The non-intubation checklist
June 17, 2013 by Cliff
Filed under All Updates, ICU, Resus
A 79 year old previously well female presents with loss of consciousness, having been found unresponsive by her daughter who saw her well one hour previously.
Examination reveals a GCS of E1V2M3 = 6 and reactive pupils with no lateralising signs. She is hypertensive. A VBG reveals a normal glucose and sodium and a pCO2 of 60 mmHg (7.9 kPa).
The emergency physician’s plan is to intubate and get a CT scan of her brain. This is explained to the daughter.
A no-brainer? You’d think so.
A consistent issue that recurs during discussions with UK emergency medicine colleagues is that of having to rely on anaesthesia and/or ICU colleagues for intubation of their patients in the ED. The pain comes not from disagreeing about who does the procedure or what drugs to use, but rather on the decision to intubate.
The refusal to intubate can stall or halt a resuscitation plan, delay care, result in risky transfers to the imaging suite, and even deny potential outcome-improving therapy (for example post-ROSC cooling). It can undermine team leadership and disrupt the team dynamic.
There are often different ways to ‘skin a cat’ and it is frequently helpful to invite the opinion of other critical care specialists. However, it is clear from multiple discussions with frustrated EM colleagues that the decision not to intubate is often influenced by non-clinical factors, most often ICU bed availability. Other times, it appears to be that the ‘gatekeeper’ to airway care (and to ICU beds) does not share the same appreciation of the clinical issues at stake. Examples here include the self-fulfilling pessimism post-ROSC based on inappropriate assignment of predictive value to neurological signs, and the assumption of non-treatable pathology in elderly patients presenting with coma.
The obvious solution to this is that the responsibility for managing the ‘A’ of ABC should not be delegated to non-emergency medicine personnel. Sadly, this is not achievable 24/7 in all UK departments right now for a number of awkward reasons.
So what’s a team leader to do when faced with a colleague’s refusal to intubate? The best approach would be to gently and politely persuade them to change their mind by stating some clinical facts that enable a shared mental model and agreed management plan, and to ensure the most senior available physicians are participating in the discussion.
Sometimes that fails. What next? Here’s a suggestion. This is slightly tongue-in-cheek but take away from it what you will.
It is imperative that the individual declining intubation appreciates the gravity of his or her decision. They must not be under the impression that they’ve done you (and the patient) a favour by giving their opinion after an ‘airway consult’. They have declined a resuscitative intervention requested by the emergency medicine team leader and should appreciate the consequences of this decision and the need to document it as such.
Perhaps say something along the lines of:
And here’s the form. It is provocative, cheeky, and in no way should really be used in its current form:
RSI haemodynamics in the field
The noxious stimulus of laryngoscopy & tracheal intubation can precipitate hypertension, tachycardia, and intracranial pressure elevation, risking exacerbation of brain injury or haemorrhage. Physicians from an English Helicopter Emergency Medical Service examined the response of heart rate and blood pressure to prehospital rapid sequence intubation (RSI). While a retrospective study, the haemodynamic data were prospectively recorded and documented using standard monitor printouts, and time of intubation could be accurately determined by the onset of capnography recordings. Their standardised system documents blood pressure recordings every three minutes. Etomidate and suxamethonium were used for RSI.
They report their findings:
A hypertensive response occurred in 79% (70/89) of patients. MAP exceeded the upper limit of estimated intact cerebral autoregulation (150 mmHg) in 18% (16/89) of cases and 9% (8/89) of patients had a greater than 100% increase in MAP and/or SBP. A single hypotensive response occurred. A tachycardic response occurred in 58% (64/110) of patients and bradycardia was induced in one.
Of note, 97 of the 115 patients had injuries that included head trauma.
The authors note that opioids are often co-administered during in-hospital RSI and that this may offset the haemodynamic stimulation, while possible increasing the complexity of the procedure in the prehospital environment. They have modified their pre-hospital anaesthesia standard operating procedure to include the use of an opioid and will report the associated outcomes and complication rates ‘in due course’.
This is interesting and important stuff, and something we should all be looking at in our respective prehospital critical care services.
The haemodynamic response to pre-hospital RSI in injured patients
Injury. 2013 May;44(5):618-23
BACKGROUND: Laryngoscopy and tracheal intubation provoke a marked sympathetic response, potentially harmful in patients with cerebral or cardiovascular pathology or haemorrhage. Standard pre-hospital rapid sequence induction of anaesthesia (RSI) does not incorporate agents that attenuate this response. It is not known if a clinically significant response occurs following pre-hospital RSI or what proportion of injured patients requiring the intervention are potentially at risk in this setting.
METHODS: We performed a retrospective analysis of 115 consecutive pre-hospital RSI’s performed on trauma patients in a physician-led Helicopter Emergency Medical Service. Primary outcome was the acute haemodynamic response to the procedure. A clinically significant response was defined as a greater than 20% change from baseline recordings during laryngoscopy and intubation.
