Airway management: contents of a difficult intubation cart

George J. A prospective randomised simulation trial comparing our novel AIR-BOX to standard airway equipment storage modalities

Background

There is little evidence guiding equipment handling during emergency endotracheal intubations (EEI). Available evidence and current practice are either outdated, anecdotal or focused on difficult-not emergency-intubation. In this study, we describe and evaluate our equipment handling unit: the AIR-BOX.

Methods

This is a proof-of-concept, prospective, randomised simulation trial. A convenience sample of 50 airway course participants voluntarily underwent randomisation: 21 to the AIR-BOX group, 14 to the intubation box group, and 15 to the crash cart group. The volunteers were asked to intubate a manikin using the equipment from the storage unit of their randomisation. Outcome measures included time-to-readiness, time-to-intubation, first-pass success, and subjective operator experience.

Results

The mean time-to-readiness was 67.2 s with the AIR-BOX, 84.6 s with the intubation box, and 115 s with the crash cart. The mean time-to-intubation was 105 s with the AIR-BOX, 127 s with the intubation box and 167 s with the crash cart. A statistically significant difference was achieved between the AIR-BOX and the crash cart. No statistically significant difference was found between the three groups with regard to first-pass success or the time between intubation readiness and intubation.

Conclusions

This study supports the AIR-BOX as a viable tool that can improve and simplify access to emergency intubating equipment. It also opens doors for multiple future innovations that can positively impact equipment handling practices. Future studies can focus on assessing whether applying the AIR-BOX will yield a clinically significant impact on patient outcomes.

Airway Management Equipment in a Metropolitan Region: An Audit

Difficult airway equipment containers are commonly found in operating rooms, but the availability of airway equipment beyond that environment is unknown. Using the Difficult Airway Society (U.K.) and American Society of Anesthesiologists’ guidelines, we conducted an inspection audit of airway equipment at all anaesthetic sites in our region. Staff knowledge about the equipment was assessed and feedback was provided to each site.

Eighteen of the 42 sites had an airway container. Equipment for an unexpected difficult intubation, according to the guidelines, was deficient at all sites. Equipment to detect oesophageal intubation was inadequate. Locations remote from the operating suite lacked emergency invasive airway equipment and were, on average, a 4.3 minute walk from the nearest appropriate equipment. Two clinics had no emergency invasive airway equipment. Half of the airway containers with check lists had items missing. One third of the items with an expiry date were expired. Quality control and implementation of airway guidelines could rectify these deficiencies. Anaesthesia organisations should be encouraged to publish detailed equipment guidelines.

A "Neurological Emergency Trolley" reduces turnaround time for high-risk medications in a general intensive care unit

OBJECTIVES

To reduce medication turnaround times during neurological emergencies, a multidisciplinary team developed a neurological emergency crash trolley in our intensive care unit. This trolley includes phenytoin, hypertonic saline and mannitol, as well as other equipment. The aim of this study was to assess whether the cart reduced turnaround times for these medications.

RESEARCH METHODOLOGY/DESIGN

In this retrospective cohort study, medication delivery times for two year epochs before and after its implementation were compared. Eligible patients were identified from our intensive care unit screening log. Adults who required emergent use of phenytoin, hypertonic saline or mannitol while in the intensive care unit were included. Groups were compared with nonparametric analyses.

SETTING

33-bed general medical-surgical intensive care unit in an academic teaching hospital.

MAIN OUTCOME MEASURES

Time to medication administration.

RESULTS

In the pre-intervention group, there were 43 patients with 66 events. In the post-intervention group, there were 45 patients with 80 events. The median medication turnaround time was significantly reduced after implementation of the neurological emergency trolley (25 vs. 10minutes, p=0.003). There was no statistically significant difference in intensive care or 30-day survival between the two cohorts.

CONCLUSION

The implementation of a novel neurological emergency crash trolley in our intensive care unit reduced medication turnaround times.

