Albert J. Varon

Prehospital Intubations and Mortality: A Level 1 Trauma Center Perspective

BACKGROUND: Ryder Trauma Center is a Level 1 trauma center with approximately 3800 emergency admissions per year. In this study, we sought to determine the incidence of failed prehospital intubations (PHI), its correlation with hospital mortality, and possible risk factors associated with PHI. METHODS: A prospective observational study was conducted evaluating trauma patients who had emergency prehospital airway management and were admitted during the period between August 2003 and June 2006. The PHI was considered a failure if the initial assessment determined improper placement of the endotracheal tube or if alternative airway management devices were used as a rescue measure after intubation was attempted. RESULTS: One-thousand-three-hundred-twenty patients had emergency airway interventions performed by an anesthesiologist upon arrival at the trauma center. Of those, 203 had been initially intubated in the field by emergency medical services personnel, with 74 of 203 (36%) surviving to discharge. When evaluating the success of the intubation, 63 of 203 (31%) met the criteria for failed PHI, all of them requiring intubation, with only 18 of 63 (29%) surviving to discharge. These patients had rescue airway management provided either via Combitube® (n = 28), Laryngeal Mask Airway® (n = 6), or a cricothyroidotomy (n = 4). An additional 25 of 63 patients (12%) had unrecognized esophageal intubations discovered upon the initial airway assessment performed on arrival. We found no difference in mortality between those patients who were properly intubated and those who were not. Several other variables, including age, gender, weight, mechanism of injury, presence of facial injuries, and emergency medical services were not correlated with an increased incidence of failed intubations. CONCLUSION: This prospective study showed a 31% incidence of failed PHI in a large metropolitan trauma center. We found no difference in mortality between patients who were properly intubated and those who were not, supporting the use of bag-valve-mask as an adequate method of airway management for critically ill trauma patients in whom intubation cannot be achieved promptly in the prehospital setting.

Clinical utility of a colorimetric end-tidal CO2 detector in cardiopulmonary resuscitation and emergency intubation

The purposes of this study were to evaluate the clinical utility of a colorimetric end-tidal CO2 (ETCO2) detector in confirming proper endotracheal intubation in patients requiring emergency intubation, to determine if this new device can be used as an adjunct to judge the effectiveness of cardiopulmonary resuscitation (CPR), and to determine whether the device can predict successful resuscitation from cardiopulmonary arrest. We studied prospectively 110 patients requiring emergency intubation for either respiratory distress (53 patients) or cardiopulmonary arrest (57 patients) by recording the color range of the indicator after the initial intubation. In patients who suffered a cardiopulmonary arrest, the color range was also recorded during CPR after the endotracheal tube was confirmed to be in the tracheal position and perfusion optimized, and at the moment CPR was stopped. The ETCO2 detector was 100% specific for correct endotracheal intubation in all patients. It was also highly sensitive (0.98) for correct endotracheal intubation in patients with respiratory distress. However, it was not sensitive (0.62) in patients with cardiopulmonary arrest and low perfusion. The sensitivity improved (0.88) when we used the ETCO2 range obtained after attempts to increase perfusion. A low ETCO2 color range in 19 patients undergoing CPR was interpreted as low cardiac output and prompted the physicians to attempt to increase perfusion. Of the patients who underwent CPR, no patient whose ETCO2 level remained less than 2% was successfully resuscitated. Those patients who had an ETCO2 level ≥2% had a significantly higher incidence of successful resuscitation. We conclude that the colorimetric ETCO2 detector is reliable and provides reassurance of correct endotracheal tube placement in patients requiring emergency intubation for respiratory distress. This device helps identify patients with low perfusion during CPR and is a useful prognostic indicator of successful short-term resuscitation.