RESULTS: Laryngoscopy and intubation provoked a hypertensive response in 79% of cases. Almost one-in-ten patients experienced a greater than 100% increase in mean arterial pressure (MAP) and/or systolic blood pressure (SBP). The mean (95% CI) increase in SBP was 41(31-51) mmHg and MAP was 30(23-37) mmHg. Conditions leaving the patient vulnerable to secondary injury from a hypertensive response were common.
CONCLUSIONS: Laryngoscopy and tracheal intubation, following a standard pre-hospital RSI, commonly induced a clinically significant hypertensive response in the trauma patients studied. We believe that, although this technique is effective in securing the pre-hospital trauma airway, it is poor at attenuating adverse physiological effects that may be detrimental in this patient group.
Difficult intubation on ICU
May 12, 2013 by Cliff
Filed under All Updates, ICU
A score to predict difficulty of intubation in ICU patients underwent derivation and validation in French ICUs. The main predictors included Mallampati score III or IV, obstructive sleep apnoea syndrome, reduced mobility of cervical spine, limited mouth opening, severe hypoxia, coma, and where the operator was a nonanesthesiologist.
The striking thing is the overall rate of difficult intubations, defined as three or more laryngoscopy attempts or taking over 10 minutes using conventional laryngoscopy(!) and the high rate of severe complications.
The incidence of difficult intubation was 11.3% (113 of 1,000 intubation procedures) in the original cohort and 8% (32 of 400 intubation procedures) in the validation cohort.
In the development cohort, overall complications occurred in 437 of 1,000 intubation procedures (43.7%), with 381 (38.1%) severe complications (26 cardiac arrests, 2.6%; five deaths, 0.5%; 274 severe collapses, 27.4%; 155 severe hypoxemia, 15.5%) and 112 (11.2%) moderate complications (15 agitations, 1.5%; 32 cardiac arrhythmias, 3.2%; 23 aspirations, 2.3%; 48 esophageal intubations, 4.8%; six dental injuries, 0.6%).
There is no comment on incidence of propofol use for induction; I was tempted to speculate whether it was implicated in any of the cardiac arrests – something we observe time and again in the critically ill – but the authors state: “The drugs used for intubation, in particular neuromuscular blockers, did not differ between groups… However, midazolam use was more frequent in case of difficult intubation.“
Capnography was used only in 46% of intubations, and there was no mention of checklist use. It is fascinating how some aspects of airway management that might be considered minimum and basic safety standards in some practice settings are not yet routine in other specialties or locations.
An interesting study, from which one of the take home messages for me has to be a resounding ‘Yikes!’.
Early Identification of Patients at Risk for Difficult Intubation in the Intensive Care Unit
Am J Respir Crit Care Med. 2013 Apr 15;187(8):832-9
Rationale: Difficult intubation in the intensive care unit (ICU) is a challenging issue.
Objectives: To develop and validate a simplified score for identifying patients with difficult intubation in the ICU and to report related complications.
Methods: Data collected in a prospective multicenter study from 1,000 consecutive intubations from 42 ICUs were used to develop a simplified score of difficult intubation, which was then validated externally in 400 consecutive intubation procedures from 18 other ICUs and internally by bootstrap on 1,000 iterations.
Measurements and Main Results: In multivariate analysis, the main predictors of difficult intubation (incidence = 11.3%) were related to patient (Mallampati score III or IV, obstructive sleep apnea syndrome, reduced mobility of cervical spine, limited mouth opening); pathology (severe hypoxia, coma); and operator (nonanesthesiologist). From the β parameter, a seven-item simplified score (MACOCHA score) was built, with an area under the curve (AUC) of 0.89 (95% confidence interval [CI], 0.85-0.94). In the validation cohort (prevalence of difficult intubation = 8%), the AUC was 0.86 (95% CI, 0.76-0.96), with a sensitivity of 73%, a specificity of 89%, a negative predictive value of 98%, and a positive predictive value of 36%. After internal validation by bootstrap, the AUC was 0.89 (95% CI, 0.86-0.93). Severe life-threatening events (severe hypoxia, collapse, cardiac arrest, or death) occurred in 38% of the 1,000 cases. Patients with difficult intubation (n = 113) had significantly higher severe life-threatening complications than those who had a nondifficult intubation (51% vs. 36%; P < 0.0001).
Conclusions: Difficult intubation in the ICU is strongly associated with severe life-threatening complications. A simple score including seven clinical items discriminates difficult and nondifficult intubation in the ICU.
The importance of first pass success
A large single-centre study in an academic tertiary care center emergency department (where residents perform most of the intubations) examined 1,828 orotracheal intubations, of which 1,333 were intubated successfully on the first attempt (72.9%).
Adverse events (AE) captured were oesophageal intubation, oxygen desaturation, witnessed aspiration, mainstem intubation, accidental extubation, cuff leak, dental trauma, laryngospasm, pneumothorax, hypotension, dysrhythmia, and cardiac arrest.
