Anesthesiology airway-related medicolegal cases from the Canadian Medical Protection Association

In the Nick of Time-Emergency Front-of-Neck Airway Access

Emergency front-of-neck access refers to all techniques that deliver oxygen into the airway lumen through the anterior neck structures and encompasses access both through the cricothyroid membrane and the tracheal wall. There has yet to be a universal agreement regarding the preferred technique. A surgical incision is currently the most common approach in prehospital and in-hospital care. This review intends to review and summarize the existing clinical, basic science, and societal guidelines for eFONA.

Spanish Society of Anesthesiology, Reanimation and Pain Therapy (SEDAR), Spanish Society of Emergency and Emergency Medicine (SEMES) and Spanish Society of Otolaryngology, Head and Neck Surgery (SEORL-CCC) Guideline for difficult airway management. Part I

The Airway Management section of the Spanish Society of Anesthesiology, Resuscitation, and Pain Therapy (SEDAR), the Spanish Society of Emergency Medicine (SEMES), and the Spanish Society of Otorhinolaryngology and Head and Neck Surgery (SEORL-CCC) present the Guide for the comprehensive management of difficult airway in adult patients. Its principles are focused on the human factors, cognitive processes for decision-making in critical situations, and optimization in the progression of strategies application to preserve adequate alveolar oxygenation in order to enhance safety and the quality of care. The document provides evidence-based recommendations, theoretical-educational tools, and implementation tools, mainly cognitive aids, applicable to airway management in the fields of anesthesiology, critical care, emergencies, and prehospital medicine. For this purpose, an extensive literature search was conducted following PRISMA-R guidelines and was analyzed using the GRADE methodology. Recommendations were formulated according to the GRADE methodology. Recommendations for sections with low-quality evidence were based on expert opinion through consensus reached via a Delphi questionnaire.

Lessons learned from examination of Canadian medico-legal cases related to interventional therapies for chronic pain management

PURPOSE

Chronic pain is a common condition affecting almost one in five Canadians. One of the methods used to treat chronic pain is injection therapies. While they are considered relatively safe procedures, they do carry inherent risk that can result in adverse events. Our goal was to investigate these patient safety events to identify themes that could be used to shape practice guidelines and standards and improve patient safety.

METHODS

We looked at closed civil legal actions and regulatory college complaints associated with injection therapies for chronic pain in the Canadian Medical Protection Association database from 2015 to 2019. Injury was defined as that arising from, or associated with, plans or actions taken during the provision of health care, rather than an underlying disease or injury.

RESULTS

Of the 91 cases identified, the most common reported complications were neurologic-related symptoms, injury, and infection. Fifty-eight percent (53/91) of patients experienced health care-related harm that had a negative effect on their health or quality of life. Peer experts were critical of the clinical care provided in 74% (67/91) of the cases. Provider-related (60%, 40/67), team-related (75%, 50/67), and system-related factors (21%, 14/67) were identified as contributing factors in these cases. Common examples of provider-related factors were deficiencies in clinical decision-making (48%, 19/40), failure to follow established procedures (43%, 17/40), and situational awareness (38%, 15/40). Common examples of team-related factors were deficiencies in medical record keeping (80%, 40/50) and communication breakdowns (56%, 28/50). All system-related factors were related to inadequate office procedures.

CONCLUSION

We recommend that clinicians conduct appropriate physical examinations, keep up-to-date with clinical standards, and ensure their documentation reflects their assessment, the patient's condition, and the treatment rationale.

Medico-legal risk and use of medical directives in the emergency department

PURPOSE

The medico-legal risk associated with application of medical directives in the emergency department (ED) is unknown. The objective of this study was to describe and analyze factors associated with medico-legal risk in cases involving medical directives in the ED.

