Incidence of aspiration pneumonia in intubated patients receiving activated charcoal

Several case reports and animal studies raise concerns over the risk of aspiration pneumonia when administering activated charcoal (AC) to intubated patients. Therefore, we sought to determine the incidence of aspiration pneumonia in intubated overdose patients who then received AC. We conducted a retrospective review from January 1994 to April 1997 of intubated patients who then received AC. Patients were transferred to, or primarily treated at, an 843-bed tertiary medical center with an annual emergency department volume of 100,000 patients. Objective evidence of infiltrate on chest radiograph during initial 48 h of hospitalization was used to determine the incidence of aspiration pneumonia. Patients with known preexisting pneumonia or with administration of AC before intubation were excluded. There were 64 patients identified. Fourteen were excluded for clinical aspiration before intubation, receiving activated charcoal before intubation, or abnormal immediate post-intubation chest radiographs. The remaining 50 patients, ages 1-64 years, 33% male, overdosing on a large variety of substances, required acute intubation and then received AC. Only two patients of these 50 (4%) with initial negative radiographs developed a new infiltrate after intubation and AC. Administration of AC to intubated overdose patients is associated with a low incidence of aspiration pneumonia.     

A prospective study of tracheal intubation in an emergency department in Hong Kong.

Emergency department (ED) doctors often intubate patients, however no data was available in Hong Kong on this aspect. Our study was to assess the competency of ED doctors in intubating critical patients in a typical ED in Hong Kong. Between March and August 1999, in an urban hospital with an emergency physician training programme, all doctors, after performing any tracheal intubation, were required to fill in a pro forma designed for the study. Data collected included the training status of the intubator, the number of intubation attempts, intubation methods and complications. A total of 214 ED patients required advanced airway management including 87 (41%) patients in cardiopulmonary arrest; 207 (97%) of them were successfully intubated by ED doctors (76 by specialists, 61 by trainees, 70 by residents) and 90% were successful in the first attempt. The remaining seven patients' airway control was eventually managed by anaesthetists who successfully intubated six patients and performed cricothyrotomy for one patient. Rapid sequence intubation was performed in 70 (33%) patients by ED doctors and specialists. There were 30 (14%) patients successfully intubated using sedative agents alone. Twenty-two (10%) patients were found to have a total of 32 complications including 13 patients with oesophageal intubation, seven with soft tissue damage, four with desaturation, three with bronchial intubation, three with hypotension, one with dental trauma, one with dysrhythmia. The majority of ED intubations for critically ill patients were performed by ED doctors with high success rate and few major complications.     

Risk Factors for Failed Tracheal Intubation in Pediatric and Neonatal Critical Care Specialty Transport

Abstract

Objective. Nearly 200,000 pediatric and neonatal transports occur in the United States each year with some patients requiring tracheal intubation. First-pass intubation rates in both pediatric and adult transport literature are variable as are the factors that influence intubation success. This study sought to determine risk factors for failed tracheal intubation in neonatal and pediatric transport. Methods. A retrospective chart review was performed over a 2.5-year period. Data were collected from a hospital-based neonatal/pediatric critical care transport team that transports 2,500 patients annually, serving 12,000 square miles. Patients were eligible if they were transported and tracheally intubated by the critical care transport team. Patients were categorized into two groups for data analysis: (1) no failed intubation attempts and (2) at least one failed intubation attempt. Data were tabulated using Epi Info Version 3.5.1 and analyzed using SPSSv17.0. Results. A total of 167 patients were eligible for enrollment and were cohorted by age (48% pediatric versus 52% neonatal). Neonates were more likely to require multiple attempts at intubation when compared to the pediatric population (69.6% versus 30.4%, p = 0.001). Use of benzodiazepines and neuromuscular blockade was associated with increased successful first attempt intubation rates (p = 0.001 and 0.008, respectively). Use of opiate premedication was not associated with first-attempt intubation success. The presence of comorbid condition(s) was associated with at least one failed intubation attempt (p = 0.006). Factors identified with increasing odds of at least one intubation failure included, neonatal patients (OR 3.01), tracheal tube size ≤ 2.5 mm (OR 3.78), use of an uncuffed tracheal tube (OR 6.85), and the presence of a comorbid conditions (OR 2.64). Conclusions. There were higher rates of tracheal intubation failure in transported neonates when compared to pediatric patients. This risk may be related to the lack of benzodiazepine and neuromuscular blocking agents used to facilitate intubation. The presence of a comorbid condition is associated with a higher risk of tracheal intubation failure.     

