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1.
Anaesthesia ; 75(1): 45-53, 2020 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-31520421

RESUMEN

Traumatic brain injury patients frequently undergo tracheal intubation. We aimed to assess current intubation practice in Europe and identify variation in practice. We analysed data from patients with traumatic brain injury included in the prospective cohort study collaborative European neurotrauma effectiveness research in traumatic brain injury (CENTER-TBI) in 45 centres in 16 European countries. We included patients who were transported to hospital by emergency medical services. We used mixed-effects multinomial regression to quantify the effects on pre-hospital or in-hospital tracheal intubation of the following: patient characteristics; injury characteristics; centre; and trauma system characteristics. A total of 3843 patients were included. Of these, 1322 (34%) had their tracheas intubated; 839 (22%) pre-hospital and 483 (13%) in-hospital. The fit of the model with only patient characteristics predicting intubation was good (Nagelkerke R2 64%). The probability of tracheal intubation increased with the following: younger age; lower pre-hospital or emergency department GCS; higher abbreviated injury scale scores (head and neck, thorax and chest, face or abdomen abbreviated injury score); and one or more unreactive pupils. The adjusted median odds ratio for intubation between two randomly chosen centres was 3.1 (95%CI 2.1-4.3) for pre-hospital intubation, and 2.7 (95%CI 1.9-3.5) for in-hospital intubation. Furthermore, the presence of an anaesthetist was independently associated with more pre-hospital intubation (OR 2.9, 95%CI 1.3-6.6), in contrast to the presence of ambulance personnel who are allowed to intubate (OR 0.5, 95%CI 0.3-0.8). In conclusion, patient and injury characteristics are key drivers of tracheal intubation. Between-centre differences were also substantial. Further studies are needed to improve the evidence base supporting recommendations for tracheal intubation.


Asunto(s)
Lesiones Traumáticas del Encéfalo/terapia , Intubación Intratraqueal/estadística & datos numéricos , Adulto , Factores de Edad , Anciano , Estudios de Cohortes , Europa (Continente) , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Índice de Severidad de la Enfermedad
2.
Anesthesiology ; 131(4): 818-829, 2019 10.
Artículo en Inglés | MEDLINE | ID: mdl-31584884

RESUMEN

BACKGROUND: Difficult or failed intubation is a major contributor to morbidity for patients and liability for anesthesiologists. Updated difficult airway management guidelines and incorporation of new airway devices into practice may have affected patient outcomes. The authors therefore compared recent malpractice claims related to difficult tracheal intubation to older claims using the Anesthesia Closed Claims Project database. METHODS: Claims with difficult tracheal intubation as the primary damaging event occurring in the years 2000 to 2012 (n = 102) were compared to difficult tracheal intubation claims from 1993 to 1999 (n = 93). Difficult intubation claims from 2000 to 2012 were evaluated for preoperative predictors and appropriateness of airway management. RESULTS: Patients in 2000 to 2012 difficult intubation claims were sicker (78% American Society of Anesthesiologists [ASA] Physical Status III to V; n = 78 of 102) and had more emergency procedures (37%; n = 37 of 102) compared to patients in 1993 to 1999 claims (47% ASA Physical Status III to V; n = 36 of 93; P < 0.001 and 22% emergency; n = 19 of 93; P = 0.025). More difficult tracheal intubation events occurred in nonperioperative locations in 2000 to 2012 than 1993 to 1999 (23%; n = 23 of 102 vs. 10%; n = 10 of 93; P = 0.035). Outcomes differed between time periods (P < 0.001), with a higher proportion of death in 2000 to 2012 claims (73%; n = 74 of 102 vs. 42%; n = 39 of 93 in 1993 to 1999 claims; P < 0.001 adjusted for multiple testing). In 2000 to 2012 claims, preoperative predictors of difficult tracheal intubation were present in 76% (78 of 102). In the 97 claims with sufficient information for assessment, inappropriate airway management occurred in 73% (71 of 97; κ = 0.44 to 0.66). A "can't intubate, can't oxygenate" emergency occurred in 80 claims with delayed surgical airway in more than one third (39%; n = 31 of 80). CONCLUSIONS: Outcomes remained poor in recent malpractice claims related to difficult tracheal intubation. Inadequate airway planning and judgment errors were contributors to patient harm. Our results emphasize the need to improve both practitioner skills and systems response when difficult or failed tracheal intubation is encountered.


Asunto(s)
Anestesiólogos/estadística & datos numéricos , Revisión de Utilización de Seguros/estadística & datos numéricos , Intubación Intratraqueal/efectos adversos , Intubación Intratraqueal/estadística & datos numéricos , Mala Praxis/estadística & datos numéricos , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estados Unidos
3.
Muscle Nerve ; 60(6): 716-723, 2019 12.
Artículo en Inglés | MEDLINE | ID: mdl-31531862

RESUMEN

INTRODUCTION: Guillain-Barré syndrome (GBS) is an inflammatory polyradiculoneuritis. Our aim in this study was to describe the clinical characteristics and the long-term sequelae of GBS in a French pediatric population. METHODS: In this multicenter, retrospective study we evaluated clinical signs, radiological examinations, laboratory tests, treatments, and outcomes. RESULTS: One hundred ten children were included in this investigation. These children presented with walking difficulties, muscle weakness, and cranial nerve impairment. Electrodiagnostic testing revealed 70% with acute inflammatory demyelinating polyradiculoneuropathy (AIDP) and 16% with acute motor axonal neuropathy (AMAN). One hundred children received immunoglobulins. At follow-up, 77% were cured, whereas 9% had sequelae, associated with an axonal form (P < .01) and a short interval between symptom onset and hospitalization (P < .01). The need for intubation was correlated with peripheral facial paralysis (P < .01) and dysautonomia (P < .01). DISCUSSION: Although AIDP and AMAN present in a similar way, the axonal form is associated with a worse outcome.


