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Roach VA, Traina DJ, Hananel DM, Speich JR, Norfleet JE, Sweet RM. Endotracheal Intubation Performance in Novices: Comparing the Training Effect Resulting From Two Airway Management Training Simulators. Mil Med 2024; 189:431-438. [PMID: 39160866 DOI: 10.1093/milmed/usae148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 01/26/2024] [Accepted: 03/15/2024] [Indexed: 08/21/2024] Open
Abstract
INTRODUCTION Between 2011 and 2014, the Combat Casualty Training Consortium research study sought to evaluate all aspects of combat casualty care, including mortality, with a special focus on the incidence and causes of potentially preventable deaths among American combat fatalities. This study identified a major training gap in critical airway management. Because of the high rate of morbidity and mortality associated with poor or incorrect airway management, an effort to address this training gap was necessary. MATERIALS AND METHODS This experiment compared the training using the Advanced Joint Airway Management System, a novel high-fidelity airway simulator, relative to one of the most utilized simulators for endotracheal intubation (ETI) via a parallel group randomized control trial design. Before training, participants (n = 19) attempted an ETI on a cadaver using direct laryngoscopy. Performance during the attempt was recorded and scored by trained blinded raters. Participants were then randomly allocated to either novel or conventional training. Post-training, participants completed a second ETI under the same parameters. Analysis was completed via 2 × 2 mixed analysis of variance for (1) ETI Score, (2) Errors, (3) Critical Failures, and (4) Duration, across both the pre- and post-training tests and between the two groups. RESULTS A priori power analysis required a total sample size of 84 participants in this experimental design. Consequently, this study is under-powered to reach statistical significance. Scores for all trainees did improve with training, yet analyses did not reveal a difference in overall ETI score between the novel and conventional training group, at baseline or at the post-training test (P = .249). CONCLUSION The Advanced Joint Airway Management System simulator presents a training effect that is comparable to the conventional training model. However, given this study's small sample size, these results must be considered preliminary and further research is merited to draw firm conclusions about its impact on trainee performance. Future studies engaging larger cohorts of trainees and exploring the other capabilities of the Advanced Joint Airway Management System (cricothyroidotomy, needle chess decompression) are needed to further examine the educational potential of this novel airway management training system.
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Affiliation(s)
- Victoria A Roach
- Center for Research in Educational and Simulation Technologies, Division of Healthcare Simulation Science, UW Medicine, University of Washington, Seattle, WA 98195-6410, USA
| | - David J Traina
- Center for Research in Educational and Simulation Technologies, Division of Healthcare Simulation Science, UW Medicine, University of Washington, Seattle, WA 98195-6410, USA
| | - David M Hananel
- Center for Research in Educational and Simulation Technologies, Division of Healthcare Simulation Science, UW Medicine, University of Washington, Seattle, WA 98195-6410, USA
| | - Jason R Speich
- Center for Research in Educational and Simulation Technologies, Division of Healthcare Simulation Science, UW Medicine, University of Washington, Seattle, WA 98195-6410, USA
| | - Jack E Norfleet
- Medical Simulation Research Branch, SFC Paul Ray Smith Simulation and Training Technology Center, U.S Army DEVCOM-SC-SED-STTC, Orlando, FL 32826-3276, USA
| | - Robert M Sweet
- Center for Research in Educational and Simulation Technologies, Division of Healthcare Simulation Science, UW Medicine, University of Washington, Seattle, WA 98195-6410, USA
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2
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Chin KW, Smith AF. Choice of airway device and the incidence and severity of postoperative pulmonary complications in older patients. Anaesthesia 2023; 78:1191-1194. [PMID: 37345266 DOI: 10.1111/anae.16077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/08/2023] [Indexed: 06/23/2023]
Affiliation(s)
- K W Chin
- Department of Anaesthesia, Royal Lancaster Infirmary, Lancaster, UK
| | - A F Smith
- Department of Anaesthesia, Royal Lancaster Infirmary, Lancaster, UK
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3
