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Kwong JL, Bourn S, Hillier M, Merko M, Grass AJ, Ednie T, Verbeek PR. A Quality Improvement Initiative to Increase Confirmation of Prehospital Endotracheal Tube Placement at Emergency Department Transfer of Care. PREHOSP EMERG CARE 2024:1-7. [PMID: 38861683 DOI: 10.1080/10903127.2024.2366401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 05/16/2024] [Indexed: 06/13/2024]
Abstract
OBJECTIVES Rates of prehospital unplanned extubation (UE) range from 0 to 25% and are the result of many factors, including patient movement. Transfer of care of intubated patients to the emergency department (ED) involves significant patient movement and represents a high-risk event for UE. Frequent confirmation of endotracheal tube (ETT) placement is imperative for early recognition of UE and to minimize patient harm. METHODS Local Practice-Our baseline rate of verbal ETT position confirmation with a member of the ED team during ED transfer of care was 74%. Our goal was to increase this practice to >90% in six months. This project was completed in partnership with Toronto Paramedic Services. Prehospital electronic patient care records (ePCRs) were reviewed weekly to determine the proportion of intubated patients who had ETT placement confirmed in the ED at transfer of care. Interventions-Pre- and post-project paramedic focus groups were conducted to identify potential drivers, change ideas, and project feedback. Three staggered interventions were introduced over five months: (1) memorandums to paramedics, ED chiefs and respiratory therapy leads, (2) individualized paramedic feedback e-mails, and (3) ePCR changes and closing rules. RESULTS The pre-project focus group identified several potential drivers, such as physical barriers, interprofessional relationships, and communication. ETT confirmation remained ≥90% for the last eight weeks and interventions resulted in special cause variation. Median cases without verbal confirmation between paramedics and ED staff reduced from 5/week (IQR 2.5, 6.5) to 1/week (IQR 0, 2). UE was identified in 0.6% (2/340) of patients with ETT confirmation. The post-project focus group noted improvements in perceived accountability, interprofessional relationships, and satisfaction with interventions. CONCLUSION Through a series of interventions, we improved the rate of ETT confirmation during ED transfer of care. Although rates of UE were low, improvement in ETT confirmation may lead to faster recognition of UE when it does occur thereby mitigating complications. The observed improvement was sustained after interventions ended.
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Affiliation(s)
- Jonathan L Kwong
- Division of Emergency Medicine, University of Toronto, Toronto, Canada
| | | | - Morgan Hillier
- Division of Emergency Medicine, University of Toronto, Toronto, Canada
- Sunnybrook Centre for Prehospital Medicine, University of Toronto, Toronto, Canada
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
| | - Mike Merko
- Sunnybrook Centre for Prehospital Medicine, University of Toronto, Toronto, Canada
| | - A J Grass
- Toronto Paramedic Services, Toronto, Canada
| | - Tim Ednie
- Toronto Paramedic Services, Toronto, Canada
| | - P Richard Verbeek
- Sunnybrook Centre for Prehospital Medicine, University of Toronto, Toronto, Canada
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Canada
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Wham C, Morin T, Sauaia A, McIntyre R, Urban S, McVaney K, Cohen M, Cralley A, Moore EE, Campion EM. Prehospital ETCO 2 is predictive of death in intubated and non-intubated patients. Am J Surg 2023; 226:886-890. [PMID: 37563074 DOI: 10.1016/j.amjsurg.2023.07.033] [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: 03/24/2023] [Revised: 07/18/2023] [Accepted: 07/22/2023] [Indexed: 08/12/2023]
Abstract
BACKGROUND Prehospital identification of shock in trauma patients lacks accurate markers. Low end tidal carbon dioxide (ETCO2) correlates with mortality in intubated patients. The predictive value of ETCO2 obtained by nasal capnography cannula (NCC) is unknown. We hypothesized that prehospital ETCO2 values obtained by NCC and in-line ventilator circuit (ILVC) would be predictive of mortality. METHODS This was a prospective, observational, multicenter study. ETCO2 values were collected by a NCC or through ILVC. AUROCs were compared with prehospital systolic blood pressure (SBP) and shock index (SI). The Youden index defined optimal cutoffs. RESULTS Of 550 enrolled patients, 487 (88.5%) had ETCO2 measured through an NCC. Median age was 37 (27-52) years; 76.5% were male; median ISS was 13 (5-22). Mortality was 10.4%. Minimum prehospital ETCO2 significantly predicted mortality with an AUROC of 0.76 (CI 0.69-0.84; Youden index = 22 mmHg), outperforming SBP with an AUROC of 0.68; (CI 0.62-0.74, p = 0.04) and shock index with an AUROC of 0.67 (CI 0.59-0.74, p = 0.03). CONCLUSION Prehospital ETCO2 measured by non-invasive NCC or ILVC may be predictive of mortality in injured patients.
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Affiliation(s)
- Courtney Wham
- Denver Health Medical Center, Department of Emergency Medicine, Denver Paramedics, United States.
| | - Theresa Morin
- Ernest E. Moore Shock Trauma Center at Denver Health, Department of Surgery, United States.
| | - Angela Sauaia
- University of Colorado, School of Public Health (AS), United States.
| | - Robert McIntyre
- University of Colorado Anschutz, Department of Surgery, United States.
| | - Shane Urban
- University of Colorado Anschutz, Department of Surgery, United States.
| | - Kevin McVaney
- Denver Health Medical Center, Department of Emergency Medicine, Denver Paramedics, United States.
| | - Mitchell Cohen
- University of Colorado Anschutz, Department of Surgery, United States.
| | - Alexis Cralley
- Ernest E. Moore Shock Trauma Center at Denver Health, Department of Surgery, United States.
| | - Ernest E Moore
- Ernest E. Moore Shock Trauma Center at Denver Health, Department of Surgery, United States.
| | - Eric M Campion
- Ernest E. Moore Shock Trauma Center at Denver Health, Department of Surgery, United States.
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Reuter PG, Ballouz C, Loeb T, Petrovic T, Lapostolle F. Detecting cervical esophagus with ultrasound on healthy voluntaries: learning curve. Ultrasound J 2023; 15:20. [PMID: 37126203 PMCID: PMC10151284 DOI: 10.1186/s13089-023-00315-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 03/12/2023] [Indexed: 05/02/2023] Open
Abstract
BACKGROUND The objective of this study was to determine the learning curve of tracheal-esophageal ultrasound by prehospital medical and paramedical staff. METHODS A single-center prospective study was carried out at a French EMS (SAMU 92). Volunteer participants first received a short theoretical training through e-learning, followed by two separate hands-on workshops on healthy volunteers, spaced one to two months apart. Learners were timed to obtain the tracheal-esophageal ultrasound target image 10 consecutive times. The first workshop was intended to perform a learning curve, and the second was to assess unlearning. The secondary objectives were to compare performance by profession and by previous ultrasound experience. RESULTS We included 32 participants with a mean age of 38 (± 10) years, consisting of 56% men. During the first workshop, the target image acquisition time was 20.4 [IQR: 10.6;41] seconds on the first try and 5.02 [3.72;7.5] seconds on the 10th (p < 0.0001). The image acquisition time during the second workshop was shorter compared to the first one (p = 0.016). In subgroup analyses, we found no significant difference between physicians and nurses (p = 0.055 at the first workshop and p = 0.164 at the second) or according to previous ultrasound experience (p = 0.054 at the first workshop and p = 0.176), counter to multivariate analysis (p = 0.02). CONCLUSIONS A short web-based learning completed by a hands-on workshop made it possible to obtain the ultrasound image in less than 10 s, regardless of the profession or previous experience in ultrasound.
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Affiliation(s)
- Paul-Georges Reuter
- Service des Urgences, SAMU, SMUR, CHU Pontchaillou, Université Rennes, Rennes, France.
- Équipe Soins Primaires et Prévention, Université Paris-Saclay, UVSQ, Univ. Paris-Sud, Inserm, CESP, 94807, Villejuif, France.
| | - Chris Ballouz
- Samu des Hauts-de-Seine, Assistance Publique-Hôpitaux de Paris, Hôpital Raymond Poincaré, 92380, Garches, France
| | - Thomas Loeb
- Samu des Hauts-de-Seine, Assistance Publique-Hôpitaux de Paris, Hôpital Raymond Poincaré, 92380, Garches, France
| | - Tomislav Petrovic
- SAMU 93 - UF Recherche-Enseignement-Qualité, Université Paris 13, Sorbonne Paris Cité, Inserm U942, Hôpital Avicenne, Assistance Publique-Hôpitaux de Paris, 125, Rue de Stalingrad, 93009, Bobigny, France
| | - Frédéric Lapostolle
- SAMU 93 - UF Recherche-Enseignement-Qualité, Université Paris 13, Sorbonne Paris Cité, Inserm U942, Hôpital Avicenne, Assistance Publique-Hôpitaux de Paris, 125, Rue de Stalingrad, 93009, Bobigny, France
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Thacker J, Stroud A, Carge M, Baldwin C, Shahait AD, Tyburski J, Dolman H, Tarras S. Utility of arterial CO2 - End-tidal CO2 gap as a mortality indicator in the surgical ICU. Am J Surg 2022. [DOI: 10.1016/j.amjsurg.2022.10.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Campion EM, Cralley A, Sauaia A, Buchheit RC, Brown AT, Spalding MC, LaRiccia A, Moore S, Tann K, Leskovan J, Camazine M, Barnes SL, Otaibi B, Hazelton JP, Jacobson LE, Williams J, Castillo R, Stewart NJ, Elterman JB, Zier L, Goodman M, Elson N, Miner J, Hardman C, Kapoen C, Mendoza AE, Schellenberg M, Benjamin E, Wakam GK, Alam HB, Kornblith LZ, Callcut RA, Coleman LE, Shatz DV, Burruss S, Linn AC, Perea L, Morgan M, Schroeppel TJ, Stillman Z, Carrick MM, Gomez MF, Berne JD, McIntyre RC, Urban S, Nahmias J, Tay E, Cohen M, Moore EE, McVaney K, Burlew CC. Prehospital end-tidal carbon dioxide is predictive of death and massive transfusion in injured patients: An Eastern Association for Surgery of Trauma multicenter trial. J Trauma Acute Care Surg 2022; 92:355-361. [PMID: 34686640 DOI: 10.1097/ta.0000000000003447] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Prehospital identification of the injured patient likely to require emergent care remains a challenge. End-tidal carbon dioxide (ETCO2) has been used in the prehospital setting to monitor respiratory physiology and confirmation of endotracheal tube placement. Low levels of ETCO2 have been demonstrated to correlate with injury severity and mortality in a number of in-hospital studies. We hypothesized that prehospital ETCO2 values would be predictive of mortality and need for massive transfusion (MT) in intubated patients. METHODS This was a retrospective multicenter trial with 24 participating centers. Prehospital, emergency department, and hospital values were collected. Receiver operating characteristic curves were created and compared. Massive transfusion defined as >10 U of blood in 6 hours or death in 6 hours with at least 1 U of blood transfused. RESULTS A total of 1,324 patients were enrolled. ETCO2 (area under the receiver operating characteristic curve [AUROC], 0.67; confidence interval [CI], 0.63-0.71) was better in predicting mortality than shock index (SI) (AUROC, 0.55; CI, 0.50-0.60) and systolic blood pressure (SBP) (AUROC, 0.58; CI, 0.53-0.62) (p < 0.0005). Prehospital lowest ETCO2 (AUROC, 0.69; CI, 0.64-0.75), SBP (AUROC, 0.75; CI, 0.70-0.81), and SI (AUROC, 0.74; CI, 0.68-0.79) were all predictive of MT. Analysis of patients with normotension demonstrated lowest prehospital ETCO2 (AUROC, 0.66; CI, 0.61-0.71), which was more predictive of mortality than SBP (AUROC, 0.52; CI, 0.47-0.58) or SI (AUROC, 0.56; CI, 0.50-0.62) (p < 0.001). Lowest prehospital ETCO2 (AUROC, 0.75; CI, 0.65-0.84), SBP (AUROC, 0.63; CI, 0.54-0.74), and SI (AUROC, 0.64; CI, 0.54-0.75) were predictive of MT in normotensive patients. ETCO2 cutoff for MT was 26 mm Hg. The positive predictive value was 16.1%, and negative predictive value was high at 98.1%. CONCLUSION Prehospital ETCO2 is predictive of mortality and MT. ETCO2 outperformed traditional measures such as SBP and SI in the prediction of mortality. ETCO2 may outperform traditional measures in predicting need for transfusion in occult shock. LEVEL OF EVIDENCE Diagnostic test, level III.
