Rapid Sequence Intubation In Patients Research Articles

Ketamine versus etomidate for rapid sequence intubation in patients with trauma: a retrospective study in a level 1 trauma center in Korea

BackgroundKetamine and etomidate are commonly used as sedatives in rapid sequence intubation (RSI). However, there is no consensus on which agent should be favored when treating patients with trauma. This study aimed to compare the effects of ketamine and etomidate on first-pass success and outcomes of patients with trauma after RSI-facilitated emergency intubation.MethodsWe retrospectively reviewed 944 patients who underwent endotracheal intubation in a trauma bay at a Korean level 1 trauma center between January 2019 and December 2021. Outcomes were compared between the ketamine and etomidate groups after propensity score matching to balance the overall distribution between the two groups.ResultsIn total, 620 patients were included in the analysis, of which 118 (19.9%) were administered ketamine and the remaining 502 (80.1%) were treated with etomidate. Patients in the ketamine group showed a significantly faster initial heart rate (105.0 ± 25.7 vs. 97.7 ± 23.6, p = 0.003), were more hypotensive (114.2 ± 32.8 mmHg vs. 139.3 ± 34.4 mmHg, p < 0.001), and had higher Glasgow Coma Scale (9.1 ± 4.0 vs. 8.2 ± 4.0, p = 0.031) and Injury Severity Score (32.5 ± 16.3 vs. 27.0 ± 13.3, p < 0.001) than those in the etomidate group. There were no significant differences in the first-pass success rate (90.7% vs. 90.1%, p > 0.999), final mortality (16.1% vs. 20.6, p = 0.348), length of stay in the intensive care unit (days) (8 [4, 15] (Interquartile range)), vs. 10 [4, 21], p = 0.998), ventilator days (4 [2, 10] vs. 5 [2, 13], p = 0.735), and hospital stay (days) (24.5 [10.25, 38.5] vs. 22 [8, 40], p = 0.322) in the 1:3 propensity score matching analysis.ConclusionIn this retrospective study of trauma resuscitation, those receiving intubation with ketamine had greater hemodynamic instability than those receiving etomidate. However, there was no significant difference in clinical outcomes between patients sedated with ketamine and those treated with etomidate.

Intubation Performance with Stylet and Preloaded Bougie for Rapid Sequence Intubation in Patients Undergoing General Anaesthesia: A Randomised Clinical Trial

Introduction: Rapid sequence induction requires quick and single attempt intubation to secure airway without any untoward complications.As the number of attempts increase, risk of desaturation and aspiration increase which is potentially life threatening.In such circumstances, miscalculation may cost loss of time which may prove fatal.Various adjuncts and techniques have been devised to prevent such calamities. Aim: To compare ease of intubation with angulated stylet versus distally preloaded bougie for rapid sequence intubation in elective general anaesthesia procedures. Materials and Methods: This randomised trial was conducted in 100 patients belonging to 18-60 years of age from November 2019 to October 2020. Patients were intubated using rapid sequence including cricoid pressure by either styletted endotracheal tube (Group S) or distally preloaded bougie (Group B), for surgeries performed under general anaesthesia. The primary outcome was to determine mean time to intubation (TTI) and number of attempts, while secondary outcomes were haemodynamic responses to intubation and complications. Data comparison between independent groups in this normally distributed data was done using student -t test while intragroup analysis was done using chi-square test. Results: A total of hundred patients were randomized into two groups- group S (mean age: 41.12 years) and group B (mean age: 37.34 years), of 50 patients each. Number of intubation attempts with stylet were single in 82%, two in 18% cases while with preloaded bougie, it was 80% and 14%, respectively (p-value=0.196). Time to intubation was 22.16 seconds (group S) versus 33.78 seconds (group B) (p-value &lt;0.05). The haemodynamic assessments revealed that tachycardia,hypertension and increased End tidal carbon dioxide (EtCO2 ) was seen for 10 minutes immediately post induction in both the groups,though the intergroup difference was non significant. The incidence of sore throat was higher with stylet than bougie, though non-significant (p-value=0.118). Conclusion: Stylet should be preferred for ease of intubation in rapid sequence inductions. However, the insertion and removal of stylet must be done cautiously to prevent postoperative sore throat.

