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Pilot Study to Evaluate the Accuracy of Ultrasound in Confirming Endotracheal Tube Placement
Research Forum Abstracts assessing their application in the management of patients with suspected sepsis in the emergency department. Methods: Procalcitonin concentration, as determined by an authomated immunofluorescent assay (BRAHMS PCT Kryptor, Henningsdorf, germany), was measured in a series of 207 patients (114 males and 93 females, mean age 58.3 years, range 14-89) referred to the emergency ward for suspected infection and signs of systemic inflammatory reaction or septic shock. The one-way ANOVA analysis followed by the Bonferroni correction test was used to assess differences among patient subgroups, whereas ROC curve evaluation was carried out to calculate sensitivity and specificity, as well as positive and negative predictive values at different procalcitonin threshold limits. Results: Based on the confirmed diagnosis at discharge, our study population could be divided into four groups: a) patients with sepsis and/or septic shock associated with documented microbial pathogens (n=49); b) viral infections or confined infections either with or without systemic involvement and shock but often with negative coltural specimens (n=66); c) non-infectious disorders in the absence of a systemic reaction, such as pulmonary embolism, chronic obstructive lung diseases, respiratory or renal failure, liver cirrhosis (n=60); d) clinical conditions associated with a systemic inflammatory response, such as complicated myocardial infarction, acute pancreatitis, and exacerbation of chronic obstructive pneumopathies (n=32). A wide dispersion was found in procalcitonin levels across our unselected population. Significant differences in mean procalcitonin values could be observed among the four subgroups of patients (p\0.0001), higher concentrations being related to positive coltural findings in subjects with sepsis or septic shock (mean 42.5 ng/mL, range 0.3-340) as compared to those measured in patients with localized infections (3.1, 0.3-15.7; p\0.05 vs. group a) or non-infectious diseases (0.9, 0.3-8.0; p\0.05 vs. group a). Results obtained in the fourth group of patients (25.2, 0.3-254; p\0.05 vs. groups b and c) did not differ significantly from levels found in the septic group. ROC curve analysis yielded 92.9% specificity and 50.0% sensitivity at a procalcitonin threshold of 16.0 ng/mL, with 11 false positive results in the group of diseases characterized by a systemic inflammatory reaction (group d, including four patients with severe heart failure and cardiogenic shock, three with acute pancreatitis, one with massive pulmonary embolism, one with emorragic shock, and two with exacerbation of chronic obstructive lung disease). Positive and negative predictive values at this procalcitonin level cut-off were 69% and 86%, respectively. Conclusion: A single-point evaluation of procalcitonin levels obtained at entry for each patient allowed to identify those subjects with a high probability of severe sepsis or septic shock from bacterial or fungal sources as well as to stratify patients with increasing risk of progression to multiorgan failure. False positive results, even with highly elevated procalcitonin concentrations, could be observed in cases with shock of non-infectious origin and severe systemic reactions.
8
Mortality Benefit After Implementation of Early Goal Directed Therapy Protocol for the Treatment of Severe Sepsis and Septic Shock
Gaieski D, McCoy J, Zeserson E, Chase M, Goyal M, University of Pennsylvania, Philadelphia, PA
Study Objectives: Early goal directed therapy (EGDT) for the treatment of severe sepsis and septic shock has been shown to decrease mortality. Recently, an EGDT protocol was implemented for the treatment of severe sepsis and septic shock in the emergency department of a large urban academic medical center. Data was collected on all patients eligible for EGDT to assess for mortality benefit of EGDT. Methods: A prospective cross sectional study with historic controls was conducted. During the first 10 weeks of EGDT protocol implementation, all patients eligible for EGDT were entered into a database. These patients were divided into 2 groups based on whether they received EGDT or standard therapy. Both groups were followed for 60 days. In house, 28-day, and 60-day mortality were the primary end points. In addition, the patients receiving EGDT were compared to a 5 month group of historic controls seen in the same Emergency Department one year prior. These historic controls were treated for severe sepsis and septic shock, and, on chart review, were deemed eligible for EGDT as defined by the current protocol. Results: During the first 10 weeks of EGDT, 38 patients presenting to the Emergency Department with severe sepsis or septic shock were deemed eligible for EGDT based on the following: 2 or more SIRS criteria; presumed or documented source of infection; and either a lactate O4 mm/dL or systolic blood pressure \90 mmHg after a 30cc/kg fluid bolus. In house mortality for these 38 patients was 42% (16/38); 28-day mortality was 47% (18/38); 60-day mortality was 50% (19/38) Of these 38 patients, 22 patients received standard therapy; 16 patients received EGDT. In house mortality was reduced from 55% (12/22) in the standard therapy group to 25% (4/16) in EDGT group; 28-day mortality was reduced from 63% (14/22) to
S4 Annals of Emergency Medicine
25% (4/16); and 60-day mortality from 63% (14/22) to 31% (5/16). When historic controls were compared to patients who received EGDT, in house mortality was reduced from 40% (8/20) to 25% (4/16); 28-day mortality from 50% (10/20) to 25% (4/16); 60-day mortality from 50% (10/20) to 31% (5/16). Conclusion: EGDT produced an absolute mortality reduction when compared to both contemporaneous patients receiving standard therapy and historic controls eligible for EGDT. This mortality benefit was seen in house, at 28-days, and 60-days.
