Dina Gomaa

Management of the Artificial Airway

Management of the artificial airway includes securing the tube to prevent dislodgement or migration as well as removal of secretions. Preventive measures include adequate humidification and appropriate airway suctioning. Monitoring airway patency and removing obstruction are potentially life-saving components of airway management. Cuff pressure management is important for preventing aspiration and mucosal damage as well as assuring adequate ventilation. A number of new monitoring techniques have been introduced, and automated cuff pressure control is becoming more common. The respiratory therapist should be adept with all these devices and understand the appropriate application and management.

Transfusion of cryopreserved packed red blood cells is safe and effective after trauma a prospective randomized trial

OBJECTIVES To determine the safety and efficacy of cryopreserved packed red blood cell (CPRBC) transfusion in trauma patients. BACKGROUND Liquid packed red blood cells (LPRBCs) have an abbreviated shelf-life and worsening storage lesion with age. CPRBCs are frozen 2 to 6 days after donation, stored up to 10 years, and are available for 14 days after thawing and washing. CPRBCs can be utilized in diverse settings, but the effect on clinical outcomes is unknown. METHODS We performed a prospective, randomized, double-blind study at 5 level 1 trauma centers. Stable trauma patients requiring transfusion were randomized to young LPRBCs (≤14 storage days), old LPRBCs (>14 storage days), or CPRBCs. Tissue oxygenation (StO2), biochemical and inflammatory mediators were measured, and clinical outcomes were determined. RESULTS Two hundred fifty-six patients with well-matched injury severity and demographics (P > 0.2) were randomized (84 young, 86 old, and 86 CPRBCs). Pretransfusion and final hematocrits were similar (P > 0.68). Patients in all groups received the same number of units postrandomization (2 [1-4]; P > 0.05). There was no difference in the change in tissue oxygenation between groups. CPRBCs contained less α2-macrogobulin, haptoglobin, C-reactive protein, and serum amyloid P (P < 0.001). Organ failure, infection rate, and mortality did not differ between groups (P > 0.2). CONCLUSIONS Transfusion of CPRBCs is as safe and effective as transfusion of young and old LPRBCs and provides a mechanism to deliver PRBCs in a wide variety of settings.

Incompatible type A plasma transfusion in patients requiring massive transfusion protocol: Outcomes of an Eastern Association for the Surgery of Trauma multicenter study

ABSTRACT With a relative shortage of type AB plasma, many centers have converted to type A plasma for resuscitation of patients whose blood type is unknown. The goal of this study is to determine outcomes for trauma patients who received incompatible plasma transfusions as part of a massive transfusion protocol (MTP). METHODS As part of an Eastern Association for the Surgery of Trauma multi-institutional trial, registry and blood bank data were collected from eight trauma centers for trauma patients (age, ≥ 15 years) receiving emergency release plasma transfusions as part of MTPs from January 2012 to August 2016. Incompatible type A plasma was defined as transfusion to patient blood type B or type AB. RESULTS Of the 1,536 patients identified, 92% received compatible plasma transfusions and 8% received incompatible type A plasma. Patient characteristics were similar except for greater penetrating injuries (48% vs 36%; p = 0.01) in the incompatible group. In the incompatible group, patients were transfused more plasma units at 4 hours (median, 9 vs. 5; p < 0.001) and overall for stay (11 vs. 9; p = 0.03). No hemolytic transfusion reactions were reported. Two transfusion-related acute lung injury events were reported in the compatible group. Between incompatible and compatible groups, there was no difference in the rates of acute respiratory distress syndrome (6% vs. 8%; p = 0.589), thromboembolic events (9% vs. 7%; p = 0.464), sepsis (6% vs. 8%; p = 0.589), or acute renal failure (8% vs. 8%, p = 0.860). Mortality at 6 (17% vs. 15%, p = 0.775) and 24 hours (25% vs. 23%, p = 0.544) and at 28 days or discharge (38% vs. 35%, p = 0.486) were similar between groups. Multivariate regression demonstrated that Injury Severity Score, older age and more red blood cell transfusion at 4 hours were independently associated with death at 28 days or discharge; Injury Severity Score and more red blood cell transfusion at 4 hours were predictors for morbidity. Incompatible transfusion was not an independent determinant of mortality or morbidity. CONCLUSION Transfusion of type A plasma to patients with blood groups B and AB as part of a MTP does not appear to be associated with significant increases in morbidity or mortality. LEVEL OF EVIDENCE Therapeutic study, level IV.

