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Römer T, Büttner C, Ossowski R, Mutlak H, Muellenbach RM. Atemwegsmanagement in der Intensivmedizin – Schritt für Schritt. Pneumologie 2023; 77:37-46. [PMID: 36716795 DOI: 10.1055/a-1906-6984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
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Morris OD, McCauley P, Boylan R, Burlacu C, Porter JM. A Simulation-Based Training Program in Rapid Sequence Induction for Novice Anesthesiology Trainees Using a Novel Checklist. THE JOURNAL OF EDUCATION IN PERIOPERATIVE MEDICINE : JEPM 2022; 24:E695. [PMID: 36545368 PMCID: PMC9753963 DOI: 10.46374/volxxiv_issue4_morris] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
BACKGROUND The novice anesthesiology trainee is required to assimilate the technical and nontechnical skills required to safely perform a rapid sequence induction (RSI). Acquisition of this core competency is traditionally achieved using operating room-based experiential learning, which may be associated with significant gaps in early trainee preparation. We conducted a study to explore the role of a new, customized, high-fidelity simulation-based training program designed to address this gap in RSI training. We then assessed mean performance scores of participants in the simulator and 4 weeks later. METHODS This observational study assessed participants' performance in the simulator on the day of training and in the workplace 4 weeks later. There is no universally agreed checklist or cognitive aid incorporating nontechnical skills and planning for unanticipated difficult airway management in RSI, so we applied a new scoring checklist developed by 6 experts using the modified Delphi technique. RESULTS Our task scoring checklist included nontechnical skills and consisted of 37 weighted parameters with a maximum performance score of 171. On the day of training, mean performance score was 105 (SD of 16). At the workplace evaluation 4 weeks after simulation training, the mean performance score of participants had increased to 140 (SD of 14.5; P = .001). The 95% confidence intervals for the simulator and workplace participant scores were 92 to 118 and 128 to 152, respectively. CONCLUSIONS The results suggest that this simulation-based training in RSI was associated with an improvement in RSI performance in novice trainees and may complement the current system of workplace-based training.
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Affiliation(s)
- Osmond D. Morris
- Osmond D. Morris and Jennifer M. Porter are Consultant Anesthesiologists in the Department of Perioperative Medicine at St. James’s Hospital, Dublin, Ireland; Peter McCauley is a Specialist Anesthesiologist Registrar in the Department of Perioperative Medicine at Beaumont Hospital, Dublin, Ireland; Ruth Boylan is a Fellow in Women’s Anesthesia in the Department of Anesthesia at Mercy Hospital for Women, Melbourne, Australia; Crina Burlacu is an Associate Clinical Professor in the Department of Anesthesiology at St. Vincent’s University Hospital, Dublin, Ireland
| | - Peter McCauley
- Osmond D. Morris and Jennifer M. Porter are Consultant Anesthesiologists in the Department of Perioperative Medicine at St. James’s Hospital, Dublin, Ireland; Peter McCauley is a Specialist Anesthesiologist Registrar in the Department of Perioperative Medicine at Beaumont Hospital, Dublin, Ireland; Ruth Boylan is a Fellow in Women’s Anesthesia in the Department of Anesthesia at Mercy Hospital for Women, Melbourne, Australia; Crina Burlacu is an Associate Clinical Professor in the Department of Anesthesiology at St. Vincent’s University Hospital, Dublin, Ireland
| | - Ruth Boylan
- Osmond D. Morris and Jennifer M. Porter are Consultant Anesthesiologists in the Department of Perioperative Medicine at St. James’s Hospital, Dublin, Ireland; Peter McCauley is a Specialist Anesthesiologist Registrar in the Department of Perioperative Medicine at Beaumont Hospital, Dublin, Ireland; Ruth Boylan is a Fellow in Women’s Anesthesia in the Department of Anesthesia at Mercy Hospital for Women, Melbourne, Australia; Crina Burlacu is an Associate Clinical Professor in the Department of Anesthesiology at St. Vincent’s University Hospital, Dublin, Ireland
| | - Crina Burlacu
- Osmond D. Morris and Jennifer M. Porter are Consultant Anesthesiologists in the Department of Perioperative Medicine at St. James’s Hospital, Dublin, Ireland; Peter McCauley is a Specialist Anesthesiologist Registrar in the Department of Perioperative Medicine at Beaumont Hospital, Dublin, Ireland; Ruth Boylan is a Fellow in Women’s Anesthesia in the Department of Anesthesia at Mercy Hospital for Women, Melbourne, Australia; Crina Burlacu is an Associate Clinical Professor in the Department of Anesthesiology at St. Vincent’s University Hospital, Dublin, Ireland
| | - Jennifer M. Porter
- Osmond D. Morris and Jennifer M. Porter are Consultant Anesthesiologists in the Department of Perioperative Medicine at St. James’s Hospital, Dublin, Ireland; Peter McCauley is a Specialist Anesthesiologist Registrar in the Department of Perioperative Medicine at Beaumont Hospital, Dublin, Ireland; Ruth Boylan is a Fellow in Women’s Anesthesia in the Department of Anesthesia at Mercy Hospital for Women, Melbourne, Australia; Crina Burlacu is an Associate Clinical Professor in the Department of Anesthesiology at St. Vincent’s University Hospital, Dublin, Ireland
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Admass BA, Endalew NS, Tawye HY, Melesse DY, Workie MM, Filatie TD. Evidence-based airway management protocol for a critical ill patient in medical intensive care unit: Systematic review. Ann Med Surg (Lond) 2022; 80:104284. [PMID: 36045781 PMCID: PMC9422313 DOI: 10.1016/j.amsu.2022.104284] [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: 06/12/2022] [Revised: 07/21/2022] [Accepted: 07/26/2022] [Indexed: 11/24/2022] Open
Abstract
Background Airway management outside the theatre is performed either to resuscitate a physiologically unstable critically ill patients or to secure an emergency airway in the absence of essential equipments. It is a life saving procedure for critically ill and injured patients. Delaying in securing airway or awaking the patient is not an option in case of difficult airway in intensive care unit. Therefore, developing and implementation of an evidence-based airway management protocol is important. Objective This review was conducted to develop a clear airway management protocol for a critical ill patient in medical intensive care unit. Methods After formulating the key questions, scope, and eligibility criteria for the evidences to be included, a comprehensive search strategy of electronic sources was conducted. The literatures were searched using advanced searching methods from data bases and websites to get evidences on airway management of a critical ill patient. Duplication of literatures was avoided by endnote. Screening of literatures was conducted based on the level of significance with proper appraisal. This review was carried out in accordance with the preferred reporting items for systematic reviews and meta-analyses (PRISMA) 2020 statement. Results A total of 626 articles were identified from data bases and websites using an electronic search. Of these articles, 95 were removed for duplication and 305 studies were excluded after reviewing their titles and abstracts. At the screening stage, 79 articles were retrieved and evaluated for the eligibility. Finally, 40 studies related to airway management of a critical ill patient in medical ICU were included in this systematic review. Conclusion A critical ill patient needs oxygenation and ventilation support. A focused and rapid assessment, with special attention of the airway and hemodynamic status of the critical ill patient is paramount. An appropriate airway management option should be employed to resuscitate or to control an emergency airway of a critical ill patent. This could be non invasive ventilation or invasive airway intervention. Airway management outside operating theatre is a common practice. A critical ill patient needs oxygenation and ventilation support. A focused airway assessment even in the most urgent situation is mandatory. Usage of appropriate airway management intervention is paramount.
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Ter Avest E, Ragavan D, Griggs J, Dias M, Mitchinson SA, Lyon R. Haemodynamic effects of a prehospital emergency anaesthesia protocol consisting of fentanyl, ketamine and rocuronium in patients with trauma: a retrospective analysis of data from a Helicopter Emergency Medical Service. BMJ Open 2021; 11:e056487. [PMID: 34930748 PMCID: PMC8689168 DOI: 10.1136/bmjopen-2021-056487] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES Prehospital rapid sequence induction (RSI) of anaesthesia is an intervention with significant associated risk. In this study, we aimed to investigate the haemodynamic response over time of a prehospital RSI protocol of fentanyl, ketamine and rocuronium in a heterogeneous population of trauma patients. DESIGN, SETTING AND PARTICIPANT We performed a retrospective study of all trauma patients who received a prehospital RSI for trauma by a physician staffed Helicopter Emergency Medical Service in the UK between 1 June 2018 and 1 February 2020. PRIMARY OUTCOME MEASURE Primary outcome was defined as the incidence of clinically relevant hypotensive (systolic blood pressure (SBP) or mean arterial pressure (MAP) >20% below baseline, with an absolute SBP <90 mm Hg or MAP <65 mm Hg) or hypertensive (SBP or MAP >20% above baseline) episodes in the first 10 minutes post-RSI. RESULTS In total, 322 patients were included. 204 patients (63%) received a full-dose induction of 3 μg/kg fentanyl, 2 mg/kg ketamine and 1 mg/kg rocuronium, whereas 128 patients (37%) received a reduced-dose induction. Blood pressures decreased on average 12 mm Hg (95% CI 7 to 16) in the full-dose group and 6 mm Hg (95% CI 1 to 11) in the reduced-dose group, p=0.10). A hypotensive episode (mean SBP drop 53 mm Hg) was noted in 29 patients: 17 (8.3%) receiving a full dose and 12 (10.2%) receiving a reduced-dose induction, p=0.69. The blood pressure nadir was recorded on average 6-8 min after RSI. A hypertensive episode was present in 22 patients (6.8%). The highest blood pressures were recorded in the first 3 min after RSI. CONCLUSION Prehospital induction of anaesthesia for trauma with fentanyl, ketamine and rocuronium is not related to a significant change in haemodynamics in most patients. However, a (delayed) hypotensive response with a significant drop in SBP should be anticipated in a minority of patients irrespective of the dose regimen chosen.
