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Mostafa M, Hasanin A, Reda B, Elsayad M, Zayed M, Abdelfatah ME. Comparing the hemodynamic effects of ketamine versus fentanyl bolus in patients with septic shock: a randomized controlled trial. J Anesth 2024:10.1007/s00540-024-03383-9. [PMID: 39154316 DOI: 10.1007/s00540-024-03383-9] [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: 05/23/2024] [Accepted: 07/27/2024] [Indexed: 08/19/2024]
Abstract
BACKGROUND Ketamine and fentanyl are commonly used for sedation and induction of anesthesia in critically ill patients. This study aimed to compare the hemodynamic effects of ketamine versus fentanyl bolus in patients with septic shock. METHODS This randomized controlled trial included mechanically ventilated adults with septic shock receiving sedation. Patients were randomized to receive either 1 mg/kg ketamine bolus or 1 mcg/kg fentanyl bolus. Cardiac output (CO), stroke volume (SV), heart rate (HR), and mean arterial pressure (MAP) were measured at the baseline, 3, 6, 10, and 15 min after the intervention. Delta CO was calculated as the change in CO at each time point in relation to baseline measurement. The primary outcome was delta CO 6 min after administration of the study drug. Other outcomes included CO, SV, HR, and MAP. RESULTS Eighty-six patients were analyzed. The median (quartiles) delta CO 6 min after drug injection was 71(37, 116)% in the ketamine group versus - 31(- 43, - 12)% in the fentanyl group, P value < 0.001. The CO, SV, HR, and MAP increased in the ketamine group and decreased in the fentanyl group in relation to the baseline reading; and all were higher in the ketamine group than the fentanyl group. CONCLUSION In patients with septic shock, ketamine bolus was associated with higher CO and SV compared to fentanyl bolus. CLINICAL TRIAL REGISTRATION Date of registration: 24/07/2023. CLINICALTRIALS gov Identifier: NCT05957302. URL: https://clinicaltrials.gov/study/NCT05957302 .
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Affiliation(s)
- Maha Mostafa
- Department of Anesthesia and Critical Care Medicine, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Ahmed Hasanin
- Department of Anesthesia and Critical Care Medicine, Faculty of Medicine, Cairo University, Cairo, Egypt.
| | - Basant Reda
- Department of Anesthesia and Critical Care Medicine, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Mohamed Elsayad
- Department of Anesthesia and Critical Care Medicine, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Marwa Zayed
- Department of Anesthesia and Critical Care Medicine, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Mohamed E Abdelfatah
- Department of Anesthesia and Critical Care Medicine, Faculty of Medicine, Cairo University, Cairo, Egypt
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Garcia SI, Finch AS, Ridgeway JL, Beckman TJ, Montori VM, Rivera M, Gajic O, Kennedy CC, Kelm DJ. Understanding Team Dynamics and Culture of Safety Using Video Reflexive Ethnography during Real-Time Emergent Intubation. Ann Am Thorac Soc 2024; 21:1065-1073. [PMID: 38470228 DOI: 10.1513/annalsats.202310-901oc] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 03/08/2024] [Indexed: 03/13/2024] Open
Abstract
Rationale: Endotracheal intubation is the third most common bedside procedure in U.S. hospitals. In over 40% of intubations, preventable complications attributable to human factors occur. A better understanding of team dynamics during intubation may improve patient safety. Objectives: To explore team dynamics and safety-related actions during emergent endotracheal intubations in the emergency department and intensive care unit and to engage members of the care team in reflection for process improvement through a novel video-based team debriefing technique. Methods: Video-reflexive ethnography involves in situ video recording and reflexive discussions with practitioners to scrutinize behaviors and to identify opportunities for improvement. In this study, real-time intubations were recorded in the emergency department and intensive care unit at Mayo Clinic Rochester, and facilitated video-reflexive sessions were conducted with the multidisciplinary procedural teams. Themes about team dynamics and safety-related action were identified inductively from transcriptions of recorded sessions. Results: Between December 2022 and January 2023, eight video-reflexive sessions were conducted with a total of 78 participants. Multidisciplinary members included nurses (n = 23), respiratory therapists (n = 16), pharmacists (n = 7), advanced practitioners (n = 5), and physicians (n = 26). In video-reflexive discussions, major safety gaps were identified and several solutions were proposed related to the use of a multidisciplinary intubation checklist, standardized communication and team positioning, developing a culture of safety, and routinely debriefing after the procedure. Conclusions: The findings of this study may inform the development of a team supervision model for emergent endotracheal intubations. This approach could integrate key components such as a multidisciplinary intubation checklist, standardized communication and team positioning, a culture of safety, and debriefing as part of the procedure itself.
