Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 2: intensive care and emergency departments

Optimising remote site airway management kit dump using the SCRAM bag-a randomised controlled trial

Background

Emergency airway management may be required at any hospital location. Remote site management is associated with increased airway morbidity and mortality. Poor planning and interrupted workflow are significant contributors. Equipment may be unfamiliar, difficult to locate or inadequate.

The SCRAM (Structured CRitical Airway Management) bag aims to provide a portable, structured and reproducible approach to airway management preparation. We hypothesised that SCRAM bag use reduces equipment preparation time, the rate of error and operator cognitive load.

Methods

Fifty experienced anaesthetists were randomised into two groups and asked to prepare (kit dump) for and manage a simulated remote site difficult airway scenario. The control group (n = 25) used a standard resuscitation trolley while the experimental group used the SCRAM bag (n = 25). The primary outcome was time taken to kit dump completion (seconds). Secondary outcomes were the number of errors and self-reported difficulty (100 mm visual analogue scale).

Results

Using the SCRAM bag, a 29% reduction in kit dump time (111.7 ± 29.5 vs 156.7 ± 45.1, p = 0.0001) was noted. Participants using the SCRAM bag reported it to be less challenging to use (18.36 ± 16.4 mm vs 50.64 ± 22.9 mm, p < 0.001), and significantly fewer errors were noted (1 (IQR 1–3) vs 8 (IQR 5–9), p = 0.03) (87.5% reduction in the total number of errors).

Conclusion

The SCRAM bag facilitates a quicker, less challenging kit dump with significantly fewer errors. We propose that this would reduce delay to airway management, reduce cognitive load and provide an improved capability to manage anticipated and unanticipated airway events.

Emergent airway management of the critically ill patient: current opinion in critical care

PURPOSE OF REVIEW

To describe techniques to facilitate safe intubation in critically ill patients.

RECENT FINDINGS

Despite advances in the treatment of critically ill patients, endotracheal intubation remains a high-risk procedure associated with complications that can lead to appreciable morbidity and mortality. In addition to the usual anatomical factors that can predict a difficult intubation, incorporating pathophysiological considerations and crisis resource management may enhance safety and mitigate risk. Enhancing preoxygenation with high-flow oxygen or noninvasive ventilation, the early use of intravenous fluids and/or vasopressors to prevent hypotension and videolaryngoscopy for first pass success are all promising additions to airway management.Facilitating intubation by either sedation with paralysis or allowing patients to continue to breathe spontaneously are reasonable options for airway management. These approaches have potential advantages and disadvantages.

SUMMARY

Recognizing the unique challenges of endotracheal intubation in critically ill patients is paramount in limiting further deterioration during this high-risk procedure. A safe approach to intubation focuses on recognizing risk factors that predict challenges in achieving an optimal view of the glottis, maintaining optimal oxygenation, and minimizing the risks and benefits of sedation/induction strategies that are meant to facilitate intubation and avoid clinical deterioration.

The knowledge of Cormack-Lehane intubation grade and intensive care unit outcome

Background

For patients on invasive mechanical ventilation (MV), it is unclear if knowledge of intubation grade influences intensive care unit (ICU) outcome. We aimed to determine if there was an independent relationship between knowledge of intubation grade during ICU admission and in-hospital mortality.

Methods

We performed a retrospective cohort study of all patients receiving invasive MV at the Alfred ICU between December 2011 and February 2015. Demographics, details of admission, the severity of illness, chronic health status, airway detail (unknown or known Cormack-Lehane (CL) grade), MV duration and in-hospital mortality data were collected. Univariable and multivariable analyses were conducted to assess the relationship. The primary outcome was in-hospital mortality, and the secondary outcome was the duration of MV.

Results

Amongst 3556 patients studied, 611 (17.2%) had an unknown CL grade. Unadjusted mortality was higher in patients with unknown CL grade compared to known CL grade patients (21.6% vs. 9.9%). After adjusting for age, sex, severity of illness, type of ICU admission, cardiac arrest, limitations to treatment and diagnosis, having an unknown CL grade during invasive MV was independently associated with an increase in mortality (adjusted OR 1.5, 95% CI 1.14-1.98, p < 0.01).

Conclusion

Amongst ICU patients receiving MV, not knowing CL grade appears to be independently associated with increased mortality. This information should be communicated and documented in all patients receiving MV in ICU.

An observational study of ad-hoc anaesthesia teams

BACKGROUND

Anaesthesia teams are temporarily assembled to cooperate with teams in emergency departments in the immediate management of events compromising patients’ airway, ventilation and circulation.

PURPOSE

The aim was to describe a temporary ad-hoc anaesthesia team’s performance.

DESIGN

An observational study was conducted.

METHODS

Data, collected with 12 non-participatory observations, were analysed using both an thematic method, and a validated assessment tool, the Team Emergency Assessment Measure.

RESULTS

Three themes were identified: (1) flexibility in assuming varying roles, (2) expertise in verbal and non-verbal communication and (3) skills dealing with the challenges of working in unfamiliar dynamic environments. Ninety per cent of anaesthesia teams scored 7.6 (0–10) on the overall assessment according to the Team Emergency Assessment Measure rating.

CONCLUSION

Ad-hoc anaesthesia team members communicated in various ways and the anaesthesia team adapted well to the unpredictable environment in the emergency department.

Methodological quality and transparency of clinical practice guidelines for difficult airway management using the appraisal of guidelines research & evaluation II instrument: A systematic review

BACKGROUND

Complications arising from airway management represent an important cause of morbidity and mortality. Clinical practice guidelines (CPGs) are systematically created documents that summarise knowledge and assist the delivery of high-quality medical care by identifying evidence that supports best clinical care.

OBJECTIVE

Using the Appraisal of Guidelines for Research & Evaluation II instrument, we aimed to evaluate the methodological rigour and transparency of unanticipated difficult airway management CPGs in adults.

DESIGN

Using PUBMED without language restrictions, we identified eligible CPGs between 1 January 1996 and 30 June 2019. All versions of a CPG were included as independent guidelines to assess improvements over time or the methodological limitations of each version. CPGs-related obstetrics or paediatrics or the management extubation in cases of difficult airway were excluded.