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Affiliation(s)
- Ewoud Ter Avest
- Air Ambulance Kent Surrey and Sussex, Redhill, Surrey, UK
- Emergency Medicine, University Medical Centre Groningen, Groningen, The Netherlands
| | - Dassen Ragavan
- Air Ambulance Kent Surrey and Sussex, Redhill, Surrey, UK
| | - Joanne Griggs
- Air Ambulance Kent Surrey and Sussex, Redhill, Surrey, UK
- University of Surrey, Guildford, Surrey, UK
| | - Michael Dias
- Air Ambulance Kent Surrey and Sussex, Redhill, Surrey, UK
| | | | - Richard Lyon
- Air Ambulance Kent Surrey and Sussex, Redhill, Surrey, UK
- School of Health Sciences, University of Surrey, Guildford, UK
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Whytock CW, Atkinson MS. Increasing use of an endotracheal intubation safety checklist in the emergency department. BMJ Open Qual 2021; 10:e001575. [PMID: 34887300 PMCID: PMC8663106 DOI: 10.1136/bmjoq-2021-001575] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 11/22/2021] [Indexed: 01/04/2023] Open
Abstract
Endotracheal intubation (ETI) is a high-risk procedure often performed in the emergency department (ED) in critically unwell patients. The fourth National Audit Project by The Royal College of Anaesthetists found the risk of adverse events is much higher when performing the intervention in this setting compared with a theatre suite, and therefore use of a safety checklist is recommended. This quality improvement project was set in a large teaching hospital in the North West of the UK, where anaesthesia and intensive care clinicians are responsible for performing this procedure. A retrospective baseline audit indicated checklist use was 16.7% of applicable cases. The project aim was to increase the incidence of checklist use in the ED to 90% within a 6-month period. The model for improvement was used as a methodological approach to the problem along with other quality improvement tools, including a driver diagram to generate change ideas. The interventions were targeted at three broad areas: awareness of the checklist and expectation of use, building a favourable view of the benefits of the checklist and increasing the likelihood it would be remembered to use the checklist in the correct moment. After implementation checklist use increased to 84%. In addition, run chart analysis indicated a pattern of nonrandom variation in the form of a shift. This coincided with the period shortly after the beginning of the interventions. The changes were viewed favourably by junior and senior anaesthetists, as well as operating department practitioners and ED staff. Limitations of the project were that some suitable cases were likely missed due to the method of capture and lack of anonymous qualitative feedback on the changes made. Overall, however, it was shown the combination of low-cost interventions made was effective in increasing checklist use when performing emergency ETI in the ED.
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Innocenti F, Stefanone VT. Errare humanum est, not using the checklist diabolicum. Intern Emerg Med 2021; 16:2227-2229. [PMID: 34148180 DOI: 10.1007/s11739-021-02789-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 06/04/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Francesca Innocenti
- High-Dependency Unit, Department of Clinical and Experimental Medicine, Azienda Ospedaliero-Universitaria Careggi, Lg. Brambilla 3, 50134, Florence, Italy.
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Does utilization of an intubation safety checklist reduce omissions during simulated resuscitation scenarios: a multi-center randomized controlled trial. CAN J EMERG MED 2021; 23:45-53. [PMID: 33683616 PMCID: PMC7747776 DOI: 10.1007/s43678-020-00010-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 09/15/2020] [Indexed: 12/02/2022]
Abstract
Objectives Checklists have been used to decrease adverse events associated with medical procedures. Simulation provides a safe setting in which to evaluate a new checklist. The objective of this study was to determine if the use of a novel peri-intubation checklist would decrease practitioners’ rates of omission of tasks during simulated airway management scenarios. Methods Fifty-four emergency medicine (EM) practitioners from two academic centers were randomized to either their usual approach or use of our checklist, then completed three simulated airway management scenarios. A minimum of two assessors documented the number of tasks omitted and the time until definitive airway management. Discrepancies between assessors were resolved by single assessor video review. Participants also completed a post-simulation survey. Results The average percentage of omitted tasks over three scenarios was 45.7% in the control group (n = 25) and 13.5% in the checklist group (n = 29)—an absolute difference of 32.2% (95% CI 27.8, 36.6%). Time to definitive airway management was longer in the checklist group in the first two of three scenarios (difference of 110.0 s, 95% CI 55.0 to 167.0; 83.0 s, 95% CI 35.0 to 128.0; and 36.0 s, 95% CI −18.0 to 98.0 respectively). Conclusions In this dual-center, randomized controlled trial, use of an airway checklist in a simulated setting significantly decreased the number of important airway tasks omitted by EM practitioners, but increased time to definitive airway management. Electronic supplementary material The online version of this article (10.1007/s43678-020-00010-w) contains supplementary material, which is available to authorized users.
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Verbal Communication During Airway Management and Emergent Endotracheal Intubation: Observations of Team Behavior Among Multi-institutional Pediatric Intensive Care Unit In Situ Simulations. J Patient Saf 2021; 16:e114-e119. [PMID: 27811586 DOI: 10.1097/pts.0000000000000272] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To assess health-care teams' verbal communication, an observable teamwork behavior, during simulations involving pediatric emergency airway management and intubation. METHODS We conducted video-recorded, risk-informed in situ simulations at 5 hospitals with pediatric intensive care units in the Chicago, Illinois, area. Clinicians participated in their clinical roles (eg, attending physician, bedside nurse) and had access to hospital operational systems (eg, electronic health record, medical imaging, laboratory services). Video-recordings were transcribed; 3 pediatric critical care physicians analyzed the transcripts to assess preintubation communication: (a) the declaration of an airway emergency, (b) intubation medication request(s), and (c) preintubation medication administration. RESULTS Ten pediatric intensive care unit simulations were analyzed. Statements to notify the care team of an airway emergency varied widely. In 3 simulations, a dosage for every medication was verbalized in the physician's initial medication request; however, in 4 simulations, a nurse was the first to verbalize the medication dosage(s) before administration. In 6 of the simulations where preintubation medications were administered, multiple requests for medications were verbalized. A clinician verbally confirmed that each medication was administered in only 2 of the simulations. CONCLUSIONS No uniform statement was identified to declare an airway emergency among the care teams. Preintubation medication dosages were not consistently included in intubation medication orders, and frequently, there were multiple requests to obtain medications. Using standardized language to declare an airway emergency and verbally communicating medication requests and dosages and confirming administration may improve the quality of care in this critical event.
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Patient Safety during ECMO Transportation: Single Center Experience and Literature Review. Emerg Med Int 2021; 2021:6633208. [PMID: 33688436 PMCID: PMC7920709 DOI: 10.1155/2021/6633208] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Revised: 02/01/2021] [Accepted: 02/10/2021] [Indexed: 11/17/2022] Open
Abstract
Background Extracorporeal membrane oxygenation (ECMO) has been proven to support in lifesaving rescue therapy. The best outcomes can be achieved in high-volume ECMO centers with dedicated emergency transport teams. Aim The aim of this study was to analyze the safety of ECMO support during medical transfer on the basis of our experience developed on innovation cooperation and review of literature. Methods A retrospective analysis of our experience of all ECMO-supported patients transferred from regional hospital of the referential ECMO center between 2015 and 2020 was carried out. Special attention was paid to transportation-related mortality and morbidity. Moreover, a systematic review of the Medline, Embase, Cochrane, and Google Scholar databases was performed. It included the original papers published before the end of 2019. Results Twelve (5 women and 7 men) critically ill ECMO-supported patients with the median age of 33 years (2-63 years) were transferred to our ECMO center. In 92% (n = 11) of the cases venovenous and in 1 case, venoarterial supports were applied. The median transfer length was 45 km (5-200). There was no mortality during transfer and no serious adverse events occurred. Of note, the first ECMO-supported transfer had been proceeded by high-fidelity simulations. For our systematic review, 68 articles were found and 22 of them satisfied the search criteria. A total number of 2647 transfers were reported, mainly primary (90%) and as ground transportations (91.6%). A rate of adverse events ranged from 1% through 20% but notably only major complications were mentioned. The 4 deaths occurred during transport (mortality 0.15%). Conclusions Our experiences and literature review showed that transportation for ECMO patients done by experienced staff was associated with low mortality rate but life-threatening adverse events might occur. Translational simulation is an excellent probing technique to improve transportation safety.
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Pellegrini M, Zoghi M, Jaberzadeh S. A Checklist to Reduce Response Variability in Studies Using Transcranial Magnetic Stimulation for Assessment of Corticospinal Excitability: A Systematic Review of the Literature. Brain Connect 2020; 10:53-71. [PMID: 32093486 DOI: 10.1089/brain.2019.0715] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Response variability between individuals (interindividual variability) and within individuals (intraindividual variability) is an important issue in the transcranial magnetic stimulation (TMS) literature. This has raised questions of the validity of TMS to assess changes in corticospinal excitability (CSE) in a predictable and reliable manner. Several participant-specific factors contribute to this observed response variability with a current lack of consensus on the degree each factor contributes. This highlights a need for consistency and structure in reporting study designs and methodologies. Currently, there is no summarized review of the participant-specific factors that can be controlled and may contribute to response variability. This systematic review aimed to develop a checklist of methodological measures taken by previously published research to increase the homogeneity of participant selection criteria, preparation of participants before experimental testing, participant scheduling, and the instructions given to participants throughout experimental testing to minimize their effect on response variability. Seven databases were searched in full. Studies were included if CSE was measured via TMS and included methodological measures to increase the homogeneity of the participants. Eighty-four studies were included. Twenty-three included measures to increase participant selection homogeneity, 21 included measures to increase participant preparation homogeneity, while 61 included measures to increase participant scheduling and instructions during experimental testing homogeneity. These methodological measures were summarized into a user-friendly checklist with considerations, suggestions, and rationale/justification for their inclusion. This may provide the framework for further insights into ways to reduce response variability in TMS research.
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Affiliation(s)
- Michael Pellegrini
- Non-Invasive Brain Stimulation and Neuroplasticity Laboratory, Department of Physiotherapy, School of Primary and Allied Health Care, Faculty of Medicine, Nursing and Health Science, Monash University, Melbourne, Victoria, Australia
| | - Maryam Zoghi
- Department of Rehabilitation, Nutrition and Sport, Discipline of Physiotherapy, School of Allied Health, La Trobe University, Melbourne, Victoria, Australia
| | - Shapour Jaberzadeh
- Non-Invasive Brain Stimulation and Neuroplasticity Laboratory, Department of Physiotherapy, School of Primary and Allied Health Care, Faculty of Medicine, Nursing and Health Science, Monash University, Melbourne, Victoria, Australia
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The critical care literature 2019. Am J Emerg Med 2020; 39:197-206. [PMID: 33036856 DOI: 10.1016/j.ajem.2020.09.059] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 09/20/2020] [Accepted: 09/22/2020] [Indexed: 11/23/2022] Open
Abstract
An emergency physician (EP) is often the first health care provider to evaluate, resuscitate, and manage a critically ill patient. In recent years, the annual hours of critical care delivered in emergency departments across the United States has steadily increased. From 2006 to 2014, emergency department (ED) visits for critically ill patients increased approximately 80%. In addition to seeing more critically ill patients, EPs are often tasked with providing critical care long beyond the initial resuscitation period. In fact, more than 50% of ED patients that require admission to the ICU remain in the ED for more than 6 h. Prolonged ED wait times for critically ill patients to be transferred to the ICU is associated with increased hospital, 30-day, and 90-day mortality. It is during these early hours of critical illness, while the patient is in the ED, where lives can be saved or lost. Therefore, it is important for the EP to be knowledgeable about recent developments in resuscitation and critical care medicine. This review summarizes important articles published in 2019 pertaining to the resuscitation and care of select critically ill patients. We chose these articles based on our opinion of the importance of the study findings and their application to emergency medicine. The following topics are covered: sepsis, rapid sequence intubation, mechanical ventilation, neurocritical care, post-cardiac arrest care, and ED-based ICUs.
