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Gómez-Ríos MÁ, Sastre JA, Onrubia-Fuertes X, López T, Abad-Gurumeta A, Casans-Frances R, Gómez-Ríos D, Garzón JC, Martínez-Pons V, Casalderrey-Rivas M, Fernández-Vaquero MÁ, Martínez-Hurtado E, Martín-Larrauri R, Reviriego-Agudo L, Gutierrez-Couto U, García-Fernández J, Serrano-Moraza A, Martín LJR, Leis CC, Ramírez SE, Orgeira JMF, Lima MJV, Mayo-Yáñez M, Parente-Arias P, Sistiaga-Suárez JA, Bernal-Sprekelsen M, Charco-Mora P. Executive Summary of the Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR) Spanish Society of Emergency and Emergency Medicine (SEMES) and Spanish Society of Otolaryngology, Head and Neck Surgery (SEORL-CCC) Guideline for difficult airway management. ACTA OTORRINOLARINGOLOGICA ESPANOLA 2024:S2173-5735(24)00061-9. [PMID: 38797374 DOI: 10.1016/j.otoeng.2024.05.001] [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: 09/06/2023] [Accepted: 03/08/2024] [Indexed: 05/29/2024]
Abstract
The Airway section of the Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR), Spanish Society of Emergency and Emergency Medicine (SEMES) and Spanish Society of Otolaryngology, Head and Neck Surgery (SEORL-CCC) present the Guidelines for the integral management of difficult airway in adult patients. This document provides recommendations based on current scientific evidence, theoretical-educational tools and implementation tools, mainly cognitive aids, applicable to the treatment of the airway in the field of anesthesiology, critical care, emergencies and prehospital medicine. Its principles are focused on the human factors, cognitive processes for decision-making in critical situations and optimization in the progression of the application of strategies to preserve adequate alveolar oxygenation in order to improve safety and quality of care.
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Affiliation(s)
- Manuel Á Gómez-Ríos
- Anesthesiology and Perioperative Medicine, Complejo Hospitalario Universitario de A Coruña, Spain.
| | - José Alfonso Sastre
- Anesthesiology and Perioperative Medicine, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | | | - Teresa López
- Anesthesiology and Perioperative Medicine, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | | | - Rubén Casans-Frances
- Department of Anesthesiology, Hospital Universitario Infanta Elena, Valdemoro, Madrid, Spain
| | | | - José Carlos Garzón
- Anesthesiology and Perioperative Medicine, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - Vicente Martínez-Pons
- Department of Anesthesiology, Hospital Universitari i Politecnic La Fe, Valencia, Spain
| | | | | | | | | | | | | | - Javier García-Fernández
- Department of Anesthesiology, Hospital Universitario Puerta de Hierro-Majadahonda, Majadahonda, Spain; Presidente de la Sociedad Española De Anestesiología, Reanimación y Terapéutica del Dolor (SEDAR), Spain
| | | | | | | | | | | | | | - Miguel Mayo-Yáñez
- Department of Otorhinolaryngology - Head Neck Surgery, Complexo Hospitalario Universitario A Coruña, Galicia, Spain
| | - Pablo Parente-Arias
- Department of Otorhinolaryngology - Head Neck Surgery, Complexo Hospitalario Universitario A Coruña, Galicia, Spain; Department of Otorhinolaryngology, Universidade de Santiago de Compostela, Galicia, Spain
| | - Jon Alexander Sistiaga-Suárez
- Department of Otorhinolaryngology, Hospital Universitario Donostia, Donostia, Spain; Presidente de la Comisión de Tumores de la OSI Donostialdea, Spain
| | - Manuel Bernal-Sprekelsen
- Department of Otorhinolaryngology, University of Barcelona, Barcelona, Spain; Department of Otorhinolaryngology, Hospital Clinic Barcelona, Spain; Presidente de la Sociedad Española de Otorrinolaringología y Cirugía de Cabeza y Cuello (SEORL-CCC), Spain
| | - Pedro Charco-Mora
- Department of Anesthesiology, Hospital Universitari i Politecnic La Fe, Valencia, Spain
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2
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Jansen G, Latka E, Bernhard M, Deicke M, Fischer D, Hoyer A, Keller Y, Kobiella A, Strickmann B, Strototte LM, Thies KC, Johanning K. Prehospital anesthesia in postcardiac arrest patients: a multicenter retrospective cohort study. Eur J Med Res 2024; 29:263. [PMID: 38698492 PMCID: PMC11067130 DOI: 10.1186/s40001-024-01864-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2024] [Accepted: 04/24/2024] [Indexed: 05/05/2024] Open
Abstract
BACKGROUND Currently, the data regarding the impact of prehospital postcardiac arrest anesthesia on target hemodynamic and ventilatory parameters of early postresuscitation care and recommendations on its implementation are rare. The present study examines the incidence and impact of prehospital postcardiac arrest anesthesia on hemodynamic and ventilatory target parameters of postresuscitation care. METHODS In this multicentre observational study between 2019 and 2021 unconscious adult patients after out-of-hospital-cardiac arrest with the presence of a return-of-spontaneous circulation until hospital admission were included. Primary endpoint was the application of postarrest anesthesia. Secondary endpoints included the medication group used, predisposing factors to its implementation, and its influence on achieving target parameters of postresuscitation care (systolic blood pressure: ≥ 100 mmHg, etCO2:35-45 mmHg, SpO2: 94-98%) at hospital handover. RESULTS During the study period 2,335 out-of-hospital resuscitations out of 391,305 prehospital emergency operations (incidence: 0.58%; 95% CI 0.54-0.63) were observed with a return of spontaneous circulation to hospital admission in 706 patients (30.7%; 95% CI 28.8-32.6; female: 34.3%; age:68.3 ± 14.2 years). Postcardiac arrest anesthesia was performed in 482 patients (68.3%; 95% CI 64.7-71.7) with application of hypnotics in 93.4% (n = 451), analgesics in 53.7% (n = 259) and relaxants in 45.6% (n = 220). Factors influencing postcardiac arrest sedation were emergency care by an anesthetist (odds ratio: 2.10; 95% CI 1.34-3.30; P < 0.001) and treatment-free interval ≤ 5 min (odds ratio: 1.59; 95% CI 1.01-2.49; P = 0.04). Although there was no evidence of the impact of performing postcardiac arrest anesthesia on achieving a systolic blood pressure ≥ 100 mmHg at the end of operation (odds ratio: 1.14; 95% CI 0.78-1.68; P = 0.48), patients with postcardiac arrest anesthesia were significantly more likely to achieve the recommended ventilation (odds ratio: 1.59; 95% CI 1.06-2.40; P = 0.02) and oxygenation (odds ratio:1.56; 95% CI 1.04-2.35; P = 0.03) targets. Comparing the substance groups, the use of hypnotics significantly more often enabled the target values for etCO2 to be reached alone (odds ratio:2.79; 95% CI 1.04-7.50; P = 0.04) as well as in combination with a systolic blood pressure ≥ 100 mmHg (odds ratio:4.42; 95% CI 1.03-19.01; P = 0.04). CONCLUSIONS Postcardiac arrest anesthesia in out-of-hospital cardiac arrest is associated with early achievement of respiratory target parameters in prehospital postresuscitation care without evidence of more frequent hemodynamic complications.
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Affiliation(s)
- Gerrit Jansen
- University Department of Anesthesiology, Intensive Care Medicine and Emergency Medicine, Johannes Wesling Klinikum Minden, Ruhr University Bochum, Hans-Nolte-Straße 1, 32429, Minden, Germany.
- Medical School OWL, Bielefeld University, Universitätsstraße 25, 33615, Bielefeld, Germany.
- Department of Medical and Emergency Services, Study Institute Westfalen-Lippe, Remterweg 44, 33617, Bielefeld, Germany.
| | - Eugen Latka
- Department of Medical and Emergency Services, Study Institute Westfalen-Lippe, Remterweg 44, 33617, Bielefeld, Germany
| | - Michael Bernhard
- Central Emergency Department, University Hospital of Düsseldorf, Moorenstrasse 5, 40225, Düsseldorf, Germany
| | - Martin Deicke
- Emergency Medical Service, Countryside of Osnabrueck, Am Schölerberg 1, 49082, Osnabrueck, Germany
- Department of Anesthesiology and Operative Intensive Care Medicine, Hospital of Osnabrueck, Am Finkenhügel 1, 49076, Osnabrueck, Germany
| | - Daniel Fischer
- Emergency Medical Service, City and District of Lippe-Detmold, Röntgenstraße 18, 32756, Detmold, Germany
| | - Annika Hoyer
- Biostatistics and Medical Biometry, Medical School OWL, Bielefeld University, Universitätsstraße 25, 33615, Bielefeld, Germany
| | - Yacin Keller
- Department of Public Order and Security, Fire and Disaster Control Office, Integrated Regional Control Centre, Scharfenberger Straße 47, 01139, Dresden, Germany
- Departement for Anesthesiology and Intensive Care Medicine, Emergency Medicine and Pain Therapy, Municipal Hospital Dresden - Friedrichstadt, Friedrichstraße 41, 01067, Dresden, Germany
| | - André Kobiella
- Emergency Medical Service, City and District of Guetersloh, Herzebrocker Strasse 140, 33324, Guetersloh, Germany
| | - Bernd Strickmann
- Emergency Medical Service, City and District of Guetersloh, Herzebrocker Strasse 140, 33324, Guetersloh, Germany
| | - Lisa Marie Strototte
- Department of Anesthesiology, Intensive Care, Emergency Medicine, Transfusion Medicine, and Pain Therapy, Protestant Hospital of the Bethel Foundation, Medical School OWL, Bielefeld University, Burgsteig 13, 33617, Bielefeld, Germany
| | - Karl-Christian Thies
- Department of Anesthesiology, Intensive Care, Emergency Medicine, Transfusion Medicine, and Pain Therapy, Protestant Hospital of the Bethel Foundation, Medical School OWL, Bielefeld University, Burgsteig 13, 33617, Bielefeld, Germany
| | - Kai Johanning
- Department of Anesthesiology, Operative Intensive Care Medicine, Emergency Medicine and Pain Therapy, Bielefeld Municipal Hospital, Medical School OWL, Bielefeld University, Campus Klinikum Bielefeld, Teutoburger Straße 50, 33604, Bielefeld, Germany
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3
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Venturini M, Van Keilegom I, De Corte W, Vens C. Predicting time-to-intubation after critical care admission using machine learning and cured fraction information. Artif Intell Med 2024; 150:102817. [PMID: 38553157 DOI: 10.1016/j.artmed.2024.102817] [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: 06/02/2023] [Revised: 02/19/2024] [Accepted: 02/20/2024] [Indexed: 04/02/2024]
Abstract
Intubation for mechanical ventilation (MV) is one of the most common high-risk procedures performed in Intensive Care Units (ICUs). Early prediction of intubation may have a positive impact by providing timely alerts to clinicians and consequently avoiding high-risk late intubations. In this work, we propose a new machine learning method to predict the time to intubation during the first five days of ICU admission, based on the concept of cure survival models. Our approach combines classification and survival analysis, to effectively accommodate the fraction of patients not at risk of intubation, and provide a better estimate of time to intubation, for patients at risk. We tested our approach and compared it to other predictive models on a dataset collected from a secondary care hospital (AZ Groeninge, Kortrijk, Belgium) from 2015 to 2021, consisting of 3425 ICU stays. Furthermore, we utilised SHAP for feature importance analysis, extracting key insights into the relative significance of variables such as vital signs, blood gases, and patient characteristics in predicting intubation in ICU settings. The results corroborate that our approach improves the prediction of time to intubation in critically ill patients, by using routinely collected data within the first hours of admission in the ICU. Early warning of the need for intubation may be used to help clinicians predict the risk of intubation and rank patients according to their expected time to intubation.
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Affiliation(s)
- Michela Venturini
- KU Leuven, Campus KULAK-Department of Public Health and Primary Care, Etienne Sabbelaan 53, Kortrijk, 8500, Belgium; ITEC-imec and KU Leuven, Etienne Sabbelaan 51, Kortrijk, 8500, Belgium.
| | - Ingrid Van Keilegom
- Research Centre for Operations Research and Statistics, KU Leuven, Naamsestraat 69, Leuven, 3000, Belgium
| | - Wouter De Corte
- Department of Anesthesiology and Intensive Care Medicine, AZ Groeninge Hospital, President Kennedylaan 4, Kortrijk, 8500, Belgium
| | - Celine Vens
- KU Leuven, Campus KULAK-Department of Public Health and Primary Care, Etienne Sabbelaan 53, Kortrijk, 8500, Belgium; ITEC-imec and KU Leuven, Etienne Sabbelaan 51, Kortrijk, 8500, Belgium.