METHODS

We conducted a descriptive analysis of closed medico-legal cases [hospital complaints, regulatory authority (i.e., College) complaints, and civil legal actions] involving emergency physicians in Canadian EDs involving medical directives (alternate terms including "standing order", "nursing initiated", "nurse initiated", "nursing order", "triage initiated", "triage ordered", "directive", "ED protocol", and "ED's protocol"). We used data from closed cases involving the Canadian Medical Protective Association from January 2016 until December 2021. We abstracted descriptive factors of the cases and used a framework for contributing factors classification.

RESULTS

From 2016 until 2021, 43,332 cases were closed and 1957 involved emergency physicians for which there was medico-legal information available for analysis. In all, 28 involved emergency physicians and medical directives. Situational awareness, team communication, and issues with clinical decision-making were the most important factors contributing to harm and medico-legal risk. Peer experts were critical of physicians not reviewing all results available for patients when initiated through a directive, misinterpreting test results, a less than thorough initial assessment, and of failing to reassess patients or re-order investigations when indicated.

CONCLUSION

Our findings suggest that the medico-legal risk exposure from the use of medical directives in the ED is low. Emergency departments may consider implementing systems to support adherence to medical directive policies, ensure physicians are alerted when medical directives are completed in a timely fashion, and leverage tools to notify the healthcare team when results have not been reviewed.

The incidence of awake tracheal intubation in anesthetic practice is decreasing: a historical cohort study of the years 2014-2020 at a single tertiary care institution

PURPOSE

Awake tracheal intubation (ATI) is recommended in airway management guidelines when significant difficulty is predicted with airway management. Use of the technique may be declining, which may have implications for patient safety or for skills acquisition and maintenance. This historical cohort database study sought to determine if the use of ATI was decreasing in our adult tertiary care center.

METHODS

With institutional research ethics board approval, we queried our anesthesia information management system for cases with ATI descriptors for each year from 2014 to 2020. Records of the retrieved cases were independently reviewed by all three authors to verify they met inclusion criteria for the ATI cohort prior to analysis for the primary outcome. Secondary outcome measures included airway device and route used for ATI, first attempt and ultimate success rates, and reported adverse issues recorded in cases of failed ATI or those requiring more than one attempt.

RESULTS

A total of 692 cases of ATI were identified between 2014 and 2020. There was a statistically significant decrease in yearly ATIs over the seven-year study period (Chi square goodness of fit, P < 0.001), with ATI use decreasing by about 50%. First attempt success was significantly greater with use of flexible bronchoscopy vs video laryngoscopy to facilitate ATI (84% vs 60%; P < 0.001), while there was no difference in first attempt success with the oral vs nasal route (82% vs 82%; P = 1.0).

CONCLUSION

In this single-center historical cohort study, the use of ATI decreased significantly from 2014 to 2020. Whether this decrease will result in morbidity or mortality related to airway management is currently unclear. Regardless, it has implications for training opportunities and maintenance of competence in performing the procedure.

Causes and Outcomes of Medicolegal Proceedings Following Gastrointestinal Endoscopy in Canada

Background and Aims

Endoscopic procedures are frequently performed in Canada but can be associated with potential complications and medicolegal implications. This study aimed to identify potential medicolegal cases in Canada relating to upper and lower endoscopies as well as advanced endoscopic procedures.

Methods

Westlaw Canada was searched for any cases regarding upper and lower endoscopies and advanced endoscopic procedures from inception to December 31, 2020. Cases were classified by type of case, procedure performed, patient and defendant demographics, outcome, and alleged reason for litigation/complaint.

Results

Twenty-nine civil cases and 9 board and tribunal decisions for upper and lower endoscopies and 3 advanced endoscopic procedure cases were analyzed. The most frequent defendant specialties were family physician, general surgery, and gastroenterology. The plaintiff was successful in 12 cases involving upper or lower endoscopy with an average award of $243,934 (2021 CDN). The most alleged reasons for litigation were procedural error or negligence (n = 19). The plaintiff was successful in 1 advanced endoscopic procedure case with an award of $153,032.