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George S, Long E, Gelbart B, Dalziel SR, Babl FE, Schibler A. Intubation practices for children in emergency departments and intensive care units across Australia and New Zealand: A survey of medical staff. Emerg Med Australas 2020; 32:1052-1058. [PMID: 32969150 DOI: 10.1111/1742-6723.13620] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Revised: 05/28/2020] [Accepted: 08/06/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Intubation of children in the emergency setting is a high-risk, low incidence event. Standardisation of clinical practice has been hampered by a lack of high-quality evidence to support one technique over another. The aim of the present study is to determine clinician preference in intubation practice of children in EDs and ICUs in Australia and New Zealand to provide baseline information to allow future targeted research focused on improving the safety and efficacy of paediatric emergency airway management. METHODS The present study was a voluntary questionnaire undertaken by medical staff at registrar level or above in EDs and ICUs associated with the Paediatric Research in Emergency Departments International Collaborative (PREDICT) and Australia and New Zealand Intensive Care Society Paediatric Study Group (ANZICS PSG) research networks. Respondents reported on their individual intubation practices, with a focus on pre-oxygenation and apnoeic oxygenation techniques, and the use of video laryngoscopy. RESULTS A total of 502 clinicians were invited to complete the survey between May and October 2018 with 336 (66.9%) responded. There was marked variation in practice between ED clinicians and ICU clinicians in the techniques used for pre-oxygenation, the frequency of use of apnoeic oxygenation and the reported use of video laryngoscopy. CONCLUSIONS Within Australia and New Zealand there is considerable variation in paediatric emergency airway clinical practice, in particular with respect to pre-oxygenation, apnoeic oxygenation and use of video laryngoscopy. Definitive clinical trials are required to best inform clinical practice in this area.
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Affiliation(s)
- Shane George
- Department of Emergency Medicine, Gold Coast University Hospital, Gold Coast, Queensland, Australia.,Department of Children's Critical Care, Gold Coast University Hospital, Gold Coast, Queensland, Australia.,Paediatric Critical Care Research Group, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,School of Medicine, Griffith University, Brisbane, Queensland, Australia
| | - Elliot Long
- Department of Emergency Medicine, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics and Centre for Integrated Critical Care, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Ben Gelbart
- Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics and Centre for Integrated Critical Care, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia.,Paediatric Intensive Care, The Royal Children's Hospital, Melbourne, Victoria, Australia
| | - Stuart R Dalziel
- Emergency Department, Starship Children's Hospital, Auckland, New Zealand.,Department of Surgery, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand.,Department of Paediatrics Child and Youth Health, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Franz E Babl
- Department of Emergency Medicine, The Royal Children's Hospital, Melbourne, Victoria, Australia.,Clinical Sciences, Murdoch Children's Research Institute, Melbourne, Victoria, Australia.,Department of Paediatrics and Centre for Integrated Critical Care, Faculty of Medicine, Dentistry and Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Andreas Schibler
- Paediatric Critical Care Research Group, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia.,Paediatric Intensive Care Unit, Queensland Children's Hospital, Brisbane, Queensland, Australia
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Cordier PY, Lyochon A, Boussen S, Cungi PJ, d'Aranda E, Bordes J, Martin E, Peytel E, Meaudre E, Goutorbe P. Rapid sequence induction traceability in an ICU dedicated patient data management system: a multicentric retrospective study. J Crit Care 2020; 54:292-297. [PMID: 31813460 DOI: 10.1016/j.jcrc.2019.08.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 07/24/2019] [Accepted: 08/09/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE Patient data management systems (PDMS) are widely used in intensive care units (ICUs) to improve care traceability. Verbal orders are still used for prescriptions requiring immediate execution but should be subsequently recorded in the system. We assessed the rapid sequence induction (RSI) traceability for endotracheal intubation in an ICU dedicated PDMS. MATERIALS AND METHODS A retrospective study was conducted on anonymous databases in 21 ICUs. Endotracheal tube insertions performed during one year were compared to the number of RSI registered in the PDMS. RESULTS We listed 5516 endotracheal tube insertions. A suxamethonium injection was registered in 829 cases and a rocuronium administration in 909 cases. The RSI traceability rate in the overall cohort was 31.5% and was greater in the units where nurses were allowed to record a drug administration before the computerized physician order entry. CONCLUSIONS PDMS are supposed to improve prescription completeness and traceability, but our study suggests an opposite result. A co-responsibility policy between physicians and nurses should be promoted to improve care traceability. PDMS ergonomic improvements and enhanced integration in clinical workflow might also result in better compliance with documentation requirements. In each centre, indicators of PDMS correct use should be defined and periodically monitored.
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Affiliation(s)
- Pierre-Yves Cordier
- Intensive Care Unit, Laveran Military Teaching Hospital, 34 Boulevard Laveran, 13384 Marseille, France; LBA, UMRT 24, Aix Marseille Université-IFSTTAR, Boulevard Pierre Dramard, 13916, Marseille cedex 20, France.
| | - Arthur Lyochon
- Intensive Care Unit, Laveran Military Teaching Hospital, 34 Boulevard Laveran, 13384 Marseille, France
| | - Salah Boussen
- LBA, UMRT 24, Aix Marseille Université-IFSTTAR, Boulevard Pierre Dramard, 13916, Marseille cedex 20, France; Department of Anesthesiology and Intensive Care, Timone University Hospital, 264 rue Saint-Pierre, 13005 Marseille, France
| | - Pierre-Julien Cungi
- Intensive Care Unit, Sainte Anne Military Teaching Hospital, 2 Boulevard Sainte Anne, BP600, 83800 Toulon, France
| | - Erwan d'Aranda
- Intensive Care Unit, Sainte Anne Military Teaching Hospital, 2 Boulevard Sainte Anne, BP600, 83800 Toulon, France
| | - Julien Bordes
- Intensive Care Unit, Sainte Anne Military Teaching Hospital, 2 Boulevard Sainte Anne, BP600, 83800 Toulon, France
| | - Edouard Martin
- Intensive Care Unit, Laveran Military Teaching Hospital, 34 Boulevard Laveran, 13384 Marseille, France
| | - Eric Peytel
- Intensive Care Unit, Laveran Military Teaching Hospital, 34 Boulevard Laveran, 13384 Marseille, France
| | - Eric Meaudre
- Intensive Care Unit, Sainte Anne Military Teaching Hospital, 2 Boulevard Sainte Anne, BP600, 83800 Toulon, France
| | - Philippe Goutorbe
- Intensive Care Unit, Sainte Anne Military Teaching Hospital, 2 Boulevard Sainte Anne, BP600, 83800 Toulon, France
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14
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Hay-David A, Herron J, Gilling P, Brennan P. Assertive followership: how to make a team safer. Br J Oral Maxillofac Surg 2020. [DOI: 10.1016/j.bjoms.2020.08.085] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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15
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Turner JS, Bucca AW, Propst SL, Ellender TJ, Sarmiento EJ, Menard LM, Hunter BR. Association of Checklist Use in Endotracheal Intubation With Clinically Important Outcomes: A Systematic Review and Meta-analysis. JAMA Netw Open 2020; 3:e209278. [PMID: 32614424 PMCID: PMC7333022 DOI: 10.1001/jamanetworkopen.2020.9278] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
IMPORTANCE Endotracheal intubation of critically ill patients is a high-risk procedure. Checklists have been advocated to improve outcomes. OBJECTIVE To assess whether the available evidence supports an association of use of airway checklists with improved clinical outcomes in patients undergoing endotracheal intubation. DATA SOURCES For this systematic review and meta-analysis, PubMed (OVID), Embase, Cochrane, CINAHL, and SCOPUS were searched without limitations using the Medical Subject Heading terms and keywords airway; management; airway management; intubation, intratracheal; checklist; and quality improvement to identify studies published between January 1, 1960, and June 1, 2019. A supplementary search of the gray literature was performed, including conference abstracts and clinical trial registries. STUDY SELECTION Full-text reviews were performed to determine final eligibility for inclusion. Included studies were randomized clinical trials or observational human studies that compared checklist use with any comparator for endotracheal intubation and assessed 1 of the predefined outcomes. DATA EXTRACTION AND SYNTHESIS Data extraction and quality assessment were performed using the Newcastle-Ottawa Scale for observational studies and Cochrane risk of bias tool for randomized clinical trials. Study results were meta-analyzed using a random-effects model. Reporting of this study follows the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. MAIN OUTCOMES AND MEASURES The primary outcome was mortality. Secondary outcomes included first-pass success and known complications of endotracheal intubation, including esophageal intubation, hypoxia, hypotension, and cardiac arrest. RESULTS The search identified 1649 unique citations of which 11 (3261 patients) met the inclusion criteria. One randomized clinical trial and 3 observational studies had a low risk of bias. Checklist use was not associated with decreased mortality (5 studies [2095 patients]; relative risk, 0.97; 95% CI, 0.80-1.18; I2 = 0%). Checklist use was associated with a decrease in hypoxic events (8 studies [3010 patients]; relative risk, 0.75; 95% CI, 0.59-0.95; I2 = 33%) but no other secondary outcomes. Studies with a low risk of bias did not demonstrate decreased hypoxia associated with checklist use. CONCLUSIONS AND RELEVANCE The findings suggest that use of airway checklists is not associated with improved clinical outcomes during and after endotracheal intubation, which may affect practitioners' decision to use checklists in this setting.
