helicopter (n = 2) and ambulance (n = 2). Median VAPOX settings were: positive end-expiratory pressure 6 (IQR 5-9), pressure support 10 (IQR 10-14) and back up respiratory rate 14 (IQR 11-18). Twelve agitated patients underwent delayed sequence induction with ketamine. There was a statistically significant increase in SpO2 after application of VAPOX (P < 0.001), followed by a slight decrease after intubation (P = 0.006). Mean SpO2 were significantly improved after intubation compared with on arrival of LRM (P = 0.016). Hypotension was present prior to VAPOX (n = 13), during VAPOX (n = 2) and post-intubation (n = 15). Two patients had cardiac arrest. Three patients were started on VAPOX but subsequently failed. There were no significant oxygen depletion or aspiration events. CONCLUSION VAPOX can be considered for pre-intubation optimisation in the retrieval environment. The incidence of post-intubation critical hypoxia was low, and hypotension was high. Pre-intubation respiratory physiology can be optimised by delivering variable pressure supported minute ventilation, achieving a low incidence of critical hypoxia.
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Affiliation(s)
- Akmez Latona
- LifeFlight Retrieval Medicine, Toowoomba, Queensland, Australia
- Emergency Department, Ipswich Hospital, Ipswich, Queensland, Australia
- School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Richard Pellatt
- LifeFlight Retrieval Medicine, Toowoomba, Queensland, Australia
- Emergency Department, Gold Coast University Hospital, Gold Coast, Queensland, Australia
- School of Medicine, Griffith University, Gold Coast, Queensland, Australia
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - David Wedgwood
- LifeFlight Retrieval Medicine, Toowoomba, Queensland, Australia
- Department of Anaesthesiology, Toowoomba Hospital, Toowoomba, Queensland, Australia
| | - Gerben Keijzers
- Emergency Department, Gold Coast University Hospital, Gold Coast, Queensland, Australia
- School of Medicine, Griffith University, Gold Coast, Queensland, Australia
- Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland, Australia
| | - Steven Grant
- Emergency Department, Gold Coast University Hospital, Gold Coast, Queensland, Australia
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Robinson AE, Pearson AM, Bunting AJ, Kennedy HJ, Prekker ME, Reardon RF, Jones GA, Simpson NS, Kummer TM, Babcock CP, Driver BE. A Practical Solution for Preoxygenation in the Prehospital Setting: A Nonrebreather Mask with Flush Rate Oxygen. PREHOSP EMERG CARE 2023; 28:215-220. [PMID: 37171895 DOI: 10.1080/10903127.2023.2213761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Revised: 05/08/2023] [Accepted: 05/10/2023] [Indexed: 05/14/2023]
Abstract
OBJECTIVE Prehospital clinicians need a practical means of providing adequate preoxygenation prior to intubation. A bag-valve-mask (BVM) can be used for preoxygenation in perfect conditions but is likely to fail in emergency settings. For this reason, many airway experts have moved away from using BVM for preoxygenation and instead suggest using a nonrebreather (NRB) mask with flush rate oxygen.Literature on preoxygenation has suggested that a NRB mask delivering flush rate oxygen (on a 15 L/min O2 regulator, maximum flow, ∼50 L/min) is noninferior to BVM at 15 L/min held with a tight seal. However, in the prehospital setting, where emergency airway management success varies, preoxygenation techniques have not been deeply explored. Our study seeks to determine whether preoxygenation can be optimally performed with NRB at flush rate oxygen. METHODS We performed a crossover trial using healthy volunteers. Subjects underwent 3-min trials of preoxygenation with NRB mask at 25 L/min oxygen delivered from a portable tank, NRB at flush rate oxygen from a portable tank, NRB with flush rate oxygen from an onboard ambulance tank, and BVM with flush rate oxygen from an onboard ambulance tank. The primary outcome was the fraction of expired oxygen (FeO2). We compared the FeO2 of the BVM-flush to other study groups, using a noninferiority margin of 10%. RESULTS We enrolled 30 subjects. Mean FeO2 values for NRB-25, NRB-flush ambulance, NRB-flush portable, and BVM-flush were 63% (95% confidence interval [CI] 58-68%), 74% (95%, CI 70-78%), 78% (95%, CI 74-83%), and 80% (95%, CI 75-84%), respectively. FeO2 values for NRB-flush on both portable tank and ambulance oxygen were noninferior to BVM-flush on the ambulance oxygen system (FeO2 differences of 1%, 95% CI -3% to 6%; and 6%, 95% CI 1-10%). FeO2 for the NRB-25 group was inferior to BVM-flush (FeO2 difference 16%, 95% CI 12-21%). CONCLUSIONS Among healthy volunteers, flush rate preoxygenation using NRB masks is noninferior to BVM using either a portable oxygen tank or ambulance oxygen. This is significant because preoxygenation using NRB masks with flush rate oxygen presents a simpler alternative to the use of BVMs. Preoxygenation using NRB masks at 25 L/min from a portable tank is inferior to BVM at flush rate.
