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Sturesson LW, Persson K, Olmstead R, Bjurström MF. Influence of airway trolley organization on efficiency and team performance: A randomized, crossover simulation study. Acta Anaesthesiol Scand 2023; 67:44-56. [PMID: 36196685 PMCID: PMC10092151 DOI: 10.1111/aas.14155] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 09/13/2022] [Accepted: 09/27/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND Failed management of unanticipated difficult airway situations contributes to significant anesthesia-related morbidity and mortality. Optimization of design and layout of difficult airway trolleys (DATs) may influence outcomes during airway emergencies. The main objective of the current study was to evaluate whether a difficult airway algorithm-based DAT with integrated cognitive aids improves efficiency and team performance in difficult airway scenarios. METHODS In a crossover design, 16 teams (anesthetist, nurse anesthetist, assistant nurse) completed two high-fidelity simulated unanticipated difficult airway scenarios. Teams used both an algorithm-based DAT and a comparison, standard DAT, in the scenarios and were randomized to order of trolley type. Outcome measures included objective efficiency parameters, team performance assessment and subjective user-ratings. Linear mixed models ANOVA, including DAT type and order of condition as main factors, was utilized for the primary analyses of the team results. RESULTS Usage of the algorithm-based DAT was associated with fewer departures from the difficult airway algorithm (p = .010), and reduced number of unnecessary drawer openings (p = .002), but no significant differences in time to retrieval of airway devices or time to first effective ventilation, compared to the standard DAT. There were no significant differences in team performance, although participants expressed strong preference for the algorithm-based DAT (all user-rated measures p < .0001). Higher percentage of female members of the team improved adherence to the difficult airway algorithm (p = .043). CONCLUSIONS Algorithm-based DATs with integrated cognitive aids may improve efficiency in difficult airway situations, compared to traditional DATs. These findings have implications for improvement of anesthetic practice.
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Affiliation(s)
- Louise W Sturesson
- Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Anaesthesiology and Intensive Care, Lund, Sweden
| | - Karolina Persson
- Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Anaesthesiology and Intensive Care, Lund, Sweden
| | - Richard Olmstead
- Norman Cousins Center for Psychoneuroimmunology, Jane and Terry Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles (UCLA), Los Angeles, California, USA
| | - Martin F Bjurström
- Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Anaesthesiology and Intensive Care, Lund, Sweden.,Norman Cousins Center for Psychoneuroimmunology, Jane and Terry Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles (UCLA), Los Angeles, California, USA
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2
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Budde AM, Kadar RB, Jabaley CS. Airway misadventures in adult critical care: a concise narrative review of managing lost or compromised artificial airways. Curr Opin Anaesthesiol 2022; 35:130-136. [PMID: 35131969 DOI: 10.1097/aco.0000000000001105] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Loss or compromise of artificial airways in critically ill adults can lead to serious adverse events, including death. In contrast to primary emergency airway management, the optimal management of such scenarios may not be well defined or appreciated. RECENT FINDINGS Endotracheal tube cuff leaks may compromise both oxygenation and ventilation, and supraglottic cuff position must first be recognized and distinguished from other reasons for gas leakage during positive pressure ventilation. Although definitive management involves tube exchange, if direct visualization is possible temporizing measures can often be considered. Unplanned extubation confers variable and context-specific risks depending on patient anatomy and physiological status. Because risk factors for unplanned extubation are well established, bundled interventions can be employed for mitigation. Tracheostomy tube dislodgement accounts for a substantial proportion of death and disability related to airway management in critical care settings. Consensus guidelines and algorithmic management of such scenarios are key elements of risk mitigation. SUMMARY Management of lost or otherwise compromised artificial airways is a key skill set for adult critical care clinicians alongside primary emergency airway management.
