Aerosol precautions and airway complications: a national prospective multicentre cohort study

Airway and respiratory complications during anaesthesia and associated with peri-operative cardiac arrest as reported to the 7th National Audit Project of the Royal College of Anaesthetists

The 7th National Audit Project (NAP7) of the Royal College of Anaesthetists studied complications of the airway and respiratory system during anaesthesia care including peri-operative cardiac arrest. Among 24,721 surveyed cases, airway and respiratory complications occurred commonly (n = 421 and n = 264, respectively). The most common airway complications were: laryngospasm (157, 37%); airway failure (125, 30%); and aspiration (27, 6%). Emergency front of neck airway was rare (1 in 8370, 95%CI 1 in 2296-30,519). The most common respiratory complications were: severe ventilation difficulty (97, 37%); hyper/hypocapnia (63, 24%); and hypoxaemia (62, 23%). Among 881 reports to NAP7 and 358 deaths, airway and respiratory complications accounted for 113 (13%) peri-operative cardiac arrests and 32 (9%) deaths, with hypoxaemia as the most common primary cause. Airway and respiratory cases had higher and lower survival rates than other causes of cardiac arrest, respectively. Patients with obesity, young children (particularly infants) and out-of-hours care were overrepresented in reports. There were six cases of unrecognised oesophageal intubation with three resulting in cardiac arrest. Of these cases, failure to correctly interpret capnography was a recurrent theme. Cases of emergency front of neck airway (6, approximately 1 in 450,000) and pulmonary aspiration (11, approximately 1 in 25,000) leading to cardiac arrest were rare. Overall, these data, while distinct from the 4th National Audit Project, suggest that airway management is likely to have become safer in the last decade, despite the surgical population having become more challenging for anaesthetists.

Real-Time Tracheal Ultrasound vs. Capnography for Intubation Confirmation during CPR Wearing a Powered Air-Purifying Respirator in COVID-19 Era

This study aimed to compare the accuracy of real-time trans-tracheal ultrasound (TTUS) with capnography to confirm intubation in cardiopulmonary resuscitation (CPR) while wearing a powered air-purifying respirator (PAPR). This setting reflects increased caution due to contagious diseases. This single-center, prospective, comparative study enrolled patients requiring CPR while wearing a PAPR who visited the emergency department of a tertiary medical center from December 2020 to August 2022. A physician performed the TTUS in real time and recorded the tube placement assessment. Another healthcare provider attached waveform capnography to the tube and recorded end-tidal carbon dioxide (EtCO2) after five ventilations. The accuracy and agreement of both methods compared with direct laryngoscopic visualization of tube placement, and the time taken by both methods was evaluated. Thirty-three patients with cardiac arrest were analyzed. TTUS confirmed tube placement with 100% accuracy, sensitivity, and specificity, whereas capnography demonstrated 97% accuracy, 96.8% sensitivity, and 100% specificity. The Kappa values for TTUS and capnography compared to direct visualization were 1.0 and 0.7843, respectively. EtCO2 was measured in 45 (37-59) seconds (median (interquartile range)), whereas TTUS required only 12 (8-23) seconds, indicating that TTUS was significantly faster (p < 0.001). No significant correlation was found between the physician's TTUS proficiency and image acquisition time. This study demonstrated that TTUS is more accurate and faster than EtCO2 measurement for confirming endotracheal tube placement during CPR, particularly in the context of PAPR usage in pandemic conditions.

The incidence of potentially serious complications during non-obstetric anaesthetic practice in the United Kingdom: an analysis from the 7th National Audit Project (NAP7) activity survey

Complications and critical incidents arising during anaesthesia due to patient, surgical or anaesthetic factors, may cause harm themselves or progress to more severe events, including cardiac arrest or death. As part of the 7th National Audit Project of the Royal College of Anaesthetists, we studied a prospective national cohort of unselected patients. Anaesthetists recorded anonymous details of all cases undertaken over 4 days at their site through an online survey. Of 416 hospital sites invited to participate, 352 (85%) completed the survey. Among 24,172 cases, 1922 discrete potentially serious complications were reported during 1337 (6%) cases. Obstetric cases had a high reported major haemorrhage rate and were excluded from further analysis. Of 20,996 non-obstetric cases, 1705 complications were reported during 1150 (5%) cases. Circulatory events accounted for most complications (616, 36%), followed by airway (418, 25%), metabolic (264, 15%), breathing (259, 15%), and neurological (41, 2%) events. A single complication was reported in 851 (4%) cases, two complications in 166 (1%) cases and three or more complications in 133 (1%) cases. In non-obstetric elective surgery, all complications were 'uncommon' (10-100 per 10,000 cases). Emergency (urgent and immediate priority) surgery accounted for 3454 (16%) of non-obstetric cases but 714 (42%) of complications with severe hypotension, major haemorrhage, severe arrhythmias, septic shock, significant acidosis and electrolyte disturbances all being 'common' (100-1000 per 10,000 cases). Based on univariate analysis, complications were associated with: younger age; higher ASA physical status; male sex; increased frailty; urgency and extent of surgery; day of the week; and time of day. These data represent the rates of potentially serious complications during routine anaesthesia care and may be valuable for risk assessment and patient consent.

Non-theatre emergency airway management: a multicentre prospective observational study

Emergency airway management events are common, unpredictable and associated with high complication rates. This multicentre prospective observational study across eight acute NHS hospitals in southeast England reports the incidence and nature of non-theatre emergency airway management events. Data were collected from non-theatre emergency airway management, including adverse events, over a continuous 28-day window, and recorded on an electronic case report form. Events were classified according to type (advanced airway; simple airway; and cardiac arrest). A total of 166 events were recorded, with 111 advanced airway events involving tracheal intubation or tracheostomy management. Senior personnel with three or more years of airway management experience were present for 105/111 (95%) advanced airway management episodes. There was a significant reduction in consultant or equivalent presence out-of-hours (21/64, 33%) vs. in-hours (34/47, 72%) (p < 0.001). We found high utilisation of videolaryngoscopy (95/106, 90%) and universal use of capnography for all advanced airway management events. This was lower during cardiac arrest when videolaryngoscopy was used in 11/16 (69%) of tracheal intubations and capnography in 21/32 (66%) of all cardiac arrest episodes. Adverse outcomes during advanced airway management (excluding during cardiac arrest) occurred in 53/111 (48%) episodes, including hypoxia (desaturation to Sp O2 < 80% in 14/111, 13%) and hypotension (systolic blood pressure < 80 mmHg in 27/111, 25%). Adverse outcomes were not associated with time of day or experience level of airway practitioners. We conclude that there is a disparity between consultant presence for advanced airway interventions in- and out-of-hours; high utilisation of videolaryngoscopy and capnography, especially for advanced airway interventions; and a high incidence of hypotension and hypoxaemia, including critical values, during non-theatre airway management.