Prophylactic Endotracheal Intubation Research Articles

Should Prophylactic Endotracheal Intubation Be Performed in Upper Gastrointestinal Bleeding?

No consensus exists on the standard of intraoperative airway management approach to prevent endoscopy complications in acute gastrointestinal (GI) bleeding. Eight years after our initial meta-analysis, we reassessed the effect of prophylactic endotracheal intubation in acute GI bleeding in hospitalized patients. Multiple databases were reviewed in 2024, identifying 10 studies that compared prophylactic endotracheal intubation (PEI) versus no intubation in acute upper GI bleeding in hospitalized patients. Outcomes of interest included pneumonia, length of hospital stay, aspiration, and mortality. The odds ratio (OR) or mean difference (MD) using the random effects model was calculated for each outcome. In total, 11 studies (10 retrospective, one prospective) were included in the meta-analysis (n = 7,332). PEI demonstrated statistically significant higher odds of pneumonia (OR = 5.83; 95% confidence interval (CI) = 3.15-10.79; p < 0.01) and longer length of stays (MD = 0.84; 95% CI = 0.12-1.56; p = 0.02). However, mortality (OR = 1.68; 95% CI = 0.78-3.64; p = 0.19) and aspiration (OR = 2.79; 95% CI = 0.89-8.7; p = 0.08) were not statistically significant. PEI before esophagogastroduodenoscopy for hospitalized upper GI bleeding patients is associated with an increased incidence of pneumonia within 48 hours and prolonged hospitalization but no statistically significant increased risk of mortality or aspiration.

Cardiopulmonary prognosis of prophylactic endotracheal intubation in patients with upper gastrointestinal bleeding undergoing endoscopy.

It is controversial whether prophylactic endotracheal intubation (PEI) protects the airway before endoscopy in critically ill patients with upper gastrointestinal bleeding (UGIB). The study aimed to explore the predictive value of PEI for cardiopulmonary outcomes and identify high-risk patients with UGIB undergoing endoscopy. Patients undergoing endoscopy for UGIB were retrospectively enrolled in the eICU Collaborative Research Database (eICU-CRD). The composite cardiopulmonary outcomes included aspiration, pneumonia, pulmonary edema, shock or hypotension, cardiac arrest, myocardial infarction, and arrhythmia. The incidence of cardiopulmonary outcomes within 48 h after endoscopy was compared between the PEI and non-PEI groups. Logistic regression analyses and propensity score matching analyses were performed to estimate effects of PEI on cardiopulmonary outcomes. Moreover, restricted cubic spline plots were used to assess for any threshold effects in the association between baseline variables and risk of cardiopulmonary outcomes (yes/no) in the PEI group. A total of 946 patients were divided into the PEI group (108/946, 11.4%) and the non-PEI group (838/946, 88.6%). After propensity score matching, the PEI group (n=50) had a higher incidence of cardiopulmonary outcomes (58.0% vs. 30.3%, P=0.001). PEI was a risk factor for cardiopulmonary outcomes after adjusting for confounders (odds ratio [OR] 3.176, 95% confidence interval [95% CI] 1.567-6.438, P=0.001). The subgroup analysis indicated the similar results. A shock index >0.77 was a predictor for cardiopulmonary outcomes in patients undergoing PEI (P=0.015). The probability of cardiopulmonary outcomes in the PEI group depended on the Charlson Comorbidity Index (OR 1.465, 95% CI 1.079-1.989, P=0.014) and shock index >0.77 (compared with shock index ≤0.77 [OR 2.981, 95% CI 1.186-7.492, P=0.020, AUC=0.764]). PEI may be associated with cardiopulmonary outcomes in elderly and critically ill patients with UGIB undergoing endoscopy. Furthermore, a shock index greater than 0.77 could be used as a predictor of a worse prognosis in patients undergoing PEI.