9
Pilot Study to Evaluate the Accuracy of Ultrasound in Confirming Endotracheal Tube Placement
Werner SL, Jones RA, Goldstein JR, Cydulka RK, MetroHealth Medical Center, Cleveland, OH
Study Objectives: Direct visualization of the cords and use of end-tidal capnography are the usual standards in confirming endotracheal (ET) tube placement. However, direct visualization is not always possible in difficult intubations, and end-tidal CO2 detection is not always reliable in patients with poor perfusion. In addition, end-tidal capnography requires ventilation in order to confirm placement which may lead to emesis in esophageal intubations. The goal of this study was to determine the accuracy of ultrasound in confirming endotracheal tube placement. Methods: This was a prospective randomized-controlled study conducted in the operating room of an academic hospital. Thirty-three adult patients were enrolled. The study was approved by the IRB and written consent was obtained from each subject. Patients eligible for the study were adults undergoing elective surgery requiring intubation. Exclusion criteria were a history of difficult intubation, abnormal airway anatomy, aspiration risk factors, or esophageal disease. For each subject, after induction of anesthesia and neuromuscular blockade, the attending anesthesiologist placed the ET tube once in the trachea and once in the esophagus in a random fashion using direct laryngoscopy. During the intubations, a high frequency linear ultrasound transducer was placed transversely on the anterior neck superior to the suprasternal notch. Two EPs with extensive ultrasound training independently recorded the location of the ET tube for each intubation based on the live ultrasound image. The EPs were blinded to the order of the intubations as well as to the actual performance of the intubations. The age, height, weight, BMI, intubation difficulty, Mallampati and ASA scores were recorded for each patient. The sensitivity and specificity of the EPs in determining the location of the ET tube and the kappa between the two EPs were calculated. Direct visualization of the location of the endotracheal tube by the anesthesiologist was the criterion standard. Results: Twenty-six women and seven men were enrolled in the study. The average age was 38.9G13.8 years. The average height was 64.9G4.1 inches. The average BMI was 28.5G6.5. The median Mallampati score was 1 and the median ASA score was 2. Sensitivity and specificity of tube placement was 100 percent for both endotracheal and esophageal intubations. Kappa was 1. One ET tube was misplaced by the anesthesiologist so both intubations were esophageal, but tube placement was correctly assessed by both EPs. Limitations: Limitations included the dichotomized study design. During each set of intubations, if placement of only one tube was confidently seen, the location of the other intubation could be assumed. Our study was also limited in that it included only adult, low risk patients and was conducted in a highly controlled environment. The study was limited to evaluation of ultrasound during intubations. We did not examine its use in static, post-intubation tube placement. In addition, the EPs conducting the study had substantial training in ultrasound. Conclusions: EPs experienced in ultrasound can accurately detect the placement of an endotracheal tube during intubation with ultrasound. Future studies should examine the use of ultrasound to confirm tube placement by EPs with only basic ultrasound training, use of the technique in the ED and with a wider range of patients, as well as ultrasound’s role in confirming tube placement in already intubated patients.
10
Comparative Study of Airway Management During Confined-Space Urban Rescue
Deibel M, Lock D, Jones JS, Hoyle J, Bernadotte M, Grand Rapids MERC/Michigan State University, Grand Rapids, MI
Study Objectives: To determine the most effective method of airway control in simulated patients confined within a collapsed structure. Methods: A prospective, cohort assessment of EMS personnel, housestaff and EM faculty performance was conducted over a 6-month study period using adult mannequins positioned in three different confined-space scenarios (i.e., collapsed
Volume 46, no. 3 : September 2005
8
Mortality Benefit After Implementation of Early Goal Directed Therapy Protocol for the Treatment of Severe Sepsis and Septic Shock
Gaieski D, McCoy J, Zeserson E, Chase M, Goyal M, University of Pennsylvania, Philadelphia, PA
Study Objectives: Early goal directed therapy (EGDT) for the treatment of severe sepsis and septic shock has been shown to decrease mortality. Recently, an EGDT protocol was implemented for the treatment of severe sepsis and septic shock in the emergency department of a large urban academic medical center. Data was collected on all patients eligible for EGDT to assess for mortality benefit of EGDT. Methods: A prospective cross sectional study with historic controls was conducted. During the first 10 weeks of EGDT protocol implementation, all patients eligible for EGDT were entered into a database. These patients were divided into 2 groups based on whether they received EGDT or standard therapy. Both groups were followed for 60 days. In house, 28-day, and 60-day mortality were the primary end points. In addition, the patients receiving EGDT were compared to a 5 month group of historic controls seen in the same Emergency Department one year prior. These historic controls were treated for severe sepsis and septic shock, and, on chart review, were deemed eligible for EGDT as defined by the current protocol. Results: During the first 10 weeks of EGDT, 38 patients presenting to the Emergency Department with severe sepsis or septic shock were deemed eligible for EGDT based on the following: 2 or more SIRS criteria; presumed or documented source of infection; and either a lactate O4 mm/dL or systolic blood pressure \90 mmHg after a 30cc/kg fluid bolus. In house mortality for these 38 patients was 42% (16/38); 28-day mortality was 47% (18/38); 60-day mortality was 50% (19/38) Of these 38 patients, 22 patients received standard therapy; 16 patients received EGDT. In house mortality was reduced from 55% (12/22) in the standard therapy group to 25% (4/16) in EDGT group; 28-day mortality was reduced from 63% (14/22) to
S4 Annals of Emergency Medicine
25% (4/16); and 60-day mortality from 63% (14/22) to 31% (5/16). When historic controls were compared to patients who received EGDT, in house mortality was reduced from 40% (8/20) to 25% (4/16); 28-day mortality from 50% (10/20) to 25% (4/16); 60-day mortality from 50% (10/20) to 31% (5/16). Conclusion: EGDT produced an absolute mortality reduction when compared to both contemporaneous patients receiving standard therapy and historic controls eligible for EGDT. This mortality benefit was seen in house, at 28-days, and 60-days.