Asunto(s)
Parálisis Facial/fisiopatología , Síndrome de Guillain-Barré/fisiopatología , Disautonomías Primarias/fisiopatología , Adolescente , Niño , Preescolar , Parálisis Facial/etiología , Femenino , Francia , Síndrome de Guillain-Barré/complicaciones , Hospitalización , Humanos , Lactante , Intubación Intratraqueal/estadística & datos numéricos , Masculino , Conducción Nerviosa , Disautonomías Primarias/etiología , Pronóstico , Recuperación de la Función , Estudios Retrospectivos , Índice de Severidad de la Enfermedad , Factores de Tiempo
4.
West J Emerg Med ; 20(4): 601-609, 2019 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-31316699

RESUMEN

Introduction: Airway management is a fundamental skill of emergency medicine (EM) practice, and suboptimal management leads to poor outcomes. Endotracheal intubation (ETI) is a procedure that is specifically taught in residency, but little is known how best to maintain proficiency in this skill throughout the practitioner's career. The goal of this study was to identify how the frequency of intubation correlated with measured performance. Methods: We assessed 44 emergency physicians for proficiency at ETI by direct laryngoscopy on a simulator. The electronic health record was then queried to obtain their average number of annual ETIs and the time since their last ETI, supervised and individually performed, over a two-year period. We evaluated the strength of correlation between these factors and assessment scores, and then conducted a receiver operator characteristic (ROC) curve analysis to identify factors that predicted proficient performance. Results: The mean score was 81% (95% confidence interval, 76% - 86%). Scores correlated well with the mean number of ETIs performed annually and with the mean number supervised annually (r = 0.6, p = 0.001 for both). ROC curve analysis identified that physicians would obtain a proficient score if they had performed an average of at least three ETIs annually (sensitivity = 90%, specificity = 64%, AUC = 0.87, p = 0.001) or supervised an average of at least five ETIs annually (sensitivity = 90%, specificity = 59%, AUC = 0.81, p = 0.006) over the previous two years. Conclusion: Performing at least three or supervising at least five ETIs annually, averaged over a two-year period, predicted proficient performance on a simulation-based skills assessment. We advocate for proactive maintenance and enhancement of skills, particularly for those who infrequently perform this procedure.


Asunto(s)
Competencia Clínica , Medicina de Emergencia , Intubación Intratraqueal/estadística & datos numéricos , Cuerpo Médico de Hospitales , Estudios Transversales , Humanos , Laringoscopía
5.
BMC Pulm Med ; 19(1): 131, 2019 Jul 18.
Artículo en Inglés | MEDLINE | ID: mdl-31319839

RESUMEN

BACKGROUND: Noninvasive ventilation (NIV) reduces the rate of endotracheal intubation (ETI) and overall mortality in severe acute exacerbation of COPD (AECOPD) with acute respiratory failure and is increasingly applied in respiratory intermediate care units. However, inadequate patient selection and incorrect management of NIV increase mortality. We aimed to identify factors that predict the outcome of NIV in AECOPD. Also, we looked for factors that influence ventilator settings and duration. METHODS: A prospective cohort study was undertaken in a respiratory intermediate care unit in an academic medical center between 2016 and 2017. Age, BMI, lung function, arterial pH and pCO2 at admission (t0), at 1-2 h (t1) and 4-6 h (t2) after admission, creatinine clearance, echocardiographic data (that defined left heart dysfunction), mean inspiratory pressure during the first 72 h (mIPAP-72 h) and hours of NIV during the first 72 h (dNIV-72 h) were recorded. Main outcome was NIV failure (i.e., ETI or in-hospital death). Secondary outcomes were in-hospital mortality, length of stay (LOS), duration of NIV (days), mIPAP-72 h, and dNIV-72 h. RESULTS: We included 89 patients (45 male, mean age 67.6 years) with AECOPD that required NIV. NIV failure was 12.4%, and in-hospital mortality was 11.2%. NIV failure was correlated with days of NIV, LOS, in-hospital mortality (p < 0.01), and kidney dysfunction (p < 0.05). In-hospital mortality was strongly associated with days of NIV (OR 1.27, 95%CI: 1.07-1.5, p < 0.01) and with FEV1 (p < 0.05). All other investigated parameters (including left heart dysfunction, dNIV-72 h, mIPAP-72 h, pH, etc.) did not influence NIV failure or mortality. dNIV-72 h and days of NIV were independent predictors of LOS (p < 0.01). Regarding the secondary outcomes, left heart dysfunction and pH at 1-2 h independently predicted NIV duration (dNIV-72 h, p < 0.01), while BMI and baseline pCO2 predicted NIV settings (mIPAP-72 h, p < 0.01). CONCLUSION: In-hospital mortality and NIV failure were not influenced by BMI, left heart dysfunction, age, nor by arterial blood gas values in the first 6 h of NIV. Patients with severe acidosis and left heart dysfunction required prolonged use of NIV. BMI and pCO2 levels influence the NIV settings in AECOPD regardless of lung function.


Asunto(s)
Mortalidad Hospitalaria , Ventilación no Invasiva/métodos , Enfermedad Pulmonar Obstructiva Crónica/terapia , Insuficiencia Respiratoria/terapia , Centros Médicos Académicos , Anciano , Anciano de 80 o más Años , Análisis de los Gases de la Sangre , Progresión de la Enfermedad , Femenino , Humanos , Intubación Intratraqueal/estadística & datos numéricos , Tiempo de Internación/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , Enfermedad Pulmonar Obstructiva Crónica/mortalidad , Análisis de Regresión , Unidades de Cuidados Respiratorios , Insuficiencia Respiratoria/mortalidad , Rumanía/epidemiología
6.
Crit Care ; 23(1): 251, 2019 07 10.
Artículo en Inglés | MEDLINE | ID: mdl-31291978