Paranasal sinusitis associated with nasotracheal intubation: a frequently unrecognized and treatable source of sepsis

Paranasal sinusitis secondary to prolonged nasotracheal intubation represents an infrequently reported source of sepsis. Of 27 nasally intubated patients who developed paranasal sinusitis over a 1-yr period, 17 patients underwent emergency blind nasotracheal intubation post-trauma or shock (group 1) and the remaining ten were intubated electively under operating room or ICU conditions (group 2). Group 1 patients were younger (mean age 33 +/- 6 vs. 57 +/- 5 yr) than those in group 2; they also developed sinusitis more quickly after intubation (mean time 8 +/- 1 vs. 15 +/- 2 days). Diagnosis was confirmed via sinus x-rays (14 cases), computed tomography (five cases), indium scan (two cases), or clinical picture. Cultures were obtained in 14 cases. Staphylococci predominated in group 1, while nosocomial Gram-negative organisms predominated in group 2. Seven patients developed pulmonary infections and two developed systemic sepsis with an organism present on sinus culture. In all cases treatment was successful with antibiotics and tracheostomy or movement of the tube to the oral route. These data indicate that patients nasally intubated are at risk for development of paranasal sinusitis; this diagnosis should be suspected in sepsis of undetermined etiology.     

Nonphysician transport of intubated pediatric patients: a system evaluation.

OBJECTIVE: To evaluate the occurrence of complications and patient deteriorations during the air and ground transportation of intubated pediatric patients, performed by a nonphysician-based team under the direction of an intensive care attending physician or fellow. DESIGN: Retrospective chart review. SETTING: A 600-bed university hospital with a 16-bed neonatal ICU and a 12-bed pediatric ICU. PATIENTS: All intubated pediatric patients (422 of 614 patients transported during the study period) transported by the dedicated neonatal/pediatric transport team from April 1988 to April 1990. MEASUREMENTS AND MAIN RESULTS: The transport records of intubated pediatric patients were abstracted. Recorded data included age, weight, gestational age, vital signs, diagnosis, interventions received, and use of paralytic agents and sedatives/analgesics. Patients were analyzed in three groups: group 1 (n = 295) included neonates; group 2 (n = 66) included patients greater than 1 month and less than 1 yr of age; and group 3 patients (n = 61) were ages greater than 1 yr. Group 1 had nine (3.1%) complications or patient deteriorations; four (1.4%) were related to the endotracheal tube. Group 2 had one (1.5%) airway complication and one deterioration. Group 3 had no complications or deteriorations. All but one of the airway complications were effectively handled by the transport team. At the referring hospital, the transport nurse or respiratory therapist intubated 62 (19.8%) patients in group 1, five (7.5%) in group 2, and three (4.9%) patients in group 3. Sixty-seven (23%), 21 (32%), and 30 (49%) patients of groups 1, 2, and 3, respectively, were paralyzed for transport. No complications were secondary to the use of paralytic agents or sedatives. CONCLUSIONS: Under proper medical guidance, well-trained nonphysician personnel can provide low-risk transport of intubated pediatric patients. Use of sedatives and paralytic drugs did not increase the risk of complications or patient deterioration.     

