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1.
Emerg Med J ; 36(9): 520-528, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31320332

RESUMO

BACKGROUND: Intubation is an essential, life-saving skill but associated with a high risk for adverse outcomes. Intubation protocols have been implemented to increase success and reduce complications, but the impact of protocol conformance is not known. Our study aimed to determine association between conformance with an intubation process model and outcomes. METHODS: An interdisciplinary expert panel developed a process model of tasks and sequencing deemed necessary for successful intubation. The model was then retrospectively used to review videos of intubations from 1 February, 2014, to 31 January, 2016, in a paediatric emergency department at a time when no process model or protocol was in existence. RESULTS: We evaluated 113 patients, 77 (68%) were successfully intubated on first attempt. Model conformance was associated with a higher likelihood of first attempt success when using direct laryngoscopy (OR 1.09, 95% CI 1.01 to 1.18). The use of video laryngoscopy was associated with an overall higher likelihood of success on first attempt (OR 2.54, 95% CI 1.10 to 5.88). Thirty-seven patients (33%) experienced adverse events. Model conformance was the only factor associated with a lower odds of adverse events (OR 0.94, 95% CI 0.88 to 0.99). CONCLUSIONS: Conformance with a task-based expert-derived process model for emergency intubation was associated with a higher rate of success on first intubation attempt when using direct laryngoscopy and a lower odds of associated adverse events. Further evaluation of the impact of human factors, such as teamwork and decision-making, on intubation process conformance and success and outcomes is needed.


Assuntos
Protocolos Clínicos/normas , Estado Terminal/terapia , Intubação Intratraqueal/normas , Guias de Prática Clínica como Assunto , Ressuscitação/normas , Adolescente , Bradicardia/epidemiologia , Bradicardia/etiologia , Criança , Pré-Escolar , Serviço Hospitalar de Emergência/normas , Feminino , Humanos , Hipóxia/epidemiologia , Hipóxia/etiologia , Lactente , Recém-Nascido , Intubação Intratraqueal/efeitos adversos , Intubação Intratraqueal/instrumentação , Laringoscópios/efeitos adversos , Masculino , Ressuscitação/efeitos adversos , Ressuscitação/instrumentação , Estudos Retrospectivos , Gravação em Vídeo , Adulto Jovem
2.
Eur J Pediatr ; 178(8): 1219-1227, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31177289

RESUMO

This study compares the performance of pediatricians and anesthetists in neonatal and pediatric endotracheal intubations (ETI) during simulated settings. Participants completed a questionnaire and performed an ETI scenario on a neonatal and a child manikin. The procedures were recorded with head cameras and cameras attached to standard laryngoscope blades. The outcomes were successful intubation, time to successful intubation, number of attempts, complications, total performance score, end-assessment rating, and an assessment whether the participant was sufficiently able to perform an ETI. Fifty-two pediatricians and 52 anesthetists were included. For the neonatal ETI, the rate of successful intubation was in favor of anesthetists although not significant. Anesthetists performed significantly better in all other outcomes. Of the pediatricians, 65% was rated sufficiently adept to perform a neonatal ETI vs 100% of the anesthetists. Pediatricians (29%) overestimated while anesthetists (33%) underestimated their performance in neonatal ETI. For the pediatric ETI, all outcomes were significantly better for anesthetists. Only 15% of all pediatricians were considered sufficiently able to perform pediatric ETI vs 94% of the anesthetists.Conclusion: Anesthetists are far more adept in performing ETI in neonates and children compared with pediatricians in a simulated setting. Complications are expected to occur less frequently and less seriously when anesthetists perform ETI. What is Known: • Endotracheal intubation (ETI) performed by inexperienced care providers can lead to unsuccessful and/or prolonged intubation attempts. This can cause complications such as hypoxemia, trauma to the oropharynx and larynx, and prolonged interruption of resuscitation, which results in a high morbidity/mortality. • Fifty to 60 real-life ETI procedures are needed before ETI can be performed with a 90% success rate. Despite this, 18% of providers still require some assistance even after performing 80 intubations. Skill fade will occur if there is too little exposure. What is New: • This study shows that, on both neonatal and child manikins, anesthetists perform better in ETI compared with pediatricians. Besides this, complications are expected to occur less frequently and less seriously when anesthetists are performing the ETIs on neonates and children. • In those countries where there are no clear interprofessional agreements made in general hospitals on who will perform ETI on neonates and children in acute care settings, these agreements are urgently necessary.


