Litigation related to airway and respiratory complications of anaesthesia: an analysis of claims against the NHS in England 1995-2007

A Prospective Study Evaluating Gender Differences of Serious Outcomes through Difficult Airway Physiological Score (DAPS) in the Emergency Department

Introduction

Gender variation in critically ill adults after resuscitation is reported in many studies. However, this variation is not well established when evaluating the physiological instability in this population. This study aimed to prospectively evaluate the gender variation in serious outcomes by the difficult airway physiological score (DAPS) among critically ill patients requiring endotracheal intubation (ETI).

Methods

This is a cohort study conducted from August 2021 to December 2022 in the emergency department of Aga Khan University. The prospective validity of the difficult airway physiological score was derived using retrospective data and includes 12 variables: sex, age, time of intubation, hypotension, respiratory distress, vomiting, shock index >0.9, pH < 7.3, fever, anticipated decline, Glasgow Coma Scale (GCS) < 15, and agitation. The serious outcomes were cardiac arrest, mortality (within 1 hour after intubation in emergency), hypotension (systolic blood pressure <90 mmHg), and oxygen desaturation (SpO2 < 92%). The difference between males and females was assessed using the chi-square test, and the association of gender and serious outcomes was explored using Cox and logistic regression analysis. ROC curve analysis and area under the curve assessed score validity separately in males and females with serious outcomes.

Results

We enrolled 326 patients with a mean age of 50.3 (±17.8), with 123 (33.7%) females and 203 (62.2%) males. 198 (60.7%) patients were >45 years old, of which 136 (67%) were male and 62 (50.4%) female. Cardiac arrest was observed in 56 (17.2%), with 24 (19.5%) females and 32 (15.8%) males, p value 0.348. Hypotension after intubation was observed in 132 (40.5%) patients, 56 (45.5%) females and 76 (37.4%) males, p value 0.149. Oxygen saturation (<92%) was observed in 80 (24.5%) patients, 32 (26%) females and 48 (23.6%) males, p value 0.630. In females, the DAPS of 11 had an area under the curve of 0.863 (0.74-0.91). The sensitivity of the score was 84.8%, the specificity was 71.9%, the PPV was 77.8%, and the NPV was 80.4% with an accuracy of 78.9%. In males, the DAPS score of 14 had an area under the curve of 0.892 (0.57-0.75). The sensitivity of the score was 67%, the specificity 93.8%, the PPV 92.2%, and the NPV 72.2% with an accuracy of 79.8%.

Conclusions

The Difficult Airway Physiological Score (DAPS) predicts the risk of serious outcomes after intubation with high precision and reliability with different score cutoffs between the two sexes, highlighting the gender variation of a difficult airway.

Medico-legal liability of injuries arising from laryngoscopy

OBJECTIVE

Dental and mucosal injuries from laryngoscopy in the peri-operative period are common medico-legal complaints. This study investigated lawsuits arising from laryngoscopy.

METHODS

Westlaw, a legal database containing trial records from across the USA, was retrospectively reviewed. Plaintiff and/or defendant characteristics, claimed injuries, legal outcomes and awards were extracted.

RESULTS

Of all laryngoscopy-related dental or mucosal injuries brought before a state or federal court, none (0 per cent) resulted in a defence verdict against the provider or monetary gain for the patient. Rulings in the patient's favour were observed only when laryngoscopy was found to be the proximate cause of multiple compounding complications that culminated in severe medical outcomes such as exsanguination, septic shock or cardiopulmonary arrest.

CONCLUSION

Proper laryngoscopy technique and a robust informed-consent process that accurately sets patients' expectations reduces litigation risk. Future litigation pursuits should consider the low likelihood of malpractice allegation success at trial.

Effects of Anesthetic Choice on the Incidence of Transcranial-Motor Potential-Induced Oral Trauma

Transcranial motor-evoked potentials (TcMEPs) play an integral role in assessing motor tract function in surgical procedures where motor function is at risk. However, transcranial stimulation creates a risk for oral trauma. Several studies have reported on distinct factors that can influence the rate of TcMEP-induced oral trauma, but little is known about how an anesthetic regimen can influence this rate. In this retrospective review, we investigated the incidence of oral injury under total intravenous anesthesia (TIVA) and balanced anesthesia in 66,166 cases from 2019 to 2021. There were 295 oral injuries in our sample, yielding an incidence of 0.45%, which is in line with ranges reported in the literature. A total of 222 of the injured patients were sedated with balanced anesthesia, while the remaining 73 were under TIVA anesthetics. This difference in distribution was statistically significant (p < 0.0002). Our findings suggest TIVA is associated with lower risk of oral trauma when TcMEPs are monitored, thereby improving patient safety.

Anaesthetic records: an evaluation of variation across England

We collected blank non-specialist anaesthetic records from 71 National Health Service Trusts in England. A data set was established by collating all data items found in an initial tranche of 28 records. All 71 records were subsequently analysed for each data item in this data set. We found significant variation: the most populated record included 216 data items and the least included 38 data items: a greater than five-fold variation. There was significant variation in the inclusion of data items commonly considered important to patient safety; 42% of records omitted documentation of fasting status, 72% omitted documentation of a discussion around the risk of accidental awareness during general anaesthesia, 92% omitted documentation of quantitative neuromuscular blockade monitoring and 63% omitted documentation for 'Stop Before You Block' when performing regional anaesthesia. The study highlights significant variability in the composition of anaesthetic records across England which may impact on its value as a data repository, an action trigger, a medicolegal account, and a tool to facilitate safe handover. Standardisation of the anaesthetic record or the establishment of standards of recording would help to allay potential risks to patient safety and assist in guiding future procurement of electronic solutions for anaesthetic records.

A novel nomogram for predicting the decision to delayed extubation after thoracoscopic lung cancer surgery

OBJECTIVE

Delayed extubation was commonly associated with increased adverse outcomes. This study aimed to explore the incidence and predictors and to construct a nomogram for delayed extubation after thoracoscopic lung cancer surgery.

METHODS

We reviewed medical records of 8716 consecutive patients undergoing this surgical treatment from January 2016 to December 2017. Using potential predictors to develop a nomogram and using a bootstrap-resampling approach to conduct internal validation. For external validation, we additionally pooled 3676 consecutive patients who underwent this procedure between January 2018 and June 2018. Extubation performed outside the operating room was defined as delayed extubation.

RESULTS

The rate of delayed extubation was 1.60%. Multivariate analysis identified age, BMI, FEV₁/FVC, lymph nodes calcification, thoracic paravertebral blockade (TPVB) usage, intraoperative transfusion, operative time and operation later than 6 p.m. as independent predictors for delayed extubation. Using these eight candidates to develop a nomogram, with a concordance statistic (C-statistic) value of 0.798 and good calibration. After internal validation, similarly good calibration and discrimination (C-statistic, 0.789; 95%CI, 0.748 to 0.830) were observed. The decision curve analysis (DCA) indicated the positive net benefit with the threshold risk range of 0 to 30%. Goodness-of-fit test and discrimination in the external validation were 0.113 and 0.785, respectively.

CONCLUSION

The proposed nomogram can reliably identify patients at high risk for the decision to delayed extubation after thoracoscopic lung cancer surgery. Optimizing four modifiable factors including BMI, FEV₁/FVC, TPVB usage, and operation later than 6 p.m. may reduce the risk of delayed extubation.Key Messages:This study identified eight independent predictors for delayed extubation, among which lymph node calcification and anaesthesia type were not commonly reported.Using these eight candidates to develop a nomogram, we could reliably identify high-risk patients for the decision to delayed extubation.Optimizing four modifiable factors, including BMI, FEV₁/FVC, TPVB usage, and operation later than 6 p.m. may reduce the risk of delayed extubation.