When the first pass was successful, the incidence of AEs was 14.2%. More than one attempt was associated with significantly more AEs. Patients requiring two attempts had 33% more AEs (47.2%) and as the number of attempts increased, so did the risk of AEs, with the largest increase in AEs occurring between an unsuccessful first attempt and the second intubation attempt.
This is a powerful argument in favour of optimising first pass success. In the prehospital service I work for, We like to include this in a ‘first pass, no desat, no hypotension’ package that includes team simulation training, pre-intubation briefing, checklist use, optimisation of position, ketamine induction (and avoidance of propofol), apnoeic oxygenation, bougie use, bimanual laryngoscopy, and waveform capnography.
The Importance of First Pass Success When Performing Orotracheal Intubation in the Emergency Department
Academic Emergency Medicine 2013;20(1):71–78, Free Full Text
Objectives The goal of this study was to determine the association of first pass success with the incidence of adverse events (AEs) during emergency department (ED) intubations.
Methods This was a retrospective analysis of prospectively collected continuous quality improvement data based on orotracheal intubations performed in an academic ED over a 4-year period. Following each intubation, the operator completed a data form regarding multiple aspects of the intubation, including patient and operator characteristics, method of intubation, device used, the number of attempts required, and AEs. Numerous AEs were tracked and included events such as witnessed aspiration, oxygen desaturation, esophageal intubation, hypotension, dysrhythmia, and cardiac arrest. Multivariable logistic regression was used to assess the relationship between the primary predictor variable of interest, first pass success, and the outcome variable, the presence of one or more AEs, after controlling for various other potential risk factors and confounders.
Results Over the 4-year study period, there were 1,828 orotracheal intubations. If the intubation was successful on the first attempt, the incidence of one or more AEs was 14.2% (95% confidence interval [CI] = 12.4% to 16.2%). In cases requiring two attempts, the incidence of one or more AEs was 47.2% (95% CI = 41.8% to 52.7%); in cases requiring three attempts, the incidence of one or more AEs was 63.6% (95% CI = 53.7% to 72.6%); and in cases requiring four or more attempts, the incidence of one or more AEs was 70.6% (95% CI = 56.2.3% to 82.5%). Multivariable logistic regression showed that more than one attempt at tracheal intubation was a significant predictor of one or more AEs (adjusted odds ratio [aOR] = 7.52, 95% CI = 5.86 to 9.63).
Conclusions When performing orotracheal intubation in the ED, first pass success is associated with a relatively small incidence of AEs. As the number of attempts increases, the incidence of AEs increases substantially.
Ketamine & cardiovascular stability
I ‘jumped ship’ from etomidate to ketamine for rapid sequence intubation (RSI) in sick patients about seven years ago. Good thing too, since I later moved to Australia where we don’t have etomidate. I’ve been one of the aggressive influences behind my prehospital service’s switch to ketamine as the standard induction agent for prehospital RSI. It’s no secret that I think propofol has no place in RSI in the critically ill.
I love ketamine for its haemodynamic stability compared with other induction agents. In fact, I very rarely see a drop in blood pressure when I use it for RSI even in significantly shocked patients. One should however try to remain open to evidence that disconfirms ones biases, lest we allow science to be replaced by religion. I therefore was interested to read a report of two cases of cardiac arrest following the administration of ketamine for rapid sequence intubation (RSI)(1).
The first case was a 25 year old with septic shock due to an intestinal perforation, with a respiratory rate of 30 ‘labored’ breaths per minute and hypoxaemia prior to intubation with 2mg/kg ketamine who became bradycardic and then had a 10-15 minute PEA arrest after ketamine administration (but prior to intubation). Pre-arrest oxygen saturation and pre-induction blood gases are not reported.
The second case was an 11 year old with septic shock and pneumonia, hypoxaemia, and a severe metabolic acidosis. She arrest with bradycardia then a brief period of asystole one minute after receiving 2.4 mg/kg ketamine with rocuronium for intubation.
Was the ketamine responsible for the arrests? Ketamine usually exhibits a stimulatory effect on the cardiovascular system, through effects which are incompletely understood but include a centrally mediated sympathetic response and probable inhibition of norepinephrine (noradrenaline) reuptake. However ketamine can have a direct depressant effect on cardiac output which is usually overridden by the sympathetic stimulation. In critically ill severely stressed patients the depressant effect may predominate. In a study on 12 critically ill surgical patients, haemodynamic indices were measured using pulmonary artery catheters within 5 minutes of ketamine administration (at a mean of 70 mg)(2). Six patients demonstrated decreases in ventricular contractility, and four had decreases in cardiac output. Mean arterial blood pressure decreased in four patients. The authors commented:
The patients..were septic, hypovolemic, or cirrhotic, and had severe stress preoperatively. It is possible that in these ill patients adrenocortical and catechol stores had been depleted prior to ketamine administration. Alternatively, in the setting of prolonged preoperative stress, there may be resistance to further sympathetic and/or adrenocotical stimulation by ketamine. In either case, preoperative stress may blunt the usual physiologic responses to ketamine, setting the stage for possible adverse effects.