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Affiliation(s)
| | | | - Jennifer L Ridgeway
- Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, Minnesota
| | | | | | | | - Ognjen Gajic
- Division of Pulmonary, Critical Care, and Sleep Medicine
| | - Cassie C Kennedy
- Division of Pulmonary, Critical Care, and Sleep Medicine
- Division of Healthcare Delivery Research, Mayo Clinic College of Medicine and Science, Rochester, Minnesota; and
| | - Diana J Kelm
- Division of Pulmonary, Critical Care, and Sleep Medicine
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Garnacho-Montero J, Gordillo-Escobar E, Trenado J, Gordo F, Fisac L, García-Prieto E, López-Martin C, Abella A, Jiménez JR, García-Garmendia JL. A Nationwide, Prospective Study of Tracheal Intubation in Critically Ill Adults in Spain: Management, Associated Complications, and Outcomes. Crit Care Med 2024; 52:786-797. [PMID: 38259143 DOI: 10.1097/ccm.0000000000006198] [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: 01/24/2024]
Abstract
OBJECTIVES Our aims were to explore current intubation practices in Spanish ICUs to determine the incidence and risk factors of peri-intubation complications (primary outcome measure: major adverse events), the rate and factors associated with first-pass success, and their impact on mortality as well as the changes of the intubation procedure observed in the COVID-19 pandemic. DESIGN Prospective, observational, and cohort study. SETTING Forty-three Spanish ICU. PATIENTS A total of 1837 critically ill adult patients undergoing tracheal intubation. The enrollment period was six months (selected by each center from April 16, 2019, to October 31, 2020). INTERVENTIONS None. MEASUREMENT AND MAIN RESULTS At least one major adverse peri-intubation event occurred in 40.4 % of the patients (973 major adverse events were registered) the most frequent being hemodynamic instability (26.5%) and severe hypoxemia (20.3%). The multivariate analysis identified seven variables independently associated with a major adverse event whereas the use of neuromuscular blocking agents (NMBAs) was associated with reduced odds of major adverse events. Intubation on the first attempt was achieved in 70.8% of the patients. The use of videolaryngoscopy at the first attempt was the only protective factor (odds ratio 0.43; 95% CI, 0.28-0.66; p < 0.001) for first-attempt intubation failure. During the COVID-19 pandemic, the use of videolaryngoscopy and NMBAs increased significantly. The occurrence of a major peri-intubation event was an independent risk factor for 28-day mortality. Cardiovascular collapse also posed a serious threat, constituting an independent predictor of death. CONCLUSIONS A major adverse event occurred in up to 40% of the adults intubated in the ICU. Peri-intubation hemodynamic instability but not severe hypoxemia was identified as an independent predictor of death. The use of NMBAs was a protective factor for major adverse events, whereas the use of videolaringoscopy increases the first-pass success rate of intubation. Intubation practices changed during the COVID-19 pandemic.
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Affiliation(s)
- José Garnacho-Montero
- Unidad Clínica de Cuidados Intensivos, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - Elena Gordillo-Escobar
- Unidad Clínica de Cuidados Intensivos, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - Josep Trenado
- Servicio Medicina Intensiva UCI-Semicritics, Hospital Universitari MutuaTerrassa, Universitat de Barcelona, Barcelona, Spain
| | - Federico Gordo
- Servicio de Medicina Intensiva, Hospital Universitario del Henares, Coslada-Madrid, Grupo de Investigación en Patología Crítica, Facultad de Medicina, Universidad Francisco de Vitoria (Pozuelo de Alarcón-Madrid), Madrid, Spain
| | - Lourdes Fisac
- Servicio Medicina Intensiva, Hospital Universitario de Burgos, Burgos, Spain
| | - Emilio García-Prieto
- Servicio de Medicina Intensiva, Hospital Universitario Central de Asturias, Instituto de Investigación Sanitaria del Principado de Asturias, Departamento de Medicina, Universidad de Oviedo, Oviedo, Spain
| | - Cristina López-Martin
- Unidad Clínica de Cuidados Intensivos. Hospital Universitario Reina Sofía, Córdoba, Spain
| | - Ana Abella
- Servicio de Medicina Intensiva, Hospital Universitario del Henares, Coslada-Madrid, Grupo de Investigación en Patología Crítica, Facultad de Medicina, Universidad Francisco de Vitoria (Pozuelo de Alarcón-Madrid), Madrid, Spain
| | - Juan Ramón Jiménez
- Unidad Clínica de Cuidados Intensivos, Hospital Universitario Virgen Macarena, Sevilla, Spain
| | - José Luis García-Garmendia
- Servicio de Cuidados Críticos y Urgencias, Hospital San Juan de Dios del Aljarafe, Bormujos, Sevilla, Spain