RESUMEN

PURPOSE: To compare the efficacy of systemic treatment with linezolid (LNZ) versus vancomycin (VAN) on methicillin-resistant Staphylococcus aureus (MRSA) burden and eradication in endotracheal tube (ETT) biofilm and ETT cuff from orotracheally intubated patients with MRSA respiratory infection. METHODS: Prospective observational clinical study was carried out at four European tertiary hospitals. Plasma and endotracheal aspirate (ETA) levels of LNZ and VAN were determined 72 h after treatment initiation through high-performance liquid chromatography or bioassay. LNZ or VAN concentration in the ETT biofilm and MRSA burden and eradication was determined upon extubation. The minimum inhibitory concentration (MIC) for LNZ and VAN was assessed by E-test strips (Biomerieux®). Scanning electron microscopy images were obtained, and ETT biofilm thickness was compared between groups. RESULTS: Twenty-five patients, 15 treated with LNZ and 10 with VAN, were included in the study. LNZ presented a significantly higher concentration (µg/mL) than VAN in ETT biofilm (72.8 [1.3-127.1] vs 0.4 [0.4-1.3], p < 0.001), although both drugs achieved therapeutic plasma levels 72 h after treatment initiation. Systemic treatment with LNZ achieved lower ETT cuff MRSA burdens than systemic treatment with VAN. Indeed, LNZ increased the MRSA eradication rate in ETT cuff compared with VAN (LNZ 75%, VAN 20%, p = 0.031). CONCLUSIONS: In ICU patients with MRSA respiratory infection intubated for long periods, systemic treatment with LNZ obtains a greater beneficial effect than VAN in limiting MRSA burden in ETT cuff.


Asunto(s)
Intubación Intratraqueal/efectos adversos , Linezolid/normas , Staphylococcus aureus Resistente a Meticilina/efectos de los fármacos , Vancomicina/normas , APACHE , Anciano , Análisis de Varianza , Antibacterianos/normas , Antibacterianos/uso terapéutico , Biopelículas/efectos de los fármacos , Biopelículas/crecimiento & desarrollo , Femenino , Humanos , Unidades de Cuidados Intensivos/organización & administración , Unidades de Cuidados Intensivos/estadística & datos numéricos , Intubación Intratraqueal/estadística & datos numéricos , Linezolid/uso terapéutico , Masculino , Staphylococcus aureus Resistente a Meticilina/patogenicidad , Microscopía Electrónica de Rastreo/métodos , Persona de Mediana Edad , Puntuaciones en la Disfunción de Órganos , Estudios Prospectivos , Vancomicina/uso terapéutico
7.
Physiother Res Int ; 24(4): e1793, 2019 Oct.
Artículo en Inglés | MEDLINE | ID: mdl-31237395

RESUMEN

OBJECTIVE: Most patients requiring intubation and mechanical ventilation are extubated successfully at the first attempt; however, a minority experience extubation failure, which is associated with increased risk of ventilator-associated pneumonia, prolonged intensive care unit (ICU) length of stay and mortality. Physiotherapists have expertise to assess cough strength, work of breathing, respiratory muscle strength, and respiratory secretion load, which are important factors in the outcome of extubation. Accurate prediction of extubation outcome could help to inform management plans pre-extubation and postextubation. The primary objective of this service evaluation was to report the accuracy of physiotherapists' prediction of extubation outcome in the adult ICU. METHODS: A single-centre case note review was undertaken. All subjects who received a physiotherapy assessment of extubation suitability prior to extubation between January and March 2016 in the adult ICU of a large teaching hospital in the United Kingdom were included. Assessment, by both specialist and nonspecialist physiotherapists-which included risk stratification of extubation failure as "high," "moderate," or "low"-was undertaken prior to extubation. Logistic regression analysis was performed to determine which pre-extubation factors were predictive of extubation outcome. RESULTS: During the evaluation period, 68 subjects were extubated following a physiotherapy assessment. Physiotherapy risk stratification as "high risk" (OR 4; 95% confidence interval, CI, [1.312]; p=0.009) and "inappropriate" neurological status (OR 3.3; 95% CI [1.0410]; p=0.037) were the only pre-extubation factors significantly associated with extubation failure. Assessment by specialist physiotherapists demonstrated greater sensitivity (100% vs. 22%) but lower specificity (68% vs. 95%) to detect extubation failure compared with the assessment performed by nonspecialist physiotherapists. CONCLUSION: Patients classified as "high risk" of extubation failure by a physiotherapist are significantly more likely to fail extubation. Specialist physiotherapists should be involved in the decision to extubate patients in the adult ICU.


Asunto(s)
Extubación Traqueal/estadística & datos numéricos , Tiempo de Internación/estadística & datos numéricos , Índice de Severidad de la Enfermedad , Desconexión del Ventilador/estadística & datos numéricos , Adulto , Femenino , Humanos , Unidades de Cuidados Intensivos , Intubación Intratraqueal/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Modalidades de Fisioterapia , Respiración Artificial/estadística & datos numéricos , Reino Unido
8.
Emerg Med J ; 36(7): 416-422, 2019 Jul.
Artículo en Inglés | MEDLINE | ID: mdl-31147349

