Predictive and protective factors for failing first pass intubation in prehospital rapid sequence intubation: an aetiology and risk systematic review with meta-analysis.

BACKGROUND: Prehospital rapid sequence intubation first pass success rates vary between 59% and 98%. Patient morbidity is associated with repeat intubation attempts. Understanding what influences first pass success can guide improvements in practice. We performed an aetiology and risk systematic review to answer the research question 'what factors are associated with success or failure at first attempt laryngoscopy in prehospital rapid sequence intubation?'. METHODS: MEDLINE, EMBASE, CINAHL, and Cochrane Library were searched on March 3, 2023 for studies examining first pass success rates for rapid sequence intubation of prehospital live patients. Screening was performed via Covidence, and data synthesised by meta-analysis. The review was registered with PROSPERO and performed and reported as per Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. RESULTS: Reasonable evidence was discovered for predictive and protective factors for failure of first pass intubation. Predictive factors included age younger than 1 yr, the presence of blood or fluid in the airway, restricted jaw or neck movement, trauma patients, nighttime procedures, chronic or acute distortions of normal face/upper airway anatomy, and equipment issues. Protective factors included an experienced intubator, adequate training, use of certain videolaryngoscopes, elevating the patient on a stretcher in an inclined position, use of a bougie, and laryngeal manoeuvres. CONCLUSIONS: Managing bloody airways, positioning well, using videolaryngoscopes with bougies, and appropriate training should be further explored as opportunities for prehospital services to increase first pass success. Heterogeneity of studies limits stronger conclusions. SYSTEMATIC REVIEW PROTOCOL: PROSPERO (CRD42022353609).

The critical care literature 2023.

The number of critically ill patients that present to emergency departments across the world continues to rise. In fact, the proportion of critically ill patients in emergency departments is now higher than pre-COVID-19 pandemic levels. [1] The emergency physician (EP) is typically the first physician to evaluate and resuscitate the critically ill patient. Given the continued shortage of intensive care unit (ICU) beds, persistent staff shortages, and overall inefficient hospital throughput, EPs are often tasked with providing intensive care to these patients long beyond the initial resuscitation phase. Prolonged boarding of critically ill patients in the ED is associated with increased ICU and hospital length of stay, increased adverse events, ED staff burnout, decreased patient and family satisfaction, and, most importantly, increased mortality. [2-5]. As such, it is imperative for the EP to be knowledgeable about recent literature in resuscitation and critical care medicine, so that critically ill ED patients can continue to receive the best, most up-to-date evidence-based care. This review summarizes important articles published in 2023 that pertain to the resuscitation and management of select critically ill ED patients. Topics included in this article include cardiac arrest, post-cardiac arrest care, septic shock, rapid sequence intubation, severe pneumonia, transfusions, trauma, and critical procedures.

Effects of different doses of alfentanil on cardiovascular response to rapid sequence intubation in elderly patients: a parallel-controlled randomized trial.

BACKGROUND: Rapid sequence intubation (RSI) have been shown to be effective in preventing reflux aspiration in patients with a full stomach during anaesthesia induction and endotracheal intubation. However, there is currently no standardized operation protocol or anaesthesia induction drug standard for RSI. Furthermore, there is a lack of evidence regarding the use of RSI in patients older than 65. In this study, we aimed to investigate the cardiovascular effects of different doses of alfentanil combined with propofol and etomidate during RSI in elderly patients aged 65-80 years. METHODS: A total of 96 patients aged 65-80 years who underwent general anaesthesia with tracheal intubation were selected for this study. The patients were randomly assigned to one of four groups using a random number table. Group A patients received an induction dose of 10 µg/kg alfentanil, group B patients received 15 µg/kg alfentanil, group C patients received 20 µg/kg alfentanil, and group D patients received 25 µg/kg alfentanil. Heart rate (HR), mean arterial pressure (MAP), cardiac index (CI), and ejection fraction (EF) were measured at three time points: 5 min before anaesthesia induction (T0), 1 min after endotracheal intubation (T1), and 5 min after endotracheal intubation (T2). Concurrently, 4 ml of arterial blood was collected from patients at three time points, and the concentrations of norepinephrine (NE) and cortisol (Cor) in plasma were detected. Occurrences of hypertension, hypotension, bradycardia and tachycardia during anesthesia induction to 5 min after tracheal intubation were noted. RESULTS: Compared with T0, the HR, MAP, NE and Cor concentrations in group A and group B were increased at the T1 and T2 time points, CI and EF values were decreased (P < 0.05). HR and MAP in groups C and D were increased at the T1 time point, while they were decreased at the T2 time point in group D (P < 0.05). The changes in CI and EF values, concentrations of NE and Cor, were not significant at T1 and T2 time points in group C (P > 0.05). Additionally, they were not significant in group D at the T1 time point (P > 0.05), but decreased at the T2 time point (P < 0.05). Compared with group A, the HR, MAP, NE and Cor concentrations in groups C and D were decreased at T1 and T2 time points (P < 0.05). The CI and EF values of groups C and D were increased at T1 time point but decreased at T2 time point in group D (P < 0.05). The incidence of hypertension and tachycardia in group A was significantly higher than that in group C and group D (P < 0.05), and the incidence of hypotension and bradycardia in group D was significantly higher than that in group A and group B (P < 0.05). CONCLUSION: Alfentanil 20 µg/kg for RSI in elderly patients, can effectively inhibit the violent cardiovascular reaction caused by intubation, and avoid the inhibition of cardiovascular system caused by large dose, hemodynamics more stable. TRIAL REGISTRATION: ChiCTR2200062034 ( www.chictr.org.cn ).