Pediatric Rapid Sequence Intubation Success with a Novel Training Program

<h3>Introduction</h3> Pediatric rapid sequence intubation (RSI) is a critical skill. PICU and ED physicians report first attempt success (FAS) rates of 62-78% and first attempt success without desaturation (FASWD) rates of 58%. Here we report air medical pediatric RSI success rates using a novel training program [HeART]. <h3>Methods</h3> All pediatric RSI patients over a five-year period (2015-2019) from a large air medical company were included. FAS and FASWD were calculated for all patients and for specific age cohorts [0-2 years, 3-8 years, 9-17 years]. Meta-analysis was performed to compare to reported physician success rates. <h3>Results</h3> A total of 1,116 pediatric RSI patients were included [0-2: n=247, 3-8: n=250, 9-17: n=619]. Intubation success rates were similar across age groups. Both FAS and FASWD rates were significantly higher than reported for PICU and ED physicians (FAS = 91% vs 61%, p<0.001; FASWD = 63% vs 58%, p=0.034). <h3>Conclusion</h3> We observed high FAS and FASWD rates for air medical pediatric RSI using a novel airway curriculum. Although RSI success rates were higher than reported for PICU and ED physicians, the comparisons may reflect undetected differences in various airway difficulty factors.

The Safety of Positive Pressure Ventilation in Pediatric Rapid Sequence Intubation

<h3>Introduction</h3> Prior data suggest that a higher preoxygenation target may be justified during pediatric rapid sequence intubation (RSI) to avoid oxygen desaturation. This may involve increased use of positive-pressure ventilation (PPV) in patients with initial SpO2 ≥94%. The safety of this approach is unknown. <h3>Methods</h3> All air medical pediatric RSI patients treated by a large air medical company over a 5-year period were included. Patients were stratified by initial SpO2 value [97-100%, 94-96%, <94%] and compared with regard to PPV use during preoxygenation and a reported complication of aspiration <h3>Results</h3> A total of 1,067 pediatric RSI patients were included. PPV rates increased with decreasing initial SpO2 [97-100%: 389/765 (51%), 94-96%: 78/130 (60%), <94%: 151/172 (88%)]. Increased aspiration rates with PPV were reported only in patients with initial SpO2 <94% vs ≥94% (3.3% vs 0.3%, p=0.011). <h3>Conclusion</h3> A low risk of aspiration with PPV was observed in air medical pediatric RSI patients with SpO2 values ≥94%. This may justify more aggressive use of PPV to achieve higher preoxygenation targets to avoid oxygen desaturation.

Examination of Primary Bougie Use in Air Medical Intubations

<h3>Introduction</h3> Use of a bougie during emergency rapid sequence intubation (RSI) appears to increase first attempt success but may increase time to a definitive airway. This analysis was performed to explore primary use of a bougie during air medical RSI. <h3>Methods</h3> For this analysis, patients undergoing RSI by air medical crews were identified from a large air medical database. First attempt success (FAS), and first attempt success without desaturation (FASWD) were used as outcome measures. Patients in whom a bougie was used during the initial intubation attempt were compared to patients undergoing intubation without the bougie. Propensity scores for bougie use were calculated and multiple logistic regression used to calculate odds ratios for both outcome measures. <h3>Results</h3> A total of 11,836 air medical RSI patients were identified. Patients in whom a bougie was used on the first attempt had more difficult airway predictors. Logistic regression analysis with propensity adjusted odds ratios revealed no associations between use of a bougie on first attempt and FAS (adjusted OR 0.92, 95% CI 0.80-1.05, p=0.212). However, FASWD rates were statistically significantly lower with use of a bougie on first attempt after adjusting for age, gender, trauma, and presence of difficult airway criteria (adjusted OR 0.85, 95% CI 0.75-0.96, p=0.009). <h3>Conclusion</h3> Primary use of the bougie during intubation resulted in similar rates of first pass success when compared to non-bougie group. Primary bougie use may be associated with a higher rate of desaturation during first attempt intubation. Limitations include the potential for selection bias not addressed by the statistical models. Further examination to explore the effects of bougie use related to desaturation is recommended.

Ketamine-based Versus Fentanyl-based Regimen for Rapid-sequence Endotracheal Intubation in Patients with Septic Shock: A Randomised Controlled Trial.

