Out-of-theatre tracheal intubation: prospective multicentre study of clinical practice and adverse events

Bowles, Teylor; Freshwater-Turner, D A; Janssen, Daphne J.; Peden, Carol J.

doi:10.1093/bja/aer251

Cited by 64 publications

(72 citation statements)

References 15 publications

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“…Furthermore, ETI was one of the most important independent predictors of mortality at multivariate analysis. The reasons of these findings are not completely clear but it could be hypothesized that an important role could be represented by the physiopathological changes induced by ETI itself, including hypotension, iatrogenic hypoxia and bradyarrhythmias [18][19][20][21][22] and by the major complications associated with it, like unrecognized oesophageal intubation, aspiration and pneumothorax [18,19,23]. In a series of 1954 patients received ETI, Wang and coll.…”

Section: Discussionmentioning

confidence: 99%

Endotracheal intubation and outcome in high-risk patients with acute myocardial infarction undergoing primary angioplasty

Tomassini¹,

Gagnor²,

Montali³

et al. 2014

J Anesthesiol Clin Sci

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Background: Patients with acute myocardial infarction (AMI) who undergo endotracheal intubation (ETI) are at high risk for mortality, but the outcome of those patients submitted to primary angioplasty (PCI) has not yet clearly reported. Methods:We collected data about all consecutive patients with AMI within 12 hours who underwent primary PCI and analyzed clinical and procedural characteristics as well as in-hospital mortality of ETI compared to no-ETI patients. Results: From September 2001 to June 2010, 1251 patients underwent primary PCI and 99 (7.9%) of them underwent ETI. ETI patients were more likely to be hypertensive (76.8% vs 67.8%, p=0.003), diabetic 43.4% vs 17.9%, p<0.0001), resuscitated by cardiac arrest (68.7% vs 0.7%, p<0.0001), to present with cardiogenic shock (CS) (61.6% % vs 8.1%, p<0.0001), with a lower left ventricular ejection fraction (LVEF) (38.9±9.4% vs 48.9±9.2%, p<0.0001) and to be treated with intra-aortic balloon counterpulsation (IABP) (60.1% vs 15.4%, p<0.0001). The in-hospital mortality was higher in ETI patients (37.4% vs 4.3%, p<0.0001) and they were more likely to undergo stent thrombosis (3% vs 0.34%, p=0.006). After using the propensity score modelling. Considering the risk profile, ETI was associated to higher in hospital mortality in the patients at higher risk (39.8% vs 18.5%, p=0.003). Moreover, ETI was one of the most powerful predictors of in-hospital mortality at multivariate analysis (OR 37.04, 95% CI 6.0-228.45, p=0.0001). Conclusions: ETI was found to be an independent predictor of mortality in high-risk AMI patients undergoing primary angioplasty. The implications for current clinical care remained undefined.

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Section: Discussionmentioning

confidence: 99%

Endotracheal intubation and outcome in high-risk patients with acute myocardial infarction undergoing primary angioplasty

Tomassini¹,

Gagnor²,

Montali³

et al. 2014

J Anesthesiol Clin Sci

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Section: Management and Protection Of The Airway Including Pulmonary mentioning

confidence: 99%

“…Reduced dose thiopental [79], propofol, midazolam plus opioid combinations are frequently used in the UK during RSI [15]. Propofol is the most common induction agent for out-of-theatre tracheal intubation in the UK [7]. Induction agent choice has not been related to outcome for patients undergoing RSI in the emergency department who are subsequently admitted to intensive care units, although the risks of developing hypotension and receiving a vasopressor at induction were greatest for propofol, and etomidate may have increased mortality before patient matching [80].…”

Section: Induction Of Anaesthesia and Pharmacologymentioning

confidence: 99%

“…It is emphasised that 25% of emergency airway management takes place outside operating theatres and since publication, several resources and recommendations have become available [4][5][6]. In the UK, out-of-theatre tracheal intubation frequently occurs in the absence of essential staff and equipment and capnography was not used in nearly a third of cases in a large observational study [7].Both difficult laryngoscopy and difficult tracheal intubation are more common in emergency patients, often outside the theatre setting [8,9]. One American study of non-theatre emergency tracheal intubation by experienced practitioners identified difficulties in over 10%, with over 4% suffering complications [10].…”

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confidence: 99%

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The principles and conduct of anaesthesia for emergency surgery

