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Our primary aim was to identify predictors of immediate hemodynamic decompensation during the peri-intubation period.We conducted a nested case-control study of a previously identified cohort of adult patients needing intubation admitted to a medical-surgical ICU during 2013-2014. Hemodynamic derangement was defined as cardiac arrest and/or the development of systolic blood pressure90mmHg and/or mean arterial pressure65mmHg 30min following intubation. Data during the peri-intubation period was analyzed.The final cohort included 420 patients. Immediate hemodynamic derangement occurred in 170 (40%) patients. On multivariate modeling, age/10year increase (OR 1.20, 95% CI 1.03-1.39, p=0.02), pre-intubation non-invasive ventilation (OR 1.71, 95% CI 1.04-2.80, p=0.03), pre-intubation shock index/1 unit (OR 5.37 95% CI 2.31-12.46, p≤0.01), and pre-intubation modified shock index/1 unit (OR 2.73 95% CI 1.48-5.06, p≤0.01) were significantly associated with hemodynamic derangement. Those experiencing hemodynamic derangement had higher ICU [47 (28%) vs. 33 (13%); p≤0.001] and hospital [69 (41%) vs. 51 (20%); p≤0.001] mortality.Hemodynamic derangement occurred at a rate of 40% and was associated with increased mortality. Increasing age, use of non-invasive ventilation before intubation, and increased pre-intubation shock and modified shock index values were significantly associated with hemodynamic derangement post-intubation.

Data regarding best practices for ventilator management strategies that improve outcomes in acute respiratory distress syndrome (ARDS) are readily available. However, little is known regarding processes to ensure compliance with these strategies. We developed a goal-directed mechanical ventilation order set that included physician-specified lung-protective ventilation and oxygenation goals to be implemented by respiratory therapists (RTs). We sought as a primary outcome to determine whether an RT-driven order set with predefined oxygenation and ventilation goals could be implemented and associated with improved adherence with best practice.We evaluated 1302 patients undergoing invasive mechanical ventilation (1693 separate episodes of invasive mechanical ventilation) prior to and after institution of a standardized, goal-directed mechanical ventilation order set using a controlled before-and-after study design. Patient-specific goals for oxygenation partial pressure of oxygen in arterial blood (PaoCompliance with the new mechanical ventilation order set was high: 88.2% compliance versus 3.8% before implementation of the order set ( P.001). Adherence to the PEEP/FioA standardized best practice mechanical ventilation order set can be implemented by a multidisciplinary team and is associated with improved compliance to written orders and adherence to the ARDSNet PEEP/Fio

Arterial desaturations experienced during endotracheal intubation (ETI) may lead to poor outcomes. Thus, our primary aim was to identify predictors of arterial desaturation (pulse oximetry90%) during the peri-intubation period and to assess outcomes of those who developed arterial hypoxemia.Adult patients admitted to a medical and/or surgical intensive care unit (ICU) over the time period of January 1st 2013 through December 31st 2014 who required ETI were included. Only the first intubation was captured. Arterial desaturation was defined as pulse oximetry readings of90% (hypoxemia) in the immediate peri-intubation period. Patients were then grouped in cases (those who developed desaturation) and controls (those who did not develop this complication).The final cohort included 420 patients. Arterial desaturations occurred in 74 (18%) patients. When adjusting for significant predictors on univariate analysis and known predictors of a difficult airway, only acute respiratory failure (OR 2.38; 95% CI: 1.15-4.93; P=0.02) and provider training level (OR 7.12; 95% CI: 1.65-30.67; P=0.016) remained significant. Higher pulse oximetry readings prior to intubation was found to be protective on multivariate analysis (OR 0.92; 95% CI: 0.89-0.96; P0.01; per one percent increase).Patients who were intubated for acute respiratory failure and those who were intubated by junior level trainees had increased odds of experiencing arterial desaturation in the peri-intubation period. Patients experiencing arterial desaturation had lower pulse oximetry readings prior to intubation suggesting a possible delay at intubation.

