Questions, Airway and Sedation 2014

1. Do you reach for video laryngoscopy or direct laryngoscopy first for intubations?

eml airway 20142. Do you use cricoid pressure during induction and paralysis?

3. How long do you keep patients NPO prior to procedural sedation?

4. When using ketamine for procedural sedation do you pretreat with benzodiazepines or anticholinergics?

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8 Responses to Questions, Airway and Sedation 2014

  1. Eugene Izsak says:

    1. Video 2. Sometimes 3. At least 1 hour 4. No

    Sent from my iPhone

    >

  2. John Hipskind says:

    1. Video 2. Never 3. Zero 4. Neither

  3. Fredrik Granholm says:

    1: DL 2: No 3: 0h 4: No

  4. David Hile says:

    1) I alternate; 2) No (but use laryngeal manipulation to enhance view of cords 3) n/a for most (emergent) cases 4) NO!

  5. patrick bruss says:

    1. I opt for DL first but always have VL ready. I have read multiple studies that show evidence for VL as superior but not all of them are done on patients in the ED. See 5 article below for further reading. These are ED patients only and I excluded any company sponsored trial. In my opinion the bugie with DL is the best combination for difficult airway.

    1. Tracheal intubation in the emergency department: a comparison of GlideScope® video laryngoscopy to direct laryngoscopy in 822 intubations.
    Sakles JC1, Mosier JM, Chiu S, Keim SM.
    Author information
    Abstract
    BACKGROUND:
    Video laryngoscopy has, in recent years, become more available to emergency physicians. However, little research has been conducted to compare their success to conventional direct laryngoscopy.
    OBJECTIVES:
    To compare the success rates of GlideScope(®) (Verathon Inc., Bothell, WA) videolaryngoscopy (GVL) with direct laryngoscopy (DL) for emergency department (ED) intubations.
    METHODS:
    This was a 24-month retrospective observational study of all patients intubated in a single academic ED with a level I trauma center. Structured data forms were completed after each intubation and entered into a continuous quality improvement database. All patients intubated in the ED with either the GlideScope(®) standard, Cobalt, Ranger, or traditional Macintosh or Miller laryngoscopes were included. All patients intubated before arrival were excluded. Primary analysis evaluated overall and first-attempt success rates, operator experience level, performance characteristics of GVL, complications, and reasons for failure.
    RESULTS:
    There were 943 patients intubated during the study period; 120 were excluded due to alternative management strategies. DL was used in 583 (62%) patients, and GVL in 360 (38%). GVL had higher first-attempt success (75%, p = 0.03); DL had a higher success rate when more than one attempt was required (57%, p = 0.003). The devices had statistically equivalent overall success rates. GVL had fewer esophageal intubations (n = 1) than DL (n = 18); p = 0.005.
    CONCLUSION:
    The two techniques performed equivalently overall, however, GVL had a higher overall success rate, and lower number of esophageal complications. In the setting of ED intubations, GVL offers an excellent option to maximize first-attempt success for airway management.
    Published by Elsevier Inc.
    PMID: 21689899 [PubMed – indexed for MEDLINE]