S647 Should Prophylactic Endotracheal Intubation Be Performed in Upper GI Bleeding? A Meta-Analysis

Introduction: Prophylactic endotracheal intubation in the setting of upper gastrointestinal bleeding (UGIB) prior to endoscopy is not uncommon. Many use this practice to prevent aspiration of blood or gastric contents. However, this practice is now controversial with results of studies being varied. Therefore, we performed the most comprehensive meta-analysis to-date to address this topic. Methods: A comprehensive search of multiple databases was performed (June 2022). Studies comparing pre-endoscopy prophylactic endotracheal intubation versus no prophylactic intubation in patients with UGIB were included. Analysis was performed using the random effects model with odds ratio (OR) and mean difference (MD) to assess for mortality, pneumonia within 48 hours, aspiration, and hospital length-of-stay (LOS). Publication bias and heterogeneity were assessed. Results: Eight studies met the inclusion criteria (n=5,769). Patients that underwent prophylactic intubation prior to endoscopy for UGIB experienced a statistically significant higher odds of pneumonia within 48 hours (OR 6.05; 95% CI: 4.01-9.14; p< 0.01) and longer hospital LOS (MD 0.84 days; 95% CI: 0.12-1.56; p=0.02) as compared to those without prophylactic intubation prior to endoscopy. However, no statistically significant differences were noted for mortality (OR 1.43; 95% CI: 0.58-3.51; p=0.44) and aspiration (OR 1.16; 95% CI: 0.48-2.77; p=0.74) between the two groups. Conclusion: UGIB patients that underwent prophylactic endotracheal intubation prior to endoscopy are more likely to develop pneumonia within 48 hours and to have longer hospital stays than patients not having prophylactic intubation. Based on these results, prophylactic endotracheal intubation prior to endoscopy does not seem to be beneficial in this population. Randomized controlled trials may be necessary to fully evaluate the utility of this practice in the future.

Changing perspectives in the prehospital management of patients with severe burns

Treatment for burn injuries has typically involved the immediate cooling of the affected area with water to reduce pain and halt the progression of heat-induced tissue necrosis. For patients suspected to be at risk of airway compromise following inhalation burn injury, historical research has long advocated early prophylactic endotracheal intubation. In contrast, current literature is showing a change in the evidence base. To investigate this, a literature review was carried out and the evidence scrutinised in conjunction with local and national guidance. Controversy has more recently emerged over whether prophylactic endotracheal intubation is appropriate in the initial emergency management of suspected inhalation burn injury. Compounding this, it appears that no appropriate evidence-based guidelines have yet been made available. Traditional indications for prophylactic endotracheal intubation are sensitive but not specific. Research has subsequently demonstrated that large numbers of patients are being unnecessarily intubated and thus placed at risk of avoidable iatrogenic harm. A higher threshold for airway intervention is warranted. Additionally, a consensus remains over the use of prehospital cooling for burn injuries. This practice is, however, informed primarily by anecdotal and animal evidence. Patients with severe burns are at significant risk of hypothermia, which is associated with mortality. There is significantly more literature demonstrating the detrimental effects of hypothermia over the benefits of burn injury cooling in patients with severe burns. Treatment should therefore focus on the maintenance of normothermia as a priority. If cooling burned areas risks inducing hypothermia, it should be postponed.

Clinical audit on management of hepatic encephalopathy in children admitted to Gastroenterology and Hepatology Unit of Assiut University Children Hospital

Introduction Hepatic encephalopathy (HE) is an important metabolic disturbance in children. It is defined as a spectrum of neuropsychiatric abnormalities in patients with liver dysfunction, after exclusion of brain disease. Patients and methods A clinical audit on management of HE was applied according to the guideline protocol used in Gastroenterology and Hepatology Unit of Assiut University Children Hospital. The study included 52 children with HE who were admitted to Gastroenterology and Hepatology Unit over 1-year period from the 1st of March 2016 to the 28th of February 2017. Results Detailed history intake was recorded in most cases, except history of drug intake, which was not recorded in 23.15% of cases; history of reversal of sleep rhythm, which was not recorded in 17.3% of cases; and history of behavioral changes, which was not recorded in 9.6% of cases. Data of examination were recorded in most cases, except for fetor hepaticus, which was recorded in 42.3% of cases; asterixis, which was recorded in 36.5% of cases; and neurological examination, which was recorded in 91.2% of cases. Basic and mandatory investigations in the diagnosis of HE were done. The standard treatment of HE has been applied except admission to the ICU and prophylactic endotracheal intubation were not applied. Moreover, oral branched-chain amino acids and rifaximin were not given. Conclusion The international guidelines for the management of HE have been followed by the Gastroenterology and Hepatology Unit of Assiut University Children Hospital in most treatment lines and that some of the default is owing to poor-resource setting and lack of medication.