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Affiliation(s)
- Joseph S. Turner
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis
| | - Antonino W. Bucca
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis
| | - Steven L. Propst
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis
- Now with Department of Emergency Medicine, CoxHealth, Springfield, Missouri
| | - Timothy J. Ellender
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis
| | - Elisa J. Sarmiento
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis
| | - Laura M. Menard
- Ruth Lilly Medical Library, Indiana University School of Medicine, Indianapolis
| | - Benton R. Hunter
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis
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16
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Rothkötter JH, Fischer D, Schmidt-Torner S. Notfallnarkose – Vorbereitung und Assistenz im Rettungsdienst. Notf Rett Med 2020. [DOI: 10.1007/s10049-019-0608-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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17
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Allene MD, Melekie TB, Ashagrie HE. Evidence based use of modified rapid sequence induction at a low income country: A systematic review. INTERNATIONAL JOURNAL OF SURGERY OPEN 2020. [DOI: 10.1016/j.ijso.2020.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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18
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Janz DR, Casey JD, Semler MW, Russell DW, Dargin J, Vonderhaar DJ, Dischert KM, West JR, Stempek S, Wozniak J, Caputo N, Heideman BE, Zouk AN, Gulati S, Stigler WS, Bentov I, Joffe AM, Rice TW, Janz DR, Vonderhaar DJ, Hoffman R, Turlapati N, Samant S, Clark P, Krishnan A, Gresens J, Hill C, Matthew B, Henry J, Miller J, Paccione R, Majid-Moosa A, Santanilla JI, Semler MW, Rice TW, Casey JD, Heideman BE, Wilfong EM, Hewlett JC, Halliday SJ, Kerchberger VE, Brown RM, Huerta LE, Merrick CM, Atwater T, Kocurek EG, McKown AC, Winters NI, Habegger LE, Mart MF, Berg JZ, Noblit CC, Flemmons LN, Dischert K, Joffe A, Bentov I, Archibald T, Arenas A, Baldridge C, Bansal G, Barnes C, Bishop N, Bryce B, Byrne L, Clement R, DeLaCruz C, Deshpande P, Gong Z, Green J, Henry A, Herstein A, Huang J, Heier J, Jenson B, Johnston L, Langeland C, Lee C, Nowlin A, Reece-Nguyen T, Schultz H, Segal G, Slade I, Solomon S, Stehpey S, Thompson R, Trausch D, Welker C, Zhang R, Russell D, Zouk A, Gulati S, Stigler W, Fain J, Garcia B, Lafon D, He C, O'Connor J, Campbell D, Powner J, McElwee S, Bardita C, D'Souza K, Pereira GB, Robinson S, Blumhof S, Dargin J, Stempek S, Wozniak J, Pataramekin P, Desai D, Yayarovich E, DeMatteo R, Somalaraiu S, Adler C, Reid C, Plourde M, Winnicki J, Noland T, Geva T, Gazourian L, Patel A, Eissa K, Giacotto J, Fitelson D, Colancecco M, Gray A, West JR, Caputo N, Ryan M, Parry T, Azan B, Khairat A, Morton R, Lewandowski D, Vaca C. Effect of a fluid bolus on cardiovascular collapse among critically ill adults undergoing tracheal intubation (PrePARE): a randomised controlled trial. THE LANCET RESPIRATORY MEDICINE 2019; 7:1039-1047. [DOI: 10.1016/s2213-2600(19)30246-2] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 05/29/2019] [Accepted: 06/13/2019] [Indexed: 01/17/2023]
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19
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Petrigna L, Karsten B, Marcolin G, Paoli A, D’Antona G, Palma A, Bianco A. A Review of Countermovement and Squat Jump Testing Methods in the Context of Public Health Examination in Adolescence: Reliability and Feasibility of Current Testing Procedures. Front Physiol 2019; 10:1384. [PMID: 31787902 PMCID: PMC6853898 DOI: 10.3389/fphys.2019.01384] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 10/21/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND In the context of a public health physical fitness (PF) examination in adolescence, a countermovement jump (CMJ) and a squat jump (SJ) are two vertical jump (VJ) tests widely used to evaluate lower limb muscle strength and power, respectively. The main criticism of both the CMJ and SJ test is the lack of test standardization. Therefore, the objectives of this review are: (a) to gather information about both jumps; (b) to investigate whether it is possible to identify common procedures referred to in the CMJ and SJ technical execution, and (c) to design standard operating procedures (SOPs) to promote CMJ and SJ standardization in an adolescent population aged 12-18 years. METHODS The review partially adopted the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Statement (PRISMA). Due to growing attention in monitoring physical health through field tests in recent years, articles were collected using the PubMed, Web of Science, and Scopus databases from January 2009 to July 2019. Original articles in which CMJ or SJ were used to assess the muscular strength in adolescents were eligible for further analysis. Articles written in English was imposed as a limit. RESULTS A total of 117 studies met the inclusion criteria. The description of the CMJ and SJ test procedures was different within the literature, with discrepancies in the jump technique, number of jumps, and measurement devices used. CONCLUSIONS A lack of method standardization for both the CMJ and the SJ test was identified. Based on the literature, SOPs for both VJs were proposed. These are useful in the context of public health PF examination in adolescents, as they facilitate an unbiased comparison of jump performance data between published studies.
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Affiliation(s)
- Luca Petrigna
- Ph.D. Program in Health Promotion and Cognitive Sciences, Department of Psychology, Educational Science and Human Movement, University of Palermo, Palermo, Italy
| | - Bettina Karsten
- Department of Exercise and Sport Science, LUNEX International University of Health, Exercise and Sports, Differdange, Luxembourg
| | - Giuseppe Marcolin
- Department of Biomedical Sciences, University of Padova, Padua, Italy
| | - Antonio Paoli
- Department of Biomedical Sciences, University of Padova, Padua, Italy
| | | | - Antonio Palma
- Ph.D. Program in Health Promotion and Cognitive Sciences, Department of Psychology, Educational Science and Human Movement, University of Palermo, Palermo, Italy
- Department of Psychology, Educational Science and Human Movement, University of Palermo, Palermo, Italy
- Regional Sport School of CONI Sicilia, Italian National Olympic Committee, Sicilia, Italy
| | - Antonino Bianco
- Ph.D. Program in Health Promotion and Cognitive Sciences, Department of Psychology, Educational Science and Human Movement, University of Palermo, Palermo, Italy
- Department of Psychology, Educational Science and Human Movement, University of Palermo, Palermo, Italy
- Regional Sport School of CONI Sicilia, Italian National Olympic Committee, Sicilia, Italy
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20
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Audit on Current Practice of Rapid Sequence Induction and Intubation of Anesthesia in the University of Gondar Hospital, Northwest Ethiopia, 2018. Anesthesiol Res Pract 2019; 2019:6842092. [PMID: 31662743 PMCID: PMC6778896 DOI: 10.1155/2019/6842092] [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: 04/07/2019] [Revised: 07/26/2019] [Accepted: 08/26/2019] [Indexed: 12/05/2022] Open
Abstract
Background In patients who are liable to the risk of pulmonary aspiration, airway control is the primary and first concern for the anesthetists both in emergency and elective surgical procedures. Rapid sequence induction is universally required in any occasion of emergent endotracheal intubation needed for unfasted patients or patients' fasting status is unknown. Methods institutional-based prospective observational study was conducted from December 2017 to January 2018 in all elective and emergency adult or pediatric patients with a risk of pulmonary aspiration who were operated under general anesthesia with rapid sequence induction and intubation during the audit period. Result A total of 35 patients were operated during the study period. Of these, 31 (88.57%) patients were adults and 4 (11.43%) patients were pediatrics. Most of the patients were emergency (29 (82.857%)), and the rest were elective (6 (17.142%)). Conclusion Most anesthetists were good at preparing all available monitoring and drugs, making sure that IV line is well-functioning, preparing suction with a suction machine, preoxygenation, application of cricoid pressure, and checking the position of the ETT after intubation was performed. Preparing difficult airway equipment during planning of rapid sequence induction and intubation, giving roles and told to proceed their assigned role for the team, attempt to ventilate with a small tidal volume, and routine use of bougie or stylet to increase the chance of success of intubation needed improvement.
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21
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Boccatonda A, Groff P. High-flow nasal cannula oxygenation utilization in respiratory failure. Eur J Intern Med 2019; 64:10-14. [PMID: 31029547 DOI: 10.1016/j.ejim.2019.04.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2019] [Revised: 04/09/2019] [Accepted: 04/19/2019] [Indexed: 10/27/2022]
Abstract
High flow nasal cannula (HFNC) represents a new oxygenation system to be used in the treatment of respiratory emergencies. During HFNC therapy, the active humidification and air heating system allow the patient to tolerate higher flows by favouring physiologic mucociliary clearance and improving fluidity of respiratory secretions. Following this, FiO2 values are more stable and reliable, by reducing losses and minimizing ambient air entrainment. Several clinical trials in acute respiratory failure patients have suggested lower rate of invasive mechanical ventilation, improved comfort and enhanced survival by early HFNC utilization in comparison with conventional oxygen therapy (COT) or non-invasive ventilation (NIV). This review aims to summarize the main evidences on the use of HFNC in the acute setting and its major indications.
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Affiliation(s)
- Andrea Boccatonda
- Department of Internal Medicine, "G. d'Annunzio" University, Chieti, Italy.
| | - Paolo Groff
- Emergency Department, "Santa Maria della Misericordia" Hospital, Perugia, Italy
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22
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Ferguson I, Bliss J, Aneman A. Does the addition of fentanyl to ketamine improve haemodynamics, intubating conditions or mortality in emergency department intubation: A systematic review. Acta Anaesthesiol Scand 2019; 63:587-593. [PMID: 30644096 DOI: 10.1111/aas.13314] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 11/09/2018] [Accepted: 11/25/2018] [Indexed: 12/17/2022]
Abstract
BACKGROUND Ketamine is an induction agent frequently used for general anaesthesia in emergency medicine. Generally regarded as haemodynamically stable, it can cause hypertension and tachycardia and may cause or worsen shock. The effects of ketamine may be improved by the addition of fentanyl to the induction regime. We conducted a systematic review to identify evidence with regard to the effect of adding fentanyl to an induction regime of ketamine and a paralysing agent on post-induction haemodynamics, intubating conditions and mortality. METHODS We conducted a search of the Cochrane library, EMBASE, MEDLINE, PROQUEST, OpenGrey and clinical trial registries. Prominent authors were contacted in order to identify additional literature pertinent to the research question. Studies were included if they pertained to intubation of adult patients in the prehospital or emergency department environments and included an induction regime of ketamine and a paralysing agent, with at least one outcome measure of haemodynamics, intubating conditions or mortality. Search results were reviewed by two investigators independently, adjudicated by a third investigator where disagreement occurred. RESULTS One observational study was identified that partially answered the research question. DISCUSSION Only one observational study was identified that partially answered the research question. This paper demonstrated that the use of fentanyl as a pretreatment increases the incidence of post-induction hypotension, a phenomenon that was seen with propofol, midazolam and ketamine. The difference in hypotension between these agents was not statistically significant. The impact of this on patient-orientated outcomes is unclear.
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Affiliation(s)
- Ian Ferguson
- Emergency Department Liverpool Hospital Liverpool New South Wales Australia
- Greater Sydney Area HEMSAmbulance NSW Sydney New South Wales Australia
- South West Sydney Clinical School University of New South Wales Sydney New South Wales Australia
| | - James Bliss
- Emergency Department Liverpool Hospital Liverpool New South Wales Australia
- Greater Sydney Area HEMSAmbulance NSW Sydney New South Wales Australia
| | - Anders Aneman
- South West Sydney Clinical School University of New South Wales Sydney New South Wales Australia
- Department of Intensive Care Medicine Liverpool Hospital Sydney New South Wales Australia
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23
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Denny JT, Mungekar SS, Landgraf BR, Rocke ZM, McRae VA, McDonough CP, Tse JT, Mellender SJ, Kiss GK. An Unusual Cause of Failure to Ventilate. J Investig Med High Impact Case Rep 2018; 6:2324709618781174. [PMID: 29977935 PMCID: PMC6024497 DOI: 10.1177/2324709618781174] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2017] [Revised: 04/26/2018] [Accepted: 05/13/2018] [Indexed: 11/16/2022] Open
Abstract
We report an unusual case of endotracheal tube failure. It was due to a manufacturing defect in the internal white plastic piece that is normally depressed by the luer-lock syringe within the blue pilot balloon. Prior to use, the endotracheal tube was tested and functioned normally. A 64-year-old patient in the intensive care unit with a history of hypertension was being mechanically ventilated after uneventful abdominal surgery. After several hours in the intensive care unit, he was noted to be suddenly no longer receiving adequate tidal volumes from the ventilator. It was found that the cuff on the endotracheal tube was not retaining air when it was filled with air from a syringe. This lead to a large "leak" around the endotracheal tube such that the intended tidal volumes set on the ventilator were not delivered to the patient. The patient was uneventfully reintubated and did well. Subsequent investigation revealed the cause to be a manufacturing defect in the internal white plastic piece that is normally depressed by the luer-lock syringe within the blue pilot balloon. Other mechanisms of cuff failure are reviewed in this case report. This case is an unusual reason for cuff failure. Illustrations supplied alert the reader how to identify the appearance of this manufacturing defect in a pilot balloon. This case illustrates the potential device malfunctions that can develop during a procedure, even when the equipment has been tested and previously functioned well. Even small defects developing in well-engineered products can lead to critical patient care emergencies.
