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Bhattacharjee S, Maitra S, Baidya DK. A comparison between video laryngoscopy and direct laryngoscopy for endotracheal intubation in the emergency department: A meta-analysis of randomized controlled trials. J Clin Anesth 2018; 47:21-26. [PMID: 29549828 DOI: 10.1016/j.jclinane.2018.03.006] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2018] [Revised: 03/01/2018] [Accepted: 03/08/2018] [Indexed: 02/02/2023]
Abstract
STUDY OBJECTIVES Direct laryngoscopy is the most commonly used modality for endotracheal intubation in the emergency department. Video laryngoscopy may improve glottic view during laryngoscopy and intubation success rate in such patients. This meta-analysis has been designed to compare clinical efficacy of video laryngoscopy with direct laryngoscopy for endotracheal intubation in the emergency department. DESIGN Meta-analysis of randomized controlled trial. SETTING Randomized controlled trials comparing video laryngoscopy and direct laryngoscopy for endotracheal intubation in adult patients in emergency department. PubMed (1946 to 20th October 2017) and The Cochrane Library databases (CENTRAL) were searched for potentially eligible trials on 20th October 2017. PATIENTS Adult patients presenting in the emergency department. INTERVENTIONS Video laryngoscopy & direct laryngoscopy for intubation in emergency department. MEASUREMENT Primary outcome was 'first intubation success rate' and secondary outcomes were overall intubation success rate, in-hospital mortality and oesophageal intubation rate. MAIN RESULTS Data of 1250 patients from 5 randomized controlled trials have been included in this study. Video laryngoscopy offers no advantage over direct laryngoscopy in terms of first intubation success rate (odds ratio 1.28, 95% CI 0.70, 2.36; p = 0.42), overall intubation success rate (OR 1.26, 95% CI 0.53, 3.01; p = 0.6) or in-hospital mortality (OR 1.25, 95% CI 0.8, 1.95; p = 0.32). However, oesophageal intubation rate is lower with the use of video laryngoscopy (OR 0.09, 95% CI 0.01, 0.7; p = 0.02). CONCLUSION Use of video laryngoscopy for emergency endotracheal intubation in adult patients is associated with reduced oesophageal intubation over direct laryngoscopy. However, no benefit was found in terms of overall intubation success.
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Meta-Analysis |
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Preoxygenation and apneic oxygenation using Transnasal Humidified Rapid-Insufflation Ventilatory Exchange for emergency intubation. J Crit Care 2016; 36:8-12. [PMID: 27546740 DOI: 10.1016/j.jcrc.2016.06.011] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2016] [Revised: 06/12/2016] [Accepted: 06/13/2016] [Indexed: 11/22/2022]
Abstract
PURPOSE Hypoxia is one of the leading causes of anesthesia-related injury. In response to the limitations of conventional preoxygenation, Transnasal Humidified Rapid-Insufflation Ventilatory Exchange (THRIVE) has been used as a method of providing both preoxygenation and apneic oxygenation during intubation. MATERIALS AND METHODS In this prospective, observational study, THRIVE was introduced in a critical care unit (CCU), operating room (OR), and emergency department (ED) during emergency intubation of patients at high risk of hypoxia. Linear regression analysis tested for correlation between apnea time or body mass index and hemoglobin saturation (Spo2). RESULTS Across 71 sequential patients, the interquartile range for apnea time and decrease in Spo2 were 60 to 125 seconds and 0% to 3%, respectively. Significant desaturation occurred in 5 (7%) patients. There was no evidence of correlation between apnea time or body mass index and Spo2 (R2=0.04 and 0.08 for CCU/ED and OR and 0.01 and 0.04 CCU/ED and OR, respectively). There were no complications reported from using THRIVE. CONCLUSIONS This study demonstrated that preoxygenation and apneic oxygenation using THRIVE were associated with a low incidence of desaturation during emergency intubation of patients at high risk of hypoxia in the CCU, OR, and ED. THRIVE has the potential to minimize the risk of hypoxia in these patient groups.
