PP23  Soiled airway tracheal intubation and the effectiveness of decontamination by north east paramedics: a randomised controlled manikin study. The satiated2 study

2020 ◽  
Vol 37 (10) ◽  
pp. e11.1-e11
Author(s):  
Graham McClelland ◽  
Richard Pilbery ◽  
Sarah Hepburn

BackgroundVomiting and regurgitation are commonly encountered in out-of-hospital cardiac arrest, but traditional paramedic suctioning techniques may be insufficient to manage severely soiled airways.A technique called Suction Assisted Laryngoscopy and Airway Decontamination (SALAD) has been developed to help clinicians manage these difficult airways. The only UK SALAD study (SATIATED) reported improved paramedic first-pass intubation success rate. This study has now been replicated in a different ambulance service.The primary research question was: Does paramedic first-pass intubation rate in North East Ambulance Service improve following training in SALAD? The secondary research question was: Does training in SALAD affect the time taken to intubate by paramedics?MethodsA randomised controlled trial of SALAD was conducted using a modified airway manikin capable of vomiting to simulate a soiled airway. The intervention comprised SALAD training and the introduction of the DuCanto catheter for post-training attempts. Participants were randomised into two groups: A01A02B01 who made two pre-training intubation attempts and one post-training attempt, and A11B11B12, who made one pre-training and two post-training attempts. Data were collected on length of service, success rates, timings and techniques used.ResultsParamedics (n=102 participants, n=99 completed the study) were recruited between August and December 2019. First-pass intubation success rates on the second attempts (A02versus B11) were 86% and 96% respectively; a non-significant improvement of 10% (95% CI 1–21%, p=0.09). Both groups intubated faster on third attempts compared to first attempts. A01 to B01 mean improvement 5 (SD 14) seconds, A11 to B12 mean improvement 9 (SD 15) seconds. There was no significant difference in improvement between groups (mean difference -4 seconds, 95% CI -11–3 seconds, p=0.22).ConclusionsNorth East Ambulance Service paramedics demonstrated improved first-pass intubation success rates in a simulated soiled airway following SALAD training and improved time to intubation. This study supports the findings of the SATIATED study.

2020 ◽  
Vol 37 (10) ◽  
pp. e4.1-e4
Author(s):  
Graham McClelland ◽  
Karl Charlton ◽  
Jacqueline Mains ◽  
Karen Millican ◽  
Caroline Cullerton

BackgroundAmbulance services transport patients with infections and diseases and could pose a cross transmission risk to patients and staff through environmental contamination. The literature suggests that environmental pathogens are present on ambulances, cleaning is inconsistent and patient/staff impact is difficult to quantify. Eco-Mist developed a dry misting decontamination system for ambulance use called AmbuGard which works in <30 minutes and is 99.9999% effective against common pathogens. The research question is ‘What pathogens are present on North East Ambulance Service ambulances and what impact does adding the AmbuGard to the deep cleaning process make?’MethodsA two armed, randomised controlled trial enrolled fourteen ambulances during their regular 24 week deep clean which were 1:1 randomised to deep cleaning (control arm) or deep cleaning plus AmbuGard (intervention arm). Polywipe swabs were taken before and after cleaning from five locations selected for high rates of contact (steering wheel, shelf, side door grab rail, patient seat armrest, rear door handle/grab rail). Microbiology culture methods identified the presence and amount of bacterial organisms present including the selected pathogens: Enterococcus spp.; Enterobacter spp.; Klebsiella spp.; Staphylococcus aureus; Acinetobacter spp.; Pseudomonas spp.; Clostridium difficile; coagulase-negative staphylococci (CoNS)). The researcher taking the swabs and the laboratory were blinded to the trial arm.ResultsPathogens of interest were found on 10 (71%) vehicles. CoNS were found on all vehicles. Pathogens were found on all locations swabbed. Normal deep cleaning was effective at eliminating pathogens and the addition of AmbuGard showed no obvious improvement in effectiveness.ConclusionPathogens associated with healthcare acquired infections were found throughout all ambulances. Normal deep cleaning was effective and adding AmbuGard showed no obvious improvement. This was a small study at a single point in time. Further research is needed into temporal trends, how to reduce pathogens during normal clinical duties and patient/staff impact.