Association of glucagon-like peptide receptor 1 agonist therapy with the presence of gastric contents in fasting patients undergoing endoscopy under anesthesia care: a historical cohort study.

PURPOSE: We aimed to estimate the association of glucagon-like peptide 1 (GLP-1) receptor agonist therapy with the incidence of endoscopically visible gastric contents after preprocedural fasting. METHODS: We reviewed the records of esophagogastroduodenoscopy (EGD) performed at our institution between 2019 and 2023 and determined the presence of residual gastric contents from the procedure notes and saved images. We compared patients taking GLP-1 agonists at the time of the procedure (GLP group, 90 procedures) with patients who started GLP-1 agonist therapy within 1,000 days after undergoing EGD (control, 102 procedures). We excluded emergent procedures without fasting, combined EGD/colonoscopy procedures, and patients with known gastroparesis or previous gastric surgery. We estimated the association between GLP-1 agonist therapy and residual gastric contents with a confounder-adjusted generalized linear mixed effect model. RESULTS: Compared with controls, the GLP cohort had a higher age, American Society of Anesthesiologists' Physical Status, and incidence of nausea and diabetes mellitus. Body mass index and fasting duration were comparable between groups. Visible gastric content was documented in 17 procedures in the GLP group (19%) and in five procedures in the control group (5%), with an associated confounder adjusted odds ratio of 5.8 (95% confidence interval, 1.7 to 19.3; P = 0.004). There were five instances of emergent endotracheal intubation in the GLP group vs one case in control and one case of pulmonary aspiration vs none in control. CONCLUSIONS: In fasting patients, GLP-1 agonist therapy was associated with an increased incidence of residual gastric contents, potentially posing an additional risk of periprocedural pulmonary aspiration.

RéSUMé: OBJECTIF: Notre objectif était d'estimer l'association d'un traitement par agonistes des récepteurs du peptide-1 de type glucagon (glucagon-like peptide 1, GLP-1) avec l'incidence de contenu gastrique visible par endoscopie malgré le jeûne préopératoire. MéTHODE: Nous avons examiné les dossiers des œsophagogastroduodénoscopies (OGD) réalisées dans notre établissement entre 2019 et 2023 et déterminé la présence de contenu gastrique résiduel à partir des notes d'intervention et des images enregistrées. Nous avons comparé les patient·es prenant des agonistes du GLP-1 au moment de l'intervention (groupe GLP, 90 procédures) avec les patient·es qui ont commencé un traitement par agonistes du GLP-1 dans les 1000 jours suivant l'OGD (groupe témoin, 102 procédures). Nous avons exclu les procédures d'urgence sans jeûne, les procédures combinées OGD/coloscopie et les patient·es présentant une gastroparésie connue ou une chirurgie gastrique antérieure. Nous avons estimé l'association entre le traitement par agonistes du récepteur GLP-1 et le contenu gastrique résiduel à l'aide d'un modèle linéaire généralisé à effets mixtes ajusté en fonction des facteurs de confusion. RéSULTATS: Par rapport aux témoins, la cohorte GLP était plus âgée, de statut physique selon l'American Society of Anesthesiologists plus élevé et présentait une incidence plus élevée de nausées et de diabète. L'indice de masse corporelle et la durée du jeûne étaient comparables entre les groupes. Du contenu gastrique visible a été documenté dans 17 procédures dans le groupe GLP (19 %) et dans cinq procédures dans le groupe témoin (5 %), avec un rapport de cotes ajusté associé de 5,8 (intervalle de confiance à 95 %, 1,7 à 19,3; P = 0,004). Il y a eu cinq cas d'intubation endotrachéale urgente dans le groupe GLP vs un cas dans le groupe témoin et un cas d'aspiration pulmonaire vs aucun dans le groupe témoin. CONCLUSION: Chez la patientèle à jeun, le traitement par agonistes des récepteurs du GLP-1 a été associé à une incidence accrue de contenu gastrique résiduel, ce qui pourrait entraîner un risque supplémentaire d'aspiration pulmonaire périprocédurale.

Selective Use of Positive-Pressure Ventilation for Preoxygenation During Air Medical Rapid Sequence Intubation.

