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Signa Vitae

Journal of Intensive Care and Emergency Medicine

Tag: intubation (Page 1 of 2)

Validation of tracheal intubation of wire-reinforced endotracheal tube with ultrasonography


Objective. The use of ultrasonography (US) is a new method for verifying the location of the endotracheal tube.

Design. Our study was designed as a paired-data and investigator-blind clinical study for evaluating the effectiveness of US for verification of wire-reinforced endotracheal tube (WR-ETT) placement compared with capnography.

Setting. This study was conducted on 56 patients scheduled for elective surgery under general anesthesia.

Patients. Fifty patients completed the study as 6 were excluded for various reasons.

Intervention. Two different investigators performed the ultrasonography and intubation independently from one another. While investigator 1 attempted to verify the location of the WR-ETT with a portable ultrasonography with sagittal trans-tracheal view, investigator 2 intubated the patient and verified the location of the ETT using capnography.

Measurements. Time for verifying the location of the ETT using both US and capnography was recorded.

Main Results. When the ultrasonography method was compared with capnography for verification of the WR-ETT placement, the results showed 95.75% sensitivity and 100% specificity. The average verification times for endotracheal intubation were 12.78 ± 7.46 s. and 24.44 ± 1.45 s. with US and capnography, respectively (p=0.003).

Conclusion. Our results suggest that ultrasound identification of a WR-ETT within the trachea is a rapid and accurate method for confirmation of tracheal placement. Larger studies are needed before widespread use of this technique.

Key words: endotracheal tube, intubation, ultrasonography, capnography

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Ketamine use for endotracheal intubation in severe sepsis and septic shock


Objective. We conducted this study to evaluate the clinical outcomes of patients with severe sepsis and septic shock who were treated with ketamine for endotracheal intubation.

Methods. A single-center, retrospective study was carried out to compare the outcomes of patients with severe sepsis and septic shock who received a ketamine or non-ketamine agent for rapid sequence intubation (RSI). We analyzed the sepsis registry for adult patients who presented to the emergency department (ED), met the criteria for severe sepsis or septic shock, and underwent endotracheal intubation between August 2008 and March 2014. The primary outcome was 28-day mortality. We performed a multivariable logistic regression analysis to assess the association between ketamine use for intubation and 28-day mortality.

Results. In all, 170 patients were intubated during the study period. Of the eligible patients, 95 received ketamine and 75 received a non-ketamine agent. The 28-day mortality of the ketamine group was not significantly different from that of the non-ketamine group (38% vs. 40%, respectively, P=0.78). The unadjusted odds ratio (OR) of ketamine use for 28-day mortality was 0.92 (95% CI: 0.49–1.70, P=0.78). The association remained insignificant after adjusting for age, gender, malignancy, initial lactate level on ED admission, time to first antibiotic administration, Acute Physiology and Chronic Health Evaluation II score on admission day, and propensity score regarding ketamine use (adjusted OR: 1.09; 95% confidence interval [CI]: 0.49–2.40; P=0.84). Initial serum lactate on ED admission was the only significant predictive factor of 28-day mortality (adjusted OR: 1.23; 95% CI: 1.10–1.38; P<0.01).

Conclusions. For patients with severe sepsis and septic shock who were intubated using RSI, we found no significant difference in 28-day mortality between those who received ketamine as a sedative agent and those who received alternative sedatives.

Key words: sepsis, ketamine, intubation, mortality

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Microbial colonization of the lower airways after insertion of a cuffed endotracheal tube in pediatric patient


Background. Ventilator-associated pneumonia (VAP) still remains a common device-associated hospital acquired infection in pediatric and adult intensive care units. The aim of our study was to determine ways of microbial transmission to the lower airways in intubated patients admitted to a single tertiary-care pediatric intensive care unit.

Methods. This was a prospective observational study. A total of 284 sample sets (oropharyngeal swabs, swabs from the lumen of the proximal tip of an endotracheal tube, and bronchoalveolar lavage samples) were collected from 62 consecutive pediatric patients intubated for > 24 hours. Pulsed-field gel electrophoresis was performed on all isolated pathogens, which were later identified by MALDI biotyper (MALDI-TOF mass spectrometry).