2020 ◽  
Vol 5 (2) ◽  
pp. 10-17
Author(s):  
Graham McClelland ◽  
Karl Charlton ◽  
Jacqueline Mains ◽  
Karen Millican ◽  
Caroline Cullerton

Background: Ambulance services transport patients with infections and diseases, and could pose a cross-transmission risk to patients and staff through environmental contamination. The literature suggests that environmental pathogens are present in ambulances, cleaning is inconsistent and patient/staff impact is difficult to quantify. Eco-Mist developed a dry misting decontamination system for ambulance use called AmbuGard, which works in < 30 minutes and is 99.9999% effective against common pathogens. The research question is: ‘What pathogens are present in North East Ambulance Service ambulances and what impact does adding AmbuGard to the deep-cleaning process make?’.Methods: A two-armed, randomised controlled trial enrolled 14 ambulances during their regular 24-week deep clean, which were 1:1 randomised to deep cleaning (control arm) or deep cleaning plus AmbuGard (intervention arm). Polywipe swabs were taken before and after cleaning from five locations selected for high rates of contact (steering wheel, shelf, side-door grab rail, patient seat armrest, rear door handle/grab rail). Microbiology culture methods identified the presence and amount of bacterial organisms present, including the selected pathogens: Enterococcus spp.; Enterobacter spp.; Klebsiella spp.; Staphylococcus aureus; Acinetobacter spp.; Pseudomonas spp.; Clostridium difficile; coagulase-negative staphylococci (CoNS). The researcher taking the swabs and the laboratory were blinded to the trial arm.Results: Pathogens of interest were found in 10 (71%) vehicles. CoNS were found in all vehicles. Pathogens were found on all locations swabbed. Normal deep cleaning was effective at eliminating pathogens and the addition of AmbuGard showed no obvious improvement in effectiveness.Conclusion: Pathogens associated with healthcare-acquired infections were found throughout all ambulances. Normal deep cleaning was effective, and adding AmbuGard showed no obvious improvement. This was a small study at a single point in time. Further research is needed into temporal trends, how to reduce pathogens during normal clinical duties and patient/staff impact.


2020 ◽  
Vol 17 ◽  
Author(s):  
Graham McClelland ◽  
Richard Pilbery ◽  
Sarah Hepburn

Introduction Vomiting and regurgitation are commonly encountered in out-of-hospital cardiac arrest, but traditional paramedic suctioning techniques may be insufficient to manage severely soiled airways. The Suction Assisted Laryngoscopy and Airway Decontamination (SALAD) technique was developed to help clinicians manage soiled airways. SATIATED2 reports the impact of SALAD training in North East Ambulance Service (NEAS) in the United Kingdom following the original SATIATED study in the Yorkshire Ambulance Service. The primary research question was: Among NEAS paramedics, does the addition of SALAD training, compared to standard training, improve the success rate of intubation for the soiled airway? Methods A randomised controlled trial of SALAD was conducted using a modified airway manikin capable of vomiting. The intervention comprised SALAD training and the introduction of the DuCanto catheter. Paramedic volunteers were block randomised into two groups: A01A02B01 who made two pre-training intubation attempts and one post-training attempt, and A11B11B12, who made one pre-training and two post-training attempts. The primary outcome was intubation success rate at the second attempt. The time taken to intubate was recorded as a secondary outcome. SATIATED2 was registered with ISRCTN (ISRCTN17329526) and funded internally with commercial support from SSCOR who supplied the DuCanto catheters. Results One-hundred and two paramedics (51 AAB, 51 ABB) were recruited between August and December 2019 with 99 participating (50 AAB, 49 ABB). The primary outcome was intubation success rate on the second attempt (A02 vs. B11) which were 86% without SALAD and 96% with SALAD; a non-significant improvement of 10% (95% CI: 1–21, p=0.09). The total intubation success rate pre-training (A01+A02+A11) was 75% (112/149) compared with 98% (145/148) post-training (B01+B11+B12). Conclusion NEAS paramedics demonstrated improved, but non-significant, intubation success rates in a simulated soiled airway following SALAD training.


2020 ◽  
Author(s):  
Wenjun Zhu ◽  
Yuchen Zhang ◽  
Jingyu Shi ◽  
Xiaoqin Wang ◽  
Renjiao Li ◽  
...  

