Central lines in the ED are more likely to get infected because they’re inserted under less scrupulously aseptic conditions than in ICU, done more urgently, and are more likely to be placed in the mucky old femoral site by clumsy emergency physicians who don’t wash their hands after scratching their arses. Anyway, the intensivists will usually replace them with a ‘more ideal’ line after ICU admission. Right? Well, that’s what’s often taught and assumed to be the case, but a new study from a single centre suggests otherwise. ED-placed central venous catheters (19% of which were femoral) were typically left in for 4 to 5 days. The infection rate was 1.9 per 1,000 catheter-days, similar to that reported for central lines in other ICU case series.
Infection and Natural History of Emergency Department–Placed Central Venous Catheters
Annals of Emergency Medicine 2010;56(5):492-7
Tag Archives: procedures
Rocuronium reusable after sugammadex
Sugammadex currently has no role in my own emergency / critical care practice. However a helpful paper informs us that patients whose rocuronium-induced neuromuscular blockade had been reversed by sugammadex may be effectively re-paralysed by a second high dose (1.2 mg/kg) of rocuronium. Onset was slower and duration shorter if the second dose of rocuronium was given within 25 minutes of the sugammadex.
The study was done with sixteen volunteers and the initial dose of roc was only 0.6 mg/kg – less than that used for rapid sequence intubation by many emergency & critical care docs.
When repeat dose roc was given five minutes after sugammadex (n=6), mean (SD) onset time maximal block was 3.06 (0.97) min; range, 1.92–4.72 min. For repeat dose time points ≥25 min after sugammadex (n=5), mean onset was faster (1.73 min) than for repeat doses <25 min (3.09 min) after sugammadex. The duration of block ranged from 17.7 min (rocuronium 5 min after sugammadex) to 46 min (repeat dose at 45 min) with mean durations of 24.8 min for repeat dosing <25 min vs 38.2 min for repeat doses ≥25 min.
Repeat dosing of rocuronium 1.2 mg kg−1 after reversal of neuromuscular block by sugammadex 4.0 mg kg−1 in anaesthetized healthy volunteers: a modelling-based pilot study
Br J Anaesth. 2010 Oct;105(4):487-92
Novel subclavian cannulation method
Ultrasound-guided subclavian vein cannulation has reduced complications, but there is still a high incidence of failure to cannulate the vein and of accidental arterial cannulation. Vassallo & Bennett noticed that a fast running intravenous infusion in the ipsilateral arm of a patient produced variable echogenicity (lighter echos) in the subclavian vein. They describe deliberately using this appearance to both identify the subclavian vein and differentiate it from the subclavian artery.
With the intravenous infusion running with frequent drips in the drip chamber, the ultrasound beam is placed in long axis to the subclavian vessels in the subclavicular position. The angle of the ultrasound beam is adjusted to reveal both the subclavian vein and artery. The variable echogenicity, together with compression, can then be used to identify the vein. The presence of variable echogenicity in the vessel gives continuous feedback that the ultrasound beam has not drifted onto the artery. In cases where the ultrasound beam has included both artery and vein in the same image, this method has clearly identified the intended target vessel.
Subclavian cannulation with ultrasound: a novel method
Anaesthesia, 2010;65:1041
Pre-hospital RSI by different specialties
This aim of the study was to evaluate the tracheal intubation success rate of doctors drawn from different clinical specialities performing rapid sequence intubation (RSI) in the pre-hospital environment operating on the Warwickshire and Northamptonshire Air Ambulance. Over a 5-year period, RSI was performed in 200 cases (3.1/month).
Failure to intubate was declared if >2 successive attempts were required to achieve intubation or an ETT could not be placed correctly necessitating the use of an alternate airway. Successful intubation occurred in 194 cases, giving a failure rate of 3% (6 cases, 95% CI 0.6 to 5.3%). While no difference in failure rate was observed between emergency department (ED) staff and anaesthetists (2.73% (3/110, 95% CI 0 to 5.7%) vs 0% (0/55, 95% CI 0 to 0%); p=0.55), a significant difference was found when non-ED, non- anaesthetic staff (GP and surgical) were compared to anaesthetists (10.34% (3/29, 95% CI 0 to 21.4%) vs 0%; p=0.04). There was no significant difference associated with seniority of practitioner (p=0.65). The authors conclude that non-anaesthetic practitioners have a higher tracheal intubation failure rate during pre-hospital RSI, which may reflect a lack of training opportunities.
The small numbers of ‘failure’ rates, combined with the definition of failure in this study, make it hard to draw generalisations. Of note is that the paper lists the outcomes of the six patients who met the failed intubation definition, all of whom appear to have had their airway satisfactorily maintained by the RSI practitioner, three by eventual tracheal intubation, one by LMA, and two by surgical airway. More data are needed before whole specialties are judged on the performance of a small group of doctors.
Should non-anaesthetists perform pre-hospital rapid sequence induction? an observational study
Emerg Med J. 2010 Jul 26. [Epub ahead of print]
EM trainee RSI experience
A single centre observational study of rapid sequence intubation (RSI) was performed in a Scottish Emergency Department (ED) over four and a quarter years, followed by a postal survey of ED RSI operators.