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Affiliation(s)
- Eric M Campion
- From the Department of Surgery (E.M.C., A.C., M. Cohen, E.E.M., C.C.B.), Denver Health Medical Center, Denver, Colorado; School of Public Health (A.S.), University of Colorado, Aurora, Colorado; Department of Surgery (R.C.B., A.T.B.), Erlanger Health System, Chattanooga, Tennessee; Department of Surgery (M.C.S., A.L.), Grant Medical Center, Columbus, Ohio; Department of Surgery (S.M., K.T.), Wakemed, Raleigh, North Carolina; Department of Surgery (J.L.), Mercy Health, Toledo, Ohio; Department of Surgery (M. Camazine, S.L.B.), University of Missouri Health Care, Columbia, Missouri; Department of Surgery (B.O., J.P.H.), Penn State Health, Hershey, Pennsylvania; Department of Surgery (L.E.J., J.W.), Ascension, Indianapolis, Indiana; Department of Surgery (R.C., N.J.S.), St. Lukes University Health Network, Bethlehem, Pennsylvania; Department of Surgery (J.B.E., L.Z.), UCHealth Medical Center of the Rockies, Loveland, Colorado; Department of Surgery (M.G., N.E.), University of Cincinnati, Cincinnati, Ohio; Department of Surgery (J.M., C.H.), Premier Health Miami Valley, Dayton, Ohio; Department of Surgery (C.K., A.E.M.), Massachusetts General Hospital, Boston, Massachusetts; USC Medical Center, University of Southern California (M.S., E.B.), Los Angeles, California; Department of Surgery (G.K.W., H.B.A.), University of Michigan, Ann Arbor, Michigan; Department of Surgery (L.Z.K., R.A.C.), Zuckerberg San Francisco General Hospital, University of California, San Francisco, San Francisco, California; Department of Surgery (L.E.C., D.V.S.), University of California, Davis, Sacramento, California; Department of Surgery (S.B., A.C.L.), Loma Linda University Health, Loma Linda, California; Department of Surgery (L.P., M.M.), Penn Medicine, Philadelphia, Pennsylvania; Department of Surgery (T.J.S., Z.S.), UCHealth Memorial Hospital, Springs Colorado, Colorado; Department of Surgery (M.M.C.), Medical City Plano, Plano, Texas; Department of Surgery (M.F.G., J.D.B.), Broward Health, Ft. Lauderdale, Florida; Department of Surgery (R.C.M., S.U.), University of Colorado Anschutz, Aurora, Colorado; University of California, Irvine (J.N., E.T.), Irvine, CA; and Denver Paramedics, Department of Emergency Medicine (K.M.), Denver Health Medical Center, Denver, Colorado
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Nooralishahi B, Faroughi R, Naghashian H, Taghizadeh A, Mehrabanian M, Dehghani Firoozabadi M. The association between end-tidal carbon dioxide and arterial partial pressure of carbon dioxide after cardiopulmonary bypass pumping in cyanotic children. J Cardiovasc Thorac Res 2021; 13:309-313. [PMID: 35047135 PMCID: PMC8749361 DOI: 10.34172/jcvtr.2021.49] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2021] [Revised: 09/07/2021] [Accepted: 10/30/2021] [Indexed: 11/09/2022] Open
Abstract
Introduction: Evidence suggests the high capability of non-invasive assessment of the End-tidal carbondioxide (ETCO2) in predicting changes in arterial carbon dioxide pressure (PCO2) following major surgeries in children. We aimed to compare EtCO2 values measured by capnography with mainstream device and EtCO2 values assessed by arterial blood gas analysis before and after cardiopulmonary bypass pumping in cyanotic children.
Methods: This cross-sectional study was performed on 32 children aged less than 12 years with ASA II suffering cyanotic heart diseases and undergoing elective cardiopulmonary bypass pumping. Arterial blood sample was prepared through arterial line before and after pumping and arterial blood gas (ABG)was analyzed. Simultaneously, the value of EtCO2 was measured by capnography with mainstream device.
Results: A significant direct relationship was found between the changes in ETCO2 and arterialPCO2 (r = 0.529, P = 0.029) postoperatively. According to significant linear association between postoperative change in ETCO2 and arterial PCO2, we revealed a new linear formula between the two indices: ΔPCO2 = 0.89× ETCO2-0.54. The association between arterial PCO2 and ETCO2 remained significant adjusted for gender, age, and body weight.
Conclusion: the value of ETCO2 can reliability estimate postoperative changes in arterial PCO2 in cyanotic children undergoing cardiopulmonary bypass pumping.
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Affiliation(s)
| | - Rozhin Faroughi
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Hooman Naghashian
- School of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Ashkan Taghizadeh
- Children’s Medical Center Hospital, Tehran University of Medical Sciences, Tehran, Iran
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Williams E, Dassios T, Greenough A. Carbon dioxide monitoring in the newborn infant. Pediatr Pulmonol 2021; 56:3148-3156. [PMID: 34365738 DOI: 10.1002/ppul.25605] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Revised: 07/28/2021] [Accepted: 07/29/2021] [Indexed: 11/06/2022]
Abstract
Carbon dioxide (CO2 ) monitoring is vital during mechanical ventilation of newborn infants, as morbidity increases when CO2 levels are inappropriate. Our aim was to review the uses and limitations of such noninvasive monitoring methods. Colorimetry is primarily utilized during resuscitation to determine whether successful intubation has occurred. False negative and positive results can however lead to delays in detecting tracheal versus esophageal intubation. Transcutaneous carbon dioxide sensors have limited use during resuscitation, but can be utilized to provide continuous trend data during on-going ventilation. End-tidal capnography can provide clinicians with quantitative end-tidal CO2 (EtCO2 ) values and a continuous real-time capnogram waveform trace. These devices are becoming more widely accepted for use in the neonatal population as the new devices are lightweight with minimal additional dead space. Nevertheless, they have been reported to have variable accuracy when compared to arterial CO2 measurements, however, divergence of results may be related to disease severity rather than technological limitations. During resuscitation EtCO2 can be detected by capnography more rapidly than by colorimetry. Furthermore, capnography can be currently utilized in neonatal research settings to determine the physiological dead space and ventilation inhomogeneity, and thus has potential to be beneficial to clinical care. In conclusion, novel modes of noninvasive carbon dioxide monitoring can be safely and reliably utilized in newborn infants during mechanical ventilation. Future randomized trials should aim to address which device provides the most optimal form of monitoring in different clinical contexts.
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Affiliation(s)
- Emma Williams
- Department of Woman and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Theodore Dassios
- Department of Woman and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK.,Neonatal Intensive Care Centre, King's College Hospital NHS Foundation Trust, London, UK
| | - Anne Greenough
- Department of Woman and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK.,Asthma UK Centre for Allergic Mechanisms in Asthma, King's College London, London, UK.,National Institute for Health Research (NIHR) Biomedical Research Centre based at Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK
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Prehospital end-tidal carbon dioxide predicts massive transfusion and death following trauma. J Trauma Acute Care Surg 2020; 89:703-707. [PMID: 32590557 DOI: 10.1097/ta.0000000000002846] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND The lack of an accurate marker of prehospital hemorrhagic shock limits our ability to triage patients to the correct level of care, delays treatment in the emergency department, and inhibits our ability to perform prehospital interventional research in trauma. End-tidal carbon dioxide (ETCO2) is the measurement of alveolar carbon dioxide concentration at end expiration and is measured noninvasively in the ventilator circuit for intubated patients in continuous manner. Several hospital-based studies have been able to demonstrate that either low or decreasing levels of ETCO2 as well as disparities between ETCO2 and plasma carbon dioxide correlate with increasing mortality in trauma. We hypothesized that prehospital ETCO2 values will be predictive of mortality and need for massive transfusion following injury. METHODS This is a single-center retrospective study from an urban level 1 trauma center. We reviewed all intubated adult patients transported for injury who had prehospital ETCO2 values available. Unadjusted comparisons of continuous variables were done with the Wilcoxon two-sample test. The predictive performance of prehospital ETCO2, the prehospital shock index, and prehospital systolic blood pressure were assessed and compared using areas under the receiver operating characteristic curves. Optimal cutoffs were estimated by maximizing the Youden index. Massive transfusion was defined as >10 U of blood or death in 24 hours. RESULTS A total of 173 patients were identified with prehospital ETCO2 values during the 2-year study period. Population was 78.5% male with a median age of 37.5 years (interquartile range, 23.5-53.5 years). Injury mechanism was penetrating in 22.8%. This cohort had a median Injury Severity Score of 26 (interquartile range, 17-36), massive transfusion rate of 34.7%, and mortality of 42.1%. In the evaluation of prediction of postinjury mortality and massive transfusion, ETCO2 outperformed systolic blood pressure and shock index, but these differences did not reach statistical significance. CONCLUSION End-tidal carbon dioxide is a novel prehospital predictor of mortality and massive transfusion after injury. LEVEL OF EVIDENCE Prognostic/Epidemiologic, level III.
