IRIS Cricoid Pressure Trial & Deimplementation (Journal Club)

Journal Club Article: Birenbaum, A., Hajage, D., Roche, S., Ntouba, A., Eurin, M., Cuvillon, P., … & Menut, R. (2018). Effect of Cricoid Pressure Compared With a Sham Procedure in the Rapid Sequence Induction of Anesthesia: The IRIS Randomized Clinical Trial. JAMA Surgery.

Background: 

Cricoid pressure or Sellick’s maneuver (first described by Dr. Sellick in the 1960’s) aims to reduce the risk of regurgitation. The technique involves the application of pressure over the cricoid cartilage with the thumb and 1-2 additional fingers, to to occlude the esophagus and prevent regurgitation of stomach contents into the upper airway.

Study Aim:

Does the cricoid pressure prevent pulmonary aspiration in patients undergoing rapid sequence induction of anesthesia?

Study Design:

A randomized, double-blind, noninferiority trial conducted across 10 academic centers. Patients undergoing anesthesia with rapid sequence intubation (RSI) were enrolled from February 2014 until February 2017 and followed up for 28 days or until hospital discharge. 3472 patients were assigned to cricoid pressure (Sellick group) or a sham procedure group. Mean age was 51 years and 51% were men. Inclusion: all adults; Exclusion: pregnancy.

Key Results: 

Primary measure of pulmonary aspiration, occurred in 10 patients (0.6%) in the Sellick group and in 9 patients (0.5%) in the sham group.

Secondary Measures:

  • No significant difference in pneumonia, length of stay and mortality.
  • The Cricoid (Sellick maneuver) group had significantly longer intubation time (median, 27 vs. 23 seconds).
  • Longer intubation time >30 seconds, Cricoid 47% vs Sham 40%; P <.001.
  • Comparison of the Cormack and Lehane grade (Grades 3 and 4) in Cricoid (10%) vs Sham (5%; P <.001).
  • All suggests an increased difficulty of tracheal intubation in the Cricoid (Sellick) group.

Summary: 

Investigators summary: “the results failed to demonstrate the noninferiority of a sham procedure in preventing pulmonary aspiration compared with the cricoid pressure. Mortality, pneumonia, and length of stay did not differ significantly between groups, and differences in intubation time and laryngoscopic exposure suggest more difficulties in the Sellick group”.

Nursing Clinical Questions:

  • Is cricoid pressure needed if there is no harm prevention and gives inferior views of the airway?
  • This study population was in theatre, can the results be transferred into the pre-hospital, ED or ICU populations (and in pregnancy)?
  • Should nurses use the evidence base to encourage the deimplementation of ‘ritualistic’ practice? See below in Deimplementation Resources.
  • Should nurses just refuse to perform a non-evidence based procedure?

Additional Resources:

Recommended Viewing on Cricoid: Cricolol by John Hinds on Vimeo.

Deimplementation Resources

Rogers, E. M. (1995) Diffusion of innovations. (5th ed.) Simon and Schuster, New York, USA. [summary article]

Nursing Education Network. (2017) Deimplementation of Practice.

Nursing Education Network. (2016) Human Centred Design.

 

 

 

 

 

Monitor Like a Pro: Continuous ST segment monitoring

Time is Muscle

Delivering continuous ST-segment monitoring for those at risk of myocardial infarction can provide a dynamic approach to cardiac monitoring, picking up changes in the ST-segment. This can supplement the continuous bedside ecg monitoring, static 12 lead ecg and monitoring the trend of cardiac enzymes such as Troponin’s, CK, CK-MB.

This is not new technology, its been around since the mid-1980s. Take a read of the resources below on the theory, how to set up, best lead for monitoring of suspected occluded coronary artery for monitoring of ischaemia.

ST and STEMI Maps

 

Keywords: ST Elevation; J-Point; Myocardial Infarction; AMI; STEMI; NSTEMI

Resources

Sangkachand, P., Sarosario, B., & Funk, M. (2011). Continuous ST-segment monitoring: nurses’ attitudes, practices, and quality of patient careAmerican Journal of Critical Care20(3), 226-238.