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Affiliation(s)
- Aaron E Robinson
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA
- Hennepin EMS, Hennepin Healthcare, Minneapolis, Minnesota, USA
- Department of Emergency Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | | | - Alec J Bunting
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA
- Hennepin EMS, Hennepin Healthcare, Minneapolis, Minnesota, USA
| | | | - Matthew E Prekker
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA
- Department of Emergency Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Robert F Reardon
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA
- Department of Emergency Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Gregg A Jones
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA
- Hennepin EMS, Hennepin Healthcare, Minneapolis, Minnesota, USA
- Department of Emergency Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Nicholas S Simpson
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA
- Hennepin EMS, Hennepin Healthcare, Minneapolis, Minnesota, USA
- Department of Emergency Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Timothy M Kummer
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA
- Hennepin EMS, Hennepin Healthcare, Minneapolis, Minnesota, USA
- Department of Emergency Medicine, University of Minnesota, Minneapolis, Minnesota, USA
| | - Corey P Babcock
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA
| | - Brian E Driver
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota, USA
- Department of Emergency Medicine, University of Minnesota, Minneapolis, Minnesota, USA
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Dodds JM, Appelqvist DI, Paleologos MS, Downey RG. Variability in oxygen delivery with bag-valve-mask devices: An observational laboratory simulation study. Anaesth Intensive Care 2023; 51:130-140. [PMID: 36722019 DOI: 10.1177/0310057x221119824] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
A bag-valve-mask (BVM) is a portable handheld medical device commonly used in airway management and manual ventilation. Outside of the operating theatre, BVM devices are often used to pre-oxygenate spontaneously breathing patients before intubation to reduce the risk of hypoxaemia. Pre-oxygenation is considered adequate when the end-tidal expiratory fraction of oxygen is greater than 0.85. There are reports that some BVM devices fail to deliver a satisfactory inspired oxygen (FiO2) in spontaneously breathing patients due to variability in design. The primary aim of this study was to evaluate the efficacy of oxygen delivery of a broad range of adult and paediatric BVM devices at increasing tidal volumes using a mechanical lung to simulate spontaneous ventilation. The secondary aim was to evaluate the effect of BVM design on performance.Forty BVM devices were evaluated in a laboratory setting as part of a safety assessment requested by HealthShare New South Wales. The oxygen inlet of each BVM device was primed with 100% oxygen (15 l/min) for two min. The BVM device was then attached to the mechanical lung and commenced spontaneous breathing at a fixed respiratory rate of 12 breaths/min with an inspiratory: expiratory ratio of 1:2. For each device FiO2 was measured after two min of spontaneous breathing. This process was repeated with small (250 ml), medium (500 ml) and large (750 ml) tidal volumes simulating adult breathing in adult BVM devices, and small (150 ml), medium (300 ml) and large (450 ml) tidal volumes simulating paediatric breathing in paediatric BVM devices. The test was repeated using up to five BVM devices of the same model (where supplied) at each tidal volume as a manufacturing quality control measure.Eight of the 40 devices tested failed to deliver a FiO2 above 0.85 for at least one tidal volume, and five models failed to achieve this at any measured tidal volume. Concerningly, three of these devices delivered a FiO2 below 0.55. Six of the eight poorly performing devices delivered reducing concentrations of inspired oxygen with increasing tidal volumes. Devices which performed the worst were those with a duckbill non-rebreather valve and without a dedicated expiratory valve.Several BVM devices available for clinical use in Australia did not deliver sufficient oxygen for reliable pre-oxygenation in a spontaneously breathing in vitro model. Devices with a duckbill non-rebreather valve and without a dedicated expiratory valve performed the worst. It is imperative that clinicians using BVM devices to deliver oxygen to spontaneously breathing patients are aware of the characteristics and limitations of the BVM devices, and that the standards for manufacture are updated to require safe performance in all clinical circumstances.