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Kim JM, Shin TG, Hwang SY, Yoon H, Cha WC, Sim MS, Jo IJ, Song KJ, Rhee JE, Jeong YK. Sedative dose and patient variable impacts on postintubation hypotension in emergency airway management. Am J Emerg Med 2018; 37:1248-1253. [PMID: 30220641 DOI: 10.1016/j.ajem.2018.09.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 08/10/2018] [Accepted: 09/11/2018] [Indexed: 12/20/2022] Open
Abstract
PURPOSE Postintubation hypotension (PIH) is an adverse event associated with poor outcomes in emergency department (ED) endotracheal intubation. This study aimed to evaluate the association between sedative dose adjustment and PIH during emergency airway management. We also investigated the impact of patient and procedural factors on the incidence of PIH. MATERIALS AND METHODS This was a single-center, retrospective study that used a prospectively collected registry of airway management performed at the ED from April 2014 to February 2017. Adult patients who received emergency endotracheal intubation were included. Multivariable logistic regression models were used to evaluate the association of PIH with sedative dose, patient variables, and procedural variables. RESULTS Overall, 689 patients were included, and 233 (33.8%) patients developed PIH. In the patients overall, multivariable logistic regression demonstrated that age > 70 years, shock index >0.8, arterial acidosis (pH < 7.2), intubation indication, and use of non-depolarizing neuromuscular blocking agent were significantly related to PIH. In patients overall, the sedative dose was not related to PIH (overdose; OR: 1.09, 95%CI: 0.57-2.06), (reduction; OR: 0.93, 95%CI: 0.61-1.42), (none used; OR: 1.28, 95%CI: 0.64-2.53). In subgroup analysis, ketamine dose was not related to PIH (overdose; OR: 0.81, 95%CI: 0.27-2.38, reduction; OR: 1.41, 95%CI: 0.78-2.54). Reduction of etomidate dose was significantly associated with decreased PIH (reduction; OR: 0.46, 95%CI: 0.22-0.98, overdose; OR: 1.77, 95%CI: 0.79-3.93). CONCLUSIONS PIH was mainly related to predisposing patient-related factors. Only adjustment of etomidate dose was associated with the incidence of PIH.
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Journal Article |
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Driver BE, Klein LR, Perlmutter MC, Reardon RF. Emergency cricothyrotomy in morbid obesity: comparing the bougie-guided and traditional techniques in a live animal model. Am J Emerg Med 2021; 50:582-586. [PMID: 34562774 DOI: 10.1016/j.ajem.2021.09.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 04/30/2021] [Accepted: 09/08/2021] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Cricothyrotomy is a rare, time sensitive procedure that is more challenging to perform when anatomical landmarks are not easily palpated before the initial incision. There is a paucity of literature describing the optimal technique for cricothyrotomy in patients with impalpable airway structures, such as in morbid obesity. In this study, we used a live sheep model of morbid obesity to compare the effectiveness of two common cricothyrotomy techniques. METHODS We randomly assigned emergency medicine residents to perform one of two cricothyrotomy techniques on a live anesthetized sheep. To simulate the anterior soft tissue neck thickness of an adult with morbid obesity we injected 120 mL of a mixture of autologous blood and saline into the anterior neck of the sheep. The traditional technique (as described in the New England Journal Video titled "Cricothyroidotomy") used a Shiley tracheostomy tube and no bougie, and the bougie-guided technique used a bougie and a standard endotracheal tube. The primary outcome was the total procedure time; the secondary outcome was first attempt success. RESULTS 23 residents were included, 11 assigned to the bougie-guided technique and 12 to the traditional technique. After injection of blood and saline, the median depth from skin to cricothyroid membrane was 3.0 cm (IQR 2.5-3.4 cm). The median time for the bougie technique was 118 s (IQR 77-200 s) compared to 183 s (IQR 134-270 s) for the traditional technique (median difference 62 s, 95% CI 10-144 s). Success on the first attempt occurred in 7/11 (64%) in the bougie group and 6/12 (50%) in the traditional technique group. CONCLUSION In this study, which simulated morbid obesity on a living animal model complete with active hemorrhage and time pressure caused by extubation before the procedure, the bougie-guided technique was faster than the traditional technique using a tracheostomy tube without a bougie.