Assuntos
Anestesistas/normas , Competência Clínica/estatística & dados numéricos , Intubação Intratraqueal , Pediatras/normas , Adulto , Criança , Estudos Transversais , Feminino , Humanos , Recém-Nascido , Intubação Intratraqueal/instrumentação , Intubação Intratraqueal/métodos , Intubação Intratraqueal/normas , Laringoscópios , Masculino , Manequins , Pessoa de Meia-Idade , Autoeficácia , Método Simples-Cego , Gravação em Vídeo
3.
Crit Care ; 23(1): 161, 2019 05 07.
Artigo em Inglês | MEDLINE | ID: mdl-31064406

RESUMO

BACKGROUND: The optimal securement method of endotracheal tubes is unknown but should prevent dislodgement while minimizing complications. The use of an endotracheal tube fastener might reduce complications among critically ill adults undergoing endotracheal intubation. METHODS: In this pragmatic, single-center, randomized trial, critically ill adults admitted to the medical intensive care unit (MICU) and expected to require invasive mechanical ventilation for greater than 24 h were randomized to adhesive tape or endotracheal tube fastener at the time of intubation. The primary endpoint was a composite of any of the following: presence of lip ulcer, endotracheal tube dislodgement (defined as moving at least 2 cm), ventilator-associated pneumonia, or facial skin tears anytime between randomization and the earlier of death or 48 h after extubation. Secondary endpoints included duration of mechanical ventilation and ICU and in-hospital mortality. RESULTS: Of 500 patients randomized over a 12-month period, 162 had a duration of mechanical ventilation less than 24 h and 40 had missing outcome data, leaving 153 evaluable patients randomized to tube fastener and 145 evaluable patients randomized to adhesive tape. Baseline characteristics were similar between the groups. The primary endpoint occurred 13 times in 12 (7.8%) patients in the tube fastener group and 30 times in 25 (17.2%) patients in the adhesive tape group (p = 0.014) for an overall incidence of 22.0 versus 52.6 per 1000 ventilator days, respectively (p = 0.020). Lip ulcers occurred in 4 (2.6%) versus 11 (7.3%) patients, or an incidence rate of 6.5 versus 19.5 per 1000 patient ventilator days (p = 0.053) in the fastener and tape groups, respectively. The endotracheal tube was dislodged 7 times in 6 (3.9%) patients in the tube fastener group and 16 times in 15 (10.3%) patients in the tape group (p = 0.03), reflecting incidences of 11.9 and 28.1 per 1000 ventilator days, respectively. Facial skin tears were similar between the groups. Mechanical ventilation duration and ICU and hospital mortality did not differ. CONCLUSION: The use of the endotracheal tube fastener to secure the endotracheal tubes reduces the rate of a composite outcome that included lip ulcers, facial skin tears, or endotracheal tube dislodgement compared to adhesive tape. TRIAL REGISTRATION: ClinicalTrials.gov NCT03760510. Retrospectively registered on November 30, 2018.


Assuntos
Intubação Intratraqueal/instrumentação , Fita Cirúrgica/efeitos adversos , Adulto , Idoso , Extubação/estatística & dados numéricos , Distribuição de Qui-Quadrado , Estado Terminal/epidemiologia , Estado Terminal/terapia , Feminino , Humanos , Unidades de Terapia Intensiva/organização & administração , Unidades de Terapia Intensiva/estatística & dados numéricos , Intubação Intratraqueal/métodos , Intubação Intratraqueal/normas , Masculino , Pessoa de Meia-Idade , Lesão por Pressão/epidemiologia , Lesão por Pressão/etiologia , Respiração Artificial/instrumentação , Respiração Artificial/métodos , Respiração Artificial/normas , Estudos Retrospectivos , Estatísticas não Paramétricas , Fita Cirúrgica/estatística & dados numéricos
4.
BMC Med Educ ; 19(1): 100, 2019 Apr 05.
Artigo em Inglês | MEDLINE | ID: mdl-30953546

