1
|
Butterfield ED, Price J, Bonsano M, Lachowycz K, Starr Z, Edmunds C, Barratt J, Major R, Rees P, Barnard EBG. Prehospital invasive arterial blood pressure monitoring in critically ill patients attended by a UK helicopter emergency medical service- a retrospective observational review of practice. Scand J Trauma Resusc Emerg Med 2024; 32:20. [PMID: 38475832 DOI: 10.1186/s13049-024-01193-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2023] [Accepted: 03/04/2024] [Indexed: 03/14/2024] Open
Abstract
BACKGROUND Accurate haemodynamic monitoring in the prehospital setting is essential. Non-invasive blood pressure measurement is susceptible to vibration and motion artefact, especially at extremes of hypotension and hypertension: invasive arterial blood pressure (IABP) monitoring is a potential solution. This study describes the largest series to date of cases of IABP monitoring being initiated prehospital. METHODS This retrospective observational study was conducted at East Anglian Air Ambulance (EAAA), a UK helicopter emergency medical service (HEMS). It included all patients attended by EAAA who underwent arterial catheterisation and initiation of IABP monitoring between 1st February 2015 and 20th April 2023. The following data were retrieved for all patients: sex; age; aetiology (medical cardiac arrest, other medical emergency, trauma); site of arterial cannulation; operator role (doctor/paramedic); time of insertion and, where applicable, times of pre-hospital emergency anaesthesia, and return of spontaneous circulation following cardiac arrest. Descriptive analyses were performed to characterise the sample. RESULTS 13,556 patients were attended: IABP monitoring was initiated in 1083 (8.0%) cases, with a median age 59 years, of which 70.8% were male. 546 cases were of medical cardiac arrest: in 22.4% of these IABP monitoring was initiated during cardiopulmonary resuscitation. 322 were trauma cases, and the remaining 215 were medical emergencies. The patients were critically unwell: 981 required intubation, of which 789 underwent prehospital emergency anaesthesia; 609 received vasoactive medication. In 424 cases IABP monitoring was instituted en route to hospital. CONCLUSION This study describes over 1000 cases of prehospital arterial catheterisation and IABP monitoring in a UK HEMS system and has demonstrated feasibility at scale. The high-fidelity of invasive arterial blood pressure monitoring with the additional benefit of arterial blood gas analysis presents an attractive translation of in-hospital critical care to the prehospital setting.
Collapse
Affiliation(s)
- Emma D Butterfield
- Department of Research, Audit, Innovation, and Development (RAID), East Anglian Air Ambulance, Norwich, UK.
| | - James Price
- Department of Research, Audit, Innovation, and Development (RAID), East Anglian Air Ambulance, Norwich, UK
- Emergency Department, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Marco Bonsano
- Department of Research, Audit, Innovation, and Development (RAID), East Anglian Air Ambulance, Norwich, UK
| | - Kate Lachowycz
- Department of Research, Audit, Innovation, and Development (RAID), East Anglian Air Ambulance, Norwich, UK
| | - Zachary Starr
- Department of Research, Audit, Innovation, and Development (RAID), East Anglian Air Ambulance, Norwich, UK
| | - Christopher Edmunds
- Department of Research, Audit, Innovation, and Development (RAID), East Anglian Air Ambulance, Norwich, UK
- Emergency and Critical Care Departments, Peterborough City Hospital, North West Anglia Foundation Trust, Peterborough, UK
- University of East Anglia, Norwich, UK
| | - Jon Barratt
- Department of Research, Audit, Innovation, and Development (RAID), East Anglian Air Ambulance, Norwich, UK
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research & Clinical Innovation), Birmingham, UK
- Emergency Department, University Hospitals of North Midlands NHS Trust, Stoke-on-Trent, UK
| | - Rob Major
- Department of Research, Audit, Innovation, and Development (RAID), East Anglian Air Ambulance, Norwich, UK
| | - Paul Rees
- Department of Research, Audit, Innovation, and Development (RAID), East Anglian Air Ambulance, Norwich, UK
- Barts Heart Centre, London, UK
- The Blizard Institute, Queen Mary University of London, London, UK
- Academic Department of Military Medicine, Royal Centre for Defence Medicine (Research & Clinical Innovation), Birmingham, UK
| | - Ed B G Barnard
- Department of Research, Audit, Innovation, and Development (RAID), East Anglian Air Ambulance, Norwich, UK
- Emergency Department, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- EuReCa, PACE Section, Department of Medicine, Cambridge University, Cambridge, UK
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research & Clinical Innovation), Birmingham, UK
| |
Collapse
|
2
|
Morton S, Spurgeon Z, Ashworth C, Samouelle J, Sherren PB. Cardiorespiratory consequences of attenuated fentanyl and augmented rocuronium dosing during protocolised prehospital emergency anaesthesia at a regional air ambulance service: a retrospective study. Scand J Trauma Resusc Emerg Med 2024; 32:12. [PMID: 38347604 PMCID: PMC10863113 DOI: 10.1186/s13049-024-01183-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 01/23/2024] [Indexed: 02/15/2024] Open
Abstract
BACKGROUND Pre-Hospital Emergency Anaesthesia (PHEA) has undergone significant developments since its inception. However, optimal drug dosing remains a challenge for both medical and trauma patients. Many prehospital teams have adopted a drug regimen of 3 mcg/kg fentanyl, 2 mg/kg ketamine and 1 mg/kg rocuronium ('3:2:1'). At Essex and Herts Air Ambulance Trust (EHAAT) a new standard dosing regimen was introduced in August 2021: 1 mcg/kg fentanyl, 2 mg/kg ketamine and 2 mg/kg rocuronium (up to a maximum dose of 150 mg) ('1:2:2'). The aim of this study was to evaluate the cardiorespiratory consequences of a new attenuated fentanyl and augmented rocuronium dosing regimen. METHODS A retrospective study was conducted at EHAAT as a service evaluation. Anonymized records were reviewed from an electronic database to compare the original ('3:2:1') drug dosing regimen (December 2019-July 2021) and the new ('1:2:2') dosing regimen (September 2021-May 2023). The primary outcome was the incidence of absolute hypotension within ten minutes of induction. Secondary outcomes included immediate hypertension, immediate hypoxia and first pass success (FPS) rates. RESULTS Following exclusions (n = 121), 720 PHEA cases were analysed (360 new vs. 360 original, no statistically significant difference in demographics). There was no difference in the rate of absolute hypotension (24.4% '1:2:2' v 23.8% '3:2:1', p = 0.93). In trauma patients, there was an increased first pass success (FPS) rate with the new regimen (95.1% v 86.5%, p = 0.01) and a reduced incidence of immediate hypoxia (7.9% v 14.8%, p = 0.05). There was no increase in immediate hypertensive episodes (22.7% vs. 24.2%, p = 0.73). No safety concerns were identified. CONCLUSION An attenuated fentanyl and augmented rocuronium dosing regimen showed no difference in absolute hypotensive episodes in a mixed cohort of medical and trauma patients. In trauma patients, the new regimen was associated with an increased FPS rate and reduced episodes of immediate hypoxia. Further research is required to understand the impact of such drug dosing in the most critically ill and injured subpopulation.
Collapse
Affiliation(s)
- Sarah Morton
- Essex & Herts Air Ambulance Trust, Essex, UK.
- Imperial College London, London, UK.
| | | | | | | | - Peter B Sherren
- Essex & Herts Air Ambulance Trust, Essex, UK
- Guy's and St Thomas' NHS Foundation Trust, London, UK
| |
Collapse
|