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Cumberworth A, Lewith H, Sud A, Jefferson H, Athanassoglou V, Pandit JJ. Major complications of airway management: a prospective multicentre observational study. Anaesthesia 2022; 77:640-648. [PMID: 35254669 DOI: 10.1111/anae.15668] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/30/2021] [Indexed: 12/12/2022]
Abstract
We conducted an observational study of serious airway complications, using similar methods to the fourth UK National Audit Project (NAP4) over a period of 1 year across four hospitals in one region in the UK. We also conducted an activity survey over a week, using NAP4 methods to yield an estimate for relevant denominators to help interpret the primary data. There were 17 serious airway complications, defined as: failed airway management leading to cancellation of surgery (eight); airway management in recovery (five); unplanned intensive care admission (three); and unplanned emergency front of neck access (one). There were no reports of death or brain damage. This was an estimate of 0.028% (1 in 3600) complications using the denominator of 61,000 general anaesthetics per year in the region. Complications in patients with 'predicted easy' airways were rare (approximately 1 in 14,200), but 45 times more common in those with 'predicted difficult' airways (approximately 1 in 315). Airway management in both groups was similar (induction of anaesthesia followed by supraglottic airway or tracheal tube). Use of awake/sedation intubation, videolaryngoscopy and high-flow nasal oxygenation were uncommon even in the predicted difficult airway patients (in 2.7%, 32.4% and 9.5% of patients, respectively). We conclude that the incidence of serious airway complications is at least as high as it was during NAP4. Despite airway prediction being used, this is not informing subsequent management.
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Affiliation(s)
- A Cumberworth
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - H Lewith
- Department of Anaesthetics, Kingston Hospital NHS Foundation Trust, Kingston, UK
| | - A Sud
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - H Jefferson
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - V Athanassoglou
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - J J Pandit
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Foundation Trust, Oxford, UK.,University of Oxford, Oxford, UK
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4
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Affiliation(s)
- Thomas Heidegger
- From the Department of Anesthesia, Spital Grabs, Grabs, and the Department of Anesthesiology and Pain Medicine, Bern University Hospital, University of Bern, Bern - both in Switzerland; and the Private University of the Principality of Liechtenstein, Triesen, Liechtenstein
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5
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Endlich Y, Beckmann LA, Choi SW, Culwick MD. A prospective six-month audit of airway incidents during anaesthesia in twelve tertiary level hospitals across Australia and New Zealand. Anaesth Intensive Care 2020; 48:389-398. [PMID: 33104443 DOI: 10.1177/0310057x20945325] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
This audit of airway incidents was conducted over six months in 12 tertiary level hospitals across Australia and New Zealand. During that time, 131,233 patients had airway management and 111 reports were submitted (incidence 0.08%). The airway incidents included a combination of difficult airway management (83), oxygen desaturation (58), aspiration (19), regurgitation (14), laryngospasm (16), airway bleeding (10), bronchospasm (5) and dental injury (4), which gave a total of 209 events in 111 reports. Most incidents occurred during general anaesthesia (GA; 83.8%) and normal working hours (81.1%). Forty-three percent were associated with head and neck surgery and 12.6% with upper abdominal procedures. Of these patients, 52% required further medical treatment or additional procedures and 16.2% required unplanned admission to an intensive care unit or a high dependency unit. A total of 31.5% of patients suffered from temporary harm and 1.8% from permanent harm. There was one death. The factors associated with a high relative risk (RR) of an airway incident included American Society of Anesthesiologists Physical Status (ASA PS) (ASA PS 2 versus 1, RR 1.75; ASA PS 3 versus 1, RR 3.56; ASA PS 4 versus 1, RR 6.1), and emergency surgery (RR 2.16 compared with elective). Sedation and monitored anaesthesia care were associated with lower RRs (RR 0.49 and RR 0.73 versus GA, respectively). Inadequate airway assessment, poor judgement and poor planning appeared to be contributors to these events. Future teaching and research should focus on these areas to further improve airway management and patient safety.