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End-tidal carbon dioxide underestimates plasma carbon dioxide during emergent trauma laparotomy leading to hypoventilation and misguided resuscitation: A Western Trauma Association Multicenter Study. J Trauma Acute Care Surg 2020; 87:1119-1124. [PMID: 31389913 DOI: 10.1097/ta.0000000000002469] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND End-tidal carbon dioxide (ETCO2) is routinely used during elective surgery to monitor ventilation. The role of ETCO2 monitoring in emergent trauma operations is poorly understood. We hypothesized that ETCO2 values underestimate plasma carbon dioxide (pCO2) values during resuscitation for hemorrhagic shock. METHODS Multicenter trial was performed analyzing the correlation between ETCO2 and pCO2 levels. RESULTS Two hundred fifty-six patients resulted in 587 matched pairs of ETCO2 and pCO2. Correlation between these two values was very poor with an R of 0.04. 40.2% of patients presented to the operating room acidotic and hypercarbic with a pH less than 7.30 and a pCO2 greater than 45 mm Hg. Correlation was worse in patients that were either acidotic or hypercarbic. Forty-five percent of patients have a difference greater than 10 mm Hg between ETCO2 and pCO2. A pH less than 7.30 was predictive of an ETCO2 to pCO2 difference greater than 10 mm Hg. A difference greater than 10 mm Hg was predictive of mortality independent of confounders. CONCLUSION Nearly one half (45%) of patients were found to have an ETCO2 level greater than 10 mm Hg discordant from their PCO2 level. Reliance on the discordant values may have contributed to the 40% of patients in the operating room that were both acidotic and hypercarbic. Early blood gas analysis is warranted, and a lower early goal of ETCO2 should be considered. LEVEL OF EVIDENCE Therapeutic, level IV.
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Bruderer T, Gaisl T, Gaugg MT, Nowak N, Streckenbach B, Müller S, Moeller A, Kohler M, Zenobi R. On-Line Analysis of Exhaled Breath Focus Review. Chem Rev 2019; 119:10803-10828. [PMID: 31594311 DOI: 10.1021/acs.chemrev.9b00005] [Citation(s) in RCA: 116] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
On-line analysis of exhaled breath offers insight into a person's metabolism without the need for sample preparation or sample collection. Due to its noninvasive nature and the possibility to sample continuously, the analysis of breath has great clinical potential. The unique features of this technology make it an attractive candidate for applications in medicine, beyond the task of diagnosis. We review the current methodologies for on-line breath analysis, discuss current and future applications, and critically evaluate challenges and pitfalls such as the need for standardization. Special emphasis is given to the use of the technology in diagnosing respiratory diseases, potential niche applications, and the promise of breath analysis for personalized medicine. The analytical methodologies used range from very small and low-cost chemical sensors, which are ideal for continuous monitoring of disease status, to optical spectroscopy and state-of-the-art, high-resolution mass spectrometry. The latter can be utilized for untargeted analysis of exhaled breath, with the capability to identify hitherto unknown molecules. The interpretation of the resulting big data sets is complex and often constrained due to a limited number of participants. Even larger data sets will be needed for assessing reproducibility and for validation of biomarker candidates. In addition, molecular structures and quantification of compounds are generally not easily available from on-line measurements and require complementary measurements, for example, a separation method coupled to mass spectrometry. Furthermore, a lack of standardization still hampers the application of the technique to screen larger cohorts of patients. This review summarizes the present status and continuous improvements of the principal on-line breath analysis methods and evaluates obstacles for their wider application.
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Affiliation(s)
- Tobias Bruderer
- Department of Chemistry and Applied Biosciences , Swiss Federal Institute of Technology , CH-8093 Zurich , Switzerland.,Division of Respiratory Medicine , University Children's Hospital Zurich and Children's Research Center Zurich , CH-8032 Zurich , Switzerland
| | - Thomas Gaisl
- Department of Pulmonology , University Hospital Zurich , CH-8091 Zurich , Switzerland.,Zurich Center for Interdisciplinary Sleep Research , University of Zurich , CH-8091 Zurich , Switzerland
| | - Martin T Gaugg
- Department of Chemistry and Applied Biosciences , Swiss Federal Institute of Technology , CH-8093 Zurich , Switzerland
| | - Nora Nowak
- Department of Chemistry and Applied Biosciences , Swiss Federal Institute of Technology , CH-8093 Zurich , Switzerland
| | - Bettina Streckenbach
- Department of Chemistry and Applied Biosciences , Swiss Federal Institute of Technology , CH-8093 Zurich , Switzerland
| | - Simona Müller
- Department of Chemistry and Applied Biosciences , Swiss Federal Institute of Technology , CH-8093 Zurich , Switzerland
| | - Alexander Moeller
- Division of Respiratory Medicine , University Children's Hospital Zurich and Children's Research Center Zurich , CH-8032 Zurich , Switzerland
| | - Malcolm Kohler
- Department of Pulmonology , University Hospital Zurich , CH-8091 Zurich , Switzerland.,Center for Integrative Human Physiology , University of Zurich , CH-8091 Zurich , Switzerland.,Zurich Center for Interdisciplinary Sleep Research , University of Zurich , CH-8091 Zurich , Switzerland
| | - Renato Zenobi
- Department of Chemistry and Applied Biosciences , Swiss Federal Institute of Technology , CH-8093 Zurich , Switzerland
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An act of balance: Interaction of central and peripheral chemosensitivity with inflammatory and anti-inflammatory factors in obstructive sleep apnoea. Respir Physiol Neurobiol 2019; 266:73-81. [DOI: 10.1016/j.resp.2019.05.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 04/30/2019] [Accepted: 05/02/2019] [Indexed: 02/05/2023]
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Li C, Xu J, Han F, Walline J, Zheng L, Fu Y, Zhu H, Chai Y, Yu X. Identification of return of spontaneous circulation during cardiopulmonary resuscitation via pulse oximetry in a porcine animal cardiac arrest model. J Clin Monit Comput 2018; 33:843-851. [PMID: 30498975 DOI: 10.1007/s10877-018-0230-4] [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: 06/03/2018] [Accepted: 11/26/2018] [Indexed: 10/27/2022]
Abstract
In this prospective study we investigated whether the pulse oximetry plethysmographic waveform (POP) could be used to identify return of spontaneous circulation (ROSC) during cardio-pulmonary resuscitation (CPR). Tweleve pigs (28 ± 2 kg) were randomly assigned to two groups: Group I (non-arrested with compressions) (n = 6); Group II (arrested with CPR and defibrillation) (n = 6). Hemodynamic parameters and POP were collected and analyzed. POP was analyzed using both a time domain method and a frequency domain method. In Group I, when compressions were carried out on subjects with a spontaneous circulation, a hybrid fluctuation or "envelope" phenomenon appeared in the time domain method and a "double" or "fusion" peak appeared in the frequency domain method. In Group II, after the period of ventricular fibrillation was induced, the POP waveform disappeared. With compressions, POP showed a regular compression wave. After defibrillation, ROSC, and continued compressions, a hybrid fluctuation or "envelope" phenomenon appeared in the time domain method and a "double" or "fusion" peak appeared in the frequency domain method, similar to Group I. Analysis of POP using the time and frequency domain methods could be used to identify ROSC during CPR.
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Affiliation(s)
- Chen Li
- Emergency Department, Tianjin Medical University General Hospital, Tianjin, China
| | - Jun Xu
- Emergency Department, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, No.1 Shuaifuyuan Wangfujing, Dongcheng District, Beijing, China.
| | - Fei Han
- Institute of Life Monitoring, Mindray Corporation, Shenzhen, China
| | - Joseph Walline
- Division of Emergency Medicine, Department of Surgery, Saint Louis University Hospital, Saint Louis, MO, USA
| | - Liangliang Zheng
- Emergency Department, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, No.1 Shuaifuyuan Wangfujing, Dongcheng District, Beijing, China
| | - Yangyang Fu
- Emergency Department, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, No.1 Shuaifuyuan Wangfujing, Dongcheng District, Beijing, China
| | - Huadong Zhu
- Emergency Department, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, No.1 Shuaifuyuan Wangfujing, Dongcheng District, Beijing, China
| | - Yanfen Chai
- Emergency Department, Tianjin Medical University General Hospital, Tianjin, China
| | - Xuezhong Yu
- Emergency Department, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, No.1 Shuaifuyuan Wangfujing, Dongcheng District, Beijing, China
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13
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Baudel JL, Dubee V, Boelle PY, Bourcier S, Leblanc G, Joffre J, Bigé N, Preda G, Dumas G, Guidet B, Maury E, Ait-Oufella H. The Weaning Index combining EtCO2 and respiratory rate early identifies Spontaneous Breathing Trial failure. Minerva Anestesiol 2018; 85:384-392. [PMID: 30482002 DOI: 10.23736/s0375-9393.18.13108-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND We aimed to evaluate the predictive value of the end-tidal CO2 (EtCO2) alone or combined with ventilation related parameters on Spontaneous Breathing Trial (SBT) outcome on mechanically ventilated patients. METHODS Prospective observational study in a medical Intensive Care Unit. Mechanically ventilated adult patients who met predefined criteria for weaning were included. Patients underwent a T-piece SBT for 30 minutes and the hemodynamic and respiratory clinical parameters including EtCO2 were recorded every five minutes. RESULTS The study included 280 patients, who were studied (age: 64±17 years, SAPS II: 44 [34-56]) during a first SBT and 76 patients during a second SBT. The Weaning Index, defined as the product of the respiratory rate and EtCO2, was a strong early predictive factor of SBT outcome; at 10 minutes, the area under the curve (AUC) was 86% ([80-90], P<0.0001) during the first SBT and 88% ([80-96], P<0.0001) during the second SBT. After 10 minutes of SBT, a Weaning Index >1100 identified patients that will not successfully complete the SBT at 30 minutes with a specificity of 98%. CONCLUSIONS In unselected mechanically ventilated patients, the Weaning Index is helpful to early identify patients who will fail the SBT during a first and a second trial.