Our primary aim was to ascertain the frequency of postintubation hypotension in immunocompromised critically ill adults with secondary aims of arriving at potential risk factors for the development of postintubation hypotension and its impact on patient-related outcomes.Critically ill adult patients (≥18 years) were included from January 1, 2010, to December 31, 2014. We defined immunocompromised as patients with any solid organ or nonsolid organ malignancy or transplant, whether solid organ or not, requiring current chemotherapy. Postintubation hypotension was defined as a decrease in systolic blood pressure to less than 90 mm Hg or a decrease in mean arterial pressure to less than 65 mm Hg or the initiation of any vasopressor medication. Patients were then stratified based on development of postintubation hypotension. Potential risk factors and intensive care unit (ICU) outcome metrics were electronically captured by a validated data mart system.The final cohort included 269 patients. Postintubation hypotension occurred in 141 (52%; 95% confidence interval: 46-58) patients. Several risk factors predicted postintubation hypotension on univariate analysis; however, only Acute Physiology and Chronic Health Evaluation III score in the first 24 hours, preintubation shock status, and preintubation hemodynamic instability remained significant on all 4 multivariate analyses. Patients developing postintubation hypotension had higher ICU and hospital mortality (54 [38%] vs 31 [24%], P = .01; 69 [49%] vs 47 [37%], P = .04).Based on previous literature, we found a higher frequency of postintubation hypotension in the immunocompromised than in the nonimmunocompromised critically ill adult patients. Acute Physiology and Chronic Health Evaluation III score in the first 24 hours, preintubation shock status, and preintubation hemodynamic instability were significant predictors on multivariate analyses. Postintubation hypotension led to higher ICU and hospital mortality in those experiencing this complication.

ObjectiveHypotension following endotracheal intubation in the ICU is associated with poor outcomes. There is no formal prediction tool to help estimate the onset of this hemodynamic compromise. Our objective was to derive and validate a prediction model for immediate hypotension following endotracheal intubation.MethodsA multicenter, prospective, cohort study enrolling 934 adults who underwent endotracheal intubation across 16 medical/surgical ICUs in the United States from July 2015-January 2017 was conducted to derive and validate a prediction model for immediate hypotension following endotracheal intubation. We defined hypotension as: 1) mean arterial pressure ResultsPost-intubation hypotension developed in 344 (36.8%) patients. In the full cohort, 11 variables were independently associated with hypotension: increasing illness severity; increasing age; sepsis diagnosis; endotracheal intubation in the setting of cardiac arrest, mean arterial pressure ConclusionsA novel multivariable risk score predicted post-intubation hypotension with accuracy in both unstable and stable critically ill patients.Study registrationClinicaltrials.gov identifier: NCT02508948 and Registered Report Identifier: RR2-10.2196/11101.

Background We aim to report the incidence of post-intubation hypotension in the critically ill, to report in-hospital mortality and length of stay in those who developed post-intubation hypotension, and to explore possible risk factors associated with post-intubation hypotension. Material/methods Adult (≥18 years) ICU patients who received emergent endotracheal intubation were included. We excluded patients if they were hemodynamically unstable 60 minutes pre-intubation. Post-intubation hypotension was defined as the administration of any vasopressor within 60 minutes following intubation. Results Twenty-nine patients developed post-intubation hypotension (29/147, 20%). Post-intubation hypotension was associated with increased in-hospital mortality (11/29, 38% vs. 19/118, 16%) and length of stay (21 [10-37] vs. 12 [7-21] days) on multivariate analysis. Three risk factors for post-intubation hypotension were identified on multivariate analysis: 1) decreasing mean arterial pressure pre-intubation (per 5 mmHg decrease) (p-value=0.04; 95% CI 1.01-1.55); 2) administration of neuromuscular blockers (p-value=0.03; 95% CI 1.12-6.53); and 3) intubation complication (p-value=0.03; 95% CI 1.16-15.57). Conclusions Post-intubation hypotension was common in the ICU and was associated with increased in-hospital mortality and length of stay. These patients were more likely to have had lower mean arterial pressure prior to intubation, received neuromuscular blockers, or suffered a complication during intubation.