RESUMEN

INTRODUCTION: Ambulance transport of patients with stroke is common, with rapid sequence intubation (RSI) to secure the airway used regularly. Randomised controlled trial evidence exists to support the use of RSI in traumatic brain injuries (TBIs), but it is not clear whether the RSI evidence from TBI can be applied to the patient with stroke. To this end, we analysed a retrospective stroke dataset to compare survival of patients with RSI compared with patients that did not receive RSI. METHODS: This study was a retrospective analysis of 10 years of in-hospital and out-of-hospital data for all patients with stroke attended by Ambulance Victoria, in Victoria Australia. Generalised boosted logistic regression was used to predict propensity scores, with initial vital signs, age and demographic variables as well as measures of illness severity and comorbidity included in the prediction model. This analysis employed a 1:1 nearest-neighbour matching which was applied to generate a dataset from which we calculated the OR of survival to hospital discharge of patients receiving RSI versus no-RSI. The sensitivity of these results to unmeasured confounding was assessed with deterministic sensitivity analysis. RESULTS: The propensity score-matched cohort showed a decreased survival for RSI in strokes with an OR 0.61 (95% CI 0.45 to 0.82; p=0.001) when compared with no-RSI. A subgroup analysis showed no significant survival difference for ischaemic strokes: OR 0.66 (95% CI 40 to 1.07; p=0.09). The survival for haemorrhagic stroke was OR 0.60 (95% CI 0.41 to 0.90; p=0.01) lesser for RSI. Results were likely robust to unmeasured confounding and missing data. CONCLUSIONS: Our retrospective analysis shows a decrease in survival when RSI is utilised by paramedics for stroke. Since RSI is commonly used for strokes, controlled trial evidence to support this practice is urgently needed.


Asunto(s)
/métodos , Accidente Cerebrovascular/tratamiento farmacológico , Anciano , Anciano de 80 o más Años , Técnicos Medios en Salud/provisión & distribución , Estudios de Cohortes , Servicios Médicos de Urgencia/normas , Servicios Médicos de Urgencia/estadística & datos numéricos , Femenino , Humanos , Intubación Intratraqueal/métodos , Intubación Intratraqueal/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Accidente Cerebrovascular/fisiopatología , Análisis de Supervivencia , Resultado del Tratamiento , Victoria
9.
J Spec Oper Med ; 19(2): 87-90, 2019.
Artículo en Inglés | MEDLINE | ID: mdl-31201757

RESUMEN

BACKGROUND: Airway obstruction is the second most common cause of potentially preventable death on the battlefield. We compared survival in the combat setting among patients undergoing prehospital versus emergency department (ED) intubation. METHODS: Patients were identified from the Department of Defense Trauma Registry (DODTR) from January 2007 to August 2016. We defined the prehospital cohort as subjects undergoing intubation prior to arrival to a forward surgical team (FST) or combat support hospital (CSH), and the ED cohort as subjects undergoing intubation at an FST or CSH. We compared study variables between these cohorts; survival was our primary outcome. RESULTS: There were 4341 intubations documented in the DODTR during the study period: 1117 (25.7%) patients were intubated prehospital and 3224 (74.3%) were intubated in the ED. Patients intubated prehospital had a lower median age (24 versus 25 years, p < .001), composed a higher proportion of host nation forces (36.1% versus 29.1%, p < .001), had a lower proportion of injuries from explosives (57.6% versus 61.0%, p = .030), and had higher median injury severity scores (20 versus 18, p = .045). A lower proportion of the prehospital cohort survived to hospital discharge (76.4% versus 84.3%, p < .001). The prehospital cohort had lower odds of survival to hospital discharge in both univariable (odds ratio [OR] 0.60, 95% confidence interval [CI] 0.51-0.71) and multivariable analyses controlling for confounders (OR 0.70, 95% CI 0.58-0.85). In a subgroup analysis of patients with a head injury, the lower odds of survival persisted in the multivariable analysis (OR 0.49, 95% CI 0.49-0.82). CONCLUSIONS: Patients intubated in the prehospital setting had a lower survival than those intubated in the ED. This finding persisted after controlling for measurable confounders.


Asunto(s)
Obstrucción de las Vías Aéreas/terapia , Servicios Médicos de Urgencia/estadística & datos numéricos , Servicio de Urgencia en Hospital/estadística & datos numéricos , Intubación Intratraqueal/estadística & datos numéricos , Heridas Relacionadas con la Guerra/terapia , Adulto , Afganistán/epidemiología , Obstrucción de las Vías Aéreas/mortalidad , Estudios de Cohortes , Humanos , Irak/epidemiología , Sistema de Registros , Análisis de Supervivencia , Resultado del Tratamiento , Heridas Relacionadas con la Guerra/mortalidad , Adulto Joven
10.
Chin J Traumatol ; 22(4): 207-211, 2019 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-31208792

RESUMEN

PURPOSE: Trauma is a major health problem in developing countries and worldwide which requires many resources and much time in an emergency department (ED). Although Advanced Trauma Life Support (ATLS) is the gold standard, operator dependence can affect the quality of care. The objective was to identify differences in numbers and time to lifesaving interventions, investigation, ED length of stay, and mortality between an in-house protocol and conventional practice. METHODS: This was a single-center prospective non-randomized study for adult trauma patients in the ED. The trauma protocol was developed from the recent ATLS guideline. RESULTS: Thirty-two and 41 cases were in the in-house protocol group and conventional practice group, respectively. Endotracheal intubation was done more frequently in the in-house protocol group (84% vs. 59%, p = 0.03). Intercostal drainage tube insertion was done faster (6-26 min, median 11 min vs. 15-84 min, median 35 min, p = 0.02) and pre-arrival notification by emergency medical service increased in the in-house protocol group (66% vs. 30%, p = 0.01). Hypothermia in the operating room was found only in the conventional practice group (62% vs. 0, p = 0.007) and a warm blanket was used significantly more often in the in-house protocol group (25% vs. 0, p < 0.001). A directed acyclic graph with multivariate analysis was used to identify confounders. Time to Focused Assessment Sonography in Trauma was significantly shorter in the in-house protocol group (6.5-15.6 min, median 11 min, p = 0.019). CONCLUSION: In addition to the ATLS guideline, the trauma protocol could improve trauma care by reduced time to investigation, early notification of the trauma team in pre-hospital situations, reduced incidence of hypothermia in the operating room, and increased use of a warm blanket.