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Affiliation(s)
- Yasmin Endlich
- Department of Anaesthesia, University of Adelaide, Adelaide, Australia
| | - Linda A Beckmann
- Department of Anaesthesia, University of Queensland, Brisbane, Australia
| | - Siu-Wai Choi
- Department of Oral and Maxillofacial Surgery, University of Hong Kong, Hong Kong SAR
| | - Martin D Culwick
- Department of Anaesthesia, Royal Brisbane and Women's Hospital, Brisbane, Australia.,The Australian and New Zealand Tripartite Anaesthetic Data Committee
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6
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Heidegger T. Airway management lessons from case reports of negative outcomes. Comment on Br J Anaesth; 125: e168-70. Br J Anaesth 2020; 125:e307-e309. [PMID: 32680606 PMCID: PMC7328571 DOI: 10.1016/j.bja.2020.06.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2020] [Revised: 06/15/2020] [Accepted: 06/16/2020] [Indexed: 11/26/2022] Open
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7
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An Anesthesiologist's Perspective on the History of Basic Airway Management: The "Modern" Era, 1960 to Present. Anesthesiology 2019; 130:686-711. [PMID: 30829659 DOI: 10.1097/aln.0000000000002646] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This fourth and last installment of my history of basic airway management discusses the current (i.e., "modern") era of anesthesia and resuscitation, from 1960 to the present. These years were notable for the implementation of intermittent positive pressure ventilation inside and outside the operating room. Basic airway management in cardiopulmonary resuscitation (i.e., expired air ventilation) was de-emphasized, as the "A-B-C" (airway-breathing-circulation) protocol was replaced with the "C-A-B" (circulation-airway-breathing) intervention sequence. Basic airway management in the operating room (i.e., face-mask ventilation) lost its predominant position to advanced airway management, as balanced anesthesia replaced inhalation anesthesia. The one-hand, generic face-mask ventilation technique was inherited from the progressive era. In the new context of providing intermittent positive pressure ventilation, the generic technique generated an underpowered grip with a less effective seal and an unspecified airway maneuver. The significant advancement that had been made in understanding the pathophysiology of upper airway obstruction was thus poorly translated into practice. In contrast to consistent progress in advanced airway management, progress in basic airway techniques and devices stagnated.
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8
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Doshi D, McCarthy S, Mowatt E, Cahill A, Peirce B, Hawking G, Osborne R, Hibble B, Ebbs K. Review article: Critical Care Airway Management eLearning modules. Emerg Med Australas 2017; 30:743-748. [PMID: 29145705 DOI: 10.1111/1742-6723.12902] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Revised: 09/11/2017] [Accepted: 10/15/2017] [Indexed: 11/29/2022]
Abstract
The Australasian College for Emergency Medicine (ACEM) has recently launched the Critical Care Airway Management eLearning modules to support emergency medicine trainees in developing their airway management skills in the ED. A team of emergency physicians and trainees worked collaboratively to develop the eLearning resources ensuring extensive stakeholder consultation. A comprehensive resource manual was written to provide learners with knowledge that underpins the modules. ACEM provided project coordination as well as administrative and technical team support to the production. Although specifically developed with early ACEM trainees in mind, it is envisaged the resources will be useful for all emergency clinicians. The project was funded by the Australian Commonwealth Department of Health.
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Affiliation(s)
- Deepak Doshi
- Medical Services, Rockhampton Hospital, Rockhampton, Queensland, Australia
| | - Sally McCarthy
- Prince of Wales Hospital, Sydney, New South Wales, Australia.,Faculty of Medicine, The University of New South Wales, Sydney, New South Wales, Australia
| | | | - Angela Cahill
- Australasian College for Emergency Medicine, Melbourne, Victoria, Australia
| | - Bronwyn Peirce
- Bunbury Regional Hospital, Bunbury, Western Australia, Australia.,Rural Clinical School of Western Australia, The University of Western Australia, Bunbury, Western Australia, Australia
| | - Geoff Hawking
