Tracheal intubation in an urban emergency department in Scotland: a prospective, observational study of 3738 intubations.

AIM: The emergency department (ED) is an area where major airway difficulties can occur, often as complications of rapid sequence induction (RSI). We undertook a prospective, observational study of tracheal intubation performed in a large, urban UK ED to study this further. METHODS: We reviewed data on every intubation attempt made in our ED between January 1999 and December 2011. We recorded techniques and drugs used, intubator details, success rate, and associated complications. Tracheal intubation in our ED is managed jointly by emergency physicians and anaesthetists; an anaesthetist is contacted to attend to support ED staff when RSI is being performed. RESULTS: We included 3738 intubations in analysis. 2749 (74%) were RSIs, 361 (10%) were other drug combinations, and 628 (17%) received no drugs. Emergency physicians performed 78% and anaesthetists 22% of intubations. Tracheal intubation was successful in 3724 patients (99.6%). First time success rate was 85%; 98% of patients were successfully intubated with two or fewer attempts, and three patients (0.1%) had more than three attempts. Intubation failed in 14 patients; five (0.13%) had a surgical airway performed. Associated complications occurred in 286 (8%) patients. The incidence of complications was associated with the number of attempts made; 7% in one attempt, 15% in two attempts, and 32% in three attempts (p<0.001). CONCLUSION: A collaborative approach between emergency physicians and anaesthetists contributed to a high rate of successful intubation and a low rate of complications. Close collaboration in training and delivery of service models is essential to maintain these high standards and achieve further improvement where possible.

Treating the donor.

PURPOSE OF REVIEW: Current pressures of organ supply and demand require maximization of potential for organ donation. The donor population is older and has more significant comorbidity than in the past.Optimal management of the donor after brain death (DBD) is essential to ensure that the greatest number of organs can be transplanted per donor. Defining evidence-based drugs and techniques to assist this has never been more important. RECENT FINDINGS: Care of patients with catastrophic brain injury incorporating supportive therapy targeted at specific goals and delivered by experienced specialists provides the best donation outcomes. Such pathways represent best practice critical care applied to this population. In this context, the value of some previously recommended therapies appears questionable and warrants reassessment. Prolonged (>24 h) incorporeal organ conditioning may have significant benefits.Extracorporeal support in the resuscitation arena is emerging and, in patients who fail to respond, may yield a new source of donors. SUMMARY: Early identification of potential DBD, best practice critical care, and achieving defined treatment goals are associated with more transplantable organs. Study of a complex intervention like donor management presents significant problems of organization, ethics and consent. This situation is recognized internationally and progress is being made.

Distance learning improves attainment of professional milestones in the early years of surgical training.

OBJECTIVES: To assess the impact of a surgical sciences e-learning programme in supporting the academic development of surgical trainees during their preparation for professional examination. BACKGROUND: In 2007, a 3-year online part-time Master of Surgical Sciences (MSc) degree programme was launched, utilizing an innovative platform with virtual case scenarios based on common surgical conditions addressed by the curriculum relating to the Membership Examination of the Royal Colleges of Surgeons (MRCS). Multiple-choice questions with feedback and discussion boards facilitated by expert clinical tutors provided formative assessment. Summative assessment comprised written examination at the end of each of the first 2 years (equivalent to MRCS level), culminating in submission of a research dissertation in year 3 toward an MSc. METHODS: Students' age, gender, and level at entry to the programme were documented. Anonymized student feedback from 2008 to 2012 was examined using online questionnaires, and performance in the MSc programme was compared to MRCS examination outcomes for students who had consented to release of their results. RESULTS: A total of 517 surgical trainees from 40 countries were recruited over the 6-year period, and 116 MSc students have graduated to date. Of 368 students, 279 (76%) were foundation doctors (interns) and had not commenced formal surgical training on enrolling in the MSc programme. However, level at entry did not influence performance (P > 0.05 across all 3 years). Average pass rates since the programme launched, for those students completing all of the required assessments, were 84% ± 11% in year 1, 85% ± 10% in year 2, and 88% ± 7% in year 3 of the MSc programme. MSc students had significantly higher MRCS pass rates than nonenrolled trainees (67% vs 51%, P < 0.01, n = 352). There was a significant correlation between MRCS examination performance and overall performance in the MSc (R = 58%; P < 0.01, n = 37). Of 248 respondents, 202 (81%) considered that the MSc would improve their chances of gaining a surgical training post, and 224 (90%) would recommend the programme to their peers. CONCLUSIONS: The online MSc programme supports academic development of trainees in the early years of surgical training, is well received by students, and is associated with improved success in their professional examination.