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Affiliation(s)
| | | | | | - Zoe M Rocke
- St. George's University, Grenada, West Indies
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24
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Ferguson I, Alkhouri H, Fogg T, Aneman A. Ketamine use for rapid sequence intubation in Australian and New Zealand emergency departments from 2010 to 2015: A registry study. Emerg Med Australas 2018; 31:205-210. [PMID: 29888875 DOI: 10.1111/1742-6723.13114] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2017] [Revised: 05/03/2018] [Accepted: 05/10/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVE This study aimed to quantify the proportion of patients undergoing rapid sequence intubation using ketamine in Australian and New Zealand EDs between 2010 and 2015. METHODS The Australian and New Zealand Emergency Department Airway Registry is a multicentre airway registry prospectively capturing data from 43 sites. Data on demographics and physiology, the attending staff and indication for intubation were recorded. The primary outcome was the annual percentage of patients intubated with ketamine. A logistic regression analysis was conducted to evaluate the factors associated with ketamine use. RESULTS A total of 4658 patients met inclusion criteria. The annual incidence of ketamine use increased from 5% to 28% over the study period (P < 0.0001). In the logistic regression analysis, the presence of an emergency physician as a team leader was the strongest predictor of ketamine use (odds ratio [OR] 1.83, 95% confidence interval [CI] 1.44-2.34). The OR for an increase in one point on the Glasgow Coma Scale was 1.10 (95% CI 1.07-1.12), whereas an increase of 1 mmHg of systolic blood pressure had an OR of 0.98 (95% CI 0.98-0.99). Intubation occurring in a major referral hospital had an OR of 0.68 (95% CI 0.56-0.82), while trauma conferred an OR of 1.38 (95% CI 1.25-1.53). CONCLUSIONS Ketamine use increased between 2010 and 2015. Lower systolic blood pressure, the presence of an emergency medicine team leader, trauma and a higher Glasgow Coma Scale were associated with increased odds of ketamine use. Intubation occurring in a major referral centre was associated with lower odds of ketamine use.
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Affiliation(s)
- Ian Ferguson
- Emergency Medicine Research Unit, Liverpool Hospital, Sydney, New South Wales, Australia.,South Western Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia.,GSA-HEMS, Ambulance Service of New South Wales, Sydney, New South Wales, Australia
| | - Hatem Alkhouri
- Emergency Care Institute, Agency for Clinical Innovation, Sydney, New South Wales, Australia
| | - Toby Fogg
- Emergency Department, Royal North Shore Hospital, Sydney, New South Wales, Australia.,CareFlight, Sydney, New South Wales, Australia
| | - Anders Aneman
- South Western Sydney Clinical School, The University of New South Wales, Sydney, New South Wales, Australia.,Intensive Care Unit, Liverpool Hospital, Sydney, New South Wales, Australia
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25
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Expert-Performed Endotracheal Intubation-Related Complications in Trauma Patients: Incidence, Possible Risk Factors, and Outcomes in the Prehospital Setting and Emergency Department. Emerg Med Int 2018; 2018:5649476. [PMID: 29984001 PMCID: PMC6015695 DOI: 10.1155/2018/5649476] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 04/19/2018] [Accepted: 05/16/2018] [Indexed: 11/18/2022] Open
Abstract
The aim of this study was to determine complication rates and possible risk factors of expert-performed endotracheal intubation (ETI) in patients with trauma, in both the prehospital setting and the emergency department. We also investigated how the occurrence of ETI-related complications affected the survival of trauma patients. This single-center retrospective observational study included all injured patients who underwent anesthesiologist-performed ETI from 2007 to 2017. ETI-related complications were defined as hypoxemia, unrecognized esophageal intubation, regurgitation, cardiac arrest, ETI failure rescued by emergency surgical airway, dental trauma, cuff leak, and mainstem bronchus intubation. Of the 537 patients included, 23.5% experienced at least one complication. Multivariable logistic regression analysis revealed that low Glasgow Coma Scale Score (adjusted odds ratio [AOR], 0.93; 95% confidence interval [CI], 0.88-0.98), elevated heart rate (AOR, 1.01; 95% CI, 1.00-1.02), and three or more ETI attempts (AOR, 15.71; 95% CI, 3.37-73.2) were independent predictors of ETI-related complications. We also found that ETI-related complications decreased the likelihood of survival of trauma patients (AOR, 0.60; 95% CI, 0.38-0.95), independently of age, male sex, Injury Severity Score, Glasgow Coma Scale Score, and off-hours presentation. Our results suggest that airway management in trauma patients carries a very high risk; this finding has implications for the practice of airway management in injured patients.
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Sunde GA, Kottmann A, Heltne JK, Sandberg M, Gellerfors M, Krüger A, Lockey D, Sollid SJM. Standardised data reporting from pre-hospital advanced airway management - a nominal group technique update of the Utstein-style airway template. Scand J Trauma Resusc Emerg Med 2018; 26:46. [PMID: 29866144 PMCID: PMC5987657 DOI: 10.1186/s13049-018-0509-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 05/09/2018] [Indexed: 12/31/2022] Open
Abstract
Background Pre-hospital advanced airway management with oxygenation and ventilation may be vital for managing critically ill or injured patients. To improve pre-hospital critical care and develop evidence-based guidelines, research on standardised high-quality data is important. We aimed to identify which airway data were most important to report today and to revise and update a previously reported Utstein-style airway management dataset. Methods We recruited sixteen international experts in pre-hospital airway management from Australia, United States of America, and Europe. We used a five-step modified nominal group technique to revise the dataset, and clinical study results from the original template were used to guide the process. Results The experts agreed on a key dataset of thirty-two operational variables with six additional system variables, organised in time, patient, airway management and system sections. Of the original variables, one remained unchanged, while nineteen were modified in name, category, definition or value. Sixteen new variables were added. The updated dataset covers risk factors for difficult intubation, checklist and standard operating procedure use, pre-oxygenation strategies, the use of drugs in airway management, airway currency training, developments in airway devices, airway management strategies, and patient safety issues not previously described. Conclusions Using a modified nominal group technique with international airway management experts, we have updated the Utstein-style dataset to report standardised data from pre-hospital advanced airway management. The dataset enables future airway management research to produce comparable high-quality data across emergency medical systems. We believe this approach will promote research and improve treatment strategies and outcomes for patients receiving pre-hospital advanced airway management. Trial registration The Regional Committee for Medical and Health Research Ethics in Western Norway exempted this study from ethical review (Reference: REK-Vest/2017/260). Electronic supplementary material The online version of this article (10.1186/s13049-018-0509-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- G A Sunde
- Norwegian Air Ambulance Foundation, Drøbak, Norway. .,Dept. of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway. .,Faculty of Health Sciences, University of Stavanger, Stavanger, Norway.
| | - A Kottmann
- Norwegian Air Ambulance Foundation, Drøbak, Norway.,Faculty of Health Sciences, University of Stavanger, Stavanger, Norway.,Emergency Dept., University Hospital of Lausanne, Lausanne, Switzerland.,Swiss Air Ambulance - Rega, Zürich, Switzerland
| | - J K Heltne
- Dept. of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway.,Dept. of Medical Sciences, University of Bergen, Bergen, Norway
| | - M Sandberg
- Air Ambulance Dept., Oslo University Hospital, Oslo, Norway.,Faculty of Medicine, University of Oslo, Oslo, Norway
| | - M Gellerfors
- Karolinska Institutet, Dept. of Clinical Science and Education, Section of Anaesthesiology and Intensive Care, Stockholm, Sweden.,Swedish Air Ambulance (SLA), Mora, Sweden.,Dept. of Anaesthesiology and Intensive Care, Södersjukhuset, Stockholm, Sweden
| | - A Krüger
- Norwegian Air Ambulance Foundation, Drøbak, Norway.,Dept. of Emergency Medicine and Pre-hospital Services, St. Olavs Hospital, Trondheim, Norway
| | - D Lockey
- Faculty of Health Sciences, University of Stavanger, Stavanger, Norway.,London's Air Ambulance, Bartshealth NHS Trust, London, UK
| | - S J M Sollid
- Norwegian Air Ambulance Foundation, Drøbak, Norway.,Faculty of Health Sciences, University of Stavanger, Stavanger, Norway.,Air Ambulance Dept., Oslo University Hospital, Oslo, Norway
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27
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Burgess MR, Crewdson K, Lockey DJ, Perkins ZB. Prehospital emergency anaesthesia: an updated survey of UK practice with emphasis on the role of standardisation and checklists. Emerg Med J 2018; 35:532-537. [PMID: 29794121 DOI: 10.1136/emermed-2017-206592] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Revised: 03/05/2018] [Accepted: 03/17/2018] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Prehospital emergency anaesthesia (PHEA or 'prehospital rapid sequence intubation') is a high-risk procedure. Standard operating procedures (SOPs) and checklists within healthcare systems have been demonstrated to reduce human error and improve patient safety. We aimed to describe the current practice of PHEA in the UK, determine the use of checklists for PHEA and describe the content, format and layout of any such checklists currently used in the UK. METHOD A survey of UK prehospital teams was conducted to establish the incidence and conduct of PHEA practice. Results were grouped into systems delivering a high volume of PHEA per year (>50 PHEAs) and low volume (≤50 PHEAs per annum). Standard and 'crash' (immediate) induction checklists were reviewed for length, content and layout. RESULTS 59 UK physician-led prehospital services were identified of which 43 (74%) participated. Thirty services (70%) provide PHEA and perform approximately 1629 PHEAs annually. Ten 'high volume' services deliver 84% of PHEAs per year with PHEA being performed on a median of 11% of active missions. The most common indication for PHEA was trauma. 25 of the 30 services (83%) used a PHEA checklist prior to induction of anaesthesia and 24 (80%) had an SOP for the procedure. 19 (76%) of the 'standard' checklists and 5 (50%) of the 'crash' induction checklists used were analysed. On average, standard checklists contained 169 (range: 52-286) words and 41 (range: 28-70) individual checks. The style and language complexity varied significantly between different checklists. CONCLUSION PHEA is now performed commonly in the UK. The use of checklists for PHEA is relatively common among prehospital systems delivering this intervention. Care must be taken to limit checklist length and to use simple, unambiguous language in order to maximise the safety of this high-risk intervention.