RESULTS

Fourteen CPGs were included. Of the six domains suggested by the Appraisal of Guidelines for Research & Evaluation II instrument, 'applicability' had the lowest score (23%) and 'scope and objectives' had the highest score (88%). The remaining domains (stakeholder involvement, editorial independence, rigour of development and clarity of presentation) had scores ranging between 56 and 81%. Overall, the highest scored CPG was the Difficult Airway Society 2015.

CONCLUSION

Future updates of CPGs for difficult airway management in adults and severely ill patients should consider more emphasis on the applicability of their recommendations to real clinical practice.

Local anaesthetic toxicity during an awake tracheal intubation course

We report a case of local anaesthetic toxicity in an anaesthetic trainee participating as a subject for an awake tracheal intubation training course. The trainee experienced symptoms of toxicity despite the dose of lidocaine administered being less than the maximum safe dose recommended for airway topicalisation. We argue this highlights the variability in absorption of local anaesthetic and the importance of safety during awake tracheal intubation training courses. It is essential to use the minimum safe dose of local anaesthetic required during topicalisation for awake tracheal intubation. We have now made it our course policy that participants cannot undergo awake tracheal intubation less than 2 weeks before a period of coryzal illness. We recommend that operators remain vigilant for signs of local anaesthetic toxicity when undertaking this procedure and adhere to newly published Difficult Airway Society awake tracheal intubation guidelines.

Description and function of a difficult airway service

The goal of the Pediatric Difficult Airway Service (DAS) is to improve the care of children with airway abnormalities primarily through identification of children at risk for failed airway management. The airway service encourages early recognition and provides consultation, a plan for airway management, expertise in airway management, and follow-up care for children who have a difficult airway. The service has improved the education of healthcare professionals and heightened awareness about the consequences of failed airway management.

Evone® Flow-Controlled Ventilation During Upper Airway Surgery: A Clinical Feasibility Study and Safety Assessment

Introduction: During upper airway surgery in a narrowed airway due to tumor or stenosis, safe ventilation, good laryngotracheal exposure, and preservation of an adequate surgical working space are of paramount importance. This can be achieved by small-lumen ventilation such as High Frequency Jet Ventilation (HFJV). However, this technique has major drawbacks, such as air-trapping and desaturation in patients with poor pulmonary reserve. Recently, an innovative ventilating system with flow-controlled ventilation (FCV) and a small-lumen endotracheal tube, the Evone® (Ventinova, Eindhoven, The Netherlands), was introduced, claiming to counter the drawbacks of HFJV. Objectives: To evaluate feasibility and safety of the Evone® FCV system in difficult upper airway surgery and to critically appraise this novel ventilation method. Patients and methods: Evone® is a FCV-device using a small-bore cuffed tube (Tritube®). This ventilator actively sucks air out of the lungs, rather than relying on the passive backflow of air like in HFJV. Data related to the medical history, surgery, and anesthesia of all consecutive patients undergoing upper airway surgery with Evone® FCV ventilation were included in a tertiary center retrospective observational study. Results: Fifteen Patients, with a median age of 54 years, were included. Surgical procedures and indications included laser-assisted endoscopic treatment of idiopathic subglottic stenosis (n = 3), tracheal stenosis (n = 1), and posterior glottic stenosis (n = 2), biopsy and/or Transoral Laser Microsurgery for laryngeal (pre)malignancy (n = 7) and resection of benign lesions with posterior (supra)glottic location (n = 2). Mean ventilation duration was 52.0 min (range 30-115 min, SD 19.6 min), mean surgery duration was 31.7 min (range 15-65 min, SD 13.2 min), mean minimal SaO₂ was 96.3% (range 89-100%, SD 4.0%) and mean peak pCO₂ was 41.4 mmHg (range 31-50 mmHg, SD = 5.5 mmHg). No anesthesia- or surgery-related complications, adverse events or intra-operative difficulties were reported during or after any of the 15 procedures. In all cases, compared to HFJV, Evone® FCV ventilation allowed a superior visualization and working space during the surgical procedure. Conclusion: The Evone® FCV ventilation system provides excellent conditions in patients undergoing upper airway surgery, as it combines excellent accessibility and visibility of the operation site with safe and stable ventilation.

Comparison of adverse events between video and direct laryngoscopes for tracheal intubations in emergency department and ICU patients-a systematic review and meta-analysis

OBJECTIVE

This systematic review and meta-analysis was designed to determine whether video laryngoscope (VL) compared with direct laryngoscope (DL) could reduce the occurrence of adverse events associated with tracheal intubation in the emergency and ICU patients.

METHODS

The current issue of Cochrane Central Register of Controlled Trials, PubMed, EMBASE, and Web of Science (from database inception to October 30, 2018) were searched. The RCTs, quasi-RCTs, observational studies comparing VL and DL for tracheal intubation in emergency or ICU patients and reporting the rates of adverse events were included. The primary outcome was the rate of esophageal intubation (EI). Review Manager 5.3 software was used to perform the pooled analysis and assess the risk of bias for each eligible RCT. The ACROBAT-NRSi Cochrane Risk of Bias Tool was applied to assess the risk of bias for each eligible observational study.

RESULTS

Twenty-three studies (13,117 patients) were included in the review for data extraction. Pooled analysis showed a lower rate of EI by using VL (relative risk [RR], 0.24; P < 0.01; high-quality evidence for RCTs and very low-quality evidence for observational studies). Subgroup analyses based on the type of studies, whether a cardiopulmonary resuscitation study, or operators' expertise showed a similar lower rate of EI by using VL compared with DL in all subgroups (P < 0.01) except for experienced operators (RR, 0.44; P = 0.09). There were no significant differences between devices for other adverse events (P > 0.05), except for a lower incidence of hypoxemia when intubation was performed with VL by inexperienced operators (P = 0.03).

CONCLUSIONS

Based on the results of this analysis, we conclude that compared with DL, VL can reduce the risk of EI during tracheal intubation in the emergency and ICU patients, but does not provide significant benefits on other adverse events associated with tracheal intubation.

Non-technical Skills Simulation Training

Purpose of Review

“Non-technical skills” are critical to patient safety and form an important part of a surgeon’s competency. Inter-disciplinary team training is now considered essential to train these valuable skills. This review discusses the importance of non-technical skills, and the role these skills have in simulation training within Otolaryngology.

