title: Delayed sequence intubation: a prospective observational study.
abstract: OBJECTIVE
  We investigate a new technique for the emergency airway management of patients with altered mental status preventing adequate preoxygenation.
  
  
  METHODS
  This was a prospective, observational, multicenter study of patients whose medical condition led them to impede optimal preintubation preparation because of delirium. A convenience sample of emergency department and ICU patients was enrolled. Patients received a dissociative dose of ketamine, allowing preoxygenation with high-flow nonrebreather mask or noninvasive positive pressure ventilation (NIPPV). After preoxygenation, patients were paralyzed and intubated. The primary outcome of this study was the difference in oxygen saturations after maximal attempts at preoxygenation before delayed sequence intubation compared with saturations just before intubation. Predetermined secondary outcomes and complications were also assessed.
  
  
  RESULTS
  A total of 62 patients were enrolled: 19 patients required delayed sequence intubation to allow nonrebreather mask, 39 patients required it to allow NIPPV, and 4 patients required it for nasogastric tube placement. Saturations increased from a mean of 89.9% before delayed sequence intubation to 98.8% afterward, with an increase of 8.9% (95% confidence interval 6.4% to 10.9%). Thirty-two patients were in a predetermined group with high potential for critical desaturation (pre-delayed sequence intubation saturations ≤93%). All of these patients increased their saturations post-delayed sequence intubation; 29 (91%) of these patients increased their post-delayed sequence intubation saturations to greater than 93%. No complications were observed in the patients receiving delayed sequence intubation.
  
  
  CONCLUSIONS
  Delayed sequence intubation could offer an alternative to rapid sequence intubation in patients requiring emergency airway management who will not tolerate preoxygenation or peri-intubation procedures. It is essentially procedural sedation, with the procedure being preoxygenation. Delayed sequence intubation seems safe and effective for use in emergency airway management.
authors.affiliation: Division of Emergency Critical Care, Department of Emergency Medicine, Stony Brook University Medical Center, Stony Brook, NY. Electronic address: scottweingart@gmail.com.
authors.forename: Scott D
authors.initials: SD
authors.lastname: Weingart
authors.affiliation: Section of Emergency Medicine, University of Chicago, Chicago, IL.
authors.forename: N Seth
authors.initials: NS
authors.lastname: Trueger
authors.affiliation: Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA.
authors.forename: Nelson
authors.initials: N
authors.lastname: Wong
authors.affiliation: Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, NY.
authors.forename: Joseph
authors.initials: J
authors.lastname: Scofi
authors.affiliation: Division of Critical Care Medicine, Montefiore Medical Center, New York, NY.
authors.forename: Neil
authors.initials: N
authors.lastname: Singh
authors.affiliation: Centre of Head and Orthopaedics, Department of Anaesthesia, Copenhagen University Hospital, Rigshospitalet, Denmark.
authors.forename: Soren S
authors.initials: SS
authors.lastname: Rudolph
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000778:Anesthetics, Dissociative / Q000627:therapeutic use; D016292:Procedural Sedation / Q000379:methods; D003693:Delirium / Q000150:complications; D004636:Emergency Service, Hospital; D005260:Female; D006801:Humans; D007362:Intensive Care Units; D007442:Intubation, Intratracheal / Q000379:methods*; D007649:Ketamine / Q000627:therapeutic use; D008297:Male; D008875:Middle Aged; D010100:Oxygen / Q000097:blood; D011446:Prospective Studies; D013995:Time; D055815:Young Adult
chemical_list: D000778:Anesthetics, Dissociative; D007649:Ketamine; D010100:Oxygen