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4
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Gómez-Ríos MÁ, Sastre JA, Onrubia-Fuertes X, López T, Abad-Gurumeta A, Casans-Francés R, Gómez-Ríos D, Garzón JC, Martínez-Pons V, Casalderrey-Rivas M, Fernández-Vaquero MÁ, Martínez-Hurtado E, Martín-Larrauri R, Reviriego-Agudo L, Gutierrez-Couto U, García-Fernández J, Serrano-Moraza A, Rodríguez Martín LJ, Camacho Leis C, Espinosa Ramírez S, Fandiño Orgeira JM, Vázquez Lima MJ, Mayo-Yáñez M, Parente-Arias P, Sistiaga-Suárez JA, Bernal-Sprekelsen M, Charco-Mora P. Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR), Spanish Society of Emergency and Emergency Medicine (SEMES) and Spanish Society of Otolaryngology, Head and Neck Surgery (SEORL-CCC) Guideline for difficult airway management. Part II. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2024; 71:207-247. [PMID: 38340790 DOI: 10.1016/j.redare.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 08/28/2023] [Indexed: 02/12/2024]
Abstract
The Airway Management section of the Spanish Society of Anesthesiology, Resuscitation, and Pain Therapy (SEDAR), the Spanish Society of Emergency Medicine (SEMES), and the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) present the Guide for the comprehensive management of difficult airway in adult patients. Its principles are focused on the human factors, cognitive processes for decision-making in critical situations, and optimization in the progression of strategies application to preserve adequate alveolar oxygenation in order to enhance safety and the quality of care. The document provides evidence-based recommendations, theoretical-educational tools, and implementation tools, mainly cognitive aids, applicable to airway management in the fields of anesthesiology, critical care, emergencies, and prehospital medicine. For this purpose, an extensive literature search was conducted following PRISMA-R guidelines and was analyzed using the GRADE methodology. Recommendations were formulated according to the GRADE methodology. Recommendations for sections with low-quality evidence were based on expert opinion through consensus reached via a Delphi questionnaire.
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Affiliation(s)
- M Á Gómez-Ríos
- Anesthesiology and Perioperative Medicine, Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain.
| | - J A Sastre
- Anesthesiology and Perioperative Medicine, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - X Onrubia-Fuertes
- Department of Anesthesiology, Hospital Universitary Dr Peset, Valencia, Spain
| | - T López
- Anesthesiology and Perioperative Medicine, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - A Abad-Gurumeta
- Department of Anesthesiology, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - R Casans-Francés
- Department of Anesthesiology, Hospital Universitario Infanta Elena, Valdemoro, Madrid, Spain
| | | | - J C Garzón
- Anesthesiology and Perioperative Medicine, Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - V Martínez-Pons
- Department of Anesthesiology, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - M Casalderrey-Rivas
- Department of Anesthesiology. Complejo Hospitalario Universitario de Ourense, Ourense, Spain
| | - M Á Fernández-Vaquero
- Department of Anesthesiology, Hospital Clínica Universitaria de Navarra, Madrid, Spain
| | - E Martínez-Hurtado
- Department of Anesthesiology, Hospital Universitario Infanta Leonor, Madrid, Spain
| | | | - L Reviriego-Agudo
- Department of Anesthesiology, Hospital Clínico Universitario, Valencia, Spain
| | - U Gutierrez-Couto
- Biblioteca, Complejo Hospitalario Universitario de Ferrol (CHUF), Ferrol, A Coruña, Spain
| | - J García-Fernández
- Department of Anesthesiology, Hospital Universitario Puerta de Hierro-Majadahonda, Majadahonda, Madrid, Spain; President of the Spanish Society of Anesthesiology, Resuscitation and Pain Therapy (SEDAR), Spain
| | | | | | | | | | - J M Fandiño Orgeira
- Emergency Department, Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain
| | - M J Vázquez Lima
- Emergency Department, Hospital do Salnes, Vilagarcía de Arousa, Pontevedra, Spain; President of the Spanish Emergency Medicine Society (SEMES), Spain
| | - M Mayo-Yáñez
- Department of Otorhinolaryngology/Head Neck Surgery, Complexo Hospitalario Universitario A Coruña, A Coruña, Spain
| | - P Parente-Arias
- Department of Otorhinolaryngology/Head Neck Surgery, Complexo Hospitalario Universitario A Coruña, A Coruña, Spain
| | - J A Sistiaga-Suárez
- Department of Otorhinolaryngology, Hospital Universitario Donostia, Donostia, Gipuzkoa, Spain
| | - M Bernal-Sprekelsen
- Department of Otorhinolaryngology, Hospital Clínic Barcelona, University of Barcelona, Barcelona, Spain; President of the Spanish Society for Otorhinolaryngology Head & Neck Surgery (SEORL-CCC), Spain
| | - P Charco-Mora
- Department of Anesthesiology, Hospital Universitari i Politècnic La Fe, Valencia, Spain
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5
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Gómez-Ríos MÁ, Sastre JA, Onrubia-Fuertes X, López T, Abad-Gurumeta A, Casans-Francés R, Gómez-Ríos D, Garzón JC, Martínez-Pons V, Casalderrey-Rivas M, Fernández-Vaquero MÁ, Martínez-Hurtado E, Martín-Larrauri R, Reviriego-Agudo L, Gutierrez-Couto U, García-Fernández J, Serrano-Moraza A, Rodríguez Martín LJ, Camacho Leis C, Espinosa Ramírez S, Fandiño Orgeira JM, Vázquez Lima MJ, Mayo-Yáñez M, Parente-Arias P, Sistiaga-Suárez JA, Bernal-Sprekelsen M, Charco-Mora P. Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR), Spanish Society of Emergency and Emergency Medicine (SEMES) and Spanish Society of Otolaryngology, Head and Neck Surgery (SEORL-CCC) Guideline for difficult airway management. Part I. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2024; 71:171-206. [PMID: 38340791 DOI: 10.1016/j.redare.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 08/28/2023] [Indexed: 02/12/2024]
Abstract
The Airway Management section of the Spanish Society of Anesthesiology, Resuscitation, and Pain Therapy (SEDAR), the Spanish Society of Emergency Medicine (SEMES), and the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) present the Guide for the comprehensive management of difficult airway in adult patients. Its principles are focused on the human factors, cognitive processes for decision-making in critical situations, and optimization in the progression of strategies application to preserve adequate alveolar oxygenation in order to enhance safety and the quality of care. The document provides evidence-based recommendations, theoretical-educational tools, and implementation tools, mainly cognitive aids, applicable to airway management in the fields of anesthesiology, critical care, emergencies, and prehospital medicine. For this purpose, an extensive literature search was conducted following PRISMA-R guidelines and was analyzed using the GRADE methodology. Recommendations were formulated according to the GRADE methodology. Recommendations for sections with low-quality evidence were based on expert opinion through consensus reached via a Delphi questionnaire.
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Affiliation(s)
- M Á Gómez-Ríos
- Anesthesiology and Perioperative Medicine. Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain.
| | - J A Sastre
- Anesthesiology and Perioperative Medicine. Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - X Onrubia-Fuertes
- Department of Anesthesiology, Hospital Universitari Dr Peset, Valencia, Spain
| | - T López
- Anesthesiology and Perioperative Medicine. Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - A Abad-Gurumeta
- Department of Anesthesiology, Hospital Universitario Infanta Leonor, Madrid, Spain
| | - R Casans-Francés
- Department of Anesthesiology. Hospital Universitario Infanta Elena, Valdemoro, Madrid, Spain
| | | | - J C Garzón
- Anesthesiology and Perioperative Medicine. Complejo Asistencial Universitario de Salamanca, Salamanca, Spain
| | - V Martínez-Pons
- Department of Anesthesiology, Hospital Universitari i Politècnic La Fe, Valencia, Spain
| | - M Casalderrey-Rivas
- Department of Anesthesiology, Complejo Hospitalario Universitario de Ourense, Ourense, Spain
| | - M Á Fernández-Vaquero
- Department of Anesthesiology, Hospital Clínica Universitaria de Navarra, Madrid, Spain
| | - E Martínez-Hurtado
- Department of Anesthesiology, Hospital Universitario Infanta Leonor, Madrid, Spain
| | | | - L Reviriego-Agudo
- Department of Anesthesiology. Hospital Clínico Universitario, Valencia, Spain
| | - U Gutierrez-Couto
- Biblioteca, Complejo Hospitalario Universitario de Ferrol (CHUF), Ferrol, A Coruña, Spain
| | - J García-Fernández
- Department of Anesthesiology, Hospital Universitario Puerta de Hierro-Majadahonda, Majadahonda, Madrid, Spain; President of the Spanish Society of Anesthesiology, Resuscitation and Pain Therapy (SEDAR), Spain
| | | | | | | | | | - J M Fandiño Orgeira
- Servicio de Urgencias, Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain
| | - M J Vázquez Lima
- Emergency Department, Hospital do Salnes, Vilagarcía de Arousa, Pontevedra, Spain; President of the Spanish Emergency Medicine Society (SEMES), Spain
| | - M Mayo-Yáñez
- Department of Otorhinolaryngology/Head Neck Surgery, Complexo Hospitalario Universitario A Coruña, A Coruña, Spain
| | - P Parente-Arias
- Department of Otorhinolaryngology/Head Neck Surgery, Complexo Hospitalario Universitario A Coruña, A Coruña, Spain
| | - J A Sistiaga-Suárez
- Department of Otorhinolaryngology, Hospital Universitario Donostia, Donostia, Gipuzkoa, Spain
| | - M Bernal-Sprekelsen
- Department of Otorhinolaryngology, Hospital Clínic Barcelona, University of Barcelona, Barcelona, Spain; President of the Spanish Society for Otorhinolaryngology Head & Neck Surgery (SEORL-CCC), Spain
| | - P Charco-Mora
- Department of Anesthesiology, Hospital Universitari i Politècnic La Fe, Valencia, Spain
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Zhang T, Gai K, Li R, Liang Y, Li L, Chen J, Nie M. Robust and self-lubricating polyvinyl alcohol tubes with a mucosa-like hierarchical architecture for endotracheal intubation. J Mater Chem B 2024; 12:1330-1343. [PMID: 38230443 DOI: 10.1039/d3tb02402d] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2024]
Abstract
Mechanical mismatch between interventional intubation tubes and human tissues often triggers inevitable friction and causes secondary injury to patients during interventional therapy. Herein, we propose a fabrication strategy of a self-lubricating polyvinyl alcohol (PVA) tube by industrial extrusion technology followed by simple infiltration with water. First, biocompatible glycerin was introduced to weaken the intrinsic hydrogen interaction of PVA by new molecular complexation, broadening the gap between the melting and decomposition temperatures and enabling the stable extrusion of the PVA tube. Subsequently, the as-prepared PVA tube was infiltrated with an aqueous solution to construct a strong hydrogen bonding network between PVA and water molecules, forming a soft hydration layer similar to the upper epithelium layer of mucosa. Benefiting from the solid and liquid properties of the hydration layer as well as the small proportion relative to the whole, the infiltrated PVA tube exhibited excellent hydration lubrication behavior and robust mechanical property. The friction coefficient, tensile strength and elongation at break were measured to be 0.05, 26.2 MPa and 654%, respectively, surpassing the values of 0.5, 16.4 MPa and 240% observed in a commercial polyvinyl chloride tube. In vitro, the PVA intubation tube demonstrated significant biocompatibility, and short-term exposure exhibited minimal impacts on the morphology and proliferation of L929 cells. Ultimately, the potential of the infiltrated PVA tube for interventional intubation was demonstrated successfully using an in vivo rabbit model, providing a new idea for the follow-up development of interventional intubation tubes.
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Affiliation(s)
- Tongrui Zhang
- State Key Laboratory of Polymer Materials Engineering, Polymer Research Institute, State Key Laboratory of Oral Diseases & National Center for Stomatology & National Clinical Research Center for Oral Diseases & Department of Prosthodontics, West China Hospital of Stomatology, Sichuan University, Chengdu 610041, Sichuan, China.
| | - Kuo Gai
- State Key Laboratory of Polymer Materials Engineering, Polymer Research Institute, State Key Laboratory of Oral Diseases & National Center for Stomatology & National Clinical Research Center for Oral Diseases & Department of Prosthodontics, West China Hospital of Stomatology, Sichuan University, Chengdu 610041, Sichuan, China.
| | - Ruyi Li
- State Key Laboratory of Polymer Materials Engineering, Polymer Research Institute, State Key Laboratory of Oral Diseases & National Center for Stomatology & National Clinical Research Center for Oral Diseases & Department of Prosthodontics, West China Hospital of Stomatology, Sichuan University, Chengdu 610041, Sichuan, China.
| | - Yi Liang
- State Key Laboratory of Polymer Materials Engineering, Polymer Research Institute, State Key Laboratory of Oral Diseases & National Center for Stomatology & National Clinical Research Center for Oral Diseases & Department of Prosthodontics, West China Hospital of Stomatology, Sichuan University, Chengdu 610041, Sichuan, China.
| | - Li Li
- State Key Laboratory of Polymer Materials Engineering, Polymer Research Institute, State Key Laboratory of Oral Diseases & National Center for Stomatology & National Clinical Research Center for Oral Diseases & Department of Prosthodontics, West China Hospital of Stomatology, Sichuan University, Chengdu 610041, Sichuan, China.
| | - Junyu Chen
- State Key Laboratory of Polymer Materials Engineering, Polymer Research Institute, State Key Laboratory of Oral Diseases & National Center for Stomatology & National Clinical Research Center for Oral Diseases & Department of Prosthodontics, West China Hospital of Stomatology, Sichuan University, Chengdu 610041, Sichuan, China.
| | - Min Nie
- State Key Laboratory of Polymer Materials Engineering, Polymer Research Institute, State Key Laboratory of Oral Diseases & National Center for Stomatology & National Clinical Research Center for Oral Diseases & Department of Prosthodontics, West China Hospital of Stomatology, Sichuan University, Chengdu 610041, Sichuan, China.