Development and validation of a regression model with nomogram for difficult video laryngoscopy in Chinese population: a prospective, single-center, and nested case-control study

Background

Airway management failure is associated with increased perioperative morbidity and mortality. Airway-related complications can be significantly reduced if difficult laryngoscopy is predicted with high accuracy. Currently, there are no large-sample studies on difficult airway assessments in Chinese populations. An airway assessment model based on the Chinese population is urgently needed to guide airway rescue strategy.

Methods

This prospective nested case-control study took place in a tertiary hospital in Shanghai, China. Information on 10,549 patients was collected, and 8,375 patients were enrolled, including 7,676 patients who underwent successful laryngoscopy and 699 patients who underwent difficult laryngoscopy. The baseline characteristics, medical history, and bedside examinations were included as predictor variables. Laryngoscopy was defined as 'successful laryngoscopy' based on a Cormack-Lehane Grades of 1-2 and as 'difficult laryngoscopy' based on a Cormack-Lehane Grades of 3-4. A model was developed by incorporating risk factors and was presented in the form of a nomogram by univariate logistic regression, least absolute shrinkage and selection operator, and stepwise logistic regression. The main outcome measures were area under the curve (AUC), sensitivity, and specificity of the predictive model.

Result

The AUC value of the prediction model was 0.807 (95% confidence interval [CI]: 0.787-0.828), with a sensitivity of 0.730 (95% CI, 0.690-0.769) and a specificity of 0.730 (95% CI, 0.718-0.742) in the training set. The AUC value of the prediction model was 0.829 (95% CI, 0.800-0.857), with a sensitivity of 0.784 (95% CI, 0.73-0.838) and a specificity of 0.722 (95% CI, 0.704-0.740) in the validation set.

Conclusion

Our model had accurate predictive performance, good clinical utility, and good robustness for difficult laryngoscopy in the Chinese population.

Influence of airway trolley organization on efficiency and team performance: A randomized, crossover simulation study

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.

How to improve intubation in the intensive care unit. Update on knowledge and devices

Tracheal intubation in the critically ill is associated with serious complications, mainly cardiovascular collapse and severe hypoxemia. In this narrative review, we present an update of interventions aiming to decrease these complications. MACOCHA is a simple score that helps to identify patients at risk of difficult intubation in the intensive care unit (ICU). Preoxygenation combining the use of inspiratory support and positive end-expiratory pressure should remain the standard method for preoxygenation of hypoxemic patients. Apneic oxygenation using high-flow nasal oxygen may be supplemented, to prevent further hypoxemia during tracheal intubation. Face mask ventilation after rapid sequence induction may also be used to prevent hypoxemia, in selected patients without high-risk of aspiration. Hemodynamic optimization and management are essential before, during and after the intubation procedure. All these elements can be integrated in a bundle. An airway management algorithm should be adopted in each ICU and adapted to the needs, situation and expertise of each operator. Videolaryngoscopes should be used by experienced operators.

Airway management in patients with suspected or confirmed traumatic spinal cord injury: a narrative review of current evidence

Around 1 million people sustain a spinal cord injury each year, which can have significant psychosocial, physical and socio‐economic consequences for patients, their families and society. The aim of this review is to provide clinicians with a summary of recent studies of direct relevance to the airway management of patients with confirmed or suspected traumatic spinal cord injury to promote best clinical practice. All airway interventions are associated with some degree of movement of the cervical spine; in general, these are very small and whether these are clinically significant in terms of impingement of the spinal cord is unclear. Manual in‐line stabilisation does not effectively immobilise the cervical spine and increases the likelihood of difficult and failed tracheal intubation. There is no clear evidence of benefit of awake tracheal intubation techniques in terms of prevention of secondary spinal cord injury. Videolaryngoscopy appears to cause a similar degree of cervical spine displacement as flexible bronchoscope‐guided tracheal intubation and is an appropriate alternative approach. Direct laryngoscopy does cause a slightly greater degree of cervical spinal movement during tracheal intubation than videolaryngoscopy, but this does not appear to increase the risk of spinal cord compression. The risk of spinal cord injury during tracheal intubation appears to be minimal even in the presence of gross cervical spine instability. Depending on the clinical situation, practitioners should choose the tracheal intubation technique with which they are most proficient and that is most likely to minimise cervical spine movement.

Perioperative Dental Injury Associated With Intubated General Anesthesia

OBJECTIVE

Factors related to perioperative dental injury have likely changed as a variety of airway devices and preventive measures have been introduced. This retrospective chart review used data from an institutional registry to evaluate the incidence, timing, and contributing factors of patient self-reported dental injury and to assess the impact of dental injury on patient satisfaction.

METHODS

Multivariate logistic analysis was performed on the records of 14,820 patients using the incidence of dental injury as the dependent variable and covariates in the anesthesia registry and a postoperative questionnaire as independent variables to investigate factors significantly associated perioperative dental injury. In addition, satisfaction with the anesthesia service was compared between patients with and without injury using a matched-pair population.

RESULTS

A total of 101 dental injuries were identified. Of those, 25% were associated with intubation and extubation in the operating room, while most other injuries occurred postoperatively. Duration of anesthesia (odds ratio [OR], 1.02; 95% confidence interval [CI], 1.00-1.03) and emergency surgery (OR, 1.92; 95% CI, 1.11-3.30) were independently associated with perioperative dental injury. Dental injury did not significantly decrease a patient's satisfaction with the anesthesia service (P = .441).

CONCLUSION

Most perioperative dental injuries are unrelated to anesthesia procedures. However, the duration of anesthesia and emergency surgery were significantly associated with perioperative dental injury, while decreased patient satisfaction was not.

Airway management in the critically ill patient with COVID-19

PURPOSE OF REVIEW

Critically ill Coronavirus disease 2019 (COVID-19) patients needing endotracheal intubation are on the verge of rapid decompensation. The aims of this review were to assess the risks, the preoxygenation, the device and the hemodynamic management of a patient with COVID-19.

RECENT FINDINGS

The proceduralist performing endotracheal intubation with the entire team are at an increased risk for exposure to COVID-19. Appropriate personal protective equipment and other measures remain essential. For preoxygenation, noninvasive ventilation allows higher oxygen saturation during intubation in severely hypoxemic patients and can be associated with apneic oxygenation and mask ventilation during apnea in selected cases. The COVID-19 pandemic has further highlighted the place of videolaryngoscopy during intubation in intensive care unit (ICU). Hemodynamic optimization is mandatory to limit hypotension and cardiac arrest associated with airway management.

SUMMARY

Future trials will better define the role of videolaryngoscopy, apneic oxygenation and mask ventilation during apnea for intubation of COVID-19 patients in ICU. The use of fluid loading and vasopressors remains to be investigated in large randomized controlled studies. Choosing the right time for intubation remains uncertain in clinical practice, and future works will probably help to identify earlier the patients who will need intubation.

