Neuromuscular blockade improves first-attempt success for intubation in the intensive care unit. A propensity matched analysis

Society of Critical Care Medicine Clinical Practice Guidelines for Rapid Sequence Intubation in the Critically Ill Adult Patient

RATIONALE

Controversies and practice variations exist related to the pharmacologic and nonpharmacologic management of the airway during rapid sequence intubation (RSI).

OBJECTIVES

To develop evidence-based recommendations on pharmacologic and nonpharmacologic topics related to RSI.

DESIGN

A guideline panel of 20 Society of Critical Care Medicine members with experience with RSI and emergency airway management met virtually at least monthly from the panel's inception in 2018 through 2020 and face-to-face at the 2020 Critical Care Congress. The guideline panel included pharmacists, physicians, a nurse practitioner, and a respiratory therapist with experience in emergency medicine, critical care medicine, anesthesiology, and prehospital medicine; consultation with a methodologist and librarian was available. A formal conflict of interest policy was followed and enforced throughout the guidelines-development process.

METHODS

Panelists created Population, Intervention, Comparison, and Outcome (PICO) questions and voted to select the most clinically relevant questions for inclusion in the guideline. Each question was assigned to a pair of panelists, who refined the PICO wording and reviewed the best available evidence using predetermined search terms. The Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) framework was used throughout and recommendations of "strong" or "conditional" were made for each PICO question based on quality of evidence and panel consensus. Recommendations were provided when evidence was actionable; suggestions, when evidence was equivocal; and best practice statements, when the benefits of the intervention outweighed the risks, but direct evidence to support the intervention did not exist.

RESULTS

From the original 35 proposed PICO questions, 10 were selected. The RSI guideline panel issued one recommendation (strong, low-quality evidence), seven suggestions (all conditional recommendations with moderate-, low-, or very low-quality evidence), and two best practice statements. The panel made two suggestions for a single PICO question and did not make any suggestions for one PICO question due to lack of evidence.

CONCLUSIONS

Using GRADE principles, the interdisciplinary panel found substantial agreement with respect to the evidence supporting recommendations for RSI. The panel also identified literature gaps that might be addressed by future research.

Approach to the Physiologically Challenging Endotracheal Intubation in the Intensive Care Unit

Endotracheal intubation for airway management is a common procedure in the ICU. Intubation may be difficult due to anatomic airway abnormalities but also due to physiologic derangements that predispose patients to cardiovascular collapse during the procedure. Results of studies demonstrate a high incidence of morbidity and mortality associated with airway management in the ICU. To reduce the likelihood of complications, medical teams must be well versed in the general principles of intubation and be prepared to manage physiologic derangements while securing the airway. In this review, we present relevant literature on the approach to endotracheal intubation in the ICU and provide pragmatic recommendations relevant to medical teams performing intubations in patients who are physiologically unstable.

Obesity is Unlikely to be an Impediment to First-Pass Success During the Intubation of Critically Ill Patients

Background: Obesity has been described as a potential risk factor for difficult intubation among critically ill patients. Our primary aim was to further elucidate the association between obesity and first-pass success. Our secondary aim was to determine whether the use of hyper-angulated video laryngoscopy improves first-pass success compared to direct laryngoscopy when utilized for the intubation of critically ill obese patients. Study Design and Methods: A retrospective cohort study of adult patients undergoing endotracheal intubation outside of the operating room or emergency department between January 30, 2016 and May 1, 2020 at 3 campuses of an academic hospital system in the Bronx, NY. Our primary outcome was first-pass success of intubation. A multivariate logistic analysis was utilized to compare obesity status with first-pass success. Results: We identified 3791 critically ill patients who underwent endotracheal intubation of which 1417 were obese (body mass index [BMI] ≥ 30). The incidence of hyper-angulated video laryngoscopy increased over the study period. A total of 46.6% of obese patients underwent intubation with hyper-angulated video laryngoscopy as compared to 35.1% of the nonobese group. First-pass success was 79.2% among the entire cohort. Obesity status did not appear to be associated with first-pass success (adjusted odds ratio [OR] 1.07, 95% confidence interval [CI]: 090-1.27; P = .47). Hyper-angulated video laryngoscopy did not seem to improve first-pass success among obese patients as compared to nonobese patients (adjusted OR 1.21, 95% CI: 0.85-1.71; P = .29). These findings persisted even after redefining the obesity cutoff as BMI ≥ 40 and excluding patients intubated during cardiac arrests. Conclusion: We did not detect an association between obesity and first-pass success. Hyper-angulated video laryngoscopy did not appear offer additional benefit over direct laryngoscopy during the intubation of critically ill obese patients.

Feasibility of a Multi-Center Respiratory Therapist Endotracheal Intubation Study

BACKGROUND

Respiratory therapists (RTs) have historically performed safe and effective intubations, yet there are limited multi-center data assessing their intubation performance. Multi-center data can be used to compare RT intubation performance to that of other professions and identify quality improvement opportunities at hospitals where RTs perform intubation. We aimed to explore the feasibility of a multi-center collaborative to evaluate RT intubation outcomes.

METHODS

A data collection tool was developed by the authors and implemented at two institutions. Following institutional review board approval at each center and completion of data-use sharing agreements, data were collected between May 25, 2020-April 30, 2022, and combined for analysis. Descriptive statistics were used to compare overall success rate, first-attempt success rate, adverse events (AEs), and type of laryngoscopy.

RESULTS

There were a total of 689 intubation courses where RTs made an attempt, 363 from center A and 326 from center B. Center A captured 85% of all RT intubation courses, and center B captured 63%. Overall, RTs were successful in 98% of attempts. RTs made 86% of initial attempts. The most common indications for intubation were cardiac arrest (42%) and respiratory failure (31%). Videolaryngoscopy was used during 65% of initial attempts and was associated with higher first-attempt success rate, higher overall success rate, and fewer AEs. Airway-related adverse event rate was 8.7%; physiologic AE rate was 16%, and desaturation rate was 11%.

CONCLUSIONS

A collaborative examining RTs intubation performance was successfully initiated at 2 separate facilities. Intubations performed by RTs had a high success rate, with AE rates comparable to published results from other types of providers.

Comparison of video laryngoscopy with direct laryngoscopy for intubation success in critically ill patients: a systematic review and Bayesian network meta-analysis

Introduction

This review compares the efficacy of video laryngoscopy (VL) with direct laryngoscopy (DL) for successful tracheal intubation in critically ill or emergency-care patients.

Methods

We searched the MEDLINE, Embase, and Cochrane Library databases for randomized controlled trials (RCTs) that compared one or more video laryngoscopes to DL. Sensitivity analysis, subgroup analysis, and network meta-analysis were used to investigate factors potentially influencing the efficacy of VL. The primary outcome was the success rate of first-attempt intubation.