RESUMO

BACKGROUND: Simulation-based medical education (SBME) is a cornerstone for procedural skill training in residency education. Multiple studies have concluded that SBME is highly effective, superior to traditional clinical education, and translates to improved patient outcomes. Additionally it is widely accepted that mastery learning, which comprises deliberate practice, is essential for expert level performance for routine skills; however, given that highly structured practice is more time and resource-intensive, it is important to assess its value for the acquisition of rarely performed technical skills. The bougie-assisted cricothyroidotomy (BAC), a rarely performed, lifesaving procedure, is an ideal skill for evaluating the utility of highly structured practice as it is relevant across many acute care specialties and rare - making it unlikely for learners to have had significant previous training or clinical experience. The purpose of this study is to compare a modified mastery learning approach with deliberate practice versus self-guided practice on technical skill performance using a bougie-assisted cricothyroidotomy model. METHODS: A multi-centre, randomized study will be conducted at four Canadian and one American residency programs with 160 residents assigned to either mastery learning and deliberate practice (ML + DP), or self-guided practice for BAC. Skill performance, using a global rating scale, will be assessed before, immediately after practice, and 6 months later. The two groups will be compared to assess whether the type of practice impacts performance and skill retention. DISCUSSION: Mastery learning coupled with deliberate practice provides systematic and focused feedback during skill acquisition. However, it is resource-intensive and its efficacy is not fully defined. This multi-centre study will provide generalizable data about the utility of highly structured practice for technical skill acquisition of a rare, lifesaving procedure within postgraduate medical education. Study findings will guide educators in the selection of an optimal training strategy, addressing both short and long term performance.


Assuntos
Competência Clínica/normas , Cartilagem Cricoide/cirurgia , Medicina de Emergência/educação , Internato e Residência , Intubação Intratraqueal/métodos , Cartilagem Tireóidea/cirurgia , Traqueostomia/educação , Canadá , Educação Baseada em Competências , Simulação por Computador , Avaliação Educacional , Medicina de Emergência/normas , Humanos , Internato e Residência/normas , Intubação Intratraqueal/normas , Traqueostomia/normas , Estados Unidos
5.
Br J Anaesth ; 123(3): 392-398, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-30987766

RESUMO

BACKGROUND: Identification of the cricothyroid membrane is frequently inaccurate in females because of less distinct anatomy compared with males. Supraglottic airway devices cause ventral displacement of the laryngeal structures. We investigated if this would impact on the accuracy of cricothyroid membrane identification using palpation. METHODS: We recruited 64 adult females who underwent assessment by volunteer participants with and without a sited i-gel® supraglottic airway device. The primary outcome was accuracy in identifying the cricothyroid membrane. Secondary outcomes included distance from participant estimate to actual cricothyroid membrane location and perceived difficulty using a visual analogue scale. Ultrasound images were analysed to determine the effect of the i-gel® on the anatomical structures relevant to cricothyroidotomy. RESULTS: The cricothyroid membrane was identified correctly in 42/64 subjects with the i-gel® in place (66%) vs 23/64 of controls (36%; P<0.001, mean difference 30%; 95% confidence interval, 12-47%). VAS (P<0.001) and distance to the cricothyroid membrane (P<0.001) decreased in the intervention group. Analysis of the ultrasound image series showed a reduction in the mean angle between the cricothyroid membrane and anterior wall of the trachea in the i-gel® group, because of the more ventral position of the cricoid cartilage compared with control images (166° vs 151°, P<0.001). CONCLUSIONS: The presence of the i-gel® improved accuracy of identifying the cricothyroid membrane using palpation in females. The cricoid cartilage was pushed ventrally by the i-gel® in the hypopharynx, creating a more palpable prominence. It may therefore be advantageous to retain a sited supraglottic airway, rather than remove it, before performing emergency cricothyroidotomy.


Assuntos
Competência Clínica , Cartilagem Cricoide/anatomia & histologia , Máscaras Laríngeas , Palpação/normas , Cartilagem Tireóidea/anatomia & histologia , Adulto , Antropometria/métodos , Cartilagem Cricoide/diagnóstico por imagem , Feminino , Humanos , Intubação Intratraqueal/instrumentação , Intubação Intratraqueal/métodos , Intubação Intratraqueal/normas , Pessoa de Meia-Idade , Estudos Prospectivos , Cartilagem Tireóidea/diagnóstico por imagem , Ultrassonografia
6.
Pediatrics ; 143(5)2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-31028159

RESUMO

OBJECTIVES: Unintended extubations (UEs) lead to significant morbidity in neonates. A quality improvement project was initiated in response to high rates in our level IV NICU. We targeted creating and sustaining UE rates below the published standard of 1 per 100 ventilator days. METHODS: This project spanned 4 time periods: baseline, epoch 1 (December 2010-May 2012), sustain, and epoch 2 (May 2015-December 2017) by using standard quality improvement methodology. Epoch 1 interventions included real-time analysis of UE events, standardization of taping, patient positioning and movement, accurate event reporting, and change in nomenclature. Epoch 2 interventions included reduction in daily chest radiographs (CXRs) and development of a high-risk tool. Patient and event characteristics were statistically compared across time points. RESULTS: Of the 612 UE events recorded over 10 years, 249 UEs occurred from May 2011 to 2017 involving 184 unique patients. UE rates decreased by 43% (from 1.75 to 0.99 per 100 ventilator days; epoch 1) and were sustained until a notable spike. Epoch 2 interventions led to a further 31% rate reduction. Single CXR use decreased by half. Median corrected gestational age at the time of an event was 35 weeks (interquartile range: 29-41). Seventy percent of infants experiencing an UE required reintubation, 29% had a previous event, and 9% had a code event. CONCLUSIONS: A decrease in UE below benchmarks can be achieved and sustained by standardization and mitigation interventions. This decline was also accompanied by a reduction in use of CXRs without increasing UE events.