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7
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Arcanjo ABB, Beccaria LM. Fatores associados à falha de extubação em unidade de terapia intensiva: estudo de caso-controle. Rev Lat Am Enfermagem 2023. [DOI: 10.1590/1518-8345.6224.3865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
Abstract
Resumo Objetivo: investigar os fatores associados à falha de extubação de pacientes na unidade de terapia intensiva. Método: caso-controle não pareado, longitudinal, retrospectivo e quantitativo com a participação de 480 pacientes por meio de parâmetros clínicos para desmame ventilatório. Dados analisados por: Teste Exato de Fisher ou o teste Qui-quadrado; teste t de Student bicaudal não pareado; e teste de Mann-Whitney. Admitiram-se significantes valores de P menores ou iguais a 0,05. Resultados: dos pacientes, 415 (86,5%) tiveram sucesso e 65 (13,5%) falharam. Grupo sucesso: balanço hídrico mais negativo, APACHE II em 20 (14-25), tosse fraca em 58 (13,9%). Grupo falha: balanço hídrico mais positivo, APACHE II em 23 (19-29), tosse fraca em 31 (47,7 %), quantidade abundante de secreção pulmonar em 47,7 %. Conclusão: o balanço hídrico positivo e a presença de tosse ineficiente ou incapacidade de higienizar a via aérea foram preditores de falhas de extubação.
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Arcanjo ABB, Beccaria LM. Factors associated with extubation failure in an intensive care unit: a case-control study. Rev Lat Am Enfermagem 2023; 31:e3864. [PMID: 36995853 PMCID: PMC10077863 DOI: 10.1590/1518-8345.6224.3864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Accepted: 10/20/2022] [Indexed: 03/29/2023] Open
Abstract
Abstract Objective: to investigate the factors associated with extubation failure of patients in the intensive care unit. Method: unpaired, longitudinal, retrospective and quantitative case-control with the participation of 480 patients through clinical parameters for ventilator weaning. Data were analyzed by: Fisher’s exact test or the chi-square test; unpaired two-tailed Student’s t test; and Mann-Whitney test. Significant P values lower than or equal to 0.05 were admitted. Results: of the patients, 415 (86.5%) were successful and 65 (13.5%) failed. Success group: the most negative fluid balance, APACHE II in 20 (14-25), weak cough in 58 (13.9%). Failure group: the most positive fluid balance, APACHE II in 23 (19-29), weak cough in 31 (47.7%), abundant amount of pulmonary secretions in 47.7%. Conclusion: positive fluid balance and the presence of inefficient cough or inability to clear the airway were predictors of extubation failure.
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Arcanjo ABB, Beccaria LM. Factores asociados al fracaso de la extubación en unidad de cuidados intensivos: estudio de caso y control. Rev Lat Am Enfermagem 2023. [DOI: 10.1590/1518-8345.6224.3863] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023] Open
Abstract
Resumen Objetivo: investigar los factores asociados al fracaso de la extubación de pacientes en la unidad de cuidados intensivos. Método: caso y control no apareado, longitudinal, retrospectivo y cuantitativo con la participación de 480 pacientes mediante parámetros clínicos para el destete de la ventilación. Datos analizados por: Prueba Exacta de Fisher o prueba de Chi-cuadrado; prueba t de Student de dos colas para datos no apareados; y prueba de Mann-Whitney. Se admitieron valores de P significativos menores o iguales a 0,05. Resultados: de los pacientes, 415 (86,5%) tuvieron éxito y 65 (13,5%) fracasaron. Grupo de éxito: balance hídrico más negativo, APACHE II en 20 (14-25), tos débil en 58 (13,9%). Grupo de fracaso: balance de líquidos más positivo, APACHE II en 23 (19-29), tos débil en 31 (47,7%), abundante cantidad de secreciones pulmonares en 47,7%. Conclusión: el balance hídrico positivo y la presencia de tos ineficaz o incapacidad para higienizar la vía aérea fueron predictores de fracaso de la extubación.
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Acquisto NM, Mosier JM, Bittner EA, Patanwala AE, Hirsch KG, Hargwood P, Oropello JM, Bodkin RP, Groth CM, Kaucher KA, Slampak-Cindric AA, Manno EM, Mayer SA, Peterson LKN, Fulmer J, Galton C, Bleck TP, Chase K, Heffner AC, Gunnerson KJ, Boling B, Murray MJ. Society of Critical Care Medicine Clinical Practice Guidelines for Rapid Sequence Intubation in the Critically Ill Adult Patient. Crit Care Med 2023; 51:1411-1430. [PMID: 37707379 DOI: 10.1097/ccm.0000000000006000] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
Abstract
RATIONALE Controversies and practice variations exist related to the pharmacologic and nonpharmacologic management of the airway during rapid sequence intubation (RSI). OBJECTIVES To develop evidence-based recommendations on pharmacologic and nonpharmacologic topics related to RSI. DESIGN A guideline panel of 20 Society of Critical Care Medicine members with experience with RSI and emergency airway management met virtually at least monthly from the panel's inception in 2018 through 2020 and face-to-face at the 2020 Critical Care Congress. The guideline panel included pharmacists, physicians, a nurse practitioner, and a respiratory therapist with experience in emergency medicine, critical care medicine, anesthesiology, and prehospital medicine; consultation with a methodologist and librarian was available. A formal conflict of interest policy was followed and enforced throughout the guidelines-development process. METHODS Panelists created Population, Intervention, Comparison, and Outcome (PICO) questions and voted to select the most clinically relevant questions for inclusion in the guideline. Each question was assigned to a pair of panelists, who refined the PICO wording and reviewed the best available evidence using predetermined search terms. The Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) framework was used throughout and recommendations of "strong" or "conditional" were made for each PICO question based on quality of evidence and panel consensus. Recommendations were provided when evidence was actionable; suggestions, when evidence was equivocal; and best practice statements, when the benefits of the intervention outweighed the risks, but direct evidence to support the intervention did not exist. RESULTS From the original 35 proposed PICO questions, 10 were selected. The RSI guideline panel issued one recommendation (strong, low-quality evidence), seven suggestions (all conditional recommendations with moderate-, low-, or very low-quality evidence), and two best practice statements. The panel made two suggestions for a single PICO question and did not make any suggestions for one PICO question due to lack of evidence. CONCLUSIONS Using GRADE principles, the interdisciplinary panel found substantial agreement with respect to the evidence supporting recommendations for RSI. The panel also identified literature gaps that might be addressed by future research.
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Affiliation(s)
- Nicole M Acquisto
- Department of Pharmacy and Emergency Medicine, University of Rochester Medical Center, Rochester, New York, NY
| | - Jarrod M Mosier
- Department of Emergency Medicine and Medicine, University of Arizona College of Medicine, Tucson, AZ
| | - Edward A Bittner
- Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, MA
| | - Asad E Patanwala
- Faculty of Medicine and Health, Sydney School of Pharmacy, The University of Sydney, Sydney, Australia
| | - Karen G Hirsch
- Department of Neurology and Neurological Sciences and Neurosurgery, Stanford University, Stanford, CA
| | - Pamela Hargwood
- Robert Wood Johnson Library of the Health Sciences, Rutgers University, New Brunswick, NJ
| | - John M Oropello
- Institute for Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ryan P Bodkin
- Department of Emergency Medicine, University of Rochester Medical Center, Rochester, New York, NY
| | - Christine M Groth
- Department of Pharmacy, University of Rochester Medical Center, Rochester, New York, NY
| | - Kevin A Kaucher
- Department of Pharmacy, University of New Mexico Hospital, Albuquerque, NM
| | | | - Edward M Manno
- Department of Neurology, Northwestern University, Feinberg School of Medicine, Chicago, IL
| | - Stephen A Mayer
- Departments of Neurology and Neurosurgery Westchester Medical Center, New York Medical College, New York, NY
| | - Lars-Kristofer N Peterson
- Departments of Critical Care Medicine and Emergency Medicine, Cooper University Health Care, Camden, NJ
| | - Jeremy Fulmer
- Respiratory Care Services, Geisinger Medical Center, Danville, PA
| | - Christopher Galton
- Departments of Anesthesiology and Perioperative Medicine and Emergency Medicine, University of Rochester Medical Center, Rochester, NY
| | - Thomas P Bleck
- Department of Neurology, Northwestern University, Feinberg School of Medicine, Chicago, IL
| | - Karin Chase
- Departments of Surgery and Emergency Medicine, University of Rochester Medical Center, Rochester, NY
| | - Alan C Heffner
- Departments of Critical Care and Emergency Medicine, Atrium Healthcare System, Charlotte, NC
| | - Kyle J Gunnerson
- Department of Emergency Medicine, University of Michigan Health System, Ann Arbor, MI
| | - Bryan Boling
- Department of Anesthesiology, Division or Critical Care Medicine, University of Kentucky, Lexington, KY
| | - Michael J Murray
- Departments of Anesthesiology and Internal Medicine/Cardiology, University of Arizona College of Medicine, Phoenix, AZ
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Hughes KE, Islam MT, Co B, Lopido M, McNinch NL, Biffar D, Subbian V, Son YJ, Mosier JM. Comparison of Force During the Endotracheal Intubation of Commercial Simulation Manikins. Cureus 2023; 15:e43808. [PMID: 37731426 PMCID: PMC10508868 DOI: 10.7759/cureus.43808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/20/2023] [Indexed: 09/22/2023] Open
Abstract
Background Medical simulation allows clinicians to safely practice the procedural skill of endotracheal intubation. Applied force to oropharyngeal structures increases the risk of patient harm, and video laryngoscopy (VL) requires less force to obtain a glottic view. It is unknown how much force is required to obtain a glottic view using commercially available simulation manikins and if variability exists. This study compares laryngoscopy force for a modified Cormack-Lehane (CL) grade I view in both normal and difficult airway scenarios between three commercially available simulation manikins. Methods Experienced clinicians (≥2 years experience) were recruited to participate from critical care, emergency medicine, and anesthesia specialties. A C-MAC size 3 VL blade was equipped with five force resistor reading (FSR) sensors (four concave surfaces, one convex), measuring resistance (Ohms) in response to applied pressure (1-100 Newtons). The study occurred in a university simulation lab. Using a randomized sequence, 49 physicians performed intubations on three manikins (Laerdal SimMan 3GPlus, Gaumard Hal S3201, CAE Apollo) in normal and difficult airway scenarios. The outcomes were sensor mean pressure, peak force, and CL grade. Summary statistics were calculated. Generalized estimating equations (GEEs) conducted for both scenarios assessed changes in pressure measured in three manikins while accounting for correlated responses of individuals assigned in random order. Paired t-test assessed for the in-manikin difference between scenarios. STATA/BE v17 (R) was used for analysis; results interpreted at type I error alpha is 0.05. Results Participants included 49 experienced clinicians. Mean years' experience was 4(±6.6); median prior intubations were 80 (IQR 50-400). Mean individual sensor pressure varied within scenarios depending on manikin (p<0.001). Higher mean forces were used in difficult scenarios (603.4±128.9, 611.1±101.4, 467.5±72.4 FSR) than normal (462.5±121.9, 596.0±90.5, 290.6±63.2 FSR) for each manikin (p<0.001). All manikins required more peak force in the difficult scenario (p<0.03). The highest mean forces (Laerdal, CAE, difficult scenario) were associated with the higher frequency of grade 2A views (p<0.001). The Gaumard manikin was rated most realistic in terms of force required to intubate. Conclusion Commercially available high-fidelity manikins had significant variability in laryngoscopy force in both normal and difficult airway scenarios. In difficult airway scenarios, significant variability existed in CL grade between manikin brands. Experienced clinicians rated Gaumard Hal as the most realistic force applied during endotracheal intubation.
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Affiliation(s)
- Kate E Hughes
- Emergency Medicine, University of Arizona, Tucson, USA
| | | | - Benjamin Co
- Emergency Medicine, University of Arizona, Tucson, USA
| | | | - Neil L McNinch
- Biostatistics, McNinch Biostats, LLC (Limited Liability Company), Kent, USA
| | - David Biffar
- Health Sciences, University of Arizona, Tucson, USA
| | - Vignesh Subbian
- Systems and Industrial Engineering, University of Arizona, Tucson, USA
| | - Young-Jun Son
- Industrial Engineering, Purdue University, West Lafayette, USA
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Mosier JM, Sammani S, Kempf C, Unger E, Garcia JGN. The impact of intravenous dodecafluoropentane on a murine model of acute lung injury. Intensive Care Med Exp 2023; 11:33. [PMID: 37322298 DOI: 10.1186/s40635-023-00518-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 05/08/2023] [Indexed: 06/17/2023] Open
Abstract
INTRODUCTION Intravenous oxygen therapeutics present an appealing option for improving arterial oxygenation in patients with acute hypoxemic respiratory failure, while limiting iatrogenic injury from conventional respiratory management. METHODS We used an established two-hit murine model of acute lung injury (ARDS/VILI) to evaluate the effect of intravenous dodecafluoropentane (DDFPe) on oxygen saturation and bronchoalveolar lavage cell counts and protein levels. Twenty hours after challenge with intratracheal lipopolysaccharide, mice were intubated and ventilated with high tidal volumes (4 h) to produce acute lung injury. DDFPe (0.6 mL/kg) or saline was administered by IV bolus injection at the initiation of mechanical ventilation and again at 2 h. Oxygen saturation was measured every 15 min. Bronchoalveolar lavage was performed at the conclusion of the experiment. RESULTS The two-hit ARDS/VILI model produced substantial inflammatory acute lung injury reflected by markedly increased bronchoalveolar lavage (BAL) cell counts compared to BAL cell counts in spontaneous breathing controls (5.29 ± 1.50 × 10-6 vs 0.74 ± 0.014 × 10-6 cells/mL) Similarly, BAL protein levels were markedly elevated in ARDS/VILI-challenged mice compared with spontaneous breathing controls (1109.27 ± 223.80 vs 129.6 ± 9.75 ng/mL). We fit a linear mixed effects model that showed a significant difference in oxygen saturation over time between DDFPe-treated mice and saline-treated mice, with separation starting after the 2-h injection. DDFPe-treated ARDS/VILI-challenged mice also exhibited significant reductions in BAL cell counts but not in BAL protein. CONCLUSION DDFPe improves oxygen saturation in a murine model of ARDS/VILI injury with the potential for serving as an intravenous oxygen therapeutic.