- Bunbury Regional Hospital, Bunbury, Western Australia, Australia.,The University of Western Australia, Bunbury, Western Australia, Australia
| | - Ruth Osborne
- Austin Health, Melbourne, Victoria, Australia.,The University of Melbourne, Melbourne, Victoria, Australia
| | - Belinda Hibble
- University Hospital Geelong and St John of God (Geelong) Hospital, Geelong, Victoria, Australia.,Deakin University, Geelong, Victoria, Australia
| | - Katharine Ebbs
- Australasian College for Emergency Medicine, Melbourne, Victoria, Australia
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9
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Pandit JJ, Heidegger T. Putting the ‘point’ back into the ritual: a binary approach to difficult airway prediction. Anaesthesia 2016; 72:283-288. [DOI: 10.1111/anae.13720] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- J. J. Pandit
- Department of Anaesthesia; Oxford University Hospitals; Oxford UK
- St John's College; Oxford UK
| | - T. Heidegger
- Spitalregion Rheintal Werdenberg Sarganserland; Grabs Switzerland
- University of Bern; Bern Switzerland
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10
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Harvey R, Foulds L, Housden T, Bennett KA, Falzon D, McNarry AF, Graham C. The impact of didactic read-aloud action cards on the performance of cannula cricothyroidotomy in a simulated ‘can't intubate can't oxygenate’ scenario. Anaesthesia 2016; 72:343-349. [DOI: 10.1111/anae.13643] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2016] [Indexed: 12/31/2022]
Affiliation(s)
- R. Harvey
- Department of Anaesthesia; Borders General Hospital; Melrose UK
| | - L. Foulds
- Department of Anaesthesia; Ninewell's Hospital; Dundee UK
| | - T. Housden
- Department of Anaesthesia; St John's Hospital; NHS Lothian; Livingston UK
| | - K. A. Bennett
- Department of Anaesthesia; Wishaw General Hospital; Wishaw UK
| | - D. Falzon
- Department of Anaesthesia; Edinburgh Royal Infirmary; NHS Lothian; Edinburgh UK
| | - A. F. McNarry
- Departments of Anaesthesia; The Western General and St John's Hospital; NHS Lothian; Edinburgh UK
| | - C. Graham
- Epidemiology and Statistics Core; Wellcome Trust Clinical Research Facility; University of Edinburgh; Edinburgh UK
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11
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Lindkaer Jensen NH, Cook TM, Kelly FE. A national survey of practical airway training in UK anaesthetic departments. Time for a national policy? Anaesthesia 2016; 71:1273-1279. [DOI: 10.1111/anae.13567] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/18/2016] [Indexed: 12/26/2022]
Affiliation(s)
- N. H. Lindkaer Jensen
- Department of Anaesthesia and Intensive Care Medicine; Royal United Hospital; Bath UK
| | - T. M. Cook
- Department of Anaesthesia and Intensive Care Medicine; Royal United Hospital; Bath UK
| | - F. E. Kelly
- Department of Anaesthesia and Intensive Care Medicine; Royal United Hospital; Bath UK
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12
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13
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14
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Pandit JJ, Marshall SD. The 2015 Difficult Airway Society guidelines: what about the anticipated difficult airway? A reply. Anaesthesia 2016; 71:468-9. [DOI: 10.1111/anae.13444] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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15
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YanHong R, Ihra GC, Gore C. Determination of gas flow through airway exchange catheters: measured and calculated values and dependence on pressure and entrainment. Anaesthesia 2015; 70:1073-8. [PMID: 25959305 DOI: 10.1111/anae.13109] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/20/2015] [Indexed: 12/17/2022]
Abstract
Serious complications have been described during oxygenation of patients with airway exchange catheters, due to catheter malpositioning, accidentally applied high airway pressures or high delivered volumes. In this in-vitro study, we analysed gas flow through various airway exchange catheters and described its dependence on driving pressure and entrainment. We applied driving pressures between 0.5 and 2.5 bar and observed maximal flow rates of 3.6 l.s(-1) . Measured gas flow values differed significantly from values calculated according to the Hagen-Poiseuille equation. Although flow restriction in ventilators and small-bore connectors will limit gas flow, large gas volumes may be unintentionally applied via the airway exchange catheters, leading to serious complications.
