David C. Ray

Case series: The McGrath® videolaryngoscope — an initial clinical evaluation

PurposeTo document tracheal intubation success rates and airway instrumentation times using the newly designed McGrath® videolaryngoscope.MethodsWe prospectively recorded factors associated with difficult tracheal intubation, factors causing actual difficulty in tracheal intubation, as well as complications arising from use of the new McGrath® videolaryngoscope in a series of adult patients with normal preoperative airway examinations. All patients were undergoing scheduled or elective surgery. In the first 75 patients (phase I), experience with airway instrumentation was documented, while in the second 75 patients (phase II), the time required to obtain an optimal view of the larynx was recorded, as well as the time to complete tracheal intubation.ResultsNinety-eight percent of all tracheal intubations were successful using the McGrath® videolaryngoscope. Cormack and Lehane grade I views were obtained in 143 patients (95%) and grade II views were achieved in six (4%). In phase II, the median time required to obtain an adequate view was 6.3 sec [interquartile range 4.7-8.7 (range 2-26.3)], and to complete tracheal intubation was 24.7 sec [18.5-34.4(11.4-286)]. Forty-nine (65%) of the tracheal intubations were completed within 30 sec, and 72 (96%) were completed within one minute. No complications were encountered in any patient.ConclusionsThe McGrath® videolaryngoscope is an effective aid to airway management in patients with normal airways, based upon intubation success rates and the ability to rapidly secure the airway. Its potential advantages of convenience and portability warrant further evaluation in comparison with other airway devices and in patients with difficult airways.RésuméObjectifDocumenter les taux de réussite d’intubation trachéale et les temps d’instrumentation des voies aériennes pour le nouveau vidéolaryngoscope McGrath®.MéthodeNous avons enregistré, de façon prospective, les facteurs associés à une intubation trachéale difficile, ceux causant une difficulté réelle de l’intubation trachéale ainsi que les complications dues à l’utilisation du nouveau vidéolaryngoscope McGrath® chez une série de patients adultes présentant une anatomie des voies aériennes normales avant l’opération. Tous les patients devaient subir une chirurgie élective. Nous avons documenté notre expérience de prise en charge des voies aériennes chez les 75 premiers patients (Phase I) et, chez les 75 autres patients (Phase II), nous avons mesuré le temps requis jusqu’à obtention d’une visualisation optimale du larynx ainsi que le temps jusqu’à l’intubation trachéale complète.RésultatsLe taux de réussite des intubations trachéales pratiquées à l’aide du vidéolaryngoscope McGrath® a été de 98%. Nous avons obtenu une visualisation de type I sur l’échelle de Cormack et Lehane chez 143 patients (95 %) et de type II chez six patients (4 %). Pendant la phase II, le temps moyen requis pour obtenir une visualisation adéquate était de 6,3 sec [écart interquartile 4,7-8,7 (écart 2-26,3)], et de 24,7 sec avant intubation trachéale complète [18,5-34,4 (11,4-286)]. On a effectué 49 (65 %) intubations trachéales en 30 sec ou moins, et 72 (96 %) en une minute ou moins. II n’y a eu aucune complication.ConclusionLe vidéolaryngoscope McGrath® est un outil efficace pour la prise en charge des voies aériennes chez des patients avec une anatomie normale, si l’on se base sur les taux de réussite d’intubation et la capacité de sécuriser rapidement les voies aériennes. Sa facilité d’utilisation et sa portabilité justifient une évaluation plus poussée, incluant une comparaison avec d’autres dispositifs semblables et une utilisation chez des patients présentant des difficultés d’intubation.