There were 329 RSIs during the study period. RSI was performed by emergency physicians (both trained specialists and training grade, or ‘registrar’ doctors) in 288 (88%) patients. Complication rates were low and there were only two failed intubations requiring surgical airways (0.6%). ED registrars were the predominant RSI operator, with 206 patients (63%). ED consultants performed RSIs on 82 (25%) patients, anaesthetic registrars on 31 (9.4%) patients, and anaesthetic consultants on 8 (2.4%) patients. An ED consultant was present during every RSI performed and an anaesthetist was present during 72 (22%). The average number of ED registrars during this period of training was 8. This equates to each ED trainee performing approximately 26 ED RSIs (6.5 RSIs/year). On average, ED consultants performed 14 RSIs during this period (approx 3.5 RSIs/year). Of the 17 questionnaires, 12 were completed, in all of which cases the trainees were confident to perform RSI independently at the end of registrar training. Interestingly, 45 (14%) of the RSIs in the study were done in the pre-hospital environment by ED staff, two thirds of which were done by ED consultants.
Training and competency in rapid sequence intubation: the perspective from a Scottish teaching hospital emergency department
Emerg Med J. 2010 Sep 15. [Epub ahead of print]
Burr holes by emergency physicians
Emergency physicians at Hennepin County Medical Centre (HCMC) are trained in skull trephination (drilling a burr hole) for patients with coma, anisocoria and epidural (extradural) haematoma (EDH) who have not responded to osmotic agents and hyperventilation. This may be particularly applicable in centres remote from neurosurgical centres where delays caused by interfacility transfer are associated with increased morbidity and mortality.
Dr Smith and colleagues from HCMC describe a series of five talk-and-deteriorate patients with EDH who underwent skull trephination. 3 had complete recovery without disability, and 2 others had mild to moderate disability but with good to excellent cognitive function. None had complications from the procedure other than external bleeding from the already lacerated middle meningeal artery. In 4 of 5 cases, the times were recorded. Mean time from ED presentation to trephination was 55 min, and mean time from ED to craniotomy was 173 min. The mean time saved was 118 min, or approximately 2 h.
All trephinations were done by emergency physicians, who had received training in skull trephination as part of the HCMC Emergency Medicine Residency or as part of the Comprehensive Advanced Life Support (CALS) course. Training was very brief and involved discussion of the treatment of EDH, review of a CT scan of EDH, and hands-on practice on the skull of a dead sheep, using the Galt trephinator.
An excellent point made by the authors reminds us that patients with EDH who talk-and-deteriorate (those with the traditionally described “lucid interval”) have minimal primary brain injury and frequently have no brain parenchymal injury. Thus, if the EDH is rapidly decompressed, the outcome is significantly better than for deterioration due to other aetiologies. The authors recommend in EDH that the procedure should be done within 60–90 min of onset of anisocoria. A review of other studies on the procedure would suggest that case selection is critical in defining the appropriateness of the procedure: talk-and-deteriorate, coma, anisocoria, and a delay to neurosurgical decompression.
Emergency Department Skull Trephination for Epidural Hematoma in Patients Who Are Awake But Deteriorate Rapidly
J Emerg Med. 2010 Sep;39(3):377-83
capnometry versus pulse oximetry during procedural sedation
During emergency department procedural sedation, some clinicians (myself included) advocate non-invasive capnography for the early detection of apnoea. Others argue against routine administration of oxygen so that if desaturation occurs it provides an earlier more correctable warning of respiratory depression than if it occurs on supplemental oxygen. A Canadian study using prospective data from research on propofol with either ketamine or fentanyl compared changes in capnography with desaturation in sedated patients breathing only room air. Desaturation detectable by pulse oximeter occurred before overt changes in capnometry were identified.
It’s hard to ascertain the relevance of this finding. The authors wisely state ‘these findings should not be extrapolated to patients administered supplemental oxygen where it is possible capnometry may be helpful’. Since I use capnography in the hope that it will assist in the earlier detection of ketamine-associated laryngospasm in children, I’m not going to discard it in favour of waiting for the saturation to fall. Perhaps we just need to be clear that capnography may be more useful at detecting apnoea than hypoventilation.
A comparative evaluation of capnometry versus pulse oximetry during procedural sedation and analgesia on room air
CJEM. 2010 Sep;12(5):397-404
EZ-IO outperformed B.I.G
A small randomised trial of adult emergency department patients showed faster insertion and higher success rates with the EZ-IO compared with the Bone Injection Gun (B.I.G). This is in keeping with my own experience and that of several services I have worked for.
Comparison of two intraosseous access devices in adult patients under resuscitation in the emergency department: A prospective, randomized study
Resuscitation. 2010 Aug;81(8):994-9
Alternative toothless mask position
An alternative position for holding the facemask when bag-mask ventilating edentulous patients is described and evaluated. 49 patients with inadequate seal and air leak during two-hand positive-pressure ventilation had significantly improved ventilation as measured by reduced air leak and increased expiratory volume when the caudal end of the mask was repositioned above the lower lip while maintaining neck extension.
Face mask ventilation in edentulous patients: a comparison of mandibular groove and lower lip placement
Anesthesiology. 2010 May;112(5):1190-3
FV cannulation in kids: 60° abduction
An ultrasound study on infants and children under general anaesthesia evaluated the femoral vein with the patients’ legs at 30° and 60° of abduction and their hips externally rotated. Measurements were taken at the level of the inguinal crease and 1 cm below the crease.
Hip rotation with 60° leg abduction significantly decreased the overlap between femoral vein and femoral artery at the level of the inguinal crease in both infants and children.
The authors recommend the optimal place for femoral vein cannulation in paediatric patients seems to be at the level of the inguinal crease with 60° leg abduction and external hip rotation.
Ultrasonographic evaluation of the femoral vein in anaesthetised infants and young children
Anaesthesia. 2010;65(9):895–898