Left Ventricular Assist Device for Cardiac Arrest?

October 7, 2014 by  
Filed under Acute Med, All Updates, ICU, Resus

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LVADguyiconAn interesting case report by Dr Heidlebaugh and colleagues from the Department of Emergency Medicine at the William Beaumont Hospital describes a 72 year old marathon runner who arrested during cardiac catheterisation. It suggests a possible novel alternative to ECMO for cardiac arrest.

The patient became bradycardic then asystolic during catheterisation of his right coronary artery. High quality CPR was initiated and an Impella LV assist device was placed. This restored cardiac output which was followed by episodes of venticular fibrillation and then ROSC. His initial low ejection fraction of 15% recovered after targeted temperature management on ICU to 50% and he fully recovered neurologically.

This patient already had femoral arterial access for introduction of the Impella, since he was in a cath lab. He also had immediate CPR on arresting, and was an abnormally fit 72 year old. It remains to be seen whether this procedure can be applied to other patients in cardiac arrest. The authors state:

..until ECLS is readily available, poor survival and neurological outcome after cardiac arrest might be avoided in many patients by the use of pLVAD to offload the LV and enhance perfusion. Furthermore, there may be a subset of patients, in whom the support that pLVAD offers is sufficient to optimize hemodynamic parameters and bridge to ROSC, thus reducing the need for ECLS.

This video by Dr. I-Wen Wang from the Barnes-Jewish Hospital explains how the Impella is inserted and how it works.

 

 

Full Neurologic Recovery and Return of Spontaneous Circulation Following Prolonged Cardiac Arrest Facilitated by Percutaneous Left Ventricular Assist Device
Ther Hypothermia Temp Manag. 2014 Sep 3. [Epub ahead of print]


Sudden cardiac arrest is associated with high early mortality, which is largely related to postcardiac arrest syndrome characterized by an acute but often transient decrease in left ventricular (LV) function. The stunned LV provides poor cardiac output, which compounds the initial global insult from hypoperfusion. If employed early, an LV assist device (LVAD) may improve survival and neurologic outcome; however, traditional methods of augmenting LV function have significant drawbacks, limiting their usefulness in the periarrest period. Full cardiac support with cardiopulmonary bypass is not always readily available but is increasingly being studied as a tool to intensify resuscitation. There have been no controlled trials studying the early use of percutaneous LVADs (pLVADs) in pericardiac arrest patients or intra-arrest as a bridge to return of spontaneous circulation. This article presents a case study and discussion of a patient who arrested while undergoing an elective coronary angioplasty and suffered prolonged cardiopulmonary resuscitation. During resuscitation, treatment included placement of a pLVAD and initiation of therapeutic hypothermia. The patient made a rapid and full recovery.
Image is of M. Joshua Morris, a happy LVAD recipient (not the patient in the described study) who kindly alerted me to this article. Used with permission.

ARISE study: EGDT no better than standard care

October 4, 2014 by  
Filed under Acute Med, All Updates, Guidelines, ICU, Resus

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periph-vasoactive-iconThe second of three major trials assessing early goal directed therapy (EGDT) in sepsis – the Australasian ARISE Trial – has been published.

ARISE tested the hypothesis that EGDT, as compared with usual care, would decrease 90-day all-cause mortality among patients presenting to the emergency department with early septic shock in diverse health care settings.

There was no difference in all-cause mortality at 90 days between EGDT and standard care, in keeping with the results from ProCESS.

Why are the results so different from Rivers’ original EGDT study? The authors explain:


“although our results differ from those in the original trial, they are consistent with previous studies showing that bias in small, single-center trials may lead to inflated effect sizes”

This cautions us all against making major practice changes based on one single centre study. In critical care we’ve learned this before with subjects like tight glycaemic control and Activated Protein C. However I do believe that the things we know to be of benefit – early recognition, source control, antibiotics, and fluids – are effective in making ‘standard’ care “as good as” EGDT because of heightened awareness of the condition and its treatment, and Rivers’ initial study and the subsequent Surviving Sepsis Campaign Guidelines have played a major role in raising that awareness.

The ARISE study is appraised by Wessex’s The Bottom Line and discussed on the one and only EMCrit podcast.