Effect of induction agent on vasopressor and steroid use, and outcome in patients with septic shock

IntroductionIn seriously ill patients, etomidate gives cardiovascular stability at induction of anaesthesia, but there is concern over possible adrenal suppression. Etomidate could reduce steroid synthesis and increase the need for vasopressor and steroid therapy. The outcome could be worse than in patients given other induction agents.MethodsWe reviewed 159 septic shock patients admitted to our intensive care unit (ICU) over a 40-month period to study the association between induction agent and clinical outcome, including vasopressor, inotrope, and steroid therapy. From our records, we retrieved induction agent use; vasopressor administration at induction; vasopressor, inotrope, and steroid administration in the ICU; and hospital outcome.ResultsHospital mortality was 65%. The numbers of patients given an induction agent were 74, etomidate; 25, propofol; 26, thiopental; 18, other agent; and 16, no agent. Vasopressor, inotrope, or steroid administration and outcome were not related to the induction agent chosen. Corticosteroid therapy given to patients who received etomidate did not affect outcome. Vasopressor therapy was required less frequently and in smaller doses when etomidate was used to induce anaesthesia. We found no evidence that either clinical outcome or therapy was affected when etomidate was used. Etomidate caused less cardiovascular depression than other induction agents in patients with septic shock.ConclusionEtomidate use for critically ill patients should consider all of these issues and not simply the possibility of adrenal suppression, which may not be important when steroid supplements are used.

Etomidate for critically ill patients. Pro: yes we can use it.

Etomidate is used to induce anaesthesia in critically ill patients in many environments, including pre-hospital care, in the emergency and critical care departments and in the operating theatre. It has a favourable cardiovascular profile, but its use has courted controversy because it suppresses adrenal function which some believe is associated with worse outcome, particularly in patients with sepsis. Because there is much evidence of harm associated with hypotension in critically ill patients, it is important to use an anaesthetic induction drug which is less likely to cause hypotension. Etomidate undoubtedly causes adrenal suppression, but the clinical consequences of this remain unclear. There is no convincing or consistent evidence that etomidate is associated with harm, particularly if adjustment is made for pre-existing severity of illness. The etomidate debate is currently in clinical equipoise in which there is genuine uncertainty within the expert medical community. We review briefly the arguments in favour of continuing to use etomidate in critically ill patients.

Tracheal intubation in an urban emergency department in Scotland: A prospective, observational study of 3738 intubations

AIM The emergency department (ED) is an area where major airway difficulties can occur, often as complications of rapid sequence induction (RSI). We undertook a prospective, observational study of tracheal intubation performed in a large, urban UK ED to study this further. METHODS We reviewed data on every intubation attempt made in our ED between January 1999 and December 2011. We recorded techniques and drugs used, intubator details, success rate, and associated complications. Tracheal intubation in our ED is managed jointly by emergency physicians and anaesthetists; an anaesthetist is contacted to attend to support ED staff when RSI is being performed. RESULTS We included 3738 intubations in analysis. 2749 (74%) were RSIs, 361 (10%) were other drug combinations, and 628 (17%) received no drugs. Emergency physicians performed 78% and anaesthetists 22% of intubations. Tracheal intubation was successful in 3724 patients (99.6%). First time success rate was 85%; 98% of patients were successfully intubated with two or fewer attempts, and three patients (0.1%) had more than three attempts. Intubation failed in 14 patients; five (0.13%) had a surgical airway performed. Associated complications occurred in 286 (8%) patients. The incidence of complications was associated with the number of attempts made; 7% in one attempt, 15% in two attempts, and 32% in three attempts (p<0.001). CONCLUSION A collaborative approach between emergency physicians and anaesthetists contributed to a high rate of successful intubation and a low rate of complications. Close collaboration in training and delivery of service models is essential to maintain these high standards and achieve further improvement where possible.

Organ donation after circulatory death: an update.

There is an ongoing shortfall of organs for donation in the UK and worldwide. Strategies including donation after circulatory death (DCD), living donation and better identification of potential donors are attempting to increase the number of donors and donated organs. The number of DCD donors in the UK increased by 808% from 37 to 336 between 2001 and 2010 and this is continuing to increase. The most common organs donated from DCD donors are the kidneys, but there is increasing experience of liver, lung and pancreas transplantation. The process of DCD varies between different countries and institutions. The outcome of DCD transplantation has been largely encouraging, particularly for kidneys. The increase in DCD has led to an appraisal of issues that may arise during the donation process; these include the Lazarus phenomenon, the dead donor rule, perimortem interventions, public opinion and conflict of interest for clinicians.