The use of supraglottic airway devices such as the King LTS-D laryngeal tube has increased in the prehospital setting because of their relative ease of successful insertion, even in the hands of inexperienced providers. However, these devices have their own associated complications. In patients with a known or suspected difficult airway, supraglottic airway device exchanges should occur under controlled conditions using an airway exchange catheter, preferably under direct visualization with a flexible fiberoptic bronchoscope. We report unanticipated difficulties with supraglottic airway exchange caused by a kinked King LTS-D laryngeal tube.

The King LT(S)-D™ laryngeal tube (King LT) has gained popularity as a bridge airway for pre-hospital airway management. In this study, we retrospectively reviewed the use of the King LT and its associated airway outcomes at a single Level 1 trauma centre. The data on all adult patients presenting to the Mayo Clinic in Rochester, Minnesota with a King LT in situ from July 1, 2007 to October 10, 2012 were retrospectively evaluated. Data collected and descriptively analyzed included patient demographics, comorbidities, etiology of respiratory failure, airway complications, subsequent definitive airway management technique, duration of mechanical ventilation, and status at discharge. Forty-eight adult patients met inclusion criteria. The most common etiology for respiratory failure requiring an artificial airway was cardiac arrest [28 (58%) patients] or trauma [9 (19%) patients]. Four of the nine trauma patients had facial trauma. Surgical tracheostomy was the definitive airway management technique in 14 (29%) patients. An airway exchange catheter, direct laryngoscopy, and video laryngoscopy were used in 11 (23%), ten (21%), and ten (21%) cases, respectively. Seven (78%) of the trauma patients underwent surgical tracheostomy compared with seven (18%) of the medical patients. Adverse events associated with King LT use occurred in 13 (27%) patients, with upper airway edema (i.e., tongue engorgement and glottic edema) being most common (19%). In this study of patients presenting to a hospital with a King LT, the majority of airway exchanges required an advanced airway management technique beyond direct laryngoscopy. Upper airway edema was the most common adverse observation associated with King LT use.

A series of toxicity tests were conducted to investigate the role of chronological age on zinc tolerance in juvenile brown trout (Salmo trutta). Four different incubation temperatures were used to control the maturation of the juveniles before zinc exposures. These 96-h exposures used flow-through conditions and four chronological ages of fish with weights ranging from 0.148 to 1.432 g. Time-to-death (TTD) data were collected throughout the exposure along with the final mortality. The results indicate that chronological age does not play a predictable role in zinc tolerance for juvenile brown trout. However, a relationship between zinc tolerance and fish size was observed in all chronological age populations, which prompted us to conduct additional exploratory data analysis to quantify how much of an effect size had during this stage of development. The smallest fish (0.148–0.423 g) were shown to be less sensitive than the largest fish (0.639–1.432 g) with LC50 values of 868 and 354 µg Zn/L, respectively. The Kaplan–Meier product estimation method was used to determine survival functions from the TTD data and supports the LC50 results with a greater median TTD for smaller fish than larger juvenile fish. These results indicate that fish size or a related characteristic may be a significant determinant of susceptibility and should be considered in acute zinc toxicity tests with specific attention paid to the expected exposure scenario in the field.

Objectives: Our primary aim was to determine the factors leading to prophylactic endotracheal intubation in intensive care unit (ICU) patients undergoing gastrointestinal endoscopy. Secondary aims were to determine the rate of unplanned endotracheal intubations during endoscopy and to determine the rate of aspiration following endoscopy for patients admitted to the ICU. Methods: Critically ill adult (≥18 years) patients who underwent upper and lower endoscopic procedures from January 2012 to July 2016 in a medical/surgical ICU were included. Determinants of prophylactic endotracheal intubation prior to endoscopy as well as other postprocedure outcomes were electronically captured by a validated data mart system. Given our focus on aspiration in those who were not endotracheally intubated prior to endoscopy, we used a validated definition a priori. Results: A total of 320 patients were included in the final analysis: 76(24%) were intubated prior to endoscopy and 244 (76%) were not. The endotracheally intubated group had a significantly higher Acute Physiologic and Chronic Health Evaluation III (44.5 [16.2] vs 39.5 [15.5]; P = .02) and Sequential Organ Failure Assessment (6.9 [4.4] vs 3.8 [3]; P ≤ .01) scores, higher rate of hematemesis within 24 hours of endoscopy (28 [37%] vs 45 [18%]; P ≤ .01), and higher rate of upper endoscopy (72 [96%] vs 181 [74%]; P ≤ .01). We composed a composite outcome for multivariable analyses, which demonstrated the rate of any complication was significantly higher among those who were intubated prior to the procedure versus those who were not intubated previously (odds ratio: 2.80, 95% confidence interval (CI): 1.16-6.72, P = .02). Conclusion: Endoscopy performed in the ICU without endotracheal intubation is safe. However, patient selection for prophylactic intubation prior to endoscopy is of critical importance as illustrated in this study with higher illness severity, planned upper endoscopy, and hematemesis 24 hours prior being key factors on deciding to perform endotracheal intubation. Prophylactic intubation for endoscopy and preexisting cardiac disease were associated with a higher rate of adverse outcomes.

