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Anaesthesia Mar 2020The multidisciplinary International Committee for the Advancement of Procedural Sedation presents the first fasting and aspiration prevention recommendations specific to... (Review)
Review
The multidisciplinary International Committee for the Advancement of Procedural Sedation presents the first fasting and aspiration prevention recommendations specific to procedural sedation, based on an extensive review of the literature. These were developed using Delphi methodology and assessment of the robustness of the available evidence. The literature evidence is clear that fasting, as currently practiced, often substantially exceeds recommended time thresholds and has known adverse consequences, for example, irritability, dehydration and hypoglycaemia. Fasting does not guarantee an empty stomach, and there is no observed association between aspiration and compliance with common fasting guidelines. The probability of clinically important aspiration during procedural sedation is negligible. In the post-1984 literature there are no published reports of aspiration-associated mortality in children, no reports of death in healthy adults (ASA physical status 1 or 2) and just nine reported deaths in adults of ASA physical status 3 or above. Current concerns about aspiration are out of proportion to the actual risk. Given the lower observed frequency of aspiration and mortality than during general anaesthesia, and the theoretical basis for assuming a lesser risk, fasting strategies in procedural sedation can reasonably be less restrictive. We present a consensus-derived algorithm in which each patient is first risk-stratified during their pre-sedation assessment, using evidence-based factors relating to patient characteristics, comorbidities, the nature of the procedure and the nature of the anticipated sedation technique. Graded fasting precautions for liquids and solids are then recommended for elective procedures based upon this categorisation of negligible, mild or moderate aspiration risk. This consensus statement can serve as a resource to practitioners and policymakers who perform and oversee procedural sedation in patients of all ages, worldwide.
Topics: Adolescent; Adult; Algorithms; Child; Child, Preschool; Conscious Sedation; Consensus; Delphi Technique; Fasting; Guideline Adherence; Humans; Infant; Infant, Newborn; Respiratory Aspiration of Gastric Contents
PubMed: 31792941
DOI: 10.1111/anae.14892 -
Chest Jan 2021Aspiration community-acquired pneumonia (ACAP) and community-acquired pneumonia (CAP) in patients with aspiration risk factors (AspRFs) are infections associated with...
BACKGROUND
Aspiration community-acquired pneumonia (ACAP) and community-acquired pneumonia (CAP) in patients with aspiration risk factors (AspRFs) are infections associated with anaerobes, but limited evidence suggests their pathogenic role.
RESEARCH QUESTION
What are the aspiration risk factors, microbiology patterns, and empiric anti-anaerobic use in patients hospitalized with CAP?
STUDY DESIGN AND METHODS
This is a secondary analysis of GLIMP, an international, multicenter, point-prevalence study of adults hospitalized with CAP. Patients were stratified into three groups: (1) ACAP, (2) CAP/AspRF+ (CAP with AspRF), and (3) CAP/AspRF- (CAP without AspRF). Data on demographics, comorbidities, microbiological results, and anti-anaerobic antibiotics were analyzed in all groups. Patients were further stratified in severe and nonsevere CAP groups.
RESULTS
We enrolled 2,606 patients with CAP, of which 193 (7.4%) had ACAP. Risk factors independently associated with ACAP were male, bedridden, underweight, a nursing home resident, and having a history of stroke, dementia, mental illness, and enteral tube feeding. Among non-ACAP patients, 1,709 (70.8%) had CAP/AspRF+ and 704 (29.2%) had CAP/AspRF-. Microbiology patterns including anaerobes were similar between CAP/AspRF-, CAP/AspRF+ and ACAP (0.0% vs 1.03% vs 1.64%). Patients with severe ACAP had higher rates of total gram-negative bacteria (64.3% vs 44.3% vs 33.3%, P = .021) and lower rates of total gram-positive bacteria (7.1% vs 38.1% vs 50.0%, P < .001) when compared with patients with severe CAP/AspRF+ and severe CAP/AspRF-, respectively. Most patients (>50% in all groups) independent of AspRFs or ACAP received specific or broad-spectrum anti-anaerobic coverage antibiotics.
INTERPRETATION
Hospitalized patients with ACAP or CAP/AspRF+ had similar anaerobic flora compared with patients without aspiration risk factors. Gram-negative bacteria were more prevalent in patients with severe ACAP. Despite having similar microbiological flora between groups, a large proportion of CAP patients received anti-anaerobic antibiotic coverage.