The negative cardiovascular effects of ketamine may also be precipitated by larger doses or repeated doses of ketamine(3).
While this small case series of cardiac arrest following ketamine administration is interesting, we should bear in mind the other possible precipitants of arrest in these patients, which are not all discussed by the authors:
i) Both patients were hypoxaemic prior to induction and their peri-intubation oxygen saturations are not reported. Arrests following bradycardia at the time of induction in the critically ill are frequently related to hypoxaemia.
ii) The second patient had a severe metabolic acidosis and the first – an abdominal sepsis patient with a labored respiratory rate of 30 – very probably did too. A failure to match a patient’s compensatory respiratory alkalosis with hyperventilation after anaesthesia is known to precipitate arrest in acidaemic patients.
iii) Finally, if the ketamine was responsible for the arrests, one should consider that the doses given to these shocked and highly unstable patients were well in excess of what many of us would recommend, and doses in the range of 0.5-1 mg/kg might not have been associated with adverse effects.
The takehome points for me are that this report is a helpful reminder that the cardiovascular stimulation-inhibition balance of ketamine may be altered by severe critical illness, and that doses of any induction agent should be significantly reduced in the critically ill patient. In no way does this convince me that I should discard ketamine as my preferred choice for RSI in such patients.
1. Cardiac Arrest Following Ketamine Administration for Rapid Sequence Intubation
J Intensive Care Med. 2012 May 29. [Epub ahead of print]
Given their relative hemodynamic stability, ketamine and etomidate are commonly chosen anesthetic agents for sedation during the endotracheal intubation of critically ill patients. As the use of etomidate has come into question particularly in patients with sepsis, due to its effect of adrenal suppression, there has been a shift in practice with more reliance on ketamine. However, as ketamine relies on a secondary sympathomimetic effect for its cardiovascular stability, cardiovascular and hemodynamic compromise may occur in patients who are catecholamine depleted. We present 2 critically ill patients who experienced cardiac arrest following the administration of ketamine for rapid sequence intubation (RSI). The literature regarding the use of etomidate and ketamine for RSI in critically ill patients is reviewed and options for sedation during endotracheal intubation in this population are discussed.
2. Cardiovascular effects of anesthetic induction with ketamine
Anesth Analg. 1980 May;59(5):355-8
Anesthetic induction with ketamine has been reported to maintain or improve cardiovascular performance in severely ill patients. Using invasive cardiovascular monitoring, we studied physiologic responses to a single dose of ketamine in 12 critically ill patients. Six patient demonstrated decreases in ventricular contractility, and four had decreases in cardiac output. Mean arterial blood pressure decreased in four patients. Pulmonary venous admixture increased in four of six patients, while oxygen consumption decreased in eight of 11 patients. Thus, a single dose of ketamine produced decreases in cardiac and pulmonary performance and in peripheral oxygen transport in this group of patients. It is proposed that in severely ill patients, preoperative stress may alter the usual physiologic responses to ketamine administration, and adverse effects may predominate. Ketamine, therefore, should be used with caution for induction of anesthesia in critically ill and in acutely traumatized patients until additional studies and further information on cardiovascular responses to ketamine are available.
3. A comparison of some cardiorespiratory effects of althesin and ketamine when used for induction of anaesthesia in patients with cardiac disease
Br J Anaesth. 1976 Nov;48(11):1071-81
Cardiorespiratory effects of ketamine and Althesin were measured in two groups of premedicated patients with cardiac disease. The drugs were given in clinically equivalent doses with a second dose administered about 10 min after induction. The first dose of ketamine caused a marked increase in systemic and pulmonary arterial pressure, heart rate, and central venous and wedge pressures and cardiac index. The first dose of Althesin caused a decrease in systemic arterial pressure, central venous pressure, cardiac index and heart work, but little change in heart rate. The second dose of induction agent was administered before the cardiorespiratory effects of the initial dose had resolved. The second dose of Althesin caused changes similar to those following the first dose, but less marked. The changes following the second dose of ketamine were opposite to those following the first dose.
Lifting the Fogg on ED Intubaton
January 1, 2013 by Cliff
Filed under All Updates, ICU, Resus
Fellow retrieval specialist and Royal North Shore Hospital emergency physician Dr Toby Fogg and coauthors have published their audit of intubations in an Australian Emergency Department(1). More important than the results themselves is that the process of monitoring ones practice inevitably leads to improvements. For example, at Toby’s institution an intubation checklist has been introduced since the audit began. Other Australasian EDs are encouraged to participate using the free resources at airwayregistry.org.au.