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Affiliation(s)
- Jarron M Dodds
- Department of Anaesthesia and Acute Pain Medicine, St Vincent's Hospital, Melbourne, Australia
| | | | - Michael S Paleologos
- Department of Anaesthesia, Royal Prince Alfred Hospital, Sydney, Australia.,Sydney Medical School, University of Sydney, Sydney, Australia
| | - Ryan G Downey
- Department of Anaesthesia, Royal Prince Alfred Hospital, Sydney, Australia.,Sydney Medical School, University of Sydney, Sydney, Australia
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Morton S, Dawson J, Wareham G, Broomhead R, Sherren P. The Prehospital Emergency Anaesthetic in 2022. Air Med J 2022; 41:530-535. [PMID: 36494168 DOI: 10.1016/j.amj.2022.08.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 07/28/2022] [Accepted: 08/15/2022] [Indexed: 12/14/2022]
Abstract
Prehospital emergency anesthesia (PHEA) is a commonly performed prehospital procedure with inherent risks. The processes and drug regimens behind PHEA are continually updated by prehospital teams across the country as part of their governance structure. Essex & Herts Air Ambulance has recently updated this practice by reviewing the entire process of performing PHEA. Through experiential learning in a high-volume service, audit, and a contemporary literature review, a new standard operating procedure has been developed to combat common problems, such as hypotension, associated with the more traditional methods of performing PHEA. The aim of this article was to summarize the literature behind this new standard operating procedure, systematically breaking down the core components of performing a PHEA and the rationale behind them. The key components identified in the review are indications for PHEA, airway assessment, peri-intubation oxygenation, preparation for PHEA, drug dosing, special circumstances, and failed intubation. One significant change is the drug dosage regimen; 1 μg/kg fentanyl, 2 mg/kg ketamine, and 2 mg/kg rocuronium is recommended as the main drug dosing regimen for both medical and trauma patients. Other changes include preoxygenation with a nasal cannula in addition to the nonrebreather mask, optimizing patients in the preparation phase by considering inopressors or fluid bolus and ensuring a "sterile cockpit" to control the surrounding environment to ensure the first intubation attempt is the best attempt.
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Affiliation(s)
- Sarah Morton
- Essex & Herts Air Ambulance, Flight House, Essex, United Kingdom; Department of Surgery, Imperial College, London, United Kingdom
| | - Jonathan Dawson
- Essex & Herts Air Ambulance, Flight House, Essex, United Kingdom
| | - Gaynor Wareham
- Essex & Herts Air Ambulance, Flight House, Essex, United Kingdom
| | - Robert Broomhead
- Essex & Herts Air Ambulance, Flight House, Essex, United Kingdom
| | - Peter Sherren
- Essex & Herts Air Ambulance, Flight House, Essex, United Kingdom; Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom.