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Pan P, Cheng T, Han T, Cao Y. A Nomogram Model for Post-Intubation Hypotension in Patients with Severe Pneumonia in the Emergency Department. J Inflamm Res 2023; 16:5221-5233. [PMID: 38026236 PMCID: PMC10655604 DOI: 10.2147/jir.s430488] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 10/17/2023] [Indexed: 12/01/2023] Open
Abstract
Background Post-intubation hypotension (PIH) frequently occurs in the management of critically ill patients and is associated with prognosis. The study aimed to construct a prediction model for PIH events by analyzing risk factors in patients with severe pneumonia in the emergency department. Methods We retrospectively enrolled 572 patients with severe pneumonia diagnosed in the emergency department of West China Hospital of Sichuan University. Five hundred patients with severe pneumonia who underwent endotracheal intubation were included in the study. All patients were randomized according to 7:3 and divided into a training cohort (n=351) and a validation cohort (n=149). Risk factors for PIH were analyzed using Least Absolute Shrinkage and Selection Operator (LASSO) and multivariable logistic regression. Calibration curves, receiver operating characteristic (ROC) curve, and decision curve analysis were applied to assess the predictive model's fitness, discrimination, and clinical utility. Results A total of 500 patients with severe pneumonia who underwent endotracheal intubation were enrolled in this study, and PIH occurred in 234 (46.8%) of these patients. Age, heart rate, systolic blood pressure, chronic obstructive pulmonary disease, acute physiology and chronic health evaluation II score, and induction agent use were identified as significant risk factors for the occurrence of PIH. Additionally, the body mass index was the opposite of the above. The area under the ROC curve (AUC) for the model was 0.856 (95% CI, 0.818-0.894) in the training cohort and 0.849 (95% CI, 0.788-0.910) in the validation cohort. The nomogram model was validated and demonstrated good calibration and high net clinical benefit. Finally, to facilitate application by clinicians, an online server has been set up which can be accessed free of charge via the website https://chinahospitals.shinyapps.io/DynNomapp/. Conclusion The nomogram is used for individualized prediction of patients with severe pneumonia prior to intubation and is simple to perform with high clinical value.
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Affiliation(s)
- Pan Pan
- Department of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, People’s Republic of China
| | - Tao Cheng
- Department of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, People’s Republic of China
| | - Tianyong Han
- Department of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, People’s Republic of China
| | - Yu Cao
- Department of Emergency Medicine, West China Hospital, Sichuan University, Chengdu, People’s Republic of China
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Knack SKS, Prekker ME, Moore JC, Klein LR, Atkins AH, Miner JR, Driver BE. The Effect of Ketamine Versus Etomidate for Rapid Sequence Intubation on Maximum Sequential Organ Failure Assessment Score: A Randomized Clinical Trial. J Emerg Med 2023; 65:e371-e382. [PMID: 37741737 DOI: 10.1016/j.jemermed.2023.06.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 05/22/2023] [Accepted: 06/13/2023] [Indexed: 09/25/2023]
Abstract
BACKGROUND The use of induction agents for rapid sequence intubation (RSI) has been associated with hypotension in critically ill patients. Choice of induction agent may be important and the most commonly used agents are etomidate and ketamine. OBJECTIVE This study aimed to compare the effects of a single dose of ketamine vs. etomidate for RSI on maximum Sequential Organ Failure Assessment (SOFA) score and incidence of hypotension. METHODS This single-center, randomized, parallel-group trial compared the use of ketamine and etomidate for RSI in critically ill adult patients in the emergency department. The study was performed under Exception from Informed Consent. The primary outcome was the maximum SOFA score within 3 days of hospitalization. RESULTS A total of 143 patients were enrolled in the trial, 70 in the ketamine group and 73 in the etomidate group. Maximum median SOFA score for the ketamine group was 6.5 (interquartile range [IQR] 5-9) vs. 7 (IQR 5-9) for etomidate with no significant difference (-0.2; 95% CI -1.4 to 1.1; p = 0.79). The incidence of post-intubation hypotension was 28% in the ketamine group vs. 26% in the etomidate group (difference 2%; 95% CI -13% to 17%). There were no significant differences in intensive care unit outcomes. Thirty-day mortality rate for the ketamine group was 11% (8 deaths) and for the etomidate group was 21% (15 deaths), which was not statistically different. CONCLUSIONS There were no significant differences in maximum SOFA score or post-intubation hypotension between critically ill adults receiving ketamine vs. etomidate for RSI.