    2. Acad Emerg Med. 2009 Sep;16(9):866-71. doi: 10.1111/j.1553-2712.2009.00492.x. Epub 2009 Aug 6.
    A comparison of GlideScope video laryngoscopy versus direct laryngoscopy intubation in the emergency department.
    Platts-Mills TF1, Campagne D, Chinnock B, Snowden B, Glickman LT, Hendey GW.
    Author information
    Abstract
    OBJECTIVES:
    The first-attempt success rate of intubation was compared using GlideScope video laryngoscopy and direct laryngoscopy in an emergency department (ED).
    METHODS:
    A prospective observational study was conducted of adult patients undergoing intubation in the ED of a Level 1 trauma center with an emergency medicine residency program. Patients were consecutively enrolled between August 2006 and February 2008. Data collected included indication for intubation, patient characteristics, device used, initial oxygen saturation, and resident postgraduate year. The primary outcome measure was success with first attempt. Secondary outcome measures included time to successful intubation, intubation failure, and lowest oxygen saturation levels. An attempt was defined as the introduction of the laryngoscope into the mouth. Failure was defined as an esophageal intubation, changing to a different device or physician, or inability to place the endotracheal tube after three attempts.
    RESULTS:
    A total of 280 patients were enrolled, of whom video laryngoscopy was used for the initial intubation attempt in 63 (22%) and direct laryngoscopy was used in 217 (78%). Reasons for intubation included altered mental status (64%), respiratory distress (47%), facial trauma (9%), and immobilization for imaging (9%). Overall, 233 (83%) intubations were successful on the first attempt, 26 (9%) failures occurred, and one patient received a cricothyrotomy. The first-attempt success rate was 51 of 63 (81%, 95% confidence interval [CI] = 70% to 89%) for video laryngoscopy versus 182 of 217 (84%, 95% CI = 79% to 88%) for direct laryngoscopy (p = 0.59). Median time to successful intubation was 42 seconds (range, 13 to 350 seconds) for video laryngoscopy versus 30 seconds (range, 11 to 600 seconds) for direct laryngoscopy (p < 0.01).
    CONCLUSIONS:
    Rates of successful intubation on first attempt were not significantly different between video and direct laryngoscopy. However, intubation using video laryngoscopy required significantly more time to complete.
    (c) 2009 by the Society for Academic Emergency Medicine.
    Comment in
    The ethics of observation. [Acad Emerg Med. 2009]

    3. Comparison of GlideScope Videolaryngoscopy to Direct Laryngoscopy for Intubation of a Pediatric Simulator by Novice Physicians
    Joni E. Rabiner,1 Marc Auerbach,2 Jeffrey R. Avner,1 Dina Daswani,1 and Hnin Khine1
    Emergency Medicine International
    Volume 2013 (2013), Article ID 407547, 6 pages
    Abstract

    Objective. To compare novice clinicians’ performance using GlideScope videolaryngoscopy (GVL) to direct laryngoscopy (DL). Methods. This was a prospective, randomized crossover study. Incoming pediatric interns intubated pediatric simulators in four normal and difficult airway scenarios with GVL and DL. Primary outcomes included time to intubation and rate of successful intubation. Interns rated their satisfaction of the devices and chose the preferred device. Results. Twenty-five interns were included. In the normal airway scenario, there were no differences in mean time for intubation with GVL or DL (61.4 versus 67.4 seconds, ) or number of successful intubations (19 versus 18, ). In the difficult airway scenario, interns took longer to intubate with GVL than DL (87.7 versus 61.3 seconds, ), but there were no differences in successful intubations (14 versus 15, ). There was a trend towards higher satisfaction for GVL than DL (7.3 versus 6.4, ), and GVL was chosen as the preferred device by a majority of interns (17/25, 68%). Conclusions. For novice clinicians, GVL does not improve time to intubation or intubation success rates in a pediatric simulator model of normal and difficult airway scenarios. Still, these novice clinicians overall preferred GVL.

    4. Comparison of video and direct laryngoscope for tracheal intubation in emergency settings: A meta-analysis

    Yi-Kung Lee, Chien-Chih Chen, Tzong-Luen Wang, Kueiyu Joshua Lin, Yung-Cheng Sucorrespondenceemail
    Received: March 13, 2012; Accepted: April 25, 2012; Published Online: June 29, 2012
    Abstract
    Background
    Video laryngoscope has recently been introduced as an alternative for performing intubation; however, its validity in emergency settings has not been thoroughly evaluated. Therefore, we conducted a meta-analysis to assess its value compared with direct laryngoscope in emergency settings.

    Purpose
    We conducted a meta-analysis to assess its value compared with direct laryngoscope in emergency settings.