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Affiliation(s)
- Anna M Budde
- Division of Critical Care Medicine, Department of Anesthesiology, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Rachel B Kadar
- Section of Critical Care Medicine, Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Craig S Jabaley
- Division of Critical Care Medicine, Department of Anesthesiology, Emory University School of Medicine
- Emory Critical Care Center, Atlanta, GA
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3
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Stone AB, Dasani SS, Grant MC, Nascimben L, Bader AM. Understanding the Economic Impact of an Essential Service: Applying Time-Driven Activity-Based Costing to the Hospital Airway Response Team. Anesth Analg 2022; 134:445-453. [PMID: 35180159 DOI: 10.1213/ane.0000000000005838] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND As the United States moves toward value-based care metrics, it will become essential for anesthesia groups nationwide to understand the costs of their services. Time-driven activity-based costing (TDABC) estimates the amount of time it takes to perform a clinical activity by dividing complex tasks into process steps and mapping each step and has historically been used to estimate the costs of various health care services. TDABC is a tool that can be adapted for variable staffing models and the volume of service provided. Anesthesia departments often provide staffing for airway response teams (ART). The economic implications of staffing ART have not been well described. We present a TDABC model for ART activation in a tertiary-care center to estimate the cost incurred by an anesthesiology department to staff an ART. METHODS Pages received by the Brigham and Women's Hospital ART over a 24-month time period (January 2019 to December 2020) were analyzed and categorized. The local administrative database was queried for the Current Procedural Terminology (CPT) code used to bill for emergency airway placements. Sessions were held by multiple members of the ART to create process maps for the different types of ART activations. We estimated the staffing costs using the estimated time it took for each type of ART activation as well as the data collected for local ART activations. RESULTS From the paging records, we analyzed 3368 activations of the ART. During the study period, 1044 airways were billed for with emergency airway CPT code. The average revenue collected per airway was $198.45 (95% CI, $190-$207). For STAT/Emergency airway team activations, process maps and non-STAT airway team activations were created, and third subprocess map was created for performing endotracheal intubation. Using the TDABC, the total staffing costs are estimated to be $218,601 for the 2-year study period. The ART generated $207,181 in revenue during the study period. CONCLUSIONS Our analysis of ART-activation pages suggests that while the revenue generated may cover the cost of staffing the team during ART activations, it does not cover consumable equipment costs. Additionally, the current fee-for-service model relies on the team being able to perform other clinical duties in addition to covering the airway pager and would be impossible to capture using traditional top-down costing methods. By using TDABC, anesthesia groups can demonstrate how certain services, such as ART, are not fully covered by current reimbursement models and how to negotiate for subsidy agreements.As the transition from traditional fee-for-service payments to value-based care models continues in the United States, improving the understanding and communication of medical care costs will be essential. In the United States, it is common for anesthesia groups to receive direct revenue from hospitals to preserve financial viability, and therefore, knowledge of true cost is essential regardless of payer model.1 With traditional payment models, what is billable and nonbillable may not reflect either the need for or the cost of providing the service. As anesthesia departments navigate the transition of care from volume to value, actual costs will be essential to understand for negotiations with hospitals for support when services are nonbillable, when revenue from payers does not cover anesthesia costs, and when calculating the appropriate share for anesthesia departments when bundled payments are distributed.
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Affiliation(s)
- Alexander B Stone
- From the Department of Anesthesiology, Pain and Perioperative Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Department of Anesthesiology, Hospital for Special Surgery, New York, New York
| | - Serena S Dasani
- From the Department of Anesthesiology, Pain and Perioperative Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Michael C Grant
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital, Baltimore, Maryland
| | - Luigino Nascimben
- From the Department of Anesthesiology, Pain and Perioperative Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Angela M Bader
- From the Department of Anesthesiology, Pain and Perioperative Medicine, Brigham and Women's Hospital, Boston, Massachusetts.,Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, Massachusetts
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4
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Renew JR, Ratzlaff R, Hernandez-Torres V, Brull SJ, Prielipp RC. Neuromuscular blockade management in the critically Ill patient. J Intensive Care 2020; 8:37. [PMID: 32483489 PMCID: PMC7245849 DOI: 10.1186/s40560-020-00455-2] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Accepted: 05/13/2020] [Indexed: 12/16/2022] Open
Abstract
Neuromuscular blocking agents (NMBAs) can be an effective modality to address challenges that arise daily in the intensive care unit (ICU). These medications are often used to optimize mechanical ventilation, facilitate endotracheal intubation, stop overt shivering during therapeutic hypothermia following cardiac arrest, and may have a role in the management of life-threatening conditions such as elevated intracranial pressure and status asthmaticus (when deep sedation fails or is not tolerated). However, current NMBA use has decreased during the last decade due to concerns of potential adverse effects such as venous thrombosis, patient awareness during paralysis, development of critical illness myopathy, autonomic interactions, and even residual paralysis following cessation of NMBA use. It is therefore essential for clinicians to be familiar with evidence-based practices regarding appropriate NMBA use in order to select appropriate indications for their use and avoid complications. We believe that selecting the right NMBA, administering concomitant sedation and analgesic therapy, and using appropriate monitoring techniques mitigate these risks for critically ill patients. Therefore, we review the indications of NMBA use in the critical care setting and discuss the most appropriate use of NMBAs in the intensive care setting based on their structure, mechanism of action, side effects, and recognized clinical indications. Lastly, we highlight the available pharmacologic antagonists, strategies for sedation, newer neuromuscular monitoring techniques, and potential complications related to the use of NMBAs in the ICU setting.
