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Tracheal intubation in critically ill patients: a comprehensive systematic review of randomized trials

1/25/2018

 
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Critical Care 2018 22:6 https://doi.org/10.1186/s13054-017-1927-3

Abstract
Background:
We performed a systematic review of randomized controlled studies evaluating any drug, technique or device aimed at improving the success rate or safety of tracheal intubation in the critically ill.

Methods:
We searched PubMed, BioMed Central, Embase and the Cochrane Central Register of Clinical Trials and references of retrieved articles. Finally, pertinent reviews were also scanned to detect further studies until May 2017. The following inclusion criteria were considered: tracheal intubation in adult critically ill patients; randomized controlled trial; study performed in Intensive Care Unit, Emergency Department or ordinary ward; and work published in the last 20 years. Exclusion criteria were pre-hospital or operating theatre settings and simulation-based studies. Two investigators selected studies for the final analysis. Extracted data included first author, publication year, characteristics of patients and clinical settings, intervention details, comparators and relevant outcomes. The risk of bias was assessed with the Cochrane Collaboration’s Risk of Bias tool.

Results:
​We identified 22 trials on use of a pre-procedure check-list (1 study), pre-oxygenation or apneic oxygenation (6 studies), sedatives (3 studies), neuromuscular blocking agents (1 study), patient positioning (1 study), video laryngoscopy (9 studies), and post-intubation lung recruitment (1 study). Pre-oxygenation with non-invasive ventilation (NIV) and/or high-flow nasal cannula (HFNC) showed a possible beneficial role. Post-intubation recruitment improved oxygenation, while ramped position increased the number of intubation attempts and thiopental had negative hemodynamic effects. No effect was found for use of a checklist, apneic oxygenation (on oxygenation and hemodynamics), videolaryngoscopy (on number and length of intubation attempts), sedatives and neuromuscular blockers (on hemodynamics). Finally, videolaryngoscopy was associated with severe adverse effects in multiple trials.

Conclusions:
The limited available evidence supports a beneficial role of pre-oxygenation with NIV and HFNC before intubation of critically ill patients. Recruitment maneuvers may increase post-intubation oxygenation. Ramped position increased the number of intubation attempts; thiopental had negative hemodynamic effects and videolaryngoscopy might favor adverse events.
Keywords: Tracheal intubation, Critically ill, Emergency department, Intensive care unit, Videolaryngoscopy, High flow nasal cannula 
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Guidelines for the management of tracheal intubation in critically ill adults

1/9/2018

 
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British Journal of Anaesthesia 2018, article in press

​Abstract
These guidelines describe a comprehensive strategy to optimize oxygenation, airway management, and tracheal intubation in critically ill patients, in all hospital locations. They are a direct response to the 4th National Audit Project of the Royal College of Anaesthetists and Difficult Airway Society, which highlighted deficient management of these extremely vulnerable patients leading to major complications and avoidable deaths. They are founded on robust evidence where available, supplemented by expert consensus opinion where it is not. These guidelines recognize that improved outcomes of emergency airway management require closer attention to human factors, rather than simply introduction of new devices or improved technical proficiency. They stress the role of the airway team, a shared mental model, planning, and communication throughout airway management. The primacy of oxygenation including pre- and peroxygenation is emphasized. A modified rapid sequence approach is recommended. Optimal management is presented in an algorithm that combines Plans B and C, incorporating elements of the Vortex approach. To avoid delays and task fixation, the importance of limiting procedural attempts, promptly recognizing failure, and transitioning to the next algorithm step are emphasized. The guidelines recommend early use of a videolaryngoscope, with a screen visible to all, and second generation supraglottic airways for airway rescue. Recommendations for emergency front of neck airway are for a scalpel–bougie–tube technique while acknowledging the value of other techniques performed by trained experts. As most critical care airway catastrophes occur after intubation, from dislodged or blocked tubes, essential methods to avoid these complications are also emphasized.
​
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Relationship between non-technical skills and technical performance during cardiopulmonary resuscitation: does stress have an influence?