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Affiliation(s)
- Jarrod M Mosier
- Department of Emergency Medicine, University of Arizona College of Medicine, 1501 N. Campbell Ave., AHSL 4170D, P.O. Box 245057, Tucson, AZ, 85724-5057, USA.
- Department of Medicine, Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, University of Arizona College of Medicine, Tucson, AZ, USA.
| | - Saad Sammani
- Department of Medicine, Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, University of Arizona College of Medicine, Tucson, AZ, USA
| | - Carrie Kempf
- Department of Medicine, Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, University of Arizona College of Medicine, Tucson, AZ, USA
| | - Evan Unger
- Department of Radiology, University of Arizona College of Medicine, Tucson, AZ, USA
| | - Joe G N Garcia
- Department of Medicine, Division of Pulmonary, Allergy, Critical Care, and Sleep Medicine, University of Arizona College of Medicine, Tucson, AZ, USA
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Mosier JM. Individualized Treatment Effects: Machine Learning Can Revolutionize Observations, but Let's Understand What We Are Observing. Am J Respir Crit Care Med 2023; 207:1550-1551. [PMID: 36952659 PMCID: PMC10273104 DOI: 10.1164/rccm.202303-0521ed] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/25/2023] Open
Affiliation(s)
- Jarrod M Mosier
- Department of Emergency Medicine and Department of Medicine, Division of Pulmonary, Allergy, Critical Care and Sleep University of Arizona College of Medicine Tucson, Arizona
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Ångerman S, Kirves H, Nurmi J. Multifaceted implementation and sustainability of a protocol for prehospital anaesthesia: a retrospective analysis of 2115 patients from helicopter emergency medical services. Scand J Trauma Resusc Emerg Med 2023; 31:21. [PMID: 37122004 PMCID: PMC10148755 DOI: 10.1186/s13049-023-01086-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Accepted: 04/18/2023] [Indexed: 05/02/2023] Open
Abstract
BACKGROUND Prehospital emergency anaesthesia (PHEA) is a high-risk procedure. We developed a prehospital anaesthesia protocol for helicopter emergency medical services (HEMS) that standardises the process and involves ambulance crews as active team members to increase efficiency and patient safety. The aim of the current study was to evaluate this change and its sustainability in (i) on-scene time, (ii) intubation first-pass success rate, and (iii) protocol compliance after a multifaceted implementation process. METHODS The protocol was implemented in 2015 in a HEMS unit and collaborating emergency medical service systems. The implementation comprised dissemination of information, lectures, simulations, skill stations, academic detailing, and cognitive aids. The methods were tailored based on implementation science frameworks. Data from missions were gathered from mission databases and patient records. RESULTS During the study period (2012-2020), 2381 adults underwent PHEA. The implementation year was excluded; 656 patients were analysed before and 1459 patients after implementation of the protocol. Baseline characteristics and patient categories were similar. On-scene time was significantly redused after the implementation (median 32 [IQR 25-42] vs. 29 [IQR 21-39] minutes, p < 0.001). First pass success rate increased constantly during the follow-up period from 74.4% (95% CI 70.7-77.8%) to 97.6% (95% CI 96.7-98.3%), p = 0.0001. Use of mechanical ventilation increased from 70.6% (95% CI 67.0-73.9%) to 93.4% (95% CI 92.3-94.8%), p = 0.0001, and use of rocuronium increased from 86.4% (95% CI 83.6-88.9%) to 98.5% (95% CI 97.7-99.0%), respectively. Deterioration in compliance indicators was not observed. CONCLUSIONS We concluded that clinical performance in PHEA can be significantly improved through multifaceted implementation strategies.
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Affiliation(s)
- Susanne Ångerman
- Department of Emergency Medicine and Services, Helsinki University Hospital and University of Helsinki, FinnHEMS 10, Vesikuja 9, 01530 Vantaa, Finland
| | - Hetti Kirves
- Department of Emergency Medicine and Services, Helsinki University Hospital and University of Helsinki, FinnHEMS 10, Vesikuja 9, 01530 Vantaa, Finland
| | - Jouni Nurmi
- Department of Emergency Medicine and Services, Helsinki University Hospital and University of Helsinki, FinnHEMS 10, Vesikuja 9, 01530 Vantaa, Finland
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Cattin L, Ferrari F, Mongodi S, Pariani E, Bettini G, Daverio F, Donadello K, Polati E, Mojoli F, Danzi V, De Rosa S. Airways management in SARS-COV-2 acute respiratory failure: A prospective observational multi-center study. Med Intensiva 2023; 47:131-139. [PMID: 36155747 PMCID: PMC9359672 DOI: 10.1016/j.medine.2022.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Revised: 06/22/2022] [Accepted: 07/06/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Few studies have reported the implications and adverse events of performing endotracheal intubation for critically ill COVID-19 patients admitted to intensive care units. The aim of the present study was to determine the adverse events related to tracheal intubation in COVID-19 patients, defined as the onset of hemodynamic instability, severe hypoxemia, and cardiac arrest. SETTING Tertiary care medical hospitals, dual-centre study performed in Northern Italy from November 2020 to May 2021. PATIENTS Adult patients with positive SARS-CoV-2 PCR test, admitted for respiratory failure and need of advanced invasive airways management. INTERVENTIONS Endotracheal Intubation Adverse Events. MAIN VARIABLES OF INTERESTS The primary endpoint was to determine the occurrence of at least 1 of the following events within 30 minutes from the start of the intubation procedure and to describe the types of major adverse peri-intubation events: severe hypoxemia defined as an oxygen saturation as measured by pulse-oximetry <80%; hemodynamic instability defined as a SBP 65 mmHg recoded at least once or SBP < 90 mmHg for 30 minutes, a new requirement or increase of vasopressors, fluid bolus >15 mL/kg to maintain the target blood pressure; cardiac arrest. RESULTS Among 142 patients, 73.94% experienced at least one major adverse peri-intubation event. The predominant event was cardiovascular instability, observed in 65.49% of all patients undergoing emergency intubation, followed by severe hypoxemia (43.54%). 2.82% of the patients had a cardiac arrest. CONCLUSION In this study of intubation practices in critically ill patients with COVID-19, major adverse peri-intubation events were frequent. CLINICAL TRIAL REGISTRATION www. CLINICALTRIALS gov identifier: NCT04909476.
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Affiliation(s)
- L Cattin
- Department of Anesthesia and Intensive Care Unit, St. Bortolo Hospital, Vicenza, Italy; Anaesthesia and Intensive Care Unit B, Department of Surgery, Dentistry, Paediatrics and Gynaecology, University of Verona, University Hospital Integrated Trust of Verona, Verona, Italy
| | - F Ferrari
- Anesthesia and Intensive Care, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - S Mongodi
- Anesthesia and Intensive Care, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - E Pariani
- Department of clinical-surgical, diagnostic and paediatric sciences, Unit of anaesthesia and intensive care, University of Pavia, Pavia, Italy
| | - G Bettini
- Department of clinical-surgical, diagnostic and paediatric sciences, Unit of anaesthesia and intensive care, University of Pavia, Pavia, Italy
| | - F Daverio
- Department of clinical-surgical, diagnostic and paediatric sciences, Unit of anaesthesia and intensive care, University of Pavia, Pavia, Italy
| | - K Donadello
- Anaesthesia and Intensive Care Unit B, Department of Surgery, Dentistry, Paediatrics and Gynaecology, University of Verona, University Hospital Integrated Trust of Verona, Verona, Italy
| | - E Polati
- Anaesthesia and Intensive Care Unit B, Department of Surgery, Dentistry, Paediatrics and Gynaecology, University of Verona, University Hospital Integrated Trust of Verona, Verona, Italy
| | - F Mojoli
- Anesthesia and Intensive Care, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; Department of clinical-surgical, diagnostic and paediatric sciences, Unit of anaesthesia and intensive care, University of Pavia, Pavia, Italy
| | - V Danzi
- Department of Anesthesia and Intensive Care Unit, St. Bortolo Hospital, Vicenza, Italy
| | - S De Rosa
- Department of Anesthesia and Intensive Care Unit, St. Bortolo Hospital, Vicenza, Italy.
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Airways management in SARS-COV-2 acute respiratory failure: A prospective observational multi-center study. Med Intensiva 2023; 47:131-139. [PMID: 36855737 PMCID: PMC9950782 DOI: 10.1016/j.medin.2022.07.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2022] [Accepted: 07/06/2022] [Indexed: 02/26/2023]
Abstract
Objective Few studies have reported the implications and adverse events of performing endotracheal intubation for critically ill COVID-19 patients admitted to intensive care units. The aim of the present study was to determine the adverse events related to tracheal intubation in COVID-19 patients, defined as the onset of hemodynamic instability, severe hypoxemia, and cardiac arrest. Setting Tertiary care medical hospitals, dual-centre study performed in Northern Italy from November 2020 to May 2021. Patients Adult patients with positive SARS-CoV-2 PCR test, admitted for respiratory failure and need of advanced invasive airways management. Interventions Endotracheal Intubation Adverse Events. Main variables of interests The primary endpoint was to determine the occurrence of at least 1 of the following events within 30 minutes from the start of the intubation procedure and to describe the types of major adverse peri-intubation events: severe hypoxemia defined as an oxygen saturation as measured by pulse-oximetry <80%; hemodynamic instability defined as a SBP 65 mmHg recoded at least once or SBP < 90 mmHg for 30 minutes, a new requirement or increase of vasopressors, fluid bolus >15 mL/kg to maintain the target blood pressure; cardiac arrest. Results Among 142 patients, 73.94% experienced at least one major adverse peri-intubation event. The predominant event was cardiovascular instability, observed in 65.49% of all patients undergoing emergency intubation, followed by severe hypoxemia (43.54%). 2.82% of the patients had a cardiac arrest. Conclusion In this study of intubation practices in critically ill patients with COVID-19, major adverse peri-intubation events were frequent. Clinical Trial registration www.clinicaltrials.gov identifier: NCT04909476.
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Key Words
- ARDS, acute respiratory distress syndrome
- Airway management
- CI, confidence interval
- COVID-19, Coronavirus disease 2019
- CPAP, continuous positive airways pressure
- Critical care
- DBP, diastolic blood pressure
- ECG, electrocardiography
- ETT, Emergency Endotracheal intubation
- EtCO2, end-tidal carbon dioxide
- HFNO, High flow nasal oxygen
- HR, heart rate
- ICU, intensive care unit
- NIV, noninvasive ventilation
- OR, odds ratio
- PCR, polymerase chain reaction
- PaO2/FiO2, arterial partial oxygen pressure / fraction of inspired oxygen
- RR, respiratory rate
- Respiratory failure
- SARS-CoV infection
- SARS-Cov2, severe acute respiratory syndrome coronavirus 2
- SBP, systolic blood pressure
- SpO2, Peripheral oxygen saturation
- Tracheal intubation
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Acute Respiratory Distress Syndrome in Pregnancy: Updates in Principles and Practice. Clin Obstet Gynecol 2023; 66:208-222. [PMID: 36657055 DOI: 10.1097/grf.0000000000000763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Acute respiratory failure occurs in 0.05% to 0.3% of pregnancies and is precipitated by pulmonary and nonpulmonary insults. Acute respiratory distress syndrome (ARDS) is the rapid onset of hypoxemic respiratory failure associated with bilateral pulmonary opacities on chest imaging attributed to noncardiogenic pulmonary edema. The pathophysiological features of ARDS include hypoxemia, diminished lung volumes, and decreased lung compliance. While there is a paucity of data concerning ARDS in the pregnant individual, management principles do not vary significantly between pregnant and nonpregnant patients. The following review will discuss the diagnosis and management of the pregnant patient with ARDS.
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Al-Saadi MA, Heidari B, Donahue KR, Shipman EM, Kinariwala KN, Masud FN. Pre-Existing Right Ventricular Dysfunction as an Independent Risk Factor for Post Intubation Cardiac Arrest and Hemodynamic Instability in Critically Ill Patients: A Retrospective Observational Study. J Intensive Care Med 2023; 38:169-178. [PMID: 35786053 DOI: 10.1177/08850666221111776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Post intubation cardiac arrest and hemodynamic instability are serious adverse events encountered in critically ill patients. The association of pre-existing right ventricular (RV) dysfunction with post intubation cardiac arrest and hemodynamic instability in critically ill patients is unknown. METHODS This is a retrospective matched cohort study of adult critically ill patients who underwent intubation from July 2016 to December 2019. The study was conducted at a quaternary medical center in Houston, Texas. A total of 340 critically ill patients who underwent intubation in the intensive care units, wards, and the emergency room were included. The study cohort was categorized into 4 groups based on the pre-existing RV function: normal function, mild dysfunction, moderate dysfunction, and severe dysfunction. Cardiac arrest and/or hemodynamic instability within one hour post intubation were the primary study outcomes. Secondary outcomes included in hospital and 60-day mortality. RESULTS Study patients were of mean age of 61.95 ± 14.28 years, including 132 (39%) females and 208 (61%) males. The primary outcomes were significantly worse in mild, moderate, and severe RV dysfunction groups compared to the normal RV function group (34.12%-P = 0.014, 47.06%-P < 0.001, 51.67%-P < 0.001, vs. 17.56%). In a multivariable logistic regression analysis, pre-existing moderate (OR = 2.65, P = 0.013) and severe RV dysfunction groups (OR = 2.66, P = 0.015) were associated with statistically significant higher cardiac arrest and hemodynamic instability post intubation. Pre-existing severe RV dysfunction was associated with statistically significant higher in hospital mortality (62.35%-P < 0.001). The multivariable Cox-regression analysis showed that pre-existing severe RV dysfunction was associated with a statistically significant higher 60-day mortality (HR = 2.57, P = 0.001). CONCLUSIONS Pre-existing moderate and severe RV dysfunctions were independently associated with significantly higher cardiac arrest and/or hemodynamic instability post intubation in critically ill patients. Pre-existing RV function may serve as a mortality predictor in critically ill patients undergoing endotracheal intubation.