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Kalmar AF, Absalom A, Rombouts P, Roets J, Dewaele F, Verdonck P, Stemerdink A, Zijlstra JG, Monsieurs KG. Automatic detection of oesophageal intubation based on ventilation pressure waveforms shows high sensitivity and specificity in patients with pulmonary disease. Resuscitation 2016; 105:36-40. [PMID: 27211837 DOI: 10.1016/j.resuscitation.2016.05.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Revised: 05/09/2016] [Accepted: 05/15/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND Unrecognised endotracheal tube misplacement in emergency intubations has a reported incidence of up to 17%. Current detection methods have many limitations restricting their reliability and availability in these circumstances. There is therefore a clinical need for a device that is small enough to be practical in emergency situations and that can detect oesophageal intubation within seconds. In a first reported evaluation, we demonstrated an algorithm based on pressure waveform analysis, able to determine tube location with high reliability in healthy patients. The aim of this study was to validate the specificity of the algorithm in patients with abnormal pulmonary compliance, and to demonstrate the reliability of a newly developed small device that incorporates the technology. MATERIALS AND METHODS Intubated patients with mild to moderate lung injury, admitted to intensive care were included in the study. The device was connected to the endotracheal tube, and three test ventilations were performed in each patient. All diagnostic data were recorded on PC for subsequent specificity/sensitivity analysis. RESULTS AND DISCUSSION A total of 105 ventilations in 35 patients with lung injury were analysed. With the threshold D-value of 0.1, the system showed a 100% sensitivity and specificity to diagnose tube location. CONCLUSION The algorithm retained its specificity in patients with decreased pulmonary compliance. We also demonstrated the feasibility to integrate sensors and diagnostic hardware in a small, portable hand-held device for convenient use in emergency situations.
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Journal Article |
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Chen M, Kronsteiner D, Pfaff JAR, Schieber S, Bendszus M, Kieser M, Wick W, Möhlenbruch MA, Ringleb PA, Bösel J, Schönenberger S. Emergency intubation during thrombectomy for acute ischemic stroke in patients under primary procedural sedation. Neurol Res Pract 2021; 3:27. [PMID: 34001285 PMCID: PMC8130257 DOI: 10.1186/s42466-021-00125-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 05/04/2021] [Indexed: 11/30/2022] Open
Abstract
Background Emergency intubation is an inherent risk of procedural sedation regimens for endovascular treatment (EVT) of acute ischemic stroke. We aimed to characterize the subgroup of patients, who had to be emergently intubated, to identify predictors of the need for intubation and assess their outcomes. Methods This is a retrospective analysis of the single-center study KEEP SIMPLEST, which evaluated a new in-house SOP for EVT under primary procedural sedation. We used descriptive statistics and regression models to examine predictors and functional outcome of emergently intubated patients. Results Twenty of 160 (12.5%) patients were emergently intubated. National Institutes of Health Stroke Scale (NIHSS) on admission, premorbid modified Rankin scale (mRS), Alberta Stroke Program Early CT Score, age and side of occlusion were not associated with need for emergency intubation. Emergency intubation was associated with a lower rate of successful reperfusion (OR, 0.174; 95%-CI, 0.045 to 0.663; p = 0.01). Emergently intubated patients had higher in-house mortality (30% vs 6.4%; p = 0.001) and a lower rate of mRS 0–2 at 3 months was observed in those patients (10.5% vs 37%, p = 0.024). Conclusions Emergency intubation during a primary procedural sedation regimen for EVT was associated with lower rate of successful reperfusion. Less favorable outcome was observed in the subgroup of emergently intubated patients. More research is required to find practical predictors of intubation need and to determine, whether emergency intubation is safe under strict primary procedural sedation regimens for EVT. Supplementary Information The online version contains supplementary material available at 10.1186/s42466-021-00125-0.