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Affiliation(s)
- J Ross Renew
- 1Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL 32224 USA
| | - Robert Ratzlaff
- 2Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL USA
| | - Vivian Hernandez-Torres
- 1Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL 32224 USA
| | - Sorin J Brull
- 1Department of Anesthesiology and Perioperative Medicine, Mayo Clinic Florida, 4500 San Pablo Road, Jacksonville, FL 32224 USA.,3Department of Anesthesiology, University of Minnesota Medical School, Minneapolis, MN USA
| | - Richard C Prielipp
- 3Department of Anesthesiology, University of Minnesota Medical School, Minneapolis, MN USA
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5
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Bjurström MF, Persson K, Sturesson LW. Availability and organization of difficult airway equipment in Swedish hospitals: A national survey of anaesthesiologists. Acta Anaesthesiol Scand 2019; 63:1313-1320. [PMID: 31286467 DOI: 10.1111/aas.13448] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 06/03/2019] [Accepted: 06/09/2019] [Indexed: 12/19/2022]
Abstract
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.
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Affiliation(s)
- Martin F. Bjurström
- Department of Clinical Sciences Lund, Anaesthesiology and Intensive Care Lund University, Skåne University Hospital Lund Sweden
| | - Karolina Persson
- Department of Clinical Sciences Lund, Anaesthesiology and Intensive Care Lund University, Skåne University Hospital Lund Sweden
| | - Louise W. Sturesson
- Department of Clinical Sciences Lund, Anaesthesiology and Intensive Care Lund University, Skåne University Hospital Lund Sweden
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6
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National survey on airway and difficult airway management in intensive care units. Med Intensiva 2018; 42:519-526. [PMID: 29467082 DOI: 10.1016/j.medin.2018.01.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 01/02/2018] [Accepted: 01/09/2018] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To know organization, management and training in airway (AW) in Spanish Intensive Care Units (ICUs), with special interest in difficult airway (DAW). DESIGN Descriptive cross-sectional study and χ2 subanalysis, conducted through a national survey from november 1th to december 15th, 2016. With the SEMICYUC's support, an online questionnaire of 27 items was sent to 179 ICUs. SETTING ICUs of public, private centers, and consortia. RESULTS In total, 101 units responded (56.4%), corresponding to 1,827 beds and almost 95,000 incomes/year. The 85.1% are public hospitals, and 83.2% had residents. Of the responders, 22.8% don't use routinely AW assessment scales, being the most frequently used the Cormack-Mallampati association (35.6%). There's not intubation (IOT) protocol in 77.2%, nor DAW protocol in 75.2%. An 82.2% have a DAW cart. The 48.5% have training in IOT, and in VAD 53.5%. Having a DAW expert is significantly associated with greater training in IOT (60% vs. 39.3%; P=.03), DAW (64.4% vs. 44.6%; P=.04), and more AW protocols (73.4% vs. 37.5%; P=.000). Having an specific guideline for DAW management in UCI is considered necessary in 99%. CONCLUSIONS There is room for improvement in AW management. It's necessary to identify an expert in DAW in each Unit, and the development of an specific guideline for DAW management in critical care.