Assuntos
Centros Médicos Acadêmicos/tendências , Extubação/tendências , Unidades de Terapia Intensiva Neonatal/tendências , Intubação Intratraqueal/tendências , Melhoria de Qualidade/tendências , Centros Médicos Acadêmicos/normas , Extubação/normas , Feminino , Humanos , Lactente , Recém-Nascido , Unidades de Terapia Intensiva Neonatal/normas , Intubação Intratraqueal/normas , Masculino , Melhoria de Qualidade/normas
7.
Ann Saudi Med ; 39(2): 87-91, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-30955017

RESUMO

BACKGROUND: In 2015, the Neonatal Resuscitation Program (NRP) guidelines were updated to recommend that nonvigorous infants delivered through meconium-stained amniotic fluid (MSAF) do not require routine intubation and tracheal suction. OBJECTIVE: Explore the implications of 2015 NRP guidelines on delivery room management and outcome of infants born through MSAF. DESIGN: Retrospective cohort study. SETTINGS: King Abdul-Aziz University Hospital (KAUH). PATIENTS AND METHODS: All term ( greater than or equal 37 weeks) infants born in KAUH through MSAF between January 1, 2016, and December 31, 2017, were included. Patients were divided into two groups according to the date of birth: period 1 (January 1, 2016, to December 31, 2016), before the implementation of the new NRP guidelines; period 2 (January 1, 2017, to December 31, 2017), after the implementation. MAIN OUTCOME MEASURES: Outcomes of infants born through MSAF. SAMPLE SIZE: 420 infants. RESULTS: A majority of infants (n=261) were born in period 1 and 159 after in period 2. No differences were found in the booking status of mothers, cesarean section rate, and number of deliveries attended by physicians between the 2 cohorts. Infants in both cohorts were of similar gestational age, birth weight, and gender. A nonsignificant lower rate of intubation at birth (2.3% vs 0.6%), admission to neonatal intensive care unit (3.8% vs 3.1%), and meconium aspiration syndrome (1.5% vs 0.6%) were found in period 2 compared with period 1. Only 1 infant died in period 1. CONCLUSION: After the implementation of 2015 NRP guidelines, fewer infants were intubated at birth for MSAF. No difference was observed in the rate of associated morbidities and mortality. LIMITATIONS: A single-center retrospective study of misclassification bias because some of the medical staff started practicing the new guidelines before the official implementation. CONFLICT OF INTEREST: None.


Assuntos
Líquido Amniótico/química , Parto Obstétrico/normas , Doenças do Recém-Nascido/terapia , Síndrome de Aspiração de Mecônio/terapia , Mecônio , Feminino , Humanos , Recém-Nascido , Unidades de Terapia Intensiva Neonatal/normas , Intubação Intratraqueal/normas , Masculino , Guias de Prática Clínica como Assunto , Gravidez , Avaliação de Programas e Projetos de Saúde , Estudos Retrospectivos , Sucção/normas
9.
Eur J Pediatr ; 178(6): 871-882, 2019 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-30903306

RESUMO

Endotracheal intubation is the gold standard for airway management. Supraglottic airway devices (SADs) are useful in airway abnormalities. SAD blind intubation enables airway management with better ventilation and a reduced risk of gastric content aspiration. The aim was to compare various SADs in blind intubation performed by inexperienced physicians in several pediatric airway scenarios. One hundred sixteen physicians with no previous experience with SAD performed blind endotracheal intubations with (1) iGEL, (2) Air-Q intubating laryngeal airway, and (3) Ambu AuraGain disposable laryngeal mask in a pediatric manikin in three airway scenarios: (A) normal airway without chest compressions, (B) normal airway with continuous chest compressions with the CORPULS CPR system, and (C) difficult airway with continuous chest compressions with the CORPULS CPR system. Intubation tube with 5.0 internal diameter was used for all blind intubation attempts. First intubation success rate, median time to SAD placement, time to endotracheal intubation with SAD, and ease to perform the intubation were investigated in this study. All these parameters were better or non-inferior for iGEL in all investigated scenarios.Conclusion: Our manikin study demonstrated that iGEL was the most effective device for blind intubation by inexperienced physicians in different pediatric airway scenarios. What is Known: • For pediatric resuscitation, bag-mask ventilation is the first-line method for airway control and ventilation. • Endotracheal intubation is considered by many scientific societies the gold standard for airway management. • Supraglottic airway devices are particularly useful when bag-mask ventilation is difficult or impossible but can be also used for blind intubation. What is New: • The iGEL laryngeal mask turns out the most effective device for blind intubation by inexperienced physicians in different pediatric airway scenarios. • It may be a reasonable first emergency blind intubation technique for inexperienced physicians in pediatric patients in normal airway with and without continuous chest compressions, as well as in difficult airway with continuous chest compressions.