The ARISE Investigators and the ANZICS Clinical Trials Group.
Goal-Directed Resuscitation for Patients with Early Septic Shock
N Engl J Med. 2014 Oct;:141001063014008.Full Text


Background
Early goal-directed therapy (EGDT) has been endorsed in the guidelines of the Surviving Sepsis Campaign as a key strategy to decrease mortality among patients presenting to the emergency department with septic shock. However, its effectiveness is uncertain.

Methods In this trial conducted at 51 centers (mostly in Australia or New Zealand), we randomly assigned patients presenting to the emergency department with early septic shock to receive either EGDT or usual care. The primary outcome was all-cause mortality within 90 days after randomization.

Results Of the 1600 enrolled patients, 796 were assigned to the EGDT group and 804 to the usual-care group. Primary outcome data were available for more than 99% of the patients. Patients in the EGDT group received a larger mean (±SD) volume of intravenous fluids in the first 6 hours after randomization than did those in the usual-care group (1964±1415 ml vs. 1713±1401 ml) and were more likely to receive vasopressor infusions (66.6% vs. 57.8%), red-cell transfusions (13.6% vs. 7.0%), and dobutamine (15.4% vs. 2.6%) (P<0.001 for all comparisons). At 90 days after randomization, 147 deaths had occurred in the EGDT group and 150 had occurred in the usual-care group, for rates of death of 18.6% and 18.8%, respectively (absolute risk difference with EGDT vs. usual care, -0.3 percentage points; 95% confidence interval, -4.1 to 3.6; P=0.90). There was no significant difference in survival time, in-hospital mortality, duration of organ support, or length of hospital stay.

Conclusions In critically ill patients presenting to the emergency department with early septic shock, EGDT did not reduce all-cause mortality at 90 days.

Non-ST-Elevation Acute Coronary Syndromes

September 29, 2014 by  
Filed under Acute Med, All Updates, EMS, Guidelines, ICU, Resus

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The latest AHA/ACC guidelines on NSTEACS have been published ahead of print in Circulation.

Full text is available, and the Executive Summary is available here

Amsterdam EA, Wenger NK, Brindis RG, Casey DE, Ganiats TG, Holmes DR, et al.
2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes: Executive Summary: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines.
Circulation. 2014 Sep 23. [Epub ahead of print]

Blunt traumatic arrest in kids

September 24, 2014 by  
Filed under All Updates, EMS, Kids, Resus, Trauma

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Traumatic cardiac arrest outcomes are not great, but they’re not so bad that resuscitation is futile – a subject I’ve ranted about before.

The largest study on blunt traumatic arrest in children to date has been published, showing that 340 / 7766 kids without signs of life in the field survived to hospital discharge. Neurological status at discharge was not documented. However, this represents 4.4%, or in other words for every 22 blunt traumatically arrested children who underwent prehospital resuscitation, one survived to discharge. The authors describe this survival as ‘dismal’. It’s not great, but my take on it is that survival is possible and in most cases resuscitation should be attempted.

The authors state:

Based on these data, EMS providers should not be discouraged from resuscitating blunt pediatric trauma patients found in the field with no signs of life

While the major focus should be on injury prevention, it is worthwhile considering whether more advanced resuscitation in the field could be provided to further increase the number of neurologically intact survivors.

Survival of pediatric blunt trauma patients presenting with no signs of life in the field
J Trauma Acute Care Surg. 2014 Sep;77(3):422-6


BACKGROUND: Prehospital traumatic cardiopulmonary arrest is associated with dismal prognosis, and patients rarely survive to hospital discharge. Recently established guidelines do not apply to the pediatric population because of paucity of data. The study objective was to determine the survival of pediatric patients presenting in the field with no signs of life after blunt trauma.

METHODS: We conducted a retrospective analysis of the National Trauma Data Bank research data set (2002-2010). All patients 18 years and younger with blunt traumatic injuries were identified (DRG International Classification of Diseases-9th Rev. codes 800-869). No signs of life (SOL) was defined on physical examination findings and included the following: pulse, 0; respiratory rate, 0; systolic blood pressure, 0; and no evidence of neurologic activity. These same criteria were reassessed on arrival at the emergency department (ED). Furthermore, we examined patients presenting to the ED who underwent resuscitative thoracotomy (Current Procedural Terminology code 34.02). Our primary outcome was survival to discharge from the hospital.