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Affiliation(s)
- Jean-Luc Baudel
- Medical Resuscitation Service, Saint-Antoine Hospital, Paris, France
| | - Vincent Dubee
- Medical Resuscitation Service, Saint-Antoine Hospital, Paris, France.,Sorbonne-Pierre et Marie Curie University, Paris, France
| | - Pierre-Yves Boelle
- Sorbonne-Pierre et Marie Curie University, Paris, France.,Public Health Service, Saint-Antoine Hospital, Paris, France
| | - Simon Bourcier
- Medical Resuscitation Service, Saint-Antoine Hospital, Paris, France.,Sorbonne-Pierre et Marie Curie University, Paris, France.,Inserm U1135, Paris, France
| | - Guillaume Leblanc
- Department of Anesthesiology and Critical Care, Laval University, Québec, QC, Canada
| | - Jeremie Joffre
- Medical Resuscitation Service, Saint-Antoine Hospital, Paris, France.,Sorbonne-Pierre et Marie Curie University, Paris, France.,Inserm U970, Paris Research Cardiovascular Center, Paris, France
| | - Naike Bigé
- Medical Resuscitation Service, Saint-Antoine Hospital, Paris, France
| | - Gabriel Preda
- Medical Resuscitation Service, Saint-Antoine Hospital, Paris, France
| | - Guillaume Dumas
- Medical Resuscitation Service, Saint-Antoine Hospital, Paris, France
| | - Bertrand Guidet
- Medical Resuscitation Service, Saint-Antoine Hospital, Paris, France.,Sorbonne-Pierre et Marie Curie University, Paris, France.,Inserm U1135, Paris, France
| | - Eric Maury
- Medical Resuscitation Service, Saint-Antoine Hospital, Paris, France.,Sorbonne-Pierre et Marie Curie University, Paris, France.,Inserm U1135, Paris, France
| | - Hafid Ait-Oufella
- Medical Resuscitation Service, Saint-Antoine Hospital, Paris, France - .,Sorbonne-Pierre et Marie Curie University, Paris, France.,Inserm U970, Paris Research Cardiovascular Center, Paris, France
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14
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Sanello A, Gausche-Hill M, Mulkerin W, Sporer KA, Brown JF, Koenig KL, Rudnick EM, Salvucci AA, Gilbert GH. Altered Mental Status: Current Evidence-based Recommendations for Prehospital Care. West J Emerg Med 2018; 19:527-541. [PMID: 29760852 PMCID: PMC5942021 DOI: 10.5811/westjem.2018.1.36559] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2017] [Revised: 11/15/2017] [Accepted: 01/04/2018] [Indexed: 12/11/2022] Open
Abstract
Introduction In the United States emergency medical services (EMS) protocols vary widely across jurisdictions. We sought to develop evidence-based recommendations for the prehospital evaluation and treatment of a patient with an acute change in mental status and to compare these recommendations against the current protocols used by the 33 EMS agencies in the State of California. Methods We performed a literature review of the current evidence in the prehospital treatment of a patient with altered mental status (AMS) and augmented this review with guidelines from various national and international societies to create our evidence-based recommendations. We then compared the AMS protocols of each of the 33 EMS agencies for consistency with these recommendations. The specific protocol components that we analyzed were patient assessment, point-of-care tests, supplemental oxygen, use of standardized scoring, evaluating for causes of AMS, blood glucose evaluation, toxicological treatment, and pediatric evaluation and management. Results Protocols across 33 EMS agencies in California varied widely. All protocols call for a blood glucose check, 21 (64%) suggest treating adults at <60mg/dL, and half allow for the use of dextrose 10%. All the protocols recommend naloxone for signs of opioid overdose, but only 13 (39%) give specific parameters. Half the agencies (52%) recommend considering other toxicological causes of AMS, often by using the mnemonic AEIOU TIPS. Eight (24%) recommend a 12-lead electrocardiogram; others simply suggest cardiac monitoring. Fourteen (42%) advise supplemental oxygen as needed; only seven (21%) give specific parameters. In terms of considering various etiologies of AMS, 25 (76%) give instructions to consider trauma, 20 (61%) to consider stroke, and 18 (55%) to consider seizure. Twenty-three (70%) of the agencies have separate pediatric AMS protocols; others include pediatric considerations within the adult protocol. Conclusion Protocols for patients with AMS vary widely across the State of California. The evidence-based recommendations that we present for the prehospital diagnosis and treatment of this condition may be useful for EMS medical directors tasked with creating and revising these protocols.
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Affiliation(s)
- Ashley Sanello
- Los Angeles County Emergency Medical Services (EMS) Agency, Santa Fe Springs, California.,David Geffen School of Medicine, Department of Emergency Medicine, Los Angeles, California
| | - Marianne Gausche-Hill
- Los Angeles County Emergency Medical Services (EMS) Agency, Santa Fe Springs, California.,Harbor UCLA, Department of Emergency Medicine, Torrance, California.,David Geffen School of Medicine, Department of Emergency Medicine, Los Angeles, California.,EMS Medical Directors Association of California
| | - William Mulkerin
- Stanford University, Department of Emergency Medicine, Stanford, California
| | - Karl A Sporer
- University of California, San Francisco, Department of Emergency Medicine, San Francisco, California.,EMS Medical Directors Association of California
| | - John F Brown
- University of California, San Francisco, Department of Emergency Medicine, San Francisco, California.,EMS Medical Directors Association of California
| | - Kristi L Koenig
- EMS Medical Directors Association of California.,County of San Diego, Health & Human Services Agency, Emergency Medical Services, San Diego, California.,University of California, Irvine, Department of Emergency Medicine, Orange, California
| | - Eric M Rudnick
- EMS Medical Directors Association of California.,NorCal EMS Agency, Redding, California
| | - Angelo A Salvucci
- EMS Medical Directors Association of California.,Ventura County EMS Agency, Oxnard, California
| | - Gregory H Gilbert
- EMS Medical Directors Association of California.,Stanford University, Department of Emergency Medicine, Stanford, California
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15
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Singer AJ, Nguyen RT, Ravishankar ST, Schoenfeld ER, Thode HC, Henry MC, Parnia S. Cerebral oximetry versus end tidal CO 2 in predicting ROSC after cardiac arrest. Am J Emerg Med 2017; 36:403-407. [PMID: 28847626 DOI: 10.1016/j.ajem.2017.08.046] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Accepted: 08/19/2017] [Indexed: 11/15/2022] Open
Abstract
STUDY OBJECTIVE Both end tidal CO2 (ETCO2) and cerebral oxygen saturations (rSO2) have been studied to determine their ability to monitor the effectiveness of CPR and predict return of spontaneous circulation (ROSC). We compared the accuracy of ETCO2 and rSO2 at predicting ROSC in ED patients with out-of-hospital cardiac arrest (OHCA). METHODS We performed a prospective, observational study of adult ED patients presenting in cardiac arrest. We collected demographic and clinical data including age, gender, presenting rhythm, rSO2, and ETCO2. We used receiver operating characteristic curves to compare how well rSO2 and ETCO2 predicted ROSC. RESULTS 225 patients presented to the ED with cardiac arrest between 10/11 and 10/14 of which 100 had both rSO2 and ETCO2 measurements. Thirty three patients (33%) had sustained ROSC, only 2 survived to discharge. The AUCs for rSO2 and ETCO2 were similar (0.69 [95% CI, 0.59-0.80] and 0.77 [95% CI, 0.68-0.86], respectively), however, rSO2 and ETCO2 were poorly correlated (0.12, 95% CI, -0.08-0.31). The optimal cutoffs for rSO2 and ETCO2 were 50% and 20mm Hg respectively. At these cutoffs, ETCO2 was more sensitive (100%, 95% CI 87-100 vs. 48%, 31-66) but rSO2 was more specific (85%, 95% CI, 74-92 vs. 45%, 33-57). CONCLUSIONS While poorly correlated, rSO2 and ETCO2 have similar diagnostic characteristics. ETCO2 is more sensitive and rSO2 is more specific at predicting ROSC in OHCA.
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Affiliation(s)
- Adam J Singer
- Department of Emergency Medicine, Stony Brook University, Stony Brook, NY, United States.
| | - Robert T Nguyen
- Department of Medicine, Stony Brook University, Stony Brook, NY, United States
| | | | | | - Henry C Thode
- Department of Emergency Medicine, Stony Brook University, Stony Brook, NY, United States
| | - Mark C Henry
- Department of Emergency Medicine, Stony Brook University, Stony Brook, NY, United States
| | - Sam Parnia
- Department of Medicine, Stony Brook University, Stony Brook, NY, United States
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16
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Gong J, Antonietti M, Yuan J. Poly(Ionic Liquid)-Derived Carbon with Site-Specific N-Doping and Biphasic Heterojunction for Enhanced CO2Capture and Sensing. Angew Chem Int Ed Engl 2017; 56:7557-7563. [DOI: 10.1002/anie.201702453] [Citation(s) in RCA: 103] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Indexed: 01/22/2023]
Affiliation(s)
- Jiang Gong
- Department of Colloid Chemistry; Max Planck Institute of Colloids and Interfaces; 14476 Potsdam Germany
| | - Markus Antonietti
- Department of Colloid Chemistry; Max Planck Institute of Colloids and Interfaces; 14476 Potsdam Germany
| | - Jiayin Yuan
- Department of Colloid Chemistry; Max Planck Institute of Colloids and Interfaces; 14476 Potsdam Germany
- Department of Chemistry and Biomolecular Science and Center for Advanced Materials Processing; Clarkson University; Potsdam NY 13699 USA
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17
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Gong J, Antonietti M, Yuan J. Poly(Ionic Liquid)-Derived Carbon with Site-Specific N-Doping and Biphasic Heterojunction for Enhanced CO2Capture and Sensing. Angew Chem Int Ed Engl 2017. [DOI: 10.1002/ange.201702453] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Jiang Gong
- Department of Colloid Chemistry; Max Planck Institute of Colloids and Interfaces; 14476 Potsdam Germany
| | - Markus Antonietti
- Department of Colloid Chemistry; Max Planck Institute of Colloids and Interfaces; 14476 Potsdam Germany
| | - Jiayin Yuan
- Department of Colloid Chemistry; Max Planck Institute of Colloids and Interfaces; 14476 Potsdam Germany
- Department of Chemistry and Biomolecular Science and Center for Advanced Materials Processing; Clarkson University; Potsdam NY 13699 USA
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18
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Sanidas E, Chantziara V, Barbetseas J. Could End-Tidal CO2 Predict Percutaneous Mitral Valve Repair? Cardiology 2017; 138:11-12. [PMID: 28501867 DOI: 10.1159/000475462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 03/29/2017] [Indexed: 11/19/2022]
Affiliation(s)
- Elias Sanidas
- Department of Cardiology, LAIKO General Hospital, "Saint Savvas" Hospital, Athens, Greece
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19
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Trimmel H, Beywinkler C, Hornung S, Kreutziger J, Voelckel WG. In-hospital airway management training for non-anesthesiologist EMS physicians: a descriptive quality control study. Scand J Trauma Resusc Emerg Med 2017; 25:45. [PMID: 28441963 PMCID: PMC5405543 DOI: 10.1186/s13049-017-0386-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 04/07/2017] [Indexed: 11/13/2022] Open
Abstract
Background Pre-hospital airway management is a major challenge for emergency medical service (EMS) personnel. Despite convincing evidence that the rescuer’s qualifications determine efficacy of tracheal intubation, in-hospital airway management training is not mandatory in Austria, and often neglected. Thus we sought to prove that airway management competence of EMS physicians can be established and maintained by a tailored training program. Methods In this descriptive quality control study we retrospectively evaluated all in- and pre-hospital airway cases managed by EMS physicians who underwent a structured in-hospital training program in anesthesia at General Hospital Wiener Neustadt. Data was obtained from electronic anesthesia and EMS documentation systems. Results From 2006 to 2016, 32 EMS physicians with 3-year post-graduate education, but without any prior experience in anesthesia were trained. Airway management proficiency was imparted in three steps: initial training, followed by an ongoing practice schedule in the operating room (OR). Median and interquartile range of number of in-hospital tracheal intubations (TIs) vs. use of supra-glottic airway devices (SGA) were 33.5 (27.5–42.5) vs. 19.0 (15.0–27.0) during initial training; 62.0 (41.8–86.5) vs. 33.5 (18.0–54.5) during the first, and 64.0 (34.5–93.8) vs. 27 (12.5–56.0) during the second year. Pre-hospitaly, every physician performed 9.0 (5.0–14.8) TIs vs. 0.0 (0.0–0.0) SGA cases during the first, and 9.0 (7.0–13.8) TIs vs. 0.0 (0.0–0.3) SGA during the second year. Use of an SGA was mandatory when TI failed after the second attempt, thus accounting for a total of 33 cases. In 8 cases, both TI and SGA failed, but bag mask ventilation was successfully performed. No critical events related to airway management were noted and overall success rate for TI with a max of 2 attempts was 95.3%. Discussion Number of TIs per EMS physician is low in the pre-hospital setting. A training concept that assures an additional 60+ TIs per year appears to minimize failure rates. Thus, a fixed amount of working days in anesthesia seems crucial to maintain proficiency. Conclusions In-hospital training programs are mandatory for non-anesthetist EMS physicians to gain competence in airway management and emergency anesthesia.Our results might be helpful when discussing the need for regulation and financing with the authorities.