The aim of this work is to compared ketamine-based versus fentanyl-based regimens for endotracheal intubation in patients with septic shock undergoing emergency surgery. This was a randomised double-blinded controlled trial. Patients with septic shock on norepinephrine infusion scheduled for emergency surgery. At induction of anaesthesia, patients were allocated into ketamine group (n=23) in which the participants received ketamine 1 mg/kg, and fentanyl group (n=19) in which the participants received fentanyl 2.5 mcg/ kg. Both groups received midazolam (0.05 mg/kg) and succinyl choline (1 mg/kg). The primary outcome was mean arterial blood pressure. The secondary outcomes included: heart rate, cardiac output, and incidence of postintubation hypotension defined as mean arterial pressure ≤80% of baseline value. Forty-two patients were available for final analysis. The mean blood pressure was higher in the ketamine group than in the fentanyl group at 1, 2 and 5 minutes after the induction of anaesthesia. Furthermore, the incidence of postinduction hypotension was lower in the ketamine group than in the fentanyl group (11 [47.8%] versus 16 [84.2%], P-value= 0.014). Other hypodynamic parameters, namely the heart rate and cardiac output, were comparable between both groups; and were generally maintained in relation to the baseline reading in each group. The ketamine-based regimen provided better hemodynamic profile compared to fentanyl-based regimen for rapid-sequence intubation in patients with septic shock undergoing emergency surgery.

IS CRITICAL CARE MYOPATHY A CONTRAINDICATION FOR SUCCINYLCHOLINE?

TOPIC: Critical Care TYPE: Fellow Case Reports INTRODUCTION: Succinylcholine, a depolarizing muscular blocker, has widespread use for rapid sequence intubation (RSI) in the intensive care unit (ICU), emergency department, and operating room. The advantageous pharmacologic profile includes rapid onset of action (40-60 secs), short duration (6-10 mins), and better intubation conditions such as ease of laryngoscopy and diaphragm inactivation. There are recognized adverse effects including benign manifestations (muscle fasciculations) to life-threatening conditions (acute hyperkalemia and malignant hyperthermia). Scenarios with increased risk include muscular dystrophies, rhabdomyolysis, crush/burn injuries, malignant hyperthermia, and abdominal infections. We present a case of life-threatening hyperkalemia after administration in the setting of critical care myopathy. CASE PRESENTATION: A 63-year-old woman was admitted for acute respiratory distress syndrome from COVID-19 pneumonia. Treatment included steroids, neuromuscular blockade, and prone positioning. Due to frequent ventilator associated pneumonias and difficulty with airway hygiene, endotracheal (ET) tube exchange was planned on hospital day 34. Succinylcholine was utilized given suitable creatinine clearance, normal serum potassium, and sinus rhythm. The removed ET tube had dark, thick, adherent secretions. Less than one minute from administration, telemetry changed to a wide QRS complex and degenerated into pulseless ventricular fibrillation. There was no preceding hypoxemia. The patient received ACLS with defibrillation for recurrent ventricular fibrillation with ROSC. DISCUSSION: Succinylcholine binds to the post-synaptic nicotinic acetylcholine receptor on the motor endplate causing depolarization. Receptor activation triggers efflux of intracellular potassium into the plasma. Receptor upregulation occurs in pathologic conditions including lower motor neuron disorders, immobilization, burns, and muscular dystrophies. Myopathies have inherent membrane fragility and increased permeability producing release of potassium. The development of critical illness myopathy, polyneuropathy, and polyneuromyopathy in the ICU has an incidence of 25-83%. Proposed mechanisms include myosin loss, necrosis of the muscle, muscle membrane dysfunction, denervation of the muscle, nerve ischemia, and axonal injury. Activation of the acetylcholine receptors and sustained muscle contraction in this state can result in devastating hyperkalemia. CONCLUSIONS: Succinylcholine as a paralytic medication for RSI in patients with critical care myopathy should give providers clinical equipoise. There is a risk for acute hyperkalemia due to the damaged muscle membrane and upregulated acetylcholine receptors. REFERENCE #1: Tran, D. T. T., et al. "Rocuronium vs. succinylcholine for rapid sequence intubation: a Cochrane systematic review." Anaesthesia 72.6 (2017): 765-777. REFERENCE #2: Martyn, J. A. Jeevendra, and Martina Richtsfeld. "Succinylcholine-induced hyperkalemia in acquired pathologic statesetiologic factors and molecular mechanisms." Anesthesiology: The Journal of the American Society of Anesthesiologists 104.1 (2006): 158-169. REFERENCE #3: Shepherd, Starane, Ayush Batra, and David P. Lerner. "Review of critical illness myopathy and neuropathy." The Neurohospitalist 7.1 (2017): 41-48. DISCLOSURES: No relevant relationships by Bhupinder Natt, source=Web Response No relevant relationships by Alan Nyquist, source=Web Response

Safety of Propofol When Used for Rapid Sequence Intubation in Septic Patients: A Multicenter Cohort Study.