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7
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End-Tidal Carbon Dioxide Use for Tracheal Intubation: Analysis From the National Emergency Airway Registry for Children (NEAR4KIDS) Registry. Pediatr Crit Care Med 2018; 19:98-105. [PMID: 29140968 DOI: 10.1097/pcc.0000000000001372] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Waveform capnography use has been incorporated into guidelines for the confirmation of tracheal intubation. We aim to describe the trend in waveform capnography use in emergency departments and PICUs and assess the association between waveform capnography use and adverse tracheal intubation-associated events. DESIGN A multicenter retrospective cohort study. SETTING Thirty-four hospitals (34 ICUs and nine emergency departments) in the National Emergency Airway Registry for Children quality improvement initiative. PATIENTS Primary tracheal intubation in children younger than 18 years. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Patient, provider, and practice data for tracheal intubation procedure including a type of end-tidal carbon dioxide measurement, as well as the procedural safety outcomes, were prospectively collected. The use of waveform capnography versus colorimetry was evaluated in association with esophageal intubation with delayed recognition, cardiac arrest, and oxygen desaturation less than 80%. During January 2011 and December 2015, 9,639 tracheal intubations were reported. Waveform capnography use increased over time (39% in 2010 to 53% in 2015; p < 0.001), whereas colorimetry use decreased (< 0.001). There was significant variability in waveform capnography use across institutions (median 49%; interquartile range, 25-85%; p < 0.001). Capnography was used more often in emergency departments as compared with ICUs (66% vs. 49%; p < 0.001). The rate of esophageal intubation with delayed recognition was similar with waveform capnography versus colorimetry (0.39% vs. 0.46%; p = 0.62). The rate of cardiac arrest was also similar (p = 0.49). Oxygen desaturation occurred less frequently when capnography was used (17% vs. 19%; p = 0.03); however, this was not significant after adjusting for patient and provider characteristics. CONCLUSIONS Significant variations existed in capnography use across institutions, with the use increasing over time in both emergency departments and ICUs. The use of capnography during intubation was not associated with esophageal intubation with delayed recognition or the occurrence of cardiac arrest.
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8
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Cook T, Boniface N, Seller C, Hughes J, Damen C, MacDonald L, Kelly F. Universal videolaryngoscopy: a structured approach to conversion to videolaryngoscopy for all intubations in an anaesthetic and intensive care department. Br J Anaesth 2018; 120:173-180. [DOI: 10.1016/j.bja.2017.11.014] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2017] [Indexed: 12/20/2022] Open
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9
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Higgs A, McGrath BA, Goddard C, Rangasami J, Suntharalingam G, Gale R, Cook TM. Guidelines for the management of tracheal intubation in critically ill adults. Br J Anaesth 2017; 120:323-352. [PMID: 29406182 DOI: 10.1016/j.bja.2017.10.021] [Citation(s) in RCA: 458] [Impact Index Per Article: 65.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 10/23/2017] [Accepted: 10/25/2017] [Indexed: 12/17/2022] Open
Abstract
These guidelines describe a comprehensive strategy to optimize oxygenation, airway management, and tracheal intubation in critically ill patients, in all hospital locations. They are a direct response to the 4th National Audit Project of the Royal College of Anaesthetists and Difficult Airway Society, which highlighted deficient management of these extremely vulnerable patients leading to major complications and avoidable deaths. They are founded on robust evidence where available, supplemented by expert consensus opinion where it is not. These guidelines recognize that improved outcomes of emergency airway management require closer attention to human factors, rather than simply introduction of new devices or improved technical proficiency. They stress the role of the airway team, a shared mental model, planning, and communication throughout airway management. The primacy of oxygenation including pre- and peroxygenation is emphasized. A modified rapid sequence approach is recommended. Optimal management is presented in an algorithm that combines Plans B and C, incorporating elements of the Vortex approach. To avoid delays and task fixation, the importance of limiting procedural attempts, promptly recognizing failure, and transitioning to the next algorithm step are emphasized. The guidelines recommend early use of a videolaryngoscope, with a screen visible to all, and second generation supraglottic airways for airway rescue. Recommendations for emergency front of neck airway are for a scalpel-bougie-tube technique while acknowledging the value of other techniques performed by trained experts. As most critical care airway catastrophes occur after intubation, from dislodged or blocked tubes, essential methods to avoid these complications are also emphasized.