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Affiliation(s)
- Helmut Trimmel
- From the Department of Anesthesiology, Emergency and Critical Care Medicine and Karl Landsteiner Institute of Emergency Medicine, General Hospital Wiener Neustadt, Corvinusring 3-5, A 2700, Wiener Neustadt, Austria. .,ÖAMTC Air Rescue, Vienna, Austria.
| | - Christoph Beywinkler
- From the Department of Anesthesiology, Emergency and Critical Care Medicine and Karl Landsteiner Institute of Emergency Medicine, General Hospital Wiener Neustadt, Corvinusring 3-5, A 2700, Wiener Neustadt, Austria
| | - Sonja Hornung
- From the Department of Anesthesiology, Emergency and Critical Care Medicine and Karl Landsteiner Institute of Emergency Medicine, General Hospital Wiener Neustadt, Corvinusring 3-5, A 2700, Wiener Neustadt, Austria.,ÖAMTC Air Rescue, Vienna, Austria
| | - Janett Kreutziger
- Department of Anesthesiology and Critical Care Medicine, Medical University, Innsbruck, Austria
| | - Wolfgang G Voelckel
- Norwegian Air Ambulance, Bergen, Norway.,Department of Anesthesiology and Critical Care Medicine, AUVA Trauma Center Salzburg, Salzburg, Austria.,University of Stavanger, Network for Medical Science, Stavanger, Norway
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20
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Darocha T, Kosiński S, Jarosz A, Podsiadło P, Ziętkiewicz M, Sanak T, Gałązkowski R, Piątek J, Konstanty-Kalandyk J, Drwiła R. Should capnography be used as a guide for choosing a ventilation strategy in circulatory shock caused by severe hypothermia? Observational case-series study. Scand J Trauma Resusc Emerg Med 2017; 25:15. [PMID: 28202085 PMCID: PMC5312422 DOI: 10.1186/s13049-017-0357-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Accepted: 01/31/2017] [Indexed: 11/16/2022] Open
Abstract
Background Severe accidental hypothermia can cause circulatory disturbances ranging from cardiac arrhythmias through circulatory shock to cardiac arrest. Severity of shock, pulmonary hypoperfusion and ventilation-perfusion mismatch are reflected by a discrepancy between measurements of CO2 levels in end-tidal air (EtCO2) and partial CO2 pressure in arterial blood (PaCO2). This disparity can pose a problem in the choice of an optimal ventilation strategy for accidental hypothermia victims, particularly in the prehospital period. We hypothesized that in severely hypothermic patients capnometry should not be used as a reliable guide to choose optimal ventilatory parameters. Methods We undertook a pilot, observational case-series study, in which we included all consecutive patients admitted to the Severe Hypothermia Treatment Centre in Cracow, Poland for VA-ECMO in stage III hypothermia and with signs of circulatory shock. We performed serial measurements of arterial blood gases and EtCO2, core temperature, and calculated a PaCO2/EtCO2 quotient. Results The study population consisted of 13 consecutive patients (ten males, three females, median 60 years old). The core temperature measured in esophagus was 20.7–29.0 °C, median 25.7 °C. In extreme cases we have observed a Pa-EtCO2 gradient of 35–36 mmHg. Median PaCO2/EtCO2 quotient was 2.15. Discussion and Conclusion Severe hypothermia seems to present an example of extremely large Pa-EtCO2 gradient. EtCO2 monitoring does not seem to be a reliable guide to ventilation parameters in severe hypothermia.
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Affiliation(s)
- Tomasz Darocha
- Severe Accidental Hypothermia Center, Cracow, Poland. .,Department of Anesthesiology and Intensive Care, John Paul II Hospital, Jagiellonian University Medical College, Cracow, Poland. .,Polish Medical Air Rescue, Warsaw, Poland.
| | - Sylweriusz Kosiński
- Severe Accidental Hypothermia Center, Cracow, Poland.,Department of Anesthesiology and Intensive Care, Pulmonary Hospital, Zakopane, Poland Tatra Mountain Rescue Service, Zakopane, Poland
| | - Anna Jarosz
- Severe Accidental Hypothermia Center, Cracow, Poland.,Department of Anesthesiology and Intensive Care, John Paul II Hospital, Jagiellonian University Medical College, Cracow, Poland
| | - Paweł Podsiadło
- Severe Accidental Hypothermia Center, Cracow, Poland.,Polish Medical Air Rescue, Warsaw, Poland.,Polish Society for Mountain Medicine and Rescue, Szczyrk, Poland
| | - Mirosław Ziętkiewicz
- Severe Accidental Hypothermia Center, Cracow, Poland.,Department of Anesthesiology and Intensive Care, John Paul II Hospital, Jagiellonian University Medical College, Cracow, Poland
| | - Tomasz Sanak
- Severe Accidental Hypothermia Center, Cracow, Poland.,Department of Disaster Medicine and Emergency Care, Jagiellonian University Medical College, Krakow, Poland.,Department of Combat Medicine, Military Institute, Warsaw, Poland
| | - Robert Gałązkowski
- Polish Medical Air Rescue, Warsaw, Poland.,Department of Emergency Medical Services, Medical University of Warsaw, Warsaw, Poland
| | - Jacek Piątek
- Severe Accidental Hypothermia Center, Cracow, Poland.,Department of Cardiac, Vascular and Transplantation Surgery, John Paul II Hospital, Jagiellonian University Medical College, Cracow, Poland
| | - Janusz Konstanty-Kalandyk
- Severe Accidental Hypothermia Center, Cracow, Poland.,Department of Cardiac, Vascular and Transplantation Surgery, John Paul II Hospital, Jagiellonian University Medical College, Cracow, Poland
| | - Rafał Drwiła
- Severe Accidental Hypothermia Center, Cracow, Poland.,Department of Anesthesiology and Intensive Care, John Paul II Hospital, Jagiellonian University Medical College, Cracow, Poland
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21
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Rapid assessment of shock in a nonhuman primate model of uncontrolled hemorrhage: Association of traditional and nontraditional vital signs to mortality risk. J Trauma Acute Care Surg 2016; 80:610-6. [PMID: 26808041 DOI: 10.1097/ta.0000000000000963] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Heart rate (HR), systolic blood pressure (SBP) and mean arterial pressure (MAP) are traditionally used to guide patient triage and resuscitation; however, they correlate poorly to shock severity. Therefore, improved acute diagnostic capabilities are needed. Here, we correlated acute alterations in tissue oxygen saturation (StO2) and end-tidal carbon dioxide (ETCO2) to mortality in a rhesus macaque model of uncontrolled hemorrhage. METHODS Uncontrolled hemorrhage was induced in anesthetized rhesus macaques by a laparoscopic 60% left-lobe hepatectomy (T = 0 minute). StO2, ETCO2, HR, as well as invasive SBP and MAP were continuously monitored through T = 480 minutes. At T = 120 minutes, bleeding was surgically controlled, and blood loss was quantified. Data analyses compared nonsurvivors (expired before T = 480 minutes, n = 5) with survivors (survived to T = 480 minutes, n = 11) using repeated-measures analysis of variance with Bonferroni correction. All p < 0.05 was considered statistically significant. Results were reported as mean ± SEM. RESULTS Baseline values were equivalent between groups for each parameter. In nonsurvivors versus survivors at T = 5 minutes, StO2 (55% ± 10% vs. 78% ± 3%, p = 0.02) and ETCO2 (15 ± 2 vs. 25 ± 2 mm Hg, p = 0.0005) were lower, while MAP (18 ± 1 vs. 23 ± 2 mm Hg, p = 0.2), SBP (26 ± 2 vs. 34 ± 3 mm Hg, p = 0.4), and HR (104 ± 13 vs. 105 ± 6 beats/min, p = 0.3) were similar. Association of values over T = 5-30 minutes to mortality demonstrated StO2 and ETCO2 equivalency with a significant group effect (p ≤ 0.009 for each parameter; R(2) = 0.92 and R(2) = 0.90, respectively). MAP and SBP associated with mortality later into the shock period (p < 0.04 for each parameter; R(2) = 0.91 and R(2) = 0.89, respectively), while HR yielded the lowest association (p = 0.8, R(2) = 0.83). CONCLUSION Acute alterations in StO2 and ETCO2 strongly associated with mortality and preceded those of traditional vital signs. The continuous, noninvasive aspects of Food and Drug Administration-approved StO2 and ETCO2 monitoring devices provide logistical benefits over other methodologies and thus warrant further investigation.
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22
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Arslan Zİ, Ertargın M, Yavuz CI, Yanal HY, Şenaylı Y, Baykara ZN, Solak M. Assessment of Some Public Hospitals in Turkey Regarding Anaesthetist, Anaesthesia and Intensive Care Equipment. Turk J Anaesthesiol Reanim 2016; 43:217-24. [PMID: 27366502 DOI: 10.5152/tjar.2015.30974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2014] [Accepted: 10/17/2014] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE Every year, 230 million patients undergo major general surgery with anaesthesia worldwide, and 7 million resulted with major complications. Monitorisation and equipment has a great role in increasing patient safety and safe surgery during anaesthesia. METHODS Turkey is divided into 12 Eurostut-NUTS regions and 26 subregions statistically. Totally, 303 hospitals that are included in these regions were enrolled in this descriptive trial. The hospitals were contacted by telephone between October 2012 and August 2013. Data collecting forms were e-mailed to any of the anaesthetists or anaesthesia technicians of the hospital and they were requested to fill the forms and forward them to one of the investigators. RESULTS Data were obtained from 221 of 303 hospitals (73%). Twenty-three hospitals were tertiary (university and education and research), 21 were city and 177 were county hospitals. No anaesthetist, operating rooms or intensive care units were available in 114 of the county hospitals. Anaesthetists were responsible for 61% of these active working theatres. Electrocardiogram, heart rate, non-invasive blood pressure and saturation could be monitored in 97% of them. End-tidal carbon dioxide could be monitored in 91% of at least one operating room in these hospitals. However, if the subject became to end-tidal carbon dioxide monitoring in every room, this ratio decreased to 63%. Defibrillators were absent in 6% of these rooms. Adult intensive care units were available in 33% of the hospitals and paediatric intensive care units were available in 32.4%; the responsibility of these intensive care units were carried out by anaesthetists at a 91.4% ratio. End-tidal carbon dioxide could be monitored in 54% of these units; invasive monitorisation could be applied in 68.4% if needed. CONCLUSION It was observed that hospitals have different standards according to their infrastructures of anaesthesia and intensive care unit equipment. We think that the elimination of these differences is an important step with respect to increasing patient safety and enhancement of the service quality in hospitals.
