Browsing by Subject "Intubation, Intratracheal"

Now showing 1 - 5 of 5
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    ItemOpen Access
    Direct vs Video Laryngoscopy for Difficult Airway Patients in the Emergency Department: A National Emergency Airway Registry Study.
    (The western journal of emergency medicine, 2022-08) Ruderman, Brandon T; Mali, Martina; Kaji, Amy H; Kilgo, Robert; Watts, Susan; Wells, Radosveta; Limkakeng, Alexander T; Borawski, Joseph B; Fantegrossi, Andrea E; Walls, Ron M; Brown, Calvin A; National Emergency Airway Registry investigators

    Introduction

    Previous studies suggest improved intubation success using video laryngoscopy (VL) vs direct laryngoscopy (DL), yet recent randomized trials have not shown clear benefit of one method over the other. These studies, however, have generally excluded difficult airways and rapid sequence intubation. In this study we looked to compare first-pass success (FPS) rates between VL and DL in adult emergency department (ED) patients with difficult airways.

    Methods

    We conducted a secondary analysis of prospectively collected observational data in the National Emergency Airway Registry (NEAR) (January 2016-December 2018). Variables included demographics, indications, methods, medications, devices, difficult airway characteristics, success, and adverse events. We included adult ED patients intubated with VL or DL who had difficult airways identified by gestalt or anatomic predictors. We stratified VL by hyperangulated (HAVL) vs standard geometry VL (SGVL). The primary outcome was FPS, and the secondary outcome was comparison of adverse event rates between groups. Data analyses included descriptive statistics with cluster-adjusted 95% confidence intervals (CI).

    Results

    Of 18,123 total intubations, 12,853 had a predicted or identified anatomically difficult airway. The FPS for difficult airways was 89.1% (95% CI 85.9-92.3) with VL and 77.7% (95% CI 75.7-79.7) with DL (P <0.00001). The FPS rates were similar between VL subtypes for all difficult airway characteristics except airways with blood or vomit, where SGVL FPS (87.3%; 95% CI 85.8-88.8) was slightly better than HAVL FPS (82.4%; 95% CI, 80.3-84.4). Adverse event rates were similar except for esophageal intubations and vomiting, which were both less common in VL than DL. Esophageal intubations occurred in 0.4% (95% CI 0.1-0.7) of VL attempts and 1.5% (95% CI 1.1-1.9) of DL attempts. Vomiting occurred in 0.6% (95% CI 0.5-0.7) of VL attempts and 1.4% (95% CI 0.9-1.9) of DL attempts.

    Conclusion

    Analysis of the NEAR database demonstrates higher first-pass success with VL compared to DL in patients with predicted or anatomically difficult airways, and reduced rate of esophageal intubations and vomiting.
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    Implementation of the TaperGuard™ endotracheal tube in an unselected surgical population to reduce postoperative pneumonia.
    (BMC anesthesiology, 2020-08) Martini, Ross P; Yanez, N David; Treggiari, Miriam M; Tekkali, Praveen; Soelberg, Cobin; Aziz, Michael F

    Background

    Endotracheal tube (ETT) designs to decrease the risk of ventilator associated pneumonia (VAP) include supraglottic suctioning, and/or modifications of the cuff shape. The TaperGuard™ ETT has a tapered, polyvinylchloride cuff designed to reduce microaspiration around channels that form with a standard barrel-shaped cuff. We compared risk of postoperative pneumonia using the TaperGuard™ ETT and the standard ETT in surgical patients requiring general anesthesia with endotracheal intubation.

    Methods

    We used an interrupted time-series design to compare endotracheal intubation using the TaperGuard™ ETT (intervention cohort), and a historic cohort using the standard ETT (baseline cohort), among surgical patients requiring hospital admission. We compared the incidence of postoperative pneumonia in the intervention and baseline cohorts. Data were collected from the electronic health record and linked to patient-level data from National Surgical Quality Improvement Project. Additionally, we performed secondary analyses in a subgroup of patients at high risk of postoperative pneumonia.