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5
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Jarvis JL, Lyng JW, Miller BL, Perlmutter MC, Abraham H, Sahni R. Prehospital Drug Assisted Airway Management: An NAEMSP Position Statement and Resource Document. PREHOSP EMERG CARE 2022; 26:42-53. [PMID: 35001829 DOI: 10.1080/10903127.2021.1990447] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Airway management is a critical intervention for patients with airway compromise, respiratory failure, and cardiac arrest. Many EMS agencies use drug-assisted airway management (DAAM) - the administration of sedatives alone or in combination with neuromuscular blockers - to facilitate advanced airway placement in patients with airway compromise or impending respiratory failure who also have altered mental status, agitation, or intact protective airway reflexes. While DAAM provides several benefits including improving laryngoscopy and making insertion of endotracheal tubes and supraglottic airways easier, DAAM also carries important risks. NAEMSP recommends:DAAM is an appropriate tool for EMS clinicians in systems with clear guidelines, sufficient training, and close EMS physician oversight. DAAM should not be used in settings without adequate resources.EMS physicians should develop clinical guidelines informed by evidence and oversee the training and credentialing for safe and effective DAAM.DAAM programs should include best practices of airway management including patient selection, assessmenct and positioning, preoxygenation strategies including apneic oxygenation, monitoring and management of physiologic abnormalities, selection of medications, post-intubation analgesia and sedation, equipment selection, airway confirmation and monitoring, and rescue airway techniques.Post-DAAM airway placement must be confirmed and continually monitored with waveform capnography.EMS clinicians must have the necessary equipment and training to manage patients with failed DAAM, including bag mask ventilation, supraglottic airway devices and surgical airway approaches.Continuous quality improvement for DAAM must include assessment of individual and aggregate performance metrics. Where available for review, continuous physiologic recordings (vital signs, pulse oximetry, and capnography), audio and video recordings, and assessment of patient outcomes should be part of DAAM continuous quality improvement.
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Kottmann A, Krüger AJ, Sunde GA, Røislien J, Heltne JK, Carron PN, Lockey D, Sollid SJM. Establishing quality indicators for prehospital advanced airway management: a modified nominal group technique consensus process. Br J Anaesth 2021; 128:e143-e150. [PMID: 34674835 PMCID: PMC8792832 DOI: 10.1016/j.bja.2021.08.031] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Revised: 08/05/2021] [Accepted: 08/20/2021] [Indexed: 12/20/2022] Open
Abstract
Background Pre-hospital advanced airway management is a complex intervention composed of numerous steps, interactions, and variables that can be delivered to a high standard in the pre-hospital setting. Standard research methods have struggled to evaluate this complex intervention because of considerable heterogeneity in patients, providers, and techniques. In this study, we aimed to develop a set of quality indicators to evaluate pre-hospital advanced airway management. Methods We used a modified nominal group technique consensus process comprising three email rounds and a consensus meeting among a group of 16 international experts. The final set of quality indicators was assessed for usability according to the National Quality Forum Measure Evaluation Criteria. Results Seventy-seven possible quality indicators were identified through a narrative literature review with a further 49 proposed by panel experts. A final set of 17 final quality indicators composed of three structure-, nine process-, and five outcome-related indicators, was identified through the consensus process. The quality indicators cover all steps of pre-hospital advanced airway management from preoxygenation and use of rapid sequence induction to the ventilatory state of the patient at hospital delivery, prior intubation experience of provider, success rates and complications. Conclusions We identified a set of quality indicators for pre-hospital advanced airway management that represent a practical tool to measure, report, analyse, and monitor quality and performance of this complex intervention.
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Affiliation(s)
- Alexandre Kottmann
- Norwegian Air Ambulance Foundation, Research and Development Department, Oslo, Norway; Lausanne University Hospital, Emergency Department, Lausanne, Switzerland; University of Stavanger, Faculty of Health Sciences, Department of Quality and Health Technology, Stavanger, Norway; Rega - Swiss Air Ambulance, Zürich, Switzerland.
