I recently came across two articles pertaining to the peri-intubation; one made me very happy (b/c it reinforces my prejudices) and the other made me quite upset (b/c it reinforces my prejudices).
Let's start with good tidings first:
In this prospective, observational trial the use of NMBAs was associated with a lower incidence of hypoxemia and complications. NMBAs also led to better intubating conditions. Now during the debate with Dr. Paul Mayo I showed a bunch of articles that said the same thing, so why is this one so important? Because this was done in a setting that really matters to EMCrit readers: the ICU. What we have known for at least a decade is that ED/ICU intubations are an entirely different animal than OR intubations. So now we have further proof of what I have always believed–if you are a skilled airway operator, paralytics will improve your intubating conditions.
Now the not so great:
Note: I am not the author of this paper, nor am I related to him.
Thanks to Minh of the Pharm for pointing this one out to me.So here is the paper's conclusion: Less than one-half of patients undergoing ETI in the ED receive sedative drugs while in the ED. These findings are congruent with prior smaller studies from single academic centers. Now I'm not sure if some of these patients were so deeply comatose that the team felt no sedation was necessary, but I can't imagine it is a huge fraction of the patients that did not get sedation. This makes me so sad. The relief of pain and suffering should be our first priority as doctors. How can this still be going on?
Update: This article in-press says the same thing–frown
(Chong ID. Long-acting neuromuscular paralysis without concurrent sedation in emergency care. American Journal of Emergency Medicine 2014;In-Press)
Tell me how these articles make you feel (b/c EMCrit cares) in the comments:
- COVID19 – Awake Pronation (aka the Pig Roast) A guest write-up by David Gordon, MD - April 6, 2020
- EMCrit Wee – Webinar I Gave to Pulm/Crit Care Fellows on Avoiding Intubation and Initial Ventilation of COVID19 Patients - April 4, 2020
- EMCrit 269 – Rationing of Critical Care and Ventilators in COVID19 with Reub Strayer - March 31, 2020