National survey to assess the content and availability of difficult-airway carts in critical-care units in the United States

We have surveyed the availability of equipment, content of difficult-airway carts (DAC), and training in the use of such equipment in intensive-care units (ICU). We devised a set of proposals regarding what constitutes the ideal DAC. We surveyed 300 ICU in the United States. The survey was conducted to inquire about the presence and content of a DAC. Only 70% of respondents had a DAC in their unit. 82% of units surveyed checked the contents of the cart daily. 80% of directors were aware of its location. 80% of units had an attached list of contents and 51% had an attached algorithm for management of a difficult airway. LMA was present in 80% followed by 35 and 30% for Combitube and pre-assembled needle cricothyroidotomy set. Under non-invasive airway devices, video laryngoscope with 48% was ahead of fibreoptic bronchoscope (38%) and lighted stylet (15%). 80% of units had a CO₂-detection device immediately available. Limited data are available on the impact of DAC in airway management in the ICU. It is strongly recommended that a DAC be present. What constitutes the ideal contents of a DAC is open to questions. We hope discussion will lead to consensus of what should or should not be included on the cart.

Retrograde intubation

Airway management in the emergency department is a critical skill that must be mastered by emergency physicians. When rapid-sequence induction with oral-tracheal intubation performed by way of direct laryngoscopy is difficult or impossible due to a variety of circumstances, an alternative method or device must be used for a rescue airway. Retrograde intubation requires little equipment and has few contraindications. This technique is easy to learn and has a high level of skill retention. Familiarity with this technique is a valuable addition to the airway-management armamentarium of emergency physicians caring for ill or injured patients. Variations of the technique have been described, and their use depends on the individual circumstances.

The anaesthesiologist in the intensive care unit

PURPOSE OF REVIEW

This review focuses on recent knowledge in areas of anaesthesia expertise which are indispensable to intensive care unit management, including airway management, vascular access, regional analgesia and the treatment of status asthmaticus and status epilepticus.

RECENT FINDINGS

Etomidate as the sole agent for intubation in the intensive care unit has a 90% success rate, while in a prehospital setting, the addition of succinylcholine to etomidate results in a 99% success rate. In determining successful intubation, capnography and laryngoscopic/fibreoptic visualization are superior to auscultation, while auscultation is as effective as the self-inflating bulb or transillumination with the lightwand. The dorsalis pedis artery is an effective alternative to radial artery cannulation, while arterial cannulation itself can result in major adverse effects if complications arise. Ultrasound guidance in the placement of central catheters results in an improved insertion success rate. Internal jugular and subclavian lines have similar risk of haemothorax or pneumothorax, while subclavian lines are associated with the lowest incidence of infection. Midazolam, thiopentone and propofol have all been found to be efficacious in terminating refractory status epilepticus, with thiopentone resulting in a lower incidence of breakthrough seizures or treatment failure but an increased incidence of hypotension. Inhalational anaesthesia using isoflurane or desflurane has also been found to be successful in refractory status epilepticus. In the management of status asthmaticus, limiting minute volume while tolerating hypercapnia and acidosis as well as the use of inhalational anesthesia have proven effective strategies in a number of refractory cases.

SUMMARY

The anaesthesiologist's unique knowledge and skills are ideally suited to the practical management of patients in a critical care setting as well as in the treatment of the critical phases of many illnesses.

Anterior cervical screw extrusion leading to acute upper airway obstruction: case report

STUDY DESIGN

Case report of late postoperative complication.

SUMMARY OF BACKGROUND DATA

There have been a number of reports of migration and extrusion of cervical fusion instrumentation. The majority of such cases have a benign outcome. To our knowledge, cervical instrumentation extrusion resulting in prevertebral abscess and acute airway obstruction has not been reported.

METHODS

A 56-year-old man who had undergone a prior C3-C6 anterior cervical decompression and fusion presented to a hospital with dysphagia and acute airway obstruction requiring an emergency tracheostomy. His neck radiograph showed that a C6 screw was missing compared to prior films. Magnetic resonance imaging showed a large prevertebral abscess anterior to C2-C7 causing complete upper airway obstruction.

RESULTS

He underwent surgical drainage of the abscess and had a good neurologic recovery.