Recently we have also seen the publication of Korean registry data on paediatric intubations performed in 13 academic EDs over 5 years(2), in which first pass success rates (overall 67.6%) were higher with emergency physicians compared with paediatricians. Interestingly, a rapid sequence intubation technique was only used in 22.4% of intubations, which was more likely to be used by emergency physicians and was associated with a greater likelihood of first pass success.
This relatively low first pass success rate is reminiscent of the American study published in September(3) which raised some eyebrows with its 52% first pass intubation success rates in a paediatric ED, and which also showed that attending-level providers were 10 times more likely to be successful on the first attempt than all trainees combined. Possible reasons for such a low first pass success rate compared with adult registry data include the rigorous video analysis method used, or perhaps more likely that paediatric emergency subspecialists are exposed to fewer critical procedures, resuscitations, and intubations than their general emergency medicine counterparts(4).
As a specialty we must continue to seek to do better, and I salute all these brave authors who are telling it like it is. Particularly with children, whose airways are relatively easy, we have to develop the training, preparation, supervision, monitoring and feedback to aim for as high a success rate as possible.
Study authors Toby Fogg and Nick Annesley demonstrate the 'Happiness Triad'
1. Prospective observational study of the practice of endotracheal intubation in the emergency department of a tertiary hospital in Sydney, Australia
Emerg Med Australas. 2012 Dec;24(6):617-24
OBJECTIVE: To describe the practice of endotracheal intubation in the ED of a tertiary hospital in Australia, with particular emphasis on the indication, staff seniority, technique, number of attempts required and the rate of complications.
METHODS: A prospective observational study.
RESULTS: Two hundred and ninety-five intubations occurred in 18 months. Trauma was the indication for intubation in 30.5% (95% CI 25.3-36.0) and medical conditions in 69.5% (95% CI 64.0-74.5). Emergency physicians were team leaders in 69.5% (95% CI 64.0-74.5), whereas ED registrars or senior Resident Medical Officers made the first attempt at intubation in 88.1% (95% CI 83.9-91.3). Difficult laryngoscopy occurred in 24.0% (95% CI 19.5-29.3) of first attempts, whereas first pass success occurred in 83.4% (95% CI 78.7-87.2). A difficult intubation occurred in 3.4% (95% CI 1.9-6.1) and all patients were intubated orally in five or less attempts. A bougie was used in 30.9% (95% CI 25.8-36.5) of first attempts, whereas a stylet in 37.5% (95% CI 32.1-43.3). Complications occurred in 29.0% (95% CI 23.5-34.1) of the patients, with desaturation the commonest in 15.7% (95% CI 11.9-20.5). Cardiac arrest occurred in 2.2% (95% CI 0.9-4.4) after intubation. No surgical airways were undertaken.
CONCLUSION: Although the majority of results are comparable with overseas data, the rates of difficult laryngoscopy and desaturation are higher than previously reported. We feel that this data has highlighted the need for practice improvement within our department and we would encourage all those who undertake emergent airway management to audit their own practice of this high-risk procedure.
2. The factors associated with successful paediatric endotracheal intubation on the first attempt in emergency departments: a 13-emergency-department registry study
Resuscitation. 2012 Nov;83(11):1363-8
BACKGROUND: We investigated which factors are associated with successful paediatric endotracheal intubation (ETI) on the first attempt in emergency department (EDs) from multicentre emergency airway registry data.
METHODS: We created a multicentre registry of intubations at 13 EDs and performed surveillance over 5 years. Each intubator filled out a data form after an intubation. We defined “paediatric patients” as patients younger than 10 years of age. We assessed the specialty and level of training of intubator, the method, the equipment, and the associated adverse events. We analysed the intubation success rates on the first attempt (first-pass success, FPS) based on these variables.
RESULTS: A total of 430 ETIs were performed on 281 children seen in the ED. The overall FPS rate was 67.6%, but emergency medicine (EM) physicians showed a significantly greater success rate of 74.4%. In the logistic regression analysis, the intubator’s specialty was the only independent predictive factor for paediatric FPS. In the subgroup analysis, the EM physicians used the rapid sequence intubation/intubation (RSI) method and Macintosh laryngoscope more frequently than physicians of other specialties. ETI-related adverse events occurred in 21 (7.2%) out of the 281 cases. The most common adverse event in the FPS group was mainstem bronchus intubation, and vomiting was the most common event in the non-FPS group. The incidence of adverse events was lower in the FPS group than in the non-FPS group, but this difference was not statistically significant.
CONCLUSIONS: The intubator’s specialty was the major factor associated with FPS in emergency department paediatric ETI, The overall ETI FPS rate among paediatric patients was 67.6%, but the EM physicians had a FPS rate of 74.4%. A well structured airway skill training program, and more actively using the RSI method are important and this could explain this differences.
3.Rapid sequence intubation for pediatric emergency patients: higher frequency of failed attempts and adverse effects found by video review.
Ann Emerg Med. 2012 Sep;60(3):251-9
STUDY OBJECTIVE: Using video review, we seek to determine the frequencies of first-attempt success and adverse effects during rapid sequence intubation (RSI) in a large, tertiary care, pediatric emergency department (ED).