Sandau, K. E., & Smith, M. (2009). Continuous ST-segment monitoring: protocol for practiceCritical care nurse29(4), 39-49.

Leeper, B. (2003). Continuous ST-segment monitoring. AACN Advanced Critical Care14(2), 145-154.

Aust, M. P. (2011). continuous St-segment Monitoring. American Journal of Critical Care20(3), 239-239.

GE Healthcare. (2010). Quick Guide 12 Lead ST-segment Monitoring.

Sydney LHD. (2015). Continuous ST Monitoring in Intensive care Unit (ICU).

Note: This post is not sponsored or endorsed by an products or companies, it’s purely focused on understanding monitoring technology and potentially enhancing the level of care delivered in acute coronary care situations. Please share any other monitoring methods or technologies in the comment section below.

Delirium in the ICU

What is Delirium?

  • “Disturbance in attention (i.e., reduced ability to direct, focus, sustain, and shift attention) and awareness (reduced orientation to the environment).
  • The disturbance develops over a short period of time (usually hours to a few days), represents an acute change from baseline attention and awareness, and tends to fluctuate in severity during the course of a day.
  • An additional disturbance in cognition (e.g.memory deficit, disorientation, language, visuospatial ability, or perception).
  • Are not better explained by a pre-existing, established or evolving neurocognitive disorder and do not occur in the context of a severely reduced level of arousal such as coma.
  • There is evidence from the history, physical examination or laboratory findings that the disturbance is a direct physiological consequence of another medical condition, substance intoxication or withdrawal (i.e. due to a drug of abuse or to a medication), or exposure to a toxin, or is due to multiple etiologies”  (DSM-5 American Psychiatric Association. 2013).

Delirium Diagnostic Tools

 Sedation and delirium in the intensive care unit by Reade & Finfer, 2014.

Standardised Approach 

The Australian Commission on Safety and Quality in Health Care (2016) Delirium Clinical Care Standard provides guidance across healthcare for consumers and professionals.

Delirium Factors

A few to consider, the full list of potentials from ICU is extensive:

  • Hyper and Hypo Delirium 
  • Sedation in ICU (SPICE study)
  • Pain
  • Sepsis
  • Anxiety
  • Environmental

Interventions That Are Not Medications.

  • Sleep (all those alarms and interruptions)
  • Day/night or light/dark cycles
  • Cognitive stimulation
  • Early mobilisation
  • Ensure sensory aids are utilised
  • Family
  • Get the hell out of ICU asap?

Post Intensive Care Syndrome

As ever early detection and intervention is essential for improving patient outcomes.

References

Australian Commission on Safety and Quality in Health Care. (2016) Delirium Clinical Care Standard. Sydney:
ACSQHC.

DSM-5 American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders. Arlington: American Psychiatric Publishing.

European Delirium Association. (2014). The DSM-5 criteria, level of arousal and delirium diagnosis: inclusiveness is saferBMC medicine12(1), 141.

Inouye, S. K., van Dyck, C. H., Alessi, C. A., Balkin, S., Siegal, A. P., & Horwitz, R. I. (1990). Clarifying confusion: The confusion assessment methoda new method for detection of deliriumAnnals of internal medicine113(12), 941-948.

Reade, M. C., & Finfer, S. (2014). Sedation and delirium in the intensive care unitNew England Journal of Medicine370(5), 444-454.

Shehabi, Y., Bellomo, R., Reade, M. C., Bailey, M., Bass, F., Howe, B., … & Sedation Practice in Intensive Care Evaluation (SPICE) Study Investigators and the ANZICS Clinical Trials Group. (2012). Early intensive care sedation predicts long-term mortality in ventilated critically ill patientsAmerican journal of respiratory and critical care medicine186(8), 724-731.

Tullmann, D. F. (2001). Assessment of delirium: Another step forward. Critical care medicine29(7), 1481-1482.