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Device and Medication Preferences of Canadian Physicians for Emergent Endotracheal Intubation in Critically Ill Patients

  • Robert S. Green (a1) (a2), Dean A. Fergusson (a3) (a4), Alexis F. Turgeon (a5) (a6) (a7), Lauralyn A. McIntyre (a3) (a8), George J. Kovacs (a9), Donald E. Griesdale (a10) (a11) (a12), Ryan Zarychanski (a13) (a14) (a15), Michael B. Butler (a1), Nelofar Kureshi (a1) and Mete Erdogan (a2)...

Abstract

Objectives

Various medications and devices are available for facilitation of emergent endotracheal intubations (EETIs). The objective of this study was to survey which medications and devices are being utilized for intubation by Canadian physicians.

Methods

A clinical scenario-based survey was developed to determine which medications physicians would administer to facilitate EETI, their first choice of intubation device, and backup strategy should their first choice fail. The survey was distributed to Canadian emergency medicine (EM) and intensive care unit (ICU) physicians using web-based and postal methods. Physicians were asked questions based on three scenarios (trauma; pneumonia; heart failure) and responded using a 5-point scale ranging from “always” to “never” to capture usual practice.

Results

The survey response rate was 50.2% (882/1,758). Most physicians indicated a Macintosh blade with direct laryngoscopy would “always/often” be their first choice of intubation device in the three scenarios (mean 85% [79%-89%]) followed by video laryngoscopy (mean 37% [30%-49%]). The most common backup device chosen was an extraglottic device (mean 59% [56%-60%]). The medications most physicians would “always/often” administer were fentanyl (mean 45% [42%-51%]) and etomidate (mean 38% [25%-50%]). EM physicians were more likely than ICU physicians to paralyze patients for EETI (adjusted odds ratio 3.40; 95% CI 2.90-4.00).

Conclusions

Most EM and ICU physicians utilize direct laryngoscopy with a Macintosh blade as a primary device for EETI and an extraglottic device as a backup strategy. This survey highlights variation in Canadian practice patterns for some aspects of intubation in critically ill patients.

Objectifs

Différents dispositifs et différents médicaments s’offrent aux médecins pour faciliter l’intubation endotrachéale (IET) en extrême urgence. L’étude décrite ici visait à déterminer quels dispositifs et quels médicaments utilisent les médecins pour l’intubation au Canada.

Méthodes

Une enquête reposant sur des scénarios cliniques a été élaborée afin de déterminer quels médicaments utiliseraient les médecins pour faciliter l’IET en extrême urgence, quel serait leur premier choix de dispositif d’intubation et quelle serait leur solution de rechange en cas d’échec. Le questionnaire a été envoyé soit par voie électronique, soit par la poste aux urgentologues et aux intensivistes travaillant au Canada. Trois scénarios (trauma, pneumonie, insuffisance cardiaque) ont été soumis aux médecins, et ceux-ci devaient répondre aux questions à l’aide d’une échelle à 5 points variant de « Toujours » à « Jamais » pour indiquer leur pratique habituelle.

Résultats

Le taux de réponse à l’enquête a atteint 50,2 % (882/1758). La plupart des médecins ont indiqué qu’une lame Macintosh sous laryngoscopie directe serait « Toujours » ou « Souvent » leur premier choix de dispositif d’intubation, et ce, dans les 3 scénarios (moyenne : 85 % [79-89 %]), puis en vidéo-laryngoscopie (moyenne : 37 % [30-49 %]). L’instrument de rechange indiqué le plus souvent était un dispositif extraglottique (moyenne : 59 % [56-60 %]). Quant aux médicaments, les médecins administreraient « Toujours » ou « Souvent » le fentanyl (moyenne : 45 % [42-51 %]) ou l’étomidate (moyenne : 38 % [25-50 %]). Enfin, les urgentologues étaient plus nombreux à recourir à la paralysie des muscles pour les IET en extrême urgence que les intensivistes (risque relatif approché après rajustement : 3,40; IC à 95 % : 2,90-4,00).

Conclusions

La plupart des urgentologues et des intensivistes ont recours à une lame Macintosh sous laryngoscopie directe comme premier dispositif d’IET en extrême urgence, et à un dispositif extraglottique comme solution de rechange. L’enquête fait ressortir des différences de pratique au Canada en ce qui concerne certains aspects de l’intubation chez les personnes gravement malades.

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Copyright

Corresponding author

Correspondence to: Robert S. Green, Room 377 Bethune Building, 1276 South Park Street, Halifax, NS B3H 2Y9, Canada; Email: greenrs@dal.ca

References

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