Randomized clinical trial of local infiltration plus patient-controlled opiate analgesia vs. epidural analgesia following liver resection surgery.

OBJECTIVES: Epidural analgesia is recommended for the provision of analgesia following major abdominal surgery. Continuous local anaesthetic wound infiltration may be an effective alternative. A prospective randomized trial was undertaken to compare these two methods following open liver resection. The primary outcome was length of time required to fulfil criteria for discharge from hospital. METHODS: Patients undergoing open liver resection were randomized to receive either epidural (EP group) or local anaesthetic wound infiltration plus patient-controlled opiate analgesia (WI group) for the first 2 days postoperatively. All other care followed a standardized enhanced recovery protocol. Time to fulfil discharge criteria, pain scores, physical activity measurements and complications were recorded. RESULTS: Between August 2009 and July 2010, 65 patients were randomized to EP (n = 32) or WI (n = 33). The mean time required to fulfil discharge criteria was 4.5 days (range: 2.5-63.5 days) in the WI group and 6.0 days (range: 3.0-42.5 days) in the EP group (P = 0.044). During the first 48 h following surgery, pain scores were significantly lower in the EP group both at rest and on movement. Resting pain scores within both groups were rated as mild (range: 0-3). There was no significant difference between the groups in time to first mobilization or overall complication rate (48.5% in the WI group vs. 58.1% in the EP group; P = 0.443). CONCLUSIONS: Local anaesthetic wound infiltration combined with patient-controlled opiate analgesia reduces the length of time required to fulfil criteria for discharge from hospital compared with epidural analgesia following open liver resection. Epidural analgesia provides superior analgesia, but does not confer benefits in terms of faster mobilization or recovery.

Etomidate for critically ill patients. Pro: yes we can use it.

Etomidate is used to induce anaesthesia in critically ill patients in many environments, including pre-hospital care, in the emergency and critical care departments and in the operating theatre. It has a favourable cardiovascular profile, but its use has courted controversy because it suppresses adrenal function which some believe is associated with worse outcome, particularly in patients with sepsis. Because there is much evidence of harm associated with hypotension in critically ill patients, it is important to use an anaesthetic induction drug which is less likely to cause hypotension. Etomidate undoubtedly causes adrenal suppression, but the clinical consequences of this remain unclear. There is no convincing or consistent evidence that etomidate is associated with harm, particularly if adjustment is made for pre-existing severity of illness. The etomidate debate is currently in clinical equipoise in which there is genuine uncertainty within the expert medical community. We review briefly the arguments in favour of continuing to use etomidate in critically ill patients.

Factors in perioperative care that determine blood loss in liver surgery.

