Williamson County EMS, Georgetown, TX; Department of Emergency Medicine, Baylor Scott & White Healthcare, Temple, TX.
Williamson County EMS, Georgetown, TX.
Ann Emerg Med. 2018 Sep;72(3):272-279.e1. doi: 10.1016/j.annemergmed.2018.01.044. Epub 2018 Mar 9.
Peri-intubation hypoxia is an important adverse event of out-of-hospital rapid sequence intubation. The aim of this project is to determine whether a clinical bundle encompassing positioning, apneic oxygenation, delayed sequence intubation, and goal-directed preoxygenation is associated with decreased peri-intubation hypoxia compared with standard out-of-hospital rapid sequence intubation.
We conducted a retrospective, before-after study using data from a suburban emergency medical services (EMS) system in central Texas. The study population included all adults undergoing out-of-hospital intubation efforts, excluding those in cardiac arrest. The before-period intervention was standard rapid sequence intubation using apneic oxygenation at flush flow, ketamine, and a paralytic. The after-period intervention was a care bundle including patient positioning (elevated head, sniffing position), apneic oxygenation, delayed sequence intubation (administration of ketamine to facilitate patient relaxation and preoxygenation with a delayed administration of paralytics), and goal-directed preoxygenation. The primary outcome was the rate of peri-intubation hypoxia, defined as the percentage of patients with a saturation less than 90% during the intubation attempt.
The before group (October 2, 2013, to December 13, 2015) included 104 patients and the after group (August 8, 2015, to July 14, 2017) included 87 patients. The 2 groups were similar in regard to sex, age, weight, ethnicity, rate of trauma, initial oxygen saturation, rates of initial hypoxia, peri-intubation peak SpO, preintubation pulse rate and systolic blood pressure, peri-intubation cardiac arrest, and first-pass and overall success rates. Compared with the before group, the after group experienced less peri-intubation hypoxia (44.2% versus 3.5%; difference -40.7% [95% confidence interval -49.5% to -32.1%]) and higher peri-intubation nadir SpO values (100% versus 93%; difference 5% [95% confidence interval 2% to 10%]).
In this single EMS system, a care bundle encompassing patient positioning, apneic oxygenation, delayed sequence intubation, and goal-directed preoxygenation was associated with lower rates of peri-intubation hypoxia than standard out-of-hospital rapid sequence intubation.
围插管期缺氧是院外快速序贯插管的一个重要不良事件。本项目旨在确定在与标准院外快速序贯插管相比，是否包含体位、无通气氧合、延迟序贯插管和目标导向预氧合的临床综合措施与围插管期缺氧减少相关。
我们使用德克萨斯州中部一个郊区急诊医疗服务（EMS）系统的数据进行了回顾性前后对照研究。研究人群包括所有接受院外插管的成年人，但不包括心脏骤停者。前一时期的干预措施是使用无通气氧合进行标准快速序贯插管，氧合时流量冲洗，给予氯胺酮，并使用肌松剂。后一时期的干预措施是包括患者体位（抬高头部、嗅探位）、无通气氧合、延迟序贯插管（给予氯胺酮以促进患者放松和预氧合，然后延迟给予肌松剂）和目标导向预氧合的护理综合措施。主要结局是围插管期缺氧的发生率，定义为插管过程中饱和度低于 90%的患者百分比。
前一组（2013 年 10 月 2 日至 2015 年 12 月 13 日）包括 104 例患者，后一组（2015 年 8 月 8 日至 2017 年 7 月 14 日）包括 87 例患者。两组在性别、年龄、体重、种族、创伤发生率、初始氧饱和度、初始缺氧率、围插管期峰值 SpO2、预插管脉搏率和收缩压、围插管期心脏骤停以及一次通过和总体成功率方面相似。与前一组相比，后一组围插管期缺氧发生率较低（44.2%比 3.5%；差异-40.7%[95%置信区间-49.5%至-32.1%]），围插管期最低 SpO2 值较高（100%比 93%；差异 5%[95%置信区间 2%至 10%]）。
在这个单一的 EMS 系统中，包含患者体位、无通气氧合、延迟序贯插管和目标导向预氧合的护理综合措施与标准院外快速序贯插管相比，与较低的围插管期缺氧发生率相关。