Litigation related to anaesthesia: analysis of claims against the NHS in England 2008-2018 and comparison against previous claim patterns

We reviewed all 1230 claims against anaesthesia notified to NHS Resolution (formerly the NHS Litigation Authority, 1995-2017) in England between 2008 and 2018. Claims were categorised by incident type, severity (whether physical or psychological), and cost, and comparisons were made against a similar published analysis of data from 1995 to 2007. While the annual number of claims against anaesthesia increased by 62% from the earlier period, anaesthesia now accounts for smaller proportions of all claims submitted to NHS Resolution (1.5% vs. 2.5%) and of the total cost of all claims (0.7% vs. 2.4%). The absolute costs related to anaesthesia claims rose over 300%, totalling £145 million between 2008 and 2018, but the mean cost per closed claim (retail price index adjusted) fell by 6% to £74,883. The most common clinical categories were regional anaesthesia (24%), inadequate anaesthesia (20%) and drug administration (20%). Claims related to airway management, central venous catheterisation and cardiac arrest remained infrequent but severe and costly. The proportion of claims relating to regional anaesthesia and obstetric anaesthesia fell significantly, but claims relating to peripheral nerve blockade doubled. Our analysis includes categories relating to organisational and human factors which are present in a substantial proportion of claims; categories with the highest mean cost per claim included delayed care, planning, monitoring and consent. Overall, the specialty of anaesthesia is at low risk of litigation. Our analysis provides important insights into current and changing patterns in claim distributions that may help improve the quality of patient care and reduce future litigation. We recommend the establishment of a structure for national review and learning from all cases of litigation.

Anatomical Evaluation of Rat and Mouse Simulators for Laboratory Animal Science Courses

Simple Summary

Over the past decades simulators of rats and mice have been developed as initial training devices for prospective researchers involved in animal testing. By using these simulators, different techniques such as blood sampling can be be learned prior to working on live animals. As this has the potential to minimize stress and suffering of experimental animals, the use of simulators is demanded by European law. Nevertheless, only little is known about frequency of their use, their anatomical correctness and learning efficiency. With this in mind, a collaborative research project named “SimulRATor” was initiated to systematically evaluate existing rat and mouse simulators. Results will serve as the basis for the development of a new 3D-printed rat simulator with realistic anatomy. In the subproject presented here, simulators were evaluated by experts of the field in order to analyze their anatomical strengths and weaknesses. The evaluation showed, that the limbs and especially the heads were perceived as anatomically unrealistic. Therefore, the authors will focus on these body regions during the construction process by e.g. including movable limbs, and a lower jaw with a tongue. This might positively affect the learning process and outcome and thereby support animal welfare.

Abstract

According to the European Directive 63/2010/EU, education and training involving living rats and mice are classified as an animal experiment and demands the implementation of the 3Rs. Therefore, as a method of refinement, rat and mouse simulators were developed to serve as an initial training device for various techniques, prior to working on living animals. Nevertheless, little is known about the implementation, anatomical correctness, learning efficiency and practical suitability of these simulators. With this in mind, a collaborative research project called “SimulRATor” was initiated to systematically evaluate the existing rat and mouse simulators in a multi-perspective approach. The objective of the study presented here was to identify the anatomical strengths and weaknesses of the available rat and mouse simulators and to determine anatomical requirements for a new anatomically correct rat simulator, specifically adapted to the needs of Laboratory Animal Science (LAS) training courses. Consequently, experts of Veterinary Anatomy and LAS evaluated the anatomy of all currently available rat and mouse simulators. The evaluation showed that compared to the anatomy of living rats and mice, the tails were perceived as the most anatomically realistic body part, followed by the general exterior and the limbs. The heads were rated as the least favored body part.

Leading Causes of Anesthesia-Related Liability Claims in Ambulatory Surgery Centers

OBJECTIVE

We present a contemporary analysis of patient injury, allegations, and contributing factors of anesthesia-related closed claims, which involved cases that specifically occurred in free-standing ambulatory surgery centers (ASCs).

METHODS

We examined ASC-closed claims data between 2007 and 2014 from The Doctors Company, a medical malpractice insurer. Findings were coded using the Comprehensive Risk Intelligence Tool developed by CRICO Strategies. We compared coded data from ASC claims with hospital operating room (HOR) claims, in terms of injury severity category, nature of injury, nature of allegation, contributing factors identified, and contributing comorbidities and claim value.

RESULTS

Ambulatory surgery center claims were more likely to be classified as medium severity than HOR claims, more likely to involve dental damage or pain than HOR claims, but less likely to involve death or respiratory or cardiac arrest. Technical performance was the most common contributing factor: 47% of ASCs and 48% of HORs. Only 7% of allegations relating to technical performance were judged to be a direct result of poor technical performance. The most common anesthesia procedures resulting in ASC claims were injection of anesthesia into a peripheral nerve (34%) and intubation (29%). Obesity was the most common contributing comorbidity in both settings. Mean closed claim value was significantly lower for ASC than HOR claims, averaging US $87,888 versus $107,325.

CONCLUSIONS

Analysis of ASC and HOR claims demonstrates significant differences and several common sources of liability. These include improving strategies for thorough screening, preoperative assessment and risk stratifying of patients, incorporating routine dental and airway assessment and documentation, diagnosing and treating perioperative pain adequately, and improving the efficacy of communication between patients and care providers.

Ultrasonography relative to Cormack-Lehane in predicting difficult laryngoscopy: a systematic review of diagnostic test accuracy

OBJECTIVE

The objective of this review is to determine the diagnostic test accuracy of point-of-care ultrasound anterior soft tissue quantification techniques for predicting difficult laryngoscopy in relation to Cormack-Lehane scores.

INTRODUCTION

Difficult airway management is a critical challenge for anesthesia providers, and a non-invasive test to confidently predict difficult airway is lacking. When difficult airway is not anticipated, the provider's management of the event deteriorates, resulting in significant morbidity or mortality. This systematic review of the diagnostic efficacy of newer ultrasound techniques has potential to advance difficult airway prediction and patient safety.

INCLUSION CRITERIA

This review will consider adults 18 years and older presenting for elective surgery, who undergo a preoperative point-of-care ultrasound anterior soft tissue airway examination that is referenced to an intraoperative Cormack-Lehane airway examination, obtained using direct laryngoscopy under general anesthesia.

METHODS

Data sources will include Ovid MEDLINE, Trip Database, Embase, CINAHL Complete, Clinicaltrials.gov, Google Scholar, MedNar, Grey Literature Report, and ProQuest Dissertations and Theses. Only studies published in English after the advent of the Cormack-Lehane reference test (1984) will be included. Studies will be critically appraised using a checklist for studies of diagnostic test accuracy. Details about the index tests, populations, study methods, and outcomes of significance to the review will be extracted. Where possible, sensitivity and specificity will be pooled in statistical bivariate meta-analysis. Diagnostic thresholds will be displayed on a paired forest plot or summary receiver operator characteristic curve, depending on the degree of variability.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42020205974.

Evaluation of lightwand-guided endotracheal intubation for patients with missing or no teeth: a randomized controlled study

Background

Unhealthy teeth can seriously affect general health and increase the risk of death in elderly people. There has been no confirmation of which device is most effective for elderly patients with teeth loss. Therefore, we compared four intubation devices in elderly patients with partial and total tooth loss aiming to reduce risk during anesthesia.

Methods

Two hundred patients were randomized to undergo tracheal intubation with the Macintosh laryngoscope, the Glidescope, the Fiberoptic bronchoscope or the Lightwand as part of general anesthesia. A unified protocol of anesthetic medications was used. HR and BP were measured at T₀, T₁, T₂, T₃, T₄ and T₅. Catecholamine (epinephrine and norepinephrine) blood samples were drawn at T₀, T₁ and T₂. Intubation time and postoperative complications, including dental damage and losses, were recorded.

Results

Reduced fluctuations in HR, DBP, and SBP were observed in the Lightwand group. Intubation time was significantly shorter in the Lightwand group (p < 0.05). There was no statistically significant difference between the groups in epinephrine levels, but norepinephrine levels were less volatile in the Fiberoptic bronchoscope and Lightwand groups. Fewer patients in the Lightwand group experienced dental damage and other postoperative complications than in the other three groups. Although a higher success rate on the first attempt was as high as in the Fiberoptic bronchoscope group, shorter intubation time was observed only in the Lightwand group.

