Pharmacotherapy optimization for rapid sequence intubation in the emergency department

Failed/difficult Intubation comparing between pre-COVID-19 and COVID-19 pandemic period using a national insurance claims database and information system of a university hospital

INTRODUCTION

Endotracheal intubation can be difficult or even fail under certain patient and anaesthesiologist conditions. During the COVID-19 pandemic a country-wide lockdown policy was enforced in Thailand which stipulated that anaesthesiologists wear personal protective equipment, powered air purifying respirator, or goggles and surgical/N95 mask during the intubation procedure. Thus, an anaesthesiologist's vision is restricted and grip on the equipment less sure. Under these conditions, the incidence of difficult intubation was expected to increase.

METHODS

This time-series study was based on the aggregated age- and sex-standardized monthly incidence of difficult intubation among all intubated patients whose data were recorded in the national insurance claims database and among patients recorded in the records of a university hospital from January 2018 to September 2022. Changes in incidence of difficult intubation following the implementation of a lockdown policy from 26 March 2020 during the COVID-19 pandemic were explored using negative binomial regression and interrupted linear regression time-series analysis.

RESULTS

Data of 922,274 individuals in the national database and 95,457 individuals in the university database were retrieved. The overall incidence of difficult intubation in both settings dropped by 25% following lockdown, significantly so in the national database (p < 0.001). At the point of interruption, a significant drop in level was evident in the national data (of 1.682 per thousand per month, P = 0.003) and a non-significant drop at the university level (of 1.118 per thousand per month, P = 0.304).

DISCUSSION

The decreased incidence of difficult intubation during the lockdown period was contrary to expectation but might be related to the deployment solely of anaesthesiologists and more experienced anaesthetic staff using videolaryngoscopes during lockdown following the recommendation for intubation during respiratory disease pandemics.

The Application and Pharmaceutical Development of Etomidate: Challenges and Strategies

Etomidate is a synthetic imidazole anesthetic that exerts hypnotic effects by potentiating the action of the inhibitory neurotransmitter γ-aminobutyric acid (GABA) or directly activating the anionic GABA (GABAA) receptor. It stands out among many anesthetics because of its multiple advantages, such as good hemodynamic stability and minimal inhibition of spontaneous respiration. However, its low water solubility and side effects, such as adrenal cortex inhibition and myoclonus, have limited the clinical application of this drug. To address these issues, extensive research has been conducted on the drug delivery of etomidate in recent decades, which has led to the emergence of different etomidate preparations. Despite so many etomidate preparations, so far some of the toxic side effects have not yet been effectively addressed. Herein we discuss the pharmaceutical design of etomidate that may resolve the above problem. We also propose targeted strategies for future research on etomidate preparations and discuss the feasibility of different administration routes and dosage forms to expand the application of this drug. Through this review, we hope to draw more attention to the potential of etomidate and its application challenges and provide valuable insights into the development of new etomidate preparations.

Anesthesia for traumatic brain injury

PURPOSE OF REVIEW

Traumatic brain injury (TBI) presents complex clinical challenges, requiring a nuanced understanding of its pathophysiology and current management principles to improve patient outcomes. Anesthetists play a critical role in care and need to stay updated with recent evidence and trends to ensure high-quality treatment. The Brain Trauma Foundation Guidelines, last updated in 2016, have shown moderate adherence, and much of the current management relies on expert opinions. This literature review synthesizes the current evidence and provides insights into the role of anesthetists in TBI management.

RECENT FINDINGS

Recent literature has emphasized the importance of tailored anesthetic management principles in treating TBI, focusing on minimizing secondary brain injury during neurosurgical interventions or extracranial surgery. Emerging trends include individualized intracranial pressure approaches and multimodal neuromonitoring for comprehensive assessment of cerebral physiology.

SUMMARY

Anesthesia for TBI patients requires a comprehensive approach that balances anesthetic goals with the unique pathophysiological factors of brain injury. Despite recent research expanding our understanding, challenges remain in standardizing protocols and addressing individual patient response variability. Adherence to established management principles, personalized approaches, and ongoing research is crucial for improving the outcomes.