Recent Findings

Otolaryngologists are uniquely positioned to encounter airway emergencies. Consequently, team-based training in crisis scenarios is especially important. Simulation can occur in situ or in the simulated setting, with “boot-camps” becoming a popular training intervention. Whilst team training within otolaryngology has been shown to be highly effective, formal assessment of these skills is not currently routine, with no assessment tool specifically tailored to ENT.

Summary

Simulation-based training is an effective and feasible method of teaching non-technical skills in Otolaryngology. With the shift towards competency-based medical education, formal assessment of these skills is important to perform.

Cricothyroidotomy needle length is associated with posterior tracheal wall injury: A randomized crossover simulation study (CONSORT)

BACKGROUND

Cricothyroidotomy is the final strategy in the "cannot intubate, cannot oxygenate" scenario, but half of needle cricothyroidotomy attempts result in failure. The most frequent complication in needle cricothyroidotomy is posterior tracheal wall injury. We hypothesized that needle length is related to posterior wall injury and compared needle cricothyroidotomy with a commercial kit to a modified shorter needle to evaluate success and posterior wall injury rates.

METHODS

The commercial kit has a needle stopper to prevent posterior wall injury, with a penetrating length of 25 mm. We made long stopper to shorten the length by 5 mm (net 20 mm penetrating length). Residents were recruited, received a lecture about cricothyroidotomy and practiced needle cricothyroidotomy using the commercial kit on a simulator. They then performed cricothyroidotomy using the commercial kit or the shorter needle on an ex-vivo porcine larynx covered with artificial skin. An intra-tracheal endoscope recorded the procedure. The video was evaluated for success/failure or posterior wall injury by independent evaluators. Larynxes with a distance from the outer surface to the inner lumen exceeding 13 mm were excluded. The distance in each larynx was measured by dissection after the study. Success and posterior wall injury rates were analyzed using Fisher exact test (P < .05 was statistically significant).

RESULTS

Forty-seven residents participated in the study. Data for two residents were excluded. There was no statistically significant difference in success rate between the commercial kit (100%, 45/45) and the shorter needle (91%, 41/45, P = .12). Failure was defined if the needle tip did not reach the lumen in four trials. Cannulated but complicated by posterior wall injury occurred in 33% (15/45) with the commercial kit and 5% (2/43) with the shorter needle (P < .01).

CONCLUSION

During needle cricothyroidotomy, force is needed for the needle to penetrate the cricothyroid ligament. The advancing needle sometimes cannot be stopped after penetrating the cricothyroid ligament. These data suggest that needle length is associated with posterior wall injury.

Interprofessional simulation training in difficult airway management: a narrative review

The aim of this narrative literature review was to explore the impact of interprofessional simulation-based team training on difficult airway management. The Fourth National Audit Project of The Royal College of Anaesthetists and The Difficult Airway Society identified recurrent deficits in practice that included delayed recognition of critical events, inadequate provision of appropriately trained staff and poor collaboration and communication strategies between teams. Computerised databases were assessed to enable data collection, and a narrative literature review and synthesis of eight quantitative studies were performed. Four core themes were identified: debriefing, measures of assessment and evaluation, non-technical skills and patient safety, and patient outcomes. There are many benefits to be gained from interprofessional simulation training as a method of teaching high-risk and infrequent clinical airway emergencies. The practised response to emergency algorithms is crucial and plays a vital role in the reduction of errors and adverse patient outcomes.

Supraglottic jet oxygenation and ventilation - A novel ventilation technique

Supraglottic jet oxygenation and ventilation (SJOV) is a novel minimally invasive supraglottic technique of jet ventilation which has shown superior results in maintaining oxygenation without any major complications. Theoretically, it could maintain PaO₂ and PaCO₂ within physiological limits for as long as required, the maximum duration reported till now is 45 min. The distinct advantage of SJOV over techniques of nasal oxygenation is its ability to record EtCO₂ during the periods of ventilation. In addition, it also provides reliable airway access by the blind passage of the endotracheal tube into the trachea with a high success rate even in Cormack-Lehane-III (CLIII) grading patients. Potential complications seen with SJOV include nasal bleed and sore throat. No studies have shown to cause severe barotrauma. In this article, we review the evidence regarding oxygenation, ventilation, indications, airway patency and complications of SJOV in comparison to other more commonly used supraglottic oxygenation and ventilation devices.

Perioperative care of the obese patient

Background

Obesity has become an increasing problem worldwide during the past few decades. Hence, surgeons and anaesthetists will care for an increasing number of obese patients in the foreseeable future, and should be prepared to provide optimal management for these individuals. This review provides an update of recent evidence regarding perioperative strategies for obese patients.

Methods

A search for papers on the perioperative care of obese patients (English language only) was performed in July 2019 using the PubMed, Scopus, Web of Science and Cochrane Library electronic databases. The review focused on the results of RCTs, although observational studies, meta-analyses, reviews, guidelines and other reports discussing the perioperative care of obese patients were also considered. When data from obese patients were not available, relevant data from non-obese populations were used.

Results and conclusion

Obese patients require comprehensive preoperative evaluation. Experienced medical teams, appropriate equipment and monitoring, careful anaesthetic management, and an adequate perioperative ventilation strategy may improve postoperative outcomes. Additional perioperative precautions are necessary in patients with severe morbid obesity, metabolic syndrome, untreated or severe obstructive sleep apnoea syndrome, or obesity hypoventilation syndrome; patients receiving home ventilatory support or postoperative opioid therapy; and obese patients undergoing open operations, long procedures or revisional surgery.

Nationwide survey on training and device utilization during tracheal intubation in French intensive care units

Background

Intubation is a lifesaving procedure that is often performed in intensive care unit (ICU) patients, but leads to serious adverse events in 20–40% of cases. Recent trials aimed to provide guidance about which medications, devices, and modalities maximize patient safety. Videolaryngoscopes are being offered in an increasing range of options and used in broadening indications (from difficult to unremarkable intubation). The objective of this study was to describe intubation practices and device availability in French ICUs.

Materials and methods

We conducted an online nationwide survey by emailing an anonymous 26-item questionnaire to physicians in French ICUs. A single questionnaire was sent to either the head or the intubation expert at each ICU.