Topics: Aged; Aged, 80 and over; Anti-Bacterial Agents; Cohort Studies; Community-Acquired Infections; Female; Hospitalization; Humans; Male; Middle Aged; Respiratory Aspiration; Risk Factors
PubMed: 32687909
DOI: 10.1016/j.chest.2020.06.079 -
JAMA Jan 2023It is uncertain whether a rapid-onset opioid is noninferior to a rapid-onset neuromuscular blocker during rapid sequence intubation when used in conjunction with a... (Comparative Study)
Comparative Study Randomized Controlled Trial
Effect of Remifentanil vs Neuromuscular Blockers During Rapid Sequence Intubation on Successful Intubation Without Major Complications Among Patients at Risk of Aspiration: A Randomized Clinical Trial.
IMPORTANCE
It is uncertain whether a rapid-onset opioid is noninferior to a rapid-onset neuromuscular blocker during rapid sequence intubation when used in conjunction with a hypnotic agent.
OBJECTIVE
To determine whether remifentanil is noninferior to rapid-onset neuromuscular blockers for rapid sequence intubation.
DESIGN, SETTING, AND PARTICIPANTS
Multicenter, randomized, open-label, noninferiority trial among 1150 adults at risk of aspiration (fasting for <6 hours, bowel occlusion, recent trauma, or severe gastroesophageal reflux) who underwent tracheal intubation in the operating room at 15 hospitals in France from October 2019 to April 2021. Follow-up was completed on May 15, 2021.
INTERVENTIONS
Patients were randomized to receive neuromuscular blockers (1 mg/kg of succinylcholine or rocuronium; n = 575) or remifentanil (3 to 4 μg/kg; n = 575) immediately after injection of a hypnotic.
MAIN OUTCOMES AND MEASURES
The primary outcome was assessed in all randomized patients (as-randomized population) and in all eligible patients who received assigned treatment (per-protocol population). The primary outcome was successful tracheal intubation on the first attempt without major complications, defined as lung aspiration of digestive content, oxygen desaturation, major hemodynamic instability, sustained arrhythmia, cardiac arrest, and severe anaphylactic reaction. The prespecified noninferiority margin was 7.0%.
RESULTS
Among 1150 randomized patients (mean age, 50.7 [SD, 17.4] years; 573 [50%] women), 1130 (98.3%) completed the trial. In the as-randomized population, tracheal intubation on the first attempt without major complications occurred in 374 of 575 patients (66.1%) in the remifentanil group and 408 of 575 (71.6%) in the neuromuscular blocker group (between-group difference adjusted for randomization strata and center, -6.1%; 95% CI, -11.6% to -0.5%; P = .37 for noninferiority), demonstrating inferiority. In the per-protocol population, 374 of 565 patients (66.2%) in the remifentanil group and 403 of 565 (71.3%) in the neuromuscular blocker group had successful intubation without major complications (adjusted difference, -5.7%; 2-sided 95% CI, -11.3% to -0.1%; P = .32 for noninferiority). An adverse event of hemodynamic instability was recorded in 19 of 575 patients (3.3%) with remifentanil and 3 of 575 (0.5%) with neuromuscular blockers (adjusted difference, 2.8%; 95% CI, 1.2%-4.4%).
CONCLUSIONS AND RELEVANCE
Among adults at risk of aspiration during rapid sequence intubation in the operating room, remifentanil, compared with neuromuscular blockers, did not meet the criterion for noninferiority with regard to successful intubation on first attempt without major complications. Although remifentanil was statistically inferior to neuromuscular blockers, the wide confidence interval around the effect estimate remains compatible with noninferiority and limits conclusions about the clinical relevance of the difference.
TRIAL REGISTRATION
ClinicalTrials.gov Identifier: NCT03960801.
Topics: Adult; Female; Humans; Male; Middle Aged; Hypnotics and Sedatives; Intubation, Intratracheal; Neuromuscular Blocking Agents; Rapid Sequence Induction and Intubation; Remifentanil; Respiratory Aspiration; Analgesics, Opioid; Aged
PubMed: 36594947
DOI: 10.1001/jama.2022.23550 -
Chest Jul 2016Hospitalizations for aspiration pneumonia have doubled among older adults. Using a bedside water swallow test (WST) to screen for swallowing-related aspiration can be... (Review)
Review
BACKGROUND
Hospitalizations for aspiration pneumonia have doubled among older adults. Using a bedside water swallow test (WST) to screen for swallowing-related aspiration can be efficient and cost-effective for preventing additional comorbidities and mortality. We evaluated screening accuracy of bedside WSTs used to identify patients at risk for dysphagia-associated aspiration.