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Affiliation(s)
- A Higgs
- Anaesthesia and Intensive Care Medicine, Warrington and Halton Hospitals NHS Foundation Trust, Cheshire, UK(8).
| | - B A McGrath
- Anaesthesia and Intensive Care Medicine, University Hospital South Manchester, Manchester, UK(9)
| | - C Goddard
- Anaesthesia & Intensive Care Medicine, Southport and Ormskirk Hospitals NHS Trust, Southport, UK(8)
| | - J Rangasami
- Anaesthesia & Intensive Care Medicine, Wexham Park Hospital, Frimley Health NHS Foundation Trust, Slough, UK(8)
| | - G Suntharalingam
- Intensive Care Medicine and Anaesthesia, London North West Healthcare NHS Trust, London, UK(10)
| | - R Gale
- Anaesthesia & Intensive Care Medicine, Countess of Chester Hospital NHS Foundation Trust, Chester, UK(11)
| | - T M Cook
- Anaesthesia and Intensive Care Medicine, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK(12)
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10
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McGrath BA, Haley D. Tracheostomy – The forgotten difficult airway? TRENDS IN ANAESTHESIA AND CRITICAL CARE 2017. [DOI: 10.1016/j.tacc.2016.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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11
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De Silva AP, Baranage DDS, Padeniya A, Sigera PC, De Alwis S, Abayadeera AU, Mahipala PG, Jayasinghe KS, Dondorp AM, Haniffa R. Critical Care Junior Doctors' Profile in a Lower Middle-income Country: A National Cross-sectional Survey. Indian J Crit Care Med 2017; 21:733-739. [PMID: 29279633 PMCID: PMC5699000 DOI: 10.4103/ijccm.ijccm_268_17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Background and Aims: Retention of junior doctors in specialties such as critical care is difficult, especially in resource-limited settings. This study describes the profile of junior doctors in adult state intensive care units in Sri Lanka, a lower middle-income country. Materials and Methods: This was a national cross-sectional survey using an anonymous self-administered electronic questionnaire. Results: Five hundred and thirty-nine doctors in 93 Intensive Care Units (ICUs) were contacted, generating 207 responses. Just under half of the respondents (93, 47%) work exclusively in ICUs. Most junior doctors (150, 75.8%) had no previous exposure to anesthesia and 134 (67.7%) had no previous ICU experience while 116 (60.7%) ICU doctors wished to specialize in critical care. However, only a few (12, 6.3%) doctors had completed a critical care diploma course. There was a statistically significant difference (P < 0.05) between the self-assessed confidence of anesthetic background junior doctors and non-anesthetists. The overall median competency for doctors improves with the length of ICU experience and is statistically significant (P < 0.05). ICU postings were less happy and more stressful compared to the last non-ICU posting (P < 0.05 for both). The vast majority, i.e., 173 (88.2%) of doctors felt the care provided for patients in their ICUs was good, very good, or excellent while 71 doctors (36.2%) would be happy to recommend the ICU where they work to a relative with the highest possible score of 10. Conclusion: Measures to improve training opportunities for these doctors and strategies to improve their retention in ICUs need to be addressed.