Results

Of 257 ICUs, 180 (70%) returned the completed questionnaire. The results showed that 43% of intubators were not fully proficient in intubation; among them, 18.8% had no intubation training or had received only basic training (lectures and observation at the bedside). Among the participating ICUs, 94.4% had a difficult intubation trolley, 74.5% an intubation protocol, 92.2% a capnography device (used routinely to check tube position in 69.3% of ICUs having the device), 91.6% a laryngeal mask, 97.2% front-of-neck access capabilities, and 76.6% a videolaryngoscope. In case of difficult intubation, 85.6% of ICUs used a bougie (154/180) and 7.8% switched to a videolaryngoscope (14/180). Use of a videolaryngoscope was reserved for difficult intubation in 84% of ICUs (154/180). Having a videolaryngoscope was significantly associated with having an intubation protocol (P = 0.043) and using capnography (P = 0.02). Airtraq^® was the most often used videolaryngoscope (39.3%), followed by McGrath^®Mac (36.9%) then by Glidescope^® (14.5%).

Conclusion

Nearly half the intubators in French ICUs are not fully proficient with OTI. Access to modern training methods such as simulation is inadequate. Most ICUs own a videolaryngoscope, but reserve it for difficult intubations.

Checklists in pre-hospital advanced airway management

BACKGROUND

In pre-hospital care, pre-intubation checklists (PICL) are widely implemented as a safety measure and guidelines support their use. However, the true value of PICL among experienced airway providers is unknown. This study aims to explore possible benefits and disadvantages of PICL in the pre-hospital setting.

METHODS

We performed a subgroup analysis of a prospective, observational, multicentre study on pre-hospital advanced airway management in the Nordic countries between May 2015 and November 2016. The original trial was designed to investigate the success rates of pre-hospital tracheal intubations and the incidence of complications. Our study limited inclusion to drug assisted intubations performed by anaesthesiologists. Intubation success rates and complication rates were plotted against checklist use.

RESULTS

We analyzed 588 pre-hospital intubations for medical and traumatic emergencies. Overall, checklists were used in 60.5% of instances. Applying checklists was associated with increased success at first and second intubation attempts. There was no significant difference in the overall success rates (99.4% and 99.1%). Oesophageal misplacement was more common in the No-PICL group (2.2% vs 0.3%) but otherwise the incidence of airway related complications did not differ between the groups. Scene time was significantly shorter in the No-PICL group (23.6 vs 27.5 minutes).

CONCLUSION

In this retrospective study, checklist use correlated with fewer attempts at intubation when securing the airway. Despite this, we found no association between checklist use and the overall TI success rate or the incidence of serious adverse events. Scene times were shorter without PICL.

Examining the Learning Practice of Emergency Airway Management Within an Academic Medical Center: Implications for Training and Improving Outcomes

Emergency airway management (EAM) is a "high stakes" clinical practice, associated with a significant risk of procedure-related complications and patient mortality. Learning within the EAM team practice is complex and challenging for trainees. Increasing concern for patient safety and changes in the structure of medical education have resulted in educational challenges and opportunities for improvement within the EAM team practice. This paper is divided into 3 sections that describe the past, present, and future of the EAM team learning practice within a large academic institution. Section 1 provides a brief overview of the evolution of the existing practice of EAM. Key features, goals, and challenges of the practice are outlined and a recently performed needs analysis to identify areas for improvement is described. Section 2 examines the underlying assumptions regarding learning within the existing practice and explores how these assumptions fit into major theories of learning. Section 3 proposes an idealized learning practice for the EAM team which includes the assumptions regarding learners, design of the learning environment, use of technology to enhance learning, and the means of assessment and measuring success. It is hoped that through this systematic exploration of the EAM team practice, learning efficacy and efficiency will be improved and remain adaptable for challenges in the future.

Teaching Endotracheal Intubation Using a Cadaver Versus a Manikin-based Model: a Randomized Controlled Trial

INTRODUCTION

The optimal method to train novice learners to perform endotracheal intubation (ETI) is unknown. The study objective was to compare two models: unembalmed cadaver vs simulation manikin.

METHODS

Fourth-year medical students, stratified by baseline ETI experience, were randomized 1:1 to train on a cadaver or simulation manikin. Students were tested and video recorded on a separate cadaver; two reviewers, blinded to the intervention, assessed the videos. Primary outcome was time to successful ETI, analyzed with a Cox proportional hazards model. Authors also compared percentage of glottic opening (POGO), number of ETI attempts, learner confidence, and satisfaction.

RESULTS

Of 97 students randomized, 78 were included in the final analysis. Median time to ETI did not differ significantly (hazard ratio [HR] 1.1; 95% CI [confidence interval], 0.7-1.8): cadaver group = 34.5 seconds (interquartile ratio [IQR]: 23.3-55.8) vs manikin group = 35.5 seconds (IQR: 23.8-80.5), with no difference in first-pass success (odds ratio [OR] = 1; 95% CI, 0.1-7.5) or median POGO: 80% cadaver vs 90% manikin (95% CI, -14-34%). Satisfaction was higher for cadavers (median difference = 0.5; p = 0.002; 95% CI, 0-1) as was change in student confidence (median difference = 0.5; p = 0.03; 95% CI, 0-1). Students rating their confidence a 5 ("extremely confident") demonstrated decreased time to ETI (HR = 4.2; 95% CI, 1.0-17.2).

CONCLUSION

Manikin and cadaver training models for ETI produced similar time to ETI, POGO, and first-pass success. Cadaver training was associated with increased student satisfaction and confidence; subjects with the highest confidence level demonstrated decreased time to ETI.

Impact of cardiopulmonary resuscitation on a cannot intubate, cannot oxygenate condition: a randomised crossover simulation research study of the interaction between two algorithms

OBJECTIVES

During a 'cannot intubate, cannot oxygenate' situation, asphyxia can lead to cardiac arrest. In this stressful situation, two complex algorithms facilitate decision-making to save a patient's life: difficult airway management and cardiopulmonary resuscitation. However, the extent to which competition between the two algorithms causes conflicts in the execution of pivotal treatment remains unknown. Due to the rare incidence of this situation and the very low feasibility of such an evaluation in clinical reality, we decided to perform a randomised crossover simulation research study. We propose that even experienced healthcare providers delay cricothyrotomy, a lifesaving approach, due to concurrent cardiopulmonary resuscitation in a 'cannot intubate, cannot oxygenate' situation.

DESIGN

Due to the rare incidence and dynamics of such a situation, we conducted a randomised crossover simulation research study.

SETTING

We collected data in our institutional simulation centre between November 2016 and November 2017.

