Iatrogenic Tracheal Rupture Related to Prehospital Emergency Intubation in Adults: A 15-Year Single Center Experience

Objective: Iatrogenic tracheal rupture is an unusual and severe complication that can be caused by tracheal intubation. The frequency, management, and outcome of iatrogenic tracheal rupture due to prehospital emergency intubation in adults by emergency response physicians has not yet been sufficiently explored. Methods: Adult patients with iatrogenic tracheal ruptures due to prehospital emergency intubation admitted to an academic referral center over a 15-year period (2004-2018) with consideration of individual risk factors were analyzed. Results: Thirteen patients (eight female) with a mean age of 67 years met the inclusion criteria and were analyzed. Of these, eight tracheal ruptures (62%) were caused during the airway management of cardiopulmonary resuscitation (CPR). Stylet use and difficult laryngoscopy requiring multiple attempts were documented in eight cases (62%) and four cases (30%), respectively. Seven patients (54%) underwent surgery, while six patients (46%) were treated conservatively. The overall 30-day mortality was 46%; five patients died due to their underlying emergencies and one patient died of tracheal rupture. Three survivors (23%) recovered with severe neurological sequelae and four (30%) were discharged in good neurological condition. Survivors had significantly smaller mean rupture sizes (2.7cm versus 6.3cm; P <.001) and less cutaneous emphysema (n = 2 versus n = 6; P = .021) than nonsurvivors. Conclusions: Iatrogenic tracheal rupture due to prehospital emergency intubation is a rare complication. Published risk factors are not consistently present and may not be applicable to identify patients at high risk, especially not in rescue situations. Treatment options depend on individual patient condition, whereas outcome largely depends on the underlying disease and rupture extension.

EXTERNAL VALIDATION OF A NOVEL DIGITAL SIGNATURE IN CONTINUOUS CARDIORESPIRATORY MONITORING TO DETECT EARLY RESPIRATORY DETERIORATION OF ICU PATIENTS

The goal of predictive analytics monitoring is the early detection of patients at high risk of subacute potentially catastrophic illnesses. A good example of a target illness is respiratory failure leading to urgent unplanned intubation, where early detection might lead to interventions that improve patient outcome. Previously, we identified signatures of this illness in the continuous cardiorespiratory monitoring data of Intensive Care Unit patients and devised algorithms to identify patients at rising risk. Here, we externally validated 3 logistic regression models to estimate risk of emergency intubation that were developed in Medical and Surgical ICUs at the University of Virginia. We calculated the model outputs for more than 8000 patients in University of California San Francisco ICUs, 240 of whom underwent emergency intubation as determined by individual chart review. We found that the AUC of the models exceeded 0.75 in this external population, and that the risk rose appreciably over the 12 hours prior to the event. We conclude that abnormal signatures of respiratory failure in the continuous cardiorespiratory monitoring are a generalizable phenomenon.

Role of Intermediate Care Unit Admission and Noninvasive Respiratory Support during the COVID-19 Pandemic: A Retrospective Cohort Study

<b><i>Background:</i></b> The COVID-19 pandemic has led to shortage of intensive care unit (ICU) capacity. We developed a triage strategy including noninvasive respiratory support and admission to the intermediate care unit (IMCU). ICU admission was restricted to patients requiring invasive ventilation. <b><i>Objectives:</i></b> The aim of this study is to describe the characteristics and outcomes of patients admitted to the IMCU. <b><i>Method:</i></b> Retrospective cohort including consecutive patients admitted between March 28 and April 27, 2020. The primary outcome was the proportion of patients with severe hypoxemic respiratory failure avoiding ICU admission. Secondary outcomes included the rate of emergency intubation, 28-day mortality, and predictors of ICU admission. <b><i>Results:</i></b> One hundred fifty-seven patients with COVID-19-associated pneumonia were admitted to the IMCU. Among the 85 patients admitted for worsening respiratory failure, 52/85 (61%) avoided ICU admission. In multivariate analysis, PaO₂/FiO₂ (OR 0.98; 95% CI: 0.96–0.99) and BMI (OR 0.88; 95% CI: 0.78–0.98) were significantly associated with ICU admission. No death or emergency intubation occurred in the IMCU. <b><i>Conclusions:</i></b> IMCU admission including standardized triage criteria, self-proning, and noninvasive respiratory support prevents ICU admission for a large proportion of patients with COVID-19 hypoxemic respiratory failure. In the context of the COVID-19 pandemic, IMCUs may play an important role in preserving ICU capacity by avoiding ICU admission for patients with worsening respiratory failure and allowing early discharge of ICU patients.

Incidence, determinants and outcomes of ventilator associated pneumonia in medical intensive care unit: a prospective cohort study from South Western India

Background: Ventilators are being increasingly used in developing countries as a result of which complications like ventilator associated pneumonia is also increasing. Present study is being undertaken to evaluate the impact of risk factors and their changing trends for Ventilator associated pneumonia.Methods: A prospective observational study was conducted in mechanically ventilated patients of medical intensive care unit from October 2013 to April 2015.Results: In present study 166 patients receiving mechanical ventilation in a medical ICU were observed. Incidence of VAP in present study is 43.5 for 1000 days of mechanical ventilation. The risk factors that were significant in the study are organ failure (p=0.001), emergency intubation (p=0.001), reintubation (p=0.023) and COPD (p=0.026). The common organisms responsible for VAP were Acinetobacter (30%), Klebsiella pneumoniae (27.1%) and Pseudomonas aeruginosa (20%). The mortality was higher in VAP group (31.3%) compared to the non VAP group (15.7%).Conclusions: There is high incidence of VAP in the developing countries. The risk factors that were found to be associated with VAP in the present study were the presence of COPD, reintubation, organ failure and emergency intubation. VAP is associated with significantly increased duration of hospital stay, morbidity and mortality.

The NIFty Method; Developing the “Neonatal Intubation Flowchart”

Introduction: When intubation is required during a neonatal emergency, it is imperative there are no delays in collecting equipment. Current practice is for the Intubation Assistant to gather intubation equipment with no memory adjuncts. This study aimed to develop a Neonatal Intubation Flowchart (NIF) and test whether it improves performance in equipment collection. Methodology: Using simulation, a control group (n = 21) was compared to an intervention group (utilizing prototype NIF 1) (n = 24), with both groups consisting of neonatal nurses, midwives, and junior and senior pediatric doctors. The simulation involved a neonate requiring emergency intubation and the participant was tasked to collect the intubation equipment. The outcomes measured were Percentage of Equipment Collected, Time to Collect Equipment, and Amount of Questions Asked. Following post-simulation feedback, the NIF 2 was developed. The same simulation was repeated to an intervention group (n = 28) which utilized NIF 2. Results: The NIF 2 displayed a significantly better Time to Collect Equipment compared to control and NIF 1 (Mean [M] = 64.3-102.0 and 150.8 s, respectively). The NIF 2 had a significantly better Percentage of Equipment Collected compared to the control and NIF 1 (M = 96%-59% and 87%, respectively). The NIF 2 demonstrated significantly less Amount of Questions Asked compared to the control and NIF 1 groups (Median = 0-1 and 2, respectively). Conclusion: The NIF 2 provides a significantly superior method to collect equipment, in a quicker time, with less distracting questions asked, compared to current practice.