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Affiliation(s)
- Sarah K S Knack
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Matthew E Prekker
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota; Department of Medicine, Division of Pulmonary and Critical Care, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Johanna C Moore
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Lauren R Klein
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Alexandra H Atkins
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | - James R Miner
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Brian E Driver
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
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6
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Fuchita M, Pattee J, Russell DW, Driver BE, Prekker ME, Barnes CR, Brewer JM, Doerschug KC, Gaillard JP, Gandotra S, Ghamande S, Gibbs KW, Hughes CG, Janz DR, Khan A, Mitchell SH, Page DB, Rice TW, Self WH, Smith LM, Stempek SB, Trent SA, Vonderhaar DJ, West JR, Whitson MR, Williamson K, Semler MW, Casey JD, Ginde AA. Prophylactic Administration of Vasopressors Prior to Emergency Intubation in Critically Ill Patients: A Secondary Analysis of Two Multicenter Clinical Trials. Crit Care Explor 2023; 5:e0946. [PMID: 37457916 PMCID: PMC10344527 DOI: 10.1097/cce.0000000000000946] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/18/2023] Open
Abstract
Hypotension affects approximately 40% of critically ill patients undergoing emergency intubation and is associated with an increased risk of death. The objective of this study was to examine the association between prophylactic vasopressor administration and the incidence of peri-intubation hypotension and other clinical outcomes. DESIGN A secondary analysis of two multicenter randomized clinical trials. The clinical effect of prophylactic vasopressor administration was estimated using a one-to-one propensity-matched cohort of patients with and without prophylactic vasopressors. SETTING Seven emergency departments and 17 ICUs across the United States. PATIENTS One thousand seven hundred ninety-eight critically ill patients who underwent emergency intubation at the study sites between February 1, 2019, and May 24, 2021. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The primary outcome was peri-intubation hypotension defined as a systolic blood pressure less than 90 mm Hg occurring between induction and 2 minutes after tracheal intubation. A total of 187 patients (10%) received prophylactic vasopressors prior to intubation. Compared with patients who did not receive prophylactic vasopressors, those who did were older, had higher Acute Physiology and Chronic Health Evaluation II scores, were more likely to have a diagnosis of sepsis, had lower pre-induction systolic blood pressures, and were more likely to be on continuous vasopressor infusions prior to intubation. In our propensity-matched cohort, prophylactic vasopressor administration was not associated with reduced risk of peri-intubation hypotension (41% vs 32%; p = 0.08) or change in systolic blood pressure from baseline (-12 vs -11 mm Hg; p = 0.66). CONCLUSIONS The administration of prophylactic vasopressors was not associated with a lower incidence of peri-intubation hypotension in our propensity-matched analysis. To address potential residual confounding, randomized clinical trials should examine the effect of prophylactic vasopressor administration on peri-intubation outcomes.
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Affiliation(s)
- Mikita Fuchita
- Department of Anesthesiology, Division of Critical Care, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Jack Pattee
- Department of Biostatistics & Informatics, Center for Innovative Design & Analysis, Colorado School of Public Health, Aurora, CO
| | - Derek W Russell
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL
- Pulmonary Section, Birmingham Veterans Affairs Medical Center, Birmingham, AL
| | - Brian E Driver
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - Matthew E Prekker
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, MN
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Hennepin County Medical Center, Minneapolis, MN
| | - Christopher R Barnes
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA
| | - Joseph M Brewer
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, University of Mississippi Medical Center, Jackson, MS
| | | | - John P Gaillard
- Department of Emergency Medicine, Wake Forest School of Medicine, Winston-Salem, NC
- Department of Anesthesiology, Section on Critical Care, Wake Forest School of Medicine, Winston-Salem, NC
| | - Sheetal Gandotra
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Shekhar Ghamande
- Department of Medicine, Division of Pulmonary Disease and Critical Care Medicine, Baylor Scott & White Medical Center, Temple, TX
| | - Kevin W Gibbs
- Department of Medicine, Section of Pulmonary, Critical Care, Allergy and Immunologic Disease, Wake Forest School of Medicine, Winston-Salem, NC
| | - Christopher G Hughes
- Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, TN
| | - David R Janz
- University Medical Center New Orleans, New Orleans, LA
- Department of Medicine, Section of Pulmonary/Critical Care Medicine and Allergy/Immunology, Louisiana State University School of Medicine, New Orleans, LA
| | - Akram Khan
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Oregon Health & Science University School of Medicine, Portland, OR
| | - Steven H Mitchell
- Department of Emergency Medicine, University of Washington, Seattle, WA
| | - David B Page
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL
- Department of Emergency Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Todd W Rice