PARTICIPANTS

We included 40 experienced staff anaesthesiologists at our tertiary university hospital centre.

INTERVENTION

The participants treated two simulated patients, both requiring cricothyrotomy: one patient required cardiopulmonary resuscitation due to asphyxia, and one patient did not require cardiopulmonary resuscitation. Cardiopulmonary resuscitation was the intervention. Participants were evaluated by video records.

PRIMARY OUTCOME MEASURES

The difference in 'time to ventilation through cricothyrotomy' between the two situations was the primary outcome measure.

RESULTS

The results of 40 participants were analysed. No carry-over effects were detected in the crossover design. During cardiopulmonary resuscitation, the median time to ventilation was 22 s (IQR 3-40.5) longer than that without cardiopulmonary resuscitation (p=0.028), including the decision-making time.

CONCLUSION

Cricothyrotomy, which is the most crucial treatment for cardiac arrest in a 'cannot intubate, cannot oxygenate' situation, was delayed by concurrent cardiopulmonary resuscitation. If cardiopulmonary resuscitation delays cricothyrotomy, it should be interrupted to first focus on cricothyrotomy.

Impact of a Critical Care Specialist Intervention on First Pass Success for Emergency Airway Management Outside the ICU

BACKGROUND

There has been limited investigation into the procedural outcomes of patients undergoing emergent endotracheal intubation (EEI) by a critical care medicine (CCM) specialist outside the intensive care unit (ICU). We hypothesized that EEI outside an ICU would be associated with lower rates of first pass success (FPS) as compared to inside an ICU.

METHODS

We performed a retrospective cohort study of all adult patients admitted to our academic medical center between January 1, 2016, and July 31, 2018, who underwent EEI by a CCM practitioner. The primary outcome of FPS was identified in the EEI procedure note. Secondary outcomes included difficult intubation (> 2 attempts at laryngoscopy) and mortality following EEI.

RESULTS

In total, 1958 patients (1035 [52.9%] inside ICU and 923 [47.1%]) outside an ICU) were included in the final cohort. Unadjusted rate of FPS was not different between patients intubated out of the ICU and patients intubated inside of the ICU (689 [74.7%] vs 775 [74.9%]; P = .91). There was also no difference in FPS between groups after adjusting for predictors of difficult intubation and baseline covariates (odds ratio: 0.95; 95% confidence interval, 0.75-1.2, P = .65). Mortality of patients undergoing EEI out of the ICU was higher at each examined time interval following EEI.

DISCUSSION

For EEI done by CCM practitioners, rate of FPS is not different between patients undergoing EEI outside an ICU as compared to inside an ICU. Despite the lack of difference between rates of procedural success, patient mortality following EEI outside an ICU is higher than EEI inside an ICU at all examined time points during hospitalization.

Availability and organization of difficult airway equipment in Swedish hospitals: A national survey of anaesthesiologists

BACKGROUND

Airway complications account for almost one third of anaesthesia-related brain damage and death. Immediate access to equipment enabling rescue airway strategies is crucial for successful management of unanticipated difficult airway situations.

METHODS

We conducted a nationwide survey of Swedish anaesthesiologists to analyse availability and organization of difficult airway trolleys (DATs), and multiple factors pertaining to difficult airway management, to highlight areas of potential improvement.

RESULTS

Six hundred and thirty-nine anaesthesiologists completed the 14-item survey. Whereas DATs were almost ubiquitous (95%) in main operating departments of hospitals, prevalence was low in remote anaesthetizing locations (20.3%) and electroconvulsive therapy units (26.6%). Approximately 60% of emergency departments had a DAT. Immediate (within 60 seconds) access to videolaryngoscopes in all units where general anaesthesia is conducted was reported by 56.8%. Almost half of anaesthesiologists reported that all DATs at their workplace were standardized. Forty-six per cent reported that the DATs were organized according to a difficult airway algorithm; almost 90% believe that such an organization can impact the outcome of a difficult airway situation positively. Only 36.2% of DATs contained second-generation supraglottic airway devices exclusively. Most Swedish anaesthesiologists use the Swedish Society of Anaesthesiology and Intensive care Medicine difficult airway algorithm, but almost one fifth prefer the Difficult Airway Society algorithm. Less than half of respondents underwent formal difficult airway training annually.

CONCLUSION

Our results motivate efforts to (a) increase availability of DATs in remote anaesthetizing locations, (b) increasingly standardize DATs and organize DATs according to airway algorithms, and (c) increase the frequency of difficult airway training.

Tracheal intubation with the McGrath MAC X-blade videolaryngoscope in morbidly obese and nonobese patients

Background/aim

Increased body mass index (BMI) and neck circumference are the two independent predictors of difficult intubation. McGrath MAC X-Blade is a videolaryngoscope specifically designed for difficult intubations.

Materials and methods

Eighty patients with the American Society of Anesthesiologists (ASA) physical status I–III undergoing elective surgery requiring endotracheal intubation were enrolled in the study. Patients were divided into two groups, nonobese (BMI < 30) and morbidly obese (BMI > 35). All patients were intubated with the McGrath MAC X-Blade in both groups. View optimization and tube insertion maneuvers such as reinsertion of the device, slight removal of the device, cricoid pressure, handling force, 90° anticlockwise rotation of the tube, use of stylet, and head flexion maneuvers were recorded. Cormack–Lehane grades, insertion times, intubation, and total intubation times were recorded. The hemodynamic changes and postoperative minor complications were also recorded.

Results

Body mass index, neck circumference, Mallampati scores, and ASA physical status were statistically higher in the morbidly obese group (P < 0.001 and P < 0.05). Sternomental distances were shorter in the morbidly obese (P < 0.05). Cormack–Lehane grades were comparable among the groups. The morbidly obese patients required more reinsertion attempts and cricoid pressure maneuvers during intubation than the nonobese patients (P = 0.019 versus P = 0.012, respectively). Slight removal of the device, handling force, use of the stylet, 90° anticlockwise rotation of the tube, and head flexion maneuvers were also helpful in both groups. Although device insertion times were similar between the groups, intubation and total intubation times were longer in the morbidly obese group (P = 0.009 and P = 0.034, respectively). The groups were comparable in hemodynamic changes and postoperative minor complications.

Conclusion

The McGrath MAC X-Blade videolaryngoscope could safely be used both in nonobese (BMI < 30) and morbidly obese (BMI > 35) patients with the aid of some key maneuvers and with a statistically significant but clinically negligible prolongation of the intubation time.