Current trends in emergency airway management: a clinical review

Airway management is a fundamental and complex process that involves a sequence of integrated tasks. Situations requiring emergency airway management may occur in the emergency department, intensive care units, and various other clinical spaces. A variety of challenges can arise during emergency airway preparation, intubation, and postintubation, which may result in significant complications for patients. Therefore, many countries are establishing step-by-step systemization and detailed guidelines and/or updating their content based on the latest research. This clinical review introduces the current trends in emergency airway management, such as emergency airway management algorithms, comparison of video and direct laryngoscopy, rapid sequence intubation, pediatric airway management, prehospital airway management, surgical airway management, and airway management education.

Ketamine, an Old-New Drug: Uses and Abuses

Ketamine as an old-new drug has a variety of clinical implications. In the last 30 years, ketamine has become popular for acute use in humans. Ketamine in standard doses is principally utilized for the induction and maintenance of surgical procedures. Besides its use in anesthesia and analgesia, recent studies have shown that ketamine has found a place in the treatment of asthma, epilepsy, depression, bipolar affective disorders, alcohol and heroin addiction. Ketamine primarily functions as a noncompetitive antagonist targeting the N-methyl-D-aspartate (NMDA) receptor, but its mechanism of action is complex. It is generally regarded as safe, with low doses and short-term use typically not leading to significant adverse effects. Also, ketamine is known as a powerful psychostimulant. During the past decade, ketamine has been one of the commonly abused drugs.

Strong Association between Inotrope Administration and Intraventricular Hemorrhage, Gestational Age, and the Use of Fentanyl in Very Low Gestational Age Infants: A Retrospective Study

This was a single center, retrospective cohort study designed to evaluate the association between the administration of inotropes to hypotensive very low gestational age infants (VLGAI) and prenatal and neonatal risk factors. Inpatient medical records were reviewed to identify neonates treated with inotropes (treated group) and a control group for comparison. Two hundred and twenty two (222) VLGAI (less than 32 weeks' gestation) were included in the final analysis and were stratified based on timing of treatment with 83 infants (37.4%) and 139 infants (62.6%) in the treated and control groups, respectively. A total of 56/83 (67%) received inotropes for arterial hypotension during the first 3 days (early treatment subgroup) and 27/83 (32.5%) after 3 days of life (late-treated subgroup). Fentanyl, severe intraventricular hemorrhage (IVH), and gestational age (GA) were the risk factors most significantly associated with the need for inotrope use both during the first 3 days of life and the whole NICU stay, before and after adjustment for confounders. In conclusion, fentanyl, severe IVH, and GA are the risk factors most strongly associated with the need for inotrope treatment in VLGAI. Measures to modify these risk factors may decrease the need for cardiovascular medications and improve outcomes.

Procedural (Conscious) Sedation and Analgesia in Emergency Setting: How to Choose Agents?

Pain has long been defined as an unpleasant sensory and emotional experience originating from any region of the body in the presence or absence of tissue injury. Physicians involved in acute medicine commonly undertake a variety of invasive and painful procedures that prompt procedural sedation and analgesia (PSA), which is a condition sparing the protective airway reflexes while depressing the patient's awareness of external stimuli. This state is achieved following obtaining the patient's informed consent, necessary point-ofcare monitoring, and complete recording of the procedures. The most commonly employed combination for PSA mostly comprises short-acting benzodiazepine (midazolam) and a potent opioid, such as fentanyl. The biggest advantage of opioids is that despite all the powerful effects, upper airway reflexes are preserved and often do not require intervention. Choices of analgesic and sedative agents should be strictly individualized and determined for the specific condition. The objective of this review article was to underline the characteristics, effectiveness, adverse effects, and pitfalls of the relevant drugs employed in adults to facilitate PSA in emergency procedures.