Objective: To describe the practice of intubation of the critically ill at a single academic institution, Mayo Clinic’s campus in Rochester, Minnesota, and to report the incidence of immediate postintubation complications. Patients and Methods: Critically ill adult (≥18 years) patients admitted to a medical–surgical intensive care unit from January 1, 2013, to December 31, 2014, who required endotracheal intubation included. Results: The final cohort included 420 patients. The mean age at intubation was 62.9 ± 16.3 years, with 58% (244) of the cohort as male. The most common reason for intubation was respiratory failure (282 [67%]). The most common airway device used was video laryngoscopy (204 [49%]). Paralysis was used in 264 (63%) patients, with ketamine as the most common sedative (194 [46%]). The most common complication was hypotension (170 [41%]; 95% confidence interval [CI]: 35.7-45.3) followed by hypoxemia (74 [17.6%]; 95% CI: 14.1-21.6), with difficult intubation occurring in 20 (5%; 95% CI: 2.9-7.3). Conclusion: We found a high success rate of first-pass intubation in critically ill patients (89.8%), despite the procedure being done primarily by trainees 92.6% of the time; video was the preferred method of laryngoscopy (48.6%). Although our difficult intubation (4.8%) and complication rates typically associated with the act of intubation such as aspiration (1.2%; 95% CI: 0.4-2.8) and esophageal intubation (0.2%; 95% CI: 0.01-1.3) are very low compared to other published rates (8.09%), postintubation hypotension (40.5%) and hypoxemia (17.6%) higher.

This study examines the effect on aquatic copper toxicity of the chemical fractionation of fulvic acid (FA) that results from its association with iron and aluminum oxyhydroxide precipitates. Fractionated and unfractionated FAs obtained from streamwater and suspended sediment were utilized in acute Cu toxicity tests on Ceriodaphnia dubia. Toxicity test results with equal FA concentrations (6 mg FA/L) show that the fractionated dissolved FA was 3 times less effective at reducing Cu toxicity (EC50 13 ± 0.6 μg Cu/L) than were the unfractionated dissolved FAs (EC50 39 ± 0.4 and 41 ± 1.2 μg Cu/L). The fractionation is a consequence of preferential sorption of molecules having strong metal-binding (more aromatic) moieties to precipitating Fe- and Al-rich oxyhydroxides, causing the remaining dissolved FA to be depleted in these functional groups. As a result, there is more bioavailable dissolved Cu in the water and hence greater potential for Cu toxicity to aquatic organisms. In predicting Cu toxicity, biotic ligand models (BLMs) take into account dissolved organic carbon (DOC) concentration; however, unless DOC characteristics are accounted for, model predictions can underestimate acute Cu toxicity for water containing fractionated dissolved FA. This may have implications for water-quality criteria in systems containing Fe- and Al-rich sediment, and in mined and mineralized areas in particular. Optical measurements, such as specific ultraviolet absorbance at 254 nm (SUVA254), show promise for use as spectral indicators of DOC chemical fractionation and inferred increased Cu toxicity.

Airway management in patients with cervical spine injury is a difficult and challenging task. Attention to head positioning and stabilization during the initial evaluation and airway management is critical in the care of these patients in order to minimize the risk of secondary neurologic insult. Awareness that these patients are at risk for airway obstruction is critical. A systemic approach and development of an individualized airway plan is necessary for optimal management of patients with cervical spine injury.

