Ruan Vlok

Intubation using apnoeic oxygenation to prevent desaturation: A systematic review and meta-analysis

Purpose: To determine whether or not apnoeic oxygenation reduces the incidence of hypoxaemia during endotracheal intubation. Materials and methods: A systematic search of six databases for all relevant studies until November 2016 was performed. All study designs using apnoeic oxygenation during intubation were eligible for inclusion. All studies were assessed for level of evidence and risk of bias. A meta‐analysis was performed on all data using Revman 5.3. Results: Seventeen studies including 2422 patients were retrieved. Overall there was a significant reduction in the incidence of desaturation (RR = 0.65; p < 0.00001), critical desaturation (RR = 0.61, p = 0.002) and safe apnoea time (WMD = 1.73 min, p < 0.00001). There was no significant difference in mortality (RR = 0.77, p = 0.08). Conclusions: In patients whom are being intubated for any indication other than respiratory failure, apnoeic oxygenation at any flow rate 15 L or greater is likely to reduce their incidence of desaturation (< 90%) and critical desaturation (< 80%). However, further high quality RCTs are required given the high degree of heterogeneity in many of the outcomes and subgroup analyses. HIGHLIGHTSThis review summarises a growing body of literature surrounding apnoeic oxygenation during intubation.Meta‐analysis of seventeen studies including 2,422 patients.Overall there was a significant reduction in the incidence of desaturation, critical desaturation and an increase in safe apnoea time.

Apneic oxygenation during intubation in the emergency department and during retrieval: A systematic review and meta-analysis

Background: Hypoxemia increases the risk of intubation markedly. Such concerns are multiplied in the emergency department (ED) and during retrieval where patients may be unstable, preparation or preoxygenation time limited and the environment uncontrolled. Apneic oxygenation is a promising means of preventing hypoxemia in this setting. Aim: To test the hypothesis that apnoeic oxygenation reduces the incidence of hypoxemia during endotracheal intubation in the ED and during retrieval. Methods: We undertook a systematic review of six databases for all relevant studies published up to November 2016. Included studies evaluated apneic oxygenation during intubation in the ED and during retrieval. There were no exemptions based on study design. All studies were assessed for level of evidence and risk of bias. The Review Manager 5.3 software was used to perform meta‐analysis of the pooled data. Results: Six trials and a total 1822 cases were included for analysis. The study found a significant reduction in the incidence of desaturation (RR = 0.76, p = 0.002) and critical desaturation (RR = 0.51, p = 0.01) when apneic oxygenation was implemented. There was also a significant improvement in first pass intubation success rate (RR = 1.09, p = 0.004). Conclusion: Apneic oxygenation may reduce patient hypoxemia during intubation performed in the ED and during retrieval. It also improves intubation first‐pass success rate in this setting.

Apnoeic oxygenation during intubation in the intensive care unit: A systematic review and meta-analysis

ABSTRACT Hypoxaemia increases the risk of cardiac arrest and mortality during intubation. The reduced physiological reserve and reduced efficacy of pre‐oxygenation in intensive care patients makes their intubation particularly dangerous. Apnoeic oxygenation is a promising means of preventing hypoxaemia in this setting. We sought to ascertain whether apnoeic oxygenation reduces the incidence of hypoxaemia when used during endotracheal intubation in the intensive care unit (ICU). A systematic review of five databases for all relevant studies published up to November 2016 was performed. Eligible studies investigated apnoeic oxygenation during intubation in the ICU, irrespective of design. All studies were assessed for risk of bias and level of evidence. A meta‐analysis was performed on all data using Revman 5.3. Six studies including 518 patients were retrieved. The study found level 1 evidence of a significant reduction in the incidence of critical desaturation (RR = 0.69, CI = 0.48–1.00, p = 0.05) and a significant increase in the lowest SpO2 value by 2.83% (CI = 2.28–3.38, p < 0.00001). There was a significant reduction in ICU stay (WMD = −2.89, 95%CI = −3.25 to −2.51, p < 0.00001). There was no significant difference between groups regarding mortality (RR = 0.77, 95%CI = 0.59–1.03, p = 0.08), first pass intubation success (RR = 1.17, 95%CI = 0.67 to 2.03, p = 0.58), arrhythmia during intubation (RR = 0.58, 95%CI = 0.08 to 4.29, p = 0.60), cardiac arrest during intubation (RR = 0.33, 95%CI = 0.01 to 7.84, p = 0.49) and duration of ventilation (WMD = −1.97, 95%CI = −5.89 to 1.95, p = 0.32). Apnoeic oxygenation reduces patient hypoxaemia during intubation performed in the ICU. This meta‐analysis found evidence that apnoeic oxygenation may significantly reduce the incidence of critical desaturation and significantly raises the minimum recorded SpO2 in this setting. We recommend apnoeic oxygenation be incorporated into ICU intubation protocol.