RESULTS: There were a total of 3,115,597 pediatric patients who were found in the field after experiencing blunt trauma. Of those, 7,766 (0.25%) had no SOL. Seventy percent of the patients with no SOL in the field were male. Survival to hospital discharge of all patients presenting with no SOL was 4.4% (n = 340). Twenty-five percent of the patients in the field with no SOL were successfully resuscitated in the field and regained SOL by the time they arrived to the ED (n = 1,913). Of those patients who regained SOL, 13.8% (n = 265) survived to hospital discharge. For patients in the field with no SOL, survival to discharge was significantly higher in patients who did not receive a resuscitative thoracotomy than in those who did.

CONCLUSION: Survival of pediatric blunt trauma patients in the field without SOL is dismal. Resuscitative thoracotomy poses a heightened risk of blood-borne pathogen exposure to involved health care workers and is associated with a significantly lower survival rate.

Resuscitationist lessons from a self-protection master

August 28, 2014 by  
Filed under All Updates, Fascinomata, Resus

UCIt’s better to have it and not need it, than to need it and not have it

My great friend and fellow Brit Lee Morrison is in Sydney again, teaching people how to save lives. Like a resuscitationist. But Lee isn’t a health care worker. He is a professional self protection instructor and martial athlete. The lives he is teaching people to save are their own and those of their friends and families. Lee has travelled the world and taught a diverse range of professionals including law enforcement and military special forces personnel. His current world tour will include the Czech Republic, USA, France, Russia and Germany after Australia.

What does this have to do with resuscitation? In my experience, almost everything. Hitting someone in self defence is technically very easy. Doing a resuscitative hysterotomy is technically very easy. Being able to do either of those things under stress can be difficult or impossible for some people.

Those who strive to understand and cultivate the Mind of the Resuscitationist know the importance of preparation through simulation under stress; the need to acknowledge and control the physiological and emotional response to stress; the necessity to train outside ones comfort zone and minimise the gap between simulated and real situations by optimising the cognitive fidelity of training scenarios; and the requirement to access the right mental state in an instant in which failure is not considered to be an option.

People who do not wish to witness the discussion or demonstration of violence or who cannot stand swearing should stop now. Those of you who want to see mastery in action watch the video below of Lee teaching in Germany.

I want you to appreciate the following:

  • Presentation style – how to connect with an audience and fully engage them through humour, passion, emphasis, intelligent discourse, and detailed explanations that connect emotionally and physically as well as intellectually.
  • The loss of fine motor skill under stress (2 min 13 sec)
  • The mindset of determination (2 min 48 sec) – consider how this relates to the perspective of the resuscitationist prepared to do a resuscitative thoracotomy under stress
  • How to influence and win arguments in a conflict situation by being assertive but providing a face-saving get-out for the aggressor. I have applied this multiple times in the resus room and in retrieval situations. (4 min 11 sec)
  • Training honestly – maintaining safety but ‘doing it like you f—-ing mean it’. Get out of your comfort zone and make the discomfort as real as possible. (7 min 37 sec)
  • How to minimise the gap between your training and what you’re training for, when legal, moral, and safety restrictions prevent you from doing the actual task for real as a training exercise. Using fatigue, pain, and disorientation as perturbations so you learn to recognise and mitigate their effects. (9 min 19 sec)
  • Accessing a single mental state that provides focus and prevents distraction from discomfort (11 min 40 sec)

If the video made you feel uncomfortable ask yourself why. If it’s because you consider yourself to be above violence and find the subject matter, language, and humour to be distasteful, that’s your right to feel like that. But try to dig a little deeper and ask yourself whether there are potential situations in your life that could confront you with fear or pain that you could be better prepared for if you trained with a different mindset.

When the situation arises that demands life-saving action and you are tired, hungry, scared, and discouraged by opposing advice or opinion, do you have the self-knowledge and resilience to see it through? If you don’t know the answer to that, isn’t it time you found out?

You can find out more about Lee at Urban Combatives

Profound hypothermia and no ECMO?

July 11, 2014 by  
Filed under Acute Med, All Updates, ICU, Kids, Resus

CPRsnow2sm

Patients in cardiac arrest due to severe hypothermia benefit from extracorporeal rewarming, and it is often recommended that they are treated at centres capable of providing cardiopulmonary bypass or extracorporeal membrane oxygenation (ECMO).

But what if they’re brought to a centre that doesn’t have those facilities?

If you work in such a centre do you have a plan, and are you familiar with what equipment you could use?

