Bhupinder Natt

Video Laryngoscopy Improves Odds of First-Attempt Success at Intubation in the Intensive Care Unit. A Propensity-matched Analysis

RATIONALE Urgent tracheal intubation is performed frequently in intensive care units and incurs higher risk than when intubation is performed under more controlled circumstances. Video laryngoscopy may improve the chances of successful tracheal intubation on the first attempt; however, existing comparative data on outcomes are limited. OBJECTIVES To compare first-attempt success and complication rates during intubation when using video laryngoscopy compared with traditional direct laryngoscopy in a tertiary academic medical intensive care unit. METHODS We prospectively collected and analyzed data from a continuous quality improvement database of all intubations in one medical intensive care unit between January 1, 2012, and December 31, 2014. Propensity matching and multivariable logistic regression were used to reduce the risk of bias and control for confounding. MEASUREMENTS AND MAIN RESULTS A total of 809 intubations took place over the study period. Of these, 673 (83.2%) were performed using video laryngoscopy and 136 (16.8%) using direct laryngoscopy. First-attempt success with video laryngoscopy was 80.4% (95% confidence interval [CI], 77.2-83.3%) compared with 65.4% (95% CI, 56.8-73.4%) for intubations performed with direct laryngoscopy (P < 0.001). In a propensity-matched analysis, the odds ratio for first-attempt success with video laryngoscopy versus direct laryngoscopy was 2.81 (95% CI, 2.27-3.59). The rate of arterial oxygen desaturation events during the first intubation attempt was significantly lower for video laryngoscopy than for direct laryngoscopy (18.3% vs. 25.9%; P = 0.04). The rate of esophageal intubation during any attempt was also significantly lower for video laryngoscopy (2.1% vs. 6.6%; P = 0.008). CONCLUSIONS Video laryngoscopy was associated with significantly improved odds of first-attempt success at tracheal intubation by nonanesthesiologists in a medical intensive care unit. Esophageal intubation and oxygen desaturation occurred less frequently with the use of video laryngoscopy. Randomized clinical trials are needed to confirm these findings.

The Impact of a Comprehensive Airway Management Training Program for Pulmonary and Critical Care Medicine Fellows. A Three-Year Experience

RATIONALE Airway management in the intensive care unit (ICU) is challenging, as many patients have limited physiologic reserve and are at risk for clinical deterioration if the airway is not quickly secured. In academic medical centers, ICU intubations are often performed by trainees, making airway management education paramount for pulmonary and critical care trainees. OBJECTIVES To improve airway management education for our trainees, we developed a comprehensive training program including an 11-month simulation-based curriculum. The curriculum emphasizes recognition of and preparation for potentially difficult intubations and procedural skills to maximize patient safety and increase the likelihood of first-attempt success. METHODS Training is provided in small group sessions twice monthly using a high-fidelity simulation program under the guidance of a core group of two to three advanced providers. The curriculum is designed with progressively more difficult scenarios requiring critical planning and execution of airway management by the trainees. Trainees consider patient position, preoxygenation, optimization of hemodynamics, choice of induction agents, selection of appropriate devices for the scenario, anticipation of difficulties, back-up plans, and immediate postintubation management. Clinical performance is monitored through a continuous quality improvement program. MEASUREMENTS AND MAIN RESULTS Sixteen fellows have completed the program since July 1, 2013. In the 18 months since the start of the curriculum (July 1, 2013-December 31, 2014), first-attempt success has improved from 74% (358/487) to 82% (305/374) compared with the 18 months before implementation (P = 0.006). During that time there were no serious complications related to airway management. Desaturation rates decreased from 26 to 17% (P = 0.002). Other complication rates are low, including aspiration (2.1%), esophageal intubation (2.7%), dental trauma (0.8%), and hypotension (8.3%). First-attempt success in a 6-month period after implementation (July 1, 2014-December 31, 2014) was significantly higher (82.1 compared with 70.9%, P = 0.03) than during a similar 6-month period before implementation (July 1, 2012-December 31, 2012). CONCLUSIONS This comprehensive airway curriculum is associated with improved first-attempt success rate for intensive care unit intubations. Such a curriculum holds the potential to improve patient care.