Clinical characteristics of paramedics' performance of pediatric endotracheal intubation

There are little data available on success rates, complications, and efficacy of intubation in the pediatric age group by prehospital personnel. In a 12-month period, paramedics successfully intubated 32 of 36 (88.9%) patients for various indications, with a total of 67 attempts. Seventeen of 36 (47.2%) patients survived to hospital admission. Patient age ranged from newborn to 14 years. Paramedics used the straight blade in 21 of 37 patients (56.8%). The study demonstrates that paramedics can intubate pediatric patients with the same success rate as in adult patients. The data support the inclusion of pediatric endotracheal intubation in the scope of paramedic practice.     

P REHOSPITAL R APID-SEQUENCE I NTUBATION : A P ILOT T RAINING P ROGRAM

Objective. To develop a training program enabling paramedics to use sedation and paralytic medications to facilitate endotracheal intubation in patients who otherwise could not be successfully intubated. Methods. Paramedics underwent a training program consisting of six hours of didactic education, two four-hour mannequin labs, one four-hour animal intubation lab, and operating room experience. Rapid-sequence intubation (RSI) runs were reviewed for appropriateness in patient selection and medication use. Non-RSI runs were reviewed to determine whether appropriate patients were being missed. Intubation success rates continue to be followed. Long-term quality assurance includes monthly run reviews, periodic quizzes, and unannounced on-site practical tests. Results. 101 patients have been intubated using RSI, including medical, trauma, pediatric, and adult cases. Of all patients receiving RSI drugs, 100 of 101 were successfully intubated. There were no undetected esophageal intubations. Paramedics were able to demonstrate proper patient selection and appropriately administer RSI medications. The use of sheep labs was a critical component of this training because it permitted multiple intubations in a live model possessing an airway quite similar to that of the human. The gum elastic bougie was felt to be critical in the intubation of three patients. Conclusion. This RSI training model can serve as a template for other agencies seeking to implement RSI. Limitations of this model include the availability of live animal labs and the expense of conducting the training. Intense medical director involvement has been key to the success of this prehospital RSI program.     

Bacterial and fungal colonization of endotracheal tubes in children: a prospective study.

OBJECTIVES: To evaluate both the frequency and route of endotracheal colonization of intubated children by pathogens and to assess the usefulness of Pediatric Risk of Mortality scoring and measurement of gastric pH in predicting this colonization. DESIGN: Prospective data collection. SETTING: A multidisciplinary pediatric ICU. PATIENTS: Nineteen children with medical/surgical problems who were intubated for at least 4 days. INTERVENTIONS: Buccal mucosa, and endotracheal and gastric aspirates were cultured for pathogens immediately after endotracheal intubation and daily for 4 to 5 days. Pediatric Risk of Mortality scores were calculated at the time of endotracheal intubation; gastric pH was measured each time that the cultures were obtained. MEASUREMENTS AND MAIN RESULTS: The buccal mucosae of ten (53%) of 19 children were colonized with Candida species at the time of endotracheal intubation. This colonization correlated with the degree of physiologic instability as measured by Pediatric Risk of Mortality scores (12.9 +/- 2.8 SEM for those patients colonized vs. 4.9 +/- 1.0 for those patients not colonized; p = .01), but not with preintubation antibiotic therapy. Eleven (58%) children acquired 27 endotracheal pathogens after the day of intubation. The buccal mucosa was the initial site of colonization of 19 (70%) of 27 of the acquired pathogens. A gastric pH of > 3.0 at the time of intubation correctly predicted colonization in nine of 11 children (p < .025, Fisher's exact test); a Pediatric Risk of Mortality score of > 8 at the time of endotracheal intubation correctly predicted colonization in eight of 11 patients (p < .05, Fisher's exact test). CONCLUSIONS: Colonization of the buccal mucosa appears to be the crucial antecedent to endotracheal colonization in children. In children, gastric pH and Pediatric Risk of Mortality scores at the time of endotracheal intubation can predict pathogenic endotracheal colonization within 4 days of intubation. Selective decontamination regimes may be appropriate for these patients, especially those regimes that are directed to the buccal mucosa.     