Conclusion

Medicolegal cases regarding gastrointestinal endoscopy in Canada occur infrequently. Endoscopy should be performed by skilled providers with appropriate informed consent from the patient, and careful consideration of whether procedures are indicated are key for endoscopic providers.

Diagnostic Efficacy and Clinical Value of Ultrasonography in Difficult Airway Assessment: Based on a Prospective Cohort Study

Objective. A case-control study was conducted to explore the diagnostic efficacy and clinical value of ultrasound in difficult airway assessment. Methods. A total of 220 patients undergoing elective surgery under general anesthesia were prospectively enrolled in our hospital from April 2018 to April 2021. General data were collected one day before operation, including sex, age, height, weight, body mass index (BMI), modified Mallampati test (MMT), inter-incisor distance (IID) and thyromental distance (TMD), the upper lip bite test (ULBT), and thyromental height (TMH). DSH, DSE, DSV, HMD, and tongue width and thickness were measured by ultrasound in the supine position before anesthesia induction on the day of operation. The above data were measured by the same anesthesiologist. After anesthesia, the patients were exposed to laryngoscope by the same senior doctor who did not participate in the data analysis, and the Cormack–Lehane (CL) grade was recorded and endotracheal intubation was completed. The relationship between DSE, DSH, DSV, HMD, and tongue width and thickness and laryngoscope exposure difficulty and tracheal intubation difficulty was analyzed. The critical value of each index for predicting laryngoscope exposure difficulty and tracheal intubation difficulty was obtained by the receiver operating characteristic curve (ROC) and Jordan index. According to the critical value, the accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of each index were calculated. Results. On comparing the general conditions of the four groups, this study prospectively included 220 patients undergoing elective surgery under general anesthesia for tracheal intubation in our hospital from April 2018 to April 2021, of which 8 cases were excluded from the study because of loss of incisors, 5 cases were excluded from the study due to unclear development of the anterior vocal cords under ultrasound, 7 cases were excluded from the study, and finally 200 patients were included in the study, including 104 males and 96 females. Among the 200 patients, difficult laryngoscope exposure was found in 26 cases (13.00%) and difficult tracheal intubation in 17 cases (8.50%). Tracheal intubation was performed in 17 patients with a visual laryngoscope and light rod, respectively. The weight and BMI of patients in the DL group were higher than in the NDL group, and the difference was statistically significant ( $P<0.05$ ); the weight and BMI of patients in the DI group were higher than in the NDI group, and the difference was statistically significant ( $P<0.05$ ); there was no significant difference in sex, age, and height between the DL group and the NDL group and the DI group and the NDI group ( $P>0.05$ ). Compared with the NDL group, IID, TMD, and TMH in the DL group were lower, and the difference was statistically significant ( $P<0.05$ ); there was no significant difference in ULBT ( $P>0.05$ ). DSE, DSH, and DSV were higher than in the NDL group, and the difference was statistically significant ( $P<0.05$ ), the HMD was lower than in the NDL group, and the difference was statistically significant ( $P<0.05$ );the width and thickness of tongue were higher than in the NDL group, and the difference was statistically significant ( $P<0.05$ ). On comparing the DI NDI groups, the IID, TMD, and TMH in group DI were lower than in group NDI, and the difference was statistically significant ( $P<0.05$ ), but there was no significant difference in ULBT ( $P>0.05$ ); DSE, DSH, and DSV were higher than in the NDI group, and the difference was statistically significant ( $P<0.05$ ); the HMD was lower than in the NDI group, and the difference was statistically significant ( $P<0.05$ ); the width and thickness of tongue were higher than in the NDL group, and the difference was statistically significant ( $P<0.05$ ). The AUC of BMI, TMH, DSE, DSV, HMD, and tongue width and thickness all ranged from 0.70 to 0.9. Laryngoscope exposure difficulty diagnostic value was medium. The AUC of TMD, MMT, ULBT, IID, and DSH ranged from 0.5 to 0.7. The diagnostic value of laryngoscope exposure difficulty was low. According to the ROC curve, the AUC value of HMD, DSE, and tongue thickness in ultrasonic indicators was higher than that of traditional indicators and the AUC value of TMH was the highest in traditional indicators. When the HMD cutoff value was 5.29 cm; the accuracy, sensitivity, specificity, PPV, and NPV were 73.6%, 96.7%, 71.6%, 31.8%, and 97.4%, respectively. Compared with tongue width, tongue thickness has a better predictive performance. The accuracy of DSH, DSV, DSE, and tongue width and thickness in predicting difficult laryngoscope exposure was lower than HMD and the difference was statistically significant ( $P<0.05$ ). The patients in the DI and NDI groups indicated that the AUC of ULBT, TMD, and IID was between 0.5 and 0.7, the diagnostic values of BMI, MMT, TMH, DSE, DSH, DSV, HMD, and tongue width and thickness were between 0.7 and0.9, and the diagnostic value for tracheal intubation difficulty was moderate. According to the ROC curve, HMD, DSE, and tongue thickness in ultrasonic indexes were higher compared to traditional indexes. Among the traditional indexes, the AUC value of TMH is the largest. In ultrasonic indexes, when the critical value of HMD DSE is 4.85 cm, the AUC value is 0.893, and its accuracy, sensitivity, specificity, PPV, and NPV are 81.6%, 93.8%, 80.6%, 30.2%, and 99.5%, respectively. In ultrasonic indexes, the prediction performance is better, followed by the tongue thickness prediction performance. The accuracy of DSH, DSV, DSE, and tongue width and thickness in predicting difficult tracheal intubation was lower than in HMD, and the difference was statistically significant ( $P<0.05$ ). Conclusion. Ultrasonic measurements such as DSH, DSE, DSV, HMD, and tongue width and thickness have predictive value for difficult airway;when the ultrasonic measurement of HMD is ˂5.29 cm, we should pay attention to the difficulty of laryngoscope exposure, and when DSE is ˂4.85 cm, we should watch out for difficult tracheal intubation. In terms of other ultrasound indexes, HMD is more valuable in predicting difficult airway.