BACKGROUND: Preoxygenation is critical to safe performance of rapid sequence intubation (RSI). The use of positive-pressure ventilation (PPV) has been advocated during preoxygenation but may increase the risk of aspiration. OBJECTIVE: To explore the risk-benefit analysis of using PPV during air medical RSI. METHODS: We performed a retrospective analysis of the Air Methods Airway Registry using patient data from over 175 bases across the U.S. over a 5-year period. Patients were separated into normoxemic (SpO2 ≥93%) and hypoxemic (SpO2 <93%) and compared in regard to demographics, clinical data, and use of PPV. Primary outcomes were first-attempt intubation success (FAS) and FAS without desaturation (FASWD). Chi-square, t-test, and logistical regression were used to analyze the data. RESULTS: There were 9778 patients who underwent intubations during the study period. FAS was 92% (8966 patients). FASWD was 90% (8775 patients). Mean SpO2 was 94.9%. There were 42% (4118 patients) of patients who received PPV prior to intubation and 1% (94) aspirated during RSI. Multivariate logistical regression showed an association between use of PPV and reduced intubation success for normoxemic patients but improved intubation success for hypoxemic patients. The use of PPV was associated with higher risk of aspiration events (p = 0.007). CONCLUSION: The use of PPV during preoxygenation prior to RSI appears beneficial for hypoxemic but not normoxemic patients due to lower intubation success and increased aspiration risk with PPV. This data supports selective use of PPV prior to the initial intubation attempt in patients undergoing RSI.

The impact of ketamine on emergency rapid sequence intubation: a systematic review and meta-analysis.

BACKGROUND: Rapid sequence intubation (RSI) is a crucial step in the resuscitation process for critically ill patients, and the judicious use of sedative drugs during RSI significantly influences the clinical outcomes of patients. Ketamine is a commonly used anesthetic sedative; however, its impact on the mortality of patients undergoing RSI has yielded inconsistent findings. Therefore, we conducted a systematic review and meta-analysis investigating ketamine's role in RSI to provide insights into selecting appropriate sedatives for critically ill patients. METHODS: In this systematic review and meta-analysis, we conducted a systematic search on MEDLINE (PubMed), Embase, and Cochrane Central Register of Controlled Trials, without restricting to randomized controlled trials (RCTs) or cohort studies. The search was performed from inception until Dec 12, 2023, with no language restrictions. All studies comparing the use of sedatives, including ketamine, and documenting in-hospital mortality were included in this study. RESULTS: A total of 991 studies were identified, out of which 15 studies (5 RCTs and 10 cohort studies) involving 16,807 participants fulfilled the inclusion criteria. No significant impact on in-hospital mortality was observed with the use of ketamine compared to other drugs during RSI (OR 0.90, 95%CI 0.72 to 1.12). Low-quality evidence suggested that ketamine might reduce mortality within the first seven days of hospitalization (OR 0.42, 95%CI 0.19 to 0.93), but it may also have a potential effect on prolonging ICU-free days at day 28 (MD -0.71, 95%CI -1.38 to -0.05). There were no significant differences in the results of the other RSI-related outcomes, such as physiological function and adverse events. CONCLUSIONS: Based on existing studies, ketamine showed no significant difference compared to other sedatives in terms of in-hospital mortality, physiological impact, and side effects following RSI. However, it may reduce mortality within 7 days while probably prolong the length of stay in the ICU. TRIAL REGISTRATION: CRD42023478020.

Pharmacotherapy optimization for rapid sequence intubation in the emergency department.

PURPOSE: Rapid-sequence intubation (RSI) is the process of administering a sedative and neuromuscular blocking agent (NMBA) in rapid succession to facilitate endotracheal intubation. It is the most common and preferred method for intubation of patients presenting to the emergency department (ED). The selection and use of medications to facilitate RSI is critical for success. The purpose of this review is to describe pharmacotherapies used during the RSI process, discuss current clinical controversies in RSI medication selection, and review pharmacotherapy considerations for alternative intubation methods. SUMMARY: There are several steps to the intubation process requiring medication considerations, including pretreatment, induction, paralysis, and post-intubation sedation and analgesia. Pretreatment medications include atropine, lidocaine, and fentanyl; but use of these agents in clinical practice has fallen out of favor as there is limited evidence for their use outside of select clinical scenarios. There are several options for induction agents, though etomidate and ketamine are the most used due to their more favorable hemodynamic profiles. Currently there is retrospective evidence that etomidate may produce less hypotension than ketamine in patients presenting with shock or sepsis. Succinylcholine and rocuronium are the preferred neuromuscular blocking agents, and the literature suggests minimal differences between succinylcholine and high dose rocuronium in first-pass success rates. Selection between the two is based on patient specific factors, half-life and adverse effect profiles. Finally, medication-assisted preoxygenation and awake intubation are less common methods for intubation in the ED but require different considerations for medication use. AREAS FOR FUTURE RESEARCH: The optimal selection, dosing, and administration of RSI medications is complicated, and further research is needed in several areas. Additional prospective studies are needed to determine optimal induction agent selection and dosing in patients presenting with shock or sepsis. Controversy exists over optimal medication administration order (paralytic first vs induction first) and medication dosing in obese patients, but there is insufficient evidence to significantly alter current practices regarding medication dosing and administration. Further research examining awareness with paralysis during RSI is needed before definitive and widespread practice changes to medication use during RSI can be made.