CONCLUSIONS

We report a case of acute upper airway obstruction from prevertebral abscess, likely secondary to a loosened anterior cervical screw penetrating the prevertebral soft tissue. In contrast to case reports in the literature involving instrumentation extrusion with a usually benign outcome, our case presented with a life-threatening condition.

Management choices for the difficult airway by anesthesiologists in Canada

PURPOSE

This study assessed difficult airway management, training and equipment availability among Canadian anesthesiologists.

METHODS

A postal survey of active members of the Canadian Anesthesiologists' Society was conducted in 2000. Respondents chose an induction condition and intubation technique for each of ten difficult airway scenarios. Availability of airway devices in their workplaces was assessed. Chi square analyses were used to compare groups. A P value of < 0.05 was considered statistically significant.

RESULTS

Eight hundred and thirty-three of 1702 (49%) surveys were returned. Staff comprised 88%, and residents 12%. Fifty-five percent had attended a difficult airway workshop within five years and 30% received mannequin airway training during residency. Direct laryngoscopy (48%) or fibreoptic bronchoscopy (34%) were the preferred techniques for intubation. For laryngeal, subglottic and unstable cervical spine scenarios, awake intubation with fibreoptic bronchoscope was most widely chosen. Asleep intubation with direct laryngoscopy was most commonly selected for trauma scenarios. Availability of difficult airway equipment varied between regions and types of hospital. Cricothyroidotomy equipment and difficult airway carts were not universally available.

CONCLUSIONS

Our survey assessed current preferences, training and equipment availability for the difficult airway amongst Canadian anesthesiologists. Direct laryngoscopy and fibreoptic bronchoscopy were the preferred technique for intubation despite widespread availability of newer airway equipment. Lack of certain essential airway equipment and difficult airway training should be addressed.

Difficult airway equipment in English emergency departments

The need for tracheal intubation in the emergency department is often unpredictable and precipitous in nature. When compared with the operating room, a higher incidence of difficult intubation is observed. There are currently no accepted guidelines with respect to the stocking of difficult airway equipment in the emergency department. We have conducted a telephone survey to determine the availability of equipment for the management of the difficult airway in English emergency departments. Overall, the majority of units held a curved laryngoscope blade (100%), gum elastic bougie (99%) and surgical airway device (98%). Of alternative devices for ventilation, a laryngeal mask airway was kept by 65% of departments, a needle cricothyroidostomy kit by 63% and an oesophageal-tracheal twin-lumen airway (Combitube) by 18%. Of alternative devices for intubation, fewer than 10% held a retrograde intubating kit, intubating laryngeal mask, bronchoscope or lighted stylet. Seventy-four per cent of departments held an end-tidal carbon dioxide detector.

Equipment for the difficult airway in obstetric units in Germany

STUDY OBJECTIVE

To examine the availability of specialized equipment for the difficult airway management in obstetric units of German departments of anesthesiology.

DESIGN AND SETTING

An anonymous questionnaire survey was mailed to the directors of 993 German departments of anesthesiology. Completed replies were grouped by number of deliveries performed each year.

MAIN RESULTS

55.5% of the hospitals responded. Data of 449 answers were evaluated for this investigation. A difficult airway cart was available in 99.3% of the departments. More detailed investigation revealed that different shaped laryngoscope blades (74.9% of the departments), laryngeal masks (91.0%), a fiberoptic bronchoscope (85.9%), and transtracheal puncture devices (59.9%) were available in the majority of the units. However, only a minority of the departments had these devices directly available in their obstetric operating rooms (OR; laryngeal masks 36.2%, fiberoptic bronchoscope 23.9%, transtracheal puncture set 22.0%). Larger units with more than 1,000 deliveries per year provided their equipment more often directly in the obstetric OR or the facility housing the obstetric unit than did smaller units with less than 1,000 deliveries per year (p< 0.001).

CONCLUSIONS

The survey of German departments of anesthesia revealed that specialized equipment for the difficult airway management often is not directly available in the obstetric OR. Anesthesiologists must familiarize themselves as to which difficult airway equipment is available in their unit and where it is stored.