Conclusion

The Lightwand offers less hemodynamic stimulation than the Macintosh laryngoscope, Glidescope, and Fiberoptic bronchoscope. Because it had the shortest intubation time, the Lightwand caused the least damage to the teeth and throat of elderly patients. Our findings showed that tracheal intubation with the Lightwand was advantageous for preventing cardiovascular stress responses with short intubation times and fewer postoperative complications.

Analysis of endotracheal intubation-related judicial precedents in South Korea

Background

Medical malpractice during endotracheal intubation can result in catastrophic complications. However, there are no reports on these severe complications in South Korea. We aimed to investigate the severe complications associated with endotracheal intubation occurring in South Korea, via medicolegal analysis.

Methods

We retrospectively analyzed the closed judicial precedents regarding complications related to endotracheal intubation lodged between January 1994 and June 2020, using the database of the Supreme Court of Korea. We collected clinical and judicial characteristics from the judgments and analyzed the medical malpractices related to endotracheal intubation.

Results

Of 220 potential cases, 63 were included in the final analysis. The most common event location was the operating room (n = 20, 31.7%). All but 3 cases were associated with significant permanent or more severe injury, including 31 deaths. The most common problems were failed or delayed intubation (n = 56, 88.9%). Supraglottic airway device was used in 5.2% (n = 3) cases of delayed or failed intubation. Fifty-one (81%) cases were ruled in favor of the plaintiff in the claims for damages, with a median payment of Korean Won 133,897,845 (38,000,000, 308,538,274). The most common malpractice recognized by the court was that of not attempting an alternative airway technique (n = 32, 50.8%), followed by violation of the duty of explanation (n = 10, 15.9%).

Conclusions

Our results could increase physicians’ awareness of the major complications related to endotracheal intubation and help ensure patient safety.

Pre-oxygenation using high-flow nasal oxygen vs. tight facemask during rapid sequence induction

Pre-oxygenation using high-flow nasal oxygen can decrease the risk of desaturation during rapid sequence induction in patients undergoing emergency surgery. Previous studies were single-centre and often in limited settings. This randomised, international, multicentre trial compared high-flow nasal oxygen with standard facemask pre-oxygenation for rapid sequence induction in emergency surgery at all hours of the day and night. A total of 350 adult patients from six centres in Sweden and one in Switzerland undergoing emergency surgery where rapid sequence induction was required were included and randomly allocated to pre-oxygenation with 100% oxygen using high-flow nasal oxygen or a standard tight-fitting facemask. The primary outcome was the number of patients developing oxygen saturations <93% from the start of pre-oxygenation until 1 min after tracheal intubation. Data from 349 of 350 patients who entered the study were analysed (174 in the high-flow nasal oxygen group and 175 in the facemask group). No difference was detected in the number of patients desaturating <93%, five (2.9%) vs. six (3.4%) patients in the high-flow nasal oxygen and facemask group, respectively (p = 0.77). The risk of desaturation was not increased during on-call hours. No difference was seen in end-tidal carbon dioxide levels in the first breath after tracheal intubation or in the number of patients with signs of regurgitation between groups. These results confirm that high-flow nasal oxygen maintains adequate oxygen levels during pre-oxygenation for rapid sequence induction.

Impact of videolaryngoscopy introduction into prehospital emergency medicine practice: a quality improvement project

INTRODUCTION

Advanced airway management is necessary in the prehospital environment and difficult airways occur more commonly in this setting. Failed intubation is closely associated with the most devastating complications of airway management. In an attempt to improve the safety and success of tracheal intubation, we implemented videolaryngoscopy (VL) as our first-line device for tracheal intubation within a UK prehospital emergency medicine (PHEM) setting.

METHODS

An East of England physician-paramedic PHEM team adopted VL as first line for undertaking all prehospital advanced airway management. The study period was 2016-2020. Statistical process control charts were used to assess whether use of VL altered first-pass intubation success, frequency of intubation-related hypoxia and laryngeal inlet views. A survey was used to collect the team's views of VL introduction.

RESULTS

919 patients underwent advanced airway management during the study period. The introduction of VL did not improve first-pass intubation success, view of laryngeal inlet or intubation-associated hypoxia. VL improved situational awareness and opportunities for training but performed poorly in some environments.

CONCLUSION

Despite the lack of objective improvement in care, subjective improvements meant that overall PHEM clinicians wanted to retain VL within their practice.

Unexpected cancellation on a catatonic patient’s electroconvulsive therapy due to the coronavirus pandemic

We report a case of a 39-year-old woman with a psychiatric history of schizoaffective disorder with catatonia, dependent personality disorder and substance use disorder whose symptoms have been very difficult to control. During her most recent inpatient admission, she was treated with electroconvulsive therapy (ECT) for catatonia. Our treatment team was hopeful that ECT was making a difference for this patient. However, she was only able to receive two sessions of treatment due to new hospital protocols related to the coronavirus pandemic. Although the patient was not suspected to have the coronavirus, she could no longer undergo ventilation with a bag and mask during the procedure. Bag–mask ventilation is known to aerosolise the coronavirus and other diseases and potentially put healthcare workers at risk. Although orotracheal intubation also aerosolises the coronavirus, this was the only means of airway management still allowed by anaesthesia providers at this time. Our psychiatry team estimated that the risks of intubation outweighed the benefits of treatment, and ECT was cancelled.

Without additional ECT treatments, the patient again decompensated for several weeks before being stabilised on clozapine, haloperidol and lorazepam. Although she eventually had a positive treatment outcome, her hospital course was likely prolonged due to unforeseen events related to the novel coronavirus. We feel that the current medical climate is unprecedented and is interfering with necessary psychiatric treatment in an unanticipated way. Anaesthesiologists will need to be flexible while working with psychiatrists and identify safe ways to provide this necessary psychiatric treatment for patients.

Difficult and failed intubation in the first 4000 incidents reported on webAIRS

A review of the first 4000 reports to the webAIRS anaesthesia incident reporting database was performed to analyse cases reported as difficult or failed intubation. Patient, task, caregiver and system factors were evaluated. Among the 4000 reports, there were 170 incidents of difficult or failed intubation. Difficult or failed intubation incidents were most common in the 40-59 years age group. More than half of cases were not predicted. A total of 40% involved patients with a body mass index >30 kg/m² and 41% involved emergency cases. A third of the reports described multiple intubation attempts. Of the reports, 18% mentioned equipment problems including endotracheal tube cuff rupture, laryngoscope light failure, dysfunctional capnography and delays with availability of additional equipment to assist with intubation. Immediate outcomes included 40 cases of oxygen desaturation below 85%; of these cases, four required cardiopulmonary resuscitation. The majority of the incidents resulted in no harm or minor harm (45%). However, 12% suffered moderate harm, 3.5% severe harm and there were three deaths (although only one related to the airway incident). Despite advances and significant developments in airway management strategies, difficult and failed intubation still occurs. Although not all incidents are predictable, nor are all preventable, the information provided by this analysis might assist with future planning, preparation and management of difficult intubation.

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

Purpose

We analyzed closed civil legal cases in 2007-2016 from the Canadian Medical Protective Association (CMPA) involving specialist anesthesiologists where airway management was the central concern.

Methods

We included all airway-related civil legal cases involving specialist anesthesiologists that closed from 2007 to 2016. The following variables were abstracted by CMPA medical analysts: clinical context, peer expert opinions of contributing factors, and patient and legal outcomes.