Asunto(s)
Atención de Apoyo Vital Avanzado en Trauma , Servicio de Urgencia en Hospital , Heridas y Traumatismos/terapia , Adulto , Drenaje/métodos , Drenaje/estadística & datos numéricos , Servicios Médicos de Urgencia , Femenino , Humanos , Hipotermia/prevención & control , Intubación Intratraqueal/estadística & datos numéricos , Masculino , Persona de Mediana Edad , Guías de Práctica Clínica como Asunto , Estudios Prospectivos , Factores de Tiempo
11.
Crit Care ; 23(1): 158, 2019 05 06.
Artículo en Inglés | MEDLINE | ID: mdl-31060580

RESUMEN

IMPORTANCE: The optimal approach to airway management during in-hospital cardiac arrest is unknown. OBJECTIVE: To describe hospital-level variation in endotracheal intubation during cardiopulmonary resuscitation (CPR) for in-hospital cardiac arrest and the association between hospital use of endotracheal intubation and arrest survival. DESIGN, SETTING, PARTICIPANTS: Retrospective cohort study of adult patients suffering in-hospital cardiac arrest at Get With The Guidelines-Resuscitation participating hospitals between January, 2000, and December, 2016. Hospitals were categorized into quartiles based on the proportion of in-hospital cardiac arrest patients managed with endotracheal intubation during CPR. Risk-adjusted mixed models with random intercepts were created to assess the association between hospital quartile of in-hospital arrests managed with endotracheal intubation during CPR and survival to hospital discharge. EXPOSURE: Hospital rate of endotracheal intubation during CPR for in-hospital arrest MAIN OUTCOMES AND MEASURES: Survival to hospital discharge RESULTS: Among 155,252 patients suffering in-hospital cardiac arrest at 656 hospitals, 69.7% of patients received endotracheal intubation during CPR and overall survival to discharge was 24.8%. At the hospital level, the median rate of endotracheal intubation use was 71.2% (interquartile range, 63.6 to 78.1%; range, 26.6 to 100%). We found a strong inverse association between hospital rate of endotracheal intubation and survival to discharge (risk-adjusted odds ratio comparing highest intubation quartile vs. lowest intubation quartile, 0.81; 95% confidence interval (CI), 0.74 to 0.90; p value < .001). This association was modified by the presence of respiratory failure prior to arrest (p for interaction < .001), and stratified analyses demonstrated lower patient survival at hospitals with higher rates of endotracheal intubation was limited to patients without respiratory failure prior to cardiac arrest. CONCLUSION: In a national sample of patients suffering IHCA, the use of endotracheal intubation during CPR varied across hospitals. We found a strong inverse association between hospital use of endotracheal intubation during CPR and survival to discharge, but this association was confined to patients without respiratory failure prior to arrest. Identifying the optimal approach to airway management for in-hospital cardiac arrest may have a significant impact on patient survival.


Asunto(s)
Manejo de la Vía Aérea/normas , Guías como Asunto , Paro Cardíaco/terapia , Resucitación/normas , Anciano , Anciano de 80 o más Años , Manejo de la Vía Aérea/métodos , Manejo de la Vía Aérea/estadística & datos numéricos , Estudios de Cohortes , Femenino , Paro Cardíaco/mortalidad , Humanos , Intubación Intratraqueal/métodos , Intubación Intratraqueal/estadística & datos numéricos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Sistema de Registros/estadística & datos numéricos , Resucitación/métodos , Estudios Retrospectivos , Análisis de Supervivencia , Factores de Tiempo
12.
Anaesthesia ; 74(9): 1158-1164, 2019 Sep.
Artículo en Inglés | MEDLINE | ID: mdl-31069782

RESUMEN

Advanced airway management is a treatment priority in trauma care. It is likely that a proportion of patients who receive urgent airway management on arrival in the emergency department represent an unmet demand for airway intervention in the pre-hospital phase. This study aimed to investigate emergency airway practice in major trauma patients and establish any unmet demand in this patient group. A retrospective review of the Trauma Audit and Research Network database was performed to identify airway intervention(s) performed for patients admitted to major trauma centres in England from 01 April 2012 to 27 June 2016. In total, 11,010 patients had airway interventions: 4375 patients (43%) had their tracheas intubated in the pre-hospital setting compared with 5889 patients (57%) in the emergency department. Of the patients whose tracheas were intubated in the emergency department, this was done within 30 min of hospital arrival in 3264 patients (75%). Excluding tracheal intubation, 1593 patients had a pre-hospital airway intervention of which 881 (55%) subsequently had their trachea intubated in the emergency department; tracheal intubation was done within 30 min of arrival in the majority of these cases (805 patients (91%)). Over 70% of emergency department tracheal intubations in patients with traumatic injuries were performed within 30 min of hospital arrival; this suggests there may be an unmet demand in pre-hospital advanced airway management for trauma patients in England.


Asunto(s)
Servicios Médicos de Urgencia/estadística & datos numéricos , Intubación Intratraqueal/estadística & datos numéricos , Heridas y Traumatismos/terapia , Adulto , Bases de Datos Factuales/estadística & datos numéricos , Inglaterra , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos
13.
Rev Bras Ter Intensiva ; 31(1): 79-85, 2019 Mar.
Artículo en Portugués, Inglés | MEDLINE | ID: mdl-30970094

RESUMEN

OBJECTIVE: We aimed to determine the incidence, risk factors, and outcomes of unplanned extubation among adult patients. METHODS: We conducted a prospective cohort study of adult intubated patients admitted to the charity wards of a government tertiary teaching hospital in the Philippines. Patients managed in both intensive care and nonintensive care settings were included. Patients were followed-up until discharge or until seven days postextubation. RESULTS: The outcomes of the 191 included patients were planned extubation (35%), unplanned extubation (19%), death (39%), and discharge against advice (7%). Competing risk regression showed that male sex (Crude OR: 2.25, 95%CI: 1.10 - 4.63) and age (Crude OR 0.976, 95%CI: 0.957 - 0.996) were significant baseline factors. The night shift (Crude OR: 24.6, 95%CI: 2.87 - 211) was also consistently associated with more unplanned extubations. Among postextubation outcomes, reintubation (unplanned extubation: 61.1% versus planned extubation: 25.4%), acute respiratory failure (unplanned extubation: 38.9% versus planned extubation: 17.5%), and cardiovascular events (unplanned extubation: 8.33% versus planned extubation: 1.49%) occurred significantly more often among the unplanned extubation patients. Admission in an intensive care unit was not associated with a lower risk of unplanned extubation (Crude OR 1.15, 95%CI: 0.594 - 2.21). CONCLUSION: Many intubated patients had unplanned extubation. Patients admitted in nonintensive care unit settings did not have significantly higher odds of unplanned extubation.