Assuntos
Competência Clínica , Medicina de Emergência/educação , Intubação Intratraqueal/instrumentação , Reanimação Cardiopulmonar/métodos , Pré-Escolar , Estudos Cross-Over , Humanos , Intubação Intratraqueal/métodos , Intubação Intratraqueal/normas , Laringoscopia/métodos , Manequins , Treinamento por Simulação
10.
Arch Dis Child Fetal Neonatal Ed ; 104(5): F461-F466, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-30796059

RESUMO

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.


Assuntos
Competência Clínica , Emergências/epidemiologia , Hipóxia , Unidades de Terapia Intensiva Neonatal , Intubação Intratraqueal , Manuseio das Vias Aéreas/métodos , Feminino , Humanos , Hipóxia/etiologia , Hipóxia/prevenção & controle , Incidência , Recém-Nascido , Recém-Nascido Prematuro , Unidades de Terapia Intensiva Neonatal/normas , Unidades de Terapia Intensiva Neonatal/estatística & dados numéricos , Intubação Intratraqueal/efeitos adversos , Intubação Intratraqueal/métodos , Intubação Intratraqueal/normas , Intubação Intratraqueal/estatística & dados numéricos , Masculino , Padrões de Prática Médica/normas , Melhoria de Qualidade/normas , Sistema de Registros , Estudos Retrospectivos , Estados Unidos/epidemiologia
12.
Respir Physiol Neurobiol ; 263: 9-13, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30790746

RESUMO

Although mice are a commonly used animal species in experimental medicine, airway management of this species is not easy due to their small size. In order to develop a new method of tracheal intubation in mice, we produced a supraglottic intubation-aid conduit (SIAC) for mice, and tested the efficacy of this device in spontaneously breathing mice anesthetized with sevoflurane inhalation. The success rate of tracheal intubation with the crude prototype of the SIAC was 50% and adverse effects on respiration and some trauma in the upper airway were occasionally observed. After refining the size and shape of the SIAC, the success rate of tracheal intubation with the refined prototype of the SIAC was 100% without any serious adverse effects. This study showed that it is possible to produce a supraglottic airway device to aid tracheal intubation in mice and that the shape and size of the SIAC play a crucial role in successful tracheal intubation in mice.


Assuntos
Desenho de Equipamento , Intubação Intratraqueal/instrumentação , Animais , Feminino , Intubação Intratraqueal/normas , Masculino , Camundongos , Camundongos Endogâmicos C57BL , Modelos Animais
13.
Int J Technol Assess Health Care ; 35(1): 27-35, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30722802

RESUMO

OBJECTIVES: The aim of this overview was to systematically identify and synthesize existing evidence from systematic reviews on the impact of prehospital physician involvement. METHODS: The Medline, Embase, and Cochrane library were searched from 1 January 2000 to 17 November 2017. We included systematic reviews comparing physician-based with non-physician-based prehospital treatment in patients with one of five critical conditions requiring a rapid response. RESULTS: Ten reviews published from 2009 to 2017 were included. Physician treatment was associated with increased survival in patients with out-of-hospital cardiac arrest and patients with severe trauma; in the latter group, the result was based on more limited evidence. The success rate of prehospital endotracheal intubation (ETI) has improved over the years, but ETI by physicians is still associated with higher success rates than intubation by paramedics. In patients with severe traumatic brain injury, intubation by paramedics who were not well skilled to do so markedly increased mortality. CONCLUSIONS: Current evidence is hinting at a benefit of physicians in selected aspects of prehospital emergency services, including treatment of patients with out-of-hospital cardiac arrest and critically ill or injured patients in need of prehospital intubation. Evidence is, however, limited by confounding and bias, and comparison is hampered by differences in case mix and the organization of emergency medical services. Future research should strive to design studies that enable appropriate control of baseline confounding and obtain follow-up data for the proportion of patients who die in the prehospital setting.


