jueves, 11 de diciembre de 2014

VAD en UCI/Difficult airway in ICU

Identificación temprana de pacientes en riesgo de intubación difícil en la UCI. Desarrollo y validación de la escala MACOCHA en un estudio multicéntrico 

Early identification of patients at risk for difficult intubation in the intensive care unit: development and validation of the MACOCHA score in a multicenter cohort study.
De Jong A1, Molinari N, Terzi N, Mongardon N, Arnal JM, Guitton C, Allaouchiche B, Paugam-Burtz C, Constantin JM, Lefrant JY, Leone M, Papazian L,Asehnoune K, Maziers N, Azoulay E, Pradel G, Jung B, Jaber S; AzuRéa Network for the Frida-Réa Study Group.
Am J Respir Crit Care Med. 2013 Apr 15;187(8):832-9. doi: 10.1164/rccm.201210-1851OC.
RATIONALE: Difficult intubation in the intensive care unit (ICU) is a challenging issue. OBJECTIVES: To develop and validate a simplified score for identifying patients with difficult intubation in the ICU and to report related complications. METHODS: Data collected in a prospective multicenter study from 1,000 consecutive intubations from 42 ICUs were used to develop a simplified score of difficult intubation, which was then validated externally in 400 consecutive intubation procedures from 18 other ICUs and internally by bootstrap on 1,000 iterations. MEASUREMENTS AND MAIN RESULTS: In multivariate analysis, the main predictors of difficult intubation (incidence = 11.3%) were related to patient (Mallampati score III or IV, obstructive sleep apnea syndrome, reduced mobility of cervical spine, limited mouth opening); pathology (severe hypoxia, coma); and operator (nonanesthesiologist). From the β parameter, a seven-item simplified score (MACOCHA score) was built, with an area under the curve (AUC) of 0.89 (95% confidence interval [CI], 0.85-0.94). In the validation cohort (prevalence of difficult intubation = 8%), the AUC was 0.86 (95% CI, 0.76-0.96), with a sensitivity of 73%, a specificity of 89%, a negative predictive value of 98%, and a positive predictive value of 36%. After internal validation by bootstrap, the AUC was 0.89 (95% CI, 0.86-0.93). Severe life-threatening events (severe hypoxia, collapse, cardiac arrest, or death) occurred in 38% of the 1,000 cases. Patients with difficult intubation (n = 113) had significantly higher severe life-threatening complications than those who had a nondifficult intubation (51% vs. 36%; P < 0.0001). CONCLUSIONS: Difficult intubation in the ICU is strongly associated with severe life-threatening complications. A simple score including seven clinical items discriminates difficult and nondifficult intubation in the ICU. Clinical trial registered with www.clinicaltrials.gov (NCT 01532063).

La intubación traqueal en la UCI: salvar o amenazar la vida?

Tracheal intubation in the ICU: Life saving or life threatening?
Divatia JV1, Khan PU, Myatra SN.
Indian J Anaesth. 2011 Sep;55(5):470-5. doi: 10.4103/0019-5049.89872.
Tracheal intubation (TI) is a routine procedure in the intensive care unit (ICU), and is often life saving. However, life-threatening complications occur in a significant proportion of procedures, making TI perhaps one the most common but underappreciated airway emergencies in the ICU. In contrast to the controlled conditions in the operating room (OR), the unstable physiologic state of critically ill patients along with underevaluation of the airways and suboptimal response to pre-oxygenation are the major factors for the high incidence of life-threatening complications like severe hypoxaemia and cardiovascular collapse in the ICU. Studies have shown that strategies planned for TI in the OR can be adapted and extrapolated for use in the ICU. Non-invasive positive-pressure ventilation for pre-oxygenation provides adequate oxygen stores during TI for patients with precarious respiratory pathology. The intubation procedure should include not only airway management but also haemodynamic, gas exchange and neurologic care, which are often crucial in critically ill patients. Hence, there is a necessity for the implementation of an Intubation Bundle during routine airway management in the ICU. Adherence to a plan for difficult airway management incorporating the use of intubation aids and airway rescue devices and strategies is useful. KEYWORDS: Complications; intensive care; intubation bundle strategy; tracheal intubation


Desastres en el manejo de la vía aérea en UCI. ¿Lecciones aprendidas?

Airway management disasters in the ICU--lessons learned?
Byhahn C, Cavus E.
Crit Care. 2012 Oct 29;16(5):162. doi: 10.1186/cc11641.
The C-MAC video laryngoscope substantially reduced poor glottic views and increased intubation success in ICU patients with at least one predictor for difficult intubation. However, all video-assisted and optical intubation devices have different view angles, thus producing different images with particular distortion, and even experts in 'old-fashioned' airway management need a substantial level of training with a certain device before using it safely and successfully in critical situations and patients. Video laryngoscopes, regardless of a particular brand or device, cannot be used intuitively - they require expert skills and routines to be turned into a life-saving airway management tool.


Anestesiología y Medicina del Dolor
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