Efficacy and adverse effects of buprenorphine in acute pain management: systematic review and meta-analysis of randomised controlled trials

&NA; Buprenorphine appears to have a ceiling effect on respiratory depression, but not analgesia in healthy young patients. However, the efficacy and side‐effects of buprenorphine in the setting of acute pain are poorly characterized. The aim of this study was to characterize the analgesic efficacy and adverse effects of buprenorphine compared with morphine in the acute pain setting. A systematic review of five databases was performed. Randomised controlled trials (RCTs) comparing buprenorphine with morphine in acute pain management were included. Studies performed outside of the hospital setting were excluded. The a priori primary outcomes included pain, respiratory depression, and sedation. Secondary outcomes included requirement for rescue analgesia, time to rescue analgesia, nausea, vomiting, dizziness, hypotension, and pruritus. Twenty‐eight RCTs with 2210 patients met the inclusion criteria. There was no difference in pain [visual analogue scale weighted mean difference (WMD)=−0.29; 95% confidence interval (CI)=−0.62 to 0.03; I2=99%; P=0.07], incidence of respiratory depression [odds ratio (OR)=2.07; 95% CI=0.78–5.51; I2=30%; P=0.14], or sedation (OR=1.44; 95% CI=0.76–2.74; I2=23%; P=0.26). There was only one secondary outcome with an overall significant difference; buprenorphine use was associated with significantly less pruritus (OR=0.31; 95% CI=0.12–0.84; I2=6%; P=0.02). Whilst a theoretical ceiling effect may exist with respect to buprenorphine and respiratory depression, in a clinical setting, it can still cause significant adverse effects on respiratory function. However, given that buprenorphine is an equally efficacious analgesic agent, it is a useful alternative opioid because of its ease of administration and reduced incidence of pruritus.

Iconography : Sublingual buprenorphine versus intravenous or intramuscular morphine in acute pain: A systematic review and meta-analysis of randomized control trials

Intro Buprenorphine is a potent analgesic agent with several unique and favourable features such as its sublingual formulation. The aim of this study is to compare the effectiveness of sublingual versus intramuscular and intravenous buprenorphine in acute pain. Methods Five major databases were systematically searched until April 2018. All randomized control trials comparing sublingual buprenorphine with intravenous or intramuscular morphine in acute pain were included in this review. These studies were assessed for level of evidence and risk of bias. The data was then analyzed both qualitatively and where appropriate by meta‐analysis. The primary outcomes were analgesic effect up to six hours and rescue analgesia requirement. The secondary outcomes were incidence of respiratory depression, nausea, vomiting, dizziness and hypotension. Results Nine studies comparing sublingual and intramuscular or intravenous buprenorphine were identified and included 826 patients. There was no difference in pain at any time point before six hours or need for rescue analgesia between the two agents. There was no difference in secondary outcomes between the two agents. Discussion Sublingual buprenorphine offers an effective alternative to intravenous or intramuscular analgesia in acute pain. Sublingual buprenorphine appears to be a viable option in patients where intravenous access is difficult or not favourable.

Hypertrophic cardiomyopathy and the potential influence of etomidate on postoperative outcomes

To the Editor, We read with interest the paper by Dhillon and colleagues1 which provided a high-quality propensity-matched observational study of perioperative outcomes in patients with hypertrophic cardiomyopathy (HCM). This study showed no difference in what they defined as ‘hard outcomes’ such as myocardial infarction, stroke and death. They did however show an increased incidence of composite end …

Buprenorphine versus Morphine in Paediatric Acute Pain: A Systematic Review and Meta-Analysis

Introduction In lab-based studies, buprenorphine appears to have a ceiling effect on respiratory depression but not on analgesia. There is increasing evidence in adult patients that buprenorphine has no ceiling effect on analgesia or side effects. The aim of this study was to investigate the efficacy and adverse effects of buprenorphine versus morphine in paediatric acute pain. Methods A systematic review of five databases was performed until May 2018. Only randomised controlled trials were eligible for inclusion. The outcomes of interest included pain, respiratory depression, nausea, sedation, dizziness, and pruritus. Results Four randomised controlled trials (n=195) were included. The only outcome measuring analgesic efficacy was time to breakthrough analgesia. Buprenorphine had a significant increase in time to breakthrough analgesia by 114.98 minutes compared to morphine (95% CI = 42.94 to 187.01; I2 = 0; p=0.002). There was no significant difference in the rates of adverse effects. Conclusions Buprenorphine provided a longer duration of analgesia than morphine. This in combination with its unique sublingual preparation could prove particularly advantageous in the paediatric population. The studies included are likely underpowered to detect differences in the incidence of adverse effects; therefore, the same precautions should be taken as with any other opioid.

Recognition and management of posterior myocardial infarction: a retrospective cohort study

Characteristic electrocardiogram (ECG) features of posterior myocardial infarction (PMI) do not include typical ST-segment elevation and, therefore, carries the risk of delayed diagnosis and management. The aim of this study was to investigate how well PMIs are recognised and whether a lack of recognition translates to a larger infarction. This was a retrospective cohort study of patients sourced from a cardiac catheterisation database. Based on ECG analysis, patients included in this study included those meeting PMI criteria and those meeting ST-elevation myocardial infarction (STEMI) criteria as the control group. Door-to-balloon times were used as an outcome measure for differences in recognition between PMIs and other STEMIs. Troponin was used as a surrogate marker to measure degree of myocardial damage. There were 14 patients meeting PMI criteria and 162 meeting STEMI criteria. PMI patients had significantly longer door-to-balloon times. There was no statistically significant difference between PMI and STEMI group initial troponins t(169)=1.05, p=0.30, or peak 24-hour troponins t(174)=-1.73, p=0.09. In conclusion, using door-to-balloon times as a marker for recognition, this study illustrated that patients suffering PMI experience delayed recognition and management compared with non-PMI STEMIs. This did not, however, result in a significantly larger size of infarction as shown by peak troponin levels.