Prophylactic endotracheal intubation in critically ill patients with upper gastrointestinal bleed: A systematic review and meta-analysis.

Background and AimProphylactic endotracheal intubation for airway protection prior to endoscopy for the management of severe upper gastrointestinal bleeding (UGIB) is controversial. The aim of this meta‐analysis is to examine the clinical outcomes and costs related to prophylactic endotracheal intubation compared to no intubation in UGIB.MethodsEMBASE, MEDLINE, and the Cochrane Central Register of Controlled Trials were used to identify studies through June 2017. Data regarding mortality, total hospital and intensive care unit length of stay (LOS), pneumonia, and cardiovascular events were collected. The DerSimonian‐Laird random effects models were used to calculate the inverse variance‐based weighted, pooled treatment effect across studies.ResultsSeven studies (five manuscripts and two abstracts) were identified (5662 total patients). Prophylactic intubation conferred an increased risk of death (odds ratio [OR], 2.59, 95% confidence interval [CI]: 1.01–6.64), hospital LOS (mean difference, 0.96 days, 95% CI: 0.26–1.67), and pneumonia (OR 6.58, 95% CI: 4.91–8.81]) compared to endoscopy without intubation. The LOS‐related cost was greater when prophylactic intubation was performed ($9020 per patient, 95% CI: $6962–10 609) compared to when it was not performed ($7510 per patient, 95% CI: $6486–8432). There was no difference in risk of cardiovascular events after sensitivity analysis.ConclusionProphylactic intubation in severe UGIB is associated with a greater risk of pneumonia, LOS, death, and cost compared to endoscopy without intubation. Randomized trials examining this issue are warranted.

Determinants of Endotracheal Intubation in Critically Ill Patients Undergoing Gastrointestinal Endoscopy Under Conscious Sedation.

Our primary aim was to determine the factors leading to prophylactic endotracheal intubation in intensive care unit (ICU) patients undergoing gastrointestinal endoscopy. Secondary aims were to determine the rate of unplanned endotracheal intubations during endoscopy and to determine the rate of aspiration following endoscopy for patients admitted to the ICU. Critically ill adult (≥18 years) patients who underwent upper and lower endoscopic procedures from January 2012 to July 2016 in a medical/surgical ICU were included. Determinants of prophylactic endotracheal intubation prior to endoscopy as well as other postprocedure outcomes were electronically captured by a validated data mart system. Given our focus on aspiration in those who were not endotracheally intubated prior to endoscopy, we used a validated definition a priori. A total of 320 patients were included in the final analysis: 76(24%) were intubated prior to endoscopy and 244 (76%) were not. The endotracheally intubated group had a significantly higher Acute Physiologic and Chronic Health Evaluation III (44.5 [16.2] vs 39.5 [15.5]; P = .02) and Sequential Organ Failure Assessment (6.9 [4.4] vs 3.8 [3]; P ≤ .01) scores, higher rate of hematemesis within 24 hours of endoscopy (28 [37%] vs 45 [18%]; P ≤ .01), and higher rate of upper endoscopy (72 [96%] vs 181 [74%]; P ≤ .01). We composed a composite outcome for multivariable analyses, which demonstrated the rate of any complication was significantly higher among those who were intubated prior to the procedure versus those who were not intubated previously (odds ratio: 2.80, 95% confidence interval (CI): 1.16-6.72, P = .02). Endoscopy performed in the ICU without endotracheal intubation is safe. However, patient selection for prophylactic intubation prior to endoscopy is of critical importance as illustrated in this study with higher illness severity, planned upper endoscopy, and hematemesis 24 hours prior being key factors on deciding to perform endotracheal intubation. Prophylactic intubation for endoscopy and preexisting cardiac disease were associated with a higher rate of adverse outcomes.