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Affiliation(s)
- Zehra İpek Arslan
- Department of Anaesthesiology and Reanimation, Kocaeli University Faculty of Medicine, Kocaeli, Turkey
| | - Mehmet Ertargın
- Department of Anaesthesiology and Reanimation, Kocaeli University Faculty of Medicine, Kocaeli, Turkey
| | - Cavit Işık Yavuz
- Department of Public Health, Hacettepe University Faculty of Medicine, Ankara, Turkey
| | - Hülya Yılmaz Yanal
- Department of Anaesthesiology and Reanimation, Kocaeli University Faculty of Medicine, Kocaeli, Turkey
| | - Yeşim Şenaylı
- Clinic of Anaesthesiology and Reanimation, Ankara Paediatrics Haematology-Oncology Training and Research Hospital, Ankara, Turkey
| | - Zehra Nur Baykara
- Department of Anaesthesiology and Reanimation, Kocaeli University Faculty of Medicine, Kocaeli, Turkey
| | - Mine Solak
- Department of Anaesthesiology and Reanimation, Kocaeli University Faculty of Medicine, Kocaeli, Turkey
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Prehospital Endotracheal Intubation in Warm Climates: Caution is Required. J Emerg Med 2016; 51:262-4. [PMID: 27381949 DOI: 10.1016/j.jemermed.2016.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Revised: 09/12/2015] [Accepted: 06/02/2016] [Indexed: 11/21/2022]
Abstract
BACKGROUND Out-of-hospital endotracheal intubation is a frequent procedure for trauma care. Nevertheless, in warm climates, sunlight and heat can interfere with the flow of the usual procedure. They can affect the equipment and hinder the operator. There are few data on this issue. The presentation of this case highlights three common complications that may occur when intubating under a hot and bright sun. CASE REPORT A 23-year-old man had a car accident in Djibouti, at 11:00 a.m., in broad sunlight. The heat was scorching. Due to a severe head trauma, with a Glasgow Coma Scale score of 8, it was decided to perform an endotracheal intubation. The operator faced three problems: the difficulty of seeing inside the mouth in the bright sunlight, the softening of the tube under the influence of the heat, and the inefficiency of colorimetric CO2 detectors in the warm atmosphere in confirming the proper endotracheal tube placement. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Solutions are simple, but must be known and planned ahead, prior to beginning the procedure: Putting a jacket over his head while doing the laryngoscopy would solve the problem of dazzle; adjuncts like a stylet or gum elastic bougie have to be used at the outset to fix the softening problem; alternative methods to exhaled CO2 detection, such as the syringe aspiration technique, to confirm the proper tube placement, should be available.
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Wally D, Velik-Salchner C. [Near-infrared spectroscopy during cardiopulmonary resuscitation and mechanical circulatory support: From the operating room to the intensive care unit]. Med Klin Intensivmed Notfmed 2015; 110:621-30. [PMID: 25917180 DOI: 10.1007/s00063-015-0012-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2014] [Revised: 01/07/2015] [Accepted: 01/13/2015] [Indexed: 12/19/2022]
Abstract
BACKGROUND Near infrared spectroscopy (NIRS) allows continuous measurement of cerebral regional oxygen saturation (rSO2). It is a weighted saturation value derived from approximately 70-75 % venous, 20-25 % arterial and 2.5-5 % capillary blood. In contrast to pulse oximetry, NIRS is independent of pulsatile flow. Therefore, it is also applicable during extracorporeal circulation, cardiopulmonary resuscitation (CPR), and hypothermia. OBJECTIVES The purpose of this work is to describe the application of cerebral and somatic NIRS in cardiology and cardiac surgery patients in the operation room, during and after CPR, and during the intensive care unit stay. MATERIALS AND METHODS This article is based on peer-reviewed literature from PubMed. RESULTS Interventions based on decline of cerebral NIRS values during on-pump cardiac surgery can reduce major organ morbidity and mortality; however, the appearance of a postoperative cognitive dysfunction is scarcely influenced. Persisting of low cerebral oximetry values during resuscitation is a marker for not achieving return of spontaneous circulation under normothermia. NIRS is an additional method for monitoring that can be used during extracorporeal circulation. CONCLUSION NIRS is a rapidly available, user-friendly, and noninvasive method for continuous measurement of rSO2. NIRS provides additional information about tissue oxygenation especially during resuscitation and extracorporeal circulatory assist support. Recommendations concerning the use of NIRS for standard monitoring during resuscitation and mechanical circulatory support are not currently available. Further studies are required to show if use of NIRS can reduce pulse control and hands-off times during resuscitation and if use of NIRS can improve outcome after CPR and mechanical circulatory support.
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Affiliation(s)
- D Wally
- Universitätsklinik für Anästhesie und Intensivmedizin, Department für Operative Medizin, Medizinische Universität Innsbruck, Anichstr. 35, 6020, Innsbruck, Österreich
| | - Corinna Velik-Salchner
- Universitätsklinik für Anästhesie und Intensivmedizin, Department für Operative Medizin, Medizinische Universität Innsbruck, Anichstr. 35, 6020, Innsbruck, Österreich.
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Ganesan AV, Ricardez-Sandoval LA. A modelling study of a new malignant hyperthermia diagnosis device. CAN J CHEM ENG 2015. [DOI: 10.1002/cjce.22191] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- Adarsh V. Ganesan
- Department of Chemical Engineering; University of Waterloo; Waterloo ON N2L 3G1 Canada
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Accuracy of CO₂ monitoring via nasal cannulas and oral bite blocks during sedation for esophagogastroduodenoscopy. J Clin Monit Comput 2015; 30:169-73. [PMID: 25895481 DOI: 10.1007/s10877-015-9696-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Accepted: 04/17/2015] [Indexed: 01/01/2023]
Abstract
Esophagogastroduodenoscopy procedures are typically performed under conscious sedation. Drug-induced respiratory depression is a major cause of serious adverse effects during sedation. Capnographic monitoring of respiratory activity improves patient safety during procedural sedation. This bench study compares the performance of the nasal cannulas and oral bite blocks used to monitor exhaled CO2 during sedation. We used a spontaneously breathing mechanical lung to evaluated four CO2 sampling nasal cannulas and three CO2 sampling bite blocks. We placed pneumatic resistors in the mouth of the manikin to simulate different levels of mouth opening. We compared CO2 measurements taken from the sampling device to CO2 measurements taken directly from the trachea. The end tidal CO2 concentration (PETCO2) measured through the bite blocks and nasal cannulas was always lower than the corresponding PETCO2 measured at the trachea. The difference became larger as the amount of oxygen delivered through the devices increased. The difference was larger during normal ventilation than during hypoventilation. The difference became larger as the amount of oral breathing increased. The two nasal cannulas without oral cups failed to provide sufficient CO2 for breath detection when the mouth was fully open and oxygen was delivered at 10 L/min. Our simulation found that respiratory rate can be accurately monitored during the procedure using a CO2 sampling bite block or a nasal cannula with oral cup. The accuracy of PETCO2 measurements depends on the device used, the amount of supplement oxygen, the amount of oral breathing and the patient's minute ventilation.
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Chen PN, Shih CK, Li YH, Cheng WC, Hsu HT, Cheng KI. Gastric perforation after accidental esophageal intubation in a patient with deep neck infection. ACTA ANAESTHESIOLOGICA TAIWANICA : OFFICIAL JOURNAL OF THE TAIWAN SOCIETY OF ANESTHESIOLOGISTS 2014; 52:143-145. [PMID: 25085018 DOI: 10.1016/j.aat.2014.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/30/2013] [Revised: 04/17/2014] [Accepted: 04/22/2014] [Indexed: 06/03/2023]
Abstract
Deep neck infection with airway obstruction may complicate endotracheal intubation with limited neck motion, pharyngeal swelling, and prominent secretion. Unrecognized esophageal intubation (EI) may unduly overinflate the stomach to inhibit effective ventilation, increase the incidence of hypoxia, and produce a ruptured visceral organ. We report an 81-year-old female patient with deep neck infection and impending respiratory failure who suffered gastric perforation after accidental EI in the intensive care unit. After failed attempts of intubation, EI was recognized rapidly as the culprit, although roughly audible bilateral breathing sounds were present but not gastric bubble sounds. A catastrophic complication of gastric rupture occurred due to ambu-bagging and mechanical ventilation. Surgical intervention was performed immediately. Possible mechanisms are discussed.
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Affiliation(s)
- Po-Nien Chen
- Department of Anesthesiology, Kaohsiung Medical University Hospital, Kaohsiung City, Taiwan
| | - Chih-Kai Shih
- Department of Anesthesiology, Kaohsiung Medical University Hospital, Kaohsiung City, Taiwan
| | - Ya-Hui Li
- Department of Anesthesiology, Kaohsiung Medical University Hospital, Kaohsiung City, Taiwan
| | - Wei-Ching Cheng
- Department of Anesthesiology, Kaohsiung Medical University Hospital, Kaohsiung City, Taiwan
| | - Hung-Te Hsu
- Department of Anesthesiology, Kaohsiung Medical University Hospital, Kaohsiung City, Taiwan; Department of Anesthesiology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung City, Taiwan
| | - Kuang-I Cheng
- Department of Anesthesiology, Kaohsiung Medical University Hospital, Kaohsiung City, Taiwan; Department of Anesthesiology, Faculty of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung City, Taiwan.
