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Signa Vitae

Journal of Intensive Care and Emergency Medicine

The Importance of Bedside Ultrasonography in Confirming the Location of Endotracheal Tube

Abstract

Objective. Endotracheal intubation may be associated with lethal complications when not applied in appropriate manner. In this study, we aimed to examine the efficiency of transcricoid and pulmonary ultrasonography in confirming the position of the tube in comparison with classical methods.

Methods. This study was carried out between 2016 and 2017 in Turkey and was registered in Clinical Trials under number NCT03081221. The location of the tube was confirmed using methods such as monitoring the vocal cords during direct laryngoscopy, condensation on endotracheal tube during respiration, epigastric-pulmonary auscultation, radiography and capnometry. After that, the transcricoid and pulmonary ultrasonography were implemented by the blinded pediatric emergency care specialist.

Results. 64 cases who needed advanced airway requirements were involved in this study. The double-line appearance could not be obtained from one patient only when using transcricoid ultrasonography, but the bilateral pleural shift movement was observed among all the cases by using pulmonary ultrasonography (sensitive: 98%-100%).

Conclusion. The determination of endoesophageal, endotracheal and endobronchial intubations can be easily made by using transcricoid and pulmonary ultrasonography. The use of ultrasonography may significantly contribute to critical airway management as fast, accurate and on time.

Keywords: Endobronchial intubation, Endotracheal intubation, Ultrasonography.

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Postintubation hypotension in elective surgery patients: a retrospective study

Abstract

Objective. Postintubation hypotension (PIH) is a common and recognized adverse event associated with poor outcomes in emergency medicine patients requiring endotracheal intubation. Our objectives were to determine the incidence of PIH following tracheal intubation in elective surgery patients.

Materials and Methods. A retrospective study by reviewing the anesthesia records of all patients presenting for elective surgery requiring tracheal intubation between February 1, 2017, and March 1, 2017 was performed. Patients were divided into 2 groups according to the severity of the operation: Group S1 (major surgery) and Group S2 (minor surgery). The primary outcome measure was the incidence of PIH. PIH was claimed when systolic blood pressure (SBP) decreased below 90 mm Hg or decreased more than 20% from the baseline in two consecutive measurements at least 15 minutes after intubation. Secondary outcome measures included the relationship between PIH and anesthetic induction agents used to facilitate ETI and ASA physical status.

Results. A total of 291 elective surgery patients were identified. The primary outcome of PIH was observed in 10.3% with no difference between study groups (major surgery-10.2% vs. minor surgery-10.3%). Most of the patients who developed PIH were ASA II score (76.6%) and propofol was the most commonly used intravenous anesthetic associated with hypotension (96.7%).

Conclusion. Although a transient decrease in systolic and diastolic blood pressure has been reported in most patients undergoing intubation for elective surgery, development of PIH occured only in 10.3% of patients. Most of the patients who developed PIH were administered propofol.

Keywords: post-intubation hypotension, elective surgery, endotracheal intubation, adverse events

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Effects of bed height on the performance of endotracheal intubation and bag mask ventilation

Abstract

Objectives. This study was performed to evaluate whether different bed heights affect the performance of airway procedures.

Methods. Thirty three medical doctors performed endotracheal intubation (EI) and bag mask ventilation (BMV) using three different bed heights; knee height, mid-thigh height, and anterior superior iliac spine (ASIS) height. For EI, performance was assessed based on intubation time, intubation success, and damage to teeth. For BMV, performance was assessed based on tidal volume, ventilation rate, peak pressure, minute ventilation, and airway opening. In addition, three numeric rating scales (NRS; 1 to 10) were used to assess the level of difficulty for each procedure and the doctors’ self-confidence. NRS scoring was based on posture (comfortable to uncomfortable), handling (easy to hard), and visual field (good to bad).