Results

This meta-analysis included 4244 patients from 22 RCTs. After sensitivity analysis, the pooled analysis revealed no significant difference in the success rate between VL and DL (VL vs. DL, 77.3% vs. 75.3%, respectively; OR, 1.36; 95% CI, 0.84-2.20; I² = 80%; low-quality evidence). However, based on a moderate certainty of evidence, VL outperformed DL in the subgroup analyses of intubation associated with difficult airways, inexperienced practitioners, or in-hospital settings. In the network meta-analysis comparing VL blade types, nonchanneled angular VL provided the best outcomes. The nonchanneled Macintosh video laryngoscope ranked second, and DL ranked third. Channeled VL was associated with the worst treatment outcomes.

Discussion

This pooled analysis found, with a low certainty of evidence, that VL does not improve intubation success relative to DL. Channeled VL had low efficacy in terms of intubation success compared with nonchanneled VL and DL.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=285702, identifier: CRD42021285702.

The effect of a multi-faceted quality improvement program on paramedic intubation success in the critical care transport environment: a before-and-after study

INTRODUCTION

Endotracheal intubation (ETI) is an infrequent but key component of prehospital and retrieval medicine. Common measures of quality of ETI are the first pass success rates (FPS) and ETI on the first attempt without occurrence of hypoxia or hypotension (DASH-1A). We present the results of a multi-faceted quality improvement program (QIP) on paramedic FPS and DASH-1A rates in a large regional critical care transport organization.

METHODS

We conducted a retrospective database analysis, comparing FPS and DASH-1A rates before and after implementation of the QIP. We included all patients undergoing advanced airway management with a first strategy of ETI during the time period from January 2016 to December 2021.

RESULTS

484 patients met the inclusion criteria during the study period. Overall, the first pass intubation success (FPS) rate was 72% (350/484). There was an increase in FPS from the pre-intervention period (60%, 86/144) to the post-intervention period (86%, 148/173), p < 0.001. DASH-1A success rates improved from 45% (55/122) during the pre-intervention period to 55% (84/153) but this difference did not meet pre-defined statistical significance (p = 0.1). On univariate analysis, factors associated with improved FPS rates were the use of video-laryngoscope (VL), neuromuscular blockage, and intubation inside a healthcare facility.

CONCLUSIONS

A multi-faceted advanced airway management QIP resulted in increased FPS intubation rates and a non-significant improvement in DASH-1A rates. A combination of modern equipment, targeted training, standardization and ongoing clinical governance is required to achieve and maintain safe intubation by paramedics in the prehospital and retrieval environment.

Resuscitation of the Obstetric Patient

Pregnancy is a time of tremendous physiologic change and vulnerability. At any point, symptoms and complications can prompt the need for emergency care, and these can range from minor to life-threatening. Emergency physicians must be prepared to treat any of these complications, in addition to rescucitating the critically ill and injured pregnant patient. To optimally care for these patients, it is paramount to be aware of the unique physiologic changes that occur during pregnancy. The focus of this review is to discuss illnesses unique to pregnancy and additional aspects of resuscitation that must be considered when caring for a critically ill pregnant patient.

Peri-intubation Cardiovascular Collapse in Patients Who Are Critically Ill: Insights from the INTUBE Study

Rationale: Cardiovascular instability/collapse is a common peri-intubation event in patients who are critically ill. Objectives: To identify potentially modifiable variables associated with peri-intubation cardiovascular instability/collapse (i.e., systolic arterial pressure <65 mm Hg [once] or <90 mm Hg for >30 minutes; new/increased vasopressor requirement; fluid bolus >15 ml/kg, or cardiac arrest). Methods: INTUBE (International Observational Study to Understand the Impact and Best Practices of Airway Management In Critically Ill Patients) was a multicenter prospective cohort study of patients who were critically ill and undergoing tracheal intubation in a convenience sample of 197 sites from 29 countries across five continents from October 1, 2018, to July 31, 2019. Measurements and Main Results: A total of 2,760 patients were included in this analysis. Peri-intubation cardiovascular instability/collapse occurred in 1,199 out of 2,760 patients (43.4%). Variables associated with this event were older age (odds ratio [OR], 1.02; 95% confidence interval [CI], 1.02-1.03), higher heart rate (OR, 1.008; 95% CI, 1.004-1.012), lower systolic blood pressure (OR, 0.98; 95% CI, 0.98-0.99), lower oxygen saturation as measured by pulse oximetry/Fi_O2 before induction (OR, 0.998; 95% CI, 0.997-0.999), and the use of propofol as an induction agent (OR, 1.28; 95% CI, 1.05-1.57). Patients with peri-intubation cardiovascular instability/collapse were at a higher risk of ICU mortality with an adjusted OR of 2.47 (95% CI, 1.72-3.55), P < 0.001. The inverse probability of treatment weighting method identified the use of propofol as the only factor independently associated with cardiovascular instability/collapse (OR, 1.23; 95% CI, 1.02-1.49). When administered before induction, vasopressors (OR, 1.33; 95% CI, 0.84-2.11) or fluid boluses (OR, 1.17; 95% CI, 0.96-1.44) did not reduce the incidence of cardiovascular instability/collapse. Conclusions: Peri-intubation cardiovascular instability/collapse was associated with an increased risk of both ICU and 28-day mortality. The use of propofol for induction was identified as a modifiable intervention significantly associated with cardiovascular instability/collapse.Clinical trial registered with clinicaltrials.gov (NCT03616054).

Apneic oxygenation with low-flow oxygen cannula for rapid sequence induction and intubation in pediatric patients: a randomized-controlled trial

BACKGROUND

Classical rapid sequence induction and intubation (RSII) is used to reduce pulmonary aspiration, but it increases the risk of hypoxemia. Apneic oxygenation (ApOx) has been studied to prolong safe apneic time, and to decrease the incidence of hypoxemia in adults. The aim of this study was to investigate the effectiveness of ApOx via low-flow nasal cannula to reduce the incidence of hypoxemia in pediatric rapid sequence induction.

METHODS

This prospective single-blind randomized controlled trial included patients aged 0-7 years, American Society of Anesthesiologists (ASA) physical status 1 to 3, who underwent elective or emergency surgery under general anesthesia with rapid sequence induction during February 2020 to March 2021. Participants were randomized to the ApOx group or the classical rapid sequence induction group. The ApOx group received oxygen flow via regular nasal cannula, as follows: 1 liter per minute (LPM) in age 0-1 month, 2 LPM in age 1-12 months, and 4 LPM in age 1-7 years. The classical group did not receive oxygen supplementation during intubation. The primary outcome was the incidence of hypoxemia, defined as oxygen saturation (SpO₂) ≤92%.

RESULTS

Sixty-four participants were recruited. The incidence of hypoxemia in both groups was 8 of 32 participants (25%) (P=1.000). Among desaturated patients, the median time to desaturation was 29.5 and 35 seconds in the ApOx and classical groups, respectively (P=0.527). The median lowest SpO₂ was 91% and 88.5% in the ApOx and classical groups, respectively (P=0.079). In non-desaturated patients, the median time to successful intubation was 40.5 and 35.5 seconds in the ApOx and classical groups, respectively (P=0.069).

