The Latest in Critical Care, 7/3/23 (Issue #7)
The Latest in Critical Care, 7/3/23 (Issue #7)
Surprisingly to me, video laryngoscopy (VL) has not consistently been shown to increase first-pass intubation success over direct laryngoscopy (DL) in critically ill patients. Most studies have been small, single center, and only some have favored video.
In the DEVICE trial, 1417 critically ill adults at 17 U.S. emergency departments and ICUs were randomized to undergo either DL or VL for intubation. More than 90% of the intubations were performed by emergency medicine residents (~70%) or critical care fellows (~23%). The trainees were inexperienced in intubation generally (a quarter had done fewer than 25) and direct laryngoscopy (half had done ~70% of their prior intubations by video, and many had done fewer than 20 DL intubations). Various video laryngoscopes were used.
The trial was stopped early when first pass success was achieved in 85% by video laryngoscopy, compared to 71% with direct laryngoscopy. Roughly equal proportions (about 21%) experienced “severe complications” including hypoxemia with oxygen saturation <80%, systolic blood pressure <65 mm Hg, need for new or increased vasopressors, cardiac arrest, or death. Esophageal intubations occurred in both groups (0.9% with VL vs 1.3% with DL) but were corrected quickly: only a tiny proportion experienced cardiac arrest or death in either group.
So, residents and fellows still honing their intubation skills (half with fewer than 50 intubations), who were much more familiar with video than direct laryngoscopy than as a group, tended to have higher first pass success with video than DL. That’s what I would have expected (as it was my own experience). A recent prospective series of >15,000 intubations in the emergency medicine literature showed a similar finding.
But like many other trials before it, DEVICE can’t answer the question of how video vs direct laryngoscopy perform in the “real world,” i.e. by experienced intensivists and emergency physicians intubating at community hospitals (because clinical trials are almost never done there). Registries like the National Emergency Airway Registry only partially address that important gap in data.
Rather than “Which method of laryngoscopy is better for intubating critically ill patients?” this trial may have inadvertently answered the question, "Are younger generations of physicians becoming less proficient at direct laryngoscopy?”
I suspect the answer is yes. Every intubation with video is one less DL rep. Attendings who trained mainly on video might not be able to train DL as effectively. There is at least one respected critical care training program in the U.S. where teaching DL was abandoned completely in favor of video (I’m not sure if that’s still the case there).
Every airway manager should ideally be an expert with both DL and VL, but mathematics and muscle memory suggest that if your training included video, and you keep doing some intubations with video, it will be more difficult to achieve or maintain the same expertise at DL as airway experts who trained exclusively on DL. (Who themselves would be less experienced at video.)
(If those grizzled veterans give you a hard time, remember, they’re also the ones who dispensed attaboys in the pre-ultrasound era like “if you’re not cannulating the carotid artery or dropping lungs, you’re not doing enough central lines!”)
It’s also worth mentioning that anesthesiology residents (not well represented in this study) typically perform hundreds of intubations in their first year—more than most ED residents and CCM fellows perform in three-year programs. Yes, mostly in the O.R. on stable patients, but a striking comparison nonetheless.
From a patient’s perspective, of course, the ideal intubation technique is whatever her physician is best at. How a physician balances that imperative with the goal of maintaining one’s skills in multiple techniques (which could benefit future patients, not to mention oneself) is a practical and ethical concern for any proceduralist or surgeon. Read in NEJM
Ischemic-reperfusion injury after cardiac arrest can lead to multi-organ failure and worsened cerebral anoxic injury. In observational studies and a phase 2 randomized trial, mild hypercapnia was associated with improved outcomes or biomarkers, perhaps by improving cerebral oxygenation.
In the TAME trial, 1700 patients from 63 ICUs in 17 countries who achieved ROSC after out-of-hospital cardiac arrest were randomized to be ventilated with mild hypercapnia (hypoventilation, with Paco2 50 to 55 mm Hg) or normocapnia (35-45 mm Hg) for the first 24 hours, followed by normocapnia for all patients.
At six months of followup, there was no difference in the rate of good neurologic outcome (43.5% vs 44.6%) or in mortality (48% vs 46%), with normocapnia nominally favored for both outcomes.
This trial doesn’t lead me to diverge from the usual practice of targeting normocapnia in mechanically ventilated patients after out-of-hospital cardiac arrest. Read in NEJM
In The News
Chemotherapy Shortage Continues
Cisplatin and carboplatin — first line chemotherapy for many solid cancers — are in increasingly short supply, and are now being overtly rationed across the U.S., with most cancer centers now reporting shortages. The result: interruptions, unintended dose reductions, and delays in treatment for tens of thousands of people living with cancer. The American Society of Clinical Oncology is even advising doctors to withhold medicines from patients with recurrent or metastatic disease, in areas where the drugs are in short supply.
One primary reason: India-based Intas Pharmaceuticals, a primary manufacturer of cisplatin and carboplatin, elected to stop production after an inspection in late 2022 identified several problems.
There’s currently no clear plan or path to resolving the shortage. Production is reportedly already over capacity at the other makers of platinum based chemo drugs. According to NBC News, the FDA is exploring a partnership with a Chinese drug manufacturer to fill the gap. Read in NYT
DEA issues new 8-hour CME requirement for all prescribers of controlled substances.
DEA is requiring all prescribers of controlled substances complete EIGHT HOURS of additional CME. As there are nearly 2 million DEA registrants, that’s 16 million life-hours that will be sucked by fiat into the screen-staring, mouse-clicking Void of Compliance.
Prescribers are required to complete the training prior to their next DEA certificate renewal on or after June 27, 2023.
Taking the sting out only slightly: the DEA-mandated time will count toward your state’s controlled substance education mandates.
NEJM provides a free course to satisfy the requirement, or choose one of the many vendors popping up to provide the training for a hefty fee. Read at AMA or ASAM
Aspirin Causes Anemia in Older Adults
Daily low dose aspirin is known to increase the risk of bleeding in older adults. Subsequent analyses of large trial data show it also increases by 20% the rate of anemia without obvious bleeding (possibly from very small and/or intermittent bleeding episodes). The USPSTF changed its recommendation last year to advise against starting aspirin for primary prevention of cardiovascular disease in adults older than 60. ASPREE Trial, USPSTF