Abstract Background: Nasal insertion is the preferred method in flexible bronchoscopy; however, the relatively narrow nasal cavity increases the difficulty of bronchoscope insertion. The aim of the study was to investigate the advantages of a prior nasal cavity probe during flexible bronchoscopy and to investigate whether this novel method could reduce the complications associated with flexible bronchoscopy.Methods: This prospective randomized controlled trial was conducted in a tertiary hospital between May 2020 and October 2020. Three hundred patients requiring diagnosis and treatment using flexible bronchoscopy were randomly allocated to three groups: a control group, a simple cotton bud detection group (CD group), and an adrenaline detection group (AD group). The outcomes were the time to pass the glottis, the first-pass intubation success rate, and postoperative complications, especially nasal bleeding.Results: In total, 189 men and 111 women were enrolled in the study, with a mean age of 55.69 ± 12.86 years. The operation time was longer in the control group (24 [14.25-45.75] s) than in the CD group (19.5 [12.25-32.75] s). Compared with that in the CD group, the first-pass intubation success rate was significantly lower in the control group (p<0.05). There was no difference in nasal bleeding between the control group and the CD group (p=0.506). Nasal bleeding after flexible bronchoscopy was more common in the CD group than in the AD group (p=0.005); however, there was no significant between-group difference in hemostatic use (p=0.245). Conclusions: Use of a prior nasal cavity probe during flexible bronchoscopy can significantly reduce the time to pass the nasal cavity, improve the first-pass intubation success rate, and reduce postoperative nasal bleeding. Nasal detection is recommended as a time-saving procedure for patients undergoing flexible bronchoscopy. Trial registration: ChiCTR2000032668, 6th May.2020.


2019 ◽  
Vol 36 (9) ◽  
pp. 535-540 ◽  
Author(s):  
Karl Charlton ◽  
John Franklin ◽  
Rebekah McNaughton

ObjectivesWe set out to investigate paramedics’ views of ethics and research, drawing on experiences from Paramedic-2, a randomised controlled trial comparing epinephrine and placebo in out-of-hospital cardiac arrest (OHCA).MethodsAn interpretative phenomenological approach was adopted. A purposive sample of paramedics (n=6) from North East Ambulance Service NHS Foundation Trust were invited to a semi-structured, in-depth interview.ResultsThree superordinate themes emerged: (1) morality, (2) emotion and (3) equipoise. Some viewed Paramedic-2 as an opportunity to improve OHCA outcomes for the many, viewing participation as a moral obligation; others viewed the study as unethical, equating participation with immoral behaviour. Morality was a motivator to drive individual action. Positive and negative emotions were exhibited by the paramedics involved reflecting the wider view each paramedic held about trial participation. Those morally driven to participate in Paramedic-2 discussed their pride in being associated with the trial, while those who found participation unethical, discussed feelings of guilt and regret. Individual experience and perceptions of epinephrine guided each paramedic’s willingness to accept or reject equipoise. Some questioned the role of epinephrine in OHCA; others believed withholding epinephrine was synonymous to denying patient care.ConclusionA paucity of evidence exists to support any beneficial role of epinephrine in OHCA. Despite this, some paramedics were reluctant to participate in Paramedic-2 and relied on their personal perceptions and experiences of epinephrine to guide their decision regarding participation. Failure to acknowledge the importance of individual perspectives may jeopardise the success of future out-of-hospital trials.


2017 ◽  
Vol 103 (5) ◽  
pp. F408-F412 ◽  
Author(s):  
Joyce E O’Shea ◽  
Prakash Loganathan ◽  
Marta Thio ◽  
C Omar Farouk Kamlin ◽  
Peter G Davis

ObjectivesNeonatal intubation is a difficult skill to learn and teach. If an attempt is unsuccessful, the intubator and instructor often cannot explain why. This study aims to review videolaryngoscopy recordings of unsuccessful intubations and explain the reasons why attempts were not successful.Study designThis is a descriptive study examining videolaryngoscopy recordings obtained from a randomised controlled trial that evaluated if neonatal intubation success rates of inexperienced trainees were superior if they used a videolaryngoscope compared with a laryngoscope. All recorded unsuccessful intubations were included and reviewed independently by two reviewers blinded to study group. Their assessment was correlated with the intubator’s perception as reported in a postintubation questionnaire. The Cormack-Lehane classification system was used for objective assessment of laryngeal view.ResultsRecordings and questionnaires from 45 unsuccessful intubations were included (15 intervention and 30 control). The most common reasons for an unsuccessful attempt were oesophageal intubation and failure to recognise the anatomy. In 36 (80%) of intubations, an intubatable view was achieved but was then either lost, not recognised or there was an apparent inability to correctly direct the endotracheal tube. Suctioning was commonly performed but rarely improved the view.ConclusionsLack of intubation success was most commonly due to failure to recognise midline anatomical structures. Trainees need to be taught to recognise the uvula and epiglottis and use these landmarks to guide intubation. Excessive secretions are rarely a factor in elective and premedicated intubations, and routine suctioning should be discouraged. Better blade design may make it easier to direct the tube through the vocal cords.