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN
| | - Wesley H Self
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN
- Vanderbilt Institute for Clinical and Translational Research, Vanderbilt University Medical Center, Nashville, TN
| | - Lane M Smith
- Department of Internal Medicine, University of Iowa, Iowa City, IA
| | - Susan B Stempek
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Lahey Hospital and Medical Center, Burlington, MA
| | - Stacy A Trent
- Department of Emergency Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
- Department of Emergency Medicine, Denver Health Medical Center, Denver, CO
| | - Derek J Vonderhaar
- Department of Pulmonary and Critical Care Medicine, Ochsner Health System, New Orleans, LA
| | - Jason R West
- Department of Emergency Medicine, NYC Health + Hospitals | Lincoln, Bronx, NY
| | - Micah R Whitson
- Department of Medicine, Division of Pulmonary, Allergy, and Critical Care Medicine, University of Alabama at Birmingham, Birmingham, AL
| | - Kayla Williamson
- Department of Biostatistics & Informatics, Center for Innovative Design & Analysis, Colorado School of Public Health, Aurora, CO
| | - Matthew W Semler
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN
| | - Jonathan D Casey
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN
| | - Adit A Ginde
- Department of Emergency Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO
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Perkins EJ, Begley JL, Brewster FM, Hanegbi ND, Ilancheran AA, Brewster DJ. The use of video laryngoscopy outside the operating room: A systematic review. PLoS One 2022; 17:e0276420. [PMID: 36264980 PMCID: PMC9584394 DOI: 10.1371/journal.pone.0276420] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 09/12/2022] [Indexed: 11/07/2022] Open
Abstract
This study aimed to describe how video laryngoscopy is used outside the operating room within the hospital setting. Specifically, we aimed to summarise the evidence for the use of video laryngoscopy outside the operating room, and detail how it appears in current clinical practice guidelines. A literature search was conducted across two databases (MEDLINE and Embase), and all articles underwent screening for relevance to our aims and pre-determined exclusion criteria. Our results include 14 clinical practice guidelines, 12 interventional studies, 38 observational studies. Our results show that video laryngoscopy is likely to improve glottic view and decrease the incidence of oesophageal intubations; however, it remains unclear as to how this contributes to first-pass success, overall intubation success and clinical outcomes such as mortality outside the operating room. Furthermore, our results indicate that the appearance of video laryngoscopy in clinical practice guidelines has increased in recent years, and particularly through the COVID-19 pandemic. Current COVID-19 airway management guidelines unanimously introduce video laryngoscopy as a first-line (rather than rescue) device.
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Affiliation(s)
| | - Jonathan L. Begley
- Alfred Health, Melbourne, VIC, Australia
- Intensive Care Unit, Cabrini Hospital, Malvern, VIC, Australia
| | - Fiona M. Brewster
- Department of Anaesthesia, Royal Women’s Hospital, Parkville, VIC, Australia
| | | | | | - David J. Brewster
- Intensive Care Unit, Cabrini Hospital, Malvern, VIC, Australia
- Central Clinical School, Monash University, Melbourne, VIC, Australia
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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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9
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Mendes PV, Besen BAMP, Lacerda FH, Ramos JGR, Taniguchi LU. Neuromuscular blockade and airway management during endotracheal intubation in Brazilian intensive care units: a national survey. Rev Bras Ter Intensiva 2021; 32:433-438. [PMID: 33053034 PMCID: PMC7595723 DOI: 10.5935/0103-507x.20200073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Accepted: 03/23/2020] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE To describe the use of neuromuscular blockade as well as other practices among Brazilian physicians in adult intensive care units. METHODS An online national survey was designed and administered to Brazilian intensivists. Questions were selected using the Delphi method and assessed physicians' demographic data, intensive care unit characteristics, practices regarding airway management, use of neuromuscular blockade and sedation during endotracheal intubation in the intensive care unit. As a secondary outcome, we applied a multivariate analysis to evaluate factors associated with the use of neuromuscular blockade. RESULTS Five hundred sixty-five intensivists from all Brazilian regions responded to the questionnaire. The majority of respondents were male (65%), with a mean age of 38 ( 8.4 years, and 58.5% had a board certification in critical care. Only 40.7% of the intensivists reported the use of neuromuscular blockade during all or in more than 75% of endotracheal intubations. In the multivariate analysis, the number of intubations performed monthly and physician specialization in anesthesiology were directly associated with frequent use of neuromuscular blockade. Etomidate and ketamine were more commonly used in the clinical situation of hypotension and shock, while propofol and midazolam were more commonly prescribed in the situation of clinical stability. CONCLUSION The reported use of neuromuscular blockade was low among intensivists, and sedative drugs were chosen in accordance with patient hemodynamic stability. These results may help the design of future studies regarding airway management in Brazil.