Aspiration of gastric contents: association with prehospital intubation

We prospectively compared the incidence of pulmonary aspiration of gastric contents between patients endotracheally intubated in the prehospital (PH) setting and those intubated in the emergency department (ED). Tracheal aspirates were collected using a standard Leukens trap from all patients as soon as possible after endotracheal intubation. Tracheal aspirates were then tested for the presence of pepsin, a sensitive and specific marker of gastric contents, using a fibrinogen digestion technique. Over 8 months, 168 patients were enrolled. The pepsin assay was positive in 10 of 20 (50%) patients intubated in the PH group, as opposed to 33 of 148 (22%) of those intubated in the ED (chi2 P=.008; odds ratio, 3.5; 95% CI, 1.34-9.08). Patients endotracheally intubated in the PH setting are more likely to have aspirated gastric contents than those intubated in the ED.     

Association of prehospital intubation with decreased survival among pediatric trauma patients in Iraq and Afghanistan

Introduction

Airway compromise is the second leading cause of preventable death on the battlefield among US military casualties. Airway management is an important component of pediatric trauma care. Yet, intubation is a challenging skill with which many prehospital providers have limited pediatric experience. We compare mortality among pediatric trauma patients undergoing intubation in the prehospital setting versus a fixed-facility emergency department.

The seeing stylet: a new device for tracheal intubation

A new tracheal intubation device is available. The 'Shikani Seeing Stylet' is a new, inexpensive, reusable high resolution endoscope with a malleable stainless-steel sheath which can be inserted through a tracheal tube allowing intubation to be performed under direct vision. We have assessed this new device on 20 patients (ASA I-II; age 25-67) scheduled to undergo elective surgery with tracheal intubation. We measured heart rate (HR), non invasive blood pressure (NIBP), oxygen saturation (SpO(2)) and end tidal carbon dioxide (ETCO(2)) at three different times: T(0) (induction of anesthesia), T(1) (beginning of intubation procedure), T(2) (end of intubation procedure); we also recorded the time interval between T(1) and T(2). All patients were successfully intubated with the device. Eleven patients were intubated at the first attempt (T(1)-T(2) mean time=8. 65 s); three patients were intubated at the first attempt using cricoid pressure (T(1)-T(2) mean time 11.6 s); four patients were intubated at the second attempt (T(1)-T(2) mean time=36.5 s); two patients were intubated at the third attempt (T(1)-T(2) mean time=54. 5 s). The HR, NIBP, SpO(2) and ETCO(2) remained fairly stable. On the basis of our preliminary experience with 20 patients, the 'Shikani Seeing Stylet' seems to be a promising adjunct for airway management.     

Training and evaluation of respiratory therapists in emergency intubation.

Endotracheal intubation in emergency situations is a recognized function of respiratory therapists, as defined by the American Association for Respiratory Therapy in 1973. A training program based in the operating room, using one-on-one instruction, was the basis for a training program designed to meet JCAH standards for endotracheal intubation. To evaluate the success of our training and our system for attempting intubations, we recorded the results of 50 consecutive intubation attempts by our therapists. All 50 patients were eventually intubated, with 35 patients intubated on the first attempt. The average number of attempts per patient was 1.48. While 39 patients were intubated within one minute, 11 required more than one minute. In five patients, physicians had attempted intubation prior to a therapist's arrival; those intubations took eleven times longer than those that were attempted by therapists only. The average time for intubations attempted solely by therapists was 54 seconds.     

Use of Etomidate as an Induction Agent for Rapid Sequence Intubation in a Pediatric Emergency Department