    Methods
    PubMed and EMBASE were searched for studies published through April 2011. Trials that reported data comparing video laryngoscope versus direct laryngoscope-assisted intubation in the emergency room or prehospital locations were included.

    Results
    Four trials reporting a total of 1305 participants were identified. During intubation, video laryngoscope failed to produce high rates of successful intubation (success rate: 0.70; 95% confidence interval [CI]: 0.49–1.01). Time to intubation was not different when using either video laryngoscope or direct laryngoscope (standardized mean difference: 0.19; 95% CI: -0.20—0.58). Furthermore, video laryngoscope seems to achieve a similar glottic view as direct laryngoscope (ratio of better glottic view: 0.96; 95% CI: 0.63–1.46).

    Conclusion
    In the reviewed studies, video laryngoscope was not superior to direct laryngoscope for performing intubation in emergency settings.

    5.Learning Curves for Direct Laryngoscopy and GlideScope® Video Laryngoscopy in an Emergency Medicine Residency

    Journal Issue:
    Western Journal of Emergency Medicine, 15(7)

    Author:
    Sakles, John C., University of Arizona, Department of Emergency Medicine, Tucson, Arizona;
    Mosier, Jarrod M., University of Arizona, Department of Emergency Medicine, Tucson, Arizona;
    Patanwala, Asad E., University of Arizona College of Pharmacy, Department of Pharmacy Practice and Science, Tucson, Arizona;
    Dicken, John M., University of Arizona College of Medicine, Tucson, Arizona

    Introduction: Our objective is to evaluate the resident learning curves for direct laryngoscopy (DL) and GlideScope® video laryngoscopy (GVL) over the course of an emergency medicine (EM) residency training program.

    Methods: This was an analysis of intubations performed in the emergency department (ED) by EM residents over a seven-year period from July 1, 2007 to June 30, 2014 at an academic ED with 70,000 annual visits. After EM residents perform an intubation in the ED they complete a continuous quality improvement (CQI) form. Data collected includes patient demographics, operator post- graduate year (PGY), difficult airway characteristics (DACs), method of intubation, device used for intubation and outcome of each attempt. We included in this analysis only adult intubations performed by EM residents using a DL or a standard reusable GVL. The primary outcome was first pass success, defined as a successful intubation with a single laryngoscope insertion. First pass success was evaluated for each PGY of training for DL and GVL. Logistic mixed-effects models were constructed for each device to determine the effect of PGY level on first pass success, after adjusting for important confounders.

    Results: Over the seven-year period, the DL was used as the initial device on 1,035 patients and the GVL was used as the initial device on 578 patients by EM residents. When using the DL the first past success of PGY-1 residents was 69.9% (160/229; 95% CI 63.5%-75.7%), of PGY-2 residents was 71.7% (274/382; 95% CI 66.9%-76.2%), and of PGY-3 residents was 72.9% (309/424; 95% CI 68.4%-77.1%). When using the GVL the first pass success of PGY-1 residents was 74.4% (87/117; 95% CI 65.5%-82.0%), of PGY-2 residents was 83.6% (194/232; 95% CI 76.7%-87.7%), and of PGY-3 residents was 90.0% (206/229; 95% CI 85.3%-93.5%). In the mixed-effects model for DL, first pass success for PGY-2 and PGY-3 residents did not improve compared to PGY-1 residents (PGY-2 aOR 1.3, 95% CI 0.9-1.9; p-value 0.236) (PGY-3 aOR 1.5, 95% CI 1.0-2.2, p-value 0.067). However, in the model for GVL, first pass success for PGY-2 and PGY-3 residents improved compared to PGY-1 residents (PGY-2 aOR 2.1, 95% CI 1.1-3.8, p-value 0.021) (PGY-3 aOR 4.1, 95% CI 2.1-8.0, p8 hours) on emesis and aspiration during
    ED procedural sedation. None of these studies demonstrated a
    significant difference in rates of emesis or aspiration when
    comparing fasting times. In addition, no serious adverse events
    caused by emesis or aspiration were found. The current evidence
    does not support the rationale put forth in the non–emergency
    medicine guidelines that adhering to a minimum fasting time
    reduces adverse events in ED procedural sedation.
    Roback et al26 performed a single-center study of 1,555
    pediatric patients undergoing procedural sedation with ketamine,
    midazolam, midazolam/ketamine, midazolam/fentanyl, and a
    small number of other agents. The study found no relationship
    between fasting time and the proportion of patients with adverse
    events. Respiratory adverse events were defined as apnea,
    laryngospasm, pulse oximetry less than 90% on room air at the
    elevation of the study site (5,280 feet), and aspiration. Any
    adverse events (vomiting or adverse respiratory event) occurred in
    12.0% in the 0- to 2-hour group, 16.4% in the 2- to 4-hour