| | - Andreas J Krüger
- Norwegian Air Ambulance Foundation, Research and Development Department, Oslo, Norway; St. Olav University Hospital, Department of Emergency Medicine and Pre-Hospital Services, Trondheim, Norway; Norwegian University of Science and Technology, Institute of Circulation and Medical Imaging, Trondheim, Norway
| | - Geir A Sunde
- Norwegian Air Ambulance Foundation, Research and Development Department, Oslo, Norway; Haukeland University Hospital, Department of Anaesthesia and Intensive Care, Bergen, Norway; Helicopter Emergency Service, Bergen, Norway
| | - Jo Røislien
- Norwegian Air Ambulance Foundation, Research and Development Department, Oslo, Norway; University of Stavanger, Faculty of Health Sciences, Department of Quality and Health Technology, Stavanger, Norway
| | - John-Kenneth Heltne
- Haukeland University Hospital, Department of Anaesthesia and Intensive Care, Bergen, Norway; Helicopter Emergency Service, Bergen, Norway; University of Bergen, Department of Clinical Medicine, Bergen, Norway
| | | | - David Lockey
- Emergency Medical Retrieval and Transfer Service, Dafen, UK; Royal College of Surgeons of Edinburgh, Faculty of Pre-hospital Care, Edinburgh, UK
| | - Stephen J M Sollid
- Norwegian Air Ambulance Foundation, Research and Development Department, Oslo, Norway; University of Stavanger, Faculty of Health Sciences, Department of Quality and Health Technology, Stavanger, Norway
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Grauman S, Johansson J, Drevhammar T. Large variations of oxygen delivery in self-inflating resuscitation bags used for preoxygenation - a mechanical simulation. Scand J Trauma Resusc Emerg Med 2021; 29:98. [PMID: 34281616 PMCID: PMC8290536 DOI: 10.1186/s13049-021-00885-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Accepted: 05/11/2021] [Indexed: 11/23/2022] Open
Abstract
Background Self-Inflating Resuscitation Bags (SIRB) are common and essential tools in airway management and ventilation. They are often used in resuscitation and emergency anaesthesia outside the operating theatre. There is a common notion that all SIRBs applied with a tight sealed mask will deliver close to 100 % oxygen during spontaneous breathing. The aim of the study was to measure the oxygen delivery of six commonly used SIRBs in a mechanical spontaneous breathing adult in vitro model. Methods Three SIRBs of each of the six models were evaluated for oxygen delivery during simulated breathing with an adult mechanical lung. The test was repeated three times per device (54 tests in total). The breathing profile was fixed to a minute volume of 10 L/min, a tidal volume of 500 mL and the SIRBs supplied with an oxygen fresh gas flow of 15 L/min. The fraction of delivered oxygen (FDO2) was measured over a three-minute period. Average FDO2 was calculated and compared at 30, 60 and 90 s. Results At 90 s all models had reached a stable FDO2. Average FDO2 at 90 s; Ambu Oval Plus 99,5 %; Ambu Spur II 99,8 %; Intersurgical BVM Resuscitator 76,7 %; Laerdal Silicone 97,3 %; Laerdal The Bag II 94,5 % and the O-Two Smart Bag 39,0 %. All differences in FDO2 were significant apart from the two Ambu models. Conclusions In simulated spontaneous breathing, four out of six (by Ambu and Laerdal) Self-Inflating Resuscitation Bags delivered a high fraction of oxygen while two (Intersurgical and O-two) underperformed in oxygen delivery. These large variations confirm results reported in other studies. It is our opinion that underperforming Self-Inflating Resuscitation Bags might pose a serious threat to patients’ health if used in resuscitation and anaesthesia. Manufacturers of Self-Inflating Resuscitation Bags rarely provide information on performance for spontaneous breathing. This poses a challenge to all organizations that need their devices to deliver adequate oxygen during spontaneous breathing.