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Affiliation(s)
- Pedro Vitale Mendes
- Disciplina de Emergências Clínicas, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil.,Unidade de Terapia Intensiva Oncológica, Hospital São Luiz Rede D'Or - São Paulo (SP), Brasil
| | - Bruno Adler Maccagnan Pinheiro Besen
- Disciplina de Emergências Clínicas, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil.,Unidade de Terapia Intensiva, Hospital da Luz - São Paulo (SP), Brasil
| | - Fabio Holanda Lacerda
- Disciplina de Emergências Clínicas, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil
| | | | - Leandro Utino Taniguchi
- Disciplina de Emergências Clínicas, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil.,Hospital Sírio-Libanês - São Paulo (SP), Brasil
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10
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Law JA, Duggan LV, Asselin M, Baker P, Crosby E, Downey A, Hung OR, Jones PM, Lemay F, Noppens R, Parotto M, Preston R, Sowers N, Sparrow K, Turkstra TP, Wong DT, Kovacs G. Canadian Airway Focus Group updated consensus-based recommendations for management of the difficult airway: part 1. Difficult airway management encountered in an unconscious patient. Can J Anaesth 2021; 68:1373-1404. [PMID: 34143394 PMCID: PMC8212585 DOI: 10.1007/s12630-021-02007-0] [Citation(s) in RCA: 56] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 03/11/2021] [Accepted: 03/14/2021] [Indexed: 02/08/2023] Open
Abstract
PURPOSE Since the last Canadian Airway Focus Group (CAFG) guidelines were published in 2013, the literature on airway management has expanded substantially. The CAFG therefore re-convened to examine this literature and update practice recommendations. This first of two articles addresses difficulty encountered with airway management in an unconscious patient. SOURCE Canadian Airway Focus Group members, including anesthesia, emergency medicine, and critical care physicians, were assigned topics to search. Searches were run in the Medline, EMBASE, Cochrane Central Register of Controlled Trials, and CINAHL databases. Results were presented to the group and discussed during video conferences every two weeks from April 2018 to July 2020. These CAFG recommendations are based on the best available published evidence. Where high-quality evidence was lacking, statements are based on group consensus. FINDINGS AND KEY RECOMMENDATIONS Most studies comparing video laryngoscopy (VL) with direct laryngoscopy indicate a higher first attempt and overall success rate with VL, and lower complication rates. Thus, resources allowing, the CAFG now recommends use of VL with appropriately selected blade type to facilitate all tracheal intubations. If a first attempt at tracheal intubation or supraglottic airway (SGA) placement is unsuccessful, further attempts can be made as long as patient ventilation and oxygenation is maintained. Nevertheless, total attempts should be limited (to three or fewer) before declaring failure and pausing to consider "exit strategy" options. For failed intubation, exit strategy options in the still-oxygenated patient include awakening (if feasible), temporizing with an SGA, a single further attempt at tracheal intubation using a different technique, or front-of-neck airway access (FONA). Failure of tracheal intubation, face-mask ventilation, and SGA ventilation together with current or imminent hypoxemia defines a "cannot ventilate, cannot oxygenate" emergency. Neuromuscular blockade should be confirmed or established, and a single final attempt at face-mask ventilation, SGA placement, or tracheal intubation with hyper-angulated blade VL can be made, if it had not already been attempted. If ventilation remains impossible, emergency FONA should occur without delay using a scalpel-bougie-tube technique (in the adult patient). The CAFG recommends all institutions designate an individual as "airway lead" to help institute difficult airway protocols, ensure adequate training and equipment, and help with airway-related quality reviews.