Assuntos
Cuidados Críticos/organização & administração , Serviços Médicos de Emergência/organização & administração , Médicos/estatística & dados numéricos , Competência Clínica/normas , Cuidados Críticos/normas , Serviços Médicos de Emergência/normas , Auxiliares de Emergência/normas , Humanos , Intubação Intratraqueal/normas , Parada Cardíaca Extra-Hospitalar/mortalidade , Parada Cardíaca Extra-Hospitalar/terapia , Literatura de Revisão como Assunto , Análise de Sobrevida , Índices de Gravidade do Trauma , Ferimentos e Lesões/mortalidade , Ferimentos e Lesões/terapia
14.
Br J Anaesth ; 122(2): 245-254, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-30686310

RESUMO

BACKGROUND: Some patients have features that indicate possible difficulty with direct laryngoscopy for tracheal intubation. Prediction of the likely outcome and selection of patients for an enhanced management algorithm would reduce the possible harm from failed intubation attempts. METHODS: Adult elective patients were assessed for seven features associated with difficult direct laryngoscopy, ranked in difficulty from 0 to 3. For a patient with at least one Class 3 feature, or two or more features of class 1 or higher, the enhanced management used a channelled videolaryngoscope Airtraq™ instead of a Macintosh laryngoscope. A long flexible angulated stylet and a flexible fibrescope would be used as the second and third steps. For patients with lesser difficulty scores, a Macintosh laryngoscope was used. Outcomes of enhanced management were analysed. Logistic regression and Random Forest algorithm, using the ranks of the predictive features, were used to predict difficulty during enhanced management. RESULTS: We prospectively studied 16 695 patients. We selected 1501 (9%) for enhanced management, and tracheal intubation was successful in all of them. Of these, 73% were intubated in less than 30 s, and only 4.5% required more than 4 min for intubation. Progression to the second and third steps of enhanced management was predicted by restriction of mouth opening and reduced cervical spine mobility. CONCLUSIONS: An enhanced management algorithm allowed successful tracheal intubation of all patients with anticipated difficult laryngoscopy. The need to combine the use of a stylet and a fibrescope with the Airtraq™ could be predicted with a high degree of certainty.


Assuntos
Manuseio das Vias Aéreas/métodos , Algoritmos , Intubação Intratraqueal/métodos , Adulto , Idoso , Manuseio das Vias Aéreas/normas , Anestesia Geral , Vértebras Cervicais/anatomia & histologia , Árvores de Decisões , Feminino , Humanos , Intubação Intratraqueal/normas , Laringoscopia , Masculino , Pessoa de Meia-Idade , Boca/anatomia & histologia , Valor Preditivo dos Testes , Estudos Prospectivos , Resultado do Tratamento
16.
Eur J Anaesthesiol ; 36(3): 221-226, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-30308524

RESUMO

BACKGROUND: In patients with predictive features associated with easy direct laryngoscopy, videolaryngoscoy with the GlideScope has been shown to require less force when compared with Macintosh direct laryngoscopy. OBJECTIVE: The aim of this study was to compare forces applied with Glidescope vs. Macintosh laryngoscopes in patients with predictive features associated with difficult direct laryngoscopy. DESIGN: A randomised study. SETTING: Toronto General Hospital, a university tertiary centre in Canada. PATIENTS: Forty-four patients aged over 18 years, with one or more features of difficult intubation, undergoing elective surgery requiring single-lumen tracheal intubation. INTERVENTION: We measured the force applied to oropharyngeal tissues by attaching three FlexiForce Sensors (A201-25) to the concave surface of Macintosh and GlideScope laryngoscope blades.Anaesthetists or experienced anaesthesia residents performed laryngoscopies with both devices in a randomised sequence. MAIN OUTCOME MEASURES: The primary outcome was peak force. The secondary outcomes were average force and impulse force. The latter is the integral of the force over the time during which the force acted. RESULTS: Complete data were available for 40 individuals. Peak and average forces decreased with GlideScope (17 vs. 21 N, P = 0.03, and 6 vs. 11 N, P < 0.001, respectively). Laryngoscopy time increased with the GlideScope (30 vs. 18 s, P < 0.001), resulting in similar median impulse forces (206 vs. 175 N, P = 0.92). CONCLUSION: GlideScope laryngoscopy resulted in reduced peak and average forces, but as the laryngoscopy duration increased, the product of force and time (impulse force) was similar with both devices. TRIAL REGISTRATION: Clinicaltrials.gov Identifier: NCT01814176.