CONCLUSIONS

In this small sample study, ApOx using age-adjusted low-flow nasal cannula was ineffective for reducing the incidence of hypoxemia in pediatric RSII.

TRIAL REGISTRATION

Thai Clinical Trials Registry TCTR20210802002.

A comparison of high-flow nasal cannula and standard facemask as pre-oxygenation technique for general anesthesia: A PRISMA-compliant systemic review and meta-analysis

BACKGROUND

Current practice guidelines recommend the use of nasal cannula as an alternative pre-oxygenation method for tracheal intubation. However, the efficacy of high-flow nasal oxygenation versus standard facemask oxygenation has not been fully evaluated.

METHODS

We searched PubMed, Cochrane Library, and ClinicalTrials.gov for English-language studies published from January 1, 2000 to November 30, 2021. We included randomized controlled trials which compared high-flow nasal oxygenation and facemask oxygenation as the pre-oxygenation maneuver. Primary outcome was arterial partial pressure of oxygen (PaO2) after pre-oxygenation. Secondary outcomes were safe apnea time, arterial desaturation during intubation, lowest peripheral capillary oxygen saturation during intubation, and patient comfort score. Random-effects models and Mantel-Haenszel method were used for data synthesis.

RESULTS

A total of 16 randomized controlled trials and 1148 patients were included. High-flow nasal oxygenation achieved a higher PaO2 compared with facemask, mean difference: 64.86 mm Hg (95% confidence interval [CI]: 32.33-97.40, P < .0001). Safe apnea time was longer in high-flow nasal oxygenation, mean difference: 131.03 seconds (95% CI: 59.39-202.66, P < .0001). There was no difference in the risk of peri-intubation desaturation or lowest peripheral capillary oxygen saturation between groups. Patient comfort score was higher in high-flow nasal oxygenation, mean difference: 1.00 (95% CI: 0.46-1.54, P = .0003).

CONCLUSION

High-flow nasal oxygenation better enhanced PaO2 and extended safe apnea time and is not inferior to facemask oxygenation in preventing desaturation during tracheal intubation. High-flow nasal oxygenation may be considered as an alternative method, especially for patients with a potential difficult airway.

Endotracheal intubation sedation in the intensive care unit

Endotracheal intubation is one of the most common, yet most dangerous procedure performed in the intensive care unit (ICU). Complications of ICU intubations include severe hypotension, hypoxemia, and cardiac arrest. Multiple observational studies have evaluated risk factors associated with these complications. Among the risk factors identified, the choice of sedative agents administered, a modifiable risk factor, has been reported to affect these complications (hypotension). Propofol, etomidate, and ketamine or in combination with benzodiazepines and opioids are commonly used sedative agents administered for endotracheal intubation. Propofol demonstrates rapid onset and offset, however, has drawbacks of profound vasodilation and associated cardiac depression. Etomidate is commonly used in the critically ill population. However, it is known to cause reversible inhibition of 11 β-hydroxylase which suppresses the adrenal production of cortisol for at least 24 h. This added organ impairment with the use of etomidate has been a potential contributing factor for the associated increased morbidity and mortality observed with its use. Ketamine is known to provide analgesia with sedation and has minimal respiratory and cardiovascular effects. However, its use can lead to tachycardia and hypertension which may be deleterious in a patient with heart disease or cause unpleasant hallucinations. Moreover, unlike propofol or etomidate, ketamine requires organ dependent elimination by the liver and kidney which may be problematic in the critically ill. Lately, a combination of ketamine and propofol, “Ketofol”, has been increasingly used as it provides a balancing effect on hemodynamics without any of the side effects known to be associated with the parent drugs. Furthermore, the doses of both drugs are reduced. In situations where a difficult airway is anticipated, awake intubation with the help of a fiberoptic scope or video laryngoscope is considered. Dexmedetomidine is a commonly used sedative agent for these procedures.

Blood pressure behavior during mechanical thrombectomy and drugs used for conscious sedation or general anesthesia

BACKGROUND

The optimal blood pressure (BP) during mechanical thrombectomy for acute ischemic stroke is currently unclear.

OBJECTIVE

To investigate BP behavior during mechanical thrombectomy in patients with acute ischemic stroke and its relationship with drugs used for sedation or general anesthesia. Additionally, we investigated the association between BP oscillation during mechanical thrombectomy and recanalization status, and with functional outcome at discharge.

METHODS

Consecutive patients treated with mechanical thrombectomy for acute ischemic stroke were evaluated in a tertiary hospital from December/2009 to December/2015. Maximum, minimum, and mean systolic and diastolic BP, and mean arterial pressures were collected during the procedure. Sedative drugs were also reviewed.

RESULTS

Fifty-three patients with a mean age of 71.9 years (60.4% men) were treated with mechanical thrombectomy. The mean reduction in systolic BP and mean arterial pressure from hospital admission to mechanical thrombectomy were respectively 42 and 36 mmHg. During the procedure, oscillations were 50.4 mmHg for systolic, and 33.2 mmHg for diastolic BP. Patients treated with neuromuscular blocking drugs had more oscillation in systolic BP from hospital admission to procedure (51.1 versus 26.2 mmHg, P=0.06). The use of cisatracurium (43.9 versus 29.6 mmHg, P=0.02) and succinylcholine (44.7 versus 29.3 mmHg, P=0.01) were associated with a significant drop in BP during the procedure.

CONCLUSIONS

Significant BP oscillation occurs during mechanical thrombectomy. Drugs used for conscious sedation or general anesthesia, specifically neuromuscular blocking agents, might have an influence upon BP levels.

Neuromuscular blockade and airway management during endotracheal intubation in Brazilian intensive care units: a national survey

OBJECTIVE

To describe the use of neuromuscular blockade as well as other practices among Brazilian physicians in adult intensive care units.

METHODS

An online national survey was designed and administered to Brazilian intensivists. Questions were selected using the Delphi method and assessed physicians' demographic data, intensive care unit characteristics, practices regarding airway management, use of neuromuscular blockade and sedation during endotracheal intubation in the intensive care unit. As a secondary outcome, we applied a multivariate analysis to evaluate factors associated with the use of neuromuscular blockade.

RESULTS

Five hundred sixty-five intensivists from all Brazilian regions responded to the questionnaire. The majority of respondents were male (65%), with a mean age of 38 ( 8.4 years, and 58.5% had a board certification in critical care. Only 40.7% of the intensivists reported the use of neuromuscular blockade during all or in more than 75% of endotracheal intubations. In the multivariate analysis, the number of intubations performed monthly and physician specialization in anesthesiology were directly associated with frequent use of neuromuscular blockade. Etomidate and ketamine were more commonly used in the clinical situation of hypotension and shock, while propofol and midazolam were more commonly prescribed in the situation of clinical stability.

