Video Laryngoscopy Compared to Augmented Direct Laryngoscopy in Adult Emergency Department Tracheal Intubations: A National Emergency Airway Registry (NEAR) Study.
成人急诊科气管插管中视频喉镜与增强直接喉镜的比较: 国家紧急气道登记 (NEAR) 研究。
- 作者列表："Brown CA 3rd","Kaji AH","Fantegrossi A","Carlson JN","April MD","Kilgo RW","Walls RM","National Emergency Airway Registry (NEAR) Investigators.
OBJECTIVE:The objective was to compare first-attempt intubation success using direct laryngoscopy augmented by laryngeal manipulation, ramped patient positioning, and use of a bougie (A-DL) with unaided video laryngoscopy (VL) in adult emergency department (ED) intubations. METHODS:This study was a secondary analysis of a multicenter prospective observational database of ED intubations from the National Emergency Airway Registry (NEAR). We compared all VL procedures to seven exploratory permutations of A-DL using multivariable regression models. We further stratified by blade shape into hyperangulated VL (HA-VL) and standard-geometry VL (SG-VL). We report differences in first-attempt intubation success and peri-intubation adverse events with cluster-adjusted odds ratios (ORs) with 95% confidence intervals (CIs). We report univariate comparisons in patient characteristics, difficult airway attributes, and intubation methods using descriptive statistics and OR with 95% CI. RESULTS:We analyzed 11,714 intubations performed from January 1, 2016, through December 31, 2017. Of these encounters, 6,938 underwent orotracheal intubation with either A-DL or unaided VL on first attempt. A-DL was used first in 3,936 (56.7%, 95% CI = 46.9 to 66.5) versus unaided VL in 3,002 (43.3%, 95% CI = 33.5 to 53.1). Of the A-DL first intubations 1,787 (45.4%) employed ramped positioning alone, 1,472 (37.4%) had external laryngeal manipulation (ELM), and 365 (9.3%) used a bougie. Rapid sequence intubation (RSI) was the most common method used in 5,602 (80.8%, 95% CI = 77.0 to 84.5) cases. First-attempt success was significantly higher with all VL (90.9%, 95% CI = 88.7 to 93.1) versus all A-DL (81.1%, 95% CI = 78.7 to 83.5) despite the VL group having more patients with reduced mouth opening, neck immobility, and an initial impression of airway difficult. Multivariable regression analyses controlling for indication, method, operator specialty and year of training, center clustering, and all registry-recorded difficult airway predictors revealed first-attempt success was higher with all unaided VL compared with any A-DL (adjusted OR [AOR] = 2.8, 95% CI = 2.4 to 3.3), DL with bougie (AOR = 2.7, 95% CI = 2.1 to 3.5), DL with ELM (AOR = 1.8, 95% CI = 1.5 to 2.2), DL with ramped positioning (AOR = 2.8, 95% CI = 2.3 to 3.3), or DL with ELM plus bougie (AOR = 2.8, 95% CI = 2.3 to 3.3). Subgroup analyses of HA-VL and SG-VL compared with any A-DL yielded similar results (AOR = 3.2, 95% CI = 2.6 to 3.0; and AOR = 2.4, 95% CI = 1.9 to 3.0, respectively). The propensity score-adjusted odds for first-attempt success with VL was also 2.8 (95% CI = 2.4 to 3.3). Fewer esophageal intubations were observed in the VL cohort (0.4% vs. 1.3%, AOR = 0.2, 95% CI = 0.1 to 0.5). CONCLUSIONS:Video laryngoscopy used without any augmenting maneuver, device, or technique results in higher first-attempt success than does DL that is augmented by use of a bougie, ELM, ramping, or combinations thereof.
目的: 本研究的目的是比较直接喉镜检查 (喉部操作增强) 、倾斜患者定位和探条 (a-DL) 的首次插管成功率。在成人急诊科 (ED) 插管中使用非辅助视频喉镜 (VL)。 方法: 本研究是对来自国家紧急气道登记处 (NEAR) 的多中心前瞻性观察性 ED 插管数据库的二次分析。我们使用多变量回归模型将所有 VL 程序与 A-DL 的 7 个探索性排列进行了比较。我们通过叶片形状进一步分层为高角 VL (HA-VL) 和标准几何 VL (SG-VL)。我们报告了首次插管成功和围插管期不良事件与 95% 置信区间 (CIs) 的集群调整比值比 (ORs) 的差异。我们使用描述性统计和 OR (95% CI) 报告了患者特征、困难气道属性和插管方法的单变量比较。 结果: 我们分析了从 2016年1月1日到 2017年12月31日进行的 11,714 次插管。在这些遭遇中，6,938 在首次尝试时接受了 A-DL 或非辅助 VL 的经口气管插管。首先使用 A-DL 的比例为 3,936 (56.7%，95% CI = 46.9 ~ 66.5)，而非辅助 VL 的比例为 3,002 (43.3%，95% CI = 33.5 ~ 53.1)。在 A-DL 首次插管中，1,787 例 (45.4%) 采用单独倾斜定位，1,472 例 (37.4%) 采用喉外操作 (ELM)，365 例 (9.3%) 采用探条。快速序列插管 (RSI) 是 5,602 (80.8%，95% CI = 77.0 ~ 84.5) 病例最常用的方法。所有 VL (90.9%，95% CI = 88.7 ~ 93.1) 的首次尝试成功率显著高于所有 A-DL (81.1%，95% CI = 78.7 ~ 83.5) 尽管 VL 组有更多的患者张口减少，颈部不动，最初印象是气道困难。多变量回归分析控制适应症、方法、操作员专业和培训年份，中心聚类, 所有登记记录的困难气道预测因子显示，与任何 A-DL 相比，所有非辅助 VL 的首次尝试成功率更高 (校正 OR [AOR] = 2.8, 95% CI = 2.4 至 3.3)，DL 伴 bougie(AOR = 2.7，95% CI = 2.1 ~ 3.5)，DL 伴 ELM (AOR = 1.8，95% CI = 1.5 ~ 2.2)，DL 伴 ramped 定位 (AOR = 2.8, 95% CI = 2.3 ~ 3.3)，or DL 伴 ELM 加 bougie (AOR = 2.8，95% CI = 2.3 ~ 3.3)。与任何 A-DL 相比，HA-VL 和 SG-VL 的亚组分析得出相似的结果 (AOR = 3.2，95% CI = 2.6 ~ 3.0; AOR = 2.4, 95% CI 分别为 1.9 ~ 3.0)。倾向评分调整后的 VL 首次尝试成功的几率也为 2.8 (95% CI = 2.4 ~ 3.3)。在 VL 队列中观察到较少的食管插管 (0.4% vs.1.3%，AOR = 0.2，95% CI = 0.1 ~ 0.5)。 结论: 在没有任何增强操作、装置或技术的情况下使用视频喉镜比使用探条、 ELM 、 ramp 增强的 DL 首次尝试成功率更高, 或其组合。