Results. No significant differences in performance were observed for EI or BMV at the three different bed heights. However, all of the NRS scores were significantly different among the different bed heights (P<0.001), and were poorest for the knee height beds: knee height (EI: posture 5.8~7.3, handling 4.3~5.7, visual field 3.9~5.5; BMV: posture 7.1~8.0, handling 5.9~7.2, 95% CI), mid-thigh height (EI: posture 2.9~4.0, handling 2.9~4.0, visual field 2.7~3.8; BMV: posture 2.4~3.2, handling 2.3~3.5) and ASIS height (EI: posture 2.2~3.5, handling 2.6~3.8, visual field 2.1~3.4; BMV: posture 2.9~4.4, handling 4.7~6.1).

Conclusions. Although the participants reported that the knee height beds were the least comfortable, hardest to handle, and made seeing the vocal cord difficult, these caveats did not affect their performance during airway procedures.

Key words: endotracheal intubation, positive pressure ventilation, bed, cardiopulmonary resuscitation

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The influence of different airway management strategies on chest compression fraction in simulated cardiopulmonary resuscitation, provided by paramedics: LMA Supreme versus Endotracheal Intubation and Combitube

Abstract

Introduction. It is strongly advised by the European Resuscitation Council not to interrupt chest compressions for airway management. An alternative to tracheal intubation is the use of a supraglottic airway device (SAD) which should shorten “hands-off” time during cardiopulmonary resuscitation (CPR). Chest compression fraction (CCF) should be above 0.6 to ensure the probability of successful CPR. We compared the performance of airway management during CPR provided by

paramedics using the laryngeal mask (LMA) Supreme, Combitube and endotracheal intubation (ET) in a manikin model.

Materials and Methods. Thirty sophomore students of emergency medicine school for paramedics took part in the study. The primary endpoint was to assess the influence of the type of airway management on CCF. The time to successful airway management (TA) was measured and the minute ventilation was assessed using the respirator Medumat Easy and program AMBU® CPR SOFTWARE during uninterrupted CPR. CCF was measured using CPRmeter – QCPR (Laerdal).

Results. Mean CCF was significantly better for LMA Supreme (0.8 vs 0.71 vs 0.65), mean TA was significantly shorter for LMA supreme: 16.5 sec vs 24.37 sec vs 28,3 sec, the success rate in the first attempt was 100% vs 66.6% vs 100%, mean air leak during chest compressions was 14% vs 8% vs 15% for LMA Supreme, ET and Combitube respectively.

Conclusion. The LMA Supreme is an effective tool for airway management during chest compression and provides adequate ventilation.

Key words: cardiopulmonary resuscitation, airway management, endotracheal intubation, supraglottic devices

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The effects of post-intubation hypertension in severe traumatic brain injury

Abstract

Introduction. The effect of post-intubation hypertension in severe traumatic brain injury (TBI) patients remains uncertain. We aimed to determine the relationship between post-intubation hypertension (mean arterial pressure (MAP) > 110mmHg) and outcomes in severe TBI.

Methods. In this retrospective cohort study, adults who presented with isolated TBI and a MAP ≥ 70mmHg were assessed. Data were retrieved from our institutional trauma registry and the admission list of our neurosurgical intensive care unit (ICU).

Results. We enrolled 126 patients, 81 of whom had a MAP ≤ 110 mmHg after intubation and were assigned to group 1; 45 patients who had a MAP > 110 mmHg were assigned to group 2. Only age (P = 0.008), heart rate (HR; P = 0.036), and MAP before intubation (P < 0.001) were significantly different between groups. We found no significant intergroup differences in mortality (35.8 vs. 35.6%, P = 1.000) or in the motor function of survivors at discharge (P = 0.333). The length of ventilator-dependent (median: 2.0 vs. 5.0 days; P = 0.003) and ICU stays (median: 4.5 vs. 10.0 days; P = 0.005) were significantly longer in group 2. Post-intubation hypertension remained significantly associated with longer ICU stay (≥ 7 days) and poor neurologic outcome (motor < 4 at discharge) after adjusting for other variables (post-intubation MAP >110 mmHg, P < 0.034, OR 3.119, 95% CI 1.087-8.953).

Conclusion. Post-intubation hypertension was associated with longer ventilator-dependent and ICU stays in patients with severe TBI.

Key words: endotracheal intubation, hemodynamics, blood pressure, mean arterial pressure, intracranial hemorrhage.

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