CONCLUSION

The reported use of neuromuscular blockade was low among intensivists, and sedative drugs were chosen in accordance with patient hemodynamic stability. These results may help the design of future studies regarding airway management in Brazil.

Practice, Outcomes, and Complications of Emergent Endotracheal Intubation by Critical Care Practitioners During the COVID-19 Pandemic

Background

For patients with COVID-19 who undergo emergency endotracheal intubation, data are limited regarding the practice, outcomes, and complications of this procedure.

Research Question

For patients with COVID-19 requiring emergency endotracheal intubation, how do the procedural techniques, the incidence of first-pass success, and the complications associated with the procedure compare with intubations of critically ill patients before the COVID-19 pandemic?

Study Design and Methods

We conducted a retrospective study of adult patients with COVID-19 at Montefiore Medical Center who underwent first-time endotracheal intubation by critical care physicians between July 19, 2019, and May 1, 2020. The first COVID-19 patient was admitted to our institution on March 11, 2020; patients admitted before this date are designated the prepandemic cohort. Descriptive statistics were used to compare groups. A Fisher exact test was used to compare categorical variables. For continuous variables, a two-tailed Student t test was used for parametric variables or a Wilcoxon rank-sum test was used for nonparametric variables.

Results

One thousand two hundred sixty intubations met inclusion criteria (782 prepandemic cohort, 478 pandemic cohort). Patients during the pandemic were more likely to be intubated for hypoxemic respiratory failure (72.6% vs 28.1%; P < .01). During the pandemic, operators were more likely to use video laryngoscopy (89.4% vs 53.3%; P < .01) and neuromuscular blocking agents (86.0% vs 46.2%; P < .01). First-pass success was higher during the pandemic period (94.6% vs 82.9%; P < .01). The rate of associated complications was higher during the pandemic (29.5% vs 15.2%; P < .01), a finding driven by a higher rate of hypoxemia during or immediately after the procedure (25.7% vs 8.2%; P < .01).

Interpretation

Video laryngoscopy and neuromuscular blockade were used increasingly during the COVID-19 pandemic. Despite a higher rate of first-pass success during the pandemic, the incidence of complications associated with the procedure was higher.

Prehospital Ketamine Use for Rapid Sequence Intubation: Are Higher Doses Associated With Adverse Events?

OBJECTIVE

Ketamine for rapid sequence intubation (RSI) is typically dosed at 1 to 2 mg/kg intravenously. The need to ensure dissociation during RSI led some to administer ketamine at doses greater than 2 mg/kg. This study assessed associations between ketamine dose and adverse events.

METHODS

This multisite, retrospective study included adult subjects undergoing RSI with intravenous ketamine. Subjects were categorized into 2 groups: a standard ketamine dose (≤ 2 mg/kg intravenously) or a high dose (> 2 mg/kg intravenously). Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated for adverse events.

RESULTS

Eighty subjects received standard-dose ketamine, and 50 received high-dose ketamine. The high-dose group had a significantly (P < .05) higher proportion of trauma patients, were younger, and had higher predose blood pressure compared with the standard-dose group. High-dose ketamine was associated with greater odds of adverse events including hypotension (OR = 7.0; 95% CI, 3.0-16.6), laryngospasm (OR = 10.8; 95% CI, 1.3-93.4), bradycardia (OR = 7.5; 95% CI, 1.5-36.6), repeat medications (OR = 12.9; 95% CI, 1.5-107.9), oxygen desaturation (OR = 6.0; 95% CI, 1.8-19.9), multiple attempts (OR = 3.2; 95% CI, 1.5-6.8%), and failed airway (OR = 3.6; 95% CI, 1.0-12.7).

CONCLUSION

Ketamine at higher doses was associated with increased odds of adverse events. Studies assessing adverse events of ketamine at lower than standard doses in shock patients are needed.

Success and Complications of the Ketamine-Only Intubation Method in the Emergency Department

BACKGROUND

Rapid sequence intubation (RSI), defined as near-simultaneous administration of a sedative and neuromuscular blocking agent, is the most common and successful method of tracheal intubation in the emergency department. However, RSI is sometimes avoided when the physician believes there is a risk of a can't intubate/can't oxygenate scenario or critical hypoxemia because of distorted anatomy or apnea intolerance. Traditionally, topical anesthesia alone or in combination with low-dose sedation are used when physicians deem RSI too risky. Recently, a ketamine-only strategy has been suggested as an alternative approach.

OBJECTIVE

We compared first attempt success and complications between ketamine-only, topical anesthesia alone or with low-dose sedation, and RSI approaches.

METHODS

We analyzed registry data from the National Emergency Airway Registry, comprising emergency department intubation data from 25 centers from January 2016 to December 2018. We excluded pediatric patients (<14 years of age), those in cardiac and respiratory arrest, or those with an alternate pharmacologic approach (i.e., neuromuscular blocking agent only or nonketamine sedative alone). We analyzed first attempt intubation success and adverse events across the 3 intubation approaches. We calculated differences in outcomes between the ketamine-only and topical anesthesia groups.

RESULTS

During the study period, 12,511 of 19,071 intubation encounters met inclusion criteria, including 102 (0.8%) intubated with ketamine alone, 80 (0.6%) who had intubation facilitated by topical anesthesia, and 12,329 (98.5%) who underwent RSI. Unadjusted first attempt success was 61%, 85%, and 90% for the 3 groups, respectively. Hypoxemia (defined as oxygen saturation <90%) occurred in 16%, 13%, and 8% of patients during the first attempt, respectively. At least 1 adverse event occurred in 32%, 19%, and 14% of the courses of intubation for the 3 groups, respectively. In comparing the ketamine-only and topical anesthesia groups, the difference in first pass success was -24% (95% confidence interval -37% to -12%), and the difference in number of cases with ≥1 adverse event was 13% (95% confidence interval 0-25%), both favoring the topical anesthesia group.

CONCLUSION

Although sometimes advocated, the ketamine-only intubation approach is uncommon and is associated with lower success and higher complications compared with topical anesthesia and RSI approaches.

The Impact of Nighttime on First Pass Success During the Emergent Endotracheal Intubation of Critically Ill Patients

BACKGROUND

While numerous investigations have described worse outcomes for patients undergoing emergent procedures at night, few studies have investigated the impact of nighttime on the outcomes of emergent endotracheal intubation (EEI). We hypothesized that for patients requiring EEI at night, the outcome of first pass success would be lower as compared to during the day.

METHODS

We performed a retrospective cohort study of all patients admitted to our institution between January 1st, 2016 and July 17st, 2019 who underwent EEI outside of an emergency department or operating room. Nighttime was defined as between 7:00 pm and 6:59 am. The primary outcome was the rate of first pass success. Logistic regression was utilized with adjustment for demographic, morbidity and procedure related covariables.