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Tao KM, Hu Y, Zhu XF, Zhang YC, Yang Y, Lu ZJ. Cardiac arrest during emergency intubation in an elderly patient with confirmed coronavirus disease 2019. J Clin Anesth 2020; 66:109951. [PMID: 32504963 PMCID: PMC7264020 DOI: 10.1016/j.jclinane.2020.109951] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2020] [Revised: 05/26/2020] [Accepted: 05/29/2020] [Indexed: 11/26/2022]
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Case Reports |
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Kübler S, Kiefer N, Ciolka R, Rixecker R, Amarasekara M, Ellerkmann RK. [Tracheal rupture following endotracheal intubation for an emergency cesarean]. Anaesthesist 2022; 71:626-630. [PMID: 35420328 DOI: 10.1007/s00101-022-01116-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 02/26/2022] [Accepted: 03/04/2022] [Indexed: 10/18/2022]
Abstract
This is a case report of a 45-year-old patient, 39 weeks of gestation, who was intubated via rapid sequence induction (RSI) for an emergency cesarean. The indication for emergency cesarean was a pathological cardiotocography during the ejection phase following labor induction.Despite the primary use of a video laryngoscope, there was difficulty aligning the laryngeal axis. Therefore, an internal stylet was used to heavily angulate the endotracheal tube (ETT) to a hockey stick shape to enter the larynx.Postoperative dyspnea and extensive facial swelling were initially diagnosed as an allergic reaction. Only 22 h later the diagnosis of tracheal rupture was confirmed following computer tomography.We hypothesized that the mechanism of injury was due to excessive pressure transmitted to the tip of the ETT. This probably occurred due to a leverage effect caused by the withdrawal of the heavily bent stylet from the ETT, forcing an intratracheal cranial movement of the ETT.By conducting an experiment on a pig's trachea, we were able to visualize this mechanism of injury. In addition, we were able to demonstrate that bending the stylet to a similar angle as the laryngoscope blade led to minimal movement of the tip of the ETT.Therefore, when using a stylet during intubation, we recommend bending the ETT and stylet to the shape of the used laryngoscope blade and retracting the stylet at a similar angle to avoid complications, such as tracheal rupture.
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Saran S, Dube M, Azim A. Less Costlier and Emergency Options for Intubation during Coronavirus Disease Times. Indian J Crit Care Med 2022; 25:1462-1463. [PMID: 35027810 PMCID: PMC8693123 DOI: 10.5005/jp-journals-10071-24049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
How to cite this article: Saran S, Dube M, Azim A. Less Costlier and Emergency Options for Intubation during Coronavirus Disease Times. Indian J Crit Care Med 2021;25(12):1462–1463.