    4. I DO NOT pretreat with benzodiazepines or anticholinergics when using ketamine. See below from ACEPs 2011 Clinical Practice Guidelines.

    Coadministered Anticholinergics
    Traditionally the prophylactic coadministration of an
    anticholinergic (ie, atropine or glycopyrrolate) has been routinely
    recommended, with the intent of mitigating oral secretions and
    thus presumably airway adverse events.1,12,15,16 However, large
    case series of patients have been safely treated without this
    adjunct.35,80 The large meta-analysis found anticholinergics to
    be associated with significantly more airway and respiratory
    adverse events and significantly less vomiting; however, both
    were at magnitudes of doubtful clinical importance.2,3,81 Given
    this lack of tangible benefit or harm, the literature is not
    supportive of anticholinergic prophylaxis. Instead, these drugs
    could be reserved for the treatment of unusual occurrences of
    clinically important hypersalivation or for patients with an
    impaired ability to mobilize secretions.
    Coadministered Benzodiazepines
    As with anticholinergics, the prophylactic coadministration of
    benzodiazepines has been traditionally recommended with the
    intent of preventing or reducing recovery reactions.4,12,15,16 A
    single controlled trial in ED adults found that midazolam
    pretreatment (0.03 mg/kg IV) significantly reduced the
    incidence of recovery agitation by 17% (number needed to
    benefit6).28 Unfortunately, this study failed to describe the
    nature or severity of these reactions, and so it remains unclear
    how many of the events were clinically important and how
    many were minor and transient. Nevertheless, midazolam
    prophylaxis appears a reasonable but nonmandatory option in
    adults.
    In children, however, 2 controlled trials82,83 and a large
    meta-analysis3 have failed to note even a trend toward benefit
    from such prophylaxis. Children have far fewer recovery
    reactions than adults, and thus the routine pretreatment of such
    patients is not supported by the evidence.
    When unpleasant ketamine-associated recovery reactions do
    rarely occur, they can be rapidly and reliably diminished with
    titrated benzodiazepines.4,12,16,19,20,36,71,83,84

  6. patrick bruss says:

    2. I do not routinely use cricoid pressure. I do not find that it helps with my view and have not been convinced about its benefit based on research I have read.Coppy and paste the link below in your browser for a nice review.

    file:///C:/Users/discharge/Downloads/annals-of-emergency-medicine-2007-ellis1.pdf

    3. In the ER I have no control over when a patient last took PO and DO NOT let it affect my decision on procedural sedation. See below from ACEPs 2014 Clinical Policies.

    CRITICAL QUESTIONS

    1. In patients undergoing procedural sedation and

    analgesia in the emergency department, does preprocedural

    fasting demonstrate a reduction in the risk of emesis or

    aspiration?

    Recommendations

    Level A recommendations. None specified.

    Level B recommendations. Do not delay procedural sedation

    in adults or pediatrics in the ED based on fasting time.

    Preprocedural fasting for any duration has not demonstrated a

    reduction in the risk of emesis or aspiration when administering

    procedural sedation and analgesia.

    Level C recommendations. None specified.