RESULTS

The final examined cohort included 1,674 EEI during the day and 1,229 EEI at night. The unadjusted rate of first pass success was not different between the day and night (77.5% vs. 74.6%, unadjusted odds ratio (OR): 0.85; 95% confidence interval (CI): 0.72, 1.0; P = 0.073 though following adjustment for prespecified covariables the odds of first pass success was lower at night (adjusted OR: 0.83, 95% CI: 0.69, 0.99; P = 0.042. Obesity was found to be an effect modifier on first pass success rate for day vs. night intubations. In obese patients, nighttime intubations had significantly lower odds of first pass success (adjusted OR: 0.71, 95% CI: 0.52, 0.98; P = 0.037).

DISCUSSION

After adjustment for patient and procedure related factors, we have found that the odds of first pass success is lower at night as compared to the day. This finding was, to some degree, driven by obesity which was found to be a significant effect modifier in this relationship.

Risk factors for and prediction of post-intubation hypotension in critically ill adults: A multicenter prospective cohort study

Objective

Hypotension following endotracheal intubation in the ICU is associated with poor outcomes. There is no formal prediction tool to help estimate the onset of this hemodynamic compromise. Our objective was to derive and validate a prediction model for immediate hypotension following endotracheal intubation.

Methods

A multicenter, prospective, cohort study enrolling 934 adults who underwent endotracheal intubation across 16 medical/surgical ICUs in the United States from July 2015-January 2017 was conducted to derive and validate a prediction model for immediate hypotension following endotracheal intubation. We defined hypotension as: 1) mean arterial pressure <65 mmHg; 2) systolic blood pressure <80 mmHg and/or decrease in systolic blood pressure of 40% from baseline; 3) or the initiation or increase in any vasopressor in the 30 minutes following endotracheal intubation.

Results

Post-intubation hypotension developed in 344 (36.8%) patients. In the full cohort, 11 variables were independently associated with hypotension: increasing illness severity; increasing age; sepsis diagnosis; endotracheal intubation in the setting of cardiac arrest, mean arterial pressure <65 mmHg, and acute respiratory failure; diuretic use 24 hours preceding endotracheal intubation; decreasing systolic blood pressure from 130 mmHg; catecholamine and phenylephrine use immediately prior to endotracheal intubation; and use of etomidate during endotracheal intubation. A model excluding unstable patients’ pre-intubation (those receiving catecholamine vasopressors and/or who were intubated in the setting of cardiac arrest) was also developed and included the above variables with the exception of sepsis and etomidate. In the full cohort, the 11 variable model had a C-statistic of 0.75 (95% CI 0.72, 0.78). In the stable cohort, the 7 variable model C-statistic was 0.71 (95% CI 0.67, 0.75). In both cohorts, a clinical risk score was developed stratifying patients’ risk of hypotension.

Conclusions

A novel multivariable risk score predicted post-intubation hypotension with accuracy in both unstable and stable critically ill patients.

Study registration

Clinicaltrials.gov identifier: NCT02508948 and Registered Report Identifier: RR2-10.2196/11101.

Urgent intubation without neuromuscular blocking agents and the risk of tracheostomy

Neuromuscular blocking agents play a significant role in improving the success rate for urgent intubation, although there is limited evidence about the effect on subsequent outcomes, such as the incidence of tracheostomy. In this retrospective cohort study, we aimed to examine the association between avoidance of neuromuscular blocking agents for urgent tracheal intubation and incidence of tracheostomy among patients in the intensive care unit (ICU). The setting of this study was an eight-bed ICU at a tertiary-care hospital in Okayama, Japan. We included patients who underwent urgent tracheal intubation at the emergency department or the ICU and were admitted to the ICU between April 2013 and November 2017. We extracted data on methods and medications of intubation, predictors for difficult intubation, Cormack-Lehane grade, patient demographics, primary diagnoses, reintubation. We estimated odds ratios and their 95% confidence intervals for elective tracheostomy during the ICU stay using logistic regression models. Of 411 patients, 46 patients underwent intubation without neuromuscular blocking agents and 61 patients underwent tracheostomy. After adjusting for potential confounders, patients who avoided neuromuscular blocking agents had more than double the odds of tracheostomy (odds ratio 2.59, 95% confidence interval 1.06-6.34, p value = 0.04). When stratifying the subjects by risk status for tracheostomy, the association was more pronounced in high-risk group, while we observed less significant association in the low-risk group. Avoidance of neuromuscular blocking agents for urgent intubation increases the risk of tracheostomy among emergency patients, especially those who have a higher risk for tracheostomy.

Impact of a Critical Care Specialist Intervention on First Pass Success for Emergency Airway Management Outside the ICU

BACKGROUND

There has been limited investigation into the procedural outcomes of patients undergoing emergent endotracheal intubation (EEI) by a critical care medicine (CCM) specialist outside the intensive care unit (ICU). We hypothesized that EEI outside an ICU would be associated with lower rates of first pass success (FPS) as compared to inside an ICU.

METHODS

We performed a retrospective cohort study of all adult patients admitted to our academic medical center between January 1, 2016, and July 31, 2018, who underwent EEI by a CCM practitioner. The primary outcome of FPS was identified in the EEI procedure note. Secondary outcomes included difficult intubation (> 2 attempts at laryngoscopy) and mortality following EEI.

RESULTS

In total, 1958 patients (1035 [52.9%] inside ICU and 923 [47.1%]) outside an ICU) were included in the final cohort. Unadjusted rate of FPS was not different between patients intubated out of the ICU and patients intubated inside of the ICU (689 [74.7%] vs 775 [74.9%]; P = .91). There was also no difference in FPS between groups after adjusting for predictors of difficult intubation and baseline covariates (odds ratio: 0.95; 95% confidence interval, 0.75-1.2, P = .65). Mortality of patients undergoing EEI out of the ICU was higher at each examined time interval following EEI.

DISCUSSION

For EEI done by CCM practitioners, rate of FPS is not different between patients undergoing EEI outside an ICU as compared to inside an ICU. Despite the lack of difference between rates of procedural success, patient mortality following EEI outside an ICU is higher than EEI inside an ICU at all examined time points during hospitalization.

Drug Order in Rapid Sequence Intubation

BACKGROUND

The optimal order of drug administration (sedative first vs. neuromuscular blocking agent first) in rapid sequence intubation (RSI) is debated.

OBJECTIVE

We sought to determine if RSI drug order was associated with the time elapsed from administration of the first RSI drug to the end of a successful first intubation attempt.

METHODS

We conducted a planned secondary analysis of a randomized trial of adult ED patients undergoing emergency orotracheal intubation that demonstrated higher first-attempt success with bougie use compared to a tracheal tube + stylet. Drug choice, dose, and the order of sedative and neuromuscular blocking agent were not stipulated. We analyzed trial patients who received both a sedative and a neuromuscular blocking agent within 30 seconds of each other who were intubated successfully on the first attempt. The primary outcome was the time elapsed from complete administration of the first RSI drug to the end of the first intubation attempt, a surrogate outcome for apnea time. We performed a multivariable analysis using a mixed-effects generalized linear model.