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Affiliation(s)
- Mark R Burgess
- Department of Anaesthesia and Critical Care, Royal Cornwall Hospitals, TRURO, UK.,Centre for Trauma Sciences, Queen Mary University of London, London, UK
| | - Kate Crewdson
- Department of Anaesthesia, North Bristol NHS Trust, Bristol, UK.,London's Air Ambulance, London, UK
| | - David J Lockey
- Centre for Trauma Sciences, Queen Mary University of London, London, UK.,London's Air Ambulance, London, UK
| | - Zane B Perkins
- Centre for Trauma Sciences, Queen Mary University of London, London, UK.,London's Air Ambulance, London, UK
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Crewdson K, Rehn M, Brohi K, Lockey DJ. Pre-hospital emergency anaesthesia in awake hypotensive trauma patients: beneficial or detrimental? Acta Anaesthesiol Scand 2018; 62:504-514. [PMID: 29315456 DOI: 10.1111/aas.13059] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2017] [Revised: 11/21/2017] [Accepted: 11/29/2017] [Indexed: 01/13/2023]
Abstract
BACKGROUND The benefits of pre-hospital emergency anaesthesia (PHEA) are controversial. Patients who are hypovolaemic prior to induction of anaesthesia are at risk of severe cardiovascular instability post-induction. This study compared mortality for hypovolaemic trauma patients (without major neurological injury) undergoing PHEA with a patient cohort with similar physiology transported to hospital without PHEA. METHODS A retrospective database review was performed to identify patients who were hypotensive on scene [systolic blood pressure (SBP) < 90 mmHg], and GCS 13-15. Patient records were reviewed independently by two pre-hospital clinicians to identify the likelihood of hypovolaemia. Primary outcome measure was mortality defined as death before hospital discharge. RESULTS Two hundred and thirty-six patients were included; 101 patients underwent PHEA. Fifteen PHEA patients died (14.9%) compared with six non-PHEA patients (4.4%), P = 0.01; unadjusted OR for death was 3.73 (1.30-12.21; P = 0.01). This association remained after adjustment for age, injury mechanism, heart rate and hypovolaemia (adjusted odds ratio 3.07 (1.03-9.14) P = 0.04). Fifty-eight PHEA patients (57.4%) were hypovolaemic prior to induction of anaesthesia, 14 died (24%). Of 43 PHEA patients (42.6%) not meeting hypovolaemia criteria, one died (2%); unadjusted OR for mortality was 13.12 (1.84-578.21). After adjustment for age, injury mechanism and initial heart rate, the odds ratio for mortality remained significant at 9.99 (1.69-58.98); P = 0.01. CONCLUSION Our results suggest an association between PHEA and in-hospital mortality in awake hypotensive trauma patients, which is strengthened when hypotension is due to hypovolaemia. If patients are hypovolaemic and awake on scene it might, where possible, be appropriate to delay induction of anaesthesia until hospital arrival.
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Affiliation(s)
- K. Crewdson
- London's Air Ambulance; Barts Health NHS Trust; London UK
- North Bristol NHS Trust; Bristol UK
| | - M. Rehn
- London's Air Ambulance; Barts Health NHS Trust; London UK
- The Norwegian Air Ambulance foundation; Drøbak Norway
| | - K. Brohi
- London's Air Ambulance; Barts Health NHS Trust; London UK
- Barts and the London School of Medicine & Dentistry; Blizard Institute; London UK
| | - D. J. Lockey
- London's Air Ambulance; Barts Health NHS Trust; London UK
- North Bristol NHS Trust; Bristol UK
- The Norwegian Air Ambulance foundation; Drøbak Norway
- Barts and the London School of Medicine & Dentistry; Blizard Institute; London UK
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Cabrini L, Landoni G, Baiardo Redaelli M, Saleh O, Votta CD, Fominskiy E, Putzu A, Snak de Souza CD, Antonelli M, Bellomo R, Pelosi P, Zangrillo A. Tracheal intubation in critically ill patients: a comprehensive systematic review of randomized trials. Crit Care 2018; 22:6. [PMID: 29351759 PMCID: PMC5775615 DOI: 10.1186/s13054-017-1927-3] [Citation(s) in RCA: 59] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 12/20/2017] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND We performed a systematic review of randomized controlled studies evaluating any drug, technique or device aimed at improving the success rate or safety of tracheal intubation in the critically ill. METHODS We searched PubMed, BioMed Central, Embase and the Cochrane Central Register of Clinical Trials and references of retrieved articles. Finally, pertinent reviews were also scanned to detect further studies until May 2017. The following inclusion criteria were considered: tracheal intubation in adult critically ill patients; randomized controlled trial; study performed in Intensive Care Unit, Emergency Department or ordinary ward; and work published in the last 20 years. Exclusion criteria were pre-hospital or operating theatre settings and simulation-based studies. Two investigators selected studies for the final analysis. Extracted data included first author, publication year, characteristics of patients and clinical settings, intervention details, comparators and relevant outcomes. The risk of bias was assessed with the Cochrane Collaboration's Risk of Bias tool. RESULTS We identified 22 trials on use of a pre-procedure check-list (1 study), pre-oxygenation or apneic oxygenation (6 studies), sedatives (3 studies), neuromuscular blocking agents (1 study), patient positioning (1 study), video laryngoscopy (9 studies), and post-intubation lung recruitment (1 study). Pre-oxygenation with non-invasive ventilation (NIV) and/or high-flow nasal cannula (HFNC) showed a possible beneficial role. Post-intubation recruitment improved oxygenation, while ramped position increased the number of intubation attempts and thiopental had negative hemodynamic effects. No effect was found for use of a checklist, apneic oxygenation (on oxygenation and hemodynamics), videolaryngoscopy (on number and length of intubation attempts), sedatives and neuromuscular blockers (on hemodynamics). Finally, videolaryngoscopy was associated with severe adverse effects in multiple trials. CONCLUSIONS The limited available evidence supports a beneficial role of pre-oxygenation with NIV and HFNC before intubation of critically ill patients. Recruitment maneuvers may increase post-intubation oxygenation. Ramped position increased the number of intubation attempts; thiopental had negative hemodynamic effects and videolaryngoscopy might favor adverse events.
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Affiliation(s)
- Luca Cabrini
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy
- Università Vita-Salute San Raffaele, Via Olgettina 58, 20132 Milan, Italy
| | - Giovanni Landoni
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy
- Università Vita-Salute San Raffaele, Via Olgettina 58, 20132 Milan, Italy
| | - Martina Baiardo Redaelli
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy
| | - Omar Saleh
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy
| | - Carmine D. Votta
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy
| | - Evgeny Fominskiy
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy
- Department of Anesthesia and Intensive Care, Siberian Biomedical Research Center of the Ministry of Health, Novosibirsk, Russia
| | - Alessandro Putzu
- Department of Cardiovascular Anesthesia and Intensive Care, Cardiocentro Ticino, Lugano, Switzerland
| | - Cézar Daniel Snak de Souza
- Department of Surgery. Discipline of Anesthesiology, Critical Care and Pain Medicine, Federal University of São Paulo, São Paulo, Brazil
| | - Massimo Antonelli
- Department of Intensive Care Medicine and Anaesthesiology, Fondazione Policlinico Universitario A. Gemelli, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Heidelberg, Australia
- School of Medicine, The University of Melbourne, Melbourne, Australia
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, San Martino Policlinico Hospital, IRCCS for Oncology, University of Genoa, Largo Rosanna Benzi 8, 16131 Genoa, Italy
| | - Alberto Zangrillo
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132 Milan, Italy
- Università Vita-Salute San Raffaele, Via Olgettina 58, 20132 Milan, Italy
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Davidson LA, Utarnachitt RB, Mason A, Sawyer T. Development and Testing of a Neonatal Intubation Checklist for an Air Medical Transport Team. Air Med J 2018; 37:41-45. [PMID: 29332775 DOI: 10.1016/j.amj.2017.09.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Revised: 08/29/2017] [Accepted: 09/28/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVE We developed a Neonatal Intubation Checklist for Airlift Northwest. Our goal was to improve the preparation, technical proficiency, and safety of neonatal intubation without increasing the time required to perform the procedure. METHODS The Neonatal Intubation Checklist, a "call and response" checklist for neonatal intubation, was developed. Its effectiveness was evaluated during a baseline assessment and 2 practice sessions after a checklist orientation. Intubation proficiency was evaluated using a validated assessment tool that included a proficiency score, a global rating scale (GRS) score, and time to perform the procedure. RESULTS Significant improvements in intubation proficiency and time to intubation were noted when teams used the intubation checklist (proficiency score: 29 [7] at baseline vs. 57 [1] with checklist, P < .001; GRS 2 [2, 2.5] at baseline vs. 5 [3, 5] with checklist, P < .001; baseline intubation time 626 [93] seconds vs. 479 (44) seconds with checklist, P < .001). These changes were associated with a large effect on proficiency (ƞ2 = 0.89), GRS (ƞ2 = 0.6), and time to successful intubation (ƞ2 = 0.52). CONCLUSION The use of the Neonatal Intubation Checklist improved transport team performance during simulated neonatal intubations and decreased the time required to successfully perform the procedure.
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Affiliation(s)
- Lisa A Davidson
- Airlift Northwest, Department of Pediatrics, Division of Neonatology, Seattle, WA.
| | | | - Andrew Mason
- Airlift Northwest, Department of Pediatrics, Division of Neonatology, Seattle, WA
| | - Taylor Sawyer
- Airlift Northwest, Department of Pediatrics, Division of Neonatology, Seattle, WA
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The Effect of Apneic Oxygenation on Reducing Hypoxemia During Rapid Sequence Induction and Intubation in the Acutely Ill or Injured. Adv Emerg Nurs J 2017; 39:309-317. [PMID: 29095183 DOI: 10.1097/tme.0000000000000168] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Apneic oxygenation during intubation is the application of oxygen via a nasal cannula, which is left in place throughout laryngoscopy. The flow rate of oxygen is set to at least 15 L/min and theoretically reduces the risk of oxygen desaturation and hypoxemia during the procedure. Over the last 5 years, there have been several studies published on this topic with differing results. Despite conflicting results, use of apneic oxygenation is becoming more prevalent and is being implemented into standard operating procedures in some clinical settings. Because of the low risk of adding a nasal cannula during intubation and the potential benefit of reducing the incidence of hypoxemia and severe oxygen desaturation, it would be prudent to implement apneic oxygenation when available.