One option if you have an ICU is to provide extracorporeal warming using a haemofiltration machine used for renal replacement therapy(1). A double lumen haemofiltration catheter is inserted into a central vein and an ICU nurse can often do the rest, although some variables have to be set by the intensivist, often aided by a standard renal replacement therapy prescription chart. The machines are mobile and can be wheeled into the resus room (I have practiced this set up in resus). It might be worth discussing and practicing this option with your ICU.

Another extracorporeal option is to rig up a rapid infusion device such as a ‘Level 1′ to connect to arterial and venous catheters so that blood from the patient flows through and is warmed by the machine before being returned to the patient(2). Rapid rewarming has been achieved by this method but it requires some modification to the usual set up and so is much less likely to be a realistic option for most teams doing this on very rare occasions.

Less technical options are the traditionally taught warm saline lavage of body cavities such as the thorax and the peritoneal cavity. These can be achieved with readily available catheters and of course should be combined with ventilation with warmed gas and administration of warm intravenous fluid.

Thoracic lavage can be achieved with open thoracotomy or tube thoracostomy. One or two chest tubes can be placed on each side. One technique was described as:


Two 36 French chest tubes were placed in each hemithorax. One tube was placed in the fourth intercostal space in the mid-clavicular line. Another tube was placed into the sixth intercostal space in the mid-axillary line. Sterile saline at 39.0◦C was infused by gravity into each superior chest tube and allowed to drain passively through each inferior tube.(3)

Rapid rewarming at a rate of 6.8◦C per hour was achieved in an arrested hypothermic man using peritoneal lavage. It was done in the operating room with peritoneal lavage (saline 40◦C) with a rapid infusion system (Level 1) through two laparoscopic access sites. It was combined with external forced air rewarming and warm intravenous infusions(4).

Finally some devices manufactured for inducing hypothermia in post-cardiac arrest patients can also be used to rewarm patients, which might be endovascular devices, such as the Cool Line® catheter(5), or external, such as the Arctic Sun® Temperature Management System(6). It’s definitely worth finding out what your critical care services have as far as this equipment goes.

In summary, although the ‘exam answer’ for cardiac arrest due to profound hypothermia is often ECMO/cardiopulmonary bypass, in most centres that’s not an option. It’s helpful to remind ourselves that (1) other extracorporeal rewarming options exist and (2) non-extracorporeal techniques can provide rapid rewarming.

 

1. Spooner K, Hassani A. Extracorporeal rewarming in a severely hypothermic patient using venovenous haemofiltration in the accident and emergency department. J Accid Emerg Med. 2000 Nov;17(6):422–4. Full text

2. Gentilello LM, Cobean RA, Offner PJ, Soderberg RW, Jurkovich GJ. Continuous arteriovenous rewarming: rapid reversal of hypothermia in critically ill patients. The Journal of Trauma: Injury, Infection, and Critical Care. 1992 Mar;32(3):316–25 PubMed

3. Plaisier BR. Thoracic lavage in accidental hypothermia with cardiac arrest — report of a case and review of the literature. Resuscitation. 2005 Jul;66(1):99–104. PubMed

4. Gruber E, Beikircher W, Pizzinini R, Marsoner H, Pörnbacher M, Brugger H, et al. Non-extracorporeal rewarming at a rate of 6.8°C per hour in a deeply hypothermic arrested patient. Resuscitation. 2014 Aug;85(8):e119–20. PubMed

5. Kiridume K, Hifumi T, Kawakita K, Okazaki T, Hamaya H, Shinohara N, et al. Clinical experience with an active intravascular rewarming technique for near-severe hypothermia associated with traumatic injury. Journal of Intensive Care. BioMed Central Ltd; 2014;2(1):11. link to abstract

6. Cocchi MN, Giberson B, Donnino MW. Rapid rewarming of hypothermic patient using arctic sun device. Journal of Intensive Care Medicine. 2012 Mar;27(2):128–30. PubMed

When to Stop Resuscitation

July 9, 2014 by  
Filed under Acute Med, All Updates, EMS, Guidelines, ICU, Kids, Resus, Trauma

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My talk at the SmaccGOLD conference in March 2014

Cliff Reid – When Should Resuscitation Stop from Social Media and Critical Care on Vimeo.

Here are the slides:

Down with “down” time!

