A closed claims analysis of vocal cord injuries related to endotracheal intubation between 2004 and 2015

Continuous cuff pressure control on middle-aged and elderly patients undergoing endoscopic submucosal dissection of the esophagus effect of airway injury

OBJECTIVE

Assessment of the effect of continuous cuff pressure control on airway injury in middle-aged and elderly patients undergoing endoscopic submucosal dissection (ESD).

METHOD

A total of 104 eligible middle-aged and elderly patients requiring esophageal ESD from July 2022-September 2023 at the First Affiliated Hospital of Nanchang University were selected and randomly divided into two groups: the group undergoing general anesthesia tracheal intubation with continuous control of cuff pressure after intubation (Group A, n = 51) and the group undergoing general anesthesia tracheal intubation with continuous monitoring without control of cuff pressure (Group B, n = 53). After endotracheal intubation in Group A, under the guidance of an automatic cuff pressure controller, the air was used to inflate the tracheal cuff until the cuff pressure was 25-30cmH2O. The cuff pressure after intubation was recorded, and then the cuff pressure parameters were directly adjusted in the range of 25-30cmH2O until tracheal extubation after the operation. After endotracheal intubation, patients in Group B inflated the tracheal cuff with clinical experience, then monitored and recorded the cuff pressure with a handheld cuff manometer and instructed the cuff not to be loosened after being connected to the handheld cuff manometer-continuous monitoring until the tracheal extubation, but without any cuff pressure regulation. The patients of the two groups performed esophageal ESD. The left recumbent position was taken before the operation, and the cuff's pressure was recorded. Then, insert the gastrointestinal endoscope to find the lesion site and perform appropriate CO2 inflation to display the diseased esophageal wall for surgical operation fully. After determining the location, the cuff pressure of the two groups was recorded when the cuff pressure was stable. After the operation, the upper gastrointestinal endoscope was removed and the cuff pressure of the two groups was recorded. Postoperative airway injury assessment was performed in both groups, and the incidence of sore throat, hoarseness, cough, and blood in sputum was recorded. The incidence of postoperative airway mucosal injury was also observed and recorded in both groups: typical, episodic congestion spots and patchy local congestion.

RESULT

The incidence of normal airway mucosa in Group A was higher than that in Group B (P < 0.05). In comparison, the incidence of occasional hyperemia and local plaque congestion in Group A was lower than in Group B (P < 0.05).

CONCLUSION

Continuous cuff pressure control during operation can reduce airway injury in patients with esophageal ESD and accelerate their early recovery after the operation.

Head-neck movement may predispose to the development of arytenoid dislocation in the intubated patient: a 5-year retrospective single-center study

Background

Arytenoid dislocation is a rare laryngeal injury that may follow endotracheal intubation. We aimed to determine the incidence and risk factors for arytenoid dislocation after surgery under general anaesthesia.

Methods

We reviewed the medical records of patients who underwent operation under general anaesthesia with endotracheal intubation from January 2014 to December 2018. Patients were divided into the non-dislocation and dislocation groups depending on the presence or absence of arytenoid dislocation. Patient, anaesthetic, and surgical factors associated with arytenoid dislocation were determined using Poisson regression analysis.

Results

Among the 25,538 patients enrolled, 33 (0.13%) had arytenoid dislocation, with higher incidence after anterior neck and brain surgery. Patients in the dislocation group were younger (52.6 ± 14.4 vs 58.2 ± 14.2 yrs, P = 0.025), more likely to be female (78.8 vs 56.5%, P = 0.014), and more likely to be intubated by a first-year anaesthesia resident (33.3 vs 18.5%, P = 0.048) compared to those in the non-dislocation group. Patient positions during surgery were significantly different between the groups (P = 0.000). Multivariable Poisson regression identified head-neck positioning (incidence rate ratio [IRR], 3.10; 95% confidence interval [CI], 1.50–6.25, P = 0.002), endotracheal intubation by a first-year anaesthesia resident (IRR, 2.30; 95% CI, 1.07–4.64, P = 0.024), and female (IRR, 3.05; 95% CI, 1.38–7.73, P = 0.010) as risk factors for arytenoid dislocation.

Conclusion

This study showed that the incidence of arytenoid dislocation was 0.13%, and that head-neck positioning during surgery, less anaesthetist experience, and female were significantly associated with arytenoid dislocation in patients who underwent surgeries under general anaesthesia with endotracheal intubation.

Documenting Difficult Intubation in the Context of Video Laryngoscopy: Results From a Clinician Survey

Ambiguity in defining difficult intubation involving video laryngoscopy (VL) may pose potential risks to patients. To improve airway documentation practices, we surveyed anesthesia providers on their difficult intubation interpretations and VL use. Of clinicians surveyed, 66.4% considered 3 or more intubation attempts difficult, while only 10.9% considered Cormack-Lehane grade 3-4 view with direct laryngoscopy difficult. Moreover, over 50% would choose VL as their first-line device for anticipated difficult intubation. These results suggest that clinicians inconsistently interpret difficult intubations, especially in cases involving VL. There is a need for provider education and standardization of airway documentation, inclusive of VL.

A comparison of difficult intubation documentation practices with existing guidelines in the advent of video laryngoscopy

STUDY OBJECTIVE

To assess whether anesthesia providers' interpretations of a difficult intubation are consistent with current guidelines and explore possible explanations for any observed discrepancy including video laryngoscopy usage.

DESIGN

A retrospective data analysis of tracheal intubation records from the electronic health record of a large healthcare system in the United States from January to June 2018.

SETTING

General anesthesia encounters that involved a tracheal intubation in the operating rooms and non-operating room areas, including procedural areas, medical/surgical floors, and intensive care units.

PATIENTS

Records for 30,072 adult patients (33,142 cases) were identified for analysis. Patient age ranged from 18 to 100 and ASA physical status from I to V.

INTERVENTIONS

None.

MEASUREMENTS

The magnitude and direction of disagreement regarding intubation difficulty was estimated by examining anesthesiologist documentation vs. the American Society of Anesthesiologists guideline definitions. Any explanations for disagreement provided by clinicians were also analyzed. Furthermore, the association between video laryngoscopy and odds of disagreement was assessed.

MAIN RESULTS

While documentation of intubation difficulty in over 95% of records was consistent with current definitions, disagreement occurred in 1.6% of cases using the number of attempts definition (N = 31,964) and in 4.6% of cases using the Cormack-Lehane grade definition (N = 25,407). Some of the most frequently identified explanations clinicians gave in these cases of disagreement included the use of video laryngoscopy (used to explain documented difficult and easy intubations), clinician experience level, and the use of airway assist devices. Video laryngoscopy use was associated with greater odds of disagreement between anesthesiologist documentation and guideline definitions.

CONCLUSIONS

A review of electronic anesthesia records suggests that clinicians inconsistently interpret and document difficult intubations in light of current guideline definitions and that video laryngoscopy usage appears to be associated, albeit not necessarily independently, with a greater discrepancy between anesthesiologist documentation and guideline definitions.