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Affiliation(s)
- R YanHong
- Department of Pulmonary and Critical Care Medicine, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - G C Ihra
- Department of Anaesthesiology, General Intensive Care Medicine and Pain Therapy, Medical University Vienna, Vienna, Austria
| | - C Gore
- Department of Anaesthesia, Intensive Care and Pain, Imperial College Healthcare NHS Trust, London, UK
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16
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Fitzgerald E, Hodzovic I, Smith AF. ‘From darkness into light’: time to make awake intubation with videolaryngoscopy the primary technique for an anticipated difficult airway? Anaesthesia 2015; 70:387-92. [DOI: 10.1111/anae.13042] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- E. Fitzgerald
- Anaesthetics & Intensive Care Medicine; Wessex Deanery UK
| | - I. Hodzovic
- Department of Anaesthetics, Intensive Care and Pain Medicine; Cardiff University; Cardiff UK
- Aneurin Bevan University Health Board; Newport UK
| | - A. F. Smith
- Department of Anaesthesia; Royal Lancaster Infirmary/Lancaster University; Lancaster UK
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17
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Pandit JJ, Andrade J, Bogod DG, Hitchman JM, Jonker WR, Lucas N, Mackay JH, Nimmo AF, O'Connor K, O'Sullivan EP, Paul RG, Palmer JHM, Plaat F, Radcliffe JJ, Sury MRJ, Torevell HE, Wang M, Hainsworth J, Cook TM. The 5th National Audit Project (NAP5) on accidental awareness during general anaesthesia: summary of main findings and risk factors. Anaesthesia 2014; 69:1089-101. [PMID: 25204236 DOI: 10.1111/anae.12826] [Citation(s) in RCA: 112] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/15/2014] [Indexed: 12/17/2022]
Abstract
We present the main findings of the 5th National Audit Project on accidental awareness during general anaesthesia. Incidences were estimated using reports of accidental awareness as the numerator, and a parallel national anaesthetic activity survey to provide denominator data. The incidence of certain/probable and possible accidental awareness cases was ~1:19 600 anaesthetics (95% CI 1:16 700-23 450). However, there was considerable variation across subtypes of techniques or subspecialties. The incidence with neuromuscular blockade was ~1:8200 (1:7030-9700), and without it was ~1:135 900 (1:78 600-299 000). The cases of accidental awareness during general anaesthesia reported to 5th National Audit Project were overwhelmingly cases of unintended awareness during neuromuscular blockade. The incidence of accidental awareness during caesarean section was ~1:670 (1:380-1300). Two thirds (82, 66%) of cases of accidental awareness experiences arose in the dynamic phases of anaesthesia, namely induction of and emergence from anaesthesia. During induction of anaesthesia, contributory factors included: use of thiopental; rapid sequence induction; obesity; difficult airway management; neuromuscular blockade; and interruptions of anaesthetic delivery during movement from anaesthetic room to theatre. During emergence from anaesthesia, residual paralysis was perceived by patients as accidental awareness, and commonly related to a failure to ensure full return of motor capacity. One third (43, 33%) of accidental awareness events arose during the maintenance phase of anaesthesia, most due to problems at induction or towards the end of anaesthesia. Factors increasing the risk of accidental awareness included: female sex; age (younger adults, but not children); obesity; anaesthetist seniority (junior trainees); previous awareness; out-of-hours operating; emergencies; type of surgery (obstetric, cardiac, thoracic); and use of neuromuscular blockade. The following factors were not risk factors for accidental awareness: ASA physical status; race; and use or omission of nitrous oxide. We recommend that an anaesthetic checklist, to be an integral part of the World Health Organization Safer Surgery checklist, is introduced as an aid to preventing accidental awareness. This paper is a shortened version describing the main findings from 5th National Audit Project - the full report can be found at http://www.nationalauditprojects.org.uk/NAP5_home#pt.