Assuntos
Manuseio das Vias Aéreas/instrumentação , Desenho de Equipamento/instrumentação , Intubação Intratraqueal/instrumentação , Laringoscópios , Laringoscopia/instrumentação , Cirurgia Vídeoassistida/instrumentação , Adulto , Idoso , Manuseio das Vias Aéreas/métodos , Manuseio das Vias Aéreas/normas , Desenho de Equipamento/normas , Feminino , Humanos , Intubação Intratraqueal/métodos , Intubação Intratraqueal/normas , Laringoscópios/normas , Laringoscopia/métodos , Laringoscopia/normas , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Cirurgia Vídeoassistida/métodos , Cirurgia Vídeoassistida/normas
17.
J Int Med Res ; 47(1): 235-243, 2019 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30556457

RESUMO

OBJECTIVE: Nasotracheal (NT) intubation is commonly applied during head and neck surgery. However, improper tube size and depth may cause complications. In the current study, we investigated whether NT tubes are being appropriately used in terms of size and depth in adult patients. METHODS: Nares were sized in 40 patients using standard nasopharyngeal airways (6.0-8.0) before elective surgery under general anesthesia. The largest sized airway that passed easily into the nasopharynx without resistance was considered as a proper size. Using a fiberoptic scope, the distances from the nares to the vocal cords and the nares to the carina were measured. Rates of proper NT tube positioning were calculated with regard to the cuff and distal tip. RESULTS: The most frequent sizes of properly fitted NT tubes were 6.5 and 6.0 in male and female patients, respectively. Positioning of the cuff and distal tip was only appropriate when using a properly sized tube in 26% and 47% of male and female patients, respectively. CONCLUSION: Care should be taken to determine the insertion depth after placing an NT tube that has been sized to fit the nostril. Moreover, NT tubes of the same diameter may be required in various lengths. Trial registration: Registered at ClinicalTrial.gov; https://clinicaltrials.gov/ct2/show/NCT02876913 ; Registration number NCT02876913.


Assuntos
Anestesia Geral/instrumentação , Procedimentos Cirúrgicos Eletivos , Intubação Intratraqueal/normas , Nasofaringe/anatomia & histologia , Traqueia/anatomia & histologia , Prega Vocal/anatomia & histologia , Adulto , Idoso , Anestesia Geral/métodos , Anestésicos Inalatórios , Face/cirurgia , Feminino , Tecnologia de Fibra Óptica , Humanos , Intubação Intratraqueal/métodos , Masculino , Maxila/cirurgia , Pessoa de Meia-Idade , Boca/cirurgia , Tamanho do Órgão , Estudos Prospectivos , Sevoflurano , Fatores Sexuais
18.
Neurocrit Care ; 30(1): 185-192, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30167898

RESUMO

BACKGROUND AND PURPOSE: Ischemic stroke (IS), intracerebral hemorrhage (ICH), and subarachnoid hemorrhage (SAH) patients often require endotracheal intubation (EI) and mechanical ventilation (MV). Predicting the need for prolonged EI and timing of tracheostomy (TR) is challenging. While TR is performed for about 10-15% of patients in the general intensive care unit (ICU), the rate in the neurological ICU and for stroke patients ranges between 15 and 35%. Thus, we performed an external validation of the recently published SETscore. METHODS: This is a retrospective review for all patients with IS, non-traumatic ICH, and SAH who required intubation within 48 h of admission to the neurological ICU. We compared the SETscore between tracheostomized versus successfully extubated patients, and early TR (within 7 days) versus late TR (after 7 days). RESULTS: Out of 511 intubated patients, 140 tracheostomized and 105 extubated were included. The sensitivity for a SETscore > 10 to predict the need for TR was 81% (95% CI 74-87%) with a specificity of 57% (95% CI 48-67%). The score had moderate accuracy in correctly identifying those requiring TR and those successfully extubated: 71% (95% CI 65-76%). The AUC of the score was 0.74 (95% CI 0.68-0.81). Multivariable logistic regression models were used to identify other independent predictors of TR. After including body mass index (BMI), African American (AA) race, ICH and a positive sputum culture in the SETscore, sensitivity, specificity, overall accuracy, and AUC improved to 90%, 78%, 85%, and 0.89 (95% CI 0.85-0.93), respectively. In our cohort, performing early TR was associated with improvement in the ICU median length of stay (LOS) (15 vs 20.5 days; p = 0.002) and mean ventilator duration (VD) (13.4 vs 18.2 days; p = 0.005) in comparison to late TR. CONCLUSIONS: SETscore is a simple score with a moderate accuracy and with a fair AUC used to predict the need for TR after MV for IS, ICH, and SAH patients. Our study also demonstrates that early TR was associated with a lower ICU LOS and VD in our cohort. The utility of this score may be improved when including additional variables such as BMI, AA race, ICH, and positive sputum cultures.