Results

We found 46 of the 406 (11%) closed cases involving anesthesiologists to be airway-related. Twenty-six cases (57%) involved elective surgery and 31 patients (67%) were categorized as American Society of Anesthesiologists physical status III. Twenty-five cases (54%) occurred outside the operating room (e.g., postanesthesia care unit, intensive care unit, or other satellite locations). In 19 (42%) cases, there was at least one predictor of a difficult airway. Peer experts identified judgement failures in 30 cases (65%), most commonly inadequate airway evaluation. In 30 cases (65%), the patient died or had a permanent brain injury. The medicolegal outcome favoured the patient in 27 (59%) cases, with a median [interquartile range] payment of 422,845 [257,637-935,673] CAD.

Conclusions

Severe patient harm is common when airway management is the focus of a CMPA medicolegal complaint involving anesthesiologists. Patients were otherwise typically low risk cases presenting for elective surgery. Failure to assess or to change management based on the airway exam or encountered difficulty were the most common errors. Our findings support the continued need for adoption, adherence, and practice of guidelines for anticipated and unanticipated difficult airway management for every patient encounter.

The Incidence of Dental Fracturing in Electroconvulsive Therapy in Sweden

OBJECTIVES

One adverse effect of electroconvulsive therapy (ECT) is dental fracture; thus, a bite guard and muscle relaxants are used to prevent it. Earlier research reported varying rates of dental fracture, but there is no large-scale study on the incidence of dental fracture during ECT. This study aimed to examine the incidence of dental fracture during ECT and to investigate whether the incidence differs between different sexes, age groups, diagnosis groups, electrode placements, or number of treatment sessions.

METHODS

This register-based study used data from the Swedish national quality register for ECT. All hospitals offering ECT report to this register, and the coverage ratio is about 90%. All registered patients who started an ECT series between January 2012 and January 2019 were included in this study, with the data representing 16,681 individuals, 38,862 series, and 254,906 sessions.

RESULTS

Forty-six dental fractures were identified, giving an incidence of dental fracture of 0.2% per series, 0.02% per session, and 0.3% per individual. We did not find any significant associations between dental fracture rates and male or female populations, age, or different diagnosis groups, nor was there any significant difference between dental fracture rates and electrode placement. The mean number of treatments was significantly higher in the dental fracture group than in patients without dental fracture.

CONCLUSIONS

There is a minimal risk of dental fracture during ECT. Our findings, together with those of other studies, provide further motivation for the use of a bite guard and muscle relaxant.

Sternomental Distance Ratio as a Predictor of Difficult Laryngoscopy: A Prospective, Double-Blind Pilot Study

Background:

No single test has shown to be an accurate predictor of difficult laryngoscopy.

Aims:

This study aims to evaluate the effectiveness of the ratio of the sternomental distance (SMD) in neutral and full neck extension position SMD ratio (SMDR) as a predictor of difficult laryngoscopy and any need of assisted intubation.

Settings and Design:

Prospective, double-blind pilot study.

Materials and Methods:

This study included 221 consecutive adult patients scheduled to undergo elective surgery under general anesthesia. Physical and airway characteristics, SMDR, difficult laryngoscopy (using Cormack/Lehane [C/L] scale), and any kind of assisted intubation were assessed.

Statistical Analysis:

The optimal cutoff point for SMDR was identified using receiver operating characteristic (ROC) analysis. The association between SMDR and the intubation method was evaluated through multiple logistic regression analysis.

Results:

A SMDR below 1.55 led in 33% of the cases to assisted intubation and 33%–53% of C/L III–IV glottic views for McCoy and Macintosh blades, respectively. On the other hand, SMDR above 1.9 led to no C/L IV glottic views for both blades and 4% and 11% C/L III views glottic views for McCoy and Macintosh, respectively. The best sensitivity and specificity cutoff point as defined by the ROC curve was identified for an SMDR value of 1.7 (area[s] under the curve: 0.815; 95% confidence interval: 0.743–0.887). Assisted intubation rates were significantly higher in patients with an SMDR inferior to 1.7 (30.5% compared to 3.5%, P < 0.001).

Conclusions:

SMDR is a simple, objective, and easy to perform test. The present study indicates that SMDR may be helpful in predicting difficult laryngoscopy and assisted intubation.

Optimising remote site airway management kit dump using the SCRAM bag-a randomised controlled trial

Background

Emergency airway management may be required at any hospital location. Remote site management is associated with increased airway morbidity and mortality. Poor planning and interrupted workflow are significant contributors. Equipment may be unfamiliar, difficult to locate or inadequate.

The SCRAM (Structured CRitical Airway Management) bag aims to provide a portable, structured and reproducible approach to airway management preparation. We hypothesised that SCRAM bag use reduces equipment preparation time, the rate of error and operator cognitive load.

Methods

Fifty experienced anaesthetists were randomised into two groups and asked to prepare (kit dump) for and manage a simulated remote site difficult airway scenario. The control group (n = 25) used a standard resuscitation trolley while the experimental group used the SCRAM bag (n = 25). The primary outcome was time taken to kit dump completion (seconds). Secondary outcomes were the number of errors and self-reported difficulty (100 mm visual analogue scale).

Results

Using the SCRAM bag, a 29% reduction in kit dump time (111.7 ± 29.5 vs 156.7 ± 45.1, p = 0.0001) was noted. Participants using the SCRAM bag reported it to be less challenging to use (18.36 ± 16.4 mm vs 50.64 ± 22.9 mm, p < 0.001), and significantly fewer errors were noted (1 (IQR 1–3) vs 8 (IQR 5–9), p = 0.03) (87.5% reduction in the total number of errors).

Conclusion

The SCRAM bag facilitates a quicker, less challenging kit dump with significantly fewer errors. We propose that this would reduce delay to airway management, reduce cognitive load and provide an improved capability to manage anticipated and unanticipated airway events.

Implementation of an Anaesthesia Quality Improvement Programme to Reduce Fibreoptic Bronchoscope Repair Incidents

Background

This study was aimed at investigating the effectiveness of the implementation of a comprehensive quality improvement programme (QIP) for reducing the repair rate of the fibreoptic bronchoscope (FOB).

Methods

A three-stage improvement strategy was implemented between January 2013 and December 2016. Stage one is the acquisition of information on violations of practice guidelines, repair rate, cost of repair, and incidence of unavailability of FOB during anaesthesia induction of the previous year through auditing. Stage two is the implementation of a quality improvement campaign (QIC) based on the results of stage one. Stage three is the programme perpetuation through monitoring compliance with policy on FOB use by regular internal audits. The effectiveness was retrospectively analyzed on a yearly basis.

Results

The annual repair rate, repair cost, and incidence of FOB unavailability before the QIP implementation were 1%, 18,757 USD, and 1.4%, respectively. After QIC, the repair rate in 2013 dropped by 81% (from 1% in 2012 to 0.19% in 2013, p < 0.05). The annual repair cost fell by 32% from 18,758 USD (2012) to 12,820 USD (2013). Besides, the incidence of FOB unavailability plummeted by 71% from 1.4% to 0.4% during the same period. The annual repair rates and incidence of FOB unavailability remained lower in subsequent three years than those before QIP implementation.

Conclusion

Implementation of a quality improvement programme was effective for reducing the rate and cost of FOB repair as well as unavailability rate, highlighting its beneficial impact on cost-effectiveness and patient safety in a tertiary referral center setting.

Management of Difficult Tracheal Intubation: A Closed Claims Analysis

BACKGROUND

Difficult or failed intubation is a major contributor to morbidity for patients and liability for anesthesiologists. Updated difficult airway management guidelines and incorporation of new airway devices into practice may have affected patient outcomes. The authors therefore compared recent malpractice claims related to difficult tracheal intubation to older claims using the Anesthesia Closed Claims Project database.

