These observations suggest that deployment of a pediatric EGA can successfully decrease the need for prehospital intubation. Although prior research suggests no improvement in neurologic outcome with ETI,the skill is taught as part of the EMT-Paramedic National Standard Curriculum and still widely practiced in EMS agencies across the U.S.As many EMS agencies progress toward widespread EGA deployment given evidence against significant benefits from intubation during initial cardiac arrest care, intubation skill retention remains largely unknown.For pediatric patients especially, the effects of implementing an EGA-first strategy decreases a paramedic’s exposure to the already rare intubation. Prior research has demonstrated a low number of clinical opportunities for paramedics to maintain procedural competency with intubation,let alone the exceedingly rare pediatric intubation. In our cohort, we observed a decline in the success rate for pediatric intubations when attempted after introducing an EGA. The effects of implementing the EGA in this system, while continuing to allow ETI, resulted in a further dilution of procedural experience. The potential difficulty with maintaining paramedic intubation skills for pediatric and adult patients, is well documented by prior studies,and may be augmented in systems such as this where ETI exists concurrently with EGA prioritization. The potential training solutions and their effectiveness have not been described. High-performance EMS agencies with intensive training, continuing education, and quality assurance report intubation success rates as great as 97% but with low first-pass success.Systems with infrequent airway management training and skill maintenance when coupled with the addition and widespread use of EGAs may experience declines in success, as those observed in our system. However,vertical grow shelf in the intubations that occurred post-protocol change, 96.4% occurred due to protocol non-adherence. Despite our reported 95% success rate with EGA placement, which is consistent with previous publications, many patients during the study period still underwent ETI attempts. Of the 36.4% with ETI attempted prior to anEGA attempt only, 85% experienced a success.
Similarly, only 54.4% were successful when attempted after an already successful EGA. Although prior commentary has suggested that EGAs, specifically the i-gel, perform well in the prehospital environment, success rates may be lower than previously demonstrated in hospital-based studies.In non-paralyzed adults, for example, ventilation with the adult size 4 i-gel may exceed the 24 millimeters of mercury laryngeal seal, causing significant air leak.For children, the degree of leak if the device is sized incorrectly is unknown. For our cohort, the rationales behind the protocol deviations were not consistently documented. It is possible that many of the ETIs after EGA placement were in fact warranted but appeared as protocol violation due to inadequate documentation of EGA failure. Providers’ perception of inadequate ventilation or incorrect device sizing may have contributed to the intubation attempts occurring after initial EGA placement.In this small cohort we did not observe any measurable effects on cardiac arrest care, although metrics such as compression fraction, CPR rate, and exact timing of EGA or ETI were not available. Also, given our small sample size and low frequency of shockable rhythms in the pediatric population,further research is required to address the initial airway management device by rhythm and likelihood of a primary respiratory arrest.We appreciate the discussion outlined by Merelman et al. regarding the important role ketamine has in emergency airway management, and agree with the sentiment that ketamine may be preferable to other agents in many different clinical scenarios. Based on our experience teaching and discussing emergency airway management with national experts, however, we believe a few points are more nuanced and warrant further discussion. For patients with predicted intubation difficulty, the authors advocate sedation with ketamine and the use of a standard laryngoscope. While this technique may be appropriate in certain clinical scenarios, there is a dearth of evidence demonstrating its success or safety and we recommend further study before it is widely implemented. Intubation with ketamine alone, in the references cited, was successful in 21/31 cases.Fiberoptic intubation success with ketamine monotherapy has also had low success rates.Ketamine may dissociate the cortex from brainstem functions, but because brainstem reflexes remain intact, vomiting can still occur when the upper airway structures are stimulated.
Emesis occurs in approximately 5-15% of ketamine administrations in adults,which often leads to aspiration–the largest contributor to morbidity in airway management globally. Ideally, patients thought to be too difficult for neuromuscular blockade are managed with meticulous topical anesthesia and as little parenteral sedation or anxiolysis as feasible; sedation without dissociation or obtundation allows the patient to follow commands, which is advantageous during endoscopic intubation. Although standard laryngoscopy is the most common emergency intubation technique, we strongly believe that flexible endoscopic intubation is an important skill within the procedural capability of emergency physicians. This has long been the gold standard method for patients deemed too risky for neuromuscular blockade. While video laryngoscopes have largely replaced direct laryngoscopy, the utilization of flexible endoscopy has remained fairly constant.Historically, the expense of flexible fiberoptic scopes and endoscopes hindered widespread access to these important devices; for this reason, many physicians have not received adequate training or ongoing practice, especially in departments that infrequently perform intubation. The advent of disposable endoscopes, now produced by multiple companies, should improve accessibility and affordability. Like any procedure, continual practice with a flexible endoscope is essential. This can be accomplished in many ways that should be feasible by all physicians. In our department we have practiced nasal intubation on each other, which has honed our topical anesthesia skills. Endoscopic evaluation of ED patients with severe sore throats, foreign body sensation, new hoarseness, and other conditions provides practice with endoscope controls; manikin-based practice is another option. Ketamine, while uncommonly causing overt respiratory depression or apnea, frequently causes sub-clinical respiratory depression.This is inconsequential in patients with normal respiratory effort , but it is important to consider when caring for critically ill patients. In our experience, when ketamine is administered to patients with high minute ventilation , they continue to breathe but with a significantly lower minute ventilation that sometimes does not meet their metabolic needs.