    Key words/phrases for literature searches: conscious sedation,

    sedation, procedural sedation, procedural analgesia, moderate

    sedation, deep sedation, fasting, gastric emptying, complication,

    aspiration, emesis, and variations and combinations of the key

    words/phrases; years January 2004 to May 2012.

    Emesis or aspiration during procedural sedation in the ED

    is rare.21 For healthy patients undergoing elective sedation/

    analgesia, other professional society guidelines outside of

    emergency medicine recommend a 2-hour fasting time for

    clear liquids, 4-hour fasting time for breast milk, and a 6-hour

    fasting time for solids. However, the guidelines are based on the

    extrapolation of general anesthesia cases in the operating room,

    in which airway manipulation during intubation and extubation

    increases the aspiration risk. Thus, it is not clear whether

    applying these guidelines to ED procedural sedation and

    analgesia reduces the risk of emesis or aspiration. Moreover, even

    within the framework of these guidelines, emergent sedations

    are an exclusion from fasting requirements.22

    As a result, guidelines for elective procedures in the operating

    room (eg, nothing by mouth, preoperative fasting guidelines) are

    not directly applicable in the ED. In addition, multiple other

    practice guidelines and systematic reviews do not find evidence to

    support a specific fasting period before ED procedural sedation.

    Two systematic reviews23,24 and 2 practice advisories11,25

    acknowledge the lack of evidence to support specific preprocedural

    fasting requirements.

    Four Class II trials with pediatric patients26-29 and 1 Class II

    trial with adult and pediatric patients30 examined the effect

    of fasting time (0 to >8 hours) on emesis and aspiration during

    ED procedural sedation. None of these studies demonstrated a

    significant difference in rates of emesis or aspiration when

    comparing fasting times. In addition, no serious adverse events

    caused by emesis or aspiration were found. The current evidence

    does not support the rationale put forth in the non–emergency

    medicine guidelines that adhering to a minimum fasting time

    reduces adverse events in ED procedural sedation.