Septic patients are at risk for hypotension, and this risk may increase during rapid sequence intubation (RSI). Sedatives such as propofol must be used carefully due to its ability to reduce vascular sympathetic tone. Since the safety of propofol for RSI is not well described in sepsis, this was a study evaluating propofol and its effects on hemodynamics when used for RSI in a septic population. We conducted a multicenter, retrospective, cohort study of patients with sepsis or severe sepsis requiring sedation for RSI. Patients receiving a propofol bolus for RSI were compared to patients undergoing RSI without a propofol bolus. The safety profile of propofol was evaluated according to the rates of post-intubation hypotension and vasopressor utilization between groups. A total of 179 patients (79 propofol, 100 non-propofol) were evaluated. There were no differences in hypotension (81% vs 78%; P = .62) or vasopressor utilization between the propofol and non-propofol groups (43% vs 49%; P = .43). Patients in the non-propofol group had increased APACHE II scores and healthcare-associated infections. In this cohort study, administration of propofol for RSI in patients with sepsis and severe sepsis did not increase incidence of hypotension or vasopressor use, but acute illness may have introduced provider selection bias causing less propofol use in the non-propofol group. Larger prospective studies are needed to better characterize the adverse hemodynamic effects of propofol, before propofol bolus doses for RSI can be considered for safe use in this population.

In Response.

We read with great interest the letter by Priebe1 regarding our review of the use of cricoid pressure (CP).2 While many of the points1 actually reiterate, not dispute, our original conclusions, we again underscore the purpose for our review, stated clearly in our opening paragraph: “[w]e therefore review the available scientific [emphasis added] evidence of the effectiveness and safety of CP…”. We are well aware that clinical care standards vary immensely.2 We also recognize that Germany has largely abandoned CP use in clinical practice3,4 and that the author himself is a strong advocate against CP use.5 Alternatively, other experts strongly defend this procedure.6 One issue that requires clarification is Priebe’s reference to the Sellick Interest in Rapid Sequence Induction (IRIS) randomized trial and the intubation difficulty posed by CP.7 We reanalyzed the original IRIS trial data of Cormack-Lehane scores. We used χ2 test, which yields significant P values in large sample sizes.8 We herein report Cramer’s V of 0.09 as the strength of association measure,9 suggesting a weak association between CP and higher Cormack-Lehane scores. Moreover, operators were asked to release CP in only 14% of CP cases and in 5% of sham group, improving the glottic view in 62% and 33% of cases, respectively.7 The sham group reported improvement in Cormack-Lehane score after sham interruption,7 likely reflecting the assessors’ anticipation of CP use. We suggest that most of the experienced operators could detect CP at laryngoscopy, while the sham itself is likely to be readily guessed (more frequently than by chance) by the operators, making them more likely to report an improved view after its release. In clinically relevant outcomes, the groups did not differ in the number of attempts at intubation or arterial oxygen desaturation, and median intubation times were similar (27 seconds in CP group and 23 seconds in sham group); a 4-second difference is statistically significant7 but not clinically relevant.10 The IRIS trial concluded, “… the interference of the CP with airway control has previously been overestimated.” Moreover, a “…significant increase in the incidence of difficult tracheal intubation…” was not observed, as Priebe1 suggested. From an evidence-based medicine point of view, the IRIS (noninferiority) study7 was severely underpowered. This limitation is acknowledged in the accompanying editorial: “the noninferiority of withholding CP could not be proven because of the overall lower-than-expected incidence of aspiration.”11 Therefore, there is no evidence-based foundation for the selective (and likely erroneous) interpretation, “the study nevertheless documents lack benefit of the application of CP with simultaneous interference with optimal airway management.”1 Alternatively, we would be remiss if we did not also acknowledge study’s tremendous value, as it is the first study granted ethical permission not to use CP during rapid sequence intubation in patients. We continue to recommend that investigators use previous findings effectively in planned research designs, and include generally accepted indicators such as percent of glottic opening score,12,13 upper lip bite test (which has the highest sensitivity for diagnosing difficult laryngoscopy),14 and modified Mallampati test (which has the highest sensitivity for diagnosing difficult tracheal intubation),14 none of which were used in the IRIS study.7 With strong opinions on either side of the argument,1,6 we believe we provided a balanced review of current evidence on CP use, and we are not surprised that our article2 incited controversy. We sincerely hope the debate will galvanize future researchers to provide definitive evidence that can then be translated into guidelines, rather than the consensus opinions that drive current clinical care. Marko Zdravkovic, MDDepartment of Anaesthesiology,Intensive Care and Pain ManagementUniversity Medical Centre MariborMaribor, SloveniaFaculty of MedicineMaribor, Slovenia Mark J. Rice, MDDepartment of AnesthesiologyVanderbilt University Medical CenterNashville, Tennessee Sorin J. Brull, MD, FCARCSI (Hon)Department of Anesthesiology and Perioperative MedicineMayo Clinic College of Medicine and ScienceJacksonville, Florida[email protected]