Asunto(s)
Extubación Traqueal/estadística & datos numéricos , Unidades de Cuidados Intensivos/estadística & datos numéricos , Intubación Intratraqueal/estadística & datos numéricos , Respiración Artificial/estadística & datos numéricos , Adulto , Anciano , Estudios de Cohortes , Femenino , Estudios de Seguimiento , Hospitales de Enseñanza , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Filipinas , Estudios Prospectivos , Factores de Riesgo , Centros de Atención Terciaria
14.
Cochrane Database Syst Rev ; 4: CD005351, 2019 04 05.
Artículo en Inglés | MEDLINE | ID: mdl-30950507

RESUMEN

BACKGROUND: Non-invasive positive pressure ventilation (NPPV) has been used to treat respiratory distress due to acute cardiogenic pulmonary oedema (ACPE). We performed a systematic review and meta-analysis update on NPPV for adults presenting with ACPE. OBJECTIVES: To evaluate the safety and effectiveness of NPPV compared to standard medical care (SMC) for adults with ACPE. The primary outcome was hospital mortality. Important secondary outcomes were endotracheal intubation, treatment intolerance, hospital and intensive care unit length of stay, rates of acute myocardial infarction, and adverse event rates. SEARCH METHODS: We searched CENTRAL (CRS Web, 20 September 2018), MEDLINE (Ovid, 1946 to 19 September 2018), Embase (Ovid, 1974 to 19 September 2018), CINAHL Plus (EBSCO, 1937 to 19 September 2018), LILACS, WHO ICTRP, and clinicaltrials.gov. We also reviewed reference lists of included studies. We applied no language restrictions. SELECTION CRITERIA: We included blinded or unblinded randomised controlled trials in adults with ACPE. Participants had to be randomised to NPPV (continuous positive airway pressure (CPAP) or bilevel NPPV) plus standard medical care (SMC) compared with SMC alone. DATA COLLECTION AND ANALYSIS: Two review authors independently screened and selected articles for inclusion. We extracted data with a standardised data collection form. We evaluated the risks of bias of each study using the Cochrane 'Risk of bias' tool. We assessed evidence quality for each outcome using the GRADE recommendations. MAIN RESULTS: We included 24 studies (2664 participants) of adult participants (older than 18 years of age) with respiratory distress due to ACPE, not requiring immediate mechanical ventilation. People with ACPE presented either to an Emergency Department or were inpatients. ACPE treatment was provided in an intensive care or Emergency Department setting. There was a median follow-up of 13 days for hospital mortality, one day for endotracheal intubation, and three days for acute myocardial infarction. Compared with SMC, NPPV may reduce hospital mortality (risk ratio (RR) 0.65, 95% confidence interval (CI) 0.51 to 0.82; participants = 2484; studies = 21; I2 = 6%; low quality of evidence) with a number needed to treat for an additional beneficial outcome (NNTB) of 17 (NNTB 12 to 32). NPPV probably reduces endotracheal intubation rates (RR 0.49, 95% CI 0.38 to 0.62; participants = 2449; studies = 20; I2 = 0%; moderate quality of evidence) with a NNTB of 13 (NNTB 11 to 18). There is probably little or no difference in acute myocardial infarction (AMI) incidence with NPPV compared to SMC for ACPE (RR 1.03, 95% CI 0.91 to 1.16; participants = 1313; studies = 5; I2 = 0%; moderate quality of evidence). We are uncertain as to whether NPPV increases hospital length of stay (mean difference (MD) -0.31 days, 95% CI -1.23 to 0.61; participants = 1714; studies = 11; I2 = 55%; very low quality of evidence). Adverse events were generally similar between NPPV and SMC groups, but evidence was of low quality. AUTHORS' CONCLUSIONS: Our review provides support for continued clinical application of NPPV for ACPE, to improve outcomes such as hospital mortality and intubation rates. NPPV is a safe intervention with similar adverse event rates to SMC alone. Additional research is needed to determine if specific subgroups of people with ACPE have greater benefit of NPPV compared to SMC. Future research should explore the benefit of NPPV for ACPE patients with hypercapnia.


Asunto(s)
Presión de las Vías Aéreas Positiva Contínua/métodos , Mortalidad Hospitalaria , Edema Pulmonar/terapia , Adulto , Presión de las Vías Aéreas Positiva Contínua/efectos adversos , Humanos , Unidades de Cuidados Intensivos , Intubación Intratraqueal/estadística & datos numéricos , Tiempo de Internación , Ventilación no Invasiva , Ensayos Clínicos Controlados Aleatorios como Asunto
15.
Zhonghua Wei Zhong Bing Ji Jiu Yi Xue ; 31(1): 44-49, 2019 Jan.
Artículo en Chino | MEDLINE | ID: mdl-30707868

