Difficult airway management resources and capnography use in Japanese intensive care units: a nationwide cross-sectional study

Neuromuscular blockade management in the critically Ill patient

Neuromuscular blocking agents (NMBAs) can be an effective modality to address challenges that arise daily in the intensive care unit (ICU). These medications are often used to optimize mechanical ventilation, facilitate endotracheal intubation, stop overt shivering during therapeutic hypothermia following cardiac arrest, and may have a role in the management of life-threatening conditions such as elevated intracranial pressure and status asthmaticus (when deep sedation fails or is not tolerated). However, current NMBA use has decreased during the last decade due to concerns of potential adverse effects such as venous thrombosis, patient awareness during paralysis, development of critical illness myopathy, autonomic interactions, and even residual paralysis following cessation of NMBA use.

It is therefore essential for clinicians to be familiar with evidence-based practices regarding appropriate NMBA use in order to select appropriate indications for their use and avoid complications. We believe that selecting the right NMBA, administering concomitant sedation and analgesic therapy, and using appropriate monitoring techniques mitigate these risks for critically ill patients. Therefore, we review the indications of NMBA use in the critical care setting and discuss the most appropriate use of NMBAs in the intensive care setting based on their structure, mechanism of action, side effects, and recognized clinical indications. Lastly, we highlight the available pharmacologic antagonists, strategies for sedation, newer neuromuscular monitoring techniques, and potential complications related to the use of NMBAs in the ICU setting.

Availability and organization of difficult airway equipment in Swedish hospitals: A national survey of anaesthesiologists

BACKGROUND

Airway complications account for almost one third of anaesthesia-related brain damage and death. Immediate access to equipment enabling rescue airway strategies is crucial for successful management of unanticipated difficult airway situations.

METHODS

We conducted a nationwide survey of Swedish anaesthesiologists to analyse availability and organization of difficult airway trolleys (DATs), and multiple factors pertaining to difficult airway management, to highlight areas of potential improvement.

RESULTS

Six hundred and thirty-nine anaesthesiologists completed the 14-item survey. Whereas DATs were almost ubiquitous (95%) in main operating departments of hospitals, prevalence was low in remote anaesthetizing locations (20.3%) and electroconvulsive therapy units (26.6%). Approximately 60% of emergency departments had a DAT. Immediate (within 60 seconds) access to videolaryngoscopes in all units where general anaesthesia is conducted was reported by 56.8%. Almost half of anaesthesiologists reported that all DATs at their workplace were standardized. Forty-six per cent reported that the DATs were organized according to a difficult airway algorithm; almost 90% believe that such an organization can impact the outcome of a difficult airway situation positively. Only 36.2% of DATs contained second-generation supraglottic airway devices exclusively. Most Swedish anaesthesiologists use the Swedish Society of Anaesthesiology and Intensive care Medicine difficult airway algorithm, but almost one fifth prefer the Difficult Airway Society algorithm. Less than half of respondents underwent formal difficult airway training annually.

CONCLUSION

Our results motivate efforts to (a) increase availability of DATs in remote anaesthetizing locations, (b) increasingly standardize DATs and organize DATs according to airway algorithms, and (c) increase the frequency of difficult airway training.

Treatment of patients with sepsis in a closed intensive care unit is associated with improved survival: a nationwide observational study in Japan

Background

The aim of this study is to investigate the association between treatment in a closed ICU and survival at discharge in patients with sepsis.

Methods

This is a post hoc analysis utilizing data from the Japan Septic Disseminated Intravascular Coagulation study, including data from patients with sepsis from 2011 to 2013. Multiple logistic regression analysis was used to estimate the association between ICU policy and survival at discharge, and propensity score matching analysis was performed including the same covariates as a sensitivity analysis. Multiple linear regression analysis for the length of ICU stay in surviving patients was also performed with adjustments for the same covariates.

Results

Two thousand four hundred ninety-five patients were analyzed. The median Acute Physiology and Chronic Health Evaluation (APACHE) II score was 22 [17–29], the median Sequential Organ Failure Assessment (SOFA) score was 9 [7–12], and the overall mortality was 33%. There were 979 patients treated in 17 open ICUs and 1516 patients in 18 closed ICUs. In comparison, the APACHE II score and SOFA scores were significantly higher in patients in closed ICUs (closed vs open = 23 [18–29] vs 21 [16–28]; p < .001, 9 [7–13] vs 9 [6–12]; p = 0.004). There was no difference in the unadjusted mortality (closed vs open; 33.1% vs 33.2%), but in multiple logistic regression analysis, treatment in a closed ICU is significantly associated with survival at discharge (odds ratio = 1.59, 95% CI [1.276–1.827], p = .001). The sensitivity analysis (702 pairs of the matching) showed a significantly higher survival rate in the closed ICU (71.8% vs 65.2%, p = 0.011). The length of ICU stay of patients in closed ICUs was significantly shorter (20% less).