METHODS: We conducted a retrospective study of children undergoing RSI in the ED of a pediatric institution. Data were collected from preexisting video and written records of care provided. The primary outcome was successful tracheal intubation on the first attempt at laryngoscopy. The secondary outcome was the occurrence of any adverse effect during RSI, including episodes of physiologic deterioration. We collected time data from the RSI process by using video review. We explored the association between physician type and first-attempt success.
RESULTS: We obtained complete records for 114 of 123 (93%) children who underwent RSI in the ED during 12 months. Median age was 2.4 years, and 89 (78%) were medical resuscitations. Of the 114 subjects, 59 (52%) were tracheally intubated on the first attempt. Seventy subjects (61%) had 1 or more adverse effects during RSI; 38 (33%) experienced oxyhemoglobin desaturation and 2 required cardiopulmonary resuscitation after physiologic deterioration. Fewer adverse effects were documented in the written records than were observed on video review. The median time from induction through final endotracheal tube placement was 3 minutes. After adjusting for patient characteristics and illness severity, attending-level providers were 10 times more likely to be successful on the first attempt than all trainees combined.
CONCLUSION: Video review of RSI revealed that first-attempt failure and adverse effects were much more common than previously reported for children in an ED.
4. A is for airway: a pediatric emergency department challenge.
Ann Emerg Med. 2012 Sep;60(3):261-3
Etomidate & sepsis
A meta-analysis attempts to quantify etomidate’s effect on mortality and adrenal suppression. Of course, we all know a meta-analysis can only be as reliable as the original data it’s analysing. I think editorialists Lauzier and Turgeon have a point with their statement:
“Given the widespread use of etomidate in the emergency room, we believe that a RCT designed to evaluate the safety of etomidate as a hypnotic agent for endotracheal intubation of patients with sepsis is not only ethical but also urgently warranted”
For a critique of the paper and subsequent discussion, check out the Academic Life in EM blog post by Brian Hayes
OBJECTIVE: To evaluate the effects of single-dose etomidate on the adrenal axis and mortality in patients with severe sepsis and septic shock.
DESIGN: A systematic review of randomized controlled trials and observational studies with meta-analysis.
SETTING: Literature search of EMBASE, Medline, Cochrane Database, and Evidence-Based Medical Reviews.
SUBJECTS: Sepsis patients who received etomidate for rapid sequence intubation.
INTERVENTIONS: None.
MEASUREMENTS AND MAIN RESULTS: We conducted a systematic review of randomized controlled trials and observational studies with meta-analysis assessing the effects of etomidate on adrenal insufficiency and all-cause mortality published between January 1950 and February 2012. We only examined studies including septic patients. All-cause mortality served as our primary end point, whereas the prevalence of adrenal insufficiency was our secondary end point. Adrenal insufficiency was determined using a cosyntropin stimulation test in all studies. We used a random effects model for analysis; heterogeneity was assessed with the I statistic. Publication bias was evaluated with Begg’s test. Five studies were identified that assessed mortality in those who received etomidate. A total of 865 subjects were included. Subjects who received etomidate were more likely to die (pooled relative risk 1.20; 95% confidence interval 1.02-1.42; Q statistic, 4.20; I2 statistic, 4.9%). Seven studies addressed the development of adrenal suppression associated with the administration of etomidate; 1,303 subjects were included. Etomidate administration increased the likelihood of developing adrenal insufficiency (pooled relative risk 1.33; 95% confidence interval 1.22-1.46; Q statistic, 10.7; I2 statistic, 43.9%).
CONCLUSIONS: Administration of etomidate for rapid sequence intubation is associated with higher rates of adrenal insufficiency and mortality in patients with sepsis.
Etomidate is associated with mortality and adrenal insufficiency in sepsis: A meta-analysis Crit Care Med. 2012 Nov;40(11):2945-53
Intubation of the critically ill in Scotland
April 16, 2012 by Minh Le Cong
Filed under All Updates, ICU, Resus
Hi folks! Cliff has given me the helm of his blogsite for this week whilst he is teaching prehospital and critical care ultrasound with the Americans at Castlefest 2012
He invited me to write an article on this latest paper in British Journal of Anaesthesia on Scottish ICU audit of emergency tracheal intubation. For those who don’t know, Cliff has a proud Scottish heritage and this paper is a useful audit of his home land’s performance of this critical care intervention. I have done airway audits and this one is quite a reasonable 4 month effort albeit not every ICU in Scotland participated, which is not unusual for those wanting to do these kind of audits. Airway management gets a bit personal and some find review of their emergency airway performance to be confronting. It should not be. Now it’s a fine distinction but its important to be clear on this. A FAILED AIRWAY DOES NOT MEAN YOU ARE A FAILURE!! FAILED OXYGENATION IS ANOTHER STORY….