RESULTS

Of 757 original trial patients, 562 patients (74%) met criteria for analysis; 153 received the sedative agent first, and 409 received the neuromuscular blocking agent first. Administration of the neuromuscular blocking agent before the sedative agent was associated with a reduction in time from RSI administration to the end of intubation attempt of 6 seconds (95% confidence interval = 0 to 11 sec).

CONCLUSION

Administration of either the neuromuscular blocking or the sedative agent first are both acceptable. Administering the neuromuscular blocking agent first may result in modestly faster time to intubation. For now, it is reasonable for physicians to continue performing RSI in the way they are most comfortable with. If future research determines that the order of medication administration is not associated with awareness of neuromuscular blockade, administration of the neuromuscular blocking agent first may be a logical default administration method to attempt to minimize apnea time during intubation.

Recent advances in laryngoscopy in adults

Recent advances in technology have made laryngoscopy less dependent upon a direct line of sight to achieve tracheal intubation. Whether these new devices are useful tools capable of increasing patient safety depends upon when and how they are used. We briefly consider the challenges in reviewing the emerging literature given the variety of devices, "experience" of the care providers, the clinical settings, and the definitions of outcome. We examine some of the limitations of conventional direct laryngoscopy, question the definitions we have used to define success, discuss the benefits of indirect (video) techniques, and review evidence pertaining to their use in the patients in the operating room, emergency department, and intensive care unit.

Nursing Considerations When Using Neuromuscular Blocking Agents to Assist With Intubation: A Review of Literature

The use of neuromuscular blocking agents (NMBAs) in acute care settings during intubation is vitally important. The NMBAs increase first pass success rates significantly while protecting patients from gastric aspiration, tracheal injury, and death. During emergent intubations, succinylcholine and rocuronium are commonly used, but each comes with specific risks and individualized interventions. First pass success can be increased by ensuring correct dosing for overweight patients and employing the use of video laryngoscope. For planned, nonemergent intubations with sustained paralysis, the chosen NMBA can be individualized to fit the patient's needs. This includes dosages based on upregulation or downregulation of acetylcholine as well as speed of administration to prevent histamine release. Nurses must provide specific care when managing the treatment in high-risk patient populations (coronary artery disease, hyperkalemia, renal failure, liver failure, and traumatic brain injuries) who may receive certain types of NMBAs. Finally, because of the wide range of adverse effects with these drugs, close assessments are essential to prevent complications.

Evaluation of the laryngoscopy view using the modified Cormack-Lehane scale during tracheal intubation in an intensive care unit. A prospective observational study

BACKGROUND AND OBJECTVIES

Tracheal intubation in the Intensive Care Unit is associated with a high incidence of difficult intubation and complications. This may be due to a poor view of the glottis during direct laryngoscopy. The aim of this study is to determine if there is a relationship between laryngoscopy view using the modified Cormack-Lehane scale with the incidence of difficult intubation and complications.

METHODS

All patients who were subjected to tracheal intubated with direct laryngoscopy in the Intensive Care Unit over a 45 month period were included in the study. In all patients, an evaluation was made of the laryngoscopy view using the modified Cormack-Lehane scale, as well as the technical difficulty (number of intubations at first attempt, operator-reported difficulty, need for a Frova introducer), and the incidence of complications (hypotension, hypoxia, oesophageal intubation).

RESULTS

A total of 360 patients were included. When the grade of the modified Cormack-Lehane scale was increased from 1 to 4, the incidence of first success rate intubation decreased (1: 97%, 2a: 94%, 2b: 80%, 3: 60%, 4: 0%, p<.001), the incidence of moderate and severe difficulty intubation increased (1: 2%, 2a: 4%, 2b: 36%, 3: 77%, 4: 100%, p<.001.), as well as the need for a Frova guide (1: 7%, 2a: 8%, 2b: 45%, 3: 60%, 4: 100%, p<.001). When the grade of the modified Cormack-Lehane scale increased from 1 to 4, the incidence of hypoxia<90% increased (1: 20%, 2a: 20%, 2b: 28%, 3: 47%, 4: 100%, p=.0073), as well as hypoxia<80% (1: 11%, 2a: 10%, 2b: 12%, 3: 27%, 4: 100%, p=.00398). No relationship was observed between the incidence of hypotension and the grade of the modified Cormack-Lehane scale (p=ns).

CONCLUSIONS

During tracheal intubation in the Intensive Care Unit a close relationship was found between a poor laryngoscopy view using the modified Cormack-Lehane scale and a higher difficulty technique of intubation. A relationship was found between the incidence of hypoxia with a higher grade in the modified Cormack-Lehane scale. No relationship was found between hypotension and the modified Cormack-Lehane scale.

Comparison of Tracheal Intubation Conditions in Operating Room and Intensive Care Unit: A Prospective, Observational Study

WHAT WE ALREADY KNOW ABOUT THIS TOPIC

WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: Tracheal intubation is a common intervention in the operating room and in the intensive care unit. The authors hypothesized that tracheal intubation using direct laryngoscopy would be associated with worse intubation conditions and more complications in the intensive care unit compared with the operating room.

METHODS

The authors prospectively evaluated during 33 months patients who were tracheally intubated with direct laryngoscopy in the operating room, and subsequently in the intensive care unit (within a 1-month time frame). The primary outcome was to compare the difference in glottic visualization using the modified Cormack-Lehane grade between intubations performed on the same patient in an intensive care unit and previously in an operating room. Secondary outcomes were to compare first-time success rate, technical difficulty (number of attempts, operator-reported difficulty, need for adjuncts), and the incidence of complications.

RESULTS

A total of 208 patients met inclusion criteria. Tracheal intubations in the intensive care unit were associated with worse glottic visualization (Cormack-Lehane grade I/IIa/IIb/III/IV: 116/24/47/19/2) compared with the operating room (Cormack-Lehane grade I/IIa/IIb/III/IV: 159/21/16/12/0; P < 0.001). First-time intubation success rate was lower in the intensive care unit (185/208; 89%) compared with the operating room (201/208; 97%; P = 0.002). Tracheal intubations in the intensive care unit had an increased incidence of moderate and difficult intubation (33/208 [16%] vs. 18/208 [9%]; P < 0.001), and need for adjuncts to direct laryngoscopy (40/208 [19%] vs. 21/208 [10%]; P = 0.002), compared with the operating room. Complications were more common during tracheal intubations in the intensive care unit (76/208; 37%) compared with the operating room (13/208; 6%; P < 0.001).

CONCLUSIONS

Compared with the operating room, tracheal intubations in the intensive care unit were associated with worse intubation conditions and an increase of complications.

Endotracheal Intubation Among the Critically Ill: Protocol for a Multicenter, Observational, Prospective Study

Background

Endotracheal intubation can occur in up to 60% of critically ill patients. Despite the frequency with which endotracheal intubation occurs, the current practice is largely unknown. This is relevant, as advances in airway equipment (ie, video laryngoscopes) have become more prevalent, leading to possible improvement of care delivered during this process. In addition to new devices, a greater emphasis on airway plans and choices in sedation have evolved, although the influence on patient morbidity and mortality is largely unknown.