12/14/2017

 
Emerg Med J 2017;34:728-733.
​

Background 
Non-technical skills, such as task management, leadership, situational awareness, communication and decision-making refer to cognitive, behavioural and social skills that contribute to safe and efficient team performance. The importance of these skills during cardiopulmonary resuscitation (CPR) is increasingly emphasised. Nonetheless, the relationship between non-technical skills and technical performance is poorly understood. We hypothesise that non-technical skills become increasingly important under stressful conditions when individuals are distracted from their tasks, and investigated the relationship between non-technical and technical skills under control conditions and when external stressors are present.
Methods 
In this simulator-based randomised cross-over study, 30 anaesthesiologists and anaesthesia residents from the VU University Medical Center, Amsterdam, the Netherlands, participated in two different CPR scenarios in random order. In one scenario, external stressors (radio noise and a distractive scripted family member) were added, while the other scenario without stressors served as control condition. Non-technical performance of the team leader and technical performance of the team were measured using the ‘Anaesthetists’ Non-technical Skill’ score and a recently developed technical skills score. Analysis of variance and Pearson correlation coefficients were used for statistical analyses.
Results Non-technical performance declined when external stressors were present (adjusted mean difference 3.9 points, 95% CI 2.4 to 5.5 points). A significant correlation between non-technical and technical performance scores was observed when external stressors were present (r=0.67, 95% CI 0.40 to 0.83, p<0.001), while no evidence for such a relationship was observed under control conditions (r=0.15, 95% CI −0.22 to 0.49, p=0.42). This was equally true for all individual domains of the non-technical performance score (task management, team working, situation awareness, decision-making).
Conclusions During CPR with external stressors, the team’s technical performance is related to the non-technical skills of the team leader. This may have important implications for training of CPR teams.
​
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Resuscitative Endovascular Balloon Occlusion of the Aorta: Principles, Initial Clinical Experience, and Considerations for the Anesthesiologist

10/27/2017

 
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Anesthesia & Analgesia: September 2017 - Volume 125 - Issue 3 - p 884–890

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is an endovascular technique that allows for temporary occlusion of the aorta in patients with severe, life-threatening, trauma-induced noncompressible hemorrhage arising below the diaphragm. REBOA utilizes a transfemoral balloon catheter inserted in a retrograde fashion into the aorta to provide inflow control and support blood pressure until definitive hemostasis can be achieved. Initial retrospective and registry clinical data in the trauma surgical literature demonstrate improvement in systolic blood pressure with balloon inflation and improved survival compared to open aortic cross-clamping via resuscitative thoracotomy. However, there are no significant reports of anesthetic implications and perioperative management in this challenging cohort. In this narrative, we review the principles, technique, and logistics of REBOA deployment, as well as initial clinical outcome data from our level-1 American College of Surgeons–verified trauma center. For anesthesiologists who may not yet be familiar with REBOA, we make several suggestions and recommendations for intraoperative management based on extrapolation from these initial surgical-based reports, opinions from a team with increasing experience, and translated experience from emergency aortic vascular surgical procedures. Further prospective data will be necessary to conclusively guide anesthetic management, especially as potential complications and implications for global organ function, including cerebral and renal, are recognized and described.
​

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Ventilation rate in adults with a tracheal tube during cardiopulmonary resuscitation: A systematic review

9/20/2017

 
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Resuscitation 2017;119:5-12
​

Abstract

Aim
The optimal ventilation rate during cardiopulmonary resuscitation (CPR) with a tracheal tube is unknown. We evaluated whether in adults with cardiac arrest and a secure airway (tracheal tube), a ventilation rate of 10 min−1, compared to any other rate during CPR, improves outcomes.

Methods
A systematic review up to 14 July 2016. We included both adult human and animal studies. A GRADE (Grades of Recommendation, Assessment, Development and Evaluation) approach was used to evaluate the quality of evidence for each outcome.