Post-intubation analgesia and sedation following succinylcholine vs. rocuronium in the emergency department.

BACKGROUND: Succinylcholine and rocuronium are the most commonly utilized neuromuscular blocker agents (NMBAs) for rapid sequence intubation (RSI) in the emergency department (ED). The duration of action of rocuronium is significantly longer (∼30 min) compared to succinylcholine (∼10 min) and previous studies have shown that patients receiving rocuronium are more likely to have longer time to sedation initiation following RSI. Furthermore, patients receiving rocuronium may be more likely to experience awareness with paralysis than those receiving succinylcholine. The primary goal for this study was to evaluate the association between NMBA use during RSI and post-intubation sedation and analgesia practices in the ED. METHODS: This was a retrospective, multicenter cohort study including patients 18 years and older that received succinylcholine or rocuronium during RSI in the ED between September 1, 2020 and August 31, 2021. Patients were excluded if they were intubated prior to ED arrival, experienced an out-of-hospital or in ED cardiac arrest, or received sugammadex within 60 min of rocuronium administration. Patients were screened in reverse chronological order until the targeted sample size was achieved and all data was abstracted from the electronic health record. The primary outcome was the time to initiation of analgesia or sedation. Secondary outcomes included dose of sedatives or analgesia administered at 30- and 60 min, and medications administered for post-intubation sedation or analgesia. FINDINGS: A total of 200 ED patients were included of which 100 received succinylcholine and 100 received rocuronium. There was no difference in the median time to initiation of analgesia or sedation between the succinylcholine and rocuronium groups (10 vs 8.5 min, p = 0.82) or in Kaplan-Meier cumulative probabilities (p = 0.17). At 60 min post-RSI, those receiving succinylcholine received significantly higher median doses of propofol (20 µg/kg/min vs. 10 µg/kg/min; p = 0.02) and fentanyl [100 µg vs. 84.2 µg; p = 0.02]. CONCLUSION: While no differences were observed in the time to initiation of post-intubation sedation or analgesia in ED patients receiving succinylcholine compared to rocuronium, differences in the intensity of post-intubation regimens was observed. Further investigation is needed to evaluate the adequacy of sedation following RSI in the ED.

The critical care literature 2021.

An emergency physician (EP) is often the first provider to evaluate, resuscitate, and manage a critically ill patient. Over the past two decades, the annual hours of critical care delivered in emergency departments across the United States has dramatically increased. During the period from 2006 to 2014, the extent of critical care provided in the emergency department (ED) to critically ill patients increased approximately 80%. During the same time period, the number of intubated patients cared for in the ED increased by approximately 16%. In addition to seeing more critically ill patients, EPs are often tasked with providing critical care long beyond the initial resuscitation period. Prolonged ED boarding times for critically ill patients is associated with increased duration of mechanical ventilation, increased intensive care unit (ICU) length of stay, increased hospital length of stay, increased medication-related adverse events, and increased in-hospital, 30-day, and 90-day mortality. As a result, it is imperative for the EP to be knowledgeable about recent developments in resuscitation and critical care medicine, so that the critically ill ED patient care receive current evidence-based care. These articles have been selected based on the authors review of key critical care, resuscitation, emergency medicine, and medicine journals and their opinion of the importance of study findings as it pertains to the care of the critically ill ED patient. Topics covered in this article include cardiac arrest, post-cardiac arrest care, rapid sequence intubation, mechanical ventilation, fluid resuscitation, cardiogenic shock, transfusions, and sepsis.

Effect of vitamin C on adrenal suppression following etomidate for rapid sequence induction in trauma patients: a randomized clinical trial.

BACKGROUND: Etomidate is an imidazole derivative that is widely used in the emergency department for Rapid Sequence Intubation (RSI). Although it has a safe hemodynamic profile, there are some concerns about its suppressant effects on the adreno-cortical axis. Vitamin C, as an antioxidant, can play a protective role in this issue. METHOD: In a controlled clinical trial, we studied adult traumatic patients who needed RSI with etomidate. In one group underwent RSI with etomidate and cortisol levels were measured three hours later. In the other group, we administered one gram of vitamin C before etomidate administration, and the cortisol level was measured three hours later. RESULTS: Fifty-one patients have been studied. The serum cortisol level was significantly lower after RSI with etomidate in both groups. In the Vitamin C group, there was a significantly higher cortisol level after RSI in comparison to the control group. CONCLUSION: Etomidate can suppress the cortisol level in trauma patients who undergo RSI. Vitamin C can reduce this suppressant effect of etomidate. TRIAL REGISTRATION: IRCT registration number: IRCT20090923002496N11, URL of trial registry record: https://en.irct.ir/trial/34586 , Date of trial registration: 19/04/2019. Full date of the first registration: 30/05/2019.