OBJECTIVES: Excessive blood loss during liver surgery contributes to postoperative morbidity and mortality and the minimizing of blood loss improves outcomes. This study examines pre- and intraoperative factors contributing to blood loss and identifies areas for improvement. METHODS: All patients who underwent elective hepatic resection between June 2007 and June 2009 were identified. Detailed information on the pre- and perioperative clinical course was analysed. Univariate and multivariate analyses were used to identify factors associated with intraoperative blood loss. RESULTS: A total of 175 patients were studied, of whom 95 (54%) underwent resection of three or more segments. Median blood loss was 782 ml. Greater blood loss occurred during major resections and prolonged surgery and was associated with an increase in postoperative complications (P= 0.026). Peak central venous pressure (CVP) of >10 cm H(2)O was associated with increased blood loss (P= 0.01). Although no differences in case mix were identified, blood loss varied significantly among anaesthetists, as did intraoperative volumes of i.v. fluids and transfusion practices. CONCLUSIONS: This study confirms a relationship between CVP and blood loss in hepatic resection. Intraoperative CVP values were higher than those described in other studies. There was variation in the intraoperative management of patients. Collaboration between surgical and anaesthesia teams is required to minimize blood loss and the standardization of intraoperative anaesthesia practice may improve outcomes following liver surgery.

Rapid sequence induction of anaesthesia in elderly patients in the emergency department.

AIM: Our primary objective was to evaluate the characteristics and outcomes of elderly (≥ 80 years) patients undergoing rapid sequence induction of anaesthesia and intubation (RSI) in our emergency department (ED). METHODS: We retrospectively analysed data collected prospectively between January 1999 and December 2007. We retrieved age; gender; presenting diagnosis; indication and urgency for RSI; complications related to RSI; hospital destination; and outcome. RESULTS: 1686 patients underwent RSI in the ED during the study period; 107 (6%) were aged ≥ 80 years. The mean age (range) was 84 (80-91) years. 94 patients (88%) were living in a private residence before presentation to the ED. Intracerebral haemorrhage, ischaemic stroke and head injury were the commonest presenting diagnoses. Forty-one patients were admitted to intensive care, 55 were admitted to a ward (31 for palliative care) and 11 died in the ED. Seventy-two patients (67%) died; of the 35 survivors, 21 (60%) made a good recovery with no requirement for increased social care. Outcome was worse after neurological diagnoses, sepsis and trauma than after cardiac or respiratory failure, seizures or drug overdose. Presenting diagnosis predicted outcome on univariable analysis (p<0.001), but it was not possible to calculate risk for individual diagnoses. RSI-related complications, of which hypotension was commonest, occurred in 15% of patients. CONCLUSION: A small number of patients who undergo RSI in our ED are aged ≥ 80 years. They generally have high mortality with only 20% surviving to hospital discharge with no increase in dependency; however 60% of survivors make a good recovery. In this highly selected elderly population age is not the main determinant of outcome which is influenced more by presenting diagnosis.

Effectiveness of epidural analgesia following open liver resection.

OBJECTIVES: Epidural analgesia is often considered the reference standard for pain relief following major abdominal surgery; however, the provision of analgesia in the context of liver surgery raises unique challenges. This study investigated the effectiveness of analgesia and the postoperative course of patients who did or did not receive epidural analgesia following liver resection. METHODS: Data were collected retrospectively on 177 patients who underwent open liver resection between June 2007 and June 2009. Patients were divided into two groups consisting, respectively, of those who received epidural analgesia (Epidural group, n= 148) and those who did not (No-Epidural group, n= 29). RESULTS: In the Epidural group, 27 patients (18%) required i.v. opiate analgesia on the day of surgery (DoS) or the first postoperative day (POD1). The Epidural group received significantly more i.v. colloid solution on the DoS (median: 1500 ml vs. 750 ml, range: 0-12,000 ml vs. 0-3500 ml; P= 0.004) and POD1 (median: 0 ml vs. 0 ml, range: 0-5000 ml vs. 0-1000 ml; P= 0.018), and total fluid on the DoS and POD1 combined (median: 6522 ml vs. 5453 ml, range: 2150-21 300 ml vs. 2875-15,886 ml; P= 0.032). CONCLUSIONS: Epidural analgesia provided inadequate postoperative pain relief in approximately 20% of liver resection patients and was associated with the administration of significantly greater volumes of i.v. colloid solution.

Surgical airway in emergency department intubation.