The HEAVEN criteria predict laryngoscopic view and intubation success for both direct and video laryngoscopy: a cohort analysis

BackgroundExisting difficult airway prediction tools are not practical for emergency intubation and do not incorporate physiological data. The HEAVEN criteria (Hypoxaemia, Extremes of size, Anatomic challenges, Vomit/blood/fluid, Exsanguination, Neck mobility) may be more relevant for emergency rapid sequence intubation (RSI).MethodsA retrospective analysis included air medical RSI patients. A checklist was used to assess HEAVEN criteria prior to RSI, and Cormack-Lehane (CL) laryngoscopic view was recorded for the first intubation attempt. The incidence of a difficult (CL III/IV) laryngoscopic view as well as failure to intubate on first attempt with and without oxygen desaturation were determined for each of the HEAVEN criteria and total number of HEAVEN criteria. In addition, the association between HEAVEN criteria and both laryngoscopic view and intubation performance were quantified using multivariate logistic regression for direct laryngoscopy (DL) and video laryngoscopy (VL) configured with a Macintosh #4 non-hyperangulated blade.ResultsA total of 5137 RSI patients over 24 months were included. Overall intubation success was 97%. A CL III/IV laryngoscopic view was reported in 25% of DL attempts and 15% of VL attempts. Each of the HEAVEN criteria and total number of HEAVEN criteria were associated with both CL III/IV laryngoscopic view and failure to intubate on the first attempt with and without oxygen desaturation for both DL and VL. These associations persisted after adjustment for multiple co-variables including the other HEAVEN criteria.ConclusionThe HEAVEN criteria may be useful to predict laryngoscopic view and intubation performance for DL and VL during emergency RSI.

Rocuronium versus succinylcholine for rapid sequence intubation in patients with bowel obstruction

Introduction. The aim of the study was to determine intubation conditions in the patients receiving rocuronium in compari-son to succinylcholine for rapid sequence intubation during the induction of anes-thesia for operative management of bowel obstruction. Methods. In the randomized controlled study 30 adult patients with bowel obstruc-tion undergoing urgent surgery were ran-domly allocated in two groups. For muscle relaxation the S-group of patients received succinylcholine (1.5 mg/kg) and the R-group rocuronium (1.2 mg/kg). Intubation conditions were evaluated using a grad-ing system according to Viby-Morgenson. Primary outcomes were intubation con-ditions 1 minute after the application of a muscle relaxant. Secondary outcome measures were heart rate, blood pressure, and pulse oximetry; potassium and myo-globin serum level.Results. All patients were orotracheally intubated in the first attempt. During in-duction, we didn’t observe vomiting or as-piration. Overall intubation conditions in the S-group were statistically significantly better than in the R-group. After RSI there was a statistically significant decrease in systolic and diastolic blood pressure in both groups and statistically significant decrease in heart rate in the S-group. After RSI the potassium level in the S-group was significantly higher in comparison to the R-group and serum myoglobin level non-significantly increased in the S-group and statistically significantly decreased in the R-group.Conclusion. The results show that rocuronium in RSI patients with bowel obstruc-tion enables the same intubation condi-tions as succinylcholine and the same risk of aspiration which allows succinylcholine replacement and avoidance of its side ef-fects.