Objective

This study aims to derive and validate prediction models for immediate airway and hemodynamic complications of intensive care unit intubations.

Methods

A multicenter, observational, prospective study of adult critically ill patients admitted to both medical and surgical intensive care units (ICUs) was conducted. Participating ICU sites were located throughout eight health and human services regions of the United States for which endotracheal intubation was needed. A steering committee composed of both anesthesia and pulmonary critical care physicians proposed a core set of data variables. These variables were incorporated into a data collection form to be used within the multiple, participating ICUs across the United States during the time of intubation. The data collection form consisted of two basic components, focusing on airway management and hemodynamic management. The form was generated using RedCap and distributed to the participating centers. Quality checks on the dataset were performed several times with each center, such that they arrived at less than 10% missing values for each data variable; the checks were subsequently entered into a database.

Results

The study is currently undergoing data analysis. Results are expected in November 2018 with publication to follow thereafter. The study protocol has not yet undergone peer review by a funding body.

Conclusions

The overall goal of this multicenter prospective study is to develop a scoring system for peri-intubation, hemodynamic, and airway-related complications so we can stratify those patients at greatest risk for decompensation as a result of these complications. This will allow critical care physicians to be better prepared in addressing these occurrences and will allow them to improve the quality of care delivered to the critically ill.

Trial Registration

ClinicalTrials.gov NCT02508948; https://clinicaltrials.gov/ct2/show/NCT02508948 (Archived by WebCite at http://www.webcitation.org/73Oj6cTFu)

International Registered Report Identifier (IRRID)

RR1-10.2196/11101

Neuromuscular blockers and reversal agents and their impact on anesthesia practice

Neuromuscular blockers have long been an intricate part of the anesthesia regimen. The scientific progress in pharmacology and physiology has strengthened their clinical relevance, has helped to delineate with precision their medical role, and has enhanced the safety and effectiveness of their use. New frontiers in research will define further the role of these agents in modern anesthesia practice and guide their expanding and discrete clinical applications.

Survey on the Current State of Endotracheal Intubation Among the Critically Ill

Objectives:

In the last decade, the practice of intubation in the intensive care unit (ICU) has evolved. To further examine the current intubation practice in the ICU, we administered a survey to critical care physicians.

Design:

Cross-sectional survey study design.

Setting:

Thirty-two academic/nonacademic centers nationally and internationally.

Measurements and Main Results:

The survey was developed among a core group of physicians with the assistance of the Survey Research Center at Mayo Clinic, Rochester, Minnesota. The survey was pilot tested for functionality and reliability. The response rate was 82 (51%) of 160 among the 32 centers. Although propofol was the induction drug of choice, there was a significant difference with actual ketamine use and those who indicated a preference for it (ketamine: 52% vs 61%; P < .001). The most common airway device used for intubation was direct laryngoscopy (Miller laryngoscope blade) at 56 (68%) followed by video laryngoscopy at 26 (32%). Most (>90%) indicated that they have a difficult airway cart, but only 55 (67%) indicated they have a documented plan to handle a difficult airway with even lower results for documented review of adverse events (49%).

Conclusion:

Although propofol was the induction drug of choice, ketamine was a medication that many preferred to use, possibly relating to the fact that the most common complication postintubation is hypotension. Direct laryngoscopy remains the primary airway device for endotracheal intubation. Finally, although the majority stated they had a difficult airway cart available, most did not have a documented plan in place when encountering a difficult airway or a documented process to review adverse events surrounding intubation.

Video versus direct laryngoscopy on successful first-pass endotracheal intubation in ICU patients

BACKGROUND

Airway management in intensive care unit (ICU) patients is challenging. The aim of this study was to compare the rate of successful first-pass intubation in the ICU by using the direct laryngoscopy (DL) and that by using the video laryngoscopy (VL).

METHODS

A randomized, non-blinded trial comparing first-pass success rate of intubation between VL and DL was performed. Patients were recruited in the period from August 2014 to August 2016. All physicians working at ICU received hands-on training in the use of the video and direct laryngoscope. The primary outcome measure was the first-pass intubation success.

RESULTS

A total of 163 ICU patients underwent intubation during the study period (81 patients in VL group and 82 in DL group). The rate of successful first-pass intubation was not significantly different between the VL and the DL group (67.9% vs. 69.5%, P=0.824). Moreover, the overall intubation success and total number of attempts to achieve intubation success did not differ between the two groups. In patients with successful first-pass intubation, the median duration of the intubation procedure did not differ between the two groups. The Cormack-Lehane grades and the percentage of glottic opening score were similar, and no significant differences were found between the two groups. There were no statistical differences between the VL and the DL group in intubation complications (all P>0.05).

CONCLUSION

Among ICU patients requiring intubation, there was no significant difference in the rate of successful first-pass intubation between VL and DL.

Video Laryngoscopy for Endotracheal Intubation of Critically Ill Adults: A Systemic Review and Meta-Analysis

BACKGROUND

Endotracheal intubation (EI) in ICU patients is associated with an increased risk of life-threatening adverse events due to unstable conditions, rapid deterioration, limited preparation time, and variability in the expertise of operators. The goal of this study was to compare the effect of video laryngoscopy (VL) and direct laryngoscopy (DL) in ICU patients requiring EI.

METHODS

We searched for relevant studies in PubMed, Embase, and the Cochrane database from inception through January 30, 2017. Randomized controlled trials were included if they reported data on any of the predefined outcomes in ICU patients requiring EI and managed with VL or DL. Results were expressed as risk ratios (RRs) or mean differences (MDs) with accompanying 95% CIs.

RESULTS

Five randomized controlled trials with 1,301 patients were included. Despite better glottic visualization with VL (RR = 1.24; 95% CI, 1.07 to 1.43; P = .003), use of VL did not result in a significant increase in the first-attempt success rate (RR = 1.08; 95% CI, 0.92-1.26; P = .35) compared with DL. In addition, time to intubation (MD = 4.12 s; 95% CI, -15.86-24.09; P = .69), difficult intubation (RR = 0.72; 95% CI, 0.30-1.70; P = .45), mortality (RR = 1.02; 95% CI, 0.84-1.25; P = .83), and most other complications were similar between the VL and DL groups.

CONCLUSIONS

The VL technique did not increase the first-attempt success rate during EI in ICU patients compared with DL. These findings do not support routine use of VL in ICU patients.

