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Katzenschlager S, Obermaier M, Kuhner M, Spöttl W, Dietrich M, Weigand MA, Weilbacher F, Popp E. [Focus on emergency medicine 2021/2022-Summary of selected emergency medicine studies]. DIE ANAESTHESIOLOGIE 2023; 72:130-142. [PMID: 36602555 PMCID: PMC9813891 DOI: 10.1007/s00101-022-01245-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 12/15/2022] [Indexed: 01/06/2023]
Affiliation(s)
- S. Katzenschlager
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - M. Obermaier
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - M. Kuhner
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - W. Spöttl
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - M. Dietrich
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - M. A. Weigand
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - F. Weilbacher
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - E. Popp
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
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Russell DW, Casey JD, Gibbs KW, Ghamande S, Dargin JM, Vonderhaar DJ, Joffe AM, Khan A, Prekker ME, Brewer JM, Dutta S, Landsperger JS, White HD, Robison SW, Wozniak JM, Stempek S, Barnes CR, Krol OF, Arroliga AC, Lat T, Gandotra S, Gulati S, Bentov I, Walters AM, Dischert KM, Nonas S, Driver BE, Wang L, Lindsell CJ, Self WH, Rice TW, Janz DR, Semler MW. Effect of Fluid Bolus Administration on Cardiovascular Collapse Among Critically Ill Patients Undergoing Tracheal Intubation: A Randomized Clinical Trial. JAMA 2022; 328:270-279. [PMID: 35707974 PMCID: PMC9204618 DOI: 10.1001/jama.2022.9792] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 05/25/2022] [Indexed: 12/12/2022]
Abstract
Importance Hypotension is common during tracheal intubation of critically ill adults and increases the risk of cardiac arrest and death. Whether administering an intravenous fluid bolus to critically ill adults undergoing tracheal intubation prevents severe hypotension, cardiac arrest, or death remains uncertain. Objective To determine the effect of fluid bolus administration on the incidence of severe hypotension, cardiac arrest, and death. Design, Setting, and Participants This randomized clinical trial enrolled 1067 critically ill adults undergoing tracheal intubation with sedation and positive pressure ventilation at 11 intensive care units in the US between February 1, 2019, and May 24, 2021. The date of final follow-up was June 21, 2021. Interventions Patients were randomly assigned to receive either a 500-mL intravenous fluid bolus (n = 538) or no fluid bolus (n = 527). Main Outcomes and Measures The primary outcome was cardiovascular collapse (defined as new or increased receipt of vasopressors or a systolic blood pressure <65 mm Hg between induction of anesthesia and 2 minutes after tracheal intubation, or cardiac arrest or death between induction of anesthesia and 1 hour after tracheal intubation). The secondary outcome was the incidence of death prior to day 28, which was censored at hospital discharge. Results Among 1067 patients randomized, 1065 (99.8%) completed the trial and were included in the primary analysis (median age, 62 years [IQR, 51-70 years]; 42.1% were women). Cardiovascular collapse occurred in 113 patients (21.0%) in the fluid bolus group and in 96 patients (18.2%) in the no fluid bolus group (absolute difference, 2.8% [95% CI, -2.2% to 7.7%]; P = .25). New or increased receipt of vasopressors occurred in 20.6% of patients in the fluid bolus group compared with 17.6% of patients in the no fluid bolus group, a systolic blood pressure of less than 65 mm Hg occurred in 3.9% vs 4.2%, respectively, cardiac arrest occurred in 1.7% vs 1.5%, and death occurred in 0.7% vs 0.6%. Death prior to day 28 (censored at hospital discharge) occurred in 218 patients (40.5%) in the fluid bolus group compared with 223 patients (42.3%) in the no fluid bolus group (absolute difference, -1.8% [95% CI, -7.9% to 4.3%]; P = .55). Conclusions and Relevance Among critically ill adults undergoing tracheal intubation, administration of an intravenous fluid bolus compared with no fluid bolus did not significantly decrease the incidence of cardiovascular collapse. Trial Registration ClinicalTrials.gov Identifier: NCT03787732.