There are always recurring themes from audits like these and I will highlight a few.
The first and foremost, is the absolutely essential role of capnography for tracheal tube confirmation and monitoring of airway patency and ventilator status. My FDEAR aeromedical intubation audit showed this was an issue of patient safety that should be improved.
This Scottish ICU study revealed that capnography was used in only 54% of emergency intubations despite the vast majority being in hospital locations where such monitoring is available! This is a recurring theme amongst emergency airway audits and coroners reports like this one.
Paradoxically this Scottish audit had a high number of intubating doctors with greater than 24 months of anaesthetic training and one hypothesis I have is that as doctors become more confident in emergency intubations, perhaps less reliance is felt required on monitoring like capnography? In human factors research into anaesthetic related crises, we call this the invulnerability or superman complex : “If I say the tube has gone in, I must be right!”
Secondly, the length of anaesthetic training of the intubating doctor appeared related to overall airway success rates and a low complication rate. There was only one surgical airway required over the 4 month period and 794 recorded intubations. The authors discuss though the potential problems that may face up and coming critical care doctors in the United Kingdom who may not be exposed to terms of anaesthetic training of up to 2 years. My own personal view is that it does not and should not matter where you get your emergency airway training but it should be structured and specific to the work that you are going to do. Learning to do epidural anaesthesia in laboring women might not be so helpful for the bilateral pneumonia swine flu patient with a BMI of 50! And certainly no point learning to use airway equipment that you will rarely or never have available where you normally work!
Thirdly and I find this fascinating having heard talks and debates on this topic by Dr Scott Weingart and Dr Paul Mayo, but in this Scottish paper of bloody sick patients needing intubation, 8% were performed without paralytics at all and overall intubation success and number of attempts were not significantly different compared to the paralytic assisted group. My view is that overall in critically ill patients , paralytics are your friend as these folks need the airway secured, one way or another. However this paper and Dr Mayo’s work certainly demonstrate that sedation only intubation is successful and is a reasonable alternative.
Finally, 61% of these emergency intubations utilized propofol and there was an association with post intubation hypotension (systolic <70mmHg). Ketamine use was low at 3% and I think this just reflects the greater anaesthetic training of the doctors in the study. I am aware Cliff has done a previous podcast rant on Propofol assasins
I don’t want to rant and am not as good at it as Cliff. BUT Choose your poison carefully! This paper reminds us what we all know. The milk of amnesia has issues! Ask the Jackson family!
Anyway that’s enough for this paper. I gotta pick myself off the floor again after listening to Cliff’s propofol rant..
- Dr Minh Le Cong, Royal Flying Doctor Service, Australia
BACKGROUND: Complications associated with tracheal intubation may occur in up to 40% of critically ill patients. Since practice in emergency airway management varies between intensive care units (ICUs) and countries, complication rates may also differ. We undertook a prospective, observational study of tracheal intubation performed by critical care doctors in Scotland to identify practice, complications, and training.METHODS: For 4 months, we collected data on any intubation performed by doctors working in critical care throughout Scotland except those in patients having elective surgery and those carried out before admission to hospital. We used a standardized data form to collect information on pre-induction physical state and organ support, the doctor carrying out the intubation, the techniques and drugs used, and complications noted.
RESULTS: Data from 794 intubations were analysed. Seventy per cent occurred in ICU and 18% occurred in emergency departments. The first-time intubation success rate was 91%, no patient required more than three attempts at intubation, and one patient required surgical tracheostomy. Severe hypoxaemia ( <80%) occurred in 22%, severe hypotension (systolic arterial pressure <80 mm Hg) in 20%, and oesophageal intubation in 2%. Three-quarters of intubations were performed by doctors with more than 24 months formal anaesthetic training and all but one doctor with <6 months training had senior supervision.
CONCLUSIONS: Tracheal intubation by critical care doctors in Scotland has a higher first-time success rate than described in previous reports of critical care intubation, and technical complications are few. Doctors carrying out intubation had undergone longer formal training in anaesthesia than described previously, and junior trainees are routinely supervised. Despite these good results, further work is necessary to reduce physiological complications and patient morbidity.
Tracheal intubation in the critically ill: a multi-centre national study of practice and complications
Br J Anaesth. 2012 May;108(5):792-9
Extubation guidelines
April 13, 2012 by Cliff
Filed under All Updates, Guidelines, ICU, Resus
Tracheal extubation is a high risk procedure in anaesthesia and critical care. Until now most guidelines have focused on intubation, with little to guide the process of extubation. Complications may relate to the following issues:
- Exaggerated reflexes – laryngospasm (which can lead to both hypoxia and negative pressure pulmonary oedema) and bronchospasm
- Reduced airway reflexes
- Dysfunctional laryngeal reflexes
- Depletion of oxygen stores at extubation
- Airway injury
- Physiological compromise in other systems
- Human factors
The goal is to ensure uninterrupted oxygen delivery to the patient’s lungs, avoid airway stimulation, and have a back-up plan, that would permit ventilation and re-intubation with minimum difficulty and delay should extubation fail.