OBJECTIVES: To determine the frequency of and primary indication for surgical airway during emergency department intubation. METHODS: Prospectively collected data from all intubations performed in the emergency department from January 1999 to July 2007 were analysed to ascertain the frequency of surgical airway access. Original data were collected on a structured proforma, entered into a regional database and analysed. Patient records were then reviewed to determine the primary indication for a surgical airway. RESULTS: Emergency department intubation was undertaken in 2524 patients. Of these, only five patients (0.2%) required a surgical airway. The most common indication for a surgical airway was trauma in four of the five patients. Two patients had attempted rapid sequence induction before surgical airway. Two patients had gaseous inductions and one patient received no drugs. In all five patients, surgical airway was performed secondary to failed endotracheal intubation attempt(s) and was never the primary technique used. CONCLUSION: In our emergency department, surgical airway is an uncommon procedure. The rate of 0.2% is significantly lower than rates quoted in other studies. The most common indication for surgical airway was severe facial or neck trauma. Our emergency department has a joint protocol for emergency intubation agreed by the Departments of Emergency Medicine, Anaesthesia and Critical Care at the Edinburgh Royal Infirmary. We believe that the low surgical airway rate is secondary to this collaborative approach. The identified low rate of emergency department surgical airway has implications for training and maintenance of skills for emergency medicine trainees and physicians.

Detailed fluid resuscitation profiles in patients with severe acute pancreatitis.

BACKGROUND AND AIM: Appropriate and timely initial fluid resuscitation in acute pancreatitis (AP) is critical. The aim of this retrospective study was to evaluate fluid therapy on an hour-by-hour basis in relation to standard indices of adequate resuscitation during AP. METHODS: Emergency room shock charts, fluid balance sheets and intensive care (ICU) charts for all patients with AP admitted to ICU in a large acute hospital were examined. Vital signs, clinical course and fluid administered during the first 72 h after admission were tabulated against urine output, central venous pressure (CVP) and inotrope/vasopressor therapy. RESULTS: Sixty-three consecutive patients with AP were initially evaluated. Inter-hospital transfers with established organ dysfunction (n= 11) or where records had insufficient detail (n= 22) were excluded. In the remaining 30 patients, in-hospital death occurred in 7. The cumulative volume of crystalloid given was significantly less at 48 h in patients who died in hospital (3331 ± 800 ml vs. survivors, 7287 ± 544 ml; P < 0.001). Non-survivors had a higher CVP, and received more inotropes/vasopressors. CONCLUSION: In severe AP-associated organ failure, fluid resuscitation profiles differ between survivors and non-survivors. CVP alone as a crude indicator of adequate resuscitation may be unreliable, potentially leading to the use of inotropes/vasopressors in the inadequately filled patient.

Integrating physician assistants into the practice setting.

The role of anaesthetic practitioner was established in England using the National Anaesthesia Practitioner Curriculum Framework (Department of Health 2005) and is now being adopted in Scotland. This article reports part of a 29-month evaluation of the first two cohorts of physician assistant (anaesthesia) students as they progressed through their education programme, and discusses the management of integrating this role in clinical practice.

Field intubation of cardiac arrest patients: a dying art?

INTRODUCTION: The most appropriate advanced airway intervention in out-of-hospital cardiac arrest (OHCA) is unproven. This study reviews prehospital advanced airway management and its complications in OHCA patients. METHODS: A 4-year, observational, retrospective case review. Patients attending the Emergency Department of the Royal Infirmary of Edinburgh, Scotland, with a primary diagnosis of OHCA were identified. Patient demographics, survival to admission, airway management technique and complication rates were identified. RESULTS: Seven hundred and ninety-four cases were identified. The aetiology of cardiac arrest was medical in 95.2%, traumatic in 3.9% and unrecorded in 0.9%. Prehospital intubation was attempted in 628 patients. Prehospital intubation was successful in 573 patients. A significant complication (multiple attempts, displaced endotracheal tube or oesophageal intubation) occurred in 55 (8.8%) patients. 165 (20.8%) patients survived to hospital admission, of whom 110 had undergone prehospital intubation. 55 patients who did not undergo prehospital tracheal intubation survived to hospital admission. CONCLUSION: The optimal method of maintaining an airway and ventilating an OHCA patient has yet to be established. Prehospital tracheal intubation for OHCA is associated with significant complications and may reduce survival. The use of tracheal intubation as a routine intervention should be reconsidered. Ambulance services should consider adopting alternative strategies in airway management.