Purpose: To assess whether exposure to modified shock index (MSI) in the first 24 hours of intensive care unit (ICU) admission is associated with increased in-hospital mortality. Methods: Adult critically ill patients were included in a case–control design with 1:2 matching. Cases (death) and controls (alive) were abstracted by a reviewer blinded to exposure status (MSI). Cases were matched to controls on 3 factors—age, end-stage renal disease, and ICU admission diagnosis. Results: Eighty-three cases and 159 controls were included. On univariate analysis, lorazepam administration (odds ratio [OR]: 5.75, confidence interval [CI] = 2.28-14.47; P ≤ .01), shock requiring vasopressors (OR: 3.62, CI = 1.77-7.40; P ≤ .01), maximum MSI (OR: 2.77 per unit, CI = 1.63-4.71; P ≤ .001), and elevated acute physiologic and chronic health evaluation (APACHE) III score at 1 hour (OR: 1.41 per 10 units, CI = 1.19-1.66; P ≤ .001) were associated with mortality. Maximum MSI (OR: 1.93 per unit, CI = 1.07-3.48, P = .03) and APACHE III score at 1 hour (OR: 1.29 per 10 units, CI = 1.09-1.53; P = .003) remained significant with mortality in the multivariate analysis. The optimal cutoff point for high MSI and mortality was 1.8. Conclusion: Critically ill patients who demonstrate an elevated MSI within the first 24 hours of ICU admission have a significant mortality risk. Given that MSI is easily calculated at the bedside, clinicians may institute interventions earlier which could improve survival.

Objectives: In the last decade, the practice of intubation in the intensive care unit (ICU) has evolved. To further examine the current intubation practice in the ICU, we administered a survey to critical care physicians. Design: Cross-sectional survey study design. Setting: Thirty-two academic/nonacademic centers nationally and internationally. Measurements and Main Results: The survey was developed among a core group of physicians with the assistance of the Survey Research Center at Mayo Clinic, Rochester, Minnesota. The survey was pilot tested for functionality and reliability. The response rate was 82 (51%) of 160 among the 32 centers. Although propofol was the induction drug of choice, there was a significant difference with actual ketamine use and those who indicated a preference for it (ketamine: 52% vs 61%; P < .001). The most common airway device used for intubation was direct laryngoscopy (Miller laryngoscope blade) at 56 (68%) followed by video laryngoscopy at 26 (32%). Most (>90%) indicated that they have a difficult airway cart, but only 55 (67%) indicated they have a documented plan to handle a difficult airway with even lower results for documented review of adverse events (49%). Conclusion: Although propofol was the induction drug of choice, ketamine was a medication that many preferred to use, possibly relating to the fact that the most common complication postintubation is hypotension. Direct laryngoscopy remains the primary airway device for endotracheal intubation. Finally, although the majority stated they had a difficult airway cart available, most did not have a documented plan in place when encountering a difficult airway or a documented process to review adverse events surrounding intubation.

Propofol is an alkylphenol derivative named 2, 6, diisopropylphenol and is a potent intravenous short-acting hypnotic agent. It is commonly used as sedation, as well as an anesthetic agent in both pediatric and adult patient populations. There have been numerous case reports describing a constellation of findings including metabolic derangements and organ system failures known collectively as propofol infusion syndrome (PRIS). Although there is a high mortality associated with PRIS, the precise mechanism of action has yet to be determined. The best preventive measure for this syndrome is awareness and avoidance of clinical scenarios associated with development of PRIS. There is no established treatment for PRIS; care is primarily supportive in nature and may include the full array of advanced cardiopulmonary support, including extracorporeal membrane oxygenation (ECMO). This article reviews the reported cases of PRIS and describes the current understanding of the underlying pathophysiology and treatment options.