2012 ◽  
Vol 116 (3) ◽  
pp. 629-636 ◽  
Author(s):  
Michael F. Aziz ◽  
Dawn Dillman ◽  
Rongwei Fu ◽  
Ansgar M. Brambrink

Background Video laryngoscopy may be useful in the setting of the difficult airway, but it remains unclear if intubation success is improved in routine difficult airway management. This study compared success rates for tracheal intubation with the C-MAC® video laryngoscope (Karl Storz, Tuttlingen, Germany) with conventional direct laryngoscopy in patients with predicted difficult airway. Methods We conducted a two arm, single-blinded randomized controlled trial that involved 300 patients. Inclusion required at least one of four predictors of difficult intubation. The primary outcome was successful tracheal intubation on first attempt. Results The use of video laryngoscopy resulted in more successful intubations on first attempt (138/149; 93%) as compared with direct laryngoscopy (124/147; 84%), P = 0.026. Cormack-Lehane laryngeal view was graded I or II in 139/149 of C-MAC attempts versus 119/147 in direct laryngoscopy attempts (P &lt; 0.01). Laryngoscopy time averaged 46 s (95% CI, 40-51) for the C-MAC group and was shorter in the direct laryngoscopy group, 33 s (95% CI, 29-36), P &lt; 0.001. The use of a gum-elastic bougie and/or external laryngeal manipulation were required less often in the C-MAC intubations (24%, 33/138) compared with direct laryngoscopy (37%, 46/124, P = 0.020). The incidence of complications was not significantly different between the C-MAC (20%, 27/138) versus direct laryngoscopy (13%, 16/124, P = 0.146). Conclusion A diverse group of anesthesia providers achieved a higher intubation success rate on first attempt with the C-MAC in a broad range of patients with predictors of difficult intubation. C-MAC laryngoscopy seems to be a useful technique for the initial approach to a potentially difficult airway.


2017 ◽  
Vol 32 (6) ◽  
pp. 621-624 ◽  
Author(s):  
Ryan Hodnick ◽  
Tony Zitek ◽  
Kellen Galster ◽  
Stephen Johnson ◽  
Bryan Bledsoe ◽  
...  

AbstractObjectiveThe primary goal of this study was to compare paramedic first pass success rate between two different video laryngoscopes and direct laryngoscopy (DL) under simulated prehospital conditions in a cadaveric model.MethodsThis was a non-randomized, group-controlled trial in which five non-embalmed, non-frozen cadavers were intubated under prehospital spinal immobilization conditions using DL and with both the GlideScope Ranger (GL; Verathon Inc, Bothell, Washington USA) and the VividTrac VT-A100 (VT; Vivid Medical, Palo Alto, California USA). Participants had to intubate each cadaver with each of the three devices (DL, GL, or VT) in a randomly assigned order. Paramedics were given 31 seconds for an intubation attempt and a maximum of three attempts per device to successfully intubate each cadaver. Confirmation of successful endotracheal intubation (ETI) was confirmed by one of the six on-site physicians.ResultsSuccessful ETI within three attempts across all devices occurred 99.5% of the time overall and individually 98.5% of the time for VT, 100.0% of the time for GL, and 100.0% of the time for DL. First pass success overall was 64.4%. Individually, first pass success was 60.0% for VT, 68.8% for GL, and 64.5% for DL. A chi-square test revealed no statistically significant difference amongst the three devices for first pass success rates (P=.583). Average time to successful intubation was 42.2 seconds for VT, 38.0 seconds for GL, and 33.7 for seconds for DL. The average number of intubation attempts for each device were as follows: 1.48 for VT, 1.40 for GL, and 1.42 for DL.ConclusionThe was no statistically significant difference in first pass or overall successful ETI rates between DL and video laryngoscopy (VL) with either the GL or VT (adult).HodnickR, ZitekT, GalsterK, JohnsonS, BledsoeB, EbbsD. A comparison of paramedic first pass endotracheal intubation success rate of the VividTrac VT-A 100, GlideScope Ranger, and direct laryngoscopy under simulated prehospital cervical spinal immobilization conditions in a cadaveric model. Prehosp Disaster Med. 2017;32(6):621–624.