9
Pilot Study to Evaluate the Accuracy of Ultrasound in Confirming Endotracheal Tube Placement
Werner SL, Jones RA, Goldstein JR, Cydulka RK, MetroHealth Medical Center, Cleveland, OH
Study Objectives: Direct visualization of the cords and use of end-tidal capnography are the usual standards in confirming endotracheal (ET) tube placement. However, direct visualization is not always possible in difficult intubations, and end-tidal CO2 detection is not always reliable in patients with poor perfusion. In addition, end-tidal capnography requires ventilation in order to confirm placement which may lead to emesis in esophageal intubations. The goal of this study was to determine the accuracy of ultrasound in confirming endotracheal tube placement. Methods: This was a prospective randomized-controlled study conducted in the operating room of an academic hospital. Thirty-three adult patients were enrolled. The study was approved by the IRB and written consent was obtained from each subject. Patients eligible for the study were adults undergoing elective surgery requiring intubation. Exclusion criteria were a history of difficult intubation, abnormal airway anatomy, aspiration risk factors, or esophageal disease. For each subject, after induction of anesthesia and neuromuscular blockade, the attending anesthesiologist placed the ET tube once in the trachea and once in the esophagus in a random fashion using direct laryngoscopy. During the intubations, a high frequency linear ultrasound transducer was placed transversely on the anterior neck superior to the suprasternal notch. Two EPs with extensive ultrasound training independently recorded the location of the ET tube for each intubation based on the live ultrasound image. The EPs were blinded to the order of the intubations as well as to the actual performance of the intubations. The age, height, weight, BMI, intubation difficulty, Mallampati and ASA scores were recorded for each patient. The sensitivity and specificity of the EPs in determining the location of the ET tube and the kappa between the two EPs were calculated. Direct visualization of the location of the endotracheal tube by the anesthesiologist was the criterion standard. Results: Twenty-six women and seven men were enrolled in the study. The average age was 38.9G13.8 years. The average height was 64.9G4.1 inches. The average BMI was 28.5G6.5. The median Mallampati score was 1 and the median ASA score was 2. Sensitivity and specificity of tube placement was 100 percent for both endotracheal and esophageal intubations. Kappa was 1. One ET tube was misplaced by the anesthesiologist so both intubations were esophageal, but tube placement was correctly assessed by both EPs. Limitations: Limitations included the dichotomized study design. During each set of intubations, if placement of only one tube was confidently seen, the location of the other intubation could be assumed. Our study was also limited in that it included only adult, low risk patients and was conducted in a highly controlled environment. The study was limited to evaluation of ultrasound during intubations. We did not examine its use in static, post-intubation tube placement. In addition, the EPs conducting the study had substantial training in ultrasound. Conclusions: EPs experienced in ultrasound can accurately detect the placement of an endotracheal tube during intubation with ultrasound. Future studies should examine the use of ultrasound to confirm tube placement by EPs with only basic ultrasound training, use of the technique in the ED and with a wider range of patients, as well as ultrasound’s role in confirming tube placement in already intubated patients.
10
Comparative Study of Airway Management During Confined-Space Urban Rescue
Deibel M, Lock D, Jones JS, Hoyle J, Bernadotte M, Grand Rapids MERC/Michigan State University, Grand Rapids, MI
Study Objectives: To determine the most effective method of airway control in simulated patients confined within a collapsed structure. Methods: A prospective, cohort assessment of EMS personnel, housestaff and EM faculty performance was conducted over a 6-month study period using adult mannequins positioned in three different confined-space scenarios (i.e., collapsed
Volume 46, no. 3 : September 2005