We believe that patients with high respiratory effort who are deemed too risky for neuromuscular blockade should be managed either with a completely awake approach , or with rapid sequence intubation,cannabis grow indoor which maximizes the chance of first-pass success and allows placement of a first line backup device should the first attempt fail. It may be preferable to cause apnea with neuromuscular blockade rather than risk a longer ketamine-facilitated intubation attempt with relative hypoventilation. The worst possible circumstance when managing these patients is to have a patient who is not breathing adequately and also not relaxed enough to facilitate tube passage or allow placement of a modern extraglottic device. Ketamine is an old drug that remains valuable in all phases of airway management. Before widespread use as a monotherapy for patients with difficult airways, however, it seems prudent to gather additional data to determine its success and safety profile relative to other approaches.The management of sepsis according to the 2017 Surviving Sepsis Campaign guidelines is multifaceted and includes the prompt administration of intravenous antibiotics. The Centers for Medicare and Medicaid Services core measures require administration of antibiotics within three hours of sepsis being identified. It is recommended that broad spectrum antibiotics be used in the initial treatment of sepsis or suspected sepsis based on systemic inflammatory response syndrome criteria.Although antibiotic treatment may be life-saving, antibiotic exposure has known potential complications, including the risk for developing Clostridium difficile infection .CDI has important implications affecting patient mortality, cost, and even potential hospital reimbursement. Studies show mortality of CDI in hospitalized patients ranges from 8-37.2%.CDI is a major contributor to healthcare expenditure in the United States and was responsible for as much as $4.8 billion U.S. dollars of cost to the health system.In addition to costs, sepsis performance data are currently being collected by The Joint Commission regarding antibiotic administration in the presentation of SIRS patients, and hospitals may soon find that it will be tied directly to reimbursement.Compliance with the CMS Sepsis Core Measures , or sepsis bundle, mandates early antibiotic administration. Providers at this facility were encouraged to use an order set that included the SEP-1 required components of sepsis management. Use of antibiotics is known to be associated with the risk of CDI.The Infectious Diseases Society of America chose not to endorse the 2016 sepsis guidelines due to concern over excessive antibiotic use and its associated risks, including CDI.We hypothesized that the incidence of CDI in this hospital would not change after implementation of the sepsis bundle-required antibiotics administration. The primary goal of this study was to measure the hospital-wide CDI rate for three years prior to implementation of the sepsis bundle vs the CDI rate two years post-implementation.
As a secondary outcome, we compared the overall number of antibiotics prescribed in the emergency department 12 months prior to administration of the sepsis protocol vs 12 months post-initiation.This study was a single-center, retrospective cohort analysis designed to test the hypothesis that the introduction of sepsis bundle antibiotics had no effect on hospital-wide CDI rates. The study was performed in an academic, suburban hospital ED with an annual census of approximately 90,000 visits per year that implemented a protocol on January 15, 2016, to help combat sepsis and increase compliance with SEP-1 guidelines. The facility’s institutional review board approved the study as exempt. Over the five-year period, the protocol in place to diagnose CDI in the hospital was updated once. Initially, a nosocomial CDI was defined as a positive C. diff polymerase chain reaction test. However, in October 2016 the infection control department changed the protocol to a laboratory panel, which includes an enzyme immunoassay test paired with a glutamate dehydrogenase test. If both return positive, the patient was considered to have CDI. If one result was positive and the other negative, the test was considered indeterminate. In that case, a follow-up polymerase chain reaction test was sent reflexively to an outside laboratory to evaluate for the presence of two C. diff, toxin-related genes . This followup PCR test was considered the final deciding factor for all indeterminate tests. We extracted data from the EPIC electronic health record with the help of the infection control department, which keeps record of nosocomial hospital infections. The overall number of hospital nosocomial CDI per 10,000 inpatient hours was reviewed and recorded monthly from January 2013– December 2017. For the secondary outcome, we queried the EHR for the daily number of antibiotics ordered on patients ≥18 years of age during their ED stay for the two-year period January 2015–January 2017 . The study focused only on antibiotics available to be ordered directly from the sepsis order set , and included only those antibiotics ordered by ED providers. Orders placed by inpatient providers were not counted, as the secondary outcome was limited to this protocol’s effect on ED provider antibiotic usage. The sepsis order set went live on January 15 of 2016. CDI rates three years before January 2016 and two years after were grouped and analyzed for an overall difference in means. For the secondary outcome, we queried, recorded and analyzed the number of antibiotics for one year before and after this date. This period was chosen, as the database for this specific information was limited to one year prior to the time period. Abstractors were blinded to the study’s hypothesis. For analysis, we performed a two-sample t-test assuming equal variances.Prior research has shown that antibiotic exposure leads to an increased risk of CDI development.When earlier CMS recommendations in the management of community acquired pneumonia outlined strict time periods for antibiotic administration, research on the topic indicated concern that these recommendations could lead to misdiagnosis and inappropriate antibiotic exposure.CMS has now put a time constraint on management of SIRS-positive patients with presumed or suspected infectious etiology, a protocol that can lead to increased antibiotic administration prior to formal diagnosis and, given the greater antibiotic exposure, a potential increased risk of CDI. As previously noted, the IDSA did not support the 2016 guidelines due to this concern.This study demonstrated a 5% increase in antibiotic prescriptions for ED patients after sepsis bundle order set initiation.