METHODS

Claims with difficult tracheal intubation as the primary damaging event occurring in the years 2000 to 2012 (n = 102) were compared to difficult tracheal intubation claims from 1993 to 1999 (n = 93). Difficult intubation claims from 2000 to 2012 were evaluated for preoperative predictors and appropriateness of airway management.

RESULTS

Patients in 2000 to 2012 difficult intubation claims were sicker (78% American Society of Anesthesiologists [ASA] Physical Status III to V; n = 78 of 102) and had more emergency procedures (37%; n = 37 of 102) compared to patients in 1993 to 1999 claims (47% ASA Physical Status III to V; n = 36 of 93; P < 0.001 and 22% emergency; n = 19 of 93; P = 0.025). More difficult tracheal intubation events occurred in nonperioperative locations in 2000 to 2012 than 1993 to 1999 (23%; n = 23 of 102 vs. 10%; n = 10 of 93; P = 0.035). Outcomes differed between time periods (P < 0.001), with a higher proportion of death in 2000 to 2012 claims (73%; n = 74 of 102 vs. 42%; n = 39 of 93 in 1993 to 1999 claims; P < 0.001 adjusted for multiple testing). In 2000 to 2012 claims, preoperative predictors of difficult tracheal intubation were present in 76% (78 of 102). In the 97 claims with sufficient information for assessment, inappropriate airway management occurred in 73% (71 of 97; κ = 0.44 to 0.66). A "can't intubate, can't oxygenate" emergency occurred in 80 claims with delayed surgical airway in more than one third (39%; n = 31 of 80).

CONCLUSIONS

Outcomes remained poor in recent malpractice claims related to difficult tracheal intubation. Inadequate airway planning and judgment errors were contributors to patient harm. Our results emphasize the need to improve both practitioner skills and systems response when difficult or failed tracheal intubation is encountered.

Rescue supraglottic airway devices at caesarean delivery: What are the options to consider?

Tracheal intubation is considered the gold standard means of securing the airway in obstetric general anaesthesia because of the increased risk of aspiration. Obstetric failed intubation is relatively rare. Difficult airway guidelines recommend the use of a supraglottic airway device to maintain the airway and to allow rescue ventilation. Failed intubation is associated with a further increased risk of aspiration, therefore there is an argument for performing supraglottic airway-guided flexible bronchoscopic intubation (SAGFBI). The technique of SAGFBI has a high success rate in the non-obstetric population, it protects the airway and it minimises task fixation on repeated attempts at laryngoscopic tracheal intubation. However, after failed intubation via laryngoscopy, there is a lack of specific recommendations or indications for SAGFBI in current obstetric difficult airway guidelines in relation to achieving tracheal intubation. Our narrative review explores the issues pertaining to airway management in these cases: the use of supraglottic airway devices and the techniques of, and technical issues related to, SAGFBI. We also discuss the factors involved in the decision-making process as to whether to proceed with surgery with the airway maintained only with a supraglottic airway device, or to proceed only after SAGFBI.

An international multidisciplinary consensus statement on fasting before procedural sedation in adults and children

The multidisciplinary International Committee for the Advancement of Procedural Sedation presents the first fasting and aspiration prevention recommendations specific to procedural sedation, based on an extensive review of the literature. These were developed using Delphi methodology and assessment of the robustness of the available evidence. The literature evidence is clear that fasting, as currently practiced, often substantially exceeds recommended time thresholds and has known adverse consequences, for example, irritability, dehydration and hypoglycaemia. Fasting does not guarantee an empty stomach, and there is no observed association between aspiration and compliance with common fasting guidelines. The probability of clinically important aspiration during procedural sedation is negligible. In the post-1984 literature there are no published reports of aspiration-associated mortality in children, no reports of death in healthy adults (ASA physical status 1 or 2) and just nine reported deaths in adults of ASA physical status 3 or above. Current concerns about aspiration are out of proportion to the actual risk. Given the lower observed frequency of aspiration and mortality than during general anaesthesia, and the theoretical basis for assuming a lesser risk, fasting strategies in procedural sedation can reasonably be less restrictive. We present a consensus-derived algorithm in which each patient is first risk-stratified during their pre-sedation assessment, using evidence-based factors relating to patient characteristics, comorbidities, the nature of the procedure and the nature of the anticipated sedation technique. Graded fasting precautions for liquids and solids are then recommended for elective procedures based upon this categorisation of negligible, mild or moderate aspiration risk. This consensus statement can serve as a resource to practitioners and policymakers who perform and oversee procedural sedation in patients of all ages, worldwide.

Periprocedural pulmonary aspiration: An analysis of medical malpractice cases and alleged causative factors

RATIONALE AIMS AND OBJECTIVES

Pulmonary aspiration is a feared complication of anaesthesia that is associated with significant morbidity and mortality. Within the small existing body of literature on medical malpractice claims related to periprocedural aspiration, very little information is available regarding the case-specific factors that were alleged to contribute to each aspiration event.

METHODS

This study searched an extensive nationwide database of medical malpractice claims and identified 43 relating to periprocedural pulmonary aspiration.

RESULTS

The most common mechanism of causation cited in these claims (37%) was the failure to secure the airway with an endotracheal tube (ETT) when an elevated aspiration risk existed, most commonly because endotracheal intubation was not originally selected as part of the anaesthetic plan. The second most common alleged category of causation (33%) was the failure to perform a proper rapid-sequence induction and/or place a nasogastric tube (NGT) for decompression prior to induction. An equal amount of cases resulted in defendant versus plaintiff verdicts (44.2% each), while a settlement was reached in the remaining 11.6% of cases.

CONCLUSION

These findings are generalizable to clinical practice improvement on a broader scale. They demonstrate the need to develop reliable, high-sensitivity tests for detecting elevated risk before clinicians can be expected to take special steps to protect susceptible patients, and they also show that medical malpractice can be alleged because of failure to uphold currently accepted standards of care even when the published evidence for those standards is weak. This study demonstrates that careful review of medical malpractice litigation can elucidate common contributory factors and facilitate improvements in clinical practice and decision-making.

Dental injuries in relation to general anaesthesia-A retrospective study

BACKGROUND

Dental injuries may occur during general anaesthesia, especially during airway management. The aim of this study was to describe cases of dental injury related to general anaesthesia, focusing on the type and extent of the injuries as well as the timing of recognition.

METHOD

We reviewed the nationwide electronic database available at the Danish Patient Compensation Association and scrutinized all claims classified as possible dental injuries in relation to general anaesthesia between 2007 and 2017.

RESULTS

During the 10-year study period, there were 2523 claims for compensation related to anaesthesia. Of these, 552 (21.9%) were cases of possible dental injuries following general anaesthesia. The most commonly injured teeth were the central maxillary incisors with 174 (25.3%) cases related to the left and 118 (17.2%) cases related to the right incisor. The most common injuries were fractures (41.2%) and subluxations (25.9%). Airway management included the use of Macintosh laryngoscope in 296 (64.4%) cases and a supraglottic airway device in 69 (15%) cases. Claims were more frequently approved if more than two intubation attempts were used (100% vs 82.8%, RR = 0.83, 95% CI [0.78-0.88], P = 0.0037). Injuries recognized in-hospital were more frequently approved than injuries recognized after discharge (91.6% vs 70.7%, RR = 0.83, 95% CI [0.70-0.86], P < 0.0001).

CONCLUSION

The most commonly reported dental injury related to general anaesthesia in the Danish Patient Compensation Association database was a fracture. Claims were more frequently approved if more than two intubation attempts were used and if the injury was recognized in-hospital.