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Affiliation(s)
- J. Adam Law
- grid.55602.340000 0004 1936 8200Department of Anesthesia, Pain Management and Perioperative Medicine, QEII Health Sciences Centre, Dalhousie University, Halifax Infirmary Site, 1796 Summer Street, Room 5452, Halifax, NS B3H 3A7 Canada
| | - Laura V. Duggan
- grid.28046.380000 0001 2182 2255Department of Anesthesiology and Pain Medicine, The Ottawa Hospital Civic Campus, University of Ottawa, Room B307, 1053 Carling Avenue, Mail Stop 249, Ottawa, ON K1Y 4E9 Canada
| | - Mathieu Asselin
- grid.23856.3a0000 0004 1936 8390Département d’anesthésiologie et de soins intensifs, Université Laval, 2325 rue de l’Université, Québec, QC G1V 0A6 Canada ,grid.411081.d0000 0000 9471 1794Département d’anesthésie du CHU de Québec, Hôpital Enfant-Jésus, 1401 18e rue, Québec, QC G1J 1Z4 Canada
| | - Paul Baker
- grid.9654.e0000 0004 0372 3343Department of Anaesthesiology, Faculty of Medical and Health Science, University of Auckland, Private Bag 92019, Auckland, 1142 New Zealand
| | - Edward Crosby
- grid.28046.380000 0001 2182 2255Department of Anesthesiology and Pain Medicine, The Ottawa Hospital, University of Ottawa, Suite CCW1401, 501 Smyth Road, Ottawa, ON K1H 8L6 Canada
| | - Andrew Downey
- grid.1055.10000000403978434Department of Anaesthesia, Perioperative and Pain Medicine, Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Orlando R. Hung
- grid.55602.340000 0004 1936 8200Department of Anesthesia, Pain Management and Perioperative Medicine, QEII Health Sciences Centre, Dalhousie University, 1796 Summer Street, Halifax, NS B3H 3A7 Canada
| | - Philip M. Jones
- grid.39381.300000 0004 1936 8884Department of Anesthesia & Perioperative Medicine, Department of Epidemiology & Biostatistics, Schulich School of Medicine & Dentistry, University of Western Ontario, LHSC- University Hospital, 339 Windermere Rd., London, ON N6A 5A5 Canada
| | - François Lemay
- grid.417661.30000 0001 2190 0479Département d’anesthésiologie, CHU de Québec – Université Laval, Hôtel-Dieu de Québec, 11, Côte du Palais, Québec, QC G1R 2J6 Canada
| | - Rudiger Noppens
- grid.39381.300000 0004 1936 8884Department of Anesthesia & Perioperative Medicine, Schulich School of Medicine & Dentistry, University of Western Ontario, LHSC- University Hospital, 339 Windermere Road, London, ON N6A 5A5 Canada
| | - Matteo Parotto
- grid.17063.330000 0001 2157 2938Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto General Hospital, Toronto, ON Canada ,grid.17063.330000 0001 2157 2938Interdepartmental Division of Critical Care Medicine, University of Toronto, EN 442 200 Elizabeth St, Toronto, ON M5G 2C4 Canada
| | - Roanne Preston
- grid.413264.60000 0000 9878 6515Department of Anesthesia, BC Women’s Hospital, 4500 Oak Street, Vancouver, BC V6H 3N1 Canada
| | - Nick Sowers
- grid.55602.340000 0004 1936 8200Department of Emergency Medicine, QEII Health Sciences Centre, Dalhousie University, 1796 Summer Street, Halifax, NS B3H 3A7 Canada
| | - Kathryn Sparrow
- grid.25055.370000 0000 9130 6822Discipline of Anesthesia, St. Clare’s Mercy Hospital, Memorial University of Newfoundland, 300 Prince Phillip Drive, St. John’s, NL A1B V6 Canada
| | - Timothy P. Turkstra
- grid.39381.300000 0004 1936 8884Department of Anesthesia & Perioperative Medicine, Schulich School of Medicine & Dentistry, University of Western Ontario, LHSC- University Hospital, 339 Windermere Road, London, ON N6A 5A5 Canada
| | - David T. Wong
- grid.17063.330000 0001 2157 2938Department of Anesthesia, Toronto Western Hospital, University Health Network, University of Toronto, 399, Bathurst St, Toronto, ON M5T2S8 Canada
| | - George Kovacs
- grid.55602.340000 0004 1936 8200Department of Emergency Medicine, QEII Health Sciences Centre, Dalhousie University, 1796 Summer Street, Halifax, NS B3H 3A7 Canada
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11
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Mohr NM, Pape SG, Runde D, Kaji AH, Walls RM, Brown CA. Etomidate Use Is Associated With Less Hypotension Than Ketamine for Emergency Department Sepsis Intubations: A NEAR Cohort Study. Acad Emerg Med 2020; 27:1140-1149. [PMID: 32602974 DOI: 10.1111/acem.14070] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 06/23/2020] [Accepted: 06/24/2020] [Indexed: 12/20/2022]
Abstract
OBJECTIVE The objectives of this study were 1) to describe the current use of etomidate and other induction agents in patients with sepsis and 2) to compare adverse events between etomidate and ketamine in sepsis. METHODS This was an observational cohort study of the prospective National Emergency Airway Registry (NEAR) data set. Descriptive statistics were used to report the distribution of induction agents used in patients with sepsis. Adverse events were compared using bivariate analysis, and a sensitivity analysis was conducted using a propensity score-adjusted analysis of etomidate versus ketamine. RESULTS A total of 531 patients were intubated for sepsis, and the majority (71%) were intubated with etomidate as the initial induction agent. Etomidate was less frequently used in sepsis patients than nonsepsis patients (71% vs. 85%, odds ratio [OR] = 0.4, 95% confidence interval [CI] = 0.4 to 0.5). Sepsis patients had a greater risk of adverse events, and vasopressor therapy was required for 25% of patients after intubation. Postprocedure hypotension was higher between those intubated for sepsis with ketamine versus etomidate (74% vs. 50%, OR = 2.9, 95% CI = 1.9 to 4.5). After confounding by indication in the propensity score-adjusted analysis was accounted for, ketamine was associated with more postprocedure hypotension (OR = 2.7, 95% CI = 1.1 to 6.7). No difference in emergency department deaths was observed. CONCLUSIONS Etomidate is used less frequently in sepsis patients than nonsepsis patients, with ketamine being the most frequently used alternative. Ketamine was associated with more postprocedural hypotension than etomidate. Future clinical trials are needed to determine the optimal induction agent in patients with sepsis.