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Secondary Insults and Adverse Events During Intrahospital Transport of Severe Traumatic Brain-Injured Patients. Neurocrit Care 2017; 26:87-95. [PMID: 27601068 DOI: 10.1007/s12028-016-0291-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Our aim was to assess the occurrence of secondary insults (SIs) or adverse events (AEs) during intrahospital transport (IHT) of severe traumatic brain injury (TBI) patients for head computed tomography (CT) scanning. METHODS A prospective study based on severe TBI patients admitted from June 2011 through June 2013 in a level I trauma center. Patients received an IHT to perform a control CT scan in the first 3 days following trauma. The occurrence of SIs and AEs was assessed during the IHT for a control CT scan. The frequency of SIs was compared to the periods "before," "during," and "after" IHT. SI was defined by an intracranial pressure (ICP) >30 mmHg, a cerebral perfusion pressure (CPP) <50 mmHg, systolic blood pressure (SBP) <90 mmHg, or saturation pulse O2 (SpO2) <90 % for more than five consecutive minutes. An AE was defined as failures of hardware or ventilator asynchrony requiring therapeutic intervention during transport. In addition, we assessed the therapeutic benefit of a CT scan control. RESULTS The final analysis included 31 patients and 31 IHTs. The median duration of IHT was 29 min [25;37]. SIs occurred in 16 patients (52 %) during transport, whereas it was observed in 4 patients (13 %) before (p = 0.002) and 4 patients (13 %) after IHT (p = 0.001). Twenty-four AEs occurred during transport of 19 patients (61 %). One patient benefited from hematoma evacuation after implementation of control CT. CONCLUSION IHT carries significant SIs and AEs in severe TBI patients. To improve a risk/benefit ratio favorable for patients, a program focusing on IHT complications regarding therapeutic impact of control CT scan is needed.
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Janz DR, Semler MW, Joffe AM, Casey JD, Lentz RJ, deBoisblanc BP, Khan YA, Santanilla JI, Bentov I, Rice TW. A Multicenter Randomized Trial of a Checklist for Endotracheal Intubation of Critically Ill Adults. Chest 2017; 153:816-824. [PMID: 28917549 DOI: 10.1016/j.chest.2017.08.1163] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Revised: 08/02/2017] [Accepted: 08/16/2017] [Indexed: 10/18/2022] Open
Abstract
BACKGROUND Hypoxemia and hypotension are common complications during endotracheal intubation of critically ill adults. Verbal performance of a written, preintubation checklist may prevent these complications. We compared a written, verbally performed, preintubation checklist with usual care regarding lowest arterial oxygen saturation or lowest systolic BP experienced by critically ill adults undergoing endotracheal intubation. METHODS A multicenter trial in which 262 adults undergoing endotracheal intubation were randomized to a written, verbally performed, preintubation checklist (checklist) or no preintubation checklist (usual care). The coprimary outcomes were lowest arterial oxygen saturation and lowest systolic BP between the time of procedural medication administration and 2 min after endotracheal intubation. RESULTS The median lowest arterial oxygen saturation was 92% (interquartile range [IQR], 79-98) in the checklist group vs 93% (IQR, 84-100) with usual care (P = .34). The median lowest systolic BP was 112 mm Hg (IQR, 94-133) in the checklist group vs 108 mm Hg (IQR, 90-132) in the usual care group (P = .61). There was no difference between the checklist and usual care in procedure duration (120 vs 118 s; P = .49), number of laryngoscopy attempts (one vs one attempt; P = .42), or severe life-threatening procedural complications (40.8% vs 32.6%; P = .20). CONCLUSIONS The verbal performance of a written, preprocedure checklist does not increase the lowest arterial oxygen saturation or lowest systolic BP during endotracheal intubation of critically ill adults compared with usual care. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT02497729; URL: www.clinicaltrials.gov.
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Affiliation(s)
- David R Janz
- Department of Medicine, Section of Pulmonary/Critical Care Medicine and Allergy/Immunology, Louisiana State University School of Medicine New Orleans, New Orleans, LA.
| | - Matthew W Semler
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN
| | - Aaron M Joffe
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, WA
| | - Jonathan D Casey
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN
| | - Robert J Lentz
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN
| | - Bennett P deBoisblanc
- Department of Medicine, Section of Pulmonary/Critical Care Medicine and Allergy/Immunology, Louisiana State University School of Medicine New Orleans, New Orleans, LA
| | - Yasin A Khan
- Department of Medicine, Section of Pulmonary/Critical Care Medicine and Allergy/Immunology, Louisiana State University School of Medicine New Orleans, New Orleans, LA
| | - Jairo I Santanilla
- Department of Medicine, Section of Pulmonary/Critical Care Medicine and Allergy/Immunology, Louisiana State University School of Medicine New Orleans, New Orleans, LA; Department of Medicine, Section of Emergency Medicine, Louisiana State University School of Medicine New Orleans, New Orleans, LA; Department of Pulmonary and Critical Care Medicine, Ochsner Health System New Orleans, New Orleans, LA
| | - Itay Bentov
- Department of Anesthesiology and Pain Medicine, University of Washington School of Medicine, Seattle, WA
| | - Todd W Rice
- Department of Medicine, Division of Allergy, Pulmonary and Critical Care Medicine, Vanderbilt University School of Medicine, Nashville, TN
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Johnston D, Franklin K, Rigby P, Bergman K, Davidson SB. Sedation and Analgesia in Transportation of Acutely and Critically Ill Patients. Crit Care Nurs Clin North Am 2017; 28:137-54. [PMID: 27215353 DOI: 10.1016/j.cnc.2016.02.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Transportation of acutely or critically ill patients is a challenge for health care providers. Among the difficulties that providers face is the balance between adequate sedation and analgesia for the transportation event and maintaining acceptable respiratory and physiologic parameters of the patient. This article describes common challenges in providing sedation and analgesia during various phases of transport.
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Affiliation(s)
- Dawn Johnston
- West Michigan Air Care, PO Box 50406, Kalamazoo, MI 49005, USA.
| | - Kevin Franklin
- West Michigan Air Care, PO Box 50406, Kalamazoo, MI 49005, USA
| | - Paul Rigby
- West Michigan Air Care, PO Box 50406, Kalamazoo, MI 49005, USA
| | - Karen Bergman
- Bronson Hospital, Western Michigan University, 601 John Street, Box 88, Kalamazoo, MI 49007, USA
| | - Scott B Davidson
- Trauma Surgery Services, Bronson Hospital, 601 John Street, Kalamazoo, MI 49007, USA
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Smischney NJ, Seisa MO, Heise KJ, Busack KD, Loftsgard TO, Schroeder DR, Diedrich DA. Practice of Intubation of the Critically Ill at Mayo Clinic. J Intensive Care Med 2017; 34:885066617691495. [PMID: 28173733 DOI: 10.1177/0885066617691495] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To describe the practice of intubation of the critically ill at a single academic institution, Mayo Clinic's campus in Rochester, Minnesota, and to report the incidence of immediate postintubation complications. PATIENTS AND METHODS Critically ill adult (≥18 years) patients admitted to a medical-surgical intensive care unit from January 1, 2013, to December 31, 2014, who required endotracheal intubation included. RESULTS The final cohort included 420 patients. The mean age at intubation was 62.9 ± 16.3 years, with 58% (244) of the cohort as male. The most common reason for intubation was respiratory failure (282 [67%]). The most common airway device used was video laryngoscopy (204 [49%]). Paralysis was used in 264 (63%) patients, with ketamine as the most common sedative (194 [46%]). The most common complication was hypotension (170 [41%]; 95% confidence interval [CI]: 35.7-45.3) followed by hypoxemia (74 [17.6%]; 95% CI: 14.1-21.6), with difficult intubation occurring in 20 (5%; 95% CI: 2.9-7.3). CONCLUSION We found a high success rate of first-pass intubation in critically ill patients (89.8%), despite the procedure being done primarily by trainees 92.6% of the time; video was the preferred method of laryngoscopy (48.6%). Although our difficult intubation (4.8%) and complication rates typically associated with the act of intubation such as aspiration (1.2%; 95% CI: 0.4-2.8) and esophageal intubation (0.2%; 95% CI: 0.01-1.3) are very low compared to other published rates (8.09%), postintubation hypotension (40.5%) and hypoxemia (17.6%) higher.
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Affiliation(s)
- Nathan J Smischney
- 1 Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA
- 2 Hemodynamic and Airway Management Group (HEMAIR), Mayo Clinic, Rochester, MN, USA
| | - Mohamed O Seisa
- 1 Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA
- 2 Hemodynamic and Airway Management Group (HEMAIR), Mayo Clinic, Rochester, MN, USA
| | | | - Kyle D Busack
- 1 Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA
| | | | | | - Daniel A Diedrich
- 1 Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA
- 2 Hemodynamic and Airway Management Group (HEMAIR), Mayo Clinic, Rochester, MN, USA
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First-Pass Intubation Success. Notf Rett Med 2016. [DOI: 10.1007/s10049-016-0168-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Chen C, Kan T, Li S, Qiu C, Gui L. Use and implementation of standard operating procedures and checklists in prehospital emergency medicine: a literature review. Am J Emerg Med 2016; 34:2432-2439. [PMID: 27742522 DOI: 10.1016/j.ajem.2016.09.057] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Revised: 09/20/2016] [Accepted: 09/22/2016] [Indexed: 10/20/2022] Open
Abstract
OBJECTIVES This review aimed to analyze published literature to introduce the use and implementation of standard operating procedures (SOPs) and checklists in prehospital emergency medicine and their impact on guideline adherence and patient outcome. METHODS An English literature search was carried out using the Cochrane Library, MEDLINE, EMBASE, Springer, Elsevier, and ProQuest databases. Original articles describing the use and implementation of SOPs or checklists in prehospital emergency medicine were included. Editorials, comments, letters, bulletins, news articles, conference abstracts, and notes were excluded from the analysis. Relevant information was extracted relating to application areas, development of SOPs/checklists, educational preparation and training regarding SOPs/checklists implementation, staff attitudes and the effects of SOPs/checklists use on guideline adherence and patient outcomes. RESULTS The literature search found 2187 potentially relevant articles, which were narrowed down following an abstract review and a full text review. A final total of 13 studies were identified that described the use and implementation of SOPs (9 studies) and checklists (4 studies) in different areas of prehospital emergency medicine including prehospital management of patients with acute exacerbated chronic obstructive pulmonary disease and acute coronary syndrome, prehospital airway management, medical documentation, Emergency Medical Services triage, and transportation of patients. CONCLUSIONS The use and implementation of SOPs and checklists in prehospital emergency medicine have shown some benefits of improving guidelines adherence and patient outcomes in airway management, patient records, identification and triage, and other prehospital interventions. More research in this area is necessary to optimize the future use and implementation of SOPs and checklists to improve emergency personnel performance and patient outcomes.