The Effect of Ketamine Versus Etomidate for Rapid Sequence Intubation on Maximum Sequential Organ Failure Assessment Score: A Randomized Clinical Trial.

BACKGROUND: The use of induction agents for rapid sequence intubation (RSI) has been associated with hypotension in critically ill patients. Choice of induction agent may be important and the most commonly used agents are etomidate and ketamine. OBJECTIVE: This study aimed to compare the effects of a single dose of ketamine vs. etomidate for RSI on maximum Sequential Organ Failure Assessment (SOFA) score and incidence of hypotension. METHODS: This single-center, randomized, parallel-group trial compared the use of ketamine and etomidate for RSI in critically ill adult patients in the emergency department. The study was performed under Exception from Informed Consent. The primary outcome was the maximum SOFA score within 3 days of hospitalization. RESULTS: A total of 143 patients were enrolled in the trial, 70 in the ketamine group and 73 in the etomidate group. Maximum median SOFA score for the ketamine group was 6.5 (interquartile range [IQR] 5-9) vs. 7 (IQR 5-9) for etomidate with no significant difference (-0.2; 95% CI -1.4 to 1.1; p = 0.79). The incidence of post-intubation hypotension was 28% in the ketamine group vs. 26% in the etomidate group (difference 2%; 95% CI -13% to 17%). There were no significant differences in intensive care unit outcomes. Thirty-day mortality rate for the ketamine group was 11% (8 deaths) and for the etomidate group was 21% (15 deaths), which was not statistically different. CONCLUSIONS: There were no significant differences in maximum SOFA score or post-intubation hypotension between critically ill adults receiving ketamine vs. etomidate for RSI.

Ketamine versus etomidate for rapid sequence intubation in patients with trauma: a retrospective study in a level 1 trauma center in Korea.

BACKGROUND: Ketamine and etomidate are commonly used as sedatives in rapid sequence intubation (RSI). However, there is no consensus on which agent should be favored when treating patients with trauma. This study aimed to compare the effects of ketamine and etomidate on first-pass success and outcomes of patients with trauma after RSI-facilitated emergency intubation. METHODS: We retrospectively reviewed 944 patients who underwent endotracheal intubation in a trauma bay at a Korean level 1 trauma center between January 2019 and December 2021. Outcomes were compared between the ketamine and etomidate groups after propensity score matching to balance the overall distribution between the two groups. RESULTS: In total, 620 patients were included in the analysis, of which 118 (19.9%) were administered ketamine and the remaining 502 (80.1%) were treated with etomidate. Patients in the ketamine group showed a significantly faster initial heart rate (105.0 ± 25.7 vs. 97.7 ± 23.6, p = 0.003), were more hypotensive (114.2 ± 32.8 mmHg vs. 139.3 ± 34.4 mmHg, p < 0.001), and had higher Glasgow Coma Scale (9.1 ± 4.0 vs. 8.2 ± 4.0, p = 0.031) and Injury Severity Score (32.5 ± 16.3 vs. 27.0 ± 13.3, p < 0.001) than those in the etomidate group. There were no significant differences in the first-pass success rate (90.7% vs. 90.1%, p > 0.999), final mortality (16.1% vs. 20.6, p = 0.348), length of stay in the intensive care unit (days) (8 [4, 15] (Interquartile range)), vs. 10 [4, 21], p = 0.998), ventilator days (4 [2, 10] vs. 5 [2, 13], p = 0.735), and hospital stay (days) (24.5 [10.25, 38.5] vs. 22 [8, 40], p = 0.322) in the 1:3 propensity score matching analysis. CONCLUSION: In this retrospective study of trauma resuscitation, those receiving intubation with ketamine had greater hemodynamic instability than those receiving etomidate. However, there was no significant difference in clinical outcomes between patients sedated with ketamine and those treated with etomidate.

The effect of rocuronium priming dose based on actual versus corrected body weight in modified rapid sequence intubation.

Background: Rapid sequence intubation (RSI) is a technique that allows patients to be quickly intubated and have the airway secured. Aims: The purpose of this study was to investigate the effect of rocuronium priming and intubation dose calculated according to actual body weight (ABW) or corrected body weight (CBW) on the neuromuscular block and intubation quality in rapid sequence induction and intubation (RSII). Patients and Methods: This prospective randomized, double-blind study was conducted on a total of 60 patients randomized into two groups using the closed-envelope method between January 2021 and December 2021, with 30 individuals in each group. In group 1, CBW was used with the formula to calculate the neuromuscular blocking drug (NMBD) dose. The ABW of patients was used to calculate the NMBD dose in group 2. Results: The data of 50 female patients who underwent group 1 (CBW, n = 25) and group 2 (ABW, n = 25) were analyzed. Age, weight, height, body mass index (BMI), quality of laryngoscopy, post-priming side effects, mean arterial pressure (MAP), and heart rate (HR) values did not differ across the groups. When train-of-four (TOF) values, priming and intubation dose, and laryngoscopy time were compared, a statistically significant difference was found between the two groups of TOF count (TOF C) 1 (the duration of action). Conclusion: This study suggests that the application of rocuronium priming and intubation dose according to CBW in RSII, especially during the pandemic, provided similar intubation conditions as the application according to ABW, while its shorter duration of action shows that it can be preferred, especially in short-term surgical cases.