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Affiliation(s)
- Derek W. Russell
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Alabama Heersink School of Medicine, Birmingham
- Pulmonary Section, Birmingham Veteran’s Affairs Medical Center, Birmingham, Alabama
| | - Jonathan D. Casey
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Kevin W. Gibbs
- Section of Pulmonary, Critical Care, Allergy, and Immunologic Disease, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Shekhar Ghamande
- Division of Pulmonary Disease and Critical Care Medicine, Department of Medicine, Baylor Scott & White Medical Center, Temple, Texas
| | - James M. Dargin
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Derek J. Vonderhaar
- Department of Pulmonary and Critical Care Medicine, Ochsner Health System, New Orleans, Louisiana
| | - Aaron M. Joffe
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle
| | - Akram Khan
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Oregon Health and Science University School of Medicine, Portland
| | - Matthew E. Prekker
- Department of Emergency Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Joseph M. Brewer
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of Mississippi Medical Center, Jackson
| | - Simanta Dutta
- Section of Pulmonary, Critical Care, Allergy, and Immunologic Disease, Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Janna S. Landsperger
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Heath D. White
- Division of Pulmonary Disease and Critical Care Medicine, Department of Medicine, Baylor Scott & White Medical Center, Temple, Texas
| | - Sarah W. Robison
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Alabama Heersink School of Medicine, Birmingham
| | - Joanne M. Wozniak
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Susan Stempek
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | | | - Olivia F. Krol
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Oregon Health and Science University School of Medicine, Portland
| | - Alejandro C. Arroliga
- Division of Pulmonary Disease and Critical Care Medicine, Department of Medicine, Baylor Scott & White Medical Center, Temple, Texas
| | - Tasnim Lat
- Division of Pulmonary Disease and Critical Care Medicine, Department of Medicine, Baylor Scott & White Medical Center, Temple, Texas
| | - Sheetal Gandotra
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Alabama Heersink School of Medicine, Birmingham
| | - Swati Gulati
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Alabama Heersink School of Medicine, Birmingham
| | - Itay Bentov
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle
| | - Andrew M. Walters
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle
| | - Kevin M. Dischert
- Department of Pulmonary and Critical Care Medicine, Ochsner Health System, New Orleans, Louisiana
| | - Stephanie Nonas
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Oregon Health and Science University School of Medicine, Portland
| | - Brian E. Driver
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Hennepin County Medical Center, Minneapolis, Minnesota
| | - Li Wang
- Department of Biostatistics, Vanderbilt University School of Medicine, Nashville, Tennessee
| | | | - Wesley H. Self
- Department of Emergency Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - Todd W. Rice
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - David R. Janz
- University Medical Center New Orleans, New Orleans, Louisiana
- Section of Pulmonary/Critical Care and Allergy/Immunology, Department of Medicine, Louisiana State University School of Medicine, New Orleans
| | - Matthew W. Semler
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee
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Jarzebowski M, Estime S, Russotto V, Karamchandani K. Challenges and outcomes in airway management outside the operating room. Curr Opin Anaesthesiol 2022; 35:109-114. [PMID: 35102045 DOI: 10.1097/aco.0000000000001100] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW Airway management outside the operating room poses unique challenges that every clinician should recognize. These include anatomic, physiologic, and logistic challenges, each of which can contribute to complications and lead to poor outcomes. Recognizing these challenges and highlighting known outcome data may better prepare the team, making this otherwise daunting procedure safer and potentially improving patient outcomes. RECENT FINDINGS Newer intubating techniques and devices have made navigating anatomic airway challenges easier. However, physiological challenges during emergency airway management remain a cause of poor patient outcomes. Hemodynamic collapse has been identified as the most common peri-intubation adverse event and a leading cause of morbidity and mortality associated with the procedure. SUMMARY Emergency airway management outside the operating room remains a high-risk procedure, associated with poor outcomes. Pre-intubation hemodynamic optimization may mitigate some of the risks, and future research should focus on identification of best strategies for hemodynamic optimization prior to and during this procedure.
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Affiliation(s)
- Mary Jarzebowski
- Department of Anesthesiology, University of Michigan Medicine, Ann Arbor, Michigan
| | - Stephen Estime
- Department of Anesthesia & Critical Care University of Chicago Medicine, Chicago, Illinois, USA
| | - Vincenzo Russotto
- Department of Anesthesia & Critical Care, University Hospital San Luigi Gonzaga, University of Turin, Italy
| | - Kunal Karamchandani
- Department of Anesthesiology and Pain Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
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Effect of the use of an endotracheal tube and stylet versus an endotracheal tube alone on first-attempt intubation success: a multicentre, randomised clinical trial in 999 patients. Intensive Care Med 2021; 47:653-664. [PMID: 34032882 PMCID: PMC8144872 DOI: 10.1007/s00134-021-06417-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 04/20/2021] [Indexed: 11/18/2022]
Abstract
Purpose The effect of the routine use of a stylet during tracheal intubation on first-attempt intubation success is unclear. We hypothesised that the first-attempt intubation success rate would be higher with tracheal tube + stylet than with tracheal tube alone. Methods In this multicentre randomised controlled trial, conducted in 32 intensive care units, we randomly assigned patients to tracheal tube + stylet or tracheal tube alone (i.e. without stylet). The primary outcome was the proportion of patients with first-attempt intubation success. The secondary outcome was the proportion of patients with complications related to tracheal intubation. Serious adverse events, i.e., traumatic injuries related to tracheal intubation, were evaluated. Results A total of 999 patients were included in the modified intention-to-treat analysis: 501 (50%) to tracheal tube + stylet and 498 (50%) to tracheal tube alone. First-attempt intubation success occurred in 392 patients (78.2%) in the tracheal tube + stylet group and in 356 (71.5%) in the tracheal tube alone group (absolute risk difference, 6.7; 95%CI 1.4–12.1; relative risk, 1.10; 95%CI 1.02–1.18; P = 0.01). A total of 194 patients (38.7%) in the tracheal tube + stylet group had complications related to tracheal intubation, as compared with 200 patients (40.2%) in the tracheal tube alone group (absolute risk difference, − 1.5; 95%CI − 7.5 to 4.6; relative risk, 0.96; 95%CI 0.83–1.12; P = 0.64). The incidence of serious adverse events was 4.0% and 3.6%, respectively (absolute risk difference, 0.4; 95%CI, − 2.0 to 2.8; relative risk, 1.10; 95%CI 0.59–2.06. P = 0.76). Conclusions Among critically ill adults undergoing tracheal intubation, using a stylet improves first-attempt intubation success. Supplementary Information The online version contains supplementary material available at 10.1007/s00134-021-06417-y.
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