RESUMEN

OBJECTIVE: To compare the influence of sevoflurane inhalation sedation and propofol intravenous sedation on duration of endotracheal intubation as well as the length of intensive care unit (ICU) stay and total length of hospital stay in postoperative critical patients. METHODS: Six databases including CNKI, Wanfang data, PubMed, Embase, Cochrane Library and Web of Science were searched for randomized controlled trials (RCTs) about the influence of sevoflurane inhalation sedation or propofol intravenous sedation on the sedation time, the duration of endotracheal intubation, the length of ICU stay, the total length of hospital stay and the adverse effects rate in postoperative critical patients from the time of database establishment to July 2018. At the same time, the reference materials of included literature were retrieved manually. All literatures were screened by three independent reviewers, and the data extraction and quality evaluation of the included studies were conducted. Meta-analysis was used for RCT that met the quality standards. RESULTS: A total of 7 RCT studies were enrolled involving 537 patients who were all transferred into ICU after surgery with trachea cannula. Among the patients, 272 received sevoflurane sedation while the other 265 received propofol sedation. All the included studies were well designed and of high quality. The results of Meta-analysis showed that compared with propofol sedation, sevoflurane sedation could significantly shorten the duration of endotracheal intubation [standardized mean difference (SMD) = -0.60, 95% confidence interval (95%CI) = -0.88 to -0.31, P < 0.000 1] and the total length of hospital stay (SMD = -0.36, 95%CI = -0.61 to -0.12, P = 0.003), and lower the cardiac troponin T (cTnT) within 12-24 hours after ICU admission (SMD = -0.61, 95%CI = -0.85 to -0.36, P < 0.000 01). There was no significant difference in the sedation time (SMD = -0.07, 95%CI = -0.29 to 0.15, P = 0.52), the length of ICU stay (SMD = -0.19, 95%CI = -0.39 to 0.01, P = 0.06), the incidence of nausea and vomiting [odds ratio (OR) = 1.19, 95%CI = 0.61 to 2.32, P = 0.61] or incidence of delirium (OR = 0.80, 95%CI = 0.34 to 1.90, P = 0.62) between sevoflurane group and propofol group. CONCLUSIONS: Sevoflurane inhalation sedation may lead to shorter duration of endotracheal intubation and total length of hospital stay, and had better protection for myocardium as compared with propofol intravenous sedation. The above conclusions needed further study to confirm, due to the lack of literature enrolled in this Meta-analysis.


Asunto(s)
Anestésicos por Inhalación , Intubación Intratraqueal/estadística & datos numéricos , Tiempo de Internación/estadística & datos numéricos , Sevoflurano/administración & dosificación , Anestésicos Intravenosos , Cuidados Críticos , Humanos , Propofol/administración & dosificación , Ensayos Clínicos Controlados Aleatorios como Asunto , Procedimientos Quirúrgicos Operativos
16.
Ann Thorac Surg ; 107(6): 1607-1612, 2019 06.
Artículo en Inglés | MEDLINE | ID: mdl-30763562

RESUMEN

BACKGROUND: Nonintubated thoracoscopic surgery for lung tumor is not widely performed. This study assessed the safety, outcome, and risk factors for conversion to tracheal intubation of nonintubated thoracoscopic surgery for lung tumor resection. METHODS: We retrospectively reviewed the records of 1,025 patients who underwent lung tumor resection by nonintubated thoracoscopic surgery from August 2009 to December 2016 at our institution. Using univariable and multivariable analyses, we focused on the operative procedures, complications, conversion rate, surgical outcome, and risk factors for conversion to tracheal intubation. RESULTS: Most patients (73% [n = 748]) were women, and 14.3% (n = 147) of all patients were smokers. The average body mass index was 22.6 kg/m2. We performed 315 lobectomies, 111 segmentectomies, and 598 wedge resections. Postoperative complications included prolonged air leak for more than 5 days (20 patients [2%]), arrhythmia (2 [0.2%]), hemothorax (3 [0.3%]), pneumonia (4 [0.4%]), and chylothorax (2 [0.2%]). No surgical deaths occurred. During the operation 20 patients (2%) were converted to tracheal intubation. The main reason for conversion was considerable mediastinal movement. Multivariable analysis revealed that a body mass index of 25 kg/m2 or higher (p < 0.001) and pulmonary anatomical resection (p < 0.001) were risk factors for conversion to intubation. CONCLUSIONS: Nonintubated thoracoscopic surgery was a safe and effective technique for lung tumor resection. Clinicians should be aware that patients with a body mass index of 25 kg/m2 or higher or who require pulmonary anatomical resection have a higher risk of conversion to tracheal intubation.


Asunto(s)
Intubación Intratraqueal/estadística & datos numéricos , Neoplasias Pulmonares/cirugía , Neumonectomía/métodos , Complicaciones Posoperatorias/epidemiología , Toracoscopía/métodos , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Niño , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Factores de Riesgo , Factores de Tiempo , Resultado del Tratamiento , Adulto Joven
17.
Arch Dis Child Fetal Neonatal Ed ; 104(5): F461-F466, 2019 Sep.
Artículo en Inglés | MEDLINE | ID: mdl-30796059

RESUMEN

OBJECTIVE: To determine the incidence, indicators and clinical impact of difficult tracheal intubations in the neonatal intensive care unit (NICU). DESIGN: Retrospective review of prospectively collected data on intubations performed in the NICU from the National Emergency Airway Registry for Neonates. SETTING: Ten academic NICUs. PATIENTS: Neonates intubated in the NICU at each of the sites between October 2014 and March 2017. MAIN OUTCOME MEASURES: Difficult intubation was defined as one requiring three or more attempts by a non-resident provider. Patient (age, weight and bedside predictors of difficult intubation), practice (intubation method and medications used), provider (training level and profession) and outcome data (intubation attempts, adverse events and oxygen desaturations) were collected for each intubation. RESULTS: Out of 2009 tracheal intubations, 276 (14%) met the definition of difficult intubation. Difficult intubations were more common in neonates <32 weeks, <1500 g. The difficult intubation group had a 4.9 odds ratio (OR) for experiencing an adverse event and a 4.2 OR for severe oxygen desaturation. Bedside screening tests of difficult intubation lacked sensitivity (receiver operator curve 0.47-0.53). CONCLUSIONS: Difficult intubations are common in the NICU and are associated with adverse event and severe oxygen desaturation. Difficult intubations occur more commonly in small preterm infants. The occurrence of a difficult intubation in other neonates is hard to predict due to the lack of sensitivity of bedside screening tests.