Effects of arginine vasopressin during resuscitation from hemorrhagic hypotension after traumatic brain injury

Objective:Two series of experiments were designed to evaluate whether early arginine vasopressin improves acute outcome following resuscitation from traumatic brain injury and severe hemorrhagic hypotension Design:Prospective randomized, blinded animal study. Setting:University laboratory. Subjects:Thirty-three swine. Interventions:In series 1 (n = 19), after traumatic brain injury with hemorrhage and 12 mins of shock (mean arterial pressure ≈20 mm Hg), survivors (n = 16) were initially resuscitated with 10 mL/kg crystalloid. After 30 mins, crystalloid and blood with either 0.1 unit·kg−1·hr−1 arginine vasopressin or placebo was titrated to a mean arterial pressure target ≥60 mm Hg. After 90 mins, all received mannitol and the target was cerebral perfusion pressure ≥60 mm Hg. To test cerebrovascular function, 7.5% inhaled CO2 was administered periodically. In series 2 (n = 14), the identical protocol was followed except the shock period was 20 mins and survivors (n = 10) received a bolus of either arginine vasopressin (0.2 units/kg) or placebo during the initial fluid resuscitation. Measurements and Main Results:In series 1, by 300 mins after traumatic brain injury with arginine vasopressin (n = 8) vs. placebo (n = 8), the fluid and transfusion requirements were reduced (both p < .01), intracranial pressure was improved (11 ± 1 vs. 23 ± 2 mmHg; p < .0001), and the CO2-evoked intracranial pressure elevation was reduced (7 ± 2 vs. 26 ± 3 mm Hg, p < .001), suggesting improved compliance. In series 2, with arginine vasopressin vs. placebo, cerebral perfusion pressure was more rapidly corrected (p < .05). With arginine vasopressin, five of five animals survived 300 mins, whereas three of five placebo animals died. The survival time with placebo was 54 ± 4 mins (p < .05 vs. arginine vasopressin). Conclusions:Early supplemental arginine vasopressin rapidly corrected cerebral perfusion pressure, improved cerebrovascular compliance, and prevented circulatory collapse during fluid resuscitation of hemorrhagic shock after traumatic brain injury.

Emotional intelligence and the relationship to resident performance: a multi-institutional study.

STUDY OBJECTIVE To test the hypothesis that emotional intelligence, as measured by a BarOn Emotional Quotient Inventory (EQ-i), the 125-item version personal inventory (EQ-i:125), correlates with resident performance. DESIGN Survey (personal inventory) instrument. SETTING Five U.S. academic anesthesiology residency programs. PARTICIPANTS Postgraduate year (PGY) 2, 3, and 4 residents enrolled in university-based anesthesiology residency programs. MEASUREMENTS Residents confidentially completed the BarOn EQ-i:125 personal inventory. The deidentified resident evaluations were sent to the principal investigator of a separate data collection study for data analysis. Data collected from the inventory were correlated with daily evaluations of the residents by residency program faculty. Results of the individual BarOn EQ-i:125 and daily faculty evaluations of the residents were compiled and analyzed. MAIN RESULTS Univariate correlation analysis and multivariate canonical analysis showed that some aspects of the BarOn EQ-i:125 were significantly correlated with, and likely to be predictors of, resident performance. CONCLUSIONS Emotional intelligence, as measured by the BarOn EQ-i personal inventory, has considerable promise as an independent indicator of performance as an anesthesiology resident.

Pain management for blunt thoracic trauma: A joint practice management guideline from the Eastern Association for the Surgery of Trauma and Trauma Anesthesiology Society

INTRODUCTION Thoracic trauma is the second most prevalent nonintentional injury in the United States and is associated with significant morbidity. Analgesia for blunt thoracic trauma was first addressed by the Eastern Association for the Surgery of Trauma (EAST) with a practice management guideline published in 2005. Since that time, it was hypothesized that there have been advances in the analgesic management for blunt thoracic trauma. As a result, updated guidelines for this topic using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) framework recently adopted by EAST are presented. METHODS Five systematic reviews were conducted using multiple databases. The search retrieved articles regarding analgesia for blunt thoracic trauma from January1967 to August 2015. Critical outcomes of interest were analgesia, postoperative pulmonary complications, changes in pulmonary function tests, need for endotracheal intubation, and mortality. Important outcomes of interest examined included hospital and intensive care unit length of stay. RESULTS Seventy articles were identified. Of these, 28 articles were selected to construct the guidelines. The overall risk of bias for all studies was high. The majority of included studies examined epidural analgesia. Epidural analgesia was associated with lower short-term pain scores in most studies, but the quality and quantity of evidence were very low, and no firm evidence of benefit or harm was found when this modality was compared with other analgesic interventions. The quality of evidence for paravertebral block, intrapleural analgesia, multimodal analgesia, and intercostal nerve blocks was very low as assessed by GRADE. The limitations with the available literature precluded the formulation of strong recommendations by our panel. CONCLUSION We propose two evidence-based recommendations regarding analgesia for patients with blunt thoracic trauma. The overall risk of bias for all studies was high. The limitations with the available literature precluded the formulation of strong recommendations by our panel. We conditionally recommend epidural analgesia and multimodal analgesia as options for patients with blunt thoracic trauma, but the overall quality of evidence supporting these modalities is low in trauma patients. These recommendations are based on very low-quality evidence but place a high value on patient preferences for analgesia. These recommendations are in contradistinction to the previously published Practice Management Guideline published by EAST.