A national survey of videolaryngoscopes and alternative intubation devices in Hungary

INTRODUCTION

Videolaryngoscopy (VL) as a new airway management technique has evolved in recent decades, and a large number of videolaryngoscopes are now available on the market. Most recent major guidelines already recommend the immediate availability and use of VL in difficult airway management scenarios. However, national data on the availability of VL, introduction into practice and patterns of use are rarely published. Therefore, the current study aimed to provide data on VL in Hungary.

MATERIALS AND METHODS

An electronic survey was designed and popularized with the help of the Hungarian Society of Anaesthesiology and Intensive Therapy to explore the availability, use, and practice of and attitudes toward VL among Hungarian anesthesiologists. The survey was conducted between 01.01.2018 and 31.12.2018.

RESULTS

In total, 324 duly completed forms were returned and analyzed. Responders were mainly males (58%), specialists (80%) and those involved mainly in anesthesia practice (68%) in the public sector. Two hundred and ten (65%) responders had access to various videolaryngoscopes and were mainly from surgery, intensive care and traumatology units. No responders reported the availability of eight videolaryngoscopes out of the eighteen listed devices, and 32% of the responders had never used any videolaryngoscope in clinical settings. The most commonly available devices were KingVision, MacGrath Mac and Airtraq. Most of the responders reported using videolaryngoscopes mainly for difficult airway management and reported using a fiberscope as the first alternative device. Popular methods for selecting videolaryngoscopes included the following: short clinical trial (n = 67/324), decision of the departmental lead (n = 65/324) and price (n = 54/324). The majority of responders had some training prior to clinical application, but training was mainly voluntary. Overall, 98% of the responders considered videolaryngoscopes beneficial.

CONCLUSIONS

Approximately two-thirds of Hungarian anesthesiologists have immediate access to videolaryngoscopes, which are used mainly for difficult airway management. The overall attitude towards VL is positive, and many videolaryngoscopes are known and have been used by Hungarian anesthesiologists. However, only a few devices on the market are used commonly. Based on the results, further improvement might be recommended regarding VL training and availability.

Management of Difficult Tracheal Intubation: A Closed Claims Analysis

BACKGROUND

Difficult or failed intubation is a major contributor to morbidity for patients and liability for anesthesiologists. Updated difficult airway management guidelines and incorporation of new airway devices into practice may have affected patient outcomes. The authors therefore compared recent malpractice claims related to difficult tracheal intubation to older claims using the Anesthesia Closed Claims Project database.

METHODS

Claims with difficult tracheal intubation as the primary damaging event occurring in the years 2000 to 2012 (n = 102) were compared to difficult tracheal intubation claims from 1993 to 1999 (n = 93). Difficult intubation claims from 2000 to 2012 were evaluated for preoperative predictors and appropriateness of airway management.

RESULTS

Patients in 2000 to 2012 difficult intubation claims were sicker (78% American Society of Anesthesiologists [ASA] Physical Status III to V; n = 78 of 102) and had more emergency procedures (37%; n = 37 of 102) compared to patients in 1993 to 1999 claims (47% ASA Physical Status III to V; n = 36 of 93; P < 0.001 and 22% emergency; n = 19 of 93; P = 0.025). More difficult tracheal intubation events occurred in nonperioperative locations in 2000 to 2012 than 1993 to 1999 (23%; n = 23 of 102 vs. 10%; n = 10 of 93; P = 0.035). Outcomes differed between time periods (P < 0.001), with a higher proportion of death in 2000 to 2012 claims (73%; n = 74 of 102 vs. 42%; n = 39 of 93 in 1993 to 1999 claims; P < 0.001 adjusted for multiple testing). In 2000 to 2012 claims, preoperative predictors of difficult tracheal intubation were present in 76% (78 of 102). In the 97 claims with sufficient information for assessment, inappropriate airway management occurred in 73% (71 of 97; κ = 0.44 to 0.66). A "can't intubate, can't oxygenate" emergency occurred in 80 claims with delayed surgical airway in more than one third (39%; n = 31 of 80).

CONCLUSIONS

Outcomes remained poor in recent malpractice claims related to difficult tracheal intubation. Inadequate airway planning and judgment errors were contributors to patient harm. Our results emphasize the need to improve both practitioner skills and systems response when difficult or failed tracheal intubation is encountered.

Advanced airway training in the UK: A national survey of senior anesthetic trainees

Background and Aims:

High-quality training in advanced airway skills is imperative to ensure safe anesthetic care and develop future airway specialists. Modern airway management skills are continually evolving in response to advancing technology and developing research. Therefore, it is of concern that training provisions and trainee competencies remain current and effective.

Material and Methods:

A survey questionnaire based on the airway competencies described in the Royal College of Anaesthetists’ curriculum and Difficult Airway Society guidelines was posted to all United Kingdom (UK) National Health Service hospitals to be completed by the most senior anesthetic trainee (ST 5–7, resident).

Results:

A total of 149 responses were analyzed from 237 hospitals with eligible anesthetic trainees (response rate 63%), including 53 (36%) and 39 (26%) respondents who had completed higher and advanced level airway training respectively. Although clinical experience with videolaryngoscopy was satisfactory, poor confidence and familiarity was identified with awake fiberoptic intubation, high frequency jet ventilation, at risk extubation techniques, and airway ultrasound assessment. Only 26 (17%) respondents had access to an airway skills room or had regular airway emergency training with multidisciplinary theater team participation. Reported barriers to training included lack of training lists, dedicated teaching time, experienced trainers, and availability of equipment.

Conclusions:

This national survey identified numerous deficiencies in airway competencies and training amongst senior anesthetic trainees (residents) in the UK. Restructuring of the airway training program and improvements in access to training facilities are essential to ensure effective airway training and the capability to produce future airway specialists.

A feasibility study of jaw thrust as an indicator assessing adequate depth of anesthesia for insertion of supraglottic airway device in morbidly obese patients

Background:

Jaw thrust has been proven as a useful test determining adequate depth of anesthesia for successful insertion of supraglottic airway device (SAD) in normal adults and children receiving intra-venous or inhalational anesthesia induction. This prospective observational study aimed to determine the feasibility and validity of this test when using as an indicator assessing adequate depth of anesthesia for successful insertion of SAD in spontaneously breathing morbidly obese patients receiving sevoflurane inhalational induction.

