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Title: Tracheal intubation in critically ill patients: a comprehensive systematic review of randomized trials.
Austin Authors: Cabrini, Luca;Landoni, Giovanni;Baiardo Radaelli, Martina;Saleh, Omar;Votta, Carmine D;Fominskiy, Evgeny;Putzu, Alessandro;Snak de Souza, Cézar Daniel;Antonelli, Massimo;Bellomo, Rinaldo ;Pelosi, Paolo;Zangrillo, Alberto
Affiliation: Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
Department of Cardiovascular Anesthesia and Intensive Care, Cardiocentro Ticino, Lugano, Switzerland
Department of Surgery. Discipline of Anesthesiology, Critical Care and Pain Medicine, Federal University of São Paulo, São Paulo, Brazil
Department of Intensive Care Medicine and Anaesthesiology, Fondazione Policlinico Universitario A. Gemelli, Università Cattolica del Sacro Cuore, Rome, Italy
Department of Intensive Care, Austin Health, Heidelberg, Victoria, Australia
Department of Surgical Sciences and Integrated Diagnostics, San Martino Policlinico Hospital, IRCCS for Oncology, University of Genoa, Largo Rosanna Benzi 8, 16131, Genoa, Italy.
Issue Date: 20-Jan-2018
Date: 2018-01-20
Publication information: Critical Care 2018; 22(1): 6
Abstract: We performed a systematic review of randomized controlled studies evaluating any drug, technique or device aimed at improving the success rate or safety of tracheal intubation in the critically ill. We searched PubMed, BioMed Central, Embase and the Cochrane Central Register of Clinical Trials and references of retrieved articles. Finally, pertinent reviews were also scanned to detect further studies until May 2017. The following inclusion criteria were considered: tracheal intubation in adult critically ill patients; randomized controlled trial; study performed in Intensive Care Unit, Emergency Department or ordinary ward; and work published in the last 20 years. Exclusion criteria were pre-hospital or operating theatre settings and simulation-based studies. Two investigators selected studies for the final analysis. Extracted data included first author, publication year, characteristics of patients and clinical settings, intervention details, comparators and relevant outcomes. The risk of bias was assessed with the Cochrane Collaboration's Risk of Bias tool. We identified 22 trials on use of a pre-procedure check-list (1 study), pre-oxygenation or apneic oxygenation (6 studies), sedatives (3 studies), neuromuscular blocking agents (1 study), patient positioning (1 study), video laryngoscopy (9 studies), and post-intubation lung recruitment (1 study). Pre-oxygenation with non-invasive ventilation (NIV) and/or high-flow nasal cannula (HFNC) showed a possible beneficial role. Post-intubation recruitment improved oxygenation, while ramped position increased the number of intubation attempts and thiopental had negative hemodynamic effects. No effect was found for use of a checklist, apneic oxygenation (on oxygenation and hemodynamics), videolaryngoscopy (on number and length of intubation attempts), sedatives and neuromuscular blockers (on hemodynamics). Finally, videolaryngoscopy was associated with severe adverse effects in multiple trials. The limited available evidence supports a beneficial role of pre-oxygenation with NIV and HFNC before intubation of critically ill patients. Recruitment maneuvers may increase post-intubation oxygenation. Ramped position increased the number of intubation attempts; thiopental had negative hemodynamic effects and videolaryngoscopy might favor adverse events.
DOI: 10.1186/s13054-017-1927-3
ORCID: 0000-0002-1650-8939
Journal: Critical Care
PubMed URL: 29351759
PubMed URL:
Type: Journal Article
Subjects: Critically ill
Emergency department
High flow nasal cannula
Intensive care unit
Tracheal intubation
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