Conclusion

This Japanese nationwide analysis of patients with sepsis shows a significant association between treatment in a closed ICU and survival at discharge, and a 20% decrease in ICU stay.

Electronic supplementary material

The online version of this article (10.1186/s40560-018-0322-8) contains supplementary material, which is available to authorized users.

End-Tidal Carbon Dioxide Use for Tracheal Intubation: Analysis From the National Emergency Airway Registry for Children (NEAR4KIDS) Registry

OBJECTIVE

Waveform capnography use has been incorporated into guidelines for the confirmation of tracheal intubation. We aim to describe the trend in waveform capnography use in emergency departments and PICUs and assess the association between waveform capnography use and adverse tracheal intubation-associated events.

DESIGN

A multicenter retrospective cohort study.

SETTING

Thirty-four hospitals (34 ICUs and nine emergency departments) in the National Emergency Airway Registry for Children quality improvement initiative.

PATIENTS

Primary tracheal intubation in children younger than 18 years.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Patient, provider, and practice data for tracheal intubation procedure including a type of end-tidal carbon dioxide measurement, as well as the procedural safety outcomes, were prospectively collected. The use of waveform capnography versus colorimetry was evaluated in association with esophageal intubation with delayed recognition, cardiac arrest, and oxygen desaturation less than 80%. During January 2011 and December 2015, 9,639 tracheal intubations were reported. Waveform capnography use increased over time (39% in 2010 to 53% in 2015; p < 0.001), whereas colorimetry use decreased (< 0.001). There was significant variability in waveform capnography use across institutions (median 49%; interquartile range, 25-85%; p < 0.001). Capnography was used more often in emergency departments as compared with ICUs (66% vs. 49%; p < 0.001). The rate of esophageal intubation with delayed recognition was similar with waveform capnography versus colorimetry (0.39% vs. 0.46%; p = 0.62). The rate of cardiac arrest was also similar (p = 0.49). Oxygen desaturation occurred less frequently when capnography was used (17% vs. 19%; p = 0.03); however, this was not significant after adjusting for patient and provider characteristics.

CONCLUSIONS

Significant variations existed in capnography use across institutions, with the use increasing over time in both emergency departments and ICUs. The use of capnography during intubation was not associated with esophageal intubation with delayed recognition or the occurrence of cardiac arrest.

Human and equipment resources for difficult airway management, airway education programs, and capnometry use in Japanese emergency departments: a nationwide cross-sectional study

BACKGROUND

Although human and equipment resources, proper training, and the verification of endotracheal intubation are vital elements of difficult airway management (DAM), their availability in Japanese emergency departments (EDs) has not been determined. How ED type and patient volume affect DAM preparation is also unclear. We conducted the present survey to address this knowledge gaps.

METHODS

This nationwide cross-sectional study was conducted from April to September 2016. All EDs received a mailed questionnaire regarding their DAM resources, airway training methods, and capnometry use for tube placement. Outcome measures were the availability of: (1) 24-h in-house back-up; (2) key DAM resources, including a supraglottic airway device (SGA), a dedicated DAM cart, surgical airway devices, and neuromuscular blocking agents; (3) anesthesiology rotation as part of an airway training program; and (4) the routine use of capnometry to verify tube placement. EDs were classified as academic, tertiary, high-volume (upper quartile of annual ambulance visits), and urban.

RESULTS

Of the 530 EDs, 324 (61.1%) returned completed questionnaires. The availability of in-house back-up coverage, surgical airway devices, and neuromuscular blocking agents was 69.4, 95.7, and 68.5%, respectively. SGAs and dedicated DAM carts were present in 51.5 and 49.7% of the EDs. The rates of routine capnometry use (47.8%) and the availability of an anesthesiology rotation (38.6%) were low. The availability of 24-h back-up coverage was significantly higher in academic EDs and tertiary EDs in both the crude and adjusted analysis. Similarly, neuromuscular blocking agents were more likely to be present in academic EDs, high-volume EDs, and tertiary EDs; and the rate of routine use of capnometry was significantly higher in tertiary EDs in both the crude and adjusted analysis.

CONCLUSIONS

In Japanese EDs, the rates of both the availability of SGAs and DAM carts and the use of routine capnometry to confirm tube placement were approximately 50%. These data demonstrate the lack of standard operating procedures for rescue ventilation and post-intubation care. Academic, tertiary, and high-volume EDs were likely to be well prepared for DAM.