Impact of Oxygenation Status on the Noninvasive Measurement of Hemoglobin

BACKGROUND Noninvasive monitoring of hemoglobin (SpHgb) via pulse oximetry has the potential to alert caregivers to blood loss. Previous studies have demonstrated that changes in oxygenation may impact accuracy. METHODS Twenty normal volunteers were monitored using SpHgb at sea level, during ascent to 14,000 feet, at 14,000 feet with 100% oxygen delivery, and again at sea level. Each period consisted of 15 minutes of monitoring. SpHgb measurements were compared to a blood sample using Bland Altman analysis. The loss of the SpHgb signal was also recorded. RESULTS The mean difference in measured hemoglobin (Hgb) between a venous sample and SpHgb was -2.6 ± 0.96 at 14,000 feet. Ascent to 14,000 feet resulted in a predictable fall in SpO2 and was associated with loss of the SpHgb signal for half the period of observation (7.4 minutes). In the other three conditions, SpHgb signal was missing 1 to 12.6% of the time. The nadir SpO2 was not predictive of the loss of SpHgb signal. DISCUSSION Changes in oxygenation in normal volunteers are associated with short-term SpHgb signal loss (<10 minutes), but no impact on the measured SpHgb.

1003: ASPIRATION OF FLUID ABOVE THE ENDOTRACHEAL TUBE CUFF

Learning Objectives: Subglottic secretion drainage (SSD) from above the endotracheal tube (ETT) cuff has been shown to reduce the incidence of ventilatorassociated pneumonia (VAP). And while numerous guidelines have recommended SSD ETT’s; logistic, economic and practical issues have minimized adoption. In the absence of a specialty ETT, clinicians often attempt to suction the oropharynx with a standard suction catheter. Methods: Two cadavers were instrumented with a 7.5 SSD ETT tube which was affixed using a standard ETT tube holder (Anchor Fast, Hollister, Libertyville, IL). The cuff was inflated to a pressure of 60 mm Hg (to prevent leakage) and 7 ml of water (with blue food coloring) was inserted above the cuff via the ETT suction lumen. The pilot balloon was connected to a continuous pressure monitor. Healthcare professionals who volunteered for the trial were asked to attempt to suction fluids from above the cuff using either a standard suction catheter (Oropharyngeal suction catheter, Sage Medical, Cary, IL) or a Sherpa SuctionTM System (Ciel Medical, San Carlos, CA). Each caregiver was allowed three attempts. When the caregiver felt the catheter was in position, they were asked to tap the cuff with the catheter to demonstrate correct positioning. Fluid was then aspirated using a 20 ml syringe. Results: Twenty-two providers (10 RT, 3 RN, 9 MD) participated. Participants had a average of 11.4 ± 10.4 yrs of experience (range 1–40 yrs) and ranked their comfort with oral suctioning from 1–3 (1-high, 2–moderate, 3–low)– mean was 1.4.No subject was able to place the standard suction catheter despite 3 attempts (0/22). Every subject (22/22) was able to place the Sherpa catheter after an average of 1.1 attempts (2 subjects required 2 attempts). No fluid (0 ml) was aspirated with a standard suction catheter, while an average of 6.2 ± 0.8 ml was aspirated using the Sherpa catheter (p<0.01,Ttest).Conclusions: In the absence of SSD ETT, the Sherpa Suction System allows removal of fluid above the cuff. The impact of this method of subglottic secretion removal on VAP should be evaluated in a clinical trial.