May 11, 2014 by  
Filed under Acute Med, All Updates, EMS, Resus

CPR-icon2A man in his 40s has a witnessed collapse and CPR is immediately started. Paramedics are on scene within 5 minutes and initiate advanced cardiac life support. He has refractory ventricular fibrillation which degenerates to asystole. He arrives in an emergency department where, with good ongoing CPR, he appears reasonably well perfused and even demonstrates some spontaneous movements and reactive pupils. He is placed on a mechanical CPR device and activation of the cardiac cath lab is requested. The patient has been in cardiac arrest now for 32 minutes. The cardiology fellow appears and asks: ‘what’s the down time?’

What’s the right answer? Would you say ‘half an hour’? ’32 minutes’?
And does it matter? Why is the cardiology fellow asking? Does she have an arbitrary cut off in mind, over which emergency coronary reperfusion will be denied?

I think there are several problems with conversations like these.
The first, is what does ‘down time’ even mean?
The second, is how relevant is a cardiac arrest time interval to prognosis in an individual patient?
The third, is what is the significance of any time interval in a patient who at the time of assessment has some signs that CPR is providing some perfusion and there is some evidence of brain function?

Let’s take the first. The definition of ‘down time’ does not appear to be standardised:

In this publication it appears to refer to the time before resuscitation is commenced, where it is demonstrated to be prognostically important.

Similarly, in this medical dictionary, it is defined as the ‘temporal duration from cardiac arrest until beginning cardiopulmonary resuscitation or advanced cardiac life support.

However, a post in Life in the Fast Lane defines it as ‘time to return of spontaneous circulation

This appears to agree with The New South Wales Government’s Intensive Care Monitoring and Coordination Unit who define it as ‘the time from when a person’s heart stops beating to the time it starts beating again

Yet another definition is used in King County, Washington, where it is defined as ‘the time interval from collapse to call 911‘.

So the first thing is to clarify what we’re talking about: “This patient received immediate bystander CPR. He has had resuscitation for 32 minutes”. My friend in the UK, nurse resuscitationist Fernando Candal Carballido, coined the term ‘Time of Supported Circulation‘, or TOSC. I quite like this and think it could catch on.

The next question is so what? What if it was 90 minutes? At what point do we declare futility? This is where I believe the game has changed. Multiple survivors of prolonged resuscitation are springing up in the news and in the literature. Particularly in the subgroup of patients with minimal comorbidity, early CPR, and who receive circulatory support via ECMO or mechanical CPR while they undergo coronary reperfusion.

For a great example of a prolonged CPR survivor, check out paramedic Wayne Schneider’s story,

…or listen to Steven Bernard describe amazing results from ECMO used in Melbourne in the CHEER study, which includes survivors of over two hours of CPR.

So, in summary:

  • Be clear on your definitions when communicating with colleagues. ‘Down time’ does not appear to have a standard definition, so I would avoid its use.
  • Some patients without comorbidities who have had early bystander CPR may survive despite long periods of CPR (or ‘TOSC’), provided the underlying cause can be treated or is reversible.
  • ECMO and even more widely available mechanical CPR devices are extending the period in which these causes can be addressed.

Breaking with tradition in paediatric RSI

April 8, 2014 by  
Filed under All Updates, EMS, ICU, Kids, Resus

‘Traditional’ rapid sequence induction of anaesthesia is often described with inclusion of cricoid pressure and the strict omission of any artifical ventilation between paralytic drug administration and insertion of the tracheal tube. These measures are aimed at preventing pulmonary aspiration of gastric contents although there is no convincing evidence base to support that. However it is known that cricoid pressure can worsen laryngoscopic view and can occlude the paediatric airway. We also know that children desaturate quickly after the onset of apnoea, and although apnoeic diffusion oxygenation via nasal cannula can prevent or delay that, in some cases it may be preferable to bag-mask ventilate the patient while awaiting full muscle relaxation for laryngoscopy.

A Swiss study looked at 1001 children undergoing RSI for non-cardiac surgery. They used a ‘controlled rapid sequence induction and intubation (cRSII)’ approach for children assumed to have full stomachs. This procedure resembled RSI the way it is currently done in many modern critical care settings, including the retrieval service I work for:

  • No cricoid pressure
  • Ketamine for induction if haemodynamically unstable
  • A non-depolarising neuromuscular blocker rather than succinylcholine
  • No cricoid pressure
  • Gentle facemask ventilation to maintain oxygenation until intubation conditions achieved
  • Intubation with a cuffed tracheal tube
  • Still no cricoid pressure

The authors comment:

The main finding was that cRSII demonstrated a considerably lower incidence of oxygen desaturation and consecutive hemodynamic adverse events during anesthesia induction than shown by a previous study on classic RSII in children. Furthermore, there was no incidence of pulmonary aspiration during induction, laryngoscopy, and further course of anesthesia.