Results
We identified one human observational study with 67 patients and ten animal studies (234 pigs and 30 dogs). All studies carried a high risk of bias. All studies evaluated for return of spontaneous circulation (ROSC). Studies showed no improvement in ROSC with a ventilation rate of 10 min-1 compared to any other rate. The evidence for longer-term outcomes such as survival to discharge and survival with favourable neurological outcome was very limited.

Conclusion
A ventilation rate recommendation of 10 min-1 during adult CPR with a tracheal tube and no pauses for chest compression is a very weak recommendation based on very low quality evidence.

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The Acute Care Anesthesiologist as Resuscitationist

7/21/2017

 
The Acute Care Anesthesiologist as Resuscitationist
Conti, Bianca MD; Greco, Karla M. MD, MHS; McCunn, Maureen MD, MIPP, FCCM
International Anesthesiology Clinics:  Summer 2017 - Volume 55 - Issue 3 - p 109–116
doi: 10.1097/AIA.0000000000000148


Abstract:
Resuscitation from critical illness or traumatic injury is no longer defined by massive crystalloid infusions, blood product transfusions without defined endpoints, or initiation of vasoactive medications at the physician’s discretion. Clearly defined, data-driven guidelines now exist that target specific goal-directed therapies in trauma, sepsis, and emergency general surgery, and incorporate both therapeutic and bedside diagnostic adjuncts. Ongoing research and controversy regarding resuscitation strategies in patients after trauma, for emergency surgery, or with sepsis will undoubtedly change current management paradigms. There is a need to maintain up-to-date knowledge and clinical excellence in the science of resuscitation that may suggest the need for specialization and expertise in the field of anesthesiology.
Anesthesiology has become more subspecialized, with recognized Accreditation Council for Graduate Medical Education (ACGME) fellowships offered in pediatrics, cardiac, critical care, pain management, and, most recently, obstetrics and regional anesthesia. There is currently a proposal to highlight the need for an additional American Board of Anesthesiology (ABA)/ACGME-approved fellowship—through the critical care track—targeted at trauma, acute care, and emergency care anesthesia practice: the acute care anesthesiologist. The question of whether this training should be unique to anesthesiologists, or should be combined with training in emergency medicine, has also been raised.Regardless of the structured curriculum that eventually develops, the management of resuscitation is rapidly maturing.
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Management of severe perioperative bleeding: guidelines from the European Society of Anaesthesiology

7/12/2017

 
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European Journal of Anaesthesiology 2017;34(6):332–395.
The management of perioperative bleeding involves multiple assessments and strategies to ensure appropriate patient care. Initially, it is important to identify those patients with an increased risk of perioperative bleeding. Next, strategies should be employed to correct preoperative anaemia and to stabilise macrocirculation and microcirculation to optimise the patient's tolerance to bleeding. Finally, targeted interventions should be used to reduce intraoperative and postoperative bleeding, and so prevent subsequent morbidity and mortality. The objective of these updated guidelines is to provide healthcare professionals with an overview of the most recent evidence to help ensure improved clinical management of patients. For this update, electronic databases were searched without language restrictions from 2011 or 2012 (depending on the search) until 2015. These searches produced 18 334 articles. All articles were assessed and the existing 2013 guidelines were revised to take account of new evidence. This update includes revisions to existing recommendations with respect to the wording, or changes in the grade of recommendation, and also the addition of new recommendations. The final draft guideline was posted on the European Society of Anaesthesiology website for four weeks for review. All comments were collated and the guidelines were amended as appropriate. This publication reflects the output of this work.
​

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Role of upper airway ultrasound in airway management

6/29/2017

 
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J Intensive Care. 2016;4:52.