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Affiliation(s)
- Mukhtar A Al-Saadi
- Department of Medicine, 23534Houston Methodist Hospital, Houston, Texas, USA
| | - Behnam Heidari
- Department of Medicine, 23534Houston Methodist Hospital, Houston, Texas, USA
| | - Kevin R Donahue
- Department of Pharmacy, 23534Houston Methodist Hospital, Houston, Texas, USA
| | - Emily M Shipman
- Department of Medicine, 23534Houston Methodist Hospital, Houston, Texas, USA
| | - Kush N Kinariwala
- Department of Medicine, 23534Houston Methodist Hospital, Houston, Texas, USA
| | - Faisal N Masud
- Department of Anesthesiology, 23534Houston Methodist Hospital, Houston, Texas, USA
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19
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Yarnell CJ, Johnson A, Dam T, Jonkman A, Liu K, Wunsch H, Brochard L, Celi LA, De Grooth HJ, Elbers P, Mehta S, Munshi L, Fowler RA, Sung L, Tomlinson G. Do Thresholds for Invasive Ventilation in Hypoxemic Respiratory Failure Exist? A Cohort Study. Am J Respir Crit Care Med 2023; 207:271-282. [PMID: 36150166 DOI: 10.1164/rccm.202206-1092oc] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Rationale: Invasive ventilation is a significant event for patients with respiratory failure. Physiologic thresholds standardize the use of invasive ventilation in clinical trials, but it is unknown whether thresholds prompt invasive ventilation in clinical practice. Objectives: To measure, in patients with hypoxemic respiratory failure, the probability of invasive ventilation within 3 hours after meeting physiologic thresholds. Methods: We studied patients admitted to intensive care receiving FiO2 of 0.4 or more via nonrebreather mask, noninvasive positive pressure ventilation, or high-flow nasal cannula, using data from the Medical Information Mart for Intensive Care (MIMIC)-IV database (2008-2019) and the Amsterdam University Medical Centers Database (AmsterdamUMCdb) (2003-2016). We evaluated 17 thresholds, including the ratio of arterial to inspired oxygen, the ratio of saturation to inspired oxygen ratio, composite scores, and criteria from randomized trials. We report the probability of invasive ventilation within 3 hours of meeting each threshold and its association with covariates using odds ratios (ORs) and 95% credible intervals (CrIs). Measurements and Main Results: We studied 4,726 patients (3,365 from MIMIC, 1,361 from AmsterdamUMCdb). Invasive ventilation occurred in 28% (1,320). In MIMIC, the highest probability of invasive ventilation within 3 hours of meeting a threshold was 20%, after meeting prespecified neurologic or respiratory criteria while on vasopressors, and 19%, after a ratio of arterial to inspired oxygen of <80 mm Hg. In AmsterdamUMCdb, the highest probability was 34%, after vasopressor initiation, and 25%, after a ratio of saturation to inspired oxygen of <90. The probability after meeting the threshold from randomized trials was 9% (MIMIC) and 13% (AmsterdamUMCdb). In MIMIC, a race/ethnicity of Black (OR, 0.75; 95% CrI, 0.57-0.96) or Asian (OR, 0.6; 95% CrI, 0.35-0.95) compared with White was associated with decreased probability of invasive ventilation after meeting a threshold. Conclusions: The probability of invasive ventilation within 3 hours of meeting physiologic thresholds was low and associated with patient race/ethnicity.
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Affiliation(s)
- Christopher J Yarnell
- Interdepartmental Division of Critical Care Medicine.,Institute of Health Policy, Management and Evaluation, and.,Division of Respirology
| | | | - Tariq Dam
- Laboratory for Critical Care Computational Intelligence, Amsterdam Medical Data Science, Department of Intensive Care Medicine, Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands
| | - Annemijn Jonkman
- Department of Intensive Care Medicine, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Kuan Liu
- Institute of Health Policy, Management and Evaluation, and
| | - Hannah Wunsch
- Interdepartmental Division of Critical Care Medicine.,Institute of Health Policy, Management and Evaluation, and.,Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Laurent Brochard
- Interdepartmental Division of Critical Care Medicine.,Keenan Research Centre for Biomedical Research, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, Ontario, Canada
| | - Leo Anthony Celi
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, Massachusetts.,Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts.,Department of Biostatistics, T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts; and
| | - Harm-Jan De Grooth
- Laboratory for Critical Care Computational Intelligence, Amsterdam Medical Data Science, Department of Intensive Care Medicine, Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands
| | - Paul Elbers
- Laboratory for Critical Care Computational Intelligence, Amsterdam Medical Data Science, Department of Intensive Care Medicine, Amsterdam UMC, Vrije Universiteit, Amsterdam, the Netherlands
| | - Sangeeta Mehta
- Interdepartmental Division of Critical Care Medicine.,Division of Respirology
| | - Laveena Munshi
- Interdepartmental Division of Critical Care Medicine.,Division of Respirology
| | - Robert A Fowler
- Interdepartmental Division of Critical Care Medicine.,Institute of Health Policy, Management and Evaluation, and.,Department of Medicine, University of Toronto, Toronto, Ontario, Canada.,Division of Haematology/Oncology.,Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Lillian Sung
- Institute of Health Policy, Management and Evaluation, and.,Division of Haematology/Oncology
| | - George Tomlinson
- Institute of Health Policy, Management and Evaluation, and.,Department of Medicine, University Health Network and Sinai Health System, Toronto, Ontario, Canada
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20
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Fonseca D, Graça MI, Salgueirinho C, Pereira H. Physiologically difficult airway: How to approach the difficulty beyond anatomy. TRENDS IN ANAESTHESIA AND CRITICAL CARE 2023. [DOI: 10.1016/j.tacc.2023.101212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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21
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Airway Management in Adult Intensive Care Units: A Survey of Two Regions in China. BIOMED RESEARCH INTERNATIONAL 2022; 2022:4653494. [DOI: 10.1155/2022/4653494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 08/14/2022] [Accepted: 11/03/2022] [Indexed: 11/22/2022]
Abstract
The critical medicine residency training in China started in 2020, but no investigation on the practice of tracheal intubation in ICUs in China has been conducted. A survey was sent to the adult ICUs in public hospitals in Shenzhen (SZ) city and Xinjiang (XJ) province using a WeChat miniprogram to be completed by intensive care physicians. It included questions on training on intubation, intubation procedures, and changes in the use of personal protective equipment due to COVID-19. We analyzed 301 valid questionnaires which were from 72 hospitals. A total of 37% of respondents had completed training in RSI (SZ, 40% vs. XJ, 30%;
), and 50% had participated in a course on the emergency front of the neck airway (SZ, 47% vs. XJ, 54%;
). Video laryngoscopy was preferred by 75% of respondents. Manual ventilation (56%) and noninvasive positive pressure ventilation (34%) were the first-line options for preoxygenation. For patients with a high risk of aspiration, nasogastric decompression (47%) and cricoid pressure (37%) were administered. Propofol (82%) and midazolam (70%) were the most commonly used induction agents. Only 19% of respondents routinely used neuromuscular blocking agents. For patients with difficult airways, a flexible endoscope was the most commonly used device by 76% of respondents. Most participants (77%) believed that the COVID-19 pandemic had significantly increased their awareness of the need for personal protective equipment during tracheal intubation. Our survey demonstrated that the ICU doctors in these areas lack adequate training in airway management.
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22
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Ljungqvist H, Pirneskoski J, Saviluoto A, Setälä P, Tommila M, Nurmi J. Intubation first-pass success in a high performing pre-hospital critical care system is not associated with 30-day mortality: a registry study of 4496 intubation attempts. Scand J Trauma Resusc Emerg Med 2022; 30:61. [PMID: 36411447 PMCID: PMC9677625 DOI: 10.1186/s13049-022-01049-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 11/12/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Lower intubation first-pass success (FPS) rate is associated with physiological deterioration, and FPS is widely used as a quality indicator of the airway management of a critically ill patient. However, data on FPS's association with survival is limited. We aimed to investigate if the FPS rate is associated with 30-day mortality or physiological complications in a pre-hospital setting. Furthermore, we wanted to describe the FPS rate in Finnish helicopter emergency medical services. METHODS This was a retrospective observational study. Data on drug-facilitated intubation attempts by helicopter emergency medical services were gathered from a national database and analysed. Multivariate logistic regression, including known prognostic factors, was performed to assess the association between FPS and 30-day mortality, collected from population registry data. RESULTS Of 4496 intubation attempts, 4082 (91%) succeeded on the first attempt. The mortality rates in FPS and non-FPS patients were 34% and 38% (P = 0.21), respectively. The adjusted odds ratio of FPS for 30-day mortality was 0.88 (95% CI 0.66-1.16). Hypoxia after intubation and at the time of handover was more frequent in the non-FPS group (12% vs. 5%, P < 0.001, and 5% vs. 3%, P = 0.01, respectively), but no significant differences were observed regarding other complications. CONCLUSION FPS is not associated with 30-day mortality in pre-hospital critical care delivered by advanced providers. It should therefore be seen more as a process quality indicator instead of a risk factor of poor outcome, at least considering the current limitations of the parameter.
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Affiliation(s)
- Harry Ljungqvist
- grid.7737.40000 0004 0410 2071University of Helsinki, Helsinki, Finland
| | - Jussi Pirneskoski
- grid.15485.3d0000 0000 9950 5666Department of Emergency Medicine and Services, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Anssi Saviluoto
- grid.15485.3d0000 0000 9950 5666Department of Emergency Medicine and Services, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Piritta Setälä
- grid.412330.70000 0004 0628 2985Centre for Prehospital Emergency Care, Helicopter Emergency Medical Services, Tampere University Hospital, Tampere, Finland
| | - Miretta Tommila
- grid.410552.70000 0004 0628 215XDepartment of Perioperative Services, Intensive Care Medicine and Pain Management, Turku University Hospital and University of Turku, Turku, Finland
| | - Jouni Nurmi
- grid.15485.3d0000 0000 9950 5666Department of Emergency Medicine and Services, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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23
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Rodríguez-Blanco J, Rodríguez-Yanez T, Rodríguez-Blanco JD, Almanza-Hurtado AJ, Martínez-Ávila MC, Borré-Naranjo D, Acuña Caballero MC, Dueñas-Castell C. Neuromuscular blocking agents in the intensive care unit. J Int Med Res 2022; 50:3000605221128148. [PMID: 36173012 PMCID: PMC9528036 DOI: 10.1177/03000605221128148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Neuromuscular blocking agents (NMBA) are a controversial therapeutic option in the approach to the critically ill patient. They are not innocuous, and the available evidence does not support their routine use in the intensive care unit. If necessary, monitoring protocols should be established to avoid residual relaxation, adverse effects, and associated complications. This narrative review discusses the current indications for the use of NMBA and the different tools for monitoring blockade in the intensive care unit. However, expanding the use of NMBA in critical settings merits the development of prospective studies.
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Affiliation(s)
- Jonathan Rodríguez-Blanco
- Divission of Pain Medicine, Department of Anesthesiology, University of Antioquia, Medellin, Colombia
| | - Tomás Rodríguez-Yanez
- Department of Critical Medicine and Intensive Care, Gestión Salud IPS, Cartagena, Colombia
| | | | | | | | - Diana Borré-Naranjo
- Department of Critical Medicine and Intensive Care, Gestión Salud IPS, Cartagena, Colombia
| | | | - Carmelo Dueñas-Castell
- Department of Critical Medicine and Intensive Care, Gestión Salud IPS, Cartagena, Colombia
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24
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Godet T, De Jong A, Garin C, Guérin R, Rieu B, Borao L, Pereira B, Molinari N, Bazin JE, Jabaudon M, Chanques G, Futier E, Jaber S. Impact of Macintosh blade size on endotracheal intubation success in intensive care units: a retrospective multicenter observational MacSize-ICU study. Intensive Care Med 2022; 48:1176-1184. [PMID: 35974189 PMCID: PMC9463307 DOI: 10.1007/s00134-022-06832-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Accepted: 07/18/2022] [Indexed: 12/19/2022]
Abstract
Purpose To investigate the impact of Macintosh blade size used during direct laryngoscopy (DL) on first-attempt intubation success of orotracheal intubation in French intensive care units (ICUs). We hypothesized that success rate would be higher with Macintosh blade size No3 than with No4. Methods Multicenter retrospective observational study based on data from prospective trials conducted in 48 French ICUs of university, and general and private hospitals. After each intubation using Macintosh DL, patients’ and operators’ characteristics, Macintosh blade size, results of first DL and alternative techniques used, as well as the need of a second operator were collected. Complications rates associated with intubation were investigated. Primary outcome was success rate of first DL using Macintosh blade. Results A total of 2139 intubations were collected, 629 with a Macintosh blade No3 and 1510 with a No4. Incidence of first-pass intubation after first DL was significantly higher with Macintosh blade No3 (79.5 vs 73.3%, p = 0.0025), despite equivalent Cormack–Lehane scores (p = 0.48). Complications rates were equivalent between groups. Multivariate analysis concluded to a significant impact of Macintosh blade size on first DL success in favor of blade No3 (OR 1.44 [95% CI 1.14–1.84]; p = 0.0025) without any significant center effect on the primary outcome (p = 0.18). Propensity scores and adjustment analyses concluded to equivalent results. Conclusion In the present study, Macintosh blade No3 was associated with improved first-passed DL in French ICUs. However, study design requires the conduct of a nationwide prospective multicenter randomized trial in different settings to confirm these results. Supplementary Information The online version contains supplementary material available at 10.1007/s00134-022-06832-9.