Objectives: Although etomidate is widely used for rapid sequence intubation (RSI), there is no consensus on the optimal induction agent and no prospective pediatric emergency department (ED) study exists. The objective of this study was to assess the effectiveness and safety of etomidate as an induction agent for RSI in the pediatric ED. Methods: Data on RSI conditions and complications were collected prospectively on patients undergoing RSI in a tertiary pediatric ED from January 2003 to December 2003. ED hemodynamic data and inpatient data were collected retrospectively via chart review. Results: Seventy‐seven of 101 patients requiring intubation underwent RSI with etomidate. The mean (± SD) age was 8.2 (± 6.2) years. All 77 patients were successfully intubated. Intubation condition data were available for 69 of 77 patients (89.6%). Conditions were good in 68 of 69 (99%; 95% confidence interval = 92.2% to 99.9%). The mean (± SD) maximal percent decrease in systolic blood pressure was 10% (± 13.6%). A greater than 20% maximal percent decrease in systolic blood pressure occurred in 12 of 69 patients (17.4%; 95% confidence interval = 9.3% to 28.4%). There was no relationship between seizures after etomidate administration and prior seizure history (p = 0.25). Corticosteroids were given to 29 of 77 patients post‐RSI for varying diagnoses. All eight patients given corticosteroids for shock were in shock at the time of intubation. Conclusions: In the pediatric ED setting, etomidate as an induction agent provided successful RSI conditions and resulted in varied hemodynamic changes that were especially favorable in those patients presenting in decompensated shock. Hypotension and seizures were uncommon and occurred in patients with confounding diagnoses. Until the significance of a single dose of etomidate on adrenal dysfunction is further clarified, caution should be used in those patients at risk for adrenal insufficiency.     

Forward displacement of the larynx for nasogastric tube insertion in intubated patients

Simple insertion of a nasogastric (NG) tube was successful in only 52 of 100 anesthetized intubated patients. After the larynx was manually pulled forward, the NG tube was successfully inserted in 33 patients. In the remaining 15 patients, the NG tube was inserted only with the aid of a finger or a laryngoscope used with Magill forceps. The difficulty of NG tube insertion was not correlated with sex, age, weight, or type of endotracheal intubation. Forward displacement of the larynx by manually gripping and lifting the thyroid cartilage is a useful and safe maneuver that facilitates NG tube insertion in anesthetized intubated patients.     

Nasotracheal intubation in the emergency department, revisited.

This retrospective study was designed to investigate the current practice of nasotracheal intubation (NTI) in the Emergency Department (ED) at the University of California, San Diego Medical Center. Over a 5-year period, 21% (105/501) of patients intubated in the ED had at least one NTI attempt. The most frequent primary diagnoses in these patients included drug overdose, congestive heart failure, and chronic obstructive pulmonary disease. We report an overall NTI success rate of 79% (83/105). Sixty-one percent (64/105) of the patients were nasally intubated on the first NTI attempt. Nasal dilators, topical neosynephrine, and sedation improved NTI success rates. Epistaxis and improper tube position were the most common immediate complications. Sinusitis, pneumonia, and sepsis were the most frequent late complications. Patients receiving thrombolytic therapy were at risk of developing severe epistaxis. A prior history of sinus disease may predispose a nasally intubated patient to sinusitis. The complication rates reported here are similar to those of previous studies. A survey of emergency medicine (EM) residency programs found that EM residents throughout the country perform an average of 2.8 NTIs during their residency training. Thus, there is limited exposure to this intubation technique in EM residency programs. Nasotracheal intubation is a useful alternative to oral intubation, particularly when oral access is compromised. While not the optimal approach, we conclude that NTI is still a valuable method for establishing an airway and should remain among the emergency physician's arsenal of intubation techniques.     

Digital intubation

Digital tracheal intubation provides a safe and efficient method of intubation when the conventional methods of endotracheal intubation are impractical or impossible. Because of difficulties encountered in the field with oral or nasal intubation, a more efficient method was sought. After paramedics were taught tactile intubation on mongrel dogs and human cadavers, the procedure was used on 66 patients in the field over a period of 20 months. Fifty-eight patients were intubated successfully using this method. In 27 of these patients, delay in airway control would have resulted if not for the institution of digital intubation. In seven cases digital intubation was unsuccessful and the patients had to be intubated by other methods. Digital tracheal intubation is a safe, rapid method of intubation and should be considered when other methods prove difficult or impossible.     