Prehospital Drug Assisted Airway Management: An NAEMSP Position Statement and Resource Document.

Airway management is a critical intervention for patients with airway compromise, respiratory failure, and cardiac arrest. Many EMS agencies use drug-assisted airway management (DAAM) - the administration of sedatives alone or in combination with neuromuscular blockers - to facilitate advanced airway placement in patients with airway compromise or impending respiratory failure who also have altered mental status, agitation, or intact protective airway reflexes. While DAAM provides several benefits including improving laryngoscopy and making insertion of endotracheal tubes and supraglottic airways easier, DAAM also carries important risks. NAEMSP recommends:DAAM is an appropriate tool for EMS clinicians in systems with clear guidelines, sufficient training, and close EMS physician oversight. DAAM should not be used in settings without adequate resources.EMS physicians should develop clinical guidelines informed by evidence and oversee the training and credentialing for safe and effective DAAM.DAAM programs should include best practices of airway management including patient selection, assessmenct and positioning, preoxygenation strategies including apneic oxygenation, monitoring and management of physiologic abnormalities, selection of medications, post-intubation analgesia and sedation, equipment selection, airway confirmation and monitoring, and rescue airway techniques.Post-DAAM airway placement must be confirmed and continually monitored with waveform capnography.EMS clinicians must have the necessary equipment and training to manage patients with failed DAAM, including bag mask ventilation, supraglottic airway devices and surgical airway approaches.Continuous quality improvement for DAAM must include assessment of individual and aggregate performance metrics. Where available for review, continuous physiologic recordings (vital signs, pulse oximetry, and capnography), audio and video recordings, and assessment of patient outcomes should be part of DAAM continuous quality improvement.

Ketamine is not associated with more post-intubation hypotension than etomidate in patients undergoing endotracheal intubation.

INTRODUCTION: Emergency department (ED) patients undergoing emergent tracheal intubation often have multiple physiologic derangements putting them at risk for post-intubation hypotension. Prior work has shown that post-intubation hypotension is independently associated with increased morbidity and mortality. The choice of induction agent may be associated with post-intubation hypotension. Etomidate and ketamine are two of the most commonly used agents in the ED, however, there is controversy regarding whether either agent is superior in the setting of hemodynamic instability. The goal of this study is to determine whether there is a difference in the rate of post-intubation hypotension who received either ketamine or etomidate for induction. Additionally, we provide a subgroup analysis of patients at pre-existing risk of cardiovascular collapse (identified by pre-intubation shock index (SI) > 0.9) to determine if differences in rates of post-intubation hypotension exist as a function of sedative choice administered during tracheal intubation in these high-risk patients. We hypothesize that there is no difference in the incidence of post-intubation hypotension in patients who receive ketamine versus etomidate. METHODS: A retrospective cohort study was conducted on a database of 469 patients having undergone emergent intubation with either etomidate or ketamine induction at a large academic health system. Patients were identified by automatic query of the electronic health records from 1/1/2016-6/30/2019. Exclusion criteria were patients <18-years-old, tracheal intubation performed outside of the ED, incomplete peri-intubation vital signs, or cardiac arrest prior to intubation. Patients at high risk for hemodynamic collapse in the post-intubation period were identified by a pre-intubation SI > 0.9. The primary outcome was the incidence of post-intubation hypotension (systolic blood pressure < 90 mmHg or mean arterial pressure < 65 mmHg). Secondary outcomes included post-intubation vasopressor use and mortality. These analyses were performed on the full cohort and an exploratory analysis in patients with SI > 0.9. We also report adjusted odds ratios (aOR) from a multivariable logistic regression model of the entire cohort controlling for plausible confounding variables to determine independent factors associated with post-intubation hypotension. RESULTS: A total of 358 patients were included (etomidate: 272; ketamine: 86). The mean pre-intubation SI was higher in the group that received ketamine than etomidate, (0.97 vs. 0.83, difference: -0.14 (95%, CI -0.2 to -0.1). The incidence of post-intubation hypotension was greater in the ketamine group prior to SI stratification (difference: -10%, 95% CI -20.9% to -0.1%). Emergency physicians were more likely to use ketamine in patients with SI > 0.9. In our multivariate logistic regression analysis, choice of induction agent was not associated with post-intubation hypotension (aOR 1.45, 95% CI 0.79 to 2.65). We found that pre-intubation shock index was the strongest predictor of post-intubation hypotension. CONCLUSION: In our cohort of patients undergoing emergent tracheal intubation, ketamine was used more often for patients with an elevated shock index. We did not identify an association between the incidence of post-intubation hypotension and induction agent between ketamine and etomidate. Patients with an elevated shock index were at higher risk of cardiovascular collapse regardless of the choice of ketamine or etomidate.