Smartphone Photographs to Document Preoperative Dental Examination

Dental injury is a common cause of malpractice claims involving anesthesiologists. Inadequate preoperative dental evaluations and incomplete documentation are often cited as contributing factors during reviews of closed claims. Point-of-care smartphone photographs are widely used in other medical fields such as dermatology and plastic surgery. We discuss the use of smartphone photographs for documenting preoperative dental examinations.

The Difficult Airway Trolley: A Narrative Review and Practical Guide

Death and severe morbidity attributable to anesthesia are commonly associated with failed difficult airway management. When an airway emergency develops, immediate access to difficult airway equipment is critical for implementation of rescue strategies. Previously, national expert consensus guidelines have provided only limited guidance for the design and setup of a difficult airway trolley. The overarching aim of the current work was to create a dedicated difficult airway trolley (for patients>12 years old) for use in anesthesia theatres, intensive care units, and emergency departments. A systematic literature search was performed, using the PubMed, Embase, and Google Scholar search engines. Based on evidence presented in 11 national or international guidelines, and peer-reviewed journals, we present and outline a difficult airway trolley organized to accommodate sequential progression through a four-step difficult airway algorithm. The contents of the top four drawers correspond to specific steps in the airway algorithm (A = intubation, B = oxygenation via a supraglottic airway device, C = facemask ventilation, and D = emergency invasive airway access). Additionally, specialized airway equipment may be included in the fifth drawer of the proposed difficult airway trolley, thus enabling widespread use. A logically designed, guideline-based difficult airway trolley is a vital resource for any clinician involved in airway management and may aid the adherence to difficult airway algorithms during evolving airway emergencies. Future research examining the availability of rescue airway devices in various clinical settings, and simulation studies comparing different types of difficult airway trolleys, are encouraged.

Pulmonary aspiration during procedural sedation: a comprehensive systematic review

Background

Although pulmonary aspiration complicating operative general anaesthesia has been extensively studied, little is known regarding aspiration during procedural sedation.

Methods

We performed a comprehensive, systematic review to identify and catalogue published instances of aspiration involving procedural sedation in patients of all ages. We sought to report descriptively the circumstances, nature, and outcomes of these events.

Results

Of 1249 records identified by our search, we found 35 articles describing one or more occurrences of pulmonary aspiration during procedural sedation. Of the 292 occurrences during gastrointestinal endoscopy, there were eight deaths. Of the 34 unique occurrences for procedures other than endoscopy, there was a single death in a moribund patient, full recovery in 31, and unknown recovery status in two. We found no occurrences of aspiration in non-fasted patients receiving procedures other than endoscopy.

Conclusions

This first systematic review of pulmonary aspiration during procedural sedation identified few occurrences outside of gastrointestinal endoscopy, with full recovery typical. Although diligent caution remains warranted, our data indicate that aspiration during procedural sedation appears rare, idiosyncratic, and typically benign.

[Management of the difficult airway : Overview of the current guidelines]

Several national airway task forces have recently updated their recommendations for the management of the difficult airway in adults. Routinely responding to airway difficulties with an algorithm-based strategy is consistently supported. The focus is increasingly not on tools and devices but more on good planning, preparation and communication. In the case of anticipated airway difficulties the airway should be secured when the patient is awake with maintenance of spontaneous ventilation. Unaltered a flexible bronchoscopic intubation technique is advised as a standard of care in such patients. The importance of maintenance of oxygenation is emphasized. Face mask ventilation and the use of supraglottic devices are recommended if unexpected airway difficulties occur. Face mask ventilation may be facilitated and optimised by early administration of neuromuscular blocking agents. If required, in not fastened patients threatened by acute hypoxia, carefully applied and pressure-controlled ventilation may ensure sufficient oxygenation until the airway is secured. Apnoeic oxygen techniques are recommended in high-risk patients and to relieve the time pressure of falling oxygen saturation during decision-making processes. The early use of video laryngoscopy is advised for endotracheal intubation in the case of failed direct laryngoscopy or if intubation is expected to be difficult. For the coverage of cannot intubate-cannot oxygenate scenarios, second generation supraglottic devices and invasive airway access are advocated. The discussion regarding the optimal technique for emergency invasive airway access is still in progress. In the case of uncontrollable respiratory deterioration and progressive hypoxia, the algorithm must be consistently executed and without delay due to ineffective activities (straightforward strategy). Although there is no evidence to support the selection of a particular approach, the importance and the need for a defined airway concept/algorithm in any anesthesia department is fostered. Simplicity and clarity are essential for recall under stressful and time-sensitive conditions. The algorithm should be adapted to local conditions and preferences and devices should be limited to a definite number. The acquisition and maintenance of expertise by education and training is demanded.

Impact of drug and equipment preparation on pre-hospital emergency Anaesthesia (PHEA) procedural time, error rate and cognitive load

BACKGROUND

We examined the effect of advanced preparation and organisation of equipment and drugs for Pre-hospital Emergency Anaesthesia (PHEA) and tracheal intubation on procedural time, error rates, and cognitive load.

METHODS

This study was a randomised, controlled experiment with a crossover design. Clinical teams (physician and paramedic) from the Emergency Medical Retrieval Service and the Scottish Air Ambulance Division were randomised to perform a standardised pre-hospital clinical simulation using either unprepared (standard practice) or pre-prepared (experimental method) PHEA equipment and drugs. Following a two-week washout period, each team performed the corresponding simulation. The primary outcome was intervention time. Secondary outcomes were safety-related incidents and errors, and degree of cognitive load.

RESULTS

In total 23 experiments were completed, 12 using experimental method and 11 using standard practice. Time required to perform PHEA using the experimental method was significantly shorter than with standard practice (11,45 versus 20:59) minutes: seconds; p = < 0.001). The experimental method also significantly reduced procedural errors (0 versus 9, p = 0.007) and the cognitive load experienced by the intubator assistant (41.9 versus 68.7 mm, p = 0.006).

CONCLUSIONS

Pre-preparation of PHEA equipment and drugs resulted in safer performance of PHEA and has the potential to reduce on-scene time by up to a third.

[Update Mallampati : Theoretical and practical knowledge of European anesthetists on basic evaluation of airways]