Management of difficult and failed intubation in the general surgical population: a historical cohort study in a tertiary care centre

PURPOSE

The objective of this study was to describe the incidence, management, and complications of difficult and failed endotracheal intubation in a general surgical population.

METHODS

This historical cohort study included all cases of difficult endotracheal intubation in general surgical patients at Mount Sinai Hospital (Toronto, ON, Canada) from 1 January 2011 to 31 December 2017. Patient charts and electronic records were reviewed to collect data on airway management and complications. Endotracheal intubation was graded as "difficult" if more than two attempts with direct laryngoscopy or if additional equipment for second or subsequent attempts was required, and "failed" if it could not be achieved despite the attempts. The primary outcome was the incidence of difficult and failed intubation. The secondary outcomes were complications, difficult airway parameters, mask ventilation, number of intubation attempts, and rescue devices including the eventually successful method.

RESULTS

We identified 111 cases of difficult intubation (0.26%) and 14 cases of failed intubation (0.03%) in 42,805 surgical cases requiring endotracheal intubation over the seven-year period. The incidence was highest in 2012 (0.36%) and lowest in 2017 (0.13%). Difficulty was anticipated in 84 (76%) patients. The median (range) number of intubation attempts was 2 (2-5). Videolaryngoscopy was the eventually successful method in those with unsuccessful first attempt direct laryngoscopy (n = 91) and videolaryngoscopy (n = 17) in 71% and 77% cases, respectively. Intubation failed in 14 patients, three of whom required a surgical airway because the lungs could not be ventilated. Poor visualization of the glottis (93%) and airway bleeding (36%) were the leading causes of failed intubation. Desaturation was seen in 8%, airway bleeding in 7%, and airway edema in 6% of cases of difficult intubation.