Decreased In-Hospital Mortality after Lobectomy Using Video-assisted Thoracoscopic Surgery Compared with Open Thoracotomy

Rationale: There is a paucity of data regarding the optimal surgical approach for lung lobectomy. Lobectomy performed by video‐assisted thoracoscopic surgery (VATS) has been associated with lower morbidity as compared with lobectomy performed by thoracotomy. However, no multicenter studies have shown improved mortality with VATS lobectomy compared with open surgical lobectomy. Objectives: We used data from the United States Healthcare Cost and Utilization Project Nationwide Inpatient Sample database from 2009 to 2012 to compare VATS with open lobectomy for in‐hospital mortality and other short‐term outcomes. Methods: We used International Classification of Diseases, Ninth Revision, Clinical Modification procedure codes to identify the patients undergoing lobectomy. We used 1:1 ratio propensity matching with the nearest neighbor method without replacement to generate matched pairs. Measurements and Main Results: Over the 4‐year period, 27,451 patients underwent lobectomy. The majority of these procedures were performed by thoracotomy (65%) as compared with VATS (35%). A total of 9,393 matched pairs were created. VATS lobectomy was associated with significantly lower in‐hospital mortality when compared with thoracotomy (1.3% vs. 2.5%, P < 0.001). A shorter length of hospital stay was observed for those undergoing VATS lobectomy (6.21 vs. 8.75 d, P < 0.001). The overall rate of perioperative complications was low, with those undergoing VATS being less likely to have any perioperative morbidity. Conclusions: In recent years, the use of VATS for lobectomy has increased relative to thoracotomy. This trend has coincided with increased survival and shorter length of stay for VATS lobectomy compared with thoracotomy. Further studies are needed to identify comorbidities that identify ideal candidates for VATS lobectomy.

The Lost Art of the History and Physical

The important contribution of the history and physical in making a correct medical diagnosis has been known for centuries. Despite this, these skills are being undermined by technology that many physicians mistakenly believe to be the new gold standard. The authors report 2 cases in which the history and physical trumped technology in making the correct diagnosis. Medical educators need to reemphasize the importance of the history and physical. This will require changes in curriculum and intense faculty development.

Pulmonary Embolism with Right Ventricular Dysfunction: Who Should Receive Thrombolytic Agents?

BACKGROUND Appropriate management of pulmonary embolism patients with right ventricular dysfunction is uncertain. Recent guidelines have stressed the need for more data on the use of thrombolytic agents in the stable pulmonary embolism patient with right ventricular dysfunction. The objective of this study is to investigate the hypothesis that thrombolytic therapy in hemodynamically stable pulmonary embolism patients with right ventricular dysfunction is not associated with improved mortality. METHODS We did a retrospective analysis using multi-institutional observational data from the Nationwide Inpatient Sample database. International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes were used to identify the patients with pulmonary embolism and right ventricular dysfunction. In-hospital mortality was defined as the primary outcome of interest. RESULTS Over the 4 years of the study period, 3668 patients with right ventricular dysfunction and pulmonary embolism were found, of which 3253 patients were identified as having hemodynamically stable right-sided heart failure with pulmonary embolism. There was no significant difference in mortality between hemodynamically stable pulmonary embolism patients with right ventricular dysfunction who received thrombolytic agents compared with those who did not. When outcomes were assessed for patients with right ventricular dysfunction and hemodynamic instability, a significant improvement in mortality was noted for patients with right ventricular dysfunction who received thrombolytic agents, which confirmed previous reports that thrombolytic therapy decreases mortality in pulmonary embolism patients who are hemodynamically unstable. CONCLUSION Our data support the use of less aggressive treatment for stable pulmonary embolism patients with right ventricular dysfunction. These results argue against the reflexive use of thrombolytic agents in stable pulmonary embolism patients with right ventricular dysfunction.