Asunto(s)
Competencia Clínica , Urgencias Médicas/epidemiología , Hipoxia , Unidades de Cuidado Intensivo Neonatal , Intubación Intratraqueal , Manejo de la Vía Aérea/métodos , Femenino , Humanos , Hipoxia/etiología , Hipoxia/prevención & control , Incidencia , Recién Nacido , Recien Nacido Prematuro , Unidades de Cuidado Intensivo Neonatal/normas , Unidades de Cuidado Intensivo Neonatal/estadística & datos numéricos , Intubación Intratraqueal/efectos adversos , Intubación Intratraqueal/métodos , Intubación Intratraqueal/normas , Intubación Intratraqueal/estadística & datos numéricos , Masculino , Pautas de la Práctica en Medicina/normas , Mejoramiento de la Calidad/normas , Sistema de Registros , Estudios Retrospectivos , Estados Unidos/epidemiología
19.
PLoS One ; 14(2): e0212976, 2019.
Artículo en Inglés | MEDLINE | ID: mdl-30811508

RESUMEN

INTRODUCTION: Difficult tracheal intubation (DTI) contributes to perioperative morbidity and mortality. There are conflicting study results about the most predictive DTI risk criteria in patients undergoing thyroid surgery. MATERIALS AND METHODS: We conducted a prospective observational study on 500 consecutive patients aged ≥18 years to identify predictors for DTI. Body weight, body mass index (BMI), inability to prognath, head movement, mouth opening, Mallampati score, neck circumference (NC), thyromental distance (TMD), neck circumference to thyromental distance ratio (NC/TMD), tracheal deviation apparent on chest x-ray, mediastinal goiter, histology and history of DTI were measured as possible predictors of DTI. Spearman's rank correlation test and multiple logistic regression analysis were performed. RESULTS: DTI was observed in 9.6% of all patients. Compared with the group of patients without DTI, the group of patients with DTI had significantly greater median values for body weight, BMI, NC, NC/TMD, Mallampati score, el-Ganzouri score, incidence of mediastinal goiter, and had reduced TMD and mouth opening. Significant correlations between BMI ≥30 kg/m2 and the Mallampati score ≥3 (R = 0.124, p = 0.00541), Cormack-Lehane ≥3 (R = 0.128, p = 0.00409), NC ≥40 cm (R = 0.376, p<0.001), and NC/TMD ≥5 (R = 0.103, p = 0.0207) were found. The logistic regression analysis revealed that an NC ≥40 cm at the goiter level, but not an NC/TMD ratio ≥5, was the strongest predictor of DTI (p<0.001). The area under the receiver operating characteristic curve for NC/TMD was better than the curve for NC. The sensitivity and specificity of NC/TMD were also greater, compared with NC. An NC of 40.00 cm and an NC/TMD of 5.85 were the estimated cut-off points. DISCUSSION: This study found that NC was a strong predictor of DTI. The results also suggested that NC/TMD could be used as a measure to stratify the risk of DTI in patients undergoing thyroid surgery.


Asunto(s)
Intubación Intratraqueal/efectos adversos , Cuello/diagnóstico por imagen , Glándula Tiroides/cirugía , Adulto , Área Bajo la Curva , Índice de Masa Corporal , Peso Corporal , Femenino , Humanos , Intubación Intratraqueal/estadística & datos numéricos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Cuello/anatomía & histología , Valor Predictivo de las Pruebas , Estudios Prospectivos , Factores de Riesgo
20.
Arch Dis Child ; 104(6): 564-576, 2019 06.
Artículo en Inglés | MEDLINE | ID: mdl-30655267

RESUMEN

OBJECTIVES: To review the effects and safety of high-flow nasal cannula (HFNC) for bronchiolitis. METHODS: Six electronic databases including PubMed, EMBASE, Cochrane Central Register of Controlled Trials, China National Knowledge Infrastructure, CQ VIP Database and Wanfang Data were searched from their inception to 1 June 2018. Randomised controlled trials (RCTs) which investigated the effects of HFNC versus other forms of oxygen therapies for bronchiolitis were included. RESULTS: Nine RCTs with 2121 children met the eligibility criteria. There was no significant difference in length of stay in hospital (LOS), length of oxygen supplementation (LOO), transfer to intensive care unit, incidence of intubation, respiratory rate, SpO2 and adverse events in HFNC group compared with standard oxygen therapy (SOT) and nasal continuous positive airway pressure (nCPAP) groups. A significant reduction of the incidence of treatment failure (risk ratio (RR) 0.50, 95% CI 0.40 to 0.62, p<0.01) was observed in HFNC group compared with SOT group, but there was a significant increase of the incidence of treatment failure (RR 1.61, 95% CI 1.06 to 2.42, p0.02) in HFNC group compared with nCPAP group. In subgroup analysis, LOS was significantly decreased in HFNC group compared with SOT group in low-income and middle-income countries. CONCLUSION: The systematic review suggests HFNC is safe as an initial respiratory management, but the evidence is still lacking to show benefits for children with bronchiolitis compared with SOT or nCPAP.


Asunto(s)
Bronquiolitis/terapia , Terapia por Inhalación de Oxígeno/métodos , Cánula , Presión de las Vías Aéreas Positiva Contínua , Humanos , Lactante , Cuidado del Lactante/métodos , Recién Nacido , Unidades de Cuidado Intensivo Pediátrico/estadística & datos numéricos , Intubación Intratraqueal/estadística & datos numéricos , Tiempo de Internación/estadística & datos numéricos , Cavidad Nasal , Terapia por Inhalación de Oxígeno/efectos adversos , Transferencia de Pacientes/estadística & datos numéricos , Ensayos Clínicos Controlados Aleatorios como Asunto/métodos , Insuficiencia del Tratamiento
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