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Affiliation(s)
- J J Pandit
- Nuffield Department of Anaesthesia, Oxford University Hospitals NHS Trust, Oxford, UK
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18
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Pandit JJ, Andrade J, Bogod DG, Hitchman JM, Jonker WR, Lucas N, Mackay JH, Nimmo AF, O'Connor K, O'Sullivan EP, Paul RG, Palmer JHMG, Plaat F, Radcliffe JJ, Sury MRJ, Torevell HE, Wang M, Hainsworth J, Cook TM. 5th National Audit Project (NAP5) on accidental awareness during general anaesthesia: summary of main findings and risk factors. Br J Anaesth 2014; 113:549-59. [PMID: 25204697 DOI: 10.1093/bja/aeu313] [Citation(s) in RCA: 267] [Impact Index Per Article: 26.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
We present the main findings of the 5th National Audit Project (NAP5) on accidental awareness during general anaesthesia (AAGA). Incidences were estimated using reports of accidental awareness as the numerator, and a parallel national anaesthetic activity survey to provide denominator data. The incidence of certain/probable and possible accidental awareness cases was ~1:19,600 anaesthetics (95% confidence interval 1:16,700-23,450). However, there was considerable variation across subtypes of techniques or subspecialities. The incidence with neuromuscular block (NMB) was ~1:8200 (1:7030-9700), and without, it was ~1:135,900 (1:78,600-299,000). The cases of AAGA reported to NAP5 were overwhelmingly cases of unintended awareness during NMB. The incidence of accidental awareness during Caesarean section was ~1:670 (1:380-1300). Two-thirds (82, 66%) of cases of accidental awareness experiences arose in the dynamic phases of anaesthesia, namely induction of and emergence from anaesthesia. During induction of anaesthesia, contributory factors included: use of thiopental, rapid sequence induction, obesity, difficult airway management, NMB, and interruptions of anaesthetic delivery during movement from anaesthetic room to theatre. During emergence from anaesthesia, residual paralysis was perceived by patients as accidental awareness, and commonly related to a failure to ensure full return of motor capacity. One-third (43, 33%) of accidental awareness events arose during the maintenance phase of anaesthesia, mostly due to problems at induction or towards the end of anaesthesia. Factors increasing the risk of accidental awareness included: female sex, age (younger adults, but not children), obesity, anaesthetist seniority (junior trainees), previous awareness, out-of-hours operating, emergencies, type of surgery (obstetric, cardiac, thoracic), and use of NMB. The following factors were not risk factors for accidental awareness: ASA physical status, race, and use or omission of nitrous oxide. We recommend that an anaesthetic checklist, to be an integral part of the World Health Organization Safer Surgery checklist, is introduced as an aid to preventing accidental awareness. This paper is a shortened version describing the main findings from NAP5--the full report can be found at http://www.nationalauditprojects.org.uk/NAP5_home.
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Affiliation(s)
- J J Pandit
- Nuffield Department of Anaesthetics, Oxford University Hospitals NHS Trust, Oxford, UK
| | - J Andrade
- Department of Psychology, School of Psychology and Cognition Institute, Plymouth University, Plymouth, UK
| | - D G Bogod
- Department of Anaesthesia, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - J M Hitchman
- Member Royal College of Anaesthetists' Lay Committee, London, UK
| | - W R Jonker
- Department of Anaesthesia, Intensive Care and Pain Medicine, Sligo Regional Hospital, Sligo, Ireland
| | - N Lucas
- Department of Anaesthesia, Northwick Park Hospital, Harrow, Middlesex, UK
| | - J H Mackay
- Department of Anaesthesia, Papworth Hospital, Cambridge, UK
| | - A F Nimmo
- Department of Anaesthesia, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - K O'Connor
- Bristol School of Anaesthesia, Bristol, UK
| | - E P O'Sullivan
- Department of Anaesthesia, St James Hospital, James Street, Dublin, Ireland
| | - R G Paul
- Adult Intensive Care Unit, Royal Brompton Hospital, London, UK
| | - J H M G Palmer
- Department of Anaesthesia, Salford Royal Hospital, Salford, UK
| | - F Plaat
- Department of Anaesthesia, Imperial College NHS Trust, London, UK
| | - J J Radcliffe
- Department of Neuroanaesthesia, National Hospital for Neurology and Neurosurgery, Queen Square, UK
| | - M R J Sury
- Department of Anaesthesia, Great Ormond Street Hospital NHS Foundation Trust, London, UK
| | - H E Torevell
- Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - M Wang
- University of Leicester, Leicester, UK
| | - J Hainsworth
- Leicestershire Partnership NHS Trust, Leicester, UK
| | - T M Cook
- Department of Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, UK
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Marshall SD, Mehra R. The effects of a displayed cognitive aid on non-technical skills in a simulated ‘can't intubate, can't oxygenate’ crisis. Anaesthesia 2014; 69:669-77. [DOI: 10.1111/anae.12601] [Citation(s) in RCA: 83] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/06/2013] [Indexed: 01/22/2023]
Affiliation(s)
- S. D. Marshall
- University of Queensland Cognitive Engineering Research Group; Brisbane Queensland Australia