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Affiliation(s)
- Thomas Godet
- Département Anesthésie Réanimation, Centre Hospitalier Universitaire (CHU) Clermont-Ferrand, 63000, Clermont-Ferrand, France. .,Département Anesthésie Réanimation B (DAR B), Hôpital Saint-Eloi, and Inserm U-1046, Centre Hospitalier Universitaire (CHU) Montpellier, 34295, Montpellier, France. .,Département Anesthésie Réanimation, Pôle de Médecine Périopératoire (MPO), Hôpital Estaing, Centre Hospitalier Universitaire (CHU) de Clermont-Ferrand, 1 place Lucie et Raymond Aubrac, 63001, Clermont-Ferrand cedex 1, France.
| | - Audrey De Jong
- Département Anesthésie Réanimation B (DAR B), Hôpital Saint-Eloi, and Inserm U-1046, Centre Hospitalier Universitaire (CHU) Montpellier, 34295, Montpellier, France
| | - Côme Garin
- Département Anesthésie Réanimation, Centre Hospitalier Universitaire (CHU) Clermont-Ferrand, 63000, Clermont-Ferrand, France
| | - Renaud Guérin
- Département Anesthésie Réanimation, Centre Hospitalier Universitaire (CHU) Clermont-Ferrand, 63000, Clermont-Ferrand, France
| | - Benjamin Rieu
- Département Anesthésie Réanimation, Centre Hospitalier Universitaire (CHU) Clermont-Ferrand, 63000, Clermont-Ferrand, France
| | - Lucile Borao
- Département Anesthésie Réanimation, Centre Hospitalier Universitaire (CHU) Clermont-Ferrand, 63000, Clermont-Ferrand, France
| | - Bruno Pereira
- Délégation à la Recherche Clinique et à l'Innovation (DRCI), Centre Hospitalier Universitaire (CHU) de Clermont-Ferrand, 63000, Clermont-Ferrand, France
| | - Nicolas Molinari
- Clinical Research Department, Centre Hospitalier Universitaire (CHU) Montpellier, 34295, Montpellier, France
| | - Jean-Etienne Bazin
- Département Anesthésie Réanimation, Centre Hospitalier Universitaire (CHU) Clermont-Ferrand, 63000, Clermont-Ferrand, France
| | - Matthieu Jabaudon
- Département Anesthésie Réanimation, Centre Hospitalier Universitaire (CHU) Clermont-Ferrand, 63000, Clermont-Ferrand, France.,iGReD, Université Clermont Auvergne, CNRS, INSERM, 63003, Clermont-Ferrand, France
| | - Gérald Chanques
- Département Anesthésie Réanimation B (DAR B), Hôpital Saint-Eloi, and Inserm U-1046, Centre Hospitalier Universitaire (CHU) Montpellier, 34295, Montpellier, France
| | - Emmanuel Futier
- Département Anesthésie Réanimation, Centre Hospitalier Universitaire (CHU) Clermont-Ferrand, 63000, Clermont-Ferrand, France.,iGReD, Université Clermont Auvergne, CNRS, INSERM, 63003, Clermont-Ferrand, France
| | - Samir Jaber
- Département Anesthésie Réanimation B (DAR B), Hôpital Saint-Eloi, and Inserm U-1046, Centre Hospitalier Universitaire (CHU) Montpellier, 34295, Montpellier, France
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25
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Russotto V, Tassistro E, Myatra SN, Parotto M, Antolini L, Bauer P, Lascarrou JB, Szułdrzyński K, Camporota L, Putensen C, Pelosi P, Sorbello M, Higgs A, Greif R, Pesenti A, Valsecchi MG, Fumagalli R, Foti G, Bellani G, Laffey JG. Peri-intubation Cardiovascular Collapse in Patients Who Are Critically Ill: Insights from the INTUBE Study. Am J Respir Crit Care Med 2022; 206:449-458. [PMID: 35536310 DOI: 10.1164/rccm.202111-2575oc] [Citation(s) in RCA: 45] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Rationale: Cardiovascular instability/collapse is a common peri-intubation event in patients who are critically ill. Objectives: To identify potentially modifiable variables associated with peri-intubation cardiovascular instability/collapse (i.e., systolic arterial pressure <65 mm Hg [once] or <90 mm Hg for >30 minutes; new/increased vasopressor requirement; fluid bolus >15 ml/kg, or cardiac arrest). Methods: INTUBE (International Observational Study to Understand the Impact and Best Practices of Airway Management In Critically Ill Patients) was a multicenter prospective cohort study of patients who were critically ill and undergoing tracheal intubation in a convenience sample of 197 sites from 29 countries across five continents from October 1, 2018, to July 31, 2019. Measurements and Main Results: A total of 2,760 patients were included in this analysis. Peri-intubation cardiovascular instability/collapse occurred in 1,199 out of 2,760 patients (43.4%). Variables associated with this event were older age (odds ratio [OR], 1.02; 95% confidence interval [CI], 1.02-1.03), higher heart rate (OR, 1.008; 95% CI, 1.004-1.012), lower systolic blood pressure (OR, 0.98; 95% CI, 0.98-0.99), lower oxygen saturation as measured by pulse oximetry/FiO2 before induction (OR, 0.998; 95% CI, 0.997-0.999), and the use of propofol as an induction agent (OR, 1.28; 95% CI, 1.05-1.57). Patients with peri-intubation cardiovascular instability/collapse were at a higher risk of ICU mortality with an adjusted OR of 2.47 (95% CI, 1.72-3.55), P < 0.001. The inverse probability of treatment weighting method identified the use of propofol as the only factor independently associated with cardiovascular instability/collapse (OR, 1.23; 95% CI, 1.02-1.49). When administered before induction, vasopressors (OR, 1.33; 95% CI, 0.84-2.11) or fluid boluses (OR, 1.17; 95% CI, 0.96-1.44) did not reduce the incidence of cardiovascular instability/collapse. Conclusions: Peri-intubation cardiovascular instability/collapse was associated with an increased risk of both ICU and 28-day mortality. The use of propofol for induction was identified as a modifiable intervention significantly associated with cardiovascular instability/collapse.Clinical trial registered with clinicaltrials.gov (NCT03616054).
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Affiliation(s)
- Vincenzo Russotto
- Department of Anesthesia and Critical Care, University Hospital San Luigi Gonzaga, University of Turin, Italy
| | - Elena Tassistro
- Bicocca Center of Bioinformatics, Biostatistics and Bioimaging (B4 center) and.,School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Sheila N Myatra
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - Matteo Parotto
- Department of Anesthesiology and Pain Medicine, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada.,Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, Ontario, Canada
| | - Laura Antolini
- Bicocca Center of Bioinformatics, Biostatistics and Bioimaging (B4 center) and.,School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Philippe Bauer
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Konstanty Szułdrzyński
- Department of Anesthesiology and Intensive Care, Central Clinical Hospital of the Ministry of Interior and Administration, Warsaw, Poland.,Faculty of Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Luigi Camporota
- Health Centre for Human and Applied Physiological Sciences, Department of Adult Critical Care, Guy's and St. Thomas' National Health Service Foundation Trust, London, United Kingdom
| | - Christian Putensen
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Paolo Pelosi
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, Istituto di Ricovero e Cura a Carattere Scientifico per l'Oncologia e le Neuroscienze, Genoa, Italy.,Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Massimiliano Sorbello
- Anesthesia and Intensive Care, Policlinico Vittorio Emanuele San Marco University Hospital, Catania, Italy
| | - Andy Higgs
- Anaesthesia and Intensive Care Medicine, Warrington & Halton Teaching Hospitals National Health Service Foundation Trust, Warrington, United Kingdom
| | - Robert Greif
- Department of Anaesthesiology and Pain Therapy, Bern University Hospital, University of Bern, Bern, Switzerland.,School of Medicine, Sigmund Freud University Vienna, Vienna, Austria
| | - Antonio Pesenti
- Dipartimento di Anestesia, Rianimazione ed Emergenza-Urgenza, Fondazione Istituto di Ricovero e Cura a Carattere Scientifico Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Maria Grazia Valsecchi
- Bicocca Center of Bioinformatics, Biostatistics and Bioimaging (B4 center) and.,School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Roberto Fumagalli
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.,Department of Anesthesiology, Azienda Socio Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Giuseppe Foti
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.,Department of Emergency and Intensive Care, University Hospital San Gerardo, Monza, Italy
| | - Giacomo Bellani
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy.,Department of Emergency and Intensive Care, University Hospital San Gerardo, Monza, Italy
| | - John G Laffey
- Regenerative Medicine Institute at CURAM Centre for Medical Devices, School of Medicine, National University of Ireland Galway, Galway, Ireland; and.,Anesthesia and Intensive Care Medicine, University Hospital Galway, Galway, Ireland
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Abstract
PURPOSE OF REVIEW Critically ill Coronavirus disease 2019 (COVID-19) patients needing endotracheal intubation are on the verge of rapid decompensation. The aims of this review were to assess the risks, the preoxygenation, the device and the hemodynamic management of a patient with COVID-19. RECENT FINDINGS The proceduralist performing endotracheal intubation with the entire team are at an increased risk for exposure to COVID-19. Appropriate personal protective equipment and other measures remain essential. For preoxygenation, noninvasive ventilation allows higher oxygen saturation during intubation in severely hypoxemic patients and can be associated with apneic oxygenation and mask ventilation during apnea in selected cases. The COVID-19 pandemic has further highlighted the place of videolaryngoscopy during intubation in intensive care unit (ICU). Hemodynamic optimization is mandatory to limit hypotension and cardiac arrest associated with airway management. SUMMARY Future trials will better define the role of videolaryngoscopy, apneic oxygenation and mask ventilation during apnea for intubation of COVID-19 patients in ICU. The use of fluid loading and vasopressors remains to be investigated in large randomized controlled studies. Choosing the right time for intubation remains uncertain in clinical practice, and future works will probably help to identify earlier the patients who will need intubation.