Assuntos
Isquemia Encefálica/terapia , Hemorragia Cerebral/terapia , Tomada de Decisão Clínica , Cuidados Críticos/normas , Intubação Intratraqueal/normas , Respiração Artificial/normas , Acidente Vascular Cerebral/terapia , Hemorragia Subaracnóidea/terapia , Traqueostomia/normas , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos
19.
Niger J Clin Pract ; 21(12): 1651-1655, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30560831

RESUMO

Background: Today, the internet is widely used to obtain any type of information. The use of internet may facilitate healthcare professionals' education as well. Objectives: We aimed to evaluate the content, accuracy, reliability and quality of YouTube videos regarding intubation, one of the most important skills for healthcare professionals. Materials and Methods: Of the 54,000 videos found using the keyword 'intubation', the first 50 were included in the study. The sources were divided into three categories: academicians, healthcare professionals and medical. The view ratio, like ratio, and video power index were used to determine the popularity while Journal of American Medical Association (JAMA) benchmark criteria were used for reliability. The extent of the information was evaluated based on the scoring system provided by us. Results: The majority of the videos were uploaded by healthcare professionals (92%) including academicians. Twenty-seven (54%) videos had training purposes. The information point was highest in the academic group (4.6 ± 2.7); however, there was no significance between groups (P = 0.2). The mean JAMA score was highest in the academic group (1.9 ± 0.8), with a statistical significance (P = 0.00055). The JAMA score and information points were significantly higher in training videos compared to non-training videos (p=<0.001 and P = 0.003, respectively). Popularity ratios were similar between groups. Conclusion: Videos regarding medical skills should be accurate. Information on YouTube regarding intubation is limited and is of low quality. The establishment of an organization authorized to evaluate the content, quality, accuracy and reliability of the information on the internet regarding medical skills is warranted.


Assuntos
Disseminação de Informação/métodos , Internet , Intubação Intratraqueal/métodos , Mídias Sociais , Gravação em Vídeo , Feminino , Humanos , Intubação Intratraqueal/normas , Garantia da Qualidade dos Cuidados de Saúde , Controle de Qualidade , Reprodutibilidade dos Testes
20.
Neonatal Netw ; 37(4): 238-247, 2018 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-30567922

RESUMO

Endotracheal intubation, a common procedure in neonatal intensive care, results in distress and disturbs physiologic homeostasis in the newborn. Analgesics, sedatives, vagolytics, and/or muscle relaxants have the potential to blunt these adverse effects, reduce the duration of the procedure, and minimize the number of attempts necessary to intubate the neonate. The medical care team must understand efficacy, safety, and pharmacokinetic data for individual medications to select the optimal cocktail for each clinical situation. Although many units utilize morphine for analgesia, remifentanil has a superior pharmacokinetic profile and efficacy data. Because of hypotensive effects in preterm neonates, sedation with midazolam should be restricted to near-term and term neonates. A vagolytic, generally atropine, blunts bradycardia induced by vagal stimulation. A muscle relaxant improves procedural success when utilized by experienced practitioners; succinylcholine has an optimal pharmacokinetic profile, but potentially concerning adverse effects; rocuronium may be the agent of choice based on more robust safety data despite a relatively prolonged duration of action. In the absence of an absolute contraindication, neonates should receive analgesia with consideration of sedation, a vagolytic, and a muscle relaxant before endotracheal intubation. Neonatal units must develop protocols for premedication and optimize logistics to ensure safe and timely administration of appropriate agents.


Assuntos
Analgésicos/uso terapêutico , Hipnóticos e Sedativos/uso terapêutico , Terapia Intensiva Neonatal/normas , Intubação Intratraqueal/normas , Enfermagem Neonatal/educação , Enfermagem Neonatal/normas , Pré-Medicação/normas , Adulto , Educação Continuada em Enfermagem , Feminino , Humanos , Recém-Nascido , Recém-Nascido Prematuro , Terapia Intensiva Neonatal/métodos , Intubação Intratraqueal/métodos , Masculino , Pessoa de Meia-Idade , Enfermeiras Neonatologistas/educação , Guias de Prática Clínica como Assunto , Pré-Medicação/métodos
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