CONCLUSION

The incidences of difficult and failed intubations in our study were 2.6 and 0.3 per 1,000 surgeries requiring laryngoscopies, respectively, with a decrease over time. Videolaryngoscopy showed a high success rate as a rescue device.

The impact of video games on training: can it change the game of endotracheal intubation?

In recent years, several studies have demonstrated that the experience derived from video games improves interventions that require technical skills. Airway management is crucial to anesthesiologists, requiring technical and non-technical skills. We evaluated the benefits of video games for video stylet-guided tracheal intubation, which allows the use of video technology in airway management of residents with anesthesiology training. In the present study, the residents working in the Department of Anesthesiology and Reanimation at the Health Sciences University of Kartal Dr. Lütfi Kırdar City Hospital in Istanbul were assigned to two groups. Active users who played video games on a regular basis formed study group (n = 14), while those who did not have video gaming habits were assigned to the control group (n = 15). Female patients with the American Society of Anesthesiologists (ASA) I and II classification undergoing elective open or laparoscopic gynecological surgery through tracheal intubation under general anesthesia were included in the study. Female patients elective open and laparoscopic gynecological surgery under GA were included in the study. Time to intubate the trachea by using video stylet in (Group 1) was found to be 29 s on average, and it was 59.9 s for Group 2 ( p < 0.01) The average number of tracheal intubation attempts was 1.1 in Group 1, and 1.4 in Group 2 (p = 0.19). Video gaming experience improves the visual attention.Those accustomed to playing with video games, video stylet- guided tracheal intubation, performed intubation in less time.

Seven years on from the Canadian Airway Focus Group Difficult Airway Guidelines: an observational survey

PURPOSE

Numerous clinical guidelines are available for management of the unanticipated difficult airway. It is unclear if practice recommendations are endorsed on regional, local, or individual levels. The objective of this observational study was to examine local and regional use of airway guidelines by anesthesiologists within a hospital partnership in Southwestern Ontario.

METHODS

Using a paper survey, distributed locally to consultant and trainee anesthesiologists in a tertiary hospital, we examined individual clinical and educational practices regarding guideline use in airway management. Respondents were asked to report which published guideline they used for unanticipated airway difficulty. The effectiveness of dissemination of the national Canadian airway guidelines-the Canadian Airway Focus Group (CAFG) Difficult Airway Guidelines-was examined. We invited anesthesia department heads within the regional hospital partnership to complete an electronic survey investigating departmental adoption of guidelines.

RESULTS

The response rate was 70% locally (79/112 anesthesiologists) and 52% regionally (11/21 department heads). Approximately 80% (64/79) of respondents reported using a formal clinical guideline if unanticipated difficulty with airway management was encountered. Seventy-two per cent of respondents (57/79) were aware of the published CAFG guidelines. Approximately 30% (16/51) of consultant anesthesiologists reported using the CAFG guidelines in clinical practice. Within the hospital partnership, 36% (4/11) of departments formally endorsed use of a specific airway management guideline.

CONCLUSIONS

Despite widespread awareness of the national CAFG Difficult Airway Guidelines, they are not widely adopted in clinical practice. Further research is warranted to explore barriers to adoption of airway management guidelines for both individual anesthesiologists and anesthesia departments.

Canadian Airway Focus Group updated consensus-based recommendations for management of the difficult airway: part 1. Difficult airway management encountered in an unconscious patient

PURPOSE

Since the last Canadian Airway Focus Group (CAFG) guidelines were published in 2013, the literature on airway management has expanded substantially. The CAFG therefore re-convened to examine this literature and update practice recommendations. This first of two articles addresses difficulty encountered with airway management in an unconscious patient.