A New Paradigm for the Design of Audible Alarms that Convey Urgency Information

ObjectiveThe current international standard (IEC 60601-1-8) stipulates that medical device audible alarms should be priority-encoded and validated for efficacy. Evidence suggests that the melodic alarms described in the standard are not functioning as originally intended. We present a multi-disciplinary, human factors paradigm for audible alarm development whereby urgency information is encoded via modulation of the physical characteristics of sounds. We also test the feasibility of this approach using information measures.MethodsWe designed series of experimental sounds that varied along controlled physical and acoustical dimensions. Subjects rated these sound series for perceived urgency. Based on these ratings, selected sounds from each series were assigned a␣priority category from ‹low’ to ‹high’ – we call these resulting sets of sounds ‹urgency-codecs’. The method of categorical judgments (based on information theory) was used to compare each urgency-codec for ability to convey urgency information.ResultsSubjects were consistent in their ratings of the three series of experimental sounds for perceived urgency. The urgency data pertaining to one of the series (harmonic interval) was successfully fit to a psychophysical empirical law. The urgency-codec derived from another sound series (melodic interval) was found to have the highest signal (correct interpretation of urgency level by subjects) transmission rate.ConclusionsThe proposed paradigm is feasible, and it offers an evidence-based strategy for alarm sound design and testing. This approach would be performed before implementation of new alarm sounds in clinical settings, and should result in development of alarm sounds that satisfy the requirements of priority-encoding and validation.

Review article: update in trauma anesthesiology: perioperative resuscitation management.

The management of trauma patients has matured significantly since a systematic approach to trauma care was introduced nearly a half century ago. The resuscitation continuum emphasizes the effect that initial therapy has on the outcome of the trauma patient. The initiation of this continuum begins with prompt field medical care and efficient transportation to designated trauma centers, where lifesaving procedures are immediately undertaken. Resuscitation with packed red blood cells and plasma, in parallel with surgical or interventional radiologic source control of bleeding, are the cornerstones of trauma management. Adjunctive pharmacologic therapy can assist with resuscitation. Tranexamic acid is used in Europe with good results, but the drug is slowly being added to the pharmacy formulary of trauma centers in United States. Recombinant factor VIIa can correct abnormal coagulation values, but its outcome benefit is less clear. Vasopressin shows promise in animal studies and case reports, but has not been subjected to a large clinical trial. The concept of “early goal-directed therapy” used in sepsis may be applicable in trauma as well. An early, appropriately aggressive resuscitation with blood products, as well as adjunctive pharmacologic therapy, may attenuate the systemic inflammatory response of trauma. Future investigations will need to determine whether this approach offers a similar survival benefit.

What is new in the blood bank for trauma resuscitation

Purpose of review The aim of the present review was to describe recent changes in blood banking thinking, practice, and products that affect trauma care. Recent findings Prompt balanced hemostatic resuscitation of major hemorrhage from trauma improves outcome and reduces blood use. New blood processes and products can help deliver appropriate doses of procoagulant plasma and platelets quicker and more safely. New processes include holding larger inventories of thawed plasma with risk of wastage and rapid plasma thawers. New products in the blood bank include group A or group A low-titer B thawed plasma and AB or A liquid (never-frozen) plasma for resuscitation, prepooled cultured whole blood–derived platelets in plasma, and prepooled cryoprecipitate in varying pool sizes. Single-donor apheresis or pooled whole blood–derived platelets in additive solution, designed to reduce plasma-related transfusion reactions, are also increasingly available but are not an appropriate blood component for hemorrhage control resuscitation because they reduce the total amount of administered plasma coagulation factors by 10%. Summary Early initiation of balanced massive transfusion protocols leading to hemostatic resuscitation is lifesaving. Changing blood product availability and composition will lead to higher complexity of massive transfusion. It is critical that anesthesiologists understand the composition of the available new blood products to use them correctly. Video abstract http://links.lww.com/COAN/A38