Evolving Techniques in RSI: Can the Choice of Induction Agent Matter in Securing a Definitive Airway in Emergency Settings?

How to cite this article: George B, Joachim N. Evolving Techniques in RSI: Can the Choice of Induction Agent Matter in Securing a Definitive Airway in Emergency Settings? Indian J Crit Care Med 2022;26(1):15-17.

Etomidate Compared to Ketamine for Induction during Rapid Sequence Intubation: A Systematic Review and Meta-analysis.

AIMS AND OBJECTIVES: The objective of the study was to compare the safety and efficacy of etomidate and ketamine as induction agents for rapid sequence intubation (RSI) in acutely ill patients in emergency department and prehospital settings with respect to post-induction hypotension and first-pass intubation success during RSI. MATERIALS AND METHODS: For this systematic review and meta-analysis, we searched PubMed, Embase, Cochrane, and ClinicalTrials.gov between database inception and June 1, 2021. Articles were included if they compared safety and efficacy of etomidate vs ketamine as induction agents, in patients undergoing RSI in emergency department and prehospital settings, without any restrictions on study design. The outcome measures were incidence of post-induction hypotension and first-pass intubation success. The dichotomous outcomes were assessed for odds ratio (OR) with 95% confidence interval (CI) using random-effects meta-analysis. RESULTS: Of 87 records identified, 9 were eligible, all assessed as having a low to moderate risk of overall bias. Six studies, including 12,060 patients from prehospital emergency medical services, air medical transport, and emergency department settings, compared post-induction hypotension incidence between etomidate and ketamine groups. The meta-analysis showed that etomidate was associated with decreased risk of post-induction hypotension compared to ketamine (OR: 0.53; 95% CI: 0.31-0.91; I 2 = 68%). Seven studies, including 15,574 patients, reported on the rate of first-pass intubation success with etomidate vs ketamine. In the pooled analysis, no differences were seen in first-pass intubation success during RSI using etomidate vs ketamine as the induction agent (OR: 1.13; 95% CI: 0.95-1.36; I 2 = 16%). CONCLUSION: The use of etomidate for induction during RSI is associated with a decreased risk of post-induction hypotension as compared to the use of ketamine, without an impact on the first-pass intubation success rate. HOW TO CITE THIS ARTICLE: Sharda SC, Bhatia MS. Etomidate Compared to Ketamine for Induction during Rapid Sequence Intubation: A Systematic Review and Meta-analysis. Indian J Crit Care Med 2022;26(1):108-113.

Use of the McGRATH™ MAC videolaryngoscope to evaluate the ability of anesthetists to give effective cricoid pressure: An interventional study.

Background and Aims: The application of cricoid pressure (CP) for rapid sequence induction is questioned on two grounds: its effectiveness in clinical settings and its impact on the laryngeal view. The main reason cited for its ineffectiveness is the lack of knowledge and training in its correct application. This study assessed, the performance of anesthetists in applying effective CP in a clinical setting. Material and Methods: Eighty-five ASA I/II adult patients posted for elective surgery requiring oral endotracheal intubation with nasogastric tube (NGT) placement participated in the study. Eighty-five anesthetists divided into five groups based on their level of experience were randomly chosen to apply CP after induction of anesthesia. An experienced anesthetist performed videolaryngoscopy and attempted NGT insertion. The primary outcome was effectiveness of CP defined as the inability to pass the NGT into the esophageal opening. We also noted that the glottic view with and without CP and the effectiveness of CP across different levels of experience of anesthetists. Results: Of the 85 anesthetists, 61 (71.8%) applied effective CP. The effectiveness improved with experience (first-year residents-11/17 [64.7%], second-year residents-11/17 [64.7%], third-year residents-10/17 [58.8%], senior residents-13/17 [76.5%], and consultants-16/17 [94.1%]) (P = 0.157). Post hoc analysis showed higher effectiveness among anesthetists with >3 years of experience (85.3%) compared with <3 years of experience (62.7%) (P = 0.024). CP did not always impede the laryngeal view, rather it has no effect or actually improves the glottic view in many instances (81%). Conclusion: CP is effective in occluding the esophageal lumen without hampering glottic view in the majority of the cases, and its effectiveness improves with experience.

Tracheal Intubation in the Critically Ill. Where We Came from and Where We Should Go.