Comparison of etomidate and sodium thiopental for induction during rapid sequence intubation in convulsive status epilepticus: A retrospective single-center study

PurposeFew outcome data are available about morbidity associated with endotracheal intubation modalities in critically ill patients with convulsive status epilepticus. We compared etomidate versus sodium thiopental for emergency rapid sequence intubation in patients with out-of-hospital convulsive status epilepticus. MethodsPatients admitted to our intensive care unit in 2006–2015 were studied retrospectively. The main outcome measure was seizure and/or status epilepticus recurrence within 12 h after rapid sequence intubation. ResultsWe included 97 patients (60% male; median age, 59 years [IQR, 48–70]). Median time from seizure onset to first antiepileptic drug was 60 min [IQR, 35–90]. Reasons for intubation were coma in 95 (98%), acute respiratory distress in 18 (19%), refractory convulsive status epilepticus in 9 (9%), and shock in 6 (6%) patients; 50 (52%) patients had more than one reason. The hypnotic drugs used were etomidate in 54 (56%) and sodium thiopental in 43 (44%) patients. Seizure and/or status epilepticus recurred in 13 (56%) patients in the etomidate group and 11 patients (44%) in the sodium thiopental group (adjusted common odds ratio [aOR], 0.98; 95%CI, 0.36–2.63; P = 0.97). The two groups were not significantly different for proportions of patients with hemodynamic instability after intubation (aOR, 0.60; 95%CI, 0.23–1.58; P = 0.30) or with difficult endotracheal intubation (OR, 1.28; 95% CI 0.23 to 7.21; P=0.77). ConclusionsOur findings argue against a difference in seizure and/or status epilepticus recurrences rates between critically ill patients with convulsive status epilepticus given etomidate vs. sodium thiopental as the induction agent for emergency intubation.

A Novel Difficult-Airway Prediction Tool for Emergency Airway Management: Validation of the HEAVEN Criteria in a Large Air Medical Cohort

BackgroundDifficult-airway prediction tools help identify optimal airway techniques, but were derived in elective surgery patients and may not be applicable to emergency rapid sequence intubation (RSI). The HEAVEN criteria (Hypoxemia, Extremes of size, Anatomic abnormalities, Vomit/blood/fluid, Exsanguination, Neck mobility issues) may be more relevant to emergency RSI patients. ObjectiveTo validate the HEAVEN criteria for difficult-airway prediction in emergency RSI using a large air medical cohort. MethodsThis was a retrospective analysis using a large air medical airway registry using data from 160 bases over a 1-year period. Standard test characteristics (sensitivity, specificity, positive predictive value, negative predictive value [NPV]) for the HEAVEN criteria were calculated for overall intubation success, first-attempt success, and first-attempt success without desaturation. In addition, multivariable logistic regression was used to quantify the independent association between each of the HEAVEN criteria, as well as the total number of criteria present and intubation success after adjusting for age, gender, and clinical category (burn, medical, trauma, nontraumatic shock). ResultsA total of 2419 patients undergoing air medical RSI were included. Excellent NPV was observed (97% for each of the HEAVEN criteria except “Exsanguination,” which had an NPV of 87% but specificity of 99%). First-attempt success was lower for each of the HEAVEN criteria, with an inverse relationship observed between total HEAVEN criteria and intubation success (first-attempt success with no criteria = 94% and with 5 + criteria = 43%). Multivariable logistic regression revealed independent associations between each of the HEAVEN criteria, as well as total number of criteria and intubation success. ConclusionsThe HEAVEN criteria seem to be a useful tool to predict difficult airways in emergency RSI.

Apneic oxygenation is associated with a reduction in the incidence of hypoxemia during the RSI of patients with intracranial hemorrhage in the emergency department.