Methods:

Thirty morbidly obese patients with a body mass index 40 to 73 kg/m² undergoing bariatric surgery in Beijing Friendship Hospital from October 2018 to January 2019 were included in this study. After adequate pre-oxygenation, 5% sevoflurane was inhaled and inhalational concentration of sevoflurane was increased by 1% every 2 min. After motor responses to jaw thrust disappeared, a SAD was inserted and insertion conditions were graded. The anatomic position of SAD was assessed using a fiberoptic bronchoscope.

Results:

The SAD was successfully inserted at the first attempt in all patients. Insertion conditions of SAD were excellent in nine patients (30%) and good in 21 patients (70%), respectively. The fiberoptic views of SAD position were adequate in 28 patients (93%).

Conclusions:

Jaw thrust test is a reliable indicator determining adequate anesthesia depth of sevoflurane inhalational induction for successful insertion of SAD in spontaneously breathing morbidly obese patients.

Clinical trial registration:

ChiCTR1800016868; http://www.chictr.org.cn/showproj.aspx?proj=28646.

Aspiration during anaesthesia in the first 4000 incidents reported to webAIRS

The first 4000 reports to the webAIRS anaesthesia incident reporting database were used to evaluate pulmonary aspiration in patients undergoing procedures under general anaesthesia or sedation. Demographic data, predisposing factors, outcome and potential preventative measures were evaluated. In these reports, 121 cases of aspiration were identified. Aspirated substances included gastric contents, bile type fluids, blood and solids; 60 (49.6%) patients were admitted to the intensive care unit/high dependency unit, and 43 (35.5%) required mechanical ventilation. Aspiration was associated with significant harm in >50% of reports, and eight (6.6%) patients died. Factors associated with a risk ratio of aspiration >1.5 and outside the 95% confidence interval for no event included: age >80 years, emergency procedure, procedure undertaken in freestanding day unit or gastroenterology department, procedure undertaken between 1800 and 2200 hours and endoscopy procedures. Only 11 (9%) cases appeared to be inadequately fasted, and 77 (64%) were definitely fasted. In the remaining 33 (27%), fasting was not mentioned. In 18 (14.9%) cases, aspiration occurred in the presence of cricoid pressure. Potential measures to prevent aspiration included using a cuffed endotracheal tube rather than a laryngeal mask airway in cases at high risk of aspiration and being made more aware of potential risk factors by improvements in team communication. Aspiration continues to be an important complication of anaesthesia, and one that can be difficult to predict and to prevent.

Effect of the introduction of C-MAC videolaryngoscopy on first-pass intubation success rates for emergency medicine registrars

OBJECTIVES

The present study investigated the impact of introducing C-MAC videolaryngoscopy as the standard method of visualising glottic structures on first-pass intubation success of emergency medicine (EM) registrars in a large tertiary academic hospital in New Zealand.

METHODS

In this retrospective cohort study, all patients receiving attempted orotracheal intubation in Auckland City Hospital ED 1 year prior to and 1 year after the introduction of C-MAC videolaryngoscopy were compared. The primary outcome was first-pass intubation success rates by EM registrars. Secondary outcomes were first-pass success rates by all intubators, and incidence of any complication of intubation.

RESULTS

There were 163 intubations by EM registrars from June 2015 to August 2017. There was a clinically important and statistically significant improvement in first-pass success from 59.2% (95% confidence interval [CI] 44.1-68.8%) to 85.1% (95% CI 76.0-91.2%, P < 0.001) after the introduction of C-MAC. In multivariate analysis, the independent predictors of success were: Airway Not Predicted Difficult, odds ratio (OR) 2.49 (95% CI 1.06-5.85, P = 0.037); and use of videolaryngoscope, OR 4.49 (95% CI 1.85-10.91, P = 0.001). Overall, complications of intubation improved significantly after introduction of C-MAC (28.9%, 95% CI 19.9-40.0% prior to C-MAC introduction; 16.1%, 95% CI 9.7-25.3% after; P = 0.048).

CONCLUSION

This is the first published study specifically addressing EM registrar intubation success rates in New Zealand, adding to the existing body of data suggesting that videolaryngoscopy may improve success rates for novice intubators.

Consensus on technical procedures for simulation-based training in anaesthesiology: A Delphi-based general needs assessment

BACKGROUND

Anaesthesiologists are expected to master an increasing number of technical procedures. Simulation-based procedural training can supplement and, in some areas, replace the classical apprenticeship approach during patient care. However, simulation-based training is very resource-intensive and must be prioritised and optimised. Developing a curriculum for simulation-based procedural training should follow a systematic approach, eg the Six-Step Approach developed by Kern. The aim of this study was to conduct a national general needs assessment to identify and prioritise technical procedures for simulation-based training in anaesthesiology.

METHODS

A three-round Delphi process was completed with anaesthesiology key opinion leaders. In the first round, the participants suggested technical procedures relevant to simulation-based training. In the second round, a needs assessment formula was used to explore the procedures and produce a preliminary prioritised list. In the third round, participants evaluated the preliminary list by eliminating and re-prioritising the procedures.

RESULTS

All teaching departments in Denmark were represented with high response rates in all three rounds: 79%, 77%, and 75%, respectively. The Delphi process produced a prioritised list of 30 procedure groups suitable for simulation-based training from the initial 138 suggestions. Top-5 on the final list was cardiopulmonary resuscitation, direct- and video laryngoscopy, defibrillation, emergency cricothyrotomy, and fibreoptic intubation. The needs assessment formula predicted the final prioritisation to a great extent.

CONCLUSION

The Delphi process produced a prioritised list of 30 procedure groups that could serve as a guide in future curriculum development for the simulation-based training of technical procedures in anaesthesiology.

Airway rescue during sedation: a proposed airway rescue pathway for nonanesthesiologists

PURPOSE OF REVIEW

This review summarizes key features of adverse airway and respiratory events for which sedation providers must be prepared to diagnose and treat in a timely manner. Key features include elements of the presedation patient evaluation that predict adverse airway and respiratory events; patient profiles, target sedation levels, and procedure types that should prompt a consult with an anesthesiologist; necessary clinical skills, essential equipment, and reversal drugs necessary to manage adverse airway and respiratory events; and a proposed airway rescue pathway that describes a sequence of interventions and prompts to call for help when encountering an adverse airway or respiratory event.