    Results

    15,388 subjects were included; 6351 in the intervention cohort and 9037 in the baseline cohort. There was no significant difference in the incidence of postoperative pneumonia between the intervention cohort (1.62%) and the baseline cohort (1.79%). The unadjusted odds ratio (OR) of postoperative pneumonia was 0.90 (95% CI: 0.70, 1.16; p = 0.423) and the OR adjusted for patient characteristics and potential confounders was 0.90 (95% CI: 0.69, 1.19; p = 0.469), comparing the intervention and baseline cohorts. There was no a priori selected subgroup of patients for whom the use of the TaperGuard™ ETT was associated with decreased odds of postoperative pneumonia relative to the standard ETT. Hospital mortality was higher in the intervention cohort (1.5%) compared with the baseline cohort (1.0%; OR 1.46, 95% CI: 1.09, 1.95; p = 0.010).

    Conclusions

    The broad implementation of the use of the TaperGuard™ ETT for intubation of surgical patients was not associated with a reduction in the risk of postoperative pneumonia. In the setting of a low underlying postoperative pneumonia risk and the use of recommended preventative VAP bundles, further risk reduction may not be achievable by simply modifying the ETT cuff design in unselected or high-risk populations undergoing inpatient surgery.

    Trial registration

    ClinicalTrials.gov, ID NCT02450929 .
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    Reducing Intubation Time in Adult Cardiothoracic Surgery Patients With a Fast-track Extubation Protocol.
    (Critical care nurse, 2021-06) Ellis, Myra F; Pena, Heather; Cadavero, Allen; Farrell, Debra; Kettle, Mollie; Kaatz, Alexandra R; Thomas, Tonda; Granger, Bradi; Ghadimi, Kamrouz

    Background

    Prolonged intubation after cardiac surgery increases the risk of morbidity and mortality and lengthens hospital stays. Factors that influence the ability to extubate patients with speed and efficiency include the operation, the patient's baseline physiological condition, workflow processes, and provider practice patterns.

    Local problem

    Progression to extubation lacked consistency and coordination across the team. The purpose of the project was to engage interprofessional stakeholders to reduce intubation times after cardiac surgery by implementing fast-track extubation and redesigned care processes.

    Methods

    This staged implementation study used the Define, Measure, Analyze, Improve, and Control approach to quality improvement. Barriers to extubation were identified and reduced through care redesign. A protocol-driven approach to extubation was also developed for the cardiothoracic intensive care unit. The team was engaged with clear goals and given progress updates.

    Results

    In the preimplementation cohort, early extubation was achieved in 48 of 101 patients (47.5%) who were designated for early extubation on admission to the cardiothoracic intensive care unit. Following implementation of a fast-track extubation protocol and improved care processes, 153 of 211 patients (72.5%) were extubated within 6 hours after cardiac surgery. Reintubation rate, length of stay, and 30-day mortality did not differ between cohorts.

    Conclusions

    The number of early extubations following cardiac surgery was successfully increased. Faster progression to extubation did not increase risk of reintubation or other adverse events. Using a framework that integrated personal, social, and environmental influences helped increase the impact of this project.
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    ItemOpen Access
    The first 20 months of the COVID-19 pandemic: Mortality, intubation and ICU rates among 104,590 patients hospitalized at 21 United States health systems.
    (PloS one, 2022-01) Fiore, Michael C; Smith, Stevens S; Adsit, Robert T; Bolt, Daniel M; Conner, Karen L; Bernstein, Steven L; Eng, Oliver D; Lazuk, David; Gonzalez, Alec; Jorenby, Douglas E; D'Angelo, Heather; Kirsch, Julie A; Williams, Brian; Nolan, Margaret B; Hayes-Birchler, Todd; Kent, Sean; Kim, Hanna; Piasecki, Thomas M; Slutske, Wendy S; Lubanski, Stan; Yu, Menggang; Suk, Youmi; Cai, Yuxin; Kashyap, Nitu; Mathew, Jomol P; McMahan, Gabriel; Rolland, Betsy; Tindle, Hilary A; Warren, Graham W; An, Lawrence C; Boyd, Andrew D; Brunzell, Darlene H; Carrillo, Victor; Chen, Li-Shiun; Davis, James M; Dilip, Deepika; Ellerbeck, Edward F; Iturrate, Eduardo; Jose, Thulasee; Khanna, Niharika; King, Andrea; Klass, Elizabeth; Newman, Michael; Shoenbill, Kimberly A; Tong, Elisa; Tsoh, Janice Y; Wilson, Karen M; Theobald, Wendy E; Baker, Timothy B

    Main objective

    There is limited information on how patient outcomes have changed during the COVID-19 pandemic. This study characterizes changes in mortality, intubation, and ICU admission rates during the first 20 months of the pandemic.