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Affiliation(s)
- Nicholas M. Mohr
- From the Department of Emergency Medicine University of Iowa Carver College of Medicine Iowa City IA USA
- the Division of Critical Care Department of Anesthesia University of Iowa Carver College of Medicine Iowa City IA USA
- the Department of Epidemiology University of Iowa College of Public Health Iowa City IA USA
| | - Stephen G. Pape
- From the Department of Emergency Medicine University of Iowa Carver College of Medicine Iowa City IA USA
| | - Dan Runde
- From the Department of Emergency Medicine University of Iowa Carver College of Medicine Iowa City IA USA
| | - Amy H. Kaji
- the Department of Emergency Medicine University of California–Los Angeles Los Angeles CA USA
| | - Ron M. Walls
- and the Department of Emergency Medicine Brigham and Women's Hospital Boston MA USA
| | - Calvin A. Brown
- and the Department of Emergency Medicine Brigham and Women's Hospital Boston MA USA
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12
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Smischney NJ, Seisa MO, Heise KJ, Wiegand RA, Busack KD, Loftsgard TO, Schroeder DR, Diedrich DA. Predictors of arterial desaturation during intubation: a nested case-control study of airway management-part I. J Thorac Dis 2017; 9:3996-4005. [PMID: 29268410 DOI: 10.21037/jtd.2017.08.138] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background Arterial desaturations experienced during endotracheal intubation (ETI) may lead to poor outcomes. Thus, our primary aim was to identify predictors of arterial desaturation (pulse oximetry <90%) during the peri-intubation period and to assess outcomes of those who developed arterial hypoxemia. Methods Adult patients admitted to a medical and/or surgical intensive care unit (ICU) over the time period of January 1st 2013 through December 31st 2014 who required ETI were included. Only the first intubation was captured. Arterial desaturation was defined as pulse oximetry readings of <90% (hypoxemia) in the immediate peri-intubation period. Patients were then grouped in cases (those who developed desaturation) and controls (those who did not develop this complication). Results The final cohort included 420 patients. Arterial desaturations occurred in 74 (18%) patients. When adjusting for significant predictors on univariate analysis and known predictors of a difficult airway, only acute respiratory failure (OR 2.38; 95% CI: 1.15-4.93; P=0.02) and provider training level (OR 7.12; 95% CI: 1.65-30.67; P=0.016) remained significant. Higher pulse oximetry readings prior to intubation was found to be protective on multivariate analysis (OR 0.92; 95% CI: 0.89-0.96; P<0.01; per one percent increase). Conclusions Patients who were intubated for acute respiratory failure and those who were intubated by junior level trainees had increased odds of experiencing arterial desaturation in the peri-intubation period. Patients experiencing arterial desaturation had lower pulse oximetry readings prior to intubation suggesting a possible delay at intubation.
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Affiliation(s)
- Nathan J Smischney
- Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA.,Hemodynamic and Airway Management Group (HEMAIR), Mayo Clinic, Rochester, MN, USA
| | - Mohamed O Seisa
- Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA.,Hemodynamic and Airway Management Group (HEMAIR), Mayo Clinic, Rochester, MN, USA
| | | | | | - Kyle D Busack
- Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA
| | | | | | - Daniel A Diedrich
- Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA.,Hemodynamic and Airway Management Group (HEMAIR), Mayo Clinic, Rochester, MN, USA
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