Background Endotracheal intubation can occur in up to 60% of critically ill patients. Despite the frequency with which endotracheal intubation occurs, the current practice is largely unknown. This is relevant, as advances in airway equipment (ie, video laryngoscopes) have become more prevalent, leading to possible improvement of care delivered during this process. In addition to new devices, a greater emphasis on airway plans and choices in sedation have evolved, although the influence on patient morbidity and mortality is largely unknown. Objective This study aims to derive and validate prediction models for immediate airway and hemodynamic complications of intensive care unit intubations. Methods A multicenter, observational, prospective study of adult critically ill patients admitted to both medical and surgical intensive care units (ICUs) was conducted. Participating ICU sites were located throughout eight health and human services regions of the United States for which endotracheal intubation was needed. A steering committee composed of both anesthesia and pulmonary critical care physicians proposed a core set of data variables. These variables were incorporated into a data collection form to be used within the multiple, participating ICUs across the United States during the time of intubation. The data collection form consisted of two basic components, focusing on airway management and hemodynamic management. The form was generated using RedCap and distributed to the participating centers. Quality checks on the dataset were performed several times with each center, such that they arrived at less than 10% missing values for each data variable; the checks were subsequently entered into a database. Results The study is currently undergoing data analysis. Results are expected in November 2018 with publication to follow thereafter. The study protocol has not yet undergone peer review by a funding body. Conclusions The overall goal of this multicenter prospective study is to develop a scoring system for peri-intubation, hemodynamic, and airway-related complications so we can stratify those patients at greatest risk for decompensation as a result of these complications. This will allow critical care physicians to be better prepared in addressing these occurrences and will allow them to improve the quality of care delivered to the critically ill. Trial registration ClinicalTrials.gov NCT02508948; https://clinicaltrials.gov/ct2/show/NCT02508948 (Archived by WebCite at http://www.webcitation.org/73Oj6cTFu). International registered report identifier (irrid) RR1-10.2196/11101.

Thyrotoxic periodic paralysis (TPP) is a disease characterized by recurrent episodes of paralysis and hypokalemia during a thyrotoxic state. The disease primarily affects people of Asian descent, but can affect other ethnic groups. In Asians, the symptoms of thyrotoxicosis are distinct and usually precede the first paralytic episode, whereas in non-Asian populations, paralysis is the presenting symptom. If TPP has not been diagnosed and the patient has a surgical procedure during general or regional anesthesia, symptoms of the disease may be confused with other adverse perioperative events such as delayed recovery from neuromuscular paralysis. No specific anesthetic regimen is superior. Current TTP treatment recommendations involve treating the underlying hyperthyroid state. Other modalities such as beta-blockade and potassium replacement are also important in the acute paralytic state. Future diagnostic and treatment innovations may lie in the genetic and molecular understanding of this disease. We present a case of an Asian male with known TPP undergoing general anesthesia, a brief case series involving 5 patients, and a review of the literature.

Objectives: Major vascular surgery such as aortic aneurysm repair may be associated with prolonged in-patient hospitalization. Certain patients undergo a tracheostomy to aid in weaning from mechanical ventilation or for secretion management. The authors hypothesized that tracheostomy after aortic reconstruction for aneurysmal disease was associated with poor outcomes. Design: A retrospective, observational study. Setting: Vascular surgical intensive care unit (ICU) of a tertiary referral hospital. Participants: Eighty-one patients who underwent a tracheostomy after open thoracoabdominal or abdominal aortic aneurysm (AAA) repair between 1993 and 2002. Interventions: None. Measurements and Main Results: Of 1,940 patients who underwent aneurysm repair, 81 (4.2%) had a tracheostomy during their index hospitalization. Of those patients, 40.7% did not survive to hospital discharge. Postoperative sepsis was associated with an increased mortality (relative risk 2.45, 95% confidence interval [CI] 1.22-4.90). Many developed postoperative renal failure and were more likely to die in the hospital (relative risk 1.53, 95% CI 1.00-2.33). The preoperative diagnosis of chronic obstructive pulmonary disease (COPD) was not associated with increased mortality (relative risk 0.471, 95% CI 0.23-0.96). Thirty-two (39.5%) patients were transferred from the ICU to a chronic ventilator dependency unit (CVDU). Conclusions: Tracheostomy in patients after aortic reconstruction for aneurysmal disease is associated with a high incidence of in-hospital mortality. Patients who survive to ICU discharge are likely to be transferred to a CVDU for further respiratory management. The preoperative diagnosis of COPD is associated with improved survival, whereas postoperative sepsis is associated with an increased mortality. These observations should be considered when counseling patients and their families regarding tracheostomy after aortic surgery.