Critically ill patients undergoing emergent intubation are at risk of oxygen desaturation during the management of their airway. Patients with intracranial hemorrhage (ICH) are particularly susceptible to the detrimental effects of hypoxemia. Apneic oxygenation (AP OX) may be able to reduce the occurrence of oxygen desaturation during the emergent intubation of these patients. We sought to assess the effect AP OX on oxygen desaturation during the rapid sequence intubation (RSI) of patients with ICH in the emergency department (ED). We prospectively collected data on all patients intubated in an urban academic ED over the 2-year period from July 1, 2013 to June 30, 2015. Following each intubation, the operator completed a standardized continuous quality improvement (CQI) data form, which included information on patient, operator and intubation characteristics. Operators recorded data on the use of AP OX, the oxygen flow rate used for AP OX, and the starting and lowest saturations during intubation. Adult patients with ICH who underwent RSI by emergency medicine (EM) residents were included in the analyses. The primary outcome variable was any oxygen saturation <90% during the intubation. We performed a backward stepwise multivariate logistic regression analysis to identify variables associated with oxygen desaturation. The primary independent variable of interest was the use of AP OX during the intubation. Inclusion criteria for the study was met by 127 patients. AP OX was used in 72 patients (AP OX group) and was not used in 55 patients (NO AP OX group). The incidence of desaturation was 5/72 (7%) in the AP OX group and was 16/55 (29%) in the NO AP OX group. In the multivariate logistic regression analysis the use of AP OX was associated with a reduced odds of desaturation (aOR 0.13; 95% CI 0.03-0.53). Patients with ICH who received AP OX during RSI in the ED were seven times less likely to have an oxygen saturation of <90% during the intubation compared to patients who did not receive AP OX. AP OX is a simple intervention that may minimize the risk of oxygen desaturation during the RSI of patients with ICH.

A survey of a population of anaesthesiologists from South India regarding practices for rapid sequence intubation in patients with head injury.

Background and Aims:Evidence and utility of the individual steps of the rapid sequence induction and tracheal intubation protocols have been debated, especially in the setting of traumatic brain injury. The purpose of this survey was to determine preferences in the current approach to rapid sequence intubation (RSI) in head injury patients among a population of anaesthesiologists from South India.Methods:A questionnaire was E-mailed to all the members of the Indian Society of Anaesthesiologists’ South Zone Chapter to ascertain their preferences, experience and comfort level with regard to their use of rapid sequence intubation techniques in adult patients with head injury. Participants were requested to indicate their practices for RSI technique for a head-injured patient upon arrival at the Emergency Medical Services department of their hospital.Results:The total response rate was 56.9% (530/932). Of the total respondents, 35% of the clinicians used cricoid pressure routinely, most respondents (68%) stated that they pre-oxygenate the patients for about 3 min prior to RSI, thiopentone (61%) and propofol (34%) were commonly used prior to intubation. Rocuronium was the muscle relaxant of choice for RSI among the majority (44%), compared to succinylcholine (39%). Statistical analyses were performed after the initial entry onto a spreadsheet. Data were summarised descriptively using frequency distribution.Conclusion:In a rapid sequence intubation situation, the practice differed significantly among anaesthesiologists. Owing to disagreements and paucity of evidence-based data regarding the standards of RSI, it is apparent that RSI practice still has considerable variability in clinical practice.

Intubation of the Neurologically Injured Patient

BackgroundIntubation of the neurologically injured patient is a critical procedure that must be done in a manner to prevent further neurologic injury. Although many different medications and techniques have been used to meet specific needs, there is little to no evidence to support many claims. ObjectiveTo review the literature regarding important topics relating to intubating patients with neurologic injury. DiscussionAirway management requires ideal preoxygenation and airway maneuvers to minimize manipulation of the larynx and to maximize first-pass success. There is no evidence that lidocaine pretreatment decreases intracerebral pressure (ICP). Fentanyl can be used to help blunt the hemodynamic response to intubation. Esmolol is another medication that can blunt the hemodynamic response. Ketamine can be used and is possibly the ideal agent, having a neutral hemodynamic profile. A prefasciculation dose for neuromuscular blockade has not been shown to have any effect on ICP. ConclusionsIdeal intubation conditions should be obtained through the use of airway manipulation techniques and appropriate medication choice for rapid sequence intubation in patients who are neurologically injured.