METHODS
Sixteen online databases, Google Scholar, and known content experts through May 2015 were searched. Only prospective studies with patients ≥ 18 years of age given WST screenings validated against nasoendoscopy or videofluoroscopy were included. Data extraction used dual masked extraction and quality assessment following Meta-analysis of Observational Studies in Epidemiology guidelines.
RESULTS
Airway response (eg, coughing/choking) with or without voice changes (eg, wet/gurgly voice quality) was used to identify aspiration during three different bedside WSTs. Pooled estimates for single sip volumes (1-5 mL) were 71% sensitive (95% CI, 63%-78%) and 90% specific (95% CI, 86%-93%). Consecutive sips of 90 to 100 mL trials were 91% sensitive (95% CI, 89%-93%) and 53% specific (95% CI, 51%-55%). Trials of progressively increasing volumes of water were 86% sensitive (95% CI, 76%-93%) and 65% specific (95% CI, 57%-73%). Airway response with voice change improved overall accuracy in identifying aspiration.
CONCLUSIONS
Currently used bedside WSTs offer sufficient, although not ideal, utility in screening for aspiration. Consecutive sips with large volumes in patients who did not present with overt airway responses or voice changes appropriately ruled out risk of aspiration. Small volumes with single sips appropriately ruled in aspiration when clinical signs were present. Combining these bedside approaches may offer improved screening accuracy, but further research is warranted.
Topics: Adult; Deglutition Disorders; Endoscopy; Humans; Mass Screening; Photofluorography; Pneumonia, Aspiration; Point-of-Care Testing; Respiratory Aspiration; Sensitivity and Specificity
PubMed: 27102184
DOI: 10.1016/j.chest.2016.03.059 -
Respiratory Care May 2021In mechanically ventilated subjects, intra-tracheal secretions can be aspirated with either open suction systems (OSS) or closed suction systems (CSS). In contrast to... (Randomized Controlled Trial)
Randomized Controlled Trial
BACKGROUND
In mechanically ventilated subjects, intra-tracheal secretions can be aspirated with either open suction systems (OSS) or closed suction systems (CSS). In contrast to CSS, conventional OSS require temporarily disconnecting the patient from the ventilator, which briefly diminishes PEEP and oxygen supply. On the other hand, CSS are more expensive and less effective at aspirating secretions. Thus, it was hypothesized that the 2 procedures differentially affect pulmonary and cardiovascular parameters after suction.
METHODS
Subjects in the ICU ( = 66) were quasi-randomized for initial treatment with OSS or CSS in a crossover design. To compare the potential for these suction systems to compromise cardiorespiratory stability, changes in cardiopulmonary physiology were assessed from before to just after use of each suction system (three 10-s aspirations).
RESULTS
For most pulmonary and cardiovascular parameters (ie, peak inspiratory pressure, airway resistance, pressure plateau, heart rate, and arterial pressures), the effects of aspiration inversely correlated with baseline values for that parameter, with a similar regression slope between suction systems. However, when controlling for baseline values, OSS caused significantly greater increases in airway resistance and peak inspiratory pressure ( < .001 and < .01 vs CSS, respectively).
CONCLUSIONS
Elevated airway resistance prior to endotracheal suction may justify use of a CSS and contraindicate a conventional OSS in mechanically ventilated subjects. Adoption of this approach into clinical guidelines may prevent suction-induced pulmonary injury in subjects, especially for those with underlying diseases involving increased airway resistance or increased alveolar pressure. (ClinicalTrials.gov registration: NCT03256214.).
Topics: Humans; Intubation, Intratracheal; Respiration, Artificial; Respiratory Physiological Phenomena; Suction; Trachea
PubMed: 33688090
DOI: 10.4187/respcare.08511 -
Journal of Investigative Medicine High... 2023A barium esophagram is a diagnostic test used for the evaluation of dysphagia. However, this test has the potential risk for aspiration of the barium contrast. Barium...