- Monash University Academic Board of Anaesthesia and Perioperative Medicine; Melbourne Victoria Australia
- Monash Simulation; Monash Health; Melbourne Victoria Australia
| | - R. Mehra
- Monash University Academic Board of Anaesthesia and Perioperative Medicine; Melbourne Victoria Australia
- Alfred Hospital; Alfred Health; Melbourne Victoria Australia
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20
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Flin R, Fioratou E, Frerk C, Trotter C, Cook TM. Human factors in the development of complications of airway management: preliminary evaluation of an interview tool. Anaesthesia 2013; 68:817-25. [DOI: 10.1111/anae.12253] [Citation(s) in RCA: 83] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/01/2013] [Indexed: 12/17/2022]
Affiliation(s)
- R. Flin
- School of Psychology; University of Aberdeen; Aberdeen; UK
| | - E. Fioratou
- MATCH, Faculty of Engineering; University of Nottingham; Nottingham; UK
| | - C. Frerk
- Department of Anaesthesia; Northampton General Hospital; Northampton; UK
| | - C. Trotter
- Department of Anaesthesia; Aberdeen Royal Infirmary; Aberdeen; UK
| | - T. M. Cook
- Department of Anaesthesia; Royal United Hospital; Bath; UK
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van Zundert TCRV, Brimacombe JR, Ferson DZ, Bacon DR, Wilkinson DJ. Archie Brain: celebrating 30 years of development in laryngeal mask airways. Anaesthesia 2012; 67:1375-85. [DOI: 10.1111/anae.12003.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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A survey of anaesthetic practice in predicting difficult intubation in UK and Europe. Eur J Anaesthesiol 2012; 29:218-22. [PMID: 22374390 DOI: 10.1097/eja.0b013e32835103e6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
CONTEXT Unexpected difficulty in tracheal intubation is an intermittent and often terrifying problem for all practising anaesthetists. There are many preoperative assessment tests to predict a difficult laryngeal view or a difficult intubation, but we found no published evidence of how frequently these predictive tests are used or how useful they are perceived to be by anaesthetists. OBJECTIVE We decided to ask UK and non-UK anaesthetists attending the Annual Scientific Meeting of the European Society of Anaesthesiology about their practice in predicting difficult intubation. DESIGN The study was conceived as a survey. SETTING The airway tests were compiled into a questionnaire, hand distributed among anaesthetists at Euroanaesthesia - the European group (after excluding UK attendees) - and posted to randomly selected anaesthetists in the UK - the UK group. PARTICIPANTS Overall, 888 of 1230 (72%) questionnaires were completed. The response rate from the UK group of anaesthetists was 69% (481 of 700) and from the European group was 77% (407 of 530). RESULTS On a scale 1 (never) to 5 (always), the mean score for frequency of use was similar for both groups of anaesthetists and ranged from about 4 for mouth opening to about 1 for Nodding Donkey. The mean score for usefulness (1 = useless, 5 = extremely useful) ranged from about 3.7 to 2 for the same two tests. The UK group found most tests slightly less useful than did the European group. With regard to the frequency of assessing the airway, 9% of the European group, but 16% of the UK group, failed always (score 5) or regularly (score 4) to assess the airway before general anaesthesia. Furthermore, 21 and 36% of the UK and European groups, respectively, failed to do so before regional anaesthesia. CONCLUSION These results are a cause for concern with regard to both airway management training and patient safety.
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Jaber S, Coisel Y, Chanques G, Futier E, Constantin JM, Michelet P, Beaussier M, Lefrant JY, Allaouchiche B, Capdevila X, Marret E. A multicentre observational study of intra-operative ventilatory management during general anaesthesia: tidal volumes and relation to body weight. Anaesthesia 2012; 67:999-1008. [DOI: 10.1111/j.1365-2044.2012.07218.x] [Citation(s) in RCA: 115] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Popat M, Mitchell V, Dravid R, Patel A, Swampillai C, Higgs A. Difficult Airway Society Guidelines for the management of tracheal extubation. Anaesthesia 2012; 67:318-40. [PMID: 22321104 DOI: 10.1111/j.1365-2044.2012.07075.x] [Citation(s) in RCA: 297] [Impact Index Per Article: 24.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Tracheal extubation is a high-risk phase of anaesthesia. The majority of problems that occur during extubation and emergence are of a minor nature, but a small and significant number may result in injury or death. The need for a strategy incorporating extubation is mentioned in several international airway management guidelines, but the subject is not discussed in detail, and the emphasis has been on extubation of the patient with a difficult airway. The Difficult Airway Society has developed guidelines for the safe management of tracheal extubation in adult peri-operative practice. The guidelines discuss the problems arising during extubation and recovery and promote a strategic, stepwise approach to extubation. They emphasise the importance of planning and preparation, and include practical techniques for use in clinical practice and recommendations for post-extubation care.