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Affiliation(s)
- Sven Grauman
- Department of Anaesthesia and Intensive Care, Östersund Hospital, Region of Jämtland Härjedalen, 83183, Östersund, Sweden
| | - Joakim Johansson
- Department of Anaesthesia and Intensive Care, Östersund Hospital, Region of Jämtland Härjedalen, 83183, Östersund, Sweden.,Department of Surgical and Perioperative Sciences, Umeå University, 90187, Umeå, Sweden
| | - Thomas Drevhammar
- Department of Anaesthesia and Intensive Care, Östersund Hospital, Region of Jämtland Härjedalen, 83183, Östersund, Sweden. .,Department of Surgical and Perioperative Sciences, Umeå University, 90187, Umeå, Sweden. .,Department of Women's and Children's Health, Karolinska Institutet. Tomtebodavägen 18A, 17177, Stockholm, Sweden.
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8
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Jarvis JL, Gonzales J, Johns D, Sager L. Implementation of a Clinical Bundle to Reduce Out-of-Hospital Peri-intubation Hypoxia. Ann Emerg Med 2018. [PMID: 29530653 DOI: 10.1016/j.annemergmed.2018.01.044] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
STUDY OBJECTIVE Peri-intubation hypoxia is an important adverse event of out-of-hospital rapid sequence intubation. The aim of this project is to determine whether a clinical bundle encompassing positioning, apneic oxygenation, delayed sequence intubation, and goal-directed preoxygenation is associated with decreased peri-intubation hypoxia compared with standard out-of-hospital rapid sequence intubation. METHODS We conducted a retrospective, before-after study using data from a suburban emergency medical services (EMS) system in central Texas. The study population included all adults undergoing out-of-hospital intubation efforts, excluding those in cardiac arrest. The before-period intervention was standard rapid sequence intubation using apneic oxygenation at flush flow, ketamine, and a paralytic. The after-period intervention was a care bundle including patient positioning (elevated head, sniffing position), apneic oxygenation, delayed sequence intubation (administration of ketamine to facilitate patient relaxation and preoxygenation with a delayed administration of paralytics), and goal-directed preoxygenation. The primary outcome was the rate of peri-intubation hypoxia, defined as the percentage of patients with a saturation less than 90% during the intubation attempt. RESULTS The before group (October 2, 2013, to December 13, 2015) included 104 patients and the after group (August 8, 2015, to July 14, 2017) included 87 patients. The 2 groups were similar in regard to sex, age, weight, ethnicity, rate of trauma, initial oxygen saturation, rates of initial hypoxia, peri-intubation peak SpO2, preintubation pulse rate and systolic blood pressure, peri-intubation cardiac arrest, and first-pass and overall success rates. Compared with the before group, the after group experienced less peri-intubation hypoxia (44.2% versus 3.5%; difference -40.7% [95% confidence interval -49.5% to -32.1%]) and higher peri-intubation nadir SpO2 values (100% versus 93%; difference 5% [95% confidence interval 2% to 10%]). CONCLUSION In this single EMS system, a care bundle encompassing patient positioning, apneic oxygenation, delayed sequence intubation, and goal-directed preoxygenation was associated with lower rates of peri-intubation hypoxia than standard out-of-hospital rapid sequence intubation.
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Affiliation(s)
- Jeffrey L Jarvis
- Williamson County EMS, Georgetown, TX; Department of Emergency Medicine, Baylor Scott & White Healthcare, Temple, TX.
| | | | | | - Lauren Sager
- Department of Biostatistics, Baylor Scott & White Healthcare, Temple, TX
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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
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10
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Reid C, Hayes-Bradley C, Burns B. Pre-hospital pre-oxygenation strategies. Anaesthesia 2017; 72:1038-1039. [DOI: 10.1111/anae.13949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- C. Reid
- Greater Sydney Area HEMS; New South Wales Australia
| | | | - B. Burns
- Greater Sydney Area HEMS; New South Wales Australia
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11
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Groombridge CJ, Konig T, Ley E, Miller M. Pre-hospital pre-oxygenation strategies: a reply. Anaesthesia 2017; 72:1039. [DOI: 10.1111/anae.13954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
| | - T. Konig
- London's Air Ambulance; London UK
| | - E. Ley
- Essex and Herts Air Ambulance Trust; Colchester UK
| | - M. Miller
- Kent Surrey and Sussex Air Ambulance Trust; Marden UK
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