Risk factors for mortality in septic patients who received etomidate

PurposeTo characterize risk factors for mortality in septic patients who received etomidate for rapid sequence intubation. Materials and MethodsThis study was a retrospective cohort conducted at a large, tertiary, urban, academic medical center that included patients with severe sepsis or septic shock who received etomidate between January 1, 2010, and December 31, 2012. ResultsA total of 169 patients were included with similar baseline characteristics. There were more men in the nonsurvivor group than in the survivor group (67.1% vs 50.6%, P = .03). Septic shock occurred in 91.5% of nonsurvivors and 69% of survivors (P < .01). Nonsurvivors also had a higher initial lactate of (5.1 ± 4.3 mmol/L vs 3.6 ± 3.4 mmol/L, P = .02) and more vasopressor therapy (91.5% vs 69%, P < .01), required a higher number of vasopressors (2.2 ± 1.1 vs 1.3 ± 1, P < .01), and were administered hydrocortisone (53.7% vs 34.5%, P = .01). Abdominal source of sepsis (P = .048) and number of vasopressors (P = .01) were predictive of 30-day mortality. ConclusionAn alternative sedative induction agent may be considered for use in rapid sequence intubation in patients on multiple vasopressors or with abdominal source of infection.

Delayed Sequence Intubation: A Prospective Observational Study

We investigate a new technique for the emergency airway management of patients with altered mental status preventing adequate preoxygenation. This was a prospective, observational, multicenter study of patients whose medical condition led them to impede optimal preintubation preparation because of delirium. A convenience sample of emergency department and ICU patients was enrolled. Patients received a dissociative dose of ketamine, allowing preoxygenation with high-flow nonrebreather mask or noninvasive positive pressure ventilation (NIPPV). After preoxygenation, patients were paralyzed and intubated. The primary outcome of this study was the difference in oxygen saturations after maximal attempts at preoxygenation before delayed sequence intubation compared with saturations just before intubation. Predetermined secondary outcomes and complications were also assessed. A total of 62 patients were enrolled: 19 patients required delayed sequence intubation to allow nonrebreather mask, 39 patients required it to allow NIPPV, and 4 patients required it for nasogastric tube placement. Saturations increased from a mean of 89.9% before delayed sequence intubation to 98.8% afterward, with an increase of 8.9% (95% confidence interval 6.4% to 10.9%). Thirty-two patients were in a predetermined group with high potential for critical desaturation (pre-delayed sequence intubation saturations ≤93%). All of these patients increased their saturations post-delayed sequence intubation; 29 (91%) of these patients increased their post-delayed sequence intubation saturations to greater than 93%. No complications were observed in the patients receiving delayed sequence intubation. Delayed sequence intubation could offer an alternative to rapid sequence intubation in patients requiring emergency airway management who will not tolerate preoxygenation or peri-intubation procedures. It is essentially procedural sedation, with the procedure being preoxygenation. Delayed sequence intubation seems safe and effective for use in emergency airway management.

Paramedic rapid sequence intubation in patients with non-traumatic coma

IntroductionPre-hospital intubation by paramedics is widely used in comatose patients prior to transportation to hospital, but the optimal technique for intubation is uncertain. One approach is paramedic rapid sequence intubation...

Rocuronium For Tracheal Intubation In Patients Undergoing Emergency Surgery

Aims: To compare the intubating conditions between inj. Rocuronium and inj. Succinylcholine during rapid sequence intubation in patients posted for emergency surgeries. The primary outcome was excellent intubation conditions. The secondary outcome was acceptable conditions and complications associated with rocuronium. Methods and Material : 60 patients posted for emergency surgeries were randomly divided randomly in to two groups. Intubating conditions at 60 seconds were compared in group-A (inj.succinylcholine 1mg/kg) and group-B(inj. rocuronium 0.6mg/kg), 30 patients in each group. Intubating conditions were judged based on the scoring of ease of jaw opening, position of the vocal cords and degree of straining after tracheal intubation. Statistical analysis used: Data obtained were be analysed by t-test, chi-square test and fisher exact test wherever applicable. Results: Mean apnoea onset time was 28.37 sec in group-A whereas it was 41.13 seconds in group-B. The mean intubation score was 9.00 ± 00 in group-A and 8.43 ± 0.85 in group-B. No side effects were observed in both the groups. Conclusions: Rocuronium (o.6mg/kg) provided acceptable intubation conditions in most of the patients at 60 seconds but, unable to provide excellent intubating conditions in all of them during rapid sequence intubation. Suxamethonium is still the best muscle relaxant to accomplish intubation in emergent cases. If suxamethonium is contraindicated, Rocuronium may be used as an alternative.