Abstract
BackgroundEfficient and timely airway management is universally recognised as a priority for major trauma patients, a proportion of whom require emergency intubation in the pre-hospital setting. Adverse events occur more commonly in emergency airway management, and hypoxia is relatively frequent. The aim of this study was to establish whether passive apnoeic oxygenation was effective in reducing the incidence of desaturation during pre-hospital emergency anaesthesia.MethodsA prospective before-after study was performed to compare patients receiving standard care and those receiving additional oxygen via nasal prongs. The primary endpoint was median oxygen saturation in the peri-rapid sequence induction period, (2 minutes pre-intubation to 2 minutes post-intubation) for all patients. Secondary endpoints included the incidence of hypoxia in predetermined subgroups.ResultsOf 725 patients included; 188 patients received standard treatment and 537 received the intervention. The overall incidence of hypoxia (first recorded SpO2 < 90%) was 16.7%; 10.9% had SpO2 < 85%. 98/725 patients (13.5%) were hypoxic post-intubation (final SpO2 < 90% 10 minutes post-intubation).Median SpO2 was 100% vs. 99% for the standard vs. intervention group. There was a statistically significant benefit from apnoeic oxygenation in reducing the frequency of peri-intubation hypoxia (SpO2 < =90%) for patients with initial SpO2 > 95%, p = 0.0001. The other significant benefit was observed in the recovery phase for patients with severe hypoxia prior to intubation.ConclusionApnoeic oxygenation did not influence peri-intubation oxygen saturations, but it did reduce the frequency and duration of hypoxia in the post-intubation period. Given that apnoeic oxygenation is a simple low-cost intervention with a low complication rate, and that hypoxia can be detrimental to outcome, application of nasal cannulas during the drug-induced phase of emergency intubation may benefit a subset of patients undergoing emergency anaesthesia.
Highlights
Efficient and timely airway management is universally recognised as a priority for major trauma patients, a proportion of whom require emergency intubation in the pre-hospital setting
This study aims to investigate whether the introduction of apnoeic oxygenation would reduce the frequency of desaturation in a population of trauma patients undergoing Pre-hospital emergency anaesthesia (PHEA)
The overall incidence of hypoxia prior to pre-oxygenation and intubation was 16.7% (121 of 725 patients); 79 patients (10.9%) had SpO2 less than 85%. 98 of 725 patients (13.5%) were hypoxic postintubation; 70 of these 98 patients (9.7%) were in the group of 79 patients who were initially hypoxic with SpO2 less than 85% prior to intubation
Summary
Efficient and timely airway management is universally recognised as a priority for major trauma patients, a proportion of whom require emergency intubation in the pre-hospital setting. Adverse events occur more commonly in emergency airway management, and hypoxia is relatively frequent. Pre-hospital emergency anaesthesia (PHEA) is required to facilitate tracheal intubation and ventilation. Adverse events associated with intubation occur more frequently during emergency airway management when repeated attempts at laryngoscopy are required [2,3,4]. Hypoxia is one of the more commonly occurring adverse events and has been demonstrated to occur in 9.2% of patients during the first attempt at intubation in an emergency setting, increasing to 37.8% of patients where there are repeated intubation attempts [4]. Pre-hospital data suggests that between 10.9 and 18.3% of patients undergoing PHEA experience episodes of hypoxaemia [5,6,7], and these episodes are associated with an increase in morbidity and mortality [8]
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