Extracorporeal Membrane Oxygenation for ARDS: National Trends in the United States 2008–2012

INTRODUCTION: Recent advances in technology and protocols have made the use of extracorporeal membrane oxygenation (ECMO) a viable rescue therapy for patients with ARDS who present with refractory hypoxemia. Despite the lack of strong evidence supporting the use of ECMO in ARDS, its use seems to be increasing. We sought to determine recent trends in the use of ECMO for ARDS. We also assessed trends in mortality among patients with ARDS in whom ECMO was used. METHODS: We performed a retrospective analysis using the largest all-payer in-patient healthcare database in the United States, the Healthcare Cost and Utilization project, the National In-patient Sample database from 2008 to 2012. Subjects with ARDS were identified using carefully chosen International Classification of Diseases, Ninth Revision codes. RESULTS: We found that in 2008, about 1 in 1,000 subjects with ARDS underwent ECMO. Over the subsequent 4-y time period, there was a 0.19% absolute increase and 70% relative increase in the use of ECMO for ARDS. The mortality rate among subjects with ARDS in whom ECMO was used declined from 78% in 2008 to 64% in 2012. We also found a trend toward a reduction in hospital stay among survivors. CONCLUSION: In the United States, between 2008 and 2012, there was an increasing trend toward the use of ECMO in patients with ARDS that coincided with a slight increase in survival among these patients.

Airway registry and training curriculum improve intubation outcomes in the intensive care unit

Background: Intubation in critically ill patients remains a highly morbid procedure, and the optimal approach is unclear. We sought to improve the safety of intubation by implementing a simulation curriculum and monitoring performance with an airway registry. Methods and Methods: This is a prospective, single-center observational study of all intubations performed by the medical intensive care unit (ICU) team over a five-year period. All fellows take part in a simulation curriculum to improve airway management performance and minimize complications. An airway registry form is completed immediately after each intubation to capture relevant patient, operator, and procedural data. Results: Over a five-year period, the medical ICU team performed 1411 intubations. From Year 1 to Year 5, there were significant increases in first-attempt success (72.6 vs. 88.0%, p<0.001), use of video laryngoscopy (72.3 vs. 93.5%, p<0.001), and use of neuromuscular blocking agents (73.5 vs. 88.4%, p<0.001). There were concurrent decreases in rates of desaturation (25.6 vs. 17.1%, p=0.01) and esophageal intubations (5 vs. 1%, p=0.009). Low rates of hypotension (8.3%) and cardiac arrest (0.6%) were also observed. Conclusions: The safety of intubation in critically ill patients can be markedly improved through joint implementation of an airway registry and simulation curriculum.