The intensive care medicine research agenda for airways, invasive and noninvasive mechanical ventilation

In an important sense, support of the respiratory system has been a defining characteristic of intensive care since its inception. The pace of basic and clinical research in this field has escalated over the past two decades, resulting in palpable improvement at the bedside as measured by both efficacy and outcome. As in all medical research, however, novel ideas built upon observations are continually proposed, tested, and either retained or discarded on the basis of the persuasiveness of the evidence. What follows are concise descriptions of the current standards of management practice in respiratory support, the areas of present-day uncertainty, and our suggested agenda for the near future of research aimed at testing current assumptions, probing uncertainties, and solidifying the foundation on which to base our progress to the next level.

Randomized Trial of Video Laryngoscopy for Endotracheal Intubation of Critically Ill Adults

OBJECTIVE

To evaluate the effect of video laryngoscopy on the rate of endotracheal intubation on first laryngoscopy attempt among critically ill adults.

DESIGN

A randomized, parallel-group, pragmatic trial of video compared with direct laryngoscopy for 150 adults undergoing endotracheal intubation by Pulmonary and Critical Care Medicine fellows.

SETTING

Medical ICU in a tertiary, academic medical center.

PATIENTS

Critically ill patients 18 years old or older.

INTERVENTIONS

Patients were randomized 1:1 to video or direct laryngoscopy for the first attempt at endotracheal intubation.

MEASUREMENTS AND MAIN RESULTS

Patients assigned to video (n = 74) and direct (n = 76) laryngoscopy were similar at baseline. Despite better glottic visualization with video laryngoscopy, there was no difference in the primary outcome of intubation on the first laryngoscopy attempt (video 68.9% vs direct 65.8%; p = 0.68) in unadjusted analyses or after adjustment for the operator's previous experience with the assigned device (odds ratio for video laryngoscopy on intubation on first attempt 2.02; 95% CI, 0.82-5.02, p = 0.12). Secondary outcomes of time to intubation, lowest arterial oxygen saturation, complications, and in-hospital mortality were not different between video and direct laryngoscopy.

CONCLUSIONS

In critically ill adults undergoing endotracheal intubation, video laryngoscopy improves glottic visualization but does not appear to increase procedural success or decrease complications.

Republication: All India Difficult Airway Association 2016 Guidelines for Tracheal Intubation in the Intensive Care Unit

Tracheal intubation (TI) is a routine procedure in the Intensive Care Unit (ICU) and is often lifesaving. In contrast to the controlled conditions in the operating room, critically ill patients with respiratory failure and shock are physiologically unstable. These factors, along with under evaluation of the airway and suboptimal response to preoxygenation, are responsible for a high incidence of life-threatening complications such as severe hypoxemia and cardiovascular collapse during TI in the ICU. The All India Difficult Airway Association (AIDAA) proposes a stepwise plan for safe management of the airway in critically ill patients. These guidelines have been developed based on available evidence; Wherever, robust evidence was lacking, recommendations were arrived at by consensus opinion of airway experts, incorporating the responses to a questionnaire sent to members of the (AIDAA) and Indian Society of Anaesthesiologists. Noninvasive positive pressure ventilation for preoxygenation provides adequate oxygen stores during TI for patients with respiratory pathology. Nasal insufflation of oxygen at 15 L/min can increase the duration of apnea before hypoxemia sets in. High flow nasal cannula oxygenation at 60-70 L/min may also increase safety during intubation of critically ill patients. Stable hemodynamics and gas exchange must be maintained during rapid sequence induction. It is necessary to implement an intubation protocol during routine airway management in the ICU. Adherence to a plan for difficult airway management incorporating the use of intubation aids and airway rescue devices and strategies is useful.

Practice of Intubation of the Critically Ill at Mayo Clinic

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.

Video Laryngoscopy Improves Odds of First-Attempt Success at Intubation in the Intensive Care Unit. A Propensity-matched Analysis

RATIONALE

Urgent tracheal intubation is performed frequently in intensive care units and incurs higher risk than when intubation is performed under more controlled circumstances. Video laryngoscopy may improve the chances of successful tracheal intubation on the first attempt; however, existing comparative data on outcomes are limited.

OBJECTIVES

To compare first-attempt success and complication rates during intubation when using video laryngoscopy compared with traditional direct laryngoscopy in a tertiary academic medical intensive care unit.

METHODS

We prospectively collected and analyzed data from a continuous quality improvement database of all intubations in one medical intensive care unit between January 1, 2012, and December 31, 2014. Propensity matching and multivariable logistic regression were used to reduce the risk of bias and control for confounding.

MEASUREMENTS AND MAIN RESULTS

A total of 809 intubations took place over the study period. Of these, 673 (83.2%) were performed using video laryngoscopy and 136 (16.8%) using direct laryngoscopy. First-attempt success with video laryngoscopy was 80.4% (95% confidence interval [CI], 77.2-83.3%) compared with 65.4% (95% CI, 56.8-73.4%) for intubations performed with direct laryngoscopy (P < 0.001). In a propensity-matched analysis, the odds ratio for first-attempt success with video laryngoscopy versus direct laryngoscopy was 2.81 (95% CI, 2.27-3.59). The rate of arterial oxygen desaturation events during the first intubation attempt was significantly lower for video laryngoscopy than for direct laryngoscopy (18.3% vs. 25.9%; P = 0.04). The rate of esophageal intubation during any attempt was also significantly lower for video laryngoscopy (2.1% vs. 6.6%; P = 0.008).

CONCLUSIONS

Video laryngoscopy was associated with significantly improved odds of first-attempt success at tracheal intubation by nonanesthesiologists in a medical intensive care unit. Esophageal intubation and oxygen desaturation occurred less frequently with the use of video laryngoscopy. Randomized clinical trials are needed to confirm these findings.

The All India Difficult Airway Association 2016 guidelines for tracheal intubation in the Intensive Care Unit

Tracheal intubation (TI) is a routine procedure in the Intensive Care Unit (ICU) and is often life-saving. In contrast to the controlled conditions in the operating room, critically ill patients with respiratory failure and shock are physiologically unstable. These factors, along with a suboptimal evaluation of the airway and limited oxygen reserves despite adequate pre-oxygenation, are responsible for a high incidence of life-threatening complications such as severe hypoxaemia and cardiovascular collapse during TI in the ICU. The All India Difficult Airway Association (AIDAA) proposes a stepwise plan for safe management of the airway in critically ill patients. These guidelines have been developed based on available evidence; wherever robust evidence was lacking, recommendations were arrived at by consensus opinion of airway experts, incorporating the responses to a questionnaire sent to members of the AIDAA and the Indian Society of Anaesthesiologists. Non-invasive positive pressure ventilation during pre-oxygenation improves oxygen stores in patients with respiratory pathology. Nasal insufflation of oxygen at 15 L/min can increase the duration of apnoea before the occurrence of hypoxaemia. High-flow nasal cannula oxygenation at 60-70 L/min may also increase safety during TI in critically ill patients. Stable haemodynamics and gas exchange must be maintained during rapid sequence induction. It is necessary to implement an intubation protocol during routine airway management in the ICU. Adherence to a plan for difficult airway management incorporating the use of intubation aids and airway rescue devices and strategies is useful.