In 1985 Mallampati et al. published a non-invasive score for the evaluation of airways (Mallampati grading scale, MGS), which originally consisted of only three different classes and has been modified several times. At present it is mostly used in the version of Samsoon and Young consisting of four different classes. Class I: soft palate, fauces, uvula, palatopharyngeal arch visible, class II: soft palate, fauces, uvula visible, class III: soft palate, base of the uvula visible and class IV: soft palate not visible. Nevertheless, other versions of MGS still exist, each having different values for sensitivity and specification. The current opinion is therefore that MGS is no longer useful as a stand-alone predictor but in combination with others it is still part of today's most relevant guidelines, such as those of the American Society of Anesthesiologists (ASA), the UK's Difficult Airway Society (DAS), the European Society of Anaesthesiology (ESA) and the German Society for Anesthesiology and Intensive Care Medicine (DGAI) and must therefore be known by anesthetists. Even in times of sophisticated tools for airway management, the procedure remains a high risk, so every anesthetist has to be prepared for and well trained in management of known and unexpected difficult airways. Evaluation of the patient's airway is a part of modern airway management to prevent problems and reduce risk of hypoxia during the procedure. The theoretical knowledge and practical skills of European anesthetists were evaluated at two international congresses, the German Anesthesia Congress (DAC) and Euroanaesthesia 2014. The DAC is an annual meeting of German speaking anesthetists, hosted by the DGAI. The Euroanaesthesia is the annual European pendant hosted by the ESA. Participation was voluntary and only physicians were allowed to take part. Theory was evaluated by a questionnaire containing open and closed questions for MGS that had to be answered by every participant alone. Apart from theory, a practical evaluation was performed. Every participant had to classify the MGS of a human airway model. The model was identical on both congresses. According to the original publication a checklist containing the factors essential for the correct performance was filled out by a supervising experienced anesthetist. During DAC 2014 n = 267 physicians participated in the study, 22 participants were excluded due to inconsistent answers, incomplete questionnaires or missing practical part. A total of 245 data sets were evaluated. During Euroanaesthesia 2014 n = 298 physicians participated in the study, 68 participants were excluded due to inconsistent answers, incomplete questionnaires or missing practical part and 230 data sets were evaluated. At the DAC the mean age (± SD) was 44.5 ± 9.5 years, 157 (64.1%) were male and 88 (35.9%) were female. Working experience was trainee anesthetist in 16.7% and other participants were experienced anesthetists. At the ESA the mean age (± SD) was 42.4 ± 9.5 years, 133 (57.8%) were male and 97 (42.2%) female. Trainee anesthetists were 15.2%, the rest were experienced anesthetists. The DAC participants knew Mallampati classes 1 (65%) and 4 (45%) better than 2 and 3 and there was no relevant differences to the ESA (close to 30% knew the classes 1-4 here). Classification of the airway model was correct in 62% and 67% at DAC and ESA, respectively. Most participants performed the practical evaluation correctly except the sitting position of the model. In agreement with earlier studies, these results show the lack of knowledge in evaluation of airways according to current guidelines of all relevant societies. This is likely to increase preventable risks for patients as unexpected difficult airway management increases the risk for hypoxia and intubation damage.

Do Difficult Airway Techniques Predispose Obese Patients to Bronchospasm?

Objective

The existing evidence separately correlates morbid obesity with difficult intubation and bronchospasm. However, there is a lack of data on whether anaesthesia provider manipulations during difficult intubation contribute to an increased ratio of bronchospasm in these patients.

Methods

This is a retrospective analysis of data prospectively taken from 50 morbidly obese patients involved in a previously published study. A possible difficult intubation was preoperatively investigated by recording the following specific physical examination indices: Mallampati and Cormack-Lehane (CL) classifications, cervical spine mobility (CSM), thyromental distance (Td) and patients' ability to open their mouth (mouth opening). Bronchospasm was clinically detected by auscultation and confirmed by measuring peak airway pressures during mechanical ventilation. The Kruskal-Wallis H test was used for data analysis, followed by the Mann-Whitney U test as applicable.

Results

Different physical examination prognostic indices, including Mallampati and CL scales (p<0.001; the CSM excluded -p=0.790), showed that they are related to difficult intubation. Bronchospasm not attributable to difficult intubation was observed in six obese patients.

Conclusion

Patients with morbid obesity constitute an increased relative risk group as far as difficult intubation is concerned, particularly if preoperative findings support a relationship between the two variables examined. In our study, difficult intubation and the concomitant use of special equipment and manipulations did not contribute to an increased rate of bronchospasm in obese patients, but in view of the lack of data, a large number of more sophisticated studies are required to elucidate such an assumption.

Thyromental distance ("Patil") revisited : Knowledge and performance of a basic airway screening tool among European anesthetists

Predicting and managing the difficult airway is a lifesaving and vital basic task for the anesthetist. Current guidelines of all important societies include thyromental distance (TMD, "Patil") as a possible predictor for a difficult airway and includes two important aspects for airway management: the mandibular space and the flexibility of the cervical spine. We evaluated knowledge and execution regarding TMD for predicting a difficult airway on participants at the Euroanaesthesia (ESA) congress and German Anaesthesia Congress (DAC) in 2014. Our evaluation consisted of a theoretical part with questions regarding general knowledge and a practical evaluation with anesthetists performing on a human airway model. Practical evaluations were performed separately from other participants. During the DAC 245 (ESA 230) physicians participated, of which 64% were male (ESA 58%). At the DAC 182 (74.3%) and ESA 82 (35.6%) participants knew about Patil/TMD. Its use as a predictive score for a difficult airway was known by 122 (49.8%; DAC) and 79 (34.4%; ESA) participants. The correct definition for intubation was given by 45 (25.7%) at the DAC and 56 (24.3%) at ESA. Only 40-41% of the participants measured the correct distance for TMD. Only 6.1-6.5% completed both the theoretical and practical parts correctly. As non-invasive TMD includes two different aspects of patient airways and is part of current guidelines, education and training must be extended to assure adequate evaluation in the future.

Are physician assistant and patient airway assessments reliable compared to anesthesiologist assessments in detecting difficult airways in general surgical patients?

Background

Airway management remains one of the most important responsibilities of anesthesiologists. Prediction of difficult airway allows time for proper selection of equipment, technique, and personnel experienced in managing patients with difficult airway. Face to face preoperative anesthesia interviews are difficult to conduct as they necessitate patients traveling to the clinics, and, in practice, are usually conducted in the morning of the procedure by the anesthesiologist, when identification of predictors of difficult intubation may lead to schedule delays or case cancelations. We hypothesized that an airway assessment tool could be used by patients or physician assistants to accurately assess their airways.

Methods

We administered an airway assessment tool, which had been constructed in consultation with a psychometrician and revised after non-medical layperson feedback, to 215 patients presenting to the preoperative clinic for evaluation. Separately, patients had the airway exam performed by a physician assistant and an anesthesiologist. Agreement was compared using kappa.

Results

We found good agreement between observers only on "can you put three fingers in your mouth?" (three-way kappa = .733, p < 0.001) and poor agreement on Mallampati classification (three-way kappa = .195, p < 0.001) and "Can you fit three fingers between your chin and your Adam's Apple?" (three-way kappa = .216, p < 0.001). The agreements for the other questions were mostly fair. Agreements between patients and anesthesiologists were similar to those between physician assistants and anesthesiologists.

Conclusions

Neither the patients' self-assessments nor the physician assistants' assessments were adequate to substitute for the anesthesiologists' airway assessments.

Tracheal extubation with suction vs. positive pressure during emergence from general anaesthesia in adults: A randomised controlled trial

BACKGROUND

After general anaesthesia (GA) in adults, the optimal tracheal extubation technique (positive pressure or suctioning) remains debated. The primary endpoint of this study was to assess the effects of these techniques on onset time of desaturation (SpO₂<92%).

METHODS

Sixty-nine patients with a body mass index<30 scheduled for elective orthopaedic surgery were allocated to positive pressure (PP) or suctioning (SUC) group. GA was standardised with propofol and remifentanil via target-controlled infusion. A morphine bolus of 0.15mg/kg was administered 20-30mins before the end of surgery. The effect of extubation technique on onset time of desaturation (T92) was assessed during the first 10mins after extubation during the spontaneous air breathing. Secondary endpoints included: frequency of desaturation, respiratory complications, need to use oxygen therapy and SpO₂ at the end of the first hour while breathing in air (ClinicalTrials.gov identifier: NCT01323049).

RESULTS

Baseline patient characteristics and intraoperative management data for the 68 patients included had no relevant clinical difference between groups. T92 (sec) after tracheal extubation was 214 (168) vs. 248 (148) in the PP and SUC groups, respectively (P=0.44). In the PP and SUC groups, 50 and 43% reached a SpO₂<92% within the first 10mins after extubation respectively (P=0.73). There were no statistically significant differences between groups for any secondary endpoints.

CONCLUSIONS

Positive pressure extubation as compared with suctioning extubation did not seem to delay onset time of desaturation after GA in standard weight adult patients.