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Team preparation and human factors |
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Appropriately designed checklists may reduce errors of omission and improve patient outcomes |
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The intubation team should consist of at least three healthcare providers, including two airway operators (one of whom should be experienced) |
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Training requirements should be well-defined and include simulation-based training |
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Patient preparation and optimization |
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Screen critically ill adults requiring tracheal intubation for both anatomic and physiologic difficulty |
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Hemodynamics should be optimized prior to tracheal intubation |
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Point-of-care ultrasound aids the assessment and management of cardio-respiratory compromise |
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Preoxygenation with non-invasive ventilation is preferred, and high flow nasal oxygen can be used to facilitate oxygen delivery during apnea |
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Careful mask ventilation may be performed to minimize desaturation |
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Sub-anesthetic doses of sedative hypnotics to facilitate pre-oxygenation while maintaining spontaneous ventilation (i.e., delayed sequence intubation) can be considered in patients who would otherwise be difficult to pre-oxygenate |
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Performing the procedure |
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Modified rapid sequence intubation should be considered |
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Ketamine or etomidate are the preferred sedative hypnotic agents, and standard anesthetic induction doses of propofol should be avoided |
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Video laryngoscopy should be available and routinely employed during the first tracheal intubation attempt |
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A stylet or bougie should be routinely employed |
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Post-intubation care |
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Tracheal tube placement should be confirmed using waveform capnography with consistent rise in amplitude during exhalation, with decline during inspiration, over at least seven breaths |
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Fluid responsiveness should be re-evaluated using dynamic indices before fluid administration in patients who develop hemodynamic instability |
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Invasive vascular access should be established in patients who develop persistent hemodynamic instability |
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Sedative hypnotic infusions guided by clinically assessed sedation depth should be used to reduce the risk of accidental awareness with recall in patients who received neuromuscular blocking agents |
Figure 1 graphically depicts both the definition of, risk factors for, and elements in the management of the PDA.
It is also important to emphasize that dissensus and/or disagreement among experts was also identified in several areas, including: the definition of an experienced airway operator, the role and management of cricoid pressure, the optimal video laryngoscope design (e.g., conventional versus hyperangulated), and the importance of routinely reversing neuromuscular blocking agents after tracheal intubation. Apart from these domains, the need to further appraise interventions to prevent cardiovascular collapse—the most common physiologic complication associated with tracheal intubation in critically ill adults—emerged as an important area for future research as current evidence is markedly lacking to adequately inform our clinical practice. Work will also be needed to further bridge the implementation gap between identified best practices and the bedside, including identifying barriers to the universal availability and application of video laryngoscopy in this patient population, developing optimal approaches to the application of point-of-care ultrasound, PDA curriculum development, and adaptation to resource limited environments.
On behalf of SOCCA’s PDA Task Force, we would like to extend a token of thanks to all SOCCA members who made this work possible, including Task Force members and those who participated as experts in the consensus effort.