1061: DURATION OF MECHANICAL VENTILATION AND PATIENT OUTCOMES FOR EXTRACORPOREAL MEMBRANE OXYGENATION

www.ccmjournal.org Critical Care Medicine • Volume 46 • Number 1 (Supplement) Learning Objectives: For patients with severe acute respiratory distress syndrome (ARDS), venovenous extracorporeal membrane oxygenation (VV-ECMO) is sometimes used to support oxygenation and allow time for lung rest. However, duration of pre-ECMO mechanical ventilation has been associated with increased mortality for patients who receive VV-ECMO and as such, prolonged mechanical ventilation has been suggested as a relative contraindication for VV-ECMO support. This study was conducted to examine the relationship between duration of preECMO mechanical ventilation and mortality for patients who received VV-ECMO therapy for ARDS. Methods: A retrospective, observational study of adult patients admitted to the ICU at an academic medical center for VV-ECMO between January 01, 2015 and July 1, 2017. Demographics, comorbidities, lab values and ventilator settings were extracted from the medical record along with outcomes such as length of stay and in-hospital mortality. Patients cannulated for ECMO more than 7 days after the initiation of mechanical ventilation were classified as the late initiation group. Results: A total of 23 patients were treated with VV-ECMO therapy during the study period. Of these, eight underwent late initiation (median ventilator days 14.5 days, IQR 10–20.5), and 15 were early initiation (median 2.0 days, IQR 0–4.0, p < 0.01). There was no difference between groups in survival to discharge (50% vs 67%, p = 0.66) however cases in which ECMO was initiated later were associated with longer duration of ECMO (median 40.5 (IQR 15.5–55.5) vs 9 days (IQR 4.012.0), p < 0.01), total duration of mechanical ventilation (median 58.5 (IQR 53.5–72.0) vs 20 days (IQR 6.0–27.0), p < 0.01), and hospital length of stay (61.5 (IQR 55.0–74.5) vs 35 days (IQR 30.0-46.0), p < 0.01). Conclusions: These data suggest that late initiation of VV-ECMO for ARDS is associated with longer duration of recovery but a similar mortality as patients initiated early. Thus the relative contraindication should be reconsidered, and a prospective study is needed to delineate which patients stand to benefit from VVECMO therapy for ARDS.

1097: EVALUATION OF THE RESP SCORE FOR SURVIVAL PREDICTION IN VENOVENOUS ECMO

www.ccmjournal.org Critical Care Medicine • Volume 46 • Number 1 (Supplement) Learning Objectives: Checklists are simple and effective measures with the potential to reduce errors having a cumulative effect amid dynamic medical environment. However, adoption of checklist in hospital settings is sub-optimal. Various factors like perceived workload and effectiveness contribute to poor compliance. The objective of this study was to identify the effect of a pager alert to the provider on checklist use and compliance. Methods: Single center, retrospective observational study of providers’ use of checklist in a mixed ICU in an academic tertiary care center in Rochester over a period of 8 months. Providers were encouraged to complete a daily rounding checklist for all patients in the ICU using a dashboard accessible on all PCs. In order to enhance compliance, a pager alert was sent to providers for patients identified as high risk using an algorithm calculating prediction scores(APPROVE) for prolonged respiratory failure or death. We compared the checklist compliance rates pre and postimplementation of the pager alert. Results: The unit had a total of 1806 cases during the period (927 pre/879 post.) of which 1114 (492 pre/622 post.) checklists were completed. 45% (419/927) and 33% (288/879) cases during the pre and post period were identified as high risk. The unit compliance changed from 53% (492/927) to 71% (622/879) (p < 0.001). Checklist completion for high risk pool changed from 25% (104/419) to 78% (222/288)(p < 0.001) after the intervention. Checklist compliance for low risk decreased from 76% (388/508) to 68% (400/591)(p = 0.001) Conclusions: A pager alert system introduction was associated with improved checklist completion for high risk patients admitted to the ICU while the checklist compliance for low risk patients decreased. Though simple by design, completion of a checklist is hindered primarily by time restriction during patient care. Sending a pager alert reminder to the providers for high risk cases can be a useful method to help providers identify the cases and use a checklist to improve outcomes.

Medical image of the week: purpura fulminans

A 54-year-old man with coronary artery disease, fibromyalgia and chronic sacral ulcers was brought to the emergency department due to acute changes in mentation and hypotension. He suffered a cardiac arrest shortly after arrival to the emergency department during emergent airway management. After successful resuscitation, he was admitted to the medical intensive care unit and treated for septic shock with fluid resuscitation, vasopressors and broad spectrum antibiotics. Laboratory results were significant for disseminated intravascular coagulopathy (DIC)thrombocytopenia, decreased fibrinogen and elevated PT, PTT and D-dimer levels. Profound metabolic acidosis and lactate elevation was also seen. Blood Cultures later revealed a multi-drug resistant E. coli bacteremia. Images of the lower extremities (Figure 1) were obtained at initial assessment and are consistent with purpura fulminans. He did not survive the stay.