SOURCE

Canadian Airway Focus Group members, including anesthesia, emergency medicine, and critical care physicians, were assigned topics to search. Searches were run in the Medline, EMBASE, Cochrane Central Register of Controlled Trials, and CINAHL databases. Results were presented to the group and discussed during video conferences every two weeks from April 2018 to July 2020. These CAFG recommendations are based on the best available published evidence. Where high-quality evidence was lacking, statements are based on group consensus.

FINDINGS AND KEY RECOMMENDATIONS

Most studies comparing video laryngoscopy (VL) with direct laryngoscopy indicate a higher first attempt and overall success rate with VL, and lower complication rates. Thus, resources allowing, the CAFG now recommends use of VL with appropriately selected blade type to facilitate all tracheal intubations. If a first attempt at tracheal intubation or supraglottic airway (SGA) placement is unsuccessful, further attempts can be made as long as patient ventilation and oxygenation is maintained. Nevertheless, total attempts should be limited (to three or fewer) before declaring failure and pausing to consider "exit strategy" options. For failed intubation, exit strategy options in the still-oxygenated patient include awakening (if feasible), temporizing with an SGA, a single further attempt at tracheal intubation using a different technique, or front-of-neck airway access (FONA). Failure of tracheal intubation, face-mask ventilation, and SGA ventilation together with current or imminent hypoxemia defines a "cannot ventilate, cannot oxygenate" emergency. Neuromuscular blockade should be confirmed or established, and a single final attempt at face-mask ventilation, SGA placement, or tracheal intubation with hyper-angulated blade VL can be made, if it had not already been attempted. If ventilation remains impossible, emergency FONA should occur without delay using a scalpel-bougie-tube technique (in the adult patient). The CAFG recommends all institutions designate an individual as "airway lead" to help institute difficult airway protocols, ensure adequate training and equipment, and help with airway-related quality reviews.

Canadian Airway Focus Group updated consensus-based recommendations for management of the difficult airway: part 2. Planning and implementing safe management of the patient with an anticipated difficult airway

PURPOSE

Since the last Canadian Airway Focus Group (CAFG) guidelines were published in 2013, the published airway management literature has expanded substantially. The CAFG therefore re-convened to examine this literature and update practice recommendations. This second of two articles addresses airway evaluation, decision-making, and safe implementation of an airway management strategy when difficulty is anticipated.

SOURCE

Canadian Airway Focus Group members, including anesthesia, emergency medicine, and critical care physicians were assigned topics to search. Searches were run in the Medline, EMBASE, Cochrane Central Register of Controlled Trials, and CINAHL databases. Results were presented to the group and discussed during video conferences every two weeks from April 2018 to July 2020. These CAFG recommendations are based on the best available published evidence. Where high-quality evidence is lacking, statements are based on group consensus.

FINDINGS AND KEY RECOMMENDATIONS

Prior to airway management, a documented strategy should be formulated for every patient, based on airway evaluation. Bedside examination should seek predictors of difficulty with face-mask ventilation (FMV), tracheal intubation using video- or direct laryngoscopy (VL or DL), supraglottic airway use, as well as emergency front of neck airway access. Patient physiology and contextual issues should also be assessed. Predicted difficulty should prompt careful decision-making on how most safely to proceed with airway management. Awake tracheal intubation may provide an extra margin of safety when impossible VL or DL is predicted, when difficulty is predicted with more than one mode of airway management (e.g., tracheal intubation and FMV), or when predicted difficulty coincides with significant physiologic or contextual issues. If managing the patient after the induction of general anesthesia despite predicted difficulty, team briefing should include triggers for moving from one technique to the next, expert assistance should be sourced, and required equipment should be present. Unanticipated difficulty with airway management can always occur, so the airway manager should have a strategy for difficulty occurring in every patient, and the institution must make difficult airway equipment readily available. Tracheal extubation of the at-risk patient must also be carefully planned, including assessment of the patient's tolerance for withdrawal of airway support and whether re-intubation might be difficult.