Role of Prophylactic Endotracheal Intubation in Severe Upper Gastrointestinal (GI) Bleeding: An Updated Systemic Review and Meta-Analysis

Introduction: Upper GI bleeding needing intensive care unit admission carries a significant risk of mortality and disease burden. Airway management to prevent aspiration during ongoing severe upper GI bleeding remains controversial and lacks evidence based guidelines. A consideration for prophylactic endotracheal intubation (PI) based on clinical judgement is recommended by most gastrointestinal societies. Evidence based guidelines at lacking in this area. A previous meta-analysis tried to address this question, however, it included only two published studies and two abstracts. New studies are available since last publication, hence the need for updated meta-analysis. Methods: On January 30,2017, we conducted a systematic search of Medline, EMBASE, Web of Science Collection databases and the Cochrane Central Register of Controlled Trials for fully published studies in English literature which involved patients with upper GI bleeding and compared complications of prophylactic intubation before endoscopy versus no intubation before the procedure. Studies which included pediatric population or lacked control arm were excluded. The primary outcome of interest was comparison of aspiration pneumonia and mortality between the two groups. Secondary outcome of interest was witnessed aspiration. Mantel-Haenszal method for fixed effect model and DerSimonian and Laird method for random effects model was used to calculate odds ratio (OR) for these outcomes. Duval and Tweedie's Trim and Fill test was used to detect any publication bias. RevMan 5.3 and CMA version 3.0 was used for statistical analyses Results: Our search identified 167 studies. Out of these 11 studies were relevant and 6 fully published studies met our inclusion criteria. Five studies reported outcomes for aspiration pneumonia. Using random effects model, our analysis for aspiration pneumonia showed significantly higher risk of aspiration pneumonia with 48 hours in patients who underwent prophylactic intubation before EGD compared to those who did not (Odds ratio OR, 4.0; 95% confidence interval CI, 1.15 - 14.2). We experienced moderate heterogeneity in our analysis (I2= 53%) which is attributed to varying baseline characteristics of included patient population. No significant publication bias was noted in this analysis. A higher mortality was noted in patients who underwent prophylactic intubation before EGD (Odds ratio, OR 1.37; 95% CI, 1.11-1.69). There was no difference in aspiration between the two groups (OR 1.45, 95% CI 0.58-3.62). Conclusion: Patients undergoing prophylactic intubation in severe upper GI bleeding has a higher odds aspiration pneumonia and mortality. A routine use of prophylactic intubation before EGD in severe upper GI bleeding should be discouraged.Figure: Forest Plot Comparing Aspiration in Prophylactic Intubation Versus No Intubation.Figure: Funnel Plot Comparing Aspiration in Prophylactic Intubation Versus No Intubation.Figure: Forest Plot Comparing Mortality in Prophylactic Intubation Versus No Intubation.

Prophylactic Endotracheal Intubation in Patients with Upper Gastrointestinal Bleeding Undergoing Endoscopy: A Systematic Review and Meta-analysis.

Background:Patients with upper gastrointestinal bleeding (UGIB) often require urgent or emergent esophagogastroduodenoscopy (EGD) and are at risk of complications such as aspiration of gastric content or blood. The role of prophylactic endotracheal intubation (PEI) in the absence of usual respiratory status-related indications is not well established.Methods:We searched Medline, EMBASE, Cochrane Library's Central Register of Controlled Trials (CENTRAL) and SCOPUS from inception through July 2017 without date or language of publication restriction. We included studies that compared PEI with usual care (UC) in patients with acute UGIB, and reported any of the following outcomes: aspiration, pneumonia, mortality and length of stay. We excluded studies in which majority of included patients required intubation due to respiratory failure or decreased level of consciousness. We used the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess the quality of evidence for each outcome.Results:We did not identify any randomized trials on this topic. We included 10 observational studies (n = 6068). We were not able to perform any adjusted analyses. PEI was associated with a significant increase in aspiration (OR 3.85, 95% CI, 1.46, 10.25; P = 0.01; I2= 56%; low-quality evidence), pneumonia (OR 4.17, 95% CI, 1.82, 9.57; P = 0.0007; I2=52%; low-quality evidence) and hospital length of stay (mean difference 0.86 days, 95% CI 0.13, 1.59; P = 0.02; I2= 0; low-quality evidence), without clear effect on mortality (OR 1.92, 95% CI, 0.71, 5.23; P = 0.2; I2= 95%; very low-quality evidence).Conclusions:Low- to very low-quality evidence from observational studies suggests that PEI in the setting of UGIB may be associated with higher rates of respiratory complications and, less likely, with increased mortality. Although the results are alarming, the lack of higher quality evidence calls for randomized trials to inform practice.