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Ismath M, Black H, Hrymak C, Rosychuk RJ, Archambault P, Fok PT, Audet T, Dufault B, Hohl C, Leeies M. Characterizing intubation practices in response to the COVID-19 pandemic: a survey of the Canadian COVID-19 Emergency Department Rapid Response Network (CCEDRRN) sites. BMC Emerg Med 2023; 23:139. [PMID: 38001415 PMCID: PMC10675858 DOI: 10.1186/s12873-023-00911-w] [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: 03/19/2023] [Accepted: 11/20/2023] [Indexed: 11/26/2023] Open
Abstract
OBJECTIVE The risk of occupational exposure during endotracheal intubation has required the global Emergency Medicine (EM), Anesthesia, and Critical Care communities to institute new COVID- protected intubation guidelines, checklists, and protocols. This survey aimed to deepen the understanding of the changes in intubation practices across Canada by evaluating the pre-COVID-19, early-COVID-19, and present-day periods, elucidating facilitators and barriers to implementation, and understanding provider impressions of the effectiveness and safety of the changes made. METHODS We conducted an electronic, self-administered, cross-sectional survey of EM physician site leads within the Canadian COVID-19 Emergency Department Rapid Response Network (CCEDRRN) to characterize and compare airway management practices in the pre-COVID-19, early-COVID-19, and present-day periods. Ethics approval for this study was obtained from the University of Manitoba Health Research Ethics Board. The electronic platform SurveyMonkey ( www.surveymonkey.com ) was used to collect and store survey tool responses. Categorical item responses, including the primary outcome, are reported as numbers and proportions. Variations in intubation practices over time were evaluated through mixed-effects logistic regression models. RESULTS Invitations were sent to 33 emergency department (ED) physician site leads in the CCEDRRN. We collected 27 survey responses, 4 were excluded, and 23 analysed. Responses were collected in English (87%) and French (13%), from across Canada and included mainly physicians practicing in mainly Academic and tertiary sites (83%). All respondents reported that the intubation protocols used in their EDs changed in response to the COVID-19 pandemic (100%, n = 23, 95% CI 0.86-1.00). CONCLUSIONS This study provides a novel summary of changes to airway management practices in response to the evolving COVID-19 pandemic in Canada. Information from this study could help inform a consensus on safe and effective emergent intubation of persons with communicable respiratory infections in the future.
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Rödler JV, Hilgers S, Rüppel M, Föhr P, Hohn A, Chorianopoulos E, Bergrath S. [Indications and success rate of endotracheal emergency intubation in clinical acute and emergency medicine]. DIE ANAESTHESIOLOGIE 2024:10.1007/s00101-024-01444-y. [PMID: 39093363 DOI: 10.1007/s00101-024-01444-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/22/2024] [Indexed: 08/04/2024]
Abstract
BACKGROUND Securing the airway in the emergency department (ED) is a high-stakes procedure; however, the primary success and complication rate are largely unknown in Germany. The aim of this study was a retrospective analysis of prospectively collected resuscitation room data for endotracheal intubation (ETI) regarding indications, performance and complications. METHOD Between 1 January 2020 and 30 June 2023 all ETIs conducted in the ED (Kliniken Maria Hilf, Moenchengladbach, Germany) were analyzed following approval by the ethics committee (EK 23-369). Primary intubations performed by the anesthesiology department were excluded. The core medical team of the ED underwent a six-week training program including a two-week anesthesia rotation prior to performing ETI in the ED. There were standard operating procedures (SOP) for both rapid sequence induction (RSI) and airway exchange with a placed laryngeal tube (LT) utilizing video laryngoscopy (C-Mac, Storz), rocuronium for relaxation and primary intubation with an elastic bougie. The primary success rate, overall success rate and intubation-related complications were analyzed. Additionally, the factor of consultant ED staff and residents was evaluated with respect to the primary success rate. RESULTS During the study period 499 patients were intubated by the core ED team and 28 patients underwent airway exchange from LT to ETI. Primary success could be achieved in 489/499 (98.0%) ETI and in 25/28 (89.3%) LT exchange patients. Surgically achieved securing of the airway was carried out in 5/527 (0.9%) patients in a cannot intubate situation and 11/527 (2.2%) patients suffered cardiac arrest minutes after the ETI. The overall first pass success rate of endotracheal tube placement was 514/527 (97.4%). The comparison of the primary success of consultants (168/175; 96.0%) vs. residents 320/325 (98.5%) yielded no significant differences (p = 0.08). CONCLUSION In clinical acute and emergency medicine, a standardized approach utilizing video laryngoscopy and a bougie following a structured training concept, can achieve an above-average high primary success rate with simultaneous low severe complications in the high-risk collective of critically ill emergency patients in an intrahospital setting.
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