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Affiliation(s)
- Ambepitiyawaduge Pubudu De Silva
- National Intensive Care Surveillance, Ministry of Health, Sri Lanka.,Intenisve Care National Audit and Research Centre, London, United Kingdom
| | - D D S Baranage
- Network for Improving Critical Care Systems and Training, Colombo, Sri Lanka
| | - Anuruddha Padeniya
- Paediatric Neurology Unit, Lady Ridgeway Hospital, Colombo, Sri Lanka.,Faculty of Medicine, University of Rajarata, Anuradhapura, Colombo, Sri Lanka.,Sri Lanka Government Medical Officers Association, Colombo, Sri Lanka
| | - Ponsuge Chathurani Sigera
- National Intensive Care Surveillance, Ministry of Health, Sri Lanka.,Network for Improving Critical Care Systems and Training, Colombo, Sri Lanka
| | - Sunil De Alwis
- Education, Training and Research Unit, Ministry of Health, Colombo, Sri Lanka
| | | | | | | | - Arjen M Dondorp
- Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
| | - Rashan Haniffa
- National Intensive Care Surveillance, Ministry of Health, Sri Lanka.,Network for Improving Critical Care Systems and Training, Colombo, Sri Lanka.,Mahidol Oxford Tropical Medicine Research Unit, Bangkok, Thailand
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12
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Sturgess DJ, Greenland KB, Senthuran S, Ajvadi FA, van Zundert A, Irwin MG. Tracheal extubation of the adult intensive care patient with a predicted difficult airway - a narrative review. Anaesthesia 2016; 72:248-261. [PMID: 27804108 DOI: 10.1111/anae.13668] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/12/2016] [Indexed: 12/17/2022]
Abstract
Management of the difficult airway is an important, but as yet poorly-studied, component of intensive care management. Although there has been a strong emphasis on prediction and intubation of the difficult airway, safe extubation of the patient with a potentially difficult airway has not received the same attention. Extubation is a particularly vulnerable time for the critically ill patient and, because of the risks involved and the consequences of failure, it warrants specific consideration. The Royal College of Anaesthetists 4th National Audit Project highlighted differences in the incidence and consequences of major complications during airway management between the operating room and the critical care environment. The findings in the section on Intensive Care and Emergency Medicine reinforce the importance of good airway management in the critical care environment and, in particular, the need for appropriate guidelines to improve patient safety. This narrative review focuses on strategies for safe extubation of the trachea for patients with potentially difficult upper airway problems in the intensive care unit.
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Affiliation(s)
- D J Sturgess
- Mater Research Institute, The University of Queensland, Brisbane, Queensland, Australia
| | - K B Greenland
- Department of Anaesthesiology, University of Hong Kong, Hong Kong SAR
| | - S Senthuran
- School of Medicine, James Cook University, Townsville, Queensland, Australia
| | - F A Ajvadi
- Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
| | - A van Zundert
- Department of Anaesthesia and Perioperative Medicine, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia.,School of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - M G Irwin
- Department of Anaesthesiology, University of Hong Kong, Hong Kong SAR
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13
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Selected abstracts presented at the World Airway Management Meeting, 12–14 November 2015, Dublin, Ireland. Br J Anaesth 2016. [DOI: 10.1093/bja/aew183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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14
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Higgs A, Cook TM, McGrath BA. Airway management in the critically ill: the same, but different. Br J Anaesth 2016; 117 Suppl 1:i5-i9. [PMID: 27147544 DOI: 10.1093/bja/aew055] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Affiliation(s)
- A Higgs
- Department of Anaesthesia and Intensive Care Medicine, Warrington & Halton Hospitals NHS Foundation Trust, Lovely Lane, Warrington, Cheshire WA5 1QG, UK
| | - T M Cook
- Department of Anaesthesia, Royal United Hospitals Bath Foundation Trust, Combe Park, Bath BA1 3NG, UK
| | - B A McGrath
- Department of Anaesthesia and Intensive Care Medicine, University Hospital South Manchester, Southmoor Road, Wythenshawe, Manchester M23 9LT, UK