Rapid sequence induction of anaesthesia in elderly patients in the emergency department.

AIM Our primary objective was to evaluate the characteristics and outcomes of elderly (≥ 80 years) patients undergoing rapid sequence induction of anaesthesia and intubation (RSI) in our emergency department (ED). METHODS We retrospectively analysed data collected prospectively between January 1999 and December 2007. We retrieved age; gender; presenting diagnosis; indication and urgency for RSI; complications related to RSI; hospital destination; and outcome. RESULTS 1686 patients underwent RSI in the ED during the study period; 107 (6%) were aged ≥ 80 years. The mean age (range) was 84 (80-91) years. 94 patients (88%) were living in a private residence before presentation to the ED. Intracerebral haemorrhage, ischaemic stroke and head injury were the commonest presenting diagnoses. Forty-one patients were admitted to intensive care, 55 were admitted to a ward (31 for palliative care) and 11 died in the ED. Seventy-two patients (67%) died; of the 35 survivors, 21 (60%) made a good recovery with no requirement for increased social care. Outcome was worse after neurological diagnoses, sepsis and trauma than after cardiac or respiratory failure, seizures or drug overdose. Presenting diagnosis predicted outcome on univariable analysis (p<0.001), but it was not possible to calculate risk for individual diagnoses. RSI-related complications, of which hypotension was commonest, occurred in 15% of patients. CONCLUSION A small number of patients who undergo RSI in our ED are aged ≥ 80 years. They generally have high mortality with only 20% surviving to hospital discharge with no increase in dependency; however 60% of survivors make a good recovery. In this highly selected elderly population age is not the main determinant of outcome which is influenced more by presenting diagnosis.

Induction drug and outcome of patients admitted to the intensive care unit after emergency laparotomy.

Background and objective Etomidate is often used to induce anaesthesia in sick patients owing to its relative cardiovascular stability. However, etomidate affects adrenal cortical activity, and there is concern that this could impair outcome in patients undergoing emergency surgery. Methods We retrospectively analysed data from 176 patients admitted to an ICU after emergency laparotomy. We retrieved ASA status, surgical diagnosis, induction drug use, blood pressure before and after induction and any vasopressor administration, steroid and vasopressor therapy in ICU and patient outcome. Choice of induction drug was at the discretion of the attending anaesthetist. Results The drugs (numbers of patients) used to induce anaesthesia were etomidate (52), thiopental (90), propofol (16), midazolam (12) and ketamine (4). Fifty-two patients (30%) died in hospital. ASA status was the only independent predictor of hospital outcome (P < 0.001). Choice of induction drug was related to ASA status. As ASA status worsened, the likelihood of using etomidate or midazolam/ketamine increased (P = 0.001). We found no association between etomidate and dying in hospital, though our study might not have had sufficient power to show a difference between induction drugs. The relative risks [95% confidence interval (CI)] of dying in hospital were etomidate 1.16 (0.72–1.87), thiopental 0.82 (0.52–1.30), propofol 0.40 (0.11–1.49) and midazolam/ketamine 1.84 (1.09–3.12). Vasopressor and steroid therapy in the ICU was not related to induction drug. The risk of developing hypotension at induction or of receiving vasopressor to treat hypotension was least with etomidate. Conclusion We found no evidence that etomidate is associated with worse outcome than thiopental or propofol in patients undergoing emergency laparotomy, but we cannot be certain that etomidate is well tolerated in this group of patients. More data are required to address this issue definitively.