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Bates DW, Saria S, Ohno-Machado L, Shah A, Escobar G. Big Data In Health Care: Using Analytics To Identify And Manage High-Risk And High-Cost Patients. Health Aff (Millwood) 2014; 33:1123-31. [DOI: 10.1377/hlthaff.2014.0041] [Citation(s) in RCA: 640] [Impact Index Per Article: 64.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- David W. Bates
- David W. Bates ( ) is chief of the Division of General Medicine, Brigham and Women’s Hospital, in Boston, Massachusetts
| | - Suchi Saria
- Suchi Saria is an assistant professor of computer science and health policy management at the Center for Population Health and IT, Johns Hopkins University, in Baltimore, Maryland
| | - Lucila Ohno-Machado
- Lucila Ohno-Machado is associate dean for informatics and technology in the Division of Biomedical Informatics, University of California, San Diego, in La Jolla
| | - Anand Shah
- Anand Shah is vice president of clinical services at PCCI, in Dallas, Texas
| | - Gabriel Escobar
- Gabriel Escobar is regional director of hospital operations research and director of the Systems Research Initiative, Division of Research, Kaiser Permanente, in Oakland, California
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Sun JT, Chou HC, Sim SS, Chong KM, Ma MHM, Wang HP, Lien WC. Ultrasonography for Proper Endotracheal Tube Placement Confirmation in Out-of-hospital Cardiac Arrest Patients: Two-center Experience. J Med Ultrasound 2014. [DOI: 10.1016/j.jmu.2014.05.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
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Nagurka R, Bechmann S, Gluckman W, Scott SR, Compton S, Lamba S. Utility of initial prehospital end-tidal carbon dioxide measurements to predict poor outcomes in adult asthmatic patients. PREHOSP EMERG CARE 2014; 18:180-4. [PMID: 24400881 DOI: 10.3109/10903127.2013.851306] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVE To determine if an initial (before treatment) prehospital end-tidal carbon dioxide (EtCO2) measurement in adult, non-chronic obstructive pulmonary disease (COPD), asthmatic patients predicts patient outcomes. METHODS This is a retrospective chart review of EtCO2 assessment data in a convenience sample of adult, asthmatic patients transported via advanced life support (ALS) units to a large, urban, academic hospital. Initial EtCO2 measurements were obtained routinely on all respiratory distress patients in the field, and emergency department physicians were unaware of the results. Data were analyzed using descriptive statistics, including percentages, means, and 95% confidence intervals (CI). RESULTS We reviewed data for prehospital initial EtCO2 measurements on 299 unique asthma patients (repeat visits by same patient were not included). Mean (SD) age was 43.1 years (12.5) and 142 (47.5%) were male. The mean EtCO2 measurement was 38.8 mmHg (SD ± 9.5; CI: 37.7-39.9; range: 14-82). Examination of initial EtCO2 measurements by deciles revealed that extreme values, in the lowest (14-28 mmHg) and highest (50-82 mmHg) deciles, experienced more markers of poor outcome than less extreme measurements. Patients were thus dichotomized by extreme (n = 59) or nonextreme (n = 240) EtCO2 measurements. More extreme patients were ultimately intubated (30.5 vs. 5.8%; p < 0.001; positive predictive value (ppv) = 30.5% ), and/or admitted to the intensive care unit (ICU) (28.8 vs. 6.7%; p <0.001; ppv = 28.8%), and/or died (5.1 vs. 0%; p = 0.007 [Fisher's exact test]; ppv = 5.1%), than nonextreme patients, respectively. CONCLUSION Extreme (both low and high) prehospital initial EtCO2 measurements may be associated with markers of poor patient outcomes. Future work will prospectively determine whether the addition of this information improves early recognition of severe asthma episodes beyond clinical assessment.
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Lockey DJ, Avery P, Harris T, Davies GE, Lossius HM. A prospective study of physician pre-hospital anaesthesia in trauma patients: oesophageal intubation, gross airway contamination and the 'quick look' airway assessment. BMC Anesthesiol 2013; 13:21. [PMID: 24024531 PMCID: PMC3848683 DOI: 10.1186/1471-2253-13-21] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2013] [Accepted: 09/03/2013] [Indexed: 11/24/2022] Open
Abstract
Background In trauma patients intubated in a physician-led pre-hospital trauma service we prospectively examined the rate of misplaced tracheal tubes, the presence and nature of gross airway contamination, and the value of ‘quick look’ airway assessment to identify patients with subsequent difficult laryngoscopy. Methods Patients requiring pre-hospital intubation in a 16 month period were included. Intubation success rate, misplaced tracheal tube rate, Cormack and Lehane grade, and the presence and nature of gross airway contamination were recorded at laryngoscopy. Tube placement was verified with carbon dioxide detection and chest x-ray. After visual assessment physicians stated whether laryngoscopy was expected to be a straightforward or ‘difficult’. The assessment was compared to subsequent laryngoscopy grade. Results 400 patients had attempted intubation and 399 were successfully intubated. 42 were in cardiac arrest and intubated without drugs. There were no oesophageal or misplaced tracheal tubes. Gross airway contamination was reported in 177 of 400 patients (44%), of which ¾ was from the upper airway. Unconscious patients had higher contamination rates (57%) than conscious patients (34%) (p ≤ 0.0001). As a test of difficult intubation, the ‘quick look’ generated sensitivity 0.597 and specificity 0.763 (PPV and NPV were 0.336 and 0.904 respectively). Conclusion This study suggests that when physicians perform pre-hospital anaesthesia they have high intubation success rates and the use of ETCO2 monitoring reduces or eliminates undetected misplaced tracheal tubes. We found high rates of airway contamination; mostly blood from the upper airway. The ‘quick look’ airway assessment had some utility but is unreliable in isolation.
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Affiliation(s)
- David J Lockey
- London's Air Ambulance, Department of Pre-hospital Care, Royal London Hospital, London E1 1BB, UK.
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Ahn A, Nasir A, Malik H, D'Orazi F, Parnia S. A pilot study examining the role of regional cerebral oxygen saturation monitoring as a marker of return of spontaneous circulation in shockable (VF/VT) and non-shockable (PEA/Asystole) causes of cardiac arrest. Resuscitation 2013; 84:1713-6. [PMID: 23948447 DOI: 10.1016/j.resuscitation.2013.07.026] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Revised: 07/24/2013] [Accepted: 07/29/2013] [Indexed: 11/28/2022]
Abstract
BACKGROUND Non-invasive monitoring of cerebral perfusion and oxygen delivery during cardiac arrest is not routinely utilized during cardiac arrest resuscitation. The objective of this study was to investigate the feasibility of using cerebral oximetry during cardiac arrest and to determine the relationship between regional cerebral oxygen saturation (rSO2) with return of spontaneous circulation (ROSC) in shockable (VF/VT) and non-shockable (PEA/asystole) types of cardiac arrest. METHODS Cerebral oximetry was applied to 50 in-hospital and out-of-hospital cardiac arrest patients. RESULTS Overall, 52% (n=26) achieved ROSC and 48% (n=24) did not achieve ROSC. There was a significant difference in mean±SD rSO2% in patients who achieved ROSC compared to those who did not (47.2±10.7% vs. 31.7±12.8%, p<0.0001). This difference was observed during asystole (median rSO2 (IQR) ROSC versus no ROSC: 45.0% (35.1-48.8) vs. 24.9% (20.5-32.9), p<0.002) and PEA (50.6% (46.7-57.5) vs. 31.6% (18.8-43.3), p=0.02), but not in the VF/VT subgroup (43.7% (41.1-54.7) vs. 42.8% (34.9-45.0), p=0.63). Furthermore, it was noted that no subjects with a mean rSO2<30% achieved ROSC. CONCLUSIONS Cerebral oximetry may have a role as a real-time, non-invasive predictor of ROSC during cardiac arrest. The main utility of rSO2 in determining ROSC appears to apply to asystole and PEA subgroups of cardiac arrest, rather than VF/VT. This observation may reflect the different physiological factors involved in recovery from PEA/asytole compared to VF/VT. Whereas in VF/VT, successful defibrillation is of prime importance, however in PEA and asytole achieving ROSC is more likely to be related to the quality of oxygen delivery. Furthermore, a persistently low rSO2 <30% in spite of optimal resuscitation methods may indicate futility of resuscitation efforts.
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Affiliation(s)
- Anna Ahn
- Resuscitation Research Group, State University of New York at Stony Brook, Stony Brook University Hospital, T17-040 Health Sciences Center, Stony Brook NY 11794-8172, NY, USA
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Hollier CA, Maxwell LJ, Harmer AR, Menadue C, Piper AJ, Black DA, Willson GN, Alison JA. Validity of arterialised-venous pH and bicarbonate in obesity hypoventilation syndrome. Respir Physiol Neurobiol 2013; 188:165-71. [DOI: 10.1016/j.resp.2013.05.031] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2013] [Revised: 05/27/2013] [Accepted: 05/27/2013] [Indexed: 10/26/2022]
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Chou HC, Chong KM, Sim SS, Ma MHM, Liu SH, Chen NC, Wu MC, Fu CM, Wang CH, Lee CC, Lien WC, Chen SC. Real-time tracheal ultrasonography for confirmation of endotracheal tube placement during cardiopulmonary resuscitation. Resuscitation 2013; 84:1708-12. [PMID: 23851048 DOI: 10.1016/j.resuscitation.2013.06.018] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2013] [Revised: 06/02/2013] [Accepted: 06/18/2013] [Indexed: 11/24/2022]
Abstract
OBJECTIVE This study aimed to evaluate the accuracy of tracheal ultrasonography for assessing endotracheal tube position during cardiopulmonary resuscitation (CPR). METHODS We performed a prospective observational study of patients undergoing emergency intubation during CPR. Real-time tracheal ultrasonography was performed during the intubation with the transducer placed transversely just above the suprasternal notch, to assess for endotracheal tube positioning and exclude esophageal intubation. The position of trachea was identified by a hyperechoic air-mucosa (A-M) interface with posterior reverberation artifact (comet-tail artifact). The endotracheal tube position was defined as endotracheal if single A-M interface with comet-tail artifact was observed. Endotracheal tube position was defined as intraesophageal if a second A-M interface appeared, suggesting a false second airway (double tract sign). The gold standard of correct endotracheal intubation was the combination of clinical auscultation and quantitative waveform capnography. The main outcome was the accuracy of tracheal ultrasonography in assessing endotracheal tube position during CPR. RESULTS Among the 89 patients enrolled, 7 (7.8%) had esophageal intubations. The sensitivity, specificity, positive predictive value, and negative predictive value of tracheal ultrasonography were 100% (95% confidence interval [CI]: 94.4-100%), 85.7% (95% CI: 42.0-99.2%), 98.8% (95% CI: 92.5-99.0%) and 100% (95% CI: 54.7-100%), respectively. Positive and negative likelihood ratios were 7.0 (95% CI: 1.1-43.0) and 0.0, respectively. CONCLUSIONS Real-time tracheal ultrasonography is an accurate method for identifying endotracheal tube position during CPR without the need for interruption of chest compression. Tracheal ultrasonography in resuscitation management may serve as a powerful adjunct in trained hands.
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Affiliation(s)
- Hao-Chang Chou
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei City, Taiwan.
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Availability of anesthesia equipment in Chinese hospitals: is the safety of anesthesia patient care assured? Anesth Analg 2012; 114:1249-53. [PMID: 22467890 DOI: 10.1213/ane.0b013e31825018cf] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Availability of physiologic monitoring equipment to ensure the safe administration of anesthesia is an expected standard in many parts of the world. Many hospitals in China may not have an adequate quantity and variety of anesthesia delivery and patient monitoring equipment to assure safe administration of anesthesia patient care. We present some typical cases of hospitals of different sizes and located in regions with different economic levels; our data demonstrate that there is a lack of available anesthesia administration and patient monitoring equipment in small hospitals and hospitals in economically underdeveloped regions.