Controlled organ donation after cardiac death: potential donors in the emergency department.

BACKGROUND.: The continuing shortfall of organs for transplantation has increased the use of donation after cardiac death (DCD). We hypothesized that some patients who undergo tracheal intubation in the emergency department (ED) and who are assessed for, but not admitted to, critical care might have potential for controlled DCD. METHODS.: We identified all patients who underwent tracheal intubation in the ED between 2004 and 2008 and studied their records to identify those not admitted to an intensive care unit. We reviewed the notes of patients extubated in the ED to ascertain the diagnosis, management, outcome, and potential exclusion criteria for controlled DCD. RESULTS.: One thousand three hundred seventy-four patients had tracheal intubation performed in the ED; 1053 received anesthetic drugs to assist intubation. Three hundred seventy-five patients were not admitted to intensive care unit; 235 died during resuscitation in the ED. Of the 49 patients extubated in the ED to allow terminal care, 26 were older than 70 years and 18 had comorbidities precluding organ donation. Fourteen patients could have been considered for DCD, but in eight, the time from extubation to death exceeded 2 hr. Thus, six patients might have been missed as potential controlled DCD from the ED in this 5-year period. CONCLUSIONS.: Identification of potential donors after cardiac death in the ED with appropriate use of critical care for selected patients may contribute to reducing the shortfall of organs for transplantation, although numbers are likely to be small. This area remains controversial and requires further informed discussion between emergency and critical care doctors and transplant teams.

Induction drug and outcome of patients admitted to the intensive care unit after emergency laparotomy.

BACKGROUND AND OBJECTIVE: Etomidate is often used to induce anaesthesia in sick patients owing to its relative cardiovascular stability. However, etomidate affects adrenal cortical activity, and there is concern that this could impair outcome in patients undergoing emergency surgery. METHODS: We retrospectively analysed data from 176 patients admitted to an ICU after emergency laparotomy. We retrieved ASA status, surgical diagnosis, induction drug use, blood pressure before and after induction and any vasopressor administration, steroid and vasopressor therapy in ICU and patient outcome. Choice of induction drug was at the discretion of the attending anaesthetist. RESULTS: The drugs (numbers of patients) used to induce anaesthesia were etomidate (52), thiopental (90), propofol (16), midazolam (12) and ketamine (4). Fifty-two patients (30%) died in hospital. ASA status was the only independent predictor of hospital outcome (P < 0.001). Choice of induction drug was related to ASA status. As ASA status worsened, the likelihood of using etomidate or midazolam/ketamine increased (P = 0.001). We found no association between etomidate and dying in hospital, though our study might not have had sufficient power to show a difference between induction drugs. The relative risks [95% confidence interval (CI)] of dying in hospital were etomidate 1.16 (0.72-1.87), thiopental 0.82 (0.52-1.30), propofol 0.40 (0.11-1.49) and midazolam/ketamine 1.84 (1.09-3.12). Vasopressor and steroid therapy in the ICU was not related to induction drug. The risk of developing hypotension at induction or of receiving vasopressor to treat hypotension was least with etomidate. CONCLUSION: We found no evidence that etomidate is associated with worse outcome than thiopental or propofol in patients undergoing emergency laparotomy, but we cannot be certain that etomidate is well tolerated in this group of patients. More data are required to address this issue definitively.

Effect of induction agent on vasopressor and steroid use, and outcome in patients with septic shock.