Tracheal intubation is commonly performed in critically ill patients. Unfortunately, this procedure also carries a high risk of complications; half of critically ill patients with difficult airways experience life-threatening complications. The high complication rates stem from difficulty with laryngoscopy and tube placement, consequences of physiologic derangement, and human factors, including failure to recognize and reluctance to manage the failed airway. The last 10 years have seen a rapid expansion in devices available that help overcome anatomic difficulties with laryngoscopy and provide rescue oxygenation in the setting of failed attempts. Recent research in critically ill patients has highlighted other important considerations for critically ill patients and evaluated interventions to reduce the risks with repeated attempts, desaturation, and cardiovascular collapse during emergency airway management. There are three actions that should be implemented to reduce the risk of danger: 1) preintubation assessment for potential difficulty (e.g., MACOCHA score); 2) preparation and optimization of the patient and team for difficulty-including using a checklist, acquiring necessary equipment, maximizing preoxygenation, and hemodynamic optimization; and 3) recognition and management of failure to restore oxygenation and reduce the risk of cardiopulmonary arrest. This review describes the history of emergency airway management and explores the challenges with modern emergency airway management in critically ill patients. We offer clinically relevant recommendations on the basis of current evidence, guidelines, and expert opinion.

The effect of cricoid pressure on tracheal intubation in adult patients: a systematic review and meta-analysis.

PURPOSE: This meta-analysis aimed to assess the impact of cricoid pressure (CP) application on intubation outcomes. SOURCE: Electronic databases (i.e., MEDLINE, PubMed, Embase, and Cochrane review) were searched from inception to 2 June 2020 for randomized-controlled trials that assessed the intubation outcomes in adult patients using laryngoscopic approaches with and without the application of CP (i.e., CP vs non-CP group). The primary outcome was the successful first-attempt intubation rate (SFAIR), and the secondary outcomes were intubation time, incidences of poor laryngoscopic views (i.e., Cormack and Lehane grade 3-4), airway complications, and pulmonary aspiration. PRINCIPAL FINDINGS: A total of five trials (published from 2005 to 2018) were included, and all tracheal intubations were performed by anesthesiologists or nurse anesthetists with a video (n = 3) or Macintosh laryngoscope (n = 2) in the operating room. We found no significant difference in SFAIR (risk ratio [RR], 0.98; P = 0.37), incidence of poor laryngoscopic views (RR, 1.49; P = 0.21), and risk of sore throat (RR, 1.17; P = 0.73) between the two groups. Nevertheless, the intubation time on the first successful attempt was slightly longer (weighted mean difference = 4.40 sec, P = 0.002) and risk of hoarseness was higher (RR, 1.70; P = 0.03) in the CP group compared with in the non-CP group. The secondary outcome "pulmonary aspiration" was not analyzed because only one trial was available. CONCLUSION: The application of CP did not have a negative impact on the SFAIR or laryngoscopic view. Nevertheless, this maneuver may slightly prolong intubation time and increase the risk of postoperative hoarseness.

RéSUMé: OBJECTIF : Cette méta-analyse a pour but d'évaluer l'impact de l'application d'une pression cricoïdienne (PC) sur les résultats de l'intubation. SOURCE : Les bases de données électroniques (c.-à-d., MEDLINE, PubMed, Embase, et Cochrane review) ont été examinées de leur création jusqu'au 2 juin 2020 pour en tirer les études randomisées contrôlées évaluant les résultats d'intubation chez les patients adultes utilisant des approches laryngoscopiques avec ou sans application de PC (soit groupe PC et non-PC). Le critère d'évaluation principal était le taux d'intubations réussies à la première tentative, et les critères secondaires incluaient le temps d'intubation, l'incidence de mauvaises vues laryngoscopies (grades 3-4 de Cormack et Lehane), les complications au niveau des voies aériennes et l'aspiration pulmonaire. CONSTATATIONS PRINCIPALES : Cinq études au total (publiées entre 2005 et 2018) ont été incluses, et toutes les intubations trachéales ont été réalisées par des anesthésiologistes ou infirmiers anesthésistes à l'aide d'un vidéolaryngoscope (n = 3) ou d'une lame de Macintosh (n = 2) en salle d'opération. Nous n'avons trouvé aucune différence significative dans le taux d'intubations réussies à la première tentative (risque relatif [RR], 0,98; P = 0,37), dans l'incidence de mauvaises vues laryngoscopiques (RR, 1,49; P = 0,21) ou dans le risque de maux de gorge (RR, 1,17; P = 0,73) entre les deux groupes. En revanche, le temps d'intubation lors de la première tentative réussie était légèrement plus long (différence moyenne pondérée = 4,40 sec, P = 0,002) et le risque d'enrouement était plus élevé (RR, 1,70; P = 0,03) dans le groupe PC que dans le groupe non-PC. Le critère d'évaluation secondaire « aspiration pulmonaire ¼ n'a pas été analysé parce qu'une seule étude le mesurait. CONCLUSION : L'application de PC n'a pas eu d'impact négatif sur le taux d'intubations réussies à la première tentative ou la vue laryngoscopique. Par contre, cette manœuvre pourrait légèrement prolonger le temps d'intubation et augmenter le risque d'enrouement postopératoire.