Preoperative intensive care unit consultations : accurate and effective

ObjectivesTo determine if a structured preoperative ICU consultation would correctly assign patients to preoperative invasive monitoring, postoperative ICU care, or recovery room care, and to compare morbidity, mortality, and resource utilization among all groups. DesignProspective, observational study. SettingA university hospital. PatientsA total of 475 patients who were referred preoperatively by surgeons for ICU consultation and were evaluated by ICU physicians. InterventionsPatients assessed to have clinical evidence of cardiovascular compromise were admitted preoperatively to the ICU for invasive hemodynamic monitoring and optimization. Patients without such evidence, but who were to undergo major operations or had anticipated major fluid replacement were independently selected for invasive monitoring by anesthesiologists. Patients who developed physiologic instability or became unstable due to hemorrhage also underwent invasive monitoring. Nonmoni-tored patients who remained stable were given postoperative ICU care or went to the recovery room based on an assessment by the surgeon and anesthesiologist at the end of the operation. Measurements and Main ResultsOf 8,916 elective surgical cases, ICU physicians were consulted in 475 (5.3%) patients preoperatively. Sixty-seven patients were admitted preoperatively to the ICU for invasive hemodynamic monitoring and optimization; 60 patients had surgery (0.7% of elective cases, 12.6% of ICU consultations). Patients selected for ICU preoperative monitoring were older than non-monitored patients and had higher numbers of cardiovascular and total risk factors than any other group. They had higher Acute Physiology and Chronic Health Evaluation (APACHE II) scores, higher Therapeutic Intervention Scoring System (TISS) points, a higher number of complications, and longer ICU stays than non-monitored postoperative ICU patients. In addition, they had a higher number of complications than nonmonitored recovery room patients. APACHE II scores, TISS points, number of complications, and ICU days in the preoperative ICU admission group were not increased when compared with all other monitored patients. Neither hospital days nor total hospital charges were increased when compared with the other elective ICU patients. Patients selected for ICU preoperative monitoring who underwent surgery had an 11.7% mortality rate and accounted for four of five cardiovascular-related deaths. ConclusionsA small number of high-risk patients can be selected for preoperative monitoring on the basis of clinical assessment without increasing ICU stay or hospital bills. A structured preoperative consultation correctly identifies those patients who need monitoring and ICU care, but does not overutilize scarce and expensive ICU beds. (Crit Care Med 1993; 21:234–239)

Use of a warming catheter to achieve normothermia in large burns

Maintaining burn patients’ body temperature during surgery is a significant challenge. Although increasing the ambient operating room (OR) temperature and other passive rewarming methods help, such measures have limited effectiveness and prove taxing on OR personnel. Initial studies indicate that an intravascular warming catheter may improve and sustain burn patient body temperatures. The authors hypothesize that the warming catheter is similarly effective at maintaining normothermia despite a lower OR temperature than in a cohort of matched control burn patients. This is a retrospective case-control study involving patients with major burns treated between January 2006 and June 2011. Cases received an intravascular warming catheter, whereas controls receive traditional temperature conserving interventions. As the catheters maintained body temperature, the room temperature was gradually lowered to normal. Twenty-three patients were involved in 31 cases using the catheter, compared with 39 controls in 62 surgeries. The mean temperature deviation for each catheter group was −0.76 ± 1°C and −0.80 ± 0.9°C for the control group. Given 20-minute intervals throughout the operations, the mean patient temperature for cases and controls never deviated by more than 1°C. OR staff satisfaction has improved with decreased room temperatures. An intravenous warming catheter reliably maintained patient core body temperature during surgery. To date, this is the largest cohort study of such a catheter among burn patients. This system may be more effective than current warming techniques, with the potential to decrease the total number of procedures and the time to complete wound closure.