INTRODUCTION: In seriously ill patients, etomidate gives cardiovascular stability at induction of anaesthesia, but there is concern over possible adrenal suppression. Etomidate could reduce steroid synthesis and increase the need for vasopressor and steroid therapy. The outcome could be worse than in patients given other induction agents. METHODS: We reviewed 159 septic shock patients admitted to our intensive care unit (ICU) over a 40-month period to study the association between induction agent and clinical outcome, including vasopressor, inotrope, and steroid therapy. From our records, we retrieved induction agent use; vasopressor administration at induction; vasopressor, inotrope, and steroid administration in the ICU; and hospital outcome. RESULTS: Hospital mortality was 65%. The numbers of patients given an induction agent were 74, etomidate; 25, propofol; 26, thiopental; 18, other agent; and 16, no agent. Vasopressor, inotrope, or steroid administration and outcome were not related to the induction agent chosen. Corticosteroid therapy given to patients who received etomidate did not affect outcome. Vasopressor therapy was required less frequently and in smaller doses when etomidate was used to induce anaesthesia. We found no evidence that either clinical outcome or therapy was affected when etomidate was used. Etomidate caused less cardiovascular depression than other induction agents in patients with septic shock. CONCLUSION: Etomidate use for critically ill patients should consider all of these issues and not simply the possibility of adrenal suppression, which may not be important when steroid supplements are used.

Case series: the McGrath videolaryngoscope--an initial clinical evaluation.

PURPOSE: To document tracheal intubation success rates and airway instrumentation times using the newly designed McGrath videolaryngoscope. METHODS: We prospectively recorded factors associated with difficult tracheal intubation, factors causing actual difficulty in tracheal intubation, as well as complications arising from use of the new McGrath videolaryngoscope in a series of adult patients with normal preoperative airway examinations. All patients were undergoing scheduled or elective surgery. In the first 75 patients (phase I), experience with airway instrumentation was documented, while in the second 75 patients (phase II), the time required to obtain an optimal view of the larynx was recorded, as well as the time to complete tracheal intubation. RESULTS: Ninety-eight percent of all tracheal intubations were successful using the McGrath videolaryngoscope. Cormack and Lehane grade I views were obtained in 143 patients (95%) and grade II views were achieved in six (4%). In phase II, the median time required to obtain an adequate view was 6.3 sec [interquartile range 4.7-8.7 (range 2-26.3)], and to complete tracheal intubation was 24.7 sec [18.5-34.4 (11.4-286)]. Fortynine (65%) of the tracheal intubations were completed within 30 sec, and 72 (96%) were completed within one minute. No complications were encountered in any patient. CONCLUSIONS: The McGrath videolaryngoscope is an effective aid to airway management in patients with normal airways, based upon intubation success rates and the ability to rapidly secure the airway. Its potential advantages of convenience and portability warrant further evaluation in comparison with other airway devices and in patients with difficult airways.

Eleven years of liver trauma: the Scottish experience.

The aim of this population based study was to assess the incidence, mechanisms, management, and outcome of patients who sustained hepatic trauma in Scotland (population 5 million) over the period 1992-2002. The Scottish Trauma Audit Group database was searched for details of any patient with liver trauma. Data on identified patients were analyzed for demographic information, mechanisms of injury, associated injuries, hemodynamic stability on presentation, management, and outcome. A total of 783 patients were identified as having sustained liver trauma. The male-to-female ratio was 3:1 with a median age of 31 years. Blunt trauma (especially road traffic accidents) accounted for 69% of injuries. Liver trauma was associated with injuries to the chest, head, and abdominal injuries other than liver injury; most commonly spleen and kidneys. In all, 166 patients died in the emergency department, and a further 164 died in hospital. The mortality rate was higher in patients with increasing age (p < 0.001), hemodynamic instability (p < 0.001), blunt trauma (p < 0.001), and increasing severity of liver injury (p < 0.001). The incidence of liver trauma in Scotland is low, but it accounts for significant mortality. Associated injuries were common. Outcome was worse in patients with advanced age, blunt trauma, multiple injuries and those requiring an immediate laparotomy.