The Difficult Airway Society has now published guidelines for the management of tracheal extubation, describing four steps:
Step 1: plan extubation.
Step 2: prepare for extubation.
Step 3: perform extubation.
Step 4: post-extubation care: recovery and follow-up.
During step 3, emphasis is on pre-oxygenation, positioning, and suction. This is followed by simultaneous deflation of the tracheal tube cuff and removal of the tube at the peak of a sustained inflation. This generates a passive exhalation, which may assist in the expulsion of secretions and possibly reduce the incidence of laryngospasm and breathholding.
The guideline refers to low-risk and at-risk extubations. ‘Low-risk’ (routine) extubation is characterised by the expectation that reintubation could be managed without difficulty, if required. ‘At-risk’ means the presence of general and/or airway risk factors that suggest that a patient may not be able to maintain his/her own airway after removal of the tracheal tube. ‘At-risk’ extubation is characterised by the concern that airway management may not be straightforward should reintubation be required.
These guidelines are written for the peri-operative patient but the text contains some interesting points that are pertinent to the ED or ICU patient. Some simple algorithms are presented:
Difficult Airway Society Guidelines for the management of tracheal extubation
Anaesthesia. 2012 Mar;67(3):318-40 Free full text
More guidelines from the Difficult Airway Society
Australasian ED Airway Registry
April 10, 2012 by Cliff
Filed under All Updates, Resus
Managing the emergency airway is one of the most important and risky things we do. We have a responsibility to record, monitor, report and improve our performance.
In the US, the National Emergency Airway Registry has been running for over a decade and has significantly contributed to our airway knowledge base.
In the UK, the NAP4 audit provided fascinating and scary insight into complications of emergency airway management.
Pre-hospital registries have been developed, like Minh Le Cong’s Flying Doctor Emergency Airway Registry; and many of us are now contributing to the Airway Management Study in Physician Manned Helicopter Emergency Medical Services (AIRPORT) study.
Now there is an opportunity for Australasian emergency departments to contribute to a national audit.
Dr Toby Fogg FACEM, emergency physician at Royal North Shore Hospital in Sydney, who began the registry, explained in a recent Life in The Fast Lane response:
I have been running an airway registry in the ED at The Royal North Shore Hospital in Sydney for the last 2 years.
I presented the first 18 months of data at the ASM in Sydney last year and I must admit, they showed room for improvement!.
One of the many things we have subsequently done is introduced a Pre Intubation Checklist which I have published, along with our preliminary findings, at www.airwayregistry.org.au.
I am happy for people to download the file and use it as is, or with appropriate modifications.
Furthermore I would love to hear from anyone keen to undertake an Airway Registry in their own ED — a PDF of the data collection form we use is also on the website.
As the authors of the NAP4 study conclude, it is essential we all audit our practice of this potentially high risk procedure.
Dr Toby Fogg uses his C-MAC video laryngoscope to demonstrate the audit form
Background: Successful airway management is one of the cornerstones of care for critically ill or injured patients in the Emergency Department (ED). The risks of intubation are known to be higher in this environment than in the operating theatre (OT) yet there are no published data on airway management in an Australian ED.
Objectives: To describe the practice of intubation in the ED of a tertiary hospital in Australia, with particular emphasis on the number of attempts, adjuncts used, the seniority of staff involved and the rate of complications.
Methods: A prospective, observational study.
Results: Over the 18-month study period, 295 episodes of intubation occurred with a total of 345 attempts. Consultant supervision occurred in 69.8% of cases, registrars made the first attempt at intubation in 57.5% and SRMOs in 31.0% of the patients. 83.7% of the patients were intubated at the first pass with a further 13.0% intubated one the second attempt. This leaves 10 patients (3.4%) that required ≥3 attempts, 4 (1.4%) ≥4 attempts and 1 (0.4%) required a 5th attempt. Difficult laryngoscopy, as defined by Cormack and Lehane grade III or IV, occurred in 24% of the first attempts. Bougies were used in 36% of attempts, whilst a stylet in 35%. Video laryngoscopy was used in 47.5% of attempts. Complications occurred in 28%.
Discussion: The success rate within two attempts is comparable to the anaesthetic literature, and although high, the rate of complications is comparable to data from EDs overseas. The rate of difficult laryngoscopy, however, is surprisingly high. The study has prompted a significant review of airway training and management within the ED at Royal North Shore Hospital and the results of the interventions will be monitored.
The Royal North Shore Hospital Emergency Department Airway Registry. A Prospective Observational Study of Airway Management in a Tertiary Hospital Emergency Department in Sydney, Australia
Annesley N,Vassiliadis J, Kerry Hitos K, Fogg T
Emerg. Med. Australas. 24 (Suppl. 1):27-28
Study authors Toby Fogg and Nick Annesley demonstrate the 'Happiness Triad'