Prophylactic Endotracheal Intubation Prior to Urgent Endoscopy in Patients with Suspected Variceal Hemorrhage: An Evaluation of Outcomes and Complications

AIM: There is limited evidence that suggests prophylactic intubation improves patient outcomes despite wide utilization. Our study aims to evaluate outcomes and complications related to prophylactic intubation through a retrospective comparison. MATERIALS AND METHODS: Urgent esophagogastroduodenoscopy (EGD) for suspected variceal hemorrhage were included in the study and categorized into two cohorts, one with prophylactic intubation and one without. Primary outcomes for the study were immediate aspiration, post EGD pneumonia, death, and other complications. Secondary outcomes included post EGD intensive care unit (ICU) stay, total ICU stay and total hospital stay. Retrospective comparison between cohorts was performed. RESULTS: Total 110 occurrences of urgent EGD were included. Prophylactic intubation was performed in 65 occurrence. Demographics, clinical background and significant comorbidities were similar in both cohorts. Immediate aspiration, post EGD pneumonia, and mortality were similar in both cohorts. Complications other than cardiac and pulmonary related were higher in prophylactic intubation group than no intubation group (40% vs 17.78%, P = 0.02). Overall average hospital stay of both cohorts and overall average ICU stay were similar. Average ICU stay post EGD was significant longer in prophylactic intubation group than no intubation group (4.7 ± 3.9 days vs 2.6 ± 2.6 days, P = 0.002). CONCLUSION: Our study revealed that prophylactic intubation prior to urgent EGD for variceal hemorrhage (VH) did not improve clinical outcomes. Our finding would suggest against routine prophylactic intubation in patients having VH with only mild encephalopathy and no ongoing hemorrhage.

Association of prophylactic endotracheal intubation in critically ill patients with upper GI bleeding and cardiopulmonary unplanned events

Prophylactic endotracheal intubation (PEI) is often advocated to mitigate the risk of cardiopulmonary adverse events in patients presenting with brisk upper GI bleeding (UGIB). However, the benefit of such a measure remains controversial. Our study aimed to compare the incidence of cardiopulmonary unplanned events between critically ill patients with brisk UGIB who underwent endotracheal intubation versus those who did not. Patients aged 18 years or older who presented at Cleveland Clinic between 2011 and 2014 with hematemesis and/or patients with melena with consequential hypovolemic shock were included. The primary outcome was a composite of several cardiopulmonary unplanned events (pneumonia, pulmonary edema, acute respiratory distress syndrome, persistent shock/hypotension after the procedure, arrhythmia, myocardial infarction, and cardiac arrest) occurring within 48 hours of the endoscopic procedure. Propensity score matching was used to match each patient 1:1 in variables that could influence the decision to intubate. These included Glasgow Blatchford Score, Charleston Comorbidity Index, and Acute Physiology and Chronic Health Evaluation scores. Two hundred patients were included in the final analysis. The baseline characteristics, comorbidity scores, and prognostic scores were similar between the 2 groups. The overall cardiopulmonary unplanned event rates were significantly higher in the intubated group compared with the nonintubated group (20% vs 6%, P= .008), which remained significant (P= .012) after adjusting for the presence of esophageal varices. PEI before an EGD for brisk UGIB in critically ill patients is associated with an increased risk of unplanned cardiopulmonary events. The benefits and risks of intubation should be carefully weighed when considering airway protection before an EGD in this group of patients.

Should We Intubate the Patient First? Outcomes of Prophylactic Endotracheal Intubation for Upper Gastrointestinal Bleeding

Should We Intubate the Patient First? Outcomes of Prophylactic Endotracheal Intubation for Upper Gastrointestinal Bleeding

Sa1006 Prophylactic Endotracheal Intubation in Critically Ill Patients with Upper Gastrointestinal Bleeding is Associated with Higher Cardiopulmonary Unplanned Events

Sa1006 Prophylactic Endotracheal Intubation in Critically Ill Patients with Upper Gastrointestinal Bleeding is Associated with Higher Cardiopulmonary Unplanned Events

Prophylactic tracheal intubation for upper GI bleeding: A meta-analysis.