The concepts of peer review and the venerable morbidity and mortality conference are familiar improvement approaches to health care providers. These 2 entities are typically provider or patient centric and are not typically extended within hospitals and health systems as a tool for organizational learning for care process or system failures. Out of a desire to deepen our understanding and accelerate learning about quality and safety opportunities in our hospitals, Mayo Clinic embarked on journey to analyze the stories of all patient deaths. This paper illuminates the lessons learned through the development and evolution of the Mayo Clinic Mortality Review System (Rochester, MN).

Objective: To summarize published data regarding the steps of rapid-sequence intubation (RSI); review premedications, induction agents, neuromuscular blockers (NMB), and studies supporting use or avoidance; and discuss the benefits and deficits of combinations of induction agents and NMBs used when drug shortages occur. Data Source: A search of Medline databases (1966–October 2013) was conducted. Study Selection and Data Extraction: Databases were searched using the terms rapid-sequence intubation, fentanyl, midazolam, atropine, lidocaine, phenylephrine, ketamine, propofol, etomidate thiopental, succinylcholine, vecuronium, atracurium, and rocuronium. Citations from publications were reviewed for additional references. Data Synthesis: Data were reviewed to support the use or avoidance of premedications, induction agents, and paralytics and combinations to consider when drug shortages occur. Conclusions: RSI is used to secure a definitive airway in often uncooperative, nonfasted, unstable, and/or critically ill patients. Choosing the appropriate premedication, induction drug, and paralytic will maximize the success of tracheal intubation and minimize complications.

A 54-yr-old male with severe Barrett’s esophagus presented for endoscopic mucosal resection for treatment of high-grade esophageal dysplasia. This procedure involves the use of an endoscopic banding device to create a pseudopolyp following submucosal injection, allowing resection (with a snare) of the neoplastic lesion. The banding device is a modification of a device used for treatment of esophageal varices (wherein the varices are suctioned into the cap and the band is fired, leading to coagulative necrosis of the varix). The patient’s airway examination showed adequate neck range of motion, adequate thyromental distance, and a Mallampati 2 view. Monitored anesthesia care was planned with intravenous fentanyl boluses and a propofol infusion. The patient initially did well; however, he later experienced a sudden inability to move air with a precipitous drop in oxygen saturations from 98% to 71%. Laryngospasm was suspected. Positive airway pressure was applied with a bag-mask device but was unsuccessful at terminating the event. Propofol and succinylcholine were administered, and the patient’s trachea was intubated easily by direct laryngoscopy. This resulted in immediate improvement in his oxygen saturations and air movement. During the intubation, the epiglottis appeared abnormal, and upon further examination, the mucosa on the lingual surface of the epiglottis showed that it had been inadvertently endoscopically banded (Figure A, arrow). The banding device has a two-way lock to prevent misfiring, but this likely malfunctioned, inadvertently fired during intubation of the esophagus, and snared the epiglottal mucosa. An otolaryngologist used forceps to remove the band without any apparent complication (Figure B). The patient’s trachea was extubated and he was discharged from the hospital that same day. Cardiopulmonary events cause up to 50% of the morbidity and mortality related to gastrointestinal endoscopy. The most common causes of respiratory failure during upper endoscopy are aspiration and drug-induced respiratory depression. Less frequently encountered respiratory complications include anaphylactic reactions, iatrogenic perforations, and mucosal damage during removal of foreign bodies. Tracheal compression from the endoscope or inadvertent endoscopic tracheal intubation may also lead to respiratory compromise. Procedural trauma to the epiglottis, as seen in this case, is an uncommon stimulus for laryngospasm and subsequent hypoxia during upper endoscopic procedures. Mortality following laryngospasm during upper endoscopy has been reported. In addition to expeditious management of laryngospasm, anesthesia personnel should consider the possibility of treatable and reversible iatrogenic causes of laryngospasm.