Looks like more dogma has been lysed, and this study supports the current trajectory away from traditional teaching towards an approach more suitable for critically ill patients.

Controlled rapid sequence induction and intubation – an analysis of 1001 children
Paediatr Anaesth. 2013 Aug;23(8):734-40


BACKGROUND: Classic rapid sequence induction puts pediatric patients at risk of cardiorespiratory deterioration and traumatic intubation due to their reduced apnea tolerance and related shortened intubation time. A ‘controlled’ rapid sequence induction and intubation technique (cRSII) with gentle facemask ventilation prior to intubation may be a safer and more appropriate approach in pediatric patients. The aim of this study was to analyze the benefits and complications of cRSII in a large cohort.

METHODS: Retrospective cohort analysis of all patients undergoing cRSII according to a standardized institutional protocol between 2007 and 2011 in a tertiary pediatric hospital. By means of an electronic patient data management system, vital sign data were reviewed for cardiorespiratory parameters, intubation conditions, general adverse respiratory events, and general anesthesia parameters.

RESULTS: A total of 1001 patients with cRSII were analyzed. Moderate hypoxemia (SpO2 80-89%) during cRSII occurred in 0.5% (n = 5) and severe hypoxemia (SpO2 <80%) in 0.3% of patients (n = 3). None of these patients developed bradycardia or hypotension. Overall, one single gastric regurgitation was observed (0.1%), but no pulmonary aspiration could be detected. Intubation was documented as ‘difficult’ in two patients with expected (0.2%) and in three patients with unexpected difficult intubation (0.3%). The further course of anesthesia as well as respiratory conditions after extubation did not reveal evidence of ‘silent aspiration’ during cRSII.

CONCLUSION: Controlled RSII with gentle facemask ventilation prior to intubation supports stable cardiorespiratory conditions for securing the airway in children with an expected or suspected full stomach. Pulmonary aspiration does not seem to be significantly increased.

Palpating neonatal tracheal tubes

April 6, 2014 by  
Filed under All Updates, EMS, ICU, Kids, Resus

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infant-intubate-iconAfter neonatal intubation, the incidence of malposition of the tip of the tracheal tube is fairly high.

A technique was evaluated involving palpation of the tube tip in the suprasternal notch, which in this small study was superior to insertion length based on a weight-based nomogram.

The suprasternal notch was chosen because it anatomically corresponds to vertebral level T2, close to the optimal position at the mid-tracheal point. Correct position on the chest radiograph was defined as any position <0.5 cm above the interclavicular midpoint and more than 1 cm above the carina.

During tracheal tube placement, the tip was gently palpated in the suprasternal notch with the index or little finger of the left hand while holding the body of the tube with the fingers of the right hand. The tube tip was adjusted until the bevelled edge was just palpable in the the suprasternal notch.

Digital palpation of endotracheal tube tip as a method of confirming endotracheal tube position in neonates: an open-label, three-armed randomized controlled trial.
Paediatr Anaesth. 2013 Oct;23(10):934-9


OBJECTIVE: To compare the malposition rates of endotracheal tubes (ETTs) when the insertional length (IL) is determined by a weight-based nomogram versus when IL is determined by palpation of the ETT tip.

DESIGN: Open-label, randomized controlled trial (RCT).

SETTING: Level III neonatal intensive care unit (NICU).

SUBJECTS: All newborn babies admitted in NICU requiring intubation.

INTERVENTIONS: Subjects were randomly allocated to one of three groups, wherein IL was determined by (i) weight-based nomogram alone, (ii) weight-based nomogram combined with suprasternal palpation of ETT tip performed by specially trained neonatology fellows, or (iii) combination of weight-based and suprasternal methods by personnel not specially trained.

PRIMARY OUTCOME: Rate of malposition of ETT as judged on chest X-ray (CXR).

RESULTS: Fifty seven babies were randomized into group 1(n = 15), group 2 (n = 20), and group 3 (n = 22). The proportion of correct ETT placement was highest in group 2, being 66.7%, 83.3%, and 66.7% in groups 1 through 3, respectively (P value = 0.58). No complication was attributable to palpation technique.

CONCLUSION: Suprasternal palpation shows promise as a simple, safe, and teachable method of confirming ETT position in neonates.

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