2019 ◽  
Vol 36 (10) ◽  
pp. e7.1-e7
Author(s):  
Richard Pilbery ◽  
M Dawn Teare

BackgroundIn more than one-in-five cases of out-of-hospital cardiac arrest, the patient’s airway is soiled by vomit and blood. If a paramedic cannot clear the airway, the patient will die. A new method of clearing the airway called suction assisted laryngoscopy and airway decontamination (SALAD) has been developed, but it’s not known whether the method can assist paramedics to intubate. This study aims to determine whether paramedics can intubate a simulated soiled airway more often on their first attempt, using SALAD.MethodsA modified airway manikin, with the oesophagus connected to a reservoir of ‘vomit’ that was propelled up the oesophagus by a pump, was used to simulate a soiled airway. The intervention consisted of a brief SALAD training session with a demonstration and opportunity to practice. Participants were randomly allocated into two groups: AAB who made two pre-training intubation attempts and one post-training attempt, and ABB, who made one pre-training and two post-training attempts, to adjust for improvement in performance due to repetition.Results164 paramedics took part in the study. First-pass intubation success with and without SALAD was 90.2% and 53.7% respectively, a significant difference of 36.6% (95%CI 24–49.1%, p<0.001). The mean successful intubation time for each attempt and patient group (AAB and ABB) was as follows: 61.8 (95%CI 55.8–67.8) and 59.4 (95%CI 53.6–65.1) seconds on the first attempt, 50.8 (95%CI 45.7–55.9) and 51.5 (95%CI 48.6–54.4) seconds on the second attempt and 53.5 (95%CI 50.4–56.6) and 46.6 (95%CI 44.0–49.1) seconds on the third attempt. There was no significant difference in success rates on the third attempt between AAB and ABB 89% vs 86.6% respectively, a difference of 2.4% (95%CI 7.6–12.4%, p=0.63).ConclusionsIn this study, paramedics were able to intubate a simulated soiled airway on their first attempt, significantly more often when using the SALAD technique.


2021 ◽  
pp. 112070002110057
Author(s):  
Niels H Bech ◽  
Inger N Sierevelt ◽  
Sheryl de Waard ◽  
Boudijn S H Joling ◽  
Gino M M J Kerkhoffs ◽  
...  

Background: Hip capsular management after hip arthroscopy remains a topic of debate. Most available current literature is of poor quality and are retrospective or cohort studies. As of today, no clear consensus exists on capsular management after hip arthroscopy. Purpose: To evaluate the effect of routine capsular closure versus unrepaired capsulotomy after interportal capsulotomy measured with NRS pain and the Copenhagen Hip and Groin Outcome Score (HAGOS). Materials and methods: All eligible patients with femoroacetabular impingement who opt for hip arthroscopy ( n = 116) were randomly assigned to one of both treatment groups and were operated by a single surgeon. Postoperative pain was measured with the NRS score weekly the first 12 weeks after surgery. The HAGOS questionnaire was measured at 12 and 52 weeks postoperatively. Results: Baseline characteristics and operation details were comparable between treatment groups. Regarding the NRS pain no significant difference was found between groups at any point the first 12 weeks after surgery ( p = 0.67). Both groups significantly improved after surgery ( p < 0.001). After 3 months follow-up there were no differences between groups for the HAGOS questionnaire except for the domain sport ( p = 0.02) in favour of the control group. After 12 months follow-up there were no differences between both treatment groups on all HAGOS domains ( p  > 0.05). Conclusions: The results of this randomised controlled trial show highest possible evidence that there is no reason for routinely capsular closure after interportal capsulotomy at the end of hip arthroscopy. Trial Registration: This trial was registered at the CCMO Dutch Trial Register: NL55669.048.15.


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