A barium esophagram is a diagnostic test used for the evaluation of dysphagia. However, this test has the potential risk for aspiration of the barium contrast. Barium aspiration typically localizes to the right lower lobe or left lingular lobe. We present a case of barium aspiration localized to the right middle lobe that persisted on chest X-ray. A 62-year-old male with a past medical history of hypertension, long-term back pain, gastritis, and anxiety presented with the complaints of hoarseness of voice, dysphagia, and weight loss for several months. During the esophagram, the patient aspirated the barium contrast. Chest X-ray confirmed the aspiration in the right middle lobe with a tree in bud appearance suggesting involvement of bronchioles. Three months later, a repeat chest X-ray revealed residual contrast. Pulmonary complications are directly related to the amount of aspirated barium and can include hypoxia, respiratory failure, secondary aspiration pneumonia, shock, and acute respiration distress syndrome. The prognosis of a barium aspiration is dependent on the amount of barium aspirated.
Topics: Humans; Middle Aged; Barium; Deglutition Disorders; Hypoxia; Respiratory Distress Syndrome; Pneumonia, Aspiration
PubMed: 37341445
DOI: 10.1177/23247096231181867 -
Acta Clinica Croatica Apr 2023Aspiration and ingestion of a foreign body is most frequently seen in children younger than 3 years. Foreign body aspiration is always a life-threatening, urgent state... (Review)
Review
Aspiration and ingestion of a foreign body is most frequently seen in children younger than 3 years. Foreign body aspiration is always a life-threatening, urgent state demanding quick recognition and treatment to avoid potentially lethal complications. Most foreign bodies that are ingested pass spontaneously through the gastrointestinal tract without complications, however, some could lead to problems if they become lodged. A literature review was performed MEDLINE database using key terms. Primary care providers should be trained to give proper initial care. Aspirated/ingested foreign bodies in children removed by rigid or flexible bronchoscopy/gastroscopy always are challenging procedures that require well-planned anesthesia management and excellent intercommunication between anesthesiologists and surgeons. Extracorporeal membrane oxygenation can be used as a rescue mode of support in children with life-threatening foreign body aspiration for stabilization before, during and after removal of the aspirated foreign body. It is of utmost importance that all foreign body extractions, if possible, be done in centers supplied with all the necessary equipment and trained personnel. However, prevention of foreign body aspiration and ingestion is still the best therapy.
Topics: Child, Preschool; Humans; Infant; Bronchoscopy; Foreign Bodies; Respiratory Aspiration; Infant, Newborn
PubMed: 38746610
DOI: 10.20471/acc.2023.62.s1.13 -
Journal of Psychopharmacology (Oxford,... Apr 2021This paper introduces a new construct, the 'pivotal mental state', which is defined as a hyper-plastic state aiding rapid and deep learning that can mediate... (Review)
Review
This paper introduces a new construct, the 'pivotal mental state', which is defined as a hyper-plastic state aiding rapid and deep learning that can mediate psychological transformation. We believe this new construct bears relevance to a broad range of psychological and psychiatric phenomena. We argue that pivotal mental states serve an important evolutionary function, that is, to aid psychological transformation when actual or perceived environmental pressures demand this. We cite evidence that chronic stress and neurotic traits are primers for a pivotal mental state, whereas acute stress can be a trigger. Inspired by research with serotonin 2A receptor agonist psychedelics, we highlight how activity at this particular receptor can robustly and reliably induce pivotal mental states, but we argue that the capacity for pivotal mental states is an inherent property of the human brain itself. Moreover, we hypothesize that serotonergic psychedelics hijack a system that has evolved to mediate rapid and deep learning when its need is sensed. We cite a breadth of evidences linking stress via a variety of inducers, with an upregulated serotonin 2A receptor system (e.g. upregulated availability of and/or binding to the receptor) and acute stress with 5-HT release, which we argue can activate this primed system to induce a pivotal mental state. The pivotal mental state model is multi-level, linking a specific molecular gateway (increased serotonin 2A receptor signaling) with the inception of a hyper-plastic brain and mind state, enhanced rate of associative learning and the potential mediation of a psychological transformation.
Topics: Aspirations, Psychological; Association Learning; Hallucinogens; Humans; Mindfulness; Mysticism; Neuronal Plasticity; Psychotic Disorders; Receptor, Serotonin, 5-HT2A; Serotonin 5-HT2 Receptor Agonists; Signal Transduction; Stress, Physiological; Stress, Psychological
PubMed: 33174492
DOI: 10.1177/0269881120959637