AIMTo evaluate usefulness of prophylactically intubating upper gastrointestinal bleeding (UGIB) patients.METHODSUGIB results in a significant number of hospital admissions annually with endoscopy being the key intervention. In these patients, risks are associated with the bleeding and the procedure, including pulmonary aspiration. However, very little literature is available assessing the use of prophylactic endotracheal intubation on aspiration in these patients. A comprehensive search was performed in May 2014 in Scopus, CINAHL, Cochrane databases, PubMed/Medline, Embase, and published abstracts from national gastroenterology meetings in the United States (2004–2014). Included studies examined UGIB patients and compared prophylactic intubation to no intubation before endoscopy. Meta-analysis was conducted using RevMan 5.2 by Mantel-Haenszel and DerSimonian and Laird models with results presented as odds ratio for aspiration, pneumonia (within 48 h), and mortality. Funnel plots were utilized for publication bias and I2 measure of inconsistency for heterogeneity assessments.RESULTSInitial search identified 571 articles. Of these articles, 10 relevant peer-reviewed articles in English and two relevant abstracts were selected to review by two independent authors (Almashhrawi AA and Bechtold ML). Of these studies, eight were excluded: Five did not have a control arm, one was a letter the editor, one was a survey study, and one was focused on prevention of UGIB. Therefore, four studies (N = 367) were included. Of the UGIB patients prophylactically intubated before endoscopy, pneumonia (within 48 h) was identified in 20 of 134 (14.9%) patients as compared to 5 of 95 (5.3%) patients that were not intubated prophylactically (P = 0.02). Despite observed trends, no significant differences were found for mortality (P = 0.18) or aspiration (P = 0.11).CONCLUSIONPneumonia within 48 h is more likely in UGIB patients who received prophylactic endotracheal intubation prior to endoscopy.

Prophylactic Tracheal Intubation Versus No Intubation for Upper GI Bleeding: Is There a True Difference in Patient Outcomes? A Meta-Analysis

Introduction: Upper gastrointestinal bleeding (UGIB) is a serious condition that accounts for large volume of hospital and intensive care unit admissions each year. Endoscopy is the key diagnostic and therapeutic intervention for UGIB. Although significant morbidity and mortality can result from pulmonary aspiration that may complicate endoscopy, only a few studies have been conducted to evaluate the effect of prophylactic endotracheal intubation on such complication. We performed a meta-analysis on the outcomes of prophylactic endotracheal intubation versus no prophylactic intubation prior to endoscopy in patients with UGIB. Methods: A comprehensive search of PubMed/MEDLINE, Embase, Scopus, CINAHL, Cochrane databases, and published abstracts from Digestive Disease Week and the American College of Gastroenterology national meetings (2004 to 2014) was performed (May 2014). All studies comparing prophylactic intubation versus no prophylactic intubation in patients with endoscopy for UGIB were included. Two authors independently extracted the data. Meta-analysis was performed using fixed and random effects models with odds ratio (OR) to assess for mortality, pneumonia within 48 hours, and aspiration. Publication bias was assessed using funnel plots. We assessed heterogeneity by calculating the I2 measures of inconsistency. RevMan 5.2 was utilized for statistical analysis. Results: Four studies met the inclusion criteria (N=367). Patients that were prophylactically intubated prior to endoscopy for UGIB experienced a statistically significant increase in pneumonia within 48 hours as compared to patients not prophylactically intubated (OR 3.13; 95% CI: 1.17-8.39; p=0.02). Although trends were noted toward worse outcomes with prophylactic intubation, no statistically significant differences were noted for aspiration (OR 3.99; 95% CI: 0.72-22.12; p=0.11) or mortality (OR 2.19; 95% CI: 0.69-6.95; p=0.18) between the two groups. Conclusion: Patients prophylactically intubated prior to endoscopy for UGIB are more likely to develop pneumonia within 48 hours than patients not prophylactically intubated. Furthermore, nonsignificant trends toward increased mortality and aspiration were observed. A randomized controlled trial is necessary to assess this issue of prophylactic intubation prior to endoscopy in patients with UGIB. Disclosure - Dr. Bechtold - Consultant: Nestle Nutrition Institute.