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Affiliation(s)
- Audrey De Jong
- Department of Anesthesia and Intensive Care Unit, Regional University Hospital of Montpellier, St-Eloi Hospital, University of Montpellier, Phymedexp, Montpellier, France
| | - Ashish K Khanna
- Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest School of Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
- Outcomes Research Consortium, Cleveland, Ohio, USA
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27
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Nasal intubation for trauma patients and increased in-hospital mortality. Eur J Trauma Emerg Surg 2022; 48:2795-2802. [DOI: 10.1007/s00068-022-01880-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 01/04/2022] [Indexed: 11/03/2022]
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Driver BE, Semler MW, Self WH, Ginde AA, Trent SA, Gandotra S, Smith LM, Page DB, Vonderhaar DJ, West JR, Joffe AM, Mitchell SH, Doerschug KC, Hughes CG, High K, Landsperger JS, Jackson KE, Howell MP, Robison SW, Gaillard JP, Whitson MR, Barnes CM, Latimer AJ, Koppurapu VS, Alvis BD, Russell DW, Gibbs KW, Wang L, Lindsell CJ, Janz DR, Rice TW, Prekker ME, Casey JD. Effect of Use of a Bougie vs Endotracheal Tube With Stylet on Successful Intubation on the First Attempt Among Critically Ill Patients Undergoing Tracheal Intubation: A Randomized Clinical Trial. JAMA 2021; 326:2488-2497. [PMID: 34879143 PMCID: PMC8655668 DOI: 10.1001/jama.2021.22002] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
IMPORTANCE For critically ill adults undergoing emergency tracheal intubation, failure to intubate the trachea on the first attempt occurs in up to 20% of cases and is associated with severe hypoxemia and cardiac arrest. Whether using a tracheal tube introducer ("bougie") increases the likelihood of successful intubation compared with using an endotracheal tube with stylet remains uncertain. OBJECTIVE To determine the effect of use of a bougie vs an endotracheal tube with stylet on successful intubation on the first attempt. DESIGN, SETTING, AND PARTICIPANTS The Bougie or Stylet in Patients Undergoing Intubation Emergently (BOUGIE) trial was a multicenter, randomized clinical trial among 1102 critically ill adults undergoing tracheal intubation in 7 emergency departments and 8 intensive care units in the US between April 29, 2019, and February 14, 2021; the date of final follow-up was March 14, 2021. INTERVENTIONS Patients were randomly assigned to use of a bougie (n = 556) or use of an endotracheal tube with stylet (n = 546). MAIN OUTCOMES AND MEASURES The primary outcome was successful intubation on the first attempt. The secondary outcome was the incidence of severe hypoxemia, defined as a peripheral oxygen saturation less than 80%. RESULTS Among 1106 patients randomized, 1102 (99.6%) completed the trial and were included in the primary analysis (median age, 58 years; 41.0% women). Successful intubation on the first attempt occurred in 447 patients (80.4%) in the bougie group and 453 patients (83.0%) in the stylet group (absolute risk difference, -2.6 percentage points [95% CI, -7.3 to 2.2]; P = .27). A total of 58 patients (11.0%) in the bougie group experienced severe hypoxemia, compared with 46 patients (8.8%) in the stylet group (absolute risk difference, 2.2 percentage points [95% CI, -1.6 to 6.0]). Esophageal intubation occurred in 4 patients (0.7%) in the bougie group and 5 patients (0.9%) in the stylet group, pneumothorax was present after intubation in 14 patients (2.5%) in the bougie group and 15 patients (2.7%) in the stylet group, and injury to oral, glottic, or thoracic structures occurred in 0 patients in the bougie group and 3 patients (0.5%) in the stylet group. CONCLUSIONS AND RELEVANCE Among critically ill adults undergoing tracheal intubation, use of a bougie did not significantly increase the incidence of successful intubation on the first attempt compared with use of an endotracheal tube with stylet. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03928925
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Affiliation(s)
- Brian E. Driver
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Matthew W. Semler
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Wesley H. Self
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Vanderbilt Institute for Clinical and Translational Sciences, Nashville, Tennessee
| | - Adit A. Ginde
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora
| | - Stacy A. Trent
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora
- Department of Emergency Medicine, Denver Health Medical Center, Denver, Colorado
| | - Sheetal Gandotra
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham
| | - Lane M. Smith
- Department of Emergency Medicine, Wake Forest Baptist Health, Winston-Salem, North Carolina
| | - David B. Page
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham
- Department of Emergency Medicine, University of Alabama at Birmingham
| | - Derek J. Vonderhaar
- Department of Pulmonary and Critical Care Medicine, Ochsner Health System, New Orleans, Louisiana
- Section of Emergency Medicine, Louisiana State University School of Medicine, New Orleans
| | - Jason R. West
- Department of Emergency Medicine, Lincoln Medical Center, Bronx, New York
| | - Aaron M. Joffe
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle
| | | | | | - Christopher G. Hughes
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kevin High
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Janna S. Landsperger
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Karen E. Jackson
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Michelle P. Howell
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora
| | - Sarah W. Robison
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham
| | - John P. Gaillard
- Department of Emergency Medicine, Wake Forest Baptist Health, Winston-Salem, North Carolina
| | - Micah R. Whitson
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham
- Department of Emergency Medicine, University of Alabama at Birmingham
| | | | | | | | - Bret D. Alvis
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Derek W. Russell
- Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham
- Pulmonary Section, Birmingham Veterans Affairs Medical Center, Birmingham, Alabama
| | - Kevin W. Gibbs
- Section of Pulmonary, Critical Care, Allergy, and Immunologic Disease, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Li Wang
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - David R. Janz
- University Medical Center New Orleans, New Orleans, Louisiana
- Section of Pulmonary/Critical Care Medicine & Allergy/Immunology, Louisiana State University School of Medicine, New Orleans
| | - Todd W. Rice
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Matthew E. Prekker
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
- Division of Pulmonary and Critical Care Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Jonathan D. Casey
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
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Jarvis N, Schiavo S, Bartoszko J, Ma M, Chin KJ, Parotto M. A specialized airway management team for COVID-19 patients: a retrospective study of the experience of two Canadian hospitals in Toronto. Can J Anaesth 2021; 69:333-342. [PMID: 34881407 PMCID: PMC8654186 DOI: 10.1007/s12630-021-02169-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 10/26/2021] [Accepted: 10/27/2021] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND In the COVID-19 pandemic, an unprecedented number of individuals required endotracheal intubation. To safely face these challenges, expert intubation teams were formed in some institutions. Here, we report on the experience of emergency rapid intubation teams (ERITs) in two Canadian hospitals. METHODS We retrospectively collected data on all airway management procedures in confirmed or suspected COVID-19 patients performed by ERITs at two academic hospitals between 3 April and 17 June 2020. The co-primary outcomes were incidence of periprocedural adverse events (hypoxemia, hypotension, and cardiac arrest within 15 min of intubation) and first-attempt intubation success rate. Secondary outcomes included number of intubation attempts, device used to achieve successful airway management, and adherence to personal protective equipment (PPE) protocols. RESULTS During the study period, 123 patients were assessed for airway management, with 117 patients receiving airway interventions performed by the ERIT. The first-attempt success rate for intubation was 92%, and a videolaryngoscope was the final successful device in 93% of procedures. Hypoxemia (peripheral oxygen saturation [SpO2] < 90%) occurred in 28 patients (24%) and severe hypoxemia (SpO2 < 70%) occurred in ten patients (9%). Hypotension (systolic blood pressure [SBP] < 90 mm Hg) occurred in 37 patients (32%) and severe hypotension (SBP < 65 mm Hg) in 11 patients (9%). Adherence to recommended PPE use among providers was high. CONCLUSION In this cohort of critically ill patients with respiratory failure requiring time-sensitive airway management, specialized ERIT teams showed high rates of successful airway management with high adherence to PPE use. Hypoxemia and hemodynamic instability were common and should be anticipated within the first 15 min following intubation. STUDY REGISTRATION www.ClinicalTrials.gov (NCT04689724); registered 30 December 2020.
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Affiliation(s)
- Nicola Jarvis
- Department of Anesthesiology and Pain Medicine, University of Toronto, EN 429 - 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.,Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada
| | - Simone Schiavo
- Department of Anesthesiology and Pain Medicine, University of Toronto, EN 429 - 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.,Department of Anesthesia and Pain Management, Toronto Western Hospital, Toronto, ON, Canada
| | - Justyna Bartoszko
- Department of Anesthesiology and Pain Medicine, University of Toronto, EN 429 - 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.,Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada
| | - Martin Ma
- Department of Anesthesiology and Pain Medicine, University of Toronto, EN 429 - 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.,Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada
| | - Ki Jinn Chin
- Department of Anesthesiology and Pain Medicine, University of Toronto, EN 429 - 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada.,Department of Anesthesia and Pain Management, Toronto Western Hospital, Toronto, ON, Canada
| | - Matteo Parotto
- Department of Anesthesiology and Pain Medicine, University of Toronto, EN 429 - 200 Elizabeth Street, Toronto, ON, M5G 2C4, Canada. .,Department of Anesthesia and Pain Management, Toronto General Hospital, Toronto, ON, Canada. .,Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.
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Dai Y, Dai J, Walline JH, Fu Y, Zhu H, Xu J, Yu X. Can bag-valve mask ventilation with positive end-expiratory pressure reduce hypoxia during intubation? A prospective, randomized, double-blind trial. Trials 2021; 22:460. [PMID: 34274023 PMCID: PMC8285778 DOI: 10.1186/s13063-021-05413-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2020] [Accepted: 06/30/2021] [Indexed: 11/25/2022] Open
Abstract
Background Hypoxia is one of the life-threatening complications of endotracheal intubation. Supplemental oxygen and ventilation play a vital role in preventing hypoxia. Bag-valve mask (BVM) ventilation is frequently used before intubation, and its ability to improve oxygenation was recently confirmed. It is still unclear if positive end-expiratory pressure (PEEP) added to BVM ventilation can further reduce hypoxia during intubation. Methods This will be a prospective, randomized, double-blind trial to determine if PEEP combined with BVM ventilation can reduce the incidence of hypoxia during intubation compared with conventional BVM ventilation. The lowest oxygen saturation and incidence of complications will be compiled to verify the comparative effectiveness and safety of the two groups. Discussion BMV ventilation with PEEP is hoped to further reduce the incidence of hypoxia during intubation. Trial registration Chinese Clinical Trial Registry ChiCTR2000035156. Registered on August 2, 2020. It had begun enrollment after passing ethical review but before registration.
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Affiliation(s)
- Yili Dai
- Emergency Department, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jiayuan Dai
- Emergency Department, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Joseph Harold Walline
- Accident and Emergency Medicine Academic Unit, Chinese University of Hong Kong, Prince of Wales Hospital, No. 30-32 Ngan Shing Street, Shatin, NT, Hong Kong, China
| | - Yangyang Fu
- Emergency Department, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Huadong Zhu
- Emergency Department, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jun Xu
- Emergency Department, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Xuezhong Yu
- Emergency Department, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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Myatra SN, Sakles JC, Roca O. Maximizing first pass success when intubating the critically ill patient: use a stylet! Intensive Care Med 2021; 47:695-697. [PMID: 34043038 DOI: 10.1007/s00134-021-06433-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 05/07/2021] [Indexed: 12/19/2022]
Affiliation(s)
- Sheila Nainan Myatra
- Department of Anesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India.
| | - John Constantine Sakles
- Department of Emergency Medicine, The University of Arizona College of Medicine, Tucson, AZ, USA
| | - Oriol Roca
- Intensive Care Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
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Abstract
Purpose of Review This paper will evaluate the recent literature and best practices in airway management in critically ill patients. Recent Findings Cardiac arrest remains a common complication of intubation in these high-risk patients. Patients with desaturation or peri-intubation hypotension are at high risk of cardiac arrest, and each of these complications have been reported in up to half of all intubations in critically ill patient populations. Summary There have been significant advances in preoxygenation and devices available for performing laryngoscopy and rescue oxygenation. However, the risk of cardiovascular collapse remains concerningly high with few studies to guide therapeutic maneuvers to reduce this risk.
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Russotto V, Myatra SN, Laffey JG, Tassistro E, Antolini L, Bauer P, Lascarrou JB, Szułdrzyński K, Camporota L, Pelosi P, Sorbello M, Higgs A, Greif R, Putensen C, Agvald-Öhman C, Chalkias A, Bokums K, Brewster D, Rossi E, Fumagalli R, Pesenti A, Foti G, Bellani G. Intubation Practices and Adverse Peri-intubation Events in Critically Ill Patients From 29 Countries. JAMA 2021; 325:1164-1172. [PMID: 33755076 PMCID: PMC7988368 DOI: 10.1001/jama.2021.1727] [Citation(s) in RCA: 225] [Impact Index Per Article: 75.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
IMPORTANCE Tracheal intubation is one of the most commonly performed and high-risk interventions in critically ill patients. Limited information is available on adverse peri-intubation events. OBJECTIVE To evaluate the incidence and nature of adverse peri-intubation events and to assess current practice of intubation in critically ill patients. DESIGN, SETTING, AND PARTICIPANTS The International Observational Study to Understand the Impact and Best Practices of Airway Management in Critically Ill Patients (INTUBE) study was an international, multicenter, prospective cohort study involving consecutive critically ill patients undergoing tracheal intubation in the intensive care units (ICUs), emergency departments, and wards, from October 1, 2018, to July 31, 2019 (August 28, 2019, was the final follow-up) in a convenience sample of 197 sites from 29 countries across 5 continents. EXPOSURES Tracheal intubation. MAIN OUTCOMES AND MEASURES The primary outcome was the incidence of major adverse peri-intubation events defined as at least 1 of the following events occurring within 30 minutes from the start of the intubation procedure: cardiovascular instability (either: systolic pressure <65 mm Hg at least once, <90 mm Hg for >30 minutes, new or increase need of vasopressors or fluid bolus >15 mL/kg), severe hypoxemia (peripheral oxygen saturation <80%) or cardiac arrest. The secondary outcomes included intensive care unit mortality. RESULTS Of 3659 patients screened, 2964 (median age, 63 years; interquartile range [IQR], 49-74 years; 62.6% men) from 197 sites across 5 continents were included. The main reason for intubation was respiratory failure in 52.3% of patients, followed by neurological impairment in 30.5%, and cardiovascular instability in 9.4%. Primary outcome data were available for all patients. Among the study patients, 45.2% experienced at least 1 major adverse peri-intubation event. The predominant event was cardiovascular instability, observed in 42.6% of all patients undergoing emergency intubation, followed by severe hypoxemia (9.3%) and cardiac arrest (3.1%). Overall ICU mortality was 32.8%. CONCLUSIONS AND RELEVANCE In this observational study of intubation practices in critically ill patients from a convenience sample of 197 sites across 29 countries, major adverse peri-intubation events-in particular cardiovascular instability-were observed frequently.