Patients with hip fracture admitted to critical care: Epidemiology, interventions and outcome

INTRODUCTION Although there is much current debate about the use of critical care to enhance peri-operative care of patients with hip fracture there are limited supporting data. We investigated the epidemiology, critical care interventions and outcomes of patients with hip fracture admitted to a large UK critical care unit. PATIENTS AND METHODS We reviewed all patients with hip fracture (excluding those with multiple trauma, and those with femoral shaft or peri-prosthetic fracture) who were admitted to our critical care unit during a four year period. We recorded patient characteristics, reason for admission to critical care, interventions and organ support performed, and patient outcome. RESULTS We identified 99 patients with a mean age of 81 years; this represented 1% of patients admitted to critical care, and 2.4% of patients with hip fracture admitted to hospital during the study period. Fifty-two patients required no organ support; 19 received only respiratory support, 13 only cardiovascular support, 12 received both respiratory and cardiovascular support, and 3 received respiratory, cardiovascular and renal support. Outcome worsened as the level of organ support increased (p=0.01). Fifteen patients died in critical care, acute hospital mortality was 33% and 1-year mortality was 54%. No patient for whom admission was planned before surgery died in critical care and the 30-day mortality for this group was 13%. Outcome was related to the time between surgery and critical care admission: patients admitted before surgery or longer than 2 days after surgery had worse outcomes (p=0.001). The reason for admission to critical care also influenced outcome: patients with sepsis had poor outcome with one-third dying in critical care and a further one-third not surviving to hospital discharge. CONCLUSIONS The major determinants of outcome in this population were reason for admission, and timing of admission to critical care. One year survival was better than that for unselected patients aged >80 years admitted to critical care. Admission to critical care and use of enhanced peri-operative care for selected hip fracture patients is entirely appropriate and beneficial.

Controlled organ donation after cardiac death: potential donors in the emergency department.

Background. The continuing shortfall of organs for transplantation has increased the use of donation after cardiac death (DCD). We hypothesized that some patients who undergo tracheal intubation in the emergency department (ED) and who are assessed for, but not admitted to, critical care might have potential for controlled DCD. Methods. We identified all patients who underwent tracheal intubation in the ED between 2004 and 2008 and studied their records to identify those not admitted to an intensive care unit. We reviewed the notes of patients extubated in the ED to ascertain the diagnosis, management, outcome, and potential exclusion criteria for controlled DCD. Results. One thousand three hundred seventy-four patients had tracheal intubation performed in the ED; 1053 received anesthetic drugs to assist intubation. Three hundred seventy-five patients were not admitted to intensive care unit; 235 died during resuscitation in the ED. Of the 49 patients extubated in the ED to allow terminal care, 26 were older than 70 years and 18 had comorbidities precluding organ donation. Fourteen patients could have been considered for DCD, but in eight, the time from extubation to death exceeded 2 hr. Thus, six patients might have been missed as potential controlled DCD from the ED in this 5-year period. Conclusions. Identification of potential donors after cardiac death in the ED with appropriate use of critical care for selected patients may contribute to reducing the shortfall of organs for transplantation, although numbers are likely to be small. This area remains controversial and requires further informed discussion between emergency and critical care doctors and transplant teams.

Adolescent tracheal intubation in an adult urban emergency department: a retrospective, observational study.

Objectives Tracheal intubation is the cornerstone of advanced emergency airway management in children and adults and there is good-quality data characterizing intubation in both groups. There are, however, few published studies on emergency tracheal intubation in adolescents. We carried out an observational study to characterize tracheal intubation in adolescents. Methods We analysed data from a previously collected Emergency Department Intubation Registry. We included all attempts at tracheal intubation performed in our adult emergency department between 1999 and 2011. We recorded the indication for intubation, the staff involved, the technique and drugs used, and the rates of successful intubation and adverse events. We classified patients into three age groups: 13–16 years (adolescent), 17–24 years (young adult) and at least 25 years (older adult). Results Trauma was the most common indication for intubation in adolescents, and rapid sequence induction was used in 88% of cases. Ninety-nine percent of tracheal intubations in adolescent patients were successful on the first or the second attempt, no adolescent underwent more than three attempts and none required a surgical airway. The initial intubation attempt in adolescents was more likely to be performed by an anaesthetist (P<0.005). The first attempt success rate was higher (P<0.01) and adverse event rate was lower (P<0.05) in adolescents than in adults. Hypotension was the only adverse event recorded in adolescents; this occurred in three patients (4.5%). Conclusion Our findings suggest that the airway in adolescent patients can be managed successfully and safely in an adult emergency department where there is close collaboration between anaesthetists and emergency physicians.