Impact of endotracheal intubation on septic shock outcome: A post hoc analysis of the SEPSISPAM trial

IntroductionThe objective of the study to is to determine the characteristics associated with endotracheal intubation in septic shock patients.MethodsThis is a post hoc analysis of the database of the SEPSISPAM study, including patients with septic shock.ResultsAmong the 776 patients, 633 (82%) were intubated within 12 hours of study inclusion (early intubation), 113 (15%) were never intubated, and 30 (4%) had delayed intubation. Intensive care units (ICUs) were classified according to frequency of early intubation: early intubation less than 80% of patients (lowest frequency: 7 ICUs, 254 patients), 80% to 90% (middle frequency: 5 ICUs, 170 patients), and greater than 90% (highest frequency: 6 ICUs, 297 patients). Type of ICU, pulmonary infection, lactate greater than 2 mmol/L, lower Pao₂/fraction of inspired oxygen ratio, lower Glasgow score, and absence of immunosuppression were independently associated with early intubation. Patients never intubated had a lower initial severity and a low mortality rate. In comparison to patients intubated early, patients with delayed intubation had had fewer days alive without organ support by day 28. Intensive care units with the highest frequency of early intubation had a higher mortality rate in comparison to ICUs with middle frequency of early intubation. A nonsignificant increased mortality was observed in ICU with lowest frequency of early intubation.ConclusionsPractices regarding the place of endotracheal intubation in septic shock may impact outcome.     

经体表测量胃肠减压插管深度的可行性研究

[目的 ]探讨胃肠减压病人经体表测量插管最佳深度的方法。 [方法 ]将胃肠减压病人随机分为观察组和对照组 ,每组 65例。观察组按测量病人前额正中发际—剑突与脐连线中点的距离插管 ,对照组按传统法测量插管 ,观察记录两组病人腹胀和引流情况以及拔管时的实际长度。 [结果 ]两组腹胀及引流液量比较均有统计学意义 (P <0 .0 1)。对照组体表测量长度与实际插管长度比较有统计学意义 (P <0 .0 1) ;观察组体表测量长度与实际插管长度比较无统计学意义。 [结论 ]采用发际—剑突与脐中点体表标志测量法插管 ,胃管插入深度可到达胃体与胃窦部 ,可达到有效的胃肠减压目的。     

老年痴呆患者两种体位下插鼻肠管的效果比较

目的 对老年痴呆患者采取两种体位插入鼻肠管的效果进行分析.方法 采用长谷川简易痴呆量表评估为痴呆的患者50例,按插入鼻肠管时间顺序随机分为观察组与对照组,对照组采用去枕平卧位头后仰插入鼻肠管,观察组采用床头抬高700～80°角,呈坐位插入鼻肠管,对两种不同体位一次插管成功率进行比较.结果 对照组一次捕管成功3例,成功率为12%,观察组一次插管成功21例,成功率为84%,经X2检验,P<0.01,差异有统计学意义.结论 对于老年痴呆患者而言,采取坐位较平卧位插入鼻肠管一次插管成功率高,减轻了患者痛苦,并且省时、省力,提高了护士的工作效率.     

Use of gum elastic bougie for prehospital difficult intubation

The objective of this study was to assess effectiveness of gum elastic bougie (GEB) in case of difficult intubation occurring in the prehospital settings. After manikin training to GEB handling, physicians were recommended to use GEB as first alternative technique in case of difficult intubation. Intubating conditions and details of patients requiring GEB-assisted laryngoscopy were recorded over 30 months. Among the 1442 extrahospital intubations performed, 41 patients (3%) required GEB. Gum elastic bougie allowed successful intubation in 33 cases (78%) and 8 patients sustained a second alternative technique. One patient was never intubated, another 1 required rescue cricothyroidotomy. Twenty-four (60%) GEB patients had associated factors for difficult intubation such as reduced or limited cervical spine mobility, morbid obesity, cervicofacial trauma, and ears, nose, and throat neoplasia. The success rate of GEB was 75% and 94%, respectively, depending on whether associated factors for difficult intubation are present or not. No adverse events associated to GEB use were noted.