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Rose L. Management of critically ill patients receiving noninvasive and invasive mechanical ventilation in the emergency department. Open Access Emerg Med 2012; 4:5-15. [PMID: 27147858 PMCID: PMC4753973 DOI: 10.2147/oaem.s25048] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Patients requiring noninvasive and invasive ventilation frequently present to emergency departments, and may remain for prolonged periods due to constrained critical care services. Emergency clinicians often do not receive the same education on management of mechanical ventilation or have similar exposure to these patients as do their critical care colleagues. The aim of this review was to synthesize the evidence on management of patients requiring noninvasive and invasive ventilation in the emergency department including indications, clinical applications, monitoring priorities, and potential complications. Noninvasive ventilation is recommended for patients with acute exacerbation of chronic obstructive pulmonary disease or cardiogenic pulmonary edema. Less evidence supports its use in asthma and other causes of acute respiratory failure. Use of noninvasive ventilation in the prehospital setting is relatively new, and some evidence suggests benefit. Monitoring priorities for noninvasive ventilation include response to treatment, respiratory and hemodynamic stability, noninvasive ventilation tolerance, detection of noninvasive ventilation failure, and identification of air leaks around the interface. Application of injurious ventilation increases patient morbidity and mortality. Lung-protective ventilation with low tidal volumes based on determination of predicted body weight and control of plateau pressure has been shown to reduce mortality in patients with acute respiratory distress syndrome, and some evidence exists to suggest this strategy should be used in patients without lung injury. Monitoring of the invasively ventilated patient should focus on assessing response to mechanical ventilation and other interventions, and avoiding complications, such as ventilator-associated pneumonia. Several key aspects of management of noninvasive and invasively ventilated patients are discussed, with a particular emphasis on initiation and ongoing monitoring priorities focused on maintaining patient safety and improving patient outcomes.
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Affiliation(s)
- Louise Rose
- Lawrence S Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
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Kusunoki R, Amano Y, Yuki T, Oka A, Okada M, Tada Y, Uno G, Moriyama I, Ishimura N, Ishihara S, Kinoshita Y. Capnographic monitoring for carbon dioxide insufflation during endoscopic mucosal dissection: comparison of transcutaneous and end-tidal capnometers. Surg Endosc 2011; 26:501-6. [PMID: 21938580 DOI: 10.1007/s00464-011-1908-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2011] [Accepted: 08/03/2011] [Indexed: 12/21/2022]
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Sitzwohl C, Langheinrich A, Schober A, Krafft P, Sessler DI, Herkner H, Gonano C, Weinstabl C, Kettner SC. Endobronchial intubation detected by insertion depth of endotracheal tube, bilateral auscultation, or observation of chest movements: randomised trial. BMJ 2010; 341:c5943. [PMID: 21062875 PMCID: PMC2977961 DOI: 10.1136/bmj.c5943] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To determine which bedside method of detecting inadvertent endobronchial intubation in adults has the highest sensitivity and specificity. DESIGN Prospective randomised blinded study. SETTING Department of anaesthesia in tertiary academic hospital. PARTICIPANTS 160 consecutive patients (American Society of Anesthesiologists category I or II) aged 19-75 scheduled for elective gynaecological or urological surgery. INTERVENTIONS Patients were randomly assigned to eight study groups. In four groups, an endotracheal tube was fibreoptically positioned 2.5-4.0 cm above the carina, whereas in the other four groups the tube was positioned in the right mainstem bronchus. The four groups differed in the bedside test used to verify the position of the endotracheal tube. To determine whether the tube was properly positioned in the trachea, in each patient first year residents and experienced anaesthetists were randomly assigned to independently perform bilateral auscultation of the chest (auscultation); observation and palpation of symmetrical chest movements (observation); estimation of the position of the tube by the insertion depth (tube depth); or a combination of all three (all three). MAIN OUTCOME MEASURES Correct and incorrect judgments of endotracheal tube position. RESULTS 160 patients underwent 320 observations by experienced and inexperienced anaesthetists. First year residents missed endobronchial intubation by auscultation in 55% of cases and performed significantly worse than experienced anaesthetists with this bedside test (odds ratio 10.0, 95% confidence interval 1.4 to 434). With a sensitivity of 88% (95% confidence interval 75% to 100%) and 100%, respectively, tube depth and the three tests combined were significantly more sensitive for detecting endobronchial intubation than auscultation (65%, 49% to 81%) or observation(43%, 25% to 60%) (P<0.001). The four tested methods had the same specificity for ruling out endobronchial intubation (that is, confirming correct tracheal intubation). The average correct tube insertion depth was 21 cm in women and 23 cm in men. By inserting the tube to these distances, however, the distal tip of the tube was less than 2.5 cm away from the carina (the recommended safety distance, to prevent inadvertent endobronchial intubation with changes in the position of the head in intubated patients) in 20% (24/118) of women and 18% (7/42) of men. Therefore optimal tube insertion depth was considered to be 20 cm in women and 22 cm in men. CONCLUSION Less experienced clinicians should rely more on tube insertion depth than on auscultation to detect inadvertent endobronchial intubation. But even experienced physicians will benefit from inserting tubes to 20-21 cm in women and 22-23 cm in men, especially when high ambient noise precludes accurate auscultation (such as in emergency situations or helicopter transport). The highest sensitivity and specificity for ruling out endobronchial intubation, however, is achieved by combining tube depth, auscultation of the lungs, and observation of symmetrical chest movements. TRIAL REGISTRATION NCT01232166.
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Affiliation(s)
- Christian Sitzwohl
- Department of Anaesthesiology, General Intensive Care, and Pain Control, Medical University of Vienna General Hospital, A-1090 Vienna, Austria.
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Concordance between capnography and capnia in adults admitted for acute dyspnea in an ED. Am J Emerg Med 2010; 28:711-4. [PMID: 20637388 DOI: 10.1016/j.ajem.2009.04.028] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2009] [Accepted: 04/16/2009] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND End-tidal carbon dioxide pressure (etCO(2)) is widely used in anaesthesia and critical care in intubated patients. The aim of our preliminary study was to evaluate the feasibility of a simple device to predict capnia in spontaneously breathing patients in an emergency department (ED). PATIENTS AND METHODS This study was a prospective, nonblind study performed in our teaching hospital ED. We included nonintubated patients with dyspnea (> or =18 years) requiring measurement of arterial blood gases, as ordered by the emergency physician in charge. There were no exclusion criteria. End-tidal CO(2) was measured by an easy-to-use device connected to a microstream capnometer, which gave a continuous measurement and graphical display of the etCO(2) level of a patient's exhaled breath. RESULTS A total of 43 patients (48 measurements) were included, and the majority had pneumonia (n = 12), acute cardiac failure (n = 8), asthma (n = 7), or chronic obstructive pulmonary disease exacerbation (n = 6). Using simple linear regression, the correlation between etCO(2) and Paco(2) was good (R = 0.82). However, 18 measurements (38%) had a difference between etCO(2) and Paco(2) of 10 mm Hg or more. The mean difference between the Paco(2) and etCO(2) levels was 8 mm Hg. Using the Bland and Altman matrix, the limits of agreement were -10 to +26 mm Hg. CONCLUSION In our preliminary study, etCO(2) using a microstream method does not seem to accurately predict Paco(2) in patients presenting to an ED for acute dyspnea.
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An intervention to decrease complications related to endotracheal intubation in the intensive care unit: a prospective, multiple-center study. Intensive Care Med 2009; 36:248-55. [DOI: 10.1007/s00134-009-1717-8] [Citation(s) in RCA: 249] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2009] [Accepted: 10/11/2009] [Indexed: 10/20/2022]
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Slattery DE, Silver A. The Hazards of Providing Care in Emergency Vehicles: An Opportunity for Reform. PREHOSP EMERG CARE 2009; 13:388-97. [DOI: 10.1080/10903120802706104] [Citation(s) in RCA: 55] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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McManus JG, Ryan KL, Morton MJ, Rickards CA, Cooke WH, Convertino VA. Limitations of End-Tidal CO2as an Early Indicator of Central Hypovolemia in Humans. PREHOSP EMERG CARE 2009; 12:199-205. [DOI: 10.1080/10903120801907182] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Endotracheal Intubation in the ICU. Intensive Care Med 2009. [DOI: 10.1007/978-0-387-92278-2_30] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Lee J, Kim JG, Mahon S, Tromberg BJ, Ryan KL, Convertino VA, Rickards CA, Osann K, Brenner M. Tissue hemoglobin monitoring of progressive central hypovolemia in humans using broadband diffuse optical spectroscopy. JOURNAL OF BIOMEDICAL OPTICS 2008; 13:064027. [PMID: 19123673 PMCID: PMC4079508 DOI: 10.1117/1.3041712] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
We demonstrate noninvasive near-infrared diffuse optical spectroscopy (DOS) measurements of tissue hemoglobin contents that can track progressive reductions in central blood volume in human volunteers. Measurements of mean arterial blood pressure (MAP), heart rate (HR), stroke volume (SV), and cardiac output (Q) are obtained in ten healthy human subjects during baseline supine rest and exposure to progressive reductions of central blood volume produced by application of lower body negative pressure (LBNP). Simultaneous quantitative noninvasive measurements of tissue oxyhemoglobin (OHb), deoxyhemoglobin (RHb), total hemoglobin concentration (THb), and tissue hemoglobin oxygen saturation (S(t)O(2)) are performed throughout LBNP application using broadband DOS. As progressively increasing amounts of LBNP are applied, HR increases, and MAP, SV, and Q decrease (p<0.001). OHb, S(t)O(2), and THb decrease (p<0.001) in correlation with progressive increases in LBNP, while tissue RHb remained relatively constant (p=0.378). The average fractional changes from baseline values in DOS OHb (fOHb) correlate closely with independently measured changes in SV (r(2)=0.95) and Q (r(2)=0.98) during LBNP. Quantitative noninvasive broadband DOS measurements of tissue hemoglobin parameters of peripheral perfusion are capable of detecting progressive reductions in central blood volume, and appear to be sensitive markers of early hypoperfusion associated with hemorrhage as simulated by LBNP.
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Affiliation(s)
- Jangwoen Lee
- University of California, Irvine, Beckman Laser Institute and Medical Clinic, 1002 Health Sciences Road East, Irvine, California 92612, USA.
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Abstract
PURPOSE OF REVIEW Numerous recent reports have described limitations in the quality of cardiopulmonary resuscitation. Thus, there has been increasing interest in the techniques available to monitor quality. This review focuses on the major publications since the review published by the International Liaison Committee on Resuscitation in 2005. Some key articles published prior to this time period have also been included. RECENT FINDINGS A number of devices can monitor various components of the quality of cardiopulmonary resuscitation. End-tidal CO2 measurement assists in confirming placement of endotracheal tubes, correlates with cardiac output and detects the return of spontaneous circulation. Turbine flow-meters monitor respiratory rate and tidal volume. Transthoracic impedance monitoring measures respiratory rate, and may assist in confirmation of endotracheal tube placement. A new mechanical device (CPREzy) and a new defibrillator/monitor allow estimation of depth (and rate) of compressions. Ventricular-fibrillation waveform analysis may facilitate better timing of defibrillation. Echocardiography detects conditions that may impair the quality of cardiopulmonary resuscitation. SUMMARY Many options are available to monitor the quality of cardiopulmonary resuscitation. Some have significant limitations, and others are only readily available in hospital. The use of the information from this more intensive monitoring promises to improve outcomes of cardiopulmonary resuscitation.
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Affiliation(s)
- Peter T Morley
- Intensive Care Unit, Royal Melbourne Hospital, Parkville, Victoria, Australia.
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