METHODS:Background: The hospitalization of patients treated in the intensive care unit (ICU) in 5−15% of cases is associated with the occurrence of a complication in the form of ventilator-associated pneumonia (VAP). Purpose: Retrospective assessment of risk factors of VAP in patients treated at ICUs in the University Hospital in Krakow. Methods: The research involved the medical documentation of 1872 patients treated at the ICU of the University Hospital in Krakow between 2014 and 2017. The patients were mechanically ventilated for at least 48 h. The obtained data were presented by qualitative and quantitative analysis (%). The qualitative variables were compared using the Chi2 test. Statistically significant was the p < 0.05 value. Results: VAP was demonstrated in 23% of all patients treated in ICU during the analyzed period, and this infection occurred in 13% of men and 10% of women. Pneumonia associated with ventilation was found primarily in patients staying in the ward for over 15 days and subjected to intratracheal intubation (17%). A statistically significant was found between VAP and co-morbidities, e.g., chronic obstructive pulmonary disease, diabetes, alcoholism, obesity, the occurrence of VAP and multi-organ trauma, hemorrhage/hemorrhagic shock, and fractures as the reasons for admitting ICU patients. Conclusions: Patients with comorbidities such as chronic obstructive pulmonary disease, obesity, diabetes, and alcoholism are a high-risk group for VAP. Particular attention should be paid to patients admitted to the ICU with multi-organ trauma, fractures, and hemorrhage/hemorrhagic shock as patients predisposed to VAP. There is a need for further research into risk factors for non-modifiable VAP such as comorbidities and reasons for ICU admission in order to allow closer monitoring of these patients for VAP.
METHODS::Backgroud Severe pneumonia is one of the most common causes for mechanical ventilation. We aimed to early identify severe pneumonia patients with high risk of extubation failure in order to improve prognosis. Methods From April 2014 to December 2015, medical records of intubated patients with severe pneumonia in intensive care unit were retrieved from database. Patients were divided into extubation success and failure groups, and multivariate logistic regressions were performed to identify independent predictors for extubation failure. Results A total of 125 eligible patients were included, of which 82 and 43 patients had extubation success and failure, respectively. APACHE II score (odds ration (OR) 1.141, 95% confident interval (CI) 1.022-1.273, P = 0.019, cutoff at 17.5), blood glucose (OR 1.122, 95%CI 1.008-1.249, P = 0.035, cutoff at 9.87mmol/L), dose of fentanyl (OR 3.010, 95%CI 1.100-8.237, P = 0.032, cutoff at 1.135mg/d), and the need for red blood cell (RBC) transfusion (OR 2.774, 95%CI 1.062-7.252, P = 0.037) were independent risk factors for extubation failure. Conclusions In patients with severe pneumonia, APACHE II score > 17.5, blood glucose > 9.87mmol/L, fentanyl usage > 1.135mg/d, and the need for RBC transfusion might be associated with higher risk of extubation failure.
METHODS:PURPOSE:To assess the association between the duration of mechanical ventilation during post resuscitation care and 30-day survival after cardiac arrest. METHODS:We conducted a retrospective observational study using data from two national registries. Comatose cardiac arrest patients admitted to general intensive care in Swedish hospitals between 2011 and 2016 were eligible. Based on the median duration of mechanical ventilation for patients who did not survive to hospital discharge, used as a proxy for the endurance of post resuscitation care, the hospitals were divided into four ordered groups for which association with 30-day survival was analyzed. RESULTS:In total, 5.113 patients in 56 hospitals were included. Median duration of mechanical ventilation for patients who did not survive to hospital discharge ranged from 17 hours in hospital group 1 to 51 hours in hospital group 4. After adjustment for baseline characteristics, 30-day survival in the entire cohort was positively and independently associated with ordered hospital group: (adjusted odds ratio (95%CI); 1.12 (1.02,1.23); p = 0.02). Thus, hospitals with a longer duration of mechanical ventilation among non-survivors had better survival rate among patients admitted to ICU after a cardiac arrest. However, in a secondary analysis restricted to patients with length of stay in the intensive care unit ≥ 48 hours, there was no significant association between 30-day survival and ordered hospital group. CONCLUSION:A tendency for longer duration of post resuscitation care in the ICU was associated with higher 30-day survival in comatose patients admitted to intensive care after cardiac arrest.