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15
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Glossop AJ, Esquinas AM. Difficult intubation and life-threatening complications in obese patients: understanding the 'environment effect'. Br J Anaesth 2015; 116:146-7. [PMID: 26675967 DOI: 10.1093/bja/aev427] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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16
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Badia M, Montserrat N, Serviá L, Baeza I, Bello G, Vilanova J, Rodríguez-Ruiz S, Trujillano J. Complicaciones graves en la intubación orotraqueal en cuidados intensivos: estudio observacional y análisis de factores de riesgo. Med Intensiva 2015; 39:26-33. [DOI: 10.1016/j.medin.2014.01.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2013] [Revised: 12/12/2013] [Accepted: 01/02/2014] [Indexed: 11/28/2022]
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De Jong A, Molinari N, Pouzeratte Y, Verzilli D, Chanques G, Jung B, Futier E, Perrigault PF, Colson P, Capdevila X, Jaber S. Difficult intubation in obese patients: incidence, risk factors, and complications in the operating theatre and in intensive care units. Br J Anaesth 2014; 114:297-306. [PMID: 25431308 DOI: 10.1093/bja/aeu373] [Citation(s) in RCA: 123] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Intubation procedure in obese patients is a challenging issue both in the intensive care unit (ICU) and in the operating theatre (OT). The objectives of the study were (i) to compare the incidence of difficult intubation and (ii) its related complications in obese patients admitted to ICU and OT. METHODS We conducted a multicentre prospective observational cohort study in ICU and OT in obese (BMI≥30 kg m(-2)) patients. The primary endpoint was the incidence of difficult intubation. Secondary endpoints were the risk factors for difficult intubation, the use of difficult airway management techniques, and severe life-threatening complications related to intubation (death, cardiac arrest, severe hypoxaemia, severe cardiovascular collapse). RESULTS In cohorts of 1400 and 11 035 consecutive patients intubated in ICU and in the OT, 282 (20%) and 2103 (19%) were obese. In obese patients, the incidence of difficult intubation was twice more frequent in ICU than in the OT (16.3% vs 8.2%, P<0.01). In both cohorts, risk factors for difficult intubation were Mallampati score III/IV, obstructive sleep apnoea syndrome, and reduced mobility of cervical spine, while limited mouth opening, severe hypoxaemia, and coma appeared only in ICU. Specific difficult airway management techniques were used in 66 (36%) cases of difficult intubation in obese patients in the OT and in 10 (22%) cases in ICU (P=0.04). Severe life-threatening complications were significantly more frequent in ICU than in the OT (41.1% vs 1.9%, relative risk 21.6, 95% confidence interval 15.4-30.3, P<0.01). CONCLUSIONS In obese patients, the incidence of difficult intubation was twice more frequent in ICU than in the OT and severe life-threatening complications related to intubation occurred 20-fold more often in ICU. CLINICAL TRIAL REGISTRATION Current controlled trials. Identifier: NCT01532063.
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Affiliation(s)
- A De Jong
- Anesthesiology and Critical Care Department B, Saint Eloi Teaching Hospital, Montpellier F-34295, France
| | - N Molinari
- Department of Medical Statistics, La Colombière University Hospital, Centre Hospitalier Universitaire Montpellier, Montpellier F-34295, France
| | - Y Pouzeratte
- Anesthesiology and Critical Care Department B, Saint Eloi Teaching Hospital, Montpellier F-34295, France
| | - D Verzilli
- Anesthesiology and Critical Care Department B, Saint Eloi Teaching Hospital, Montpellier F-34295, France
| | - G Chanques
- Anesthesiology and Critical Care Department B, Saint Eloi Teaching Hospital, Montpellier F-34295, France
| | - B Jung
- Anesthesiology and Critical Care Department B, Saint Eloi Teaching Hospital, Montpellier F-34295, France Institut National de la Santé et de la Recherche Médicale U1046
| | - E Futier
- Anesthesiology and Critical Care Department B, Saint Eloi Teaching Hospital, Montpellier F-34295, France
| | - P-F Perrigault
- Anesthesiology and Critical Care Department C, Gui de Chauliac Hospital, Montpellier F-34295, France
| | - P Colson
- Anesthesiology and Critical Care Department D, Arnaud de Villeneuve Teaching Hospital
| | - X Capdevila