Gray

Morris

2012

Anaesthesia

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SummaryIn this second article we examine the principles underlying delivery of the components of anaesthesia. Topics considered include anaesthetic technique, management of the airway and lung ventilation, induction and maintenance of anaesthesia, patient monitoring including the place of cardiac output devices. We summarise recent research on the management of shock and sepsis syndromes including goal directed therapy and examine some controversies around intravenous fluid therapy. Finally, we discuss intra-operative awareness and challenges during emergence including perioperative cognitive dysfunction. Choice of anaesthetic techniqueOptimal anaesthetic technique is dependent upon an individualised assessment of patient and surgical requirements. Prospective, randomised, controlled trials of rival anaesthetic techniques, e.g. the GALA trial, are rare [1]. Emergency anaesthesia lacks this evidence base and extrapolations from meta-analyses typically fail to reach clear recommendations for clinicians [2]. The nature of surgery, patient co-morbidities, and urgency will frequently decide the anaesthetic choice but clinicians should remain mindful of the options of local or regional anaesthesia and sedation in appropriate patients, especially when a 'lesser' procedure becomes feasible e.g. percutaneous drainage. Management and protection of the airway including pulmonary aspirationThe fourth National Audit Project (NAP4) of the Royal College of Anaesthetists recorded the epidemiology and management of airway complications in UK practice and is essential reading [3]. It is emphasised that 25% of emergency airway management takes place outside operating theatres and since publication, several resources and recommendations have become available [4][5][6]. In the UK, out-of-theatre tracheal intubation frequently occurs in the absence of essential staff and equipment and capnography was not used in nearly a third of cases in a large observational study [7].Both difficult laryngoscopy and difficult tracheal intubation are more common in emergency patients, often outside the theatre setting [8,9]. One American study of non-theatre emergency tracheal intubation by experienced practitioners identified difficulties in over 10%, with over 4% suffering complications [10]. Predictors of complications included multiple attempts and poor views at laryngoscopy and intubation in a ward or emergency department setting. Human factors are increasingly recognised in airway complications and an unfamiliar environment during airway management is likely to be important [3].

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“…Verification of the ETT in mechanically ventilated patients is therefore important. [3][4][5][6][7][8] Different methods can be used to verify the placement of the ETT.…”

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confidence: 99%

Endotracheal tube verification in adult mechanically ventilated patients

2015

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Objective. To explore the methods that can be used to verify endotracheal tube (ETT) placement in adult mechanically ventilated patients.Methods. An integrative literature search was conducted in 2012 -2013 of research citations published in English on the topic of discussion. Electronic databases searched were: the Cumulative Index of Nursing and Allied Health (CINAHL), MEDLINE, PubMed, the Joanna Briggs Institute (JBI) systematic review library, the Cochrane Library and the National Guidelines Clearinghouse. In addition, reference lists of articles, conference summaries and hand searching was performed. Citations were selected based on the inclusion and exclusion criteria as decided upon by the researchers. The process of critical appraisal was done by the researchers as well as an independent reviewer, all skilled in the research methodology and subject matter related to the topic of discussion. A total of 45 articles were included for critical appraisal. On completion of the critical appraisal, which was done by two independent reviewers, 34 articles were excluded and 11 articles were included in the integrative review analyses. Data were extracted following the critical appraisal process. Owing to the heterogeneity of studies, a metasynthesis could not be done. Results. Based on the reviewed studies, various methods have been identified to verify ETT placement in adult mechanically ventilated patients, namely ultrasonography, the use of centimetre scale printed on the ETT, manual cuff palpation, bilateral auscultation of chest and palpation of symmetrical chest movements, oesophageal detector devices, visualisation of the ETT, use of chest X-ray, pulse oximetry and capnography. Both ultrasonography and capnography had excellent sensitivity and specificity in verifying ETT placement. Conclusion. Although there are various methods reported for ETT verification, the review results recommended ultrasonography and capnography as the most accurate and reliable verification methods.

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Out-of-theatre tracheal intubation: prospective multicentre study of clinical practice and adverse events

Abstract: Out-of-theatre intubation frequently occurs in the absence of essential safety equipment, despite the existing guidelines. The associated adverse event rate is high.

Cited by 64 publications

References 15 publications

Endotracheal intubation and outcome in high-risk patients with acute myocardial infarction undergoing primary angioplasty

Endotracheal intubation and outcome in high-risk patients with acute myocardial infarction undergoing primary angioplasty

The principles and conduct of anaesthesia for emergency surgery

Endotracheal tube verification in adult mechanically ventilated patients

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