RECENT FINDINGS

Several studies have reported adverse events from sedation. Although the overall rate can approach 4.5%, the incidence of events associated with severe harm is low (e.g., <0.5%). Some that are most harmful are prolonged ventilatory compromise leading to hypoxic brain injury or death. Inadequate clinical skills that contribute to these poor outcomes include undetected or delayed detection of hypopnea, apnea, and partial or complete airway obstruction, inadequate rescue skills to manage drug-induced ventilatory depression or airway obstruction, and/or a delay or no attempt to call for expert help followed by a timely response and intervention from that expert help.

SUMMARY

To improve outcomes in detecting and managing adverse airway and respiratory events, nonanesthesiologists sedation practitioners must be trained in patient selection, monitoring, pharmacology, physiology, and airway management. One gap in sedation training curriculum is a roadmap to use when managing an adverse airway or respiratory events. This review puts forth a suggested airway rescue pathway for nonanesthesiologist sedation practitioners to use as a decision aid during an adverse airway or respiratory event associated with procedural sedation.

Improvement in the Safety of Rapid Sequence Intubation in the Emergency Department with the Use of an Airway Continuous Quality Improvement Program

Introduction

Airway management in the critically ill is associated with a high prevalence of failed first attempts and adverse events which negatively impacts patient care. The purpose of this investigation is to describe an airway continuous quality improvement (CQI) program and its effect on the safety of rapid sequence intubation (RSI) in the emergency department (ED) over a 10-year period.

Methods

An airway CQI program with an ongoing airway registry was initiated in our ED on July 1, 2007 (Academic Year 1) and continued through June 30, 2017 (Academic Year 10). Data were prospectively collected on all patients intubated in the ED during this period using a structured airway data collection form. Key data points included method of intubation, drugs and devices used for intubation, operator specialty and level of training, number of intubation attempts, and adverse events. Adult patients who underwent RSI in the ED with an initial intubation attempt by emergency medicine (EM) resident were included in the analysis. The primary outcome was first pass success which was defined as successful tracheal intubation with a single laryngoscope insertion. The secondary outcome was the prevalence of adverse events associated with intubation. Educational and clinical interventions were introduced throughout the study period with the goal of optimizing these outcomes. Data were analyzed by academic year and are reported descriptively with 95% confidence intervals (CI) of the difference of means.

Results

EM residents performed RSI on 342 adult patients during Academic Year 1 and on 445 adult patients during Academic Year 10. Over the 10-year study period, first pass success increased from 73.1% to 92.4% (difference = 19.3%, 95% CI 14.0% to 24.6%). The percentage of patients who experienced an adverse event associated with intubation decreased from 22.5% to 14.4% (difference = −7.9%, 95% CI −13.4% to −2.4%). The percentage of patients with first pass success without an adverse event increased from 64.0% to 80.9% (difference = 16.9%, 95% CI 10.6% to 23.1%).

Conclusion

The use of an airway CQI program with an ongoing airway registry resulted in a substantial improvement in the overall safety of RSI in the ED as evidenced by an increase in first pass success and a decrease in adverse events.

Prophylactic endotracheal intubation in critically ill patients with upper gastrointestinal bleed: A systematic review and meta-analysis

Background and Aim

Prophylactic endotracheal intubation for airway protection prior to endoscopy for the management of severe upper gastrointestinal bleeding (UGIB) is controversial. The aim of this meta‐analysis is to examine the clinical outcomes and costs related to prophylactic endotracheal intubation compared to no intubation in UGIB.

Methods

EMBASE, MEDLINE, and the Cochrane Central Register of Controlled Trials were used to identify studies through June 2017. Data regarding mortality, total hospital and intensive care unit length of stay (LOS), pneumonia, and cardiovascular events were collected. The DerSimonian‐Laird random effects models were used to calculate the inverse variance‐based weighted, pooled treatment effect across studies.

Results

Seven studies (five manuscripts and two abstracts) were identified (5662 total patients). Prophylactic intubation conferred an increased risk of death (odds ratio [OR], 2.59, 95% confidence interval [CI]: 1.01–6.64), hospital LOS (mean difference, 0.96 days, 95% CI: 0.26–1.67), and pneumonia (OR 6.58, 95% CI: 4.91–8.81]) compared to endoscopy without intubation. The LOS‐related cost was greater when prophylactic intubation was performed ($9020 per patient, 95% CI: $6962–10 609) compared to when it was not performed ($7510 per patient, 95% CI: $6486–8432). There was no difference in risk of cardiovascular events after sensitivity analysis.

Conclusion

Prophylactic intubation in severe UGIB is associated with a greater risk of pneumonia, LOS, death, and cost compared to endoscopy without intubation. Randomized trials examining this issue are warranted.

Augmented reality glasses improve adherence to evidence-based intubation practice

Background: The risk of failing or delaying endotracheal intubation in critically ill patients has commonly been associated with inadequate procedure preparation. Clinicians and trainees in simulation courses for tracheal intubation are encouraged to recall the steps of how to intubate in order to mitigate the risk of a failed intubation. The purpose of this study was to assess the effectiveness of using optical head mounted display augmented reality (AR) glasses as an assistance tool to perform intubation simulation procedure. Methods: A total of 32 subjects with a mean age of 30±7.8, AR (n₁=15) vs non-augmented reality(non-AR) (n₂=17). The majority were males (n=22, 68.7%). Subjects were randomly assigned into two groups: the AR group and the non-AR group. Both groups reviewed a video on how to intubate following the New England Journal of Medicine (NEJM) intubation guidelines. The AR group had to intubate using the AR glasses head mount display compared to the non-AR where they performed regular intubation. Results: The AR group took longer median (min, max) time (seconds) to ventilate than the non-AR group (280 (130,740) vs 205 (100,390); η ² =1.0, p=0.005, respectively). Similarly, there was a higher percent adherence of NEJM intubation checklist (100% in the AR group vs 82.4% in the non-AR group; η²=1.8, p<0.001). Conclusion: The AR glasses showed promise in assisting different health care professionals on endotracheal intubation simulation. Participants in the AR group took a longer time to ventilate but scored 100% in the developed checklist that followed the NEJM protocol. This finding shows that the AR technology can be used in a simulation setting and requires further study before clinical use.