Abstract:
Upper airway ultrasound is a valuable, non-invasive, simple, and portable point of care ultrasound (POCUS) for evaluation of airway management even in anatomy distorted by pathology or trauma. Ultrasound enables us to identify important sonoanatomy of the upper airway such as thyroid cartilage, epiglottis, cricoid cartilage, cricothyroid membrane, tracheal cartilages, and esophagus. Understanding this applied sonoanatomy facilitates clinician to use ultrasound in assessment of airway anatomy for difficult intubation, ETT and LMA placement and depth, assessment of airway size, ultrasound-guided invasive procedures such as percutaneous needle cricothyroidotomy and tracheostomy, prediction of postextubation stridor and left double-lumen bronchial tube size, and detecting upper airway pathologies. Widespread POCUS awareness, better technological advancements, portability, and availability of ultrasound in most critical areas facilitate upper airway ultrasound to become the potential first-line non-invasive airway assessment tool in the future.
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Cardiopulmonary Resuscitation in Adults and Children With Mechanical Circulatory Support A Scientific Statement From the American Heart Association

6/15/2017

 
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ABSTRACT: Cardiac arrest in patients on mechanical support is a new phenomenon brought about by the increased use of this therapy in patients with end-stage heart failure. This American Heart Association scientific statement highlights the recognition and treatment of cardiovascular collapse or cardiopulmonary arrest in an adult or pediatric patient who
has a ventricular assist device or total artificial heart. Specific, expert consensus recommendations are provided for the role of external chest compressions in such patients. 
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Association Between Tracheal Intubation During Adult In-Hospital Cardiac Arrest and Survival.

5/30/2017

 
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JAMA. 2017 Feb 7;317(5):494-506.

IMPORTANCE:Tracheal intubation is common during adult in-hospital cardiac arrest, but little is known about the association between tracheal intubation and survival in this setting.

OBJECTIVE:To determine whether tracheal intubation during adult in-hospital cardiac arrest is associated with survival to hospital discharge.

DESIGN, SETTING, AND PARTICIPANTS:Observational cohort study of adult patients who had an in-hospital cardiac arrest from January 2000 through December 2014 included in the Get With The Guidelines-Resuscitation registry, a US-based multicenter registry of in-hospital cardiac arrest. Patients who had an invasive airway in place at the time of cardiac arrest were excluded. Patients intubated at any given minute (from 0-15 minutes) were matched with patients at risk of being intubated within the same minute (ie, still receiving resuscitation) based on a time-dependent propensity score calculated from multiple patient, event, and hospital characteristics.

EXPOSURE:Tracheal intubation during cardiac arrest.

MAIN OUTCOMES AND MEASURES:The primary outcome was survival to hospital discharge. Secondary outcomes included return of spontaneous circulation (ROSC) and a good functional outcome. A cerebral performance category score of 1 (mild or no neurological deficit) or 2 (moderate cerebral disability) was considered a good functional outcome.

RESULTS:The propensity-matched cohort was selected from 108 079 adult patients at 668 hospitals. The median age was 69 years (interquartile range, 58-79 years), 45 073 patients (42%) were female, and 24 256 patients (22.4%) survived to hospital discharge. Of 71 615 patients (66.3%) who were intubated within the first 15 minutes, 43 314 (60.5%) were matched to a patient not intubated in the same minute. Survival was lower among patients who were intubated compared with those not intubated: 7052 of 43 314 (16.3%) vs 8407 of 43 314 (19.4%), respectively (risk ratio [RR] = 0.84; 95% CI, 0.81-0.87; P < .001). The proportion of patients with ROSC was lower among intubated patients than those not intubated: 25 022 of 43 311 (57.8%) vs 25 685 of 43 310 (59.3%), respectively (RR = 0.97; 95% CI, 0.96-0.99; P < .001). Good functional outcome was also lower among intubated patients than those not intubated: 4439 of 41 868 (10.6%) vs 5672 of 41 733 (13.6%), respectively (RR = 0.78; 95% CI, 0.75-0.81; P < .001). Although differences existed in prespecified subgroup analyses, intubation was not associated with improved outcomes in any subgroup.

CONCLUSIONS AND RELEVANCE:Among adult patients with in-hospital cardiac arrest, initiation of tracheal intubation within any given minute during the first 15 minutes of resuscitation, compared with no intubation during that minute, was associated with decreased survival to hospital discharge. Although the study design does not eliminate the potential for confounding by indication, these findings do not support early tracheal intubation for adult in-hospital cardiac arrest.
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