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LETTER TO EDITOR
Year : 2021  |  Volume : 5  |  Issue : 1  |  Page : 10-11

Emergent airway management in intensive care unit without peripheral intravenous access


1 Critical Care Medicine, Regions Hosptial, Saint Paul, MN, USA
2 St. Francis Medical Center, Monroe, LA, USA
3 Center of Biomedical Research, University of Cartagena, Cartagena de Indias, Colombia

Date of Submission21-Dec-2020
Date of Acceptance23-Dec-2020
Date of Web Publication23-Apr-2021

Correspondence Address:
Luis Rafael Moscote-Salazar
Center of Biomedical Research, University of Cartagena, Cartagena de Indias
Colombia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sccj.sccj_68_20

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How to cite this article:
Janjua T, Villa O, Moscote-Salazar LR. Emergent airway management in intensive care unit without peripheral intravenous access. Saudi Crit Care J 2021;5:10-1

How to cite this URL:
Janjua T, Villa O, Moscote-Salazar LR. Emergent airway management in intensive care unit without peripheral intravenous access. Saudi Crit Care J [serial online] 2021 [cited 2021 May 14];5:10-1. Available from: https://www.sccj-sa.org/text.asp?2021/5/1/10/314443

Air management in critical care practice is mostly emergent and requires strong collaborative teamwork. Most of the patients are unstable with either acute respiratory failure or hemodynamically on vasopressors. There are patients with acute neurological crisis who will require intubation such as imminent brain herniation from cerebral edema, intracranial hemorrhage, acute seizures, or severe drug overdose or withdrawal. These intubations are done with precise accuracy with limited time. All intubations require sedation and analgesia except awake control intubation. Adequate and predictable intravenous (IV) access is prudent for timely successful intubation. There are certain intubations where this is very difficult or almost impossible. Here, we describe methodology for such intubations with examples.
  Case A Top
A 25-year-old patient presented to emergency department with acute abdominal pain with active history of heavy drinking. He was found to have serum lipase of 2200 mg/dl and admitted to medical floor. Overnight, he progressively got confused and transferred to intensive care unit. On arrival to unit, he was found to be markedly confused, combative, and not able to stay in bed. He pulled his two peripheral IV accesses and did not let staff give him intramuscular sedation. His agitation was extreme to a level that 7 people have to apply 14-point physical restrains: one each limb, two for the torso, and one for the head. He was tachycardiac, tachypneic, and profusely sweating. Alcohol withdrawal and acute nonobstructive pancreatitis was the admitting diagnosis to the unit. Intramuscular injection of diazepam was tried, but his muscles were stiff, and risk of needle fracture was too high. Staff was able to achieve IV access twice, but due to sweating and his agitation, both got dislodged. At this stage, a quick ultrasound marking was placed at the right femoral vein site. The site was cleaned with 2% chlorhexidine, and a central line was placed with maximizing hold on his lower torso and extremities. Immediately, 50-mg propofol injected through the distal port after confirming all three ports had good return of venous blood. This gave about a couple of minutes of reduced agitation. The access was secured, and infusion of propofol started during those 2 min. Etomidate 20 mg and propofol 100 mg were given, followed by succinylcholine 100 mg through femoral access. A video laryngoscope was used to confirm Mallampati class 4 airway, followed by endotracheal intubation with direct view of vocal cords. Propofol, dexmedetomidine, and fentanyl infusions started, and one dose of cisatracurium was given. The next day, the line was changed to internal jugular access.
  Case B Top
A 52-year-old woman presented with a past medical history of obesity, hypertension, and diabetes who was intubated 3 days earlier due to COVID-19-induced acute respiratory distress syndrome. She had daily sedation vacation, followed by self-extubation. She also removed the peripheral IV access. Shortly after, the patient became cyanotic, obtunded, and hypoxic prompting a rapid intubation process. An emergent IV access was achieved by canalizing femoral vein under ultrasound guidance, with a syringe preloaded with 5 mg of midazolam. Rocuronium 100 mg was also preloaded into a second syringe, which was administered, and immediately, a guidewire was inserted to secure access. Video laryngoscope was used to intubate the patient. The central line was completed by deploying a triple-lumen catheter and removing the guidewire. The entire procedure lasted approximately 2 min with no hemodynamic instability. The above two cases highlight an unusual task management in intensive care medicine [Figure 1]. Intubation in a critical care unstable patient is the key fundamental procedure for any intensivist. The field of medicine requires doctors to be trained, be proficient, and keep an active competency in a relatively controlled but high-risk procedural environment. Provision of sedation and paralysis for intubation helps with the safety and comfort of the patient who will not be able to tolerate even seconds of hypoxemia. Having a functional IV access is must except where intensivists have to achieve this access as a part of team to provide the necessary medications. There are three modes of emergent continuous access to high flow venous access: central line, intraosseous (IO), and monitored anesthesia care (MAC) with an inhalational agent. IO is routinely used in the field as a bridge for definitive access.[1] Another approach, although cumbersome and requires some planning, is to use MAC in the intensive care to achieve access. It is much easier in the anesthesia suite to follow this pathway.[2] Achieving a central access in the femoral vein is fast and can get medications for intubation. Central access can help to continue resuscitation for some time till definitive access is achieved.
Figure 1: Flowchart showing methodology for access in critical care intubation. EAM: Emergent airway management, IO: Intraosseous, CVC: Central venous catheter, MAC: Monitored anesthesia care

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Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

 
  References Top

1.
Johnson M, Inaba K, Byerly S, Falsgraf E, Lam L, Benjamin E, et al. Intraosseous infusion as a bridge to definitive access. Am Surg 2016;82:876-80. Dang PT, Sriratana B. Conducting prolonged general anesthesia without intravenous access in a child with hypoplastic left heart syndrome. Case Rep Anesthesiol 2017;2017:5604975.   Back to cited text no. 1
    


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