    Roback et al26 performed a single-center study of 1,555

    pediatric patients undergoing procedural sedation with ketamine,

    midazolam, midazolam/ketamine, midazolam/fentanyl, and a

    small number of other agents. The study found no relationship

    between fasting time and the proportion of patients with adverse

    events. Respiratory adverse events were defined as apnea,

    laryngospasm, pulse oximetry less than 90% on room air at the

    elevation of the study site (5,280 feet), and aspiration. Any

    adverse events (vomiting or adverse respiratory event) occurred in

    12.0% in the 0- to 2-hour group, 16.4% in the 2- to 4-hour group, 14.0% in the 4- to 6-hour group, 14.6% in the 6- to
    8-hour group, and 14.5% in the greater than 8 hours group.
    Using the group that fasted 0 to 2 hours as the reference group,
    the difference in proportion of any adverse events was 4.3% in
    the 2- to 4-hour group, 2.0% in the 4- to 6-hour group, 2.6% in
    the 6- to 8-hour group, and 2.5% in the greater than 8 hours
    group. There were no aspiration events documented in the entire
    cohort of 1,555 patients.
    Treston27 included 257 pediatric patients undergoing
    procedural sedation with ketamine. In this study also, fasting
    time did not correlate with the incidence of emesis, which
    occurred in 6.6% in the 1 hour or less fasting group, 14.0% in
    the 1- to 2-hour fasting group, and 15.7% in the 3 hours or
    greater group. Using the group that fasted 1 hour or less as the
    reference group, the difference in proportion of vomiting in the
    1- to 2-hour fasting group was 7.3%; in the 3-hour or greater
    group, 9.1%. No clinically detectable aspiration occurred, and no
    airway maneuvers or suctioning was required.
    Babl et al28conducted a study of 218 consecutive pediatric
    patients undergoing procedural sedation with nitrous oxide.
    Fasting guidelines for solids were not met by 71.1% of the patients.
    There was no statistical difference in incidence of emesis, which
    occurred in 7.1% of patients who did not meet fasting guidelines
    for solids compared with 6.3% in those who met guidelines.
    Serious adverse events were defined as pulse oximetry less than
    95%, apnea, stridor, airway misalignment requiring repositioning,
    laryngospasm, bronchospasm, cardiovascular instability,
    pulmonary aspiration, unplanned hospital admission,
    endotracheal intubation, permanent neurologic injury, or death.
    There were no serious adverse events observed.
    McKee et al29 examined 471 pediatric patients undergoing
    procedural sedation with ketamine, in which presedation oral
    analgesic administration was recorded. In this Class II study,
    42.7% of patients received oral analgesics within 6 hours of
    sedation. Emesis occurred in 5.0% of patients who received oral
    analgesics compared with 2.6% of patients who did not receive
    oral analgesics. Additional adverse events recorded were hypoxia
    (desaturation requiring supplemental oxygen), hypoventilation,
    laryngospasm, apnea, bradycardia, or tachycardia. Total adverse
    events were similar for patients receiving oral analgesia (5.0%)
    and those not receiving oral analgesia (5.6%). The authors did
    not report episodes of intubation, aspiration, unplanned
    admission, or death, although these were not explicit outcome
    measures in the study.
    Bell et al30 followed 400 adult and pediatric patients
    undergoing procedural sedation with propofol. The authors
    found that 70.5% of those enrolled did not meet American
    Society of Anesthesiologists (ASA) fasting guidelines for solids or
    liquids. They identified no significant difference between the
    groups meeting and not meeting fasting guidelines with respect
    to adverse events that included emesis and respiratory
    interventions. Emesis occurred in 0.4% of patients who did not
    meet fasting guidelines compared with 0.8% of those who met
    guidelines. The combined endpoint of respiratory adverse events
    was defined as transient apnea, pulse oximetry less than 95%,
    respiratory rate less than 12 breaths/min, elevated end-tidal
    carbon dioxide (ETCO2) greater than 10 mm Hg, vomiting, and
    aspiration. Respiratory adverse events occurred in 22.4% of
    patients who did not meet fasting guidelines compared with
    19.5% of those who met guidelines. With only 2 episodes of
    emesis and no aspiration events, this combined endpoint was
    driven primarily by interventions less likely to be related to
    fasting, such as respiratory depression and desaturation. The
    combined endpoint of respiratory interventions was defined as
    basic airway maneuvers, Guedel/bag-valve-mask, and suctioning.
    Respiratory interventions occurred in 33.3% of patients who did
    not meet fasting guidelines compared with 24.6% of those who
    met guidelines. With only 3 interventions requiring suctioning,
    this combined endpoint is predominantly weighted by basic
    airway and bag-valve-mask interventions, which are less likely to
    be affected by fasting. There were no aspiration events,
    intubations, laryngeal mask airway insertions, or unplanned
    admissions related to sedation or recovery in either group.
    Future research should focus on the identification of a
    potential high-risk population that might benefit from a fasting
    time or a sedation agent with better efficacy after patient fasting if
    such a delay is to be relevant in any ED procedural sedations. In
    addition, research into the harms of enforcing fasting periods
    would bring balance to the literature. Concerns about procedural
    difficulty, ED resource utilization, and pediatric hypoglycemia
    related to enforced fasting periods for ED procedural sedation
    have not been evaluated.

  7. Matt King says:

    1. I go for DL first unless PT can cooperate and I know their Mallampatti is 3-4 or their LEMON is poor, then VL first. Then VL is for a second attempt after DL if I get a very low or 0/100 POGO score or first DL attempt w/ bougie is unsuccessful. 2. No cricoid pressure. 3. I work prehospital so no luxury of NPO. 4. I do not pretreat before I give ketamine, but I do resuscitate first if possible then follow with Midazolam boluses appropriately after. No anticholinergics either.

  8. Julina says:

    1. Lately…video
    2. No
    3. Zero mins
    4. Never

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