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Affiliation(s)
- Vincenzo Russotto
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Intensive Care, University Hospital San Gerardo, Monza, Italy
| | - Sheila Nainan Myatra
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India
| | - John G. Laffey
- Regenerative Medicine Institute at CURAM Centre for Medical Devices, School of Medicine, National University of Ireland Galway, Galway, Ireland
- Anesthesia and Intensive Care Medicine, University Hospital Galway, Galway, Ireland
| | - Elena Tassistro
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Bicocca Center of Bioinformatics, Biostatistics and Bioimaging (B4 center), University of Milano-Bicocca, Monza, Italy
| | - Laura Antolini
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Bicocca Center of Bioinformatics, Biostatistics and Bioimaging (B4 center), University of Milano-Bicocca, Monza, Italy
| | - Philippe Bauer
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota
| | | | - Konstanty Szułdrzyński
- Department of Interdisciplinary Intensive Care, Faculty of Medicine, Jagiellonian University Medical College, Krakow, Poland
| | - Luigi Camporota
- Health Centre for Human and Applied Physiological Sciences, Department of Adult Critical Care, Guy's and St Thomas’ NHS Foundation Trust, London, United Kingdom
| | - Paolo Pelosi
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
| | - Massimiliano Sorbello
- Anesthesia and Intensive Care, Policlinico Vittorio Emanuele San Marco University Hospital, Catania, Italy
| | - Andy Higgs
- Anaesthesia and Intensive Care Medicine, Warrington and Halton Hospitals NHS Foundation Trust, Warrington, United Kingdom
| | - Robert Greif
- Department of Anaesthesiology and Pain Therapy, Bern University Hospital, University of Bern, Bern, Switzerland
- School of Medicine, Sigmund Freud University Vienna, Vienna, Austria
| | - Christian Putensen
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Christina Agvald-Öhman
- Anaesthesiology and Intensive Care, Karolinska University Hospital Huddinge, Stockholm, Sweden
| | | | | | - David Brewster
- Intensive Care Unit, Cabrini Hospital, Malvern, Victoria, Australia
- Central Clinical School, Monash University, Clayton, Victoria, Australia
| | - Emanuela Rossi
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Bicocca Center of Bioinformatics, Biostatistics and Bioimaging (B4 center), University of Milano-Bicocca, Monza, Italy
| | - Roberto Fumagalli
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Anesthesiology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Antonio Pesenti
- Dipartimento di Anestesia, Rianimazione ed Emergenza-Urgenza, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Giuseppe Foti
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Intensive Care, University Hospital San Gerardo, Monza, Italy
| | - Giacomo Bellani
- School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
- Department of Emergency and Intensive Care, University Hospital San Gerardo, Monza, Italy
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Bessmann EL, Rasmussen LS, Konge L, Kristensen MS, Rewers M, Kotinis A, Rosenstock CV, Graeser K, Pfeiffer P, Lauritsen T, Østergaard D. Anesthesiologists' airway management expertise: Identifying subjective and objective knowledge gaps. Acta Anaesthesiol Scand 2021; 65:58-67. [PMID: 32888194 DOI: 10.1111/aas.13696] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 07/21/2020] [Accepted: 08/19/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Failure in airway management continues to cause preventable patient harm, and the recommended continuing education is challenged by anesthesiologists' unknown knowledge gaps. This study aimed to identify anesthesiologists' subjective and objective knowledge gaps as well as areas where anesthesiologists are incorrect and unaware. METHODS An adaptive E-learning program with 103 questions on adult airway management was used for subjective and objective assessment of anesthesiologists' knowledge. All anesthesiologists in the Capital Region of Denmark were invited to participate. RESULTS The response rate was 67% (191/285). For preoperative planning, participants stated low confidence (subjective assessment) regarding predictors of difficult airway management in particular (69.1%-79.1%). Test scores (objective assessment) were lowest for obstructive sleep apnea as a predictor of difficult airway management (28.8% correct), with participants being incorrect and unaware in 33.5% of the answers. For optimization of basic techniques, the lowest confidence ratings related to patient positioning and prediction of difficulties (57.4%-83.2%), which agreed with the lowest test scores. Concerning advanced techniques, videolaryngoscopy prompted the lowest confidence (72.4%-85.9%), while emergency cricothyrotomy resulted in the lowest test scores (47.4%-67.8%). Subjective and objective assessments correlated and lower confidence was associated with lower test scores: preoperative planning [r = -.58, P < .001], optimization of basic techniques [r = -.58, P = .002], and advanced techniques [r = -.71, P < .001]. CONCLUSION We identified knowledge gaps in important areas of adult airway management with differing findings from the subjective and objective assessments. This underlines the importance of objective assessment to guide continuing education.
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Affiliation(s)
- Ebbe L. Bessmann
- Copenhagen Academy for Medical Education and Simulation Copenhagen Denmark
- Faculty of Health and Medical Sciences University of Copenhagen Copenhagen Denmark
| | - Lars S. Rasmussen
- Department of Anaesthesia Centre of Head and Orthopaedics Rigshospitalet Copenhagen Denmark
- Department of Clinical Medicine University of Copenhagen Copenhagen Denmark
| | - Lars Konge
- Copenhagen Academy for Medical Education and Simulation Copenhagen Denmark
- Department of Clinical Medicine University of Copenhagen Copenhagen Denmark
| | - Michael S. Kristensen
- Department of Anaesthesia Centre of Head and Orthopaedics Rigshospitalet Copenhagen Denmark
| | - Mikael Rewers
- Copenhagen Academy for Medical Education and Simulation Copenhagen Denmark
| | - Alexandros Kotinis
- Department of Anesthesia and Intensive Care, Brain and Nervous Diseases Rigshospitalet Glostrup Denmark
| | | | - Karin Graeser
- Department of Anaesthesia and Intensive Care Bispebjerg and Frederiksberg Hospital Copenhagen Denmark
| | - Peter Pfeiffer
- Department of Anaesthesia Herlev and Gentofte Hospital Gentofte Denmark
| | - Torsten Lauritsen
- Department of Anaesthesia The Juliane Marie Center Rigshospitalet Copenhagen Denmark
| | - Doris Østergaard
- Copenhagen Academy for Medical Education and Simulation Copenhagen Denmark
- Department of Clinical Medicine University of Copenhagen Copenhagen Denmark
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36
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Oliver M, Caputo ND, West JR, Hackett R, Sakles JC. Emergency physician use of end-tidal oxygen monitoring for rapidsequence intubation. J Am Coll Emerg Physicians Open 2020; 1:706-713. [PMID: 33145509 PMCID: PMC7593475 DOI: 10.1002/emp2.12260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 09/02/2020] [Accepted: 09/03/2020] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND End-tidal oxygen (ETO2) monitoring is used by anesthesiologists to quantify the efficacy of preoxygenation before intubation but is generally not used in emergency departments (EDs). We have previously published our findings describing preoxygenation practices in the ED during blinded use of ETO2. The purpose of this investigation is to determine whether the unblinded use of ETO2 monitoring led to improvements in preoxygenation during rapid sequence intubation in the ED and also the oxygen device or technique changes that were used to achieve higher ETO2 levels. METHODS We conducted an interventional study at 2 academic EDs in Sydney, Australia and New York City, New York using ETO2 monitoring to investigate the preoxygenation process and effectiveness. We used data collected during a previous descriptive study for the control group, in which care teams in the same 2 EDs were blinded to the ETO2 value. In the study group, clinicians could utilize ETO2 to improve preoxygenation. Following an education process, clinicians were able to choose the method of preoxygenation and the techniques required to attempt to achieve an ETO2 level >85%. The primary outcome was the difference in ETO2 levels at the time of induction between the control and study group and the secondary outcome included the methods that were attempted to improve preoxygenation. RESULTS A convenience sample of 100 patients was enrolled in each group. The median ETO2 level achieved at the time of induction was 80% (interquartile range 61 to 86, overall range 73) in the control group and 90% in the study group (interquartile range 83 to 92, overall range 41); the median difference was 12 (95% confidence interval: 8, 16, P = < 0.001). The majority of oxygen device changes were from non-rebreather mask to bag-valve-mask (BVM) (15%, n = 15) and changes in technique from improvements in mask seal (54%, n = 34). The final device used in the study group was BVM in 87% of cases. CONCLUSIONS In 2 clinical studies of ETO2 in academic EDs, we have demonstrated that the use of ETO2 is feasible and associated with specific and potentially improved approaches to preoxygenation. A clinical trial is needed to further study the impact of ETO2 on the preoxygenation process and the rate of hypoxemia.
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Affiliation(s)
- Matthew Oliver
- Department of Emergency MedicineRoyal Prince Alfred HospitalSydneyAustralia
- Sydney Medical SchoolUniversity of SydneySydneyAustralia
| | | | - Jason R. West
- Department of Emergency MedicineLincoln Medical CenterBronxNew YorkUSA
| | - Robert Hackett
- Department of AnaesthesiaRoyal Prince Alfred HospitalSydneyAustralia
| | - John C. Sakles
- Department of Emergency MedicineUniversity of Arizona College of MedicineArizonaTucsonUSA
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de Alencar JCG, Marques B, Marchini JFM, Marino LO, Ribeiro SCDC, Bueno CG, da Cunha VP, Lazar Neto F, Valente FS, Rahhal H, Pereira JBR, Padrão EMH, Wanderley APB, Costa MGP, Brandão Neto RA, Souza HP. First-attempt intubation success and complications in patients with COVID-19 undergoing emergency intubation. J Am Coll Emerg Physicians Open 2020; 1:699-705. [PMID: 32838394 PMCID: PMC7436702 DOI: 10.1002/emp2.12219] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Revised: 07/17/2020] [Accepted: 07/23/2020] [Indexed: 11/08/2022] Open
Abstract
Objectives To evaluate the first-attempt success rates and complications of endotracheal intubation of coronavirus disease 2019 (COVID-19) patients by emergency physicians. Methods This prospective observational study was conducted from March 24, 2020 through May 28, 2020 at the emergency department (ED) of an urban, academic trauma center. We enrolled patients consecutively admitted to the ED with suspected or confirmed COVID-19 submitted to endotracheal intubation. No patients were excluded. The primary outcome was first-attempt intubation success, defined as successful endotracheal tube placement with the first device passed (endotracheal tube) during the first laryngoscope insertion confirmed with capnography. Secondary outcomes included the following complications: hypotension, hypoxemia, aspiration, and esophageal intubation. Results A total of 112 patients with confirmed or suspected COVID-19 were enrolled. Median age was 61 years and 61 patients (54%) were men. The primary outcome, first-attempt intubation success, was achieved in 82% of patients. Among the 20 patients who were not intubated on the first attempt, 75% were intubated on the second attempt and 20% on the third attempt; cricothyrotomy was performed in 1 patient. Forty-eight (42%) patients were hypotensive and required norepinephrine immediately post-intubation. Fifty-eight (52%) experienced peri-intubation hypoxemia, and 2 patients (2%) had cardiac arrest. There were no cases of failed intubation resulting in death up to 24 hours after the procedure. Conclusion Emergency physicians achieve high success rates when intubating COVID19 patients, although complications are frequent. However, these findings should be considered provisional until their generalizability is assessed in their institutions and setting.
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Affiliation(s)
| | - Bruno Marques
- Emergency DepartmentHospital das Clínicas da Faculdade de Medicina da Universidade de São PauloSão PauloBrazil
| | | | - Lucas Oliveira Marino
- Emergency DepartmentHospital das Clínicas da Faculdade de Medicina da Universidade de São PauloSão PauloBrazil
| | | | - Cauê Gasparotto Bueno
- Emergency DepartmentHospital das Clínicas da Faculdade de Medicina da Universidade de São PauloSão PauloBrazil
| | - Victor Paro da Cunha
- Emergency DepartmentHospital das Clínicas da Faculdade de Medicina da Universidade de São PauloSão PauloBrazil
| | - Felippe Lazar Neto
- Emergency DepartmentHospital das Clínicas da Faculdade de Medicina da Universidade de São PauloSão PauloBrazil
| | - Fernando Salvetti Valente
- Emergency DepartmentHospital das Clínicas da Faculdade de Medicina da Universidade de São PauloSão PauloBrazil
| | - Hassan Rahhal
- Emergency DepartmentHospital das Clínicas da Faculdade de Medicina da Universidade de São PauloSão PauloBrazil
| | | | | | | | | | | | - Heraldo Possolo Souza
- Emergency DepartmentHospital das Clínicas da Faculdade de Medicina da Universidade de São PauloSão PauloBrazil
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Mosier J, Reardon RF, DeVries PA, Stang JL, Nelsen A, Prekker ME, Driver BE. Time to Loss of Preoxygenation in Emergency Department Patients. J Emerg Med 2020; 59:637-642. [PMID: 32771321 DOI: 10.1016/j.jemermed.2020.06.064] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Revised: 06/04/2020] [Accepted: 06/20/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND In patients requiring emergency rapid sequence intubation (RSI), 100% oxygen is often delivered for preoxygenation to replace alveolar nitrogen with oxygen. Sometimes, however, preoxygenation devices are prematurely removed from the patient prior to the onset of apnea, which can lead to rapid loss of preoxygenation. OBJECTIVE We sought to determine the elapsed time, on average, between removing the oxygen source and the loss of preoxygenation among non-critically ill patients in the emergency department (ED). METHODS We conducted a prospective, crossover study of non-critically ill patients in the ED. Each patient received two identical preoxygenation trials for 4 min using a non-rebreather mask with oxygen flow at flush rate and a nasal cannula with oxygen flow at 10 L/min. After each preoxygenation trial, patients underwent two trials in random order while continuing spontaneous breathing: 1) removal of both oxygen sources and 2) removal of non-rebreather mask with nasal cannula left in place. We defined loss of preoxygenation as an end-tidal oxygen (exhaled oxygen percentage; EtO2) value < 70%. We measured EtO2 breath by breath until loss of preoxygenation occurred. RESULTS We enrolled 42 patients, median age was 43 years (interquartile range [IQR] 30 to 54 years) and 72% were male. Median time to loss of preoxygenation was 20 s (IQR 17-25 s, 4.5 breaths) when all oxygen devices were removed, and 39 s (IQR 21-56 s, 8 breaths) when the nasal cannula was left in place. CONCLUSIONS In this population of non-critically ill ED patients, most had loss of preoxygenation after 5 breaths if all oxygen devices were removed, and after 8 breaths if a nasal cannula was left in place. These data suggest that during ED RSI, preoxygenation devices should be left in place until the patient is completely apneic.
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Affiliation(s)
- Jarrod Mosier
- Department of Emergency Medicine and Department of Medicine, Division of Pulmonary, Allergy, Critical Care and Sleep, University of Arizona College of Medicine, Tucson, Arizona
| | - Robert F Reardon
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Paige A DeVries
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Jamie L Stang
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | | | - Matthew E Prekker
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota; Division of Pulmonary/Critical Care, Department of Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Brian E Driver
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
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