Results. Overall colonization rates were high and did not differ significantly at different time points in the oropharynx (75%–100%) and the lower airways (50%–76.5%). The endotracheal tube was colonized at lower rates: on day 1–3 (28.8%), on day 4–6 (52.7%), on day 7–9 (61.8%) and on day 10-12 (52.9%) (P < 0.001). A total of 191 matched sample sets from the lower airways and at least one site above were collected from 46 (74.2%) patients. In the oropharynx-lower airways group, Candida spp. (76.9%) and upper airway bacteria (63.2%); in the endotracheal tube-lower airway group, S. aureus (15.7%) and upper airway bacteria (21.1%); in the oropharynx-endotracheal tube-lower airway group, Enterobacteriaceae (70.8%) prevailed (P < 0.001). The mean survival (entrance) time to lower airways for the Acinetobacter/Pseudomonas/Stenotrophomonas group was 8.28 ± 0.81 days; for the Enterobacteriaceae group, 5.63 ± 0.41; and for Candida spp. group, 3.00 ± 0.82 days (P < 0.005).

Conclusions. Oropharyngeal contamination of the lower airways is the most important route of colonization. Different pathogens enter the lower airways at different time intervals from the insertion of an endotracheal tube.

Key words: colonization, airway, intubation, mechanical ventilation, bronchoalveolar lavage, ventilator-associated pneumonia

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Impact of prehospital rapid sequence intubation and mechanical ventilation on prehospital vital signs and outcome in trauma patients


Introduction. Medications during rapid sequence intubation (RSI) have known detrimental side effects. Prehospital mechanical ventilation after successful endotracheal intubation also increases mortality due to hyperventilation and positive pressure ventilation. The aim of this retrospective analysis was to determine the impact of RSI on prehospital hemodynamic parameters and prehospital ventilation status on mortality rate and functional outcome in trauma patients.

Methods. Charts of 73 trauma patients, who underwent prehospital RSI over a 12-year period, were retrospectively reviewed. Prehospital vital signs, before and after RSI, were compared. Patients were divided, according to ventilation status, into three groups based on initial PaCO2: hypocarbic/hyperventilated (PaCO2<35mmHg), normocarbic/normoventilated (PaCO2 35-45 mmHg) and hypercarbic/hypoventilated (PaCO2>45mmHg).

Results. Seventy-three patients were enrolled in the retrospective analysis. There was a significant difference in respiratory rate (p=0.046), arterial oxygen saturation (p<0.001), mean arterial pressure (p<0.001) and Glasgow Coma Scale (GCS) (p<0.001) before and after RSI. GCS at discharge (p=0.003) and arterial oxygen saturation (p=0.05) were significantly higher in the normoventilated group. There was no significant difference in survival to hospital discharge among compared groups.

Conclusion. Our retrospective analysis suggests that prehospital RSI has no detrimental hemodynamic side effects and that normoventilation leads to a favorable neurological outcome.

Key words: intubation, prehospital, mechanical ventilation, trauma, hemodynamics

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A comparison of the effectiveness of intubation using a McGrath Series 5 videolaryngoscope with either a Truflex articulating stylet or a standard intubation stylet in a group of medical students


Background. Intubation is the optimal method for opening the airway and effective ventilation of the patient. However, there are occasional problems with intubation, especially in patients with injuries under pre-hospital conditions. Therefore, it is important to identify devices, e.g., videolaryngoscopes or guides, which may facilitate and shorten the procedure. This study addresses the use of a Truflex articulated guide with a videolaryngoscope.

Objectives. The main objective of the study is to evaluate the effectiveness of intubation using a Truflex articulating stylet with a McGrath videolaryngoscope, and to determine whether the average time of intubation using a Truflex articulating stylet is shorter than that using a standard intubation stylet.

Materials and methods. The study involved 43 full-time 5th year medical students. All tests were performed on training manikins with a difficult airway in January 2013. Chi-square test was used for statistical analysis with a significance level of p < 0.01. Calculations were performed using the Statistica package.

Results. Intubation using a McGrath videolaryngoscope with a Truflex articulating stylet was more effective than that using a standard intubation stylet with the same laryngoscope: 71% as compared to 40%. The mean time of successful intubation using a Truflex articulating stylet was shorter than that using a standard intubation stylet guide (31.1 ± 12.8 s and 39.8 ± 12.4 s, respectively).

Conclusions. The mean time of tracheal intubation using a Truflex articulating stylet is shorter than that using a standard intubation stylet. Intubation is also more effective when a Truflex articulating stylet is used together with a McGrath videolaryngoscope.

Key words: Truflex articulating stylet, Truflex, intubation, McGrath

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