Intubating the Critically Ill in the ED-are There Enough Evidence?
1The National hospital of SriLanka, SriLankan society of Critical Care and emergency Medicine, SriLanka
Critically ill patients regularly require endotracheal intubation in the (ICU), in the emergency department (ED), or during in-hospital emergency in general wards. Seriously ill patients varies from elective patients intubated in the operation room: Mostly they present with severe respiratory compromise, cardiovascular instability, increased sensitivity to the side effects of narcotics, full stomach , and cardiac or cerebrovascular diseases. Airway management outside the operating theatre has a high rate of major complications, such as severe hypoxia, hemodynamic collapse, cardiac arrest, and death . Moreover, the incidence of difficult intubation is high when compared to elective intubation in the operating room . Lack of training, supervision and assistance, failure to identify patients at risk, failure to plan and carry out a backup strategy if required, and deficiency in available equipment, all are the most relevant modifiable risk factors . Other factors that could increase the incidence of adverse events include the emergent requirement of tracheal intubation preventing adequate preparation, and the commonly limited physical space around beds. Accordingly, interventions to improve everyday practice, in particular pre-oxygenation and first-attempt success rate, have been proposed and evaluated individually or as combined in bundles . However, these protocols are based mostly on expert opinions, low-quality retrospective or before-after studies, or are derived from guidelines developed for elective intubation in the operating theatre. So far, there has not been a systematic review focused on randomized controlled trials (RCTs).