Safety of gastric lavage using nasogastric ryle’s tube in pesticide poisoning

Objective: Gastric lavage is mandatory irrespective of nature in all patients with acute poisoning in India. Present study was undertaken with aim whether lavage done using nasogastric Ryle’s tube and small aliquots of water or normal saline is safe. Patients and Methods: All the patients above 12 years of age admitted consecutively with pesticide ingestion or exposure between July 2004 to June 2005 were studied with respect to complications associated with lavage using Ryle’s tube. Forty five patients were admitted directly to our hospital and lavage was undertaken using Ryle’s tube (16F ) with 100 - 200 mL of aliquots till 1 - 1.5 liters of fluid was lavaged, with prophylactic endotracheal intubation in patients with Glasgow coma scale ( GCS) < 10 (group I). The incidence of complications related to lavage in group I was compared to that in 53 patients admitted during same period with pesticide poisoning but lavaged outside using nasogastric Ryle’s tube and referred to our institute (group II). Results: The significant complications observed in group I were significant drop in SaO2 (6 patients) laryngospasm, tachycardia, electrolyte imbalance and tube getting struck in throat (one each). In one patient in group I (had no prophylactic intubation though GCS 3) In group II, 7 had aspiration pneumonia (no prophylactic intubation). Other significant complication was drop in SaO2 during lavage. None of them had any serious life threatening complication. Conclusion: Gastric lavage carried out using nasogastric Ryle’s tube and small aliquots of water or normal saline is relatively safe in patients with pesticide poisoning when combined with prophylactic endotracheal intubation in patients with GCS < 10. In absence of prophylactic intubation, risk of aspiration is there. However aspiration pneumonia is generally mild and not life threatening.

Prophylactic Endotracheal Intubation for Emergency Endoscopy in Critically Ill Patients?

Rehman A, Iscimen R, Yilmaz M, et al. (Division of Pulmonary and Critical Care Medicine, Rochester, Minnesota; Bursa, Antalya, Turkey). Prophylactic endotracheal intubation in critically ill patients undergoing endoscopy for upper GI hemorrhage. Gastrointest Endosc 2009;69:e55–59.

Prophylactic endotracheal intubation in critically ill patients undergoing endoscopy for upper GI hemorrhage

Prophylactic endotracheal intubation in critically ill patients undergoing endoscopy for upper GI hemorrhage

Prophylactic endotracheal intubation in critically ill patients undergoing endoscopy for upper GI hemorrhage

Prophylactic endotracheal intubation in critically ill patients undergoing endoscopy for upper GI hemorrhage

Prophylactic endotracheal intubation in critically ill patients undergoing endoscopy for upper GI hemorrhage

Cardiopulmonary complications are common after endoscopy for upper GI (UGI) hemorrhage in the intensive care unit (ICU). To evaluate the practice and outcome of elective prophylactic endotracheal intubation before endoscopy for UGI hemorrhage in the ICU. Retrospective, propensity-matched case-control study. A 24-bed medical ICU in a tertiary center. ICU patients who underwent endoscopy for UGI hemorrhage. Cardiopulmonary complications, ICU and hospital length of stay, and mortality. In a propensity analysis, patients who were intubated for airway protection before UGI endoscopy were matched by probability of intubation to controls who were not intubated before UGI endoscopy. Of 307 patients, 53 underwent elective prophylactic intubation before UGI endoscopy. The probability of intubation depended on the Acute Physiology and Chronic Health Evaluation III (APACHE III) score (OR 1.4; 95% CI, 1.2-1.6), age (OR 0.97; 95% CI, 0.95-0.09), the presence of hemetemesis (OR 1.9; 95% CI, 0.8-5.1), previous lung disease (OR 2.1; 95% CI, 0.8-4.9), and the number of transfusions (OR 1.1; 95% CI, 1.0-1.1 per unit). Nonintubated matched controls were identified for all but 4 patients with active massive hemetemesis, who were excluded from matched analysis. Cumulative incidence of cardiopulmonary complications (53% vs 45%, P = .414), ICU length of stay (median 2.2 vs 1.8 days, P = .138), hospital length of stay (6.9 vs 5.9 days, P = .785), and hospital mortality (14% vs 20%, P = .366) were similar. Cardiopulmonary complications are frequent after endoscopy for acute UGI bleeding in ICU patients and are largely unaffected by the practice of prophylactic intubation.