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Crosby ET. An evidence-based approach to airway management: is there a role for clinical practice guidelines? Anaesthesia 2011; 66 Suppl 2:112-8. [PMID: 22074085 DOI: 10.1111/j.1365-2044.2011.06940.x] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Complications arising out of airway management represent an important cause of anaesthesia-associated morbidity and mortality. Anaesthetic practice itself can lead to preventable harm, a particular example being persistent attempts at direct laryngoscopy, that results in delay in employing alternative strategies (or devices) when intubation is difficult. When patients are injured, expert review is called upon and often concludes that airway management provided by the anaesthetists was substandard. Many training programmes do not offer their trainees structured or organised teaching in airway management and many trainees probably enter practice with limited skills to deal with difficult airways. The literature on the management of the difficult airway in anaesthesia practice (especially as it relates to new technology and salvage strategies) is expanding rapidly. New technologies and practised response algorithms may be helpful in the management of the difficult airway, reducing the potential for adverse patient outcomes. Specialist societies and national interest groups can play an important role by critically reviewing and then applying the evidence base to generate clinical practice guidelines. The recommendations contained in such guidelines should be based on the most current evidence and they should be reviewed regularly for their content and continued relevance.
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Affiliation(s)
- E T Crosby
- Department of Anesthesiology, University of Ottawa, The Ottawa Hospital, Ottawa, Canada.
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Pandit JJ, Cook TM. Guest editors’ commentary: ‘State of the art’ in airway management in 2011. Anaesthesia 2011; 66 Suppl 2:1-2. [DOI: 10.1111/j.1365-2044.2011.06927.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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Isono S, Greif R, Mort TC. Airway research: the current status and future directions. Anaesthesia 2011; 66 Suppl 2:3-10. [DOI: 10.1111/j.1365-2044.2011.06928.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Ward DS, Karan SB, Pandit JJ. Hypoxia: developments in basic science, physiology and clinical studies. Anaesthesia 2011; 66 Suppl 2:19-26. [DOI: 10.1111/j.1365-2044.2011.06930.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Woodall N, Frerk C, Cook TM. Can we make airway management (even) safer? - lessons from national audit. Anaesthesia 2011; 66 Suppl 2:27-33. [DOI: 10.1111/j.1365-2044.2011.06931.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Wilkes AR, Pandit JJ, O’Sullivan E. The history of anaesthetic equipment evaluation in the United Kingdom: lessons for developing future strategy. Anaesthesia 2011; 66 Suppl 2:34-9. [DOI: 10.1111/j.1365-2044.2011.06932.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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McElwain J, Simpkin A, Newell J, Laffey JG. Determination of the utility of the Intubation Difficulty Scale for use with indirect laryngoscopes. Anaesthesia 2011; 66:1127-33. [DOI: 10.1111/j.1365-2044.2011.06891.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Abstract
Succinylcholine has been indicted on account of the diverse risks associated with its administration, which include hyperkalemia, vagal arrest, and malignant hyperthermia. However, it provides excellent intubating conditions reliably and quickly, characteristics that sustain its appeal for use in the intensive care unit, where airway management is challenging. There is an increasing body of evidence, outlined here, that rocuronium is an acceptable alternative to succinylcholine.
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Affiliation(s)
- Gerard F Curley
- Department of Anaesthesia and Intensive Care Medicine, Galway University Hospitals, Newcastle Road, Galway, Ireland.
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Edwards A, Carapiet D, Torlot K. The use of capnography to confirm tracheal intubation during cardiac arrest. Anaesthesia 2011; 66:844-5. [DOI: 10.1111/j.1365-2044.2011.06808.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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