- Anesthesiology and Critical Care Department A, Lapeyronie Teaching Hospital, and Université Montpellier 1, Centre Hospitalier Universitaire Montpellier, Montpellier F-34295, France
| | - S Jaber
- Anesthesiology and Critical Care Department B, Saint Eloi Teaching Hospital, Montpellier F-34295, France Institut National de la Santé et de la Recherche Médicale U1046,
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Duwat A, Turbelin A, Petiot S, Hubert V, Deransy R, Mahjoub Y, Dupont H. [French national survey on difficult intubation in intensive care units]. ACTA ACUST UNITED AC 2014; 33:297-303. [PMID: 24810379 DOI: 10.1016/j.annfar.2014.03.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2013] [Accepted: 03/07/2014] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Assessing the theoretical knowledge, practical experience of French intensivists, and their compliance with French Anesthesiology and Critical Care Society's difficult airway algorithms of the expert's SFAR conference of 2006. STUDY DESIGN Prospective and descriptive national survey. MATERIAL AND METHODS An anonymous questionnaire with 40 questions was emailed to physicians working in intensive care units in France. RESULTS Five hundred and eight intensivists answered the survey. Ninety-seven percent of physicians reported having a portable storage unit for difficult intubation. As for practical experience, 421 physicians (83 %) have set up less than 10 laryngeal mask airway, 257 (51 %) have performed less than 10 intubations under fibroscopy and 269 (53 %) have never performed a cricothyroidotomy on mannequin, and 331 (65 %) on a patient. In case of emergency intubation, 29 % of them do not use a rapid sequence induction. Three hundred physicians (59 %) use capnography as monitoring of the endotracheal position. Two hundred and nine (42 %) consider they have not been trained to difficult intubation and 443 (87 %) would like to participate in high fidelity simulations mannequin. CONCLUSIONS National airway management algorithm was insufficiently followed. Alternative techniques do not seem to be mastered by all physicians. French intensivists expect more training on difficult intubation, including high fidelity simulation.
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Affiliation(s)
- A Duwat
- Département d'anesthésie-réanimation, CHU d'Amiens, place Victor-Pauchet, 80054 Amiens cedex 1, France.
| | - A Turbelin
- Département d'anesthésie-réanimation, CHU d'Amiens, place Victor-Pauchet, 80054 Amiens cedex 1, France
| | - S Petiot
- Département d'anesthésie-réanimation, CHU d'Amiens, place Victor-Pauchet, 80054 Amiens cedex 1, France
| | - V Hubert
- Département d'anesthésie-réanimation, CHU d'Amiens, place Victor-Pauchet, 80054 Amiens cedex 1, France
| | - R Deransy
- Département d'anesthésie-réanimation, CHU d'Amiens, place Victor-Pauchet, 80054 Amiens cedex 1, France
| | - Y Mahjoub
- Département d'anesthésie-réanimation, CHU d'Amiens, place Victor-Pauchet, 80054 Amiens cedex 1, France
| | - H Dupont
- Département d'anesthésie-réanimation, CHU d'Amiens, place Victor-Pauchet, 80054 Amiens cedex 1, France
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Kingston EV, Loh NH. Use of capnography may cause airway complications in intensive care. Br J Anaesth 2014; 112:388-9. [PMID: 24431363 DOI: 10.1093/bja/aet571] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Lawrence N, Oakley L, Swanevelder C, Palmer M. Tracheostomy Emergency Guidelines: A Survey of the East of England Training Region. J Intensive Care Soc 2013. [DOI: 10.1177/175114371301400222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Natasha Lawrence
- SpR in Anaesthesia and Intensive Care Medicine
- Department of Intensive Care, West Suffolk Hospital, Bury St Edmunds
| | - Laura Oakley
- CT3 ACCS Trainee in Anaesthesia and Intensive Care Medicine
- Department of Intensive Care, West Suffolk Hospital, Bury St Edmunds
| | - Carin Swanevelder
- Consultant in Anaesthesia and Intensive Care Medicine
- Department of Intensive Care, West Suffolk Hospital, Bury St Edmunds
| | - Michael Palmer
- Consultant in Anaesthesia and Intensive Care Medicine
- Department of Intensive Care, West Suffolk Hospital, Bury St Edmunds
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Cook T, MacDougall-Davis S. Complications and failure of airway management. Br J Anaesth 2012; 109 Suppl 1:i68-i85. [DOI: 10.1093/bja/aes393] [Citation(s) in RCA: 269] [Impact Index Per Article: 22.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
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