    Study design and methods

    University of Wisconsin researchers collected and harmonized electronic health record data from 1.1 million COVID-19 patients across 21 United States health systems from February 2020 through September 2021. The analysis comprised data from 104,590 adult hospitalized COVID-19 patients. Inclusion criteria for the analysis were: (1) age 18 years or older; (2) COVID-19 ICD-10 diagnosis during hospitalization and/or a positive COVID-19 PCR test in a 14-day window (+/- 7 days of hospital admission); and (3) health system contact prior to COVID-19 hospitalization. Outcomes assessed were: (1) mortality (primary), (2) endotracheal intubation, and (3) ICU admission.

    Results and significance

    The 104,590 hospitalized participants had a mean age of 61.7 years and were 50.4% female, 24% Black, and 56.8% White. Overall risk-standardized mortality (adjusted for age, sex, race, ethnicity, body mass index, insurance status and medical comorbidities) declined from 16% of hospitalized COVID-19 patients (95% CI: 16% to 17%) early in the pandemic (February-April 2020) to 9% (CI: 9% to 10%) later (July-September 2021). Among subpopulations, males (vs. females), those on Medicare (vs. those on commercial insurance), the severely obese (vs. normal weight), and those aged 60 and older (vs. younger individuals) had especially high mortality rates both early and late in the pandemic. ICU admission and intubation rates also declined across these 20 months.

    Conclusions

    Mortality, intubation, and ICU admission rates improved markedly over the first 20 months of the pandemic among adult hospitalized COVID-19 patients although gains varied by subpopulation. These data provide important information on the course of COVID-19 and identify hospitalized patient groups at heightened risk for negative outcomes.

    Trial registration

    ClinicalTrials.gov Identifier: NCT04506528 (https://clinicaltrials.gov/ct2/show/NCT04506528).
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    Variation in propofol induction doses administered to surgical patients over age 65.
    (Journal of the American Geriatrics Society, 2021-08) Schonberger, Robert B; Bardia, Amit; Dai, Feng; Michel, George; Yanez, David; Curtis, Jeptha P; Vaughn, Michelle T; Burg, Matthew M; Mathis, Michael; Kheterpal, Sachin; Akhtar, Shamsuddin; Shah, Nirav

    Background/objectives

    Advanced age is associated with increased susceptibility to acute adverse effects of propofol. The present study aimed to describe patterns of propofol dosing for induction of general anesthesia before endotracheal intubation in a nationwide sample of older adults presenting for surgery.

    Design

    Retrospective observational study using the Multicenter Perioperative Outcomes Group data set.

    Setting

    Thirty-six institutions across the United States.

    Participants

    A total of 350,766 patients aged over 65 years who received propofol for general anesthetic induction and endotracheal intubation between 2014 and 2018.

    Intervention

    None.

    Measurements

    Total induction bolus dose of propofol administered.

    Results

    The mean (SD) weight-adjusted propofol dose was 1.7 (0.6) mg/kg. The mean prevalent propofol induction dose exceeded the upper bound of what has been described as the typical geriatric dose requirement across every age category examined. The percent of patients receiving propofol induction doses above the described typical geriatric range was 64.8% (95% CI 64.6-65.0), varying from 73.8% among patients aged 65-69 to 45.8% among patients aged 80 and older.

    Conclusion

    The present study of a large multicenter cohort demonstrates that prevalent propofol dosing commonly falls above the published typically required dose range for patients aged ≥65 in nationwide anesthetic practice. Widespread variability in induction dose administration remains incompletely explained by known patient variables. The nature and clinical consequences of these unexplained dosing decisions remain important topics for further study. Observed discordance between expected and actual induction dosing raises the question of whether there should be reconsideration of widespread provider practice or, alternatively, whether what is published as the typical propofol induction dose range should be revisited.