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Affiliation(s)
- Chulin Chen
- Department of Emergency Nursing, School of Nursing, Second Military Medical University, Shanghai, China.
| | - Ting Kan
- Department of Emergency Nursing, School of Nursing, Second Military Medical University, Shanghai, China.
| | - Shuang Li
- Department of Emergency Nursing, School of Nursing, Second Military Medical University, Shanghai, China.
| | - Chen Qiu
- Department of Emergency Nursing, School of Nursing, Second Military Medical University, Shanghai, China.
| | - Li Gui
- Department of Emergency Nursing, School of Nursing, Second Military Medical University, Shanghai, China.
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Ono Y, Sugiyama T, Chida Y, Sato T, Kikuchi H, Suzuki D, Ikeda M, Tanigawa K, Shinohara K. Association between off-hour presentation and endotracheal-intubation-related adverse events in trauma patients with a predicted difficult airway: A historical cohort study at a community emergency department in Japan. Scand J Trauma Resusc Emerg Med 2016; 24:106. [PMID: 27576447 PMCID: PMC5006537 DOI: 10.1186/s13049-016-0296-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Accepted: 08/22/2016] [Indexed: 11/30/2022] Open
Abstract
Background A reduction in medical staff such as occurs in hospitals during nights and weekends (off hours) is associated with a worse outcome in patients with several unanticipated critical conditions. Although difficult airway management (DAM) requires the simultaneous assistance of several appropriately trained medical caregivers, data are scarce regarding the association between off-hour presentation and endotracheal intubation (ETI)-related adverse events, especially in the trauma population. The aim of this study was to determine whether off-hour presentation was associated with ETI complications in injured patients with a predicted difficult airway. Methods This historical cohort study was conducted at a Japanese community emergency department (ED). All patients with inhalation burn, comminuted facial trauma (Abbreviated Injury Scale Score Face ≥3), and penetrating neck injury who underwent ETI from January 2007 to January 2016 in our ED were included. Primary exposure was off-hour presentation, defined as the period from 6:01 PM to 8:00 AM weekdays plus the entire weekend. The primary outcome measure was the occurrence of an ETI-related adverse event, including hypoxemia, unrecognized esophageal intubation, regurgitation, cardiac arrest, ETI failure rescued by emergency surgical airway, cuff leak, and mainstem bronchus intubation. Results Of the 123 patients, 75 (61.0 %) were intubated during off hours. Crude analysis showed that off-hour presentation was significantly associated with an increased risk of ETI-related adverse events [odds ratio (OR), 2.5; 95 % confidence interval (CI), 1.1–5.6; p = 0.033]. The increased risk remained significant after adjusting for potential confounders, including operator being an anesthesiologist, use of a paralytic agent, and injury severity score (OR, 3.0; 95 % CI, 1.1–8.4; p = 0.034). Conclusions In this study, off-hour presentation was independently associated with ETI-related adverse events in trauma patients with a predicted difficult airway. These data imply the need for more attentive hospital care during nights and weekends. Electronic supplementary material The online version of this article (doi:10.1186/s13049-016-0296-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Yuko Ono
- Department of Anesthesiology, Ohta General Hospital Foundation, Ohta Nishinouchi Hospital, 2-5-20 Nishinouchi, Koriyama, Fukushima, 963-8558, Japan. .,Emergency and Critical Care Medical Center, Fukushima Medical University Hospital, 1 Hikarigaoka, Fukushima, 960-1295, Japan.
| | - Takuya Sugiyama
- Department of Anesthesiology, Ohta General Hospital Foundation, Ohta Nishinouchi Hospital, 2-5-20 Nishinouchi, Koriyama, Fukushima, 963-8558, Japan
| | - Yasuyuki Chida
- Department of Anesthesiology, Ohta General Hospital Foundation, Ohta Nishinouchi Hospital, 2-5-20 Nishinouchi, Koriyama, Fukushima, 963-8558, Japan
| | - Tetsuya Sato
- Department of Anesthesiology, Ohta General Hospital Foundation, Ohta Nishinouchi Hospital, 2-5-20 Nishinouchi, Koriyama, Fukushima, 963-8558, Japan
| | - Hiroaki Kikuchi
- Department of Anesthesiology, Ohta General Hospital Foundation, Ohta Nishinouchi Hospital, 2-5-20 Nishinouchi, Koriyama, Fukushima, 963-8558, Japan
| | - Daiji Suzuki
- Department of Head and Neck Surgery, Ohta General Hospital Foundation, Ohta Nishinouchi Hospital, 2-5-20 Nishinouchi, Koriyama, Fukushima, 963-8558, Japan
| | - Masakazu Ikeda
- Department of Otolaryngology, Fukushima Medical University, 1 Hikarigaoka, Fukushima, 960-1295, Japan
| | - Koichi Tanigawa
- Fukushima Medical University, 1 Hikarigaoka, Fukushima, 960-1295, Japan.,Fukushima Global Medical Science Center, 1 Hikarigaoka, Fukushima, 960-1295, Japan
| | - Kazuaki Shinohara
- Department of Anesthesiology, Ohta General Hospital Foundation, Ohta Nishinouchi Hospital, 2-5-20 Nishinouchi, Koriyama, Fukushima, 963-8558, Japan
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Long E, Fitzpatrick P, Cincotta DR, Grindlay J, Barrett MJ. A randomised controlled trial of cognitive aids for emergency airway equipment preparation in a Paediatric Emergency Department. Scand J Trauma Resusc Emerg Med 2016; 24:8. [PMID: 26817789 PMCID: PMC4730650 DOI: 10.1186/s13049-016-0201-z] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Accepted: 01/18/2016] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Safety of emergency intubation may be improved by standardising equipment preparation; the efficacy of cognitive aids is unknown. METHODS This randomised controlled trial compared no cognitive aid (control) with the use of a checklist or picture template for emergency airway equipment preparation in the Emergency Department of The Royal Children's Hospital, Melbourne. RESULTS Sixty-three participants were recruited, 21 randomised to each group. Equal numbers of nursing, junior medical, and senior medical staff were included in each group. Compared to controls, the checklist or template group had significantly lower equipment omission rates (median 30% IQR 20-40% control, median 10% IQR 5-10 % checklist, median 10% IQR 5-20% template; p < 0.05). The combined omission rate and sizing error rate was lower using a checklist or template (median 35 % IQR 30-45 % control, median 15% IQR 10-20% checklist, median 15% IQR 10-30% template; p < 0.05). The template group had less variation in equipment location compared to checklist or controls. There was no significant difference in preparation time in controls (mean 3 min 14 s sd 56 s) compared to checklist (mean 3 min 46 s sd 1 min 15 s) or template (mean 3 min 6 s sd 49 s; p = 0.06). DISCUSSION Template use reduces variation in airway equipment location during preparation foremergency intubation, with an equivalent reduction in equipment omission rate to the use of a checklist. The use of a template for equipment preparation and a checklist for team, patient, and monitoring preparation may provide the best combination of both cognitive aids. CONCLUSIONS The use of a cognitive aid for emergency airway equipment preparation reduces errors of omission. Template utilisation reduces variation in equipment location. TRIAL REGISTRATION Australian and New Zealand Trials Registry (ACTRN12615000541505).
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Affiliation(s)
- Elliot Long
- Department of Emergency Medicine, The Royal Children's Hospital, 50 Flemington Road, Parkville, VIC, 3052, Australia.
- Murdoch Children's Research Institute, 50 Flemington Road, Parkville, Australia.
- Department of Paediatrics, Faculty of Medicine, Dentistry, and Health Sciences, University of Melbourne, Parkville, VIC, Australia.
| | - Patrick Fitzpatrick
- Department of Emergency Medicine, The Royal Children's Hospital, 50 Flemington Road, Parkville, VIC, 3052, Australia.
- Murdoch Children's Research Institute, 50 Flemington Road, Parkville, Australia.
| | - Domenic R Cincotta
- Department of Emergency Medicine, The Royal Children's Hospital, 50 Flemington Road, Parkville, VIC, 3052, Australia.
- Murdoch Children's Research Institute, 50 Flemington Road, Parkville, Australia.
- Department of Paediatrics, Faculty of Medicine, Dentistry, and Health Sciences, University of Melbourne, Parkville, VIC, Australia.
| | - Joanne Grindlay
- Department of Emergency Medicine, The Royal Children's Hospital, 50 Flemington Road, Parkville, VIC, 3052, Australia.
- Murdoch Children's Research Institute, 50 Flemington Road, Parkville, Australia.
- Department of Paediatrics, Faculty of Medicine, Dentistry, and Health Sciences, University of Melbourne, Parkville, VIC, Australia.
| | - Michael Joseph Barrett
- Department of Emergency Medicine, The Royal Children's Hospital, 50 Flemington Road, Parkville, VIC, 3052, Australia.
- Murdoch Children's Research Institute, 50 Flemington Road, Parkville, Australia.
- Paediatric Emergency Research Unit, National Children's Research Centre, Crumlin, Dublin, Ireland.
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Grant S, Khan F, Keijzers G, Shirran M, Marneros L. Ventilator-assisted preoxygenation: Protocol for combining non-invasive ventilation and apnoeic oxygenation using a portable ventilator. Emerg Med Australas 2016; 28:67-72. [DOI: 10.1111/1742-6723.12524] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2015] [Revised: 09/25/2015] [Accepted: 10/28/2015] [Indexed: 11/27/2022]
Affiliation(s)
- Steven Grant
- Gold Coast University and Robina Hospital Emergency Departments; Gold Coast Queensland Australia
| | - Faisal Khan
- Gold Coast University and Robina Hospital Emergency Departments; Gold Coast Queensland Australia
- Griffith University; Gold Coast Queensland Australia
| | - Gerben Keijzers
- Gold Coast University and Robina Hospital Emergency Departments; Gold Coast Queensland Australia
- Griffith University; Gold Coast Queensland Australia
- Bond University; Gold Coast Queensland Australia
| | - Mark Shirran
- Gold Coast University and Robina Hospital Emergency Departments; Gold Coast Queensland Australia
- Griffith University; Gold Coast Queensland Australia
| | - Leo Marneros
- Gold Coast University and Robina Hospital Emergency Departments; Gold Coast Queensland Australia
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Fogg T, Alkhouri H, Vassiliadis J. The Royal North Shore Hospital Emergency Department airway registry: Closing the audit loop. Emerg Med Australas 2015; 28:27-33. [DOI: 10.1111/1742-6723.12496] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/13/2015] [Indexed: 12/01/2022]
Affiliation(s)
- Toby Fogg
- Emergency Department; Royal North Shore Hospital; Sydney New South Wales, Australia
- CareFlight; Sydney New South Wales, Australia
- Discipline of Emergency Medicine; Sydney University Medical School; Sydney New South Wales, Australia
| | - Hatem Alkhouri
- Emergency Care Institute; Agency for Clinical Innovation; Sydney New South Wales, Australia
| | - John Vassiliadis
- Emergency Department; Royal North Shore Hospital; Sydney New South Wales, Australia
- Discipline of Emergency Medicine; Sydney University Medical School; Sydney New South Wales, Australia
- Sydney Clinical Skills and Simulation Centre; Royal North Shore Hospital; Sydney New South Wales, Australia
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