Challenges and outcomes in airway management outside the operating room

PURPOSE OF REVIEW

Airway management outside the operating room poses unique challenges that every clinician should recognize. These include anatomic, physiologic, and logistic challenges, each of which can contribute to complications and lead to poor outcomes. Recognizing these challenges and highlighting known outcome data may better prepare the team, making this otherwise daunting procedure safer and potentially improving patient outcomes.

RECENT FINDINGS

Newer intubating techniques and devices have made navigating anatomic airway challenges easier. However, physiological challenges during emergency airway management remain a cause of poor patient outcomes. Hemodynamic collapse has been identified as the most common peri-intubation adverse event and a leading cause of morbidity and mortality associated with the procedure.

SUMMARY

Emergency airway management outside the operating room remains a high-risk procedure, associated with poor outcomes. Pre-intubation hemodynamic optimization may mitigate some of the risks, and future research should focus on identification of best strategies for hemodynamic optimization prior to and during this procedure.

141. A Blind Spot for Antibiotic Stewardship Programs: Misadministration of Perioperative Antibiotics

Background

Hospitalized patients requiring intravenous antibiotics frequently undergo surgical intervention. These surgeries involve multiple transitions of care that may lead to antibiotic delay, additional unnecessary doses, omission, or substitution. While many studies examine the use of antibiotics for surgical site infection prophylaxis, there are no studies investigating antibiotic use in the perioperative period for inpatients already on an IV antibiotic regimen. This study examined the incidence and nature of antibiotic misadministration in the perioperative period among inpatients.

Methods

We conducted a retrospective cross-sectional study at a Veterans Affairs Medical Center involving all inpatients who underwent surgery in 2019. Patients 18 years or older who were on an IV antibacterial regimen prior to surgery were included. Patients undergoing cardiac surgery and patients only receiving surgical infection prophylaxis were excluded. Through manual chart review, we collected information on the prescribed IV antibiotic regimen and timing of antibiotic doses in the perioperative period. Errors were classified as administration of additional unnecessary IV antibiotics and missed, delayed, and additional doses of prescribed IV antibiotics.

Results

There were 168 inpatients on an IV antibiotic regimen who underwent surgery in 2019. Complete data was available for 158 patients. Errors in antibiotic administration in the perioperative period were identified in 64 (41%) patients. Missed, delayed, additional unnecessary antibiotics, and additional doses of prescribed IV antibiotics were identified in 21 patients (13%), 14 patients (9%), 13 patients (8%), and 7 patients (4%), respectively (Figure 1).

Conclusion

We found errors in antibiotic administration for inpatients undergoing surgery to be common, with the most frequent error being a missed dose of a prescribed IV antibiotic. This illustrates an area for quality improvement in inpatient antibiotic stewardship in our hospital and we suspect in other hospitals as well. Future work will incorporate more centers and examine how these errors affect outcomes for inpatients undergoing surgery, particularly in patients with sepsis or those requiring surgery for infection source control.

Disclosures

All Authors: No reported disclosures

Severe Shivering on Venoarterial Extracorporeal Membrane Oxygenation-Raising the Circuit Temperature to Stop Rhabdomyolysis: A Case Report

We report a case of severe shivering resulting in rhabdomyolysis while on venoarterial extracorporeal membrane oxygenation (ECMO) that resolved after hyperthermia was induced using the ECMO circuit. The patient developed shivering approximately 24 hours after venoarterial ECMO cannulation for refractory ventricular tachycardia. The shivering caused rhabdomyolysis and necessitated cisatracurium infusion. The shivering failed to resolve after the patient was diagnosed and treated for ventilator-associated pneumonia. Suspecting sepsis as the etiology of shivering, the ECMO circuit temperature was increased to 38 °C, and the shivering was resolved. This case demonstrates therapeutic hyperthermia to treat infection-induced severe shivering and rhabdomyolysis while on ECMO.

Creating an Intensive Care Unit From a Postanesthesia Care Unit for the COVID-19 Surge at the Veterans Affairs Ann Arbor Healthcare System

Objectives

To prepare for the predicted surge of patients with COVID-19 in Southeast Michigan, the US Department of Veterans Affairs Ann Arbor Healthcare System engineered, built, and staffed a 12-bed intensive care unit (ICU) from the existing postanesthesia care unit (PACU).

Observations

Considerations including floor planning, reversal of airflow, strict airborne precautions, sealing off a dedicated nursing station, and developing an infection control plan in an open care unit. A staffing model was created that included anesthesiologist intensivists, advanced practice providers, residents, certified registered nurse anesthetists, and perioperative nurses working alongside ICU trained nurses. Challenges arose in infection control, communication, mechanical ventilation using anesthesia machines, providing renal replacement therapy, and maintaining patient privacy in an open unit.

Conclusions

This article describes the setup, challenges, and solutions that allowed the creation of the PACU-ICU to help serve veterans and civilians during a time of unprecedented strain on the health care system due to COVID-19.

Change in management of predicted difficult airways following introduction of video laryngoscopes

AIM

To determine if video laryngoscopy (VL) has significantly impacted management of difficult airways by decreasing the rate of awake fiberoptic intubation (FOI).

METHODS

Anesthetic records of 3723 patients who underwent general anesthesia at Rush University Medical Center were reviewed over a 2-mo period prior to the introduction of VLs in 2009 (“pre-VL” group) and over the same 2-mo period after the introduction of VLs in 2012 (“post-VL” group). Patient records with predicted difficult airways based on pre-operative airway examination were analyzed. The primary outcome was rate of awake FOI.

RESULTS

To control for possible factors that may influence the FOI rate, a logistic regression was performed with these factors included as covariates. The rate of awake FOI was 13.1% in pre-VL group compared to 9.0% in post-VL group. Although this decrease was not statistically significant individually (P = 0.1768), it showed a trend toward significance when covariates were accounted for (P = 0.0910). Several factors predicting a higher likelihood of awake FOI were found to be statistically significant: Morbid obesity (larger BMI P = 0.0154, OR = 1.5 per 10 point BMI increase), male gender (P = 0.0026, OR = 3.0) and a higher el-Ganzouri airway score (P = 0.0007, OR = 1.5). Although VLs were seen to be used to intubate 51% of predicted difficult airways, the rate of awake FOI has not significantly changed.

CONCLUSION

Although VL may continue to grow in popularity, the most difficult airways are still managed using awake FOI.

Older patients' perceptions of medication importance and worth: an exploratory pilot study

BACKGROUND

Cost-related medication non-adherence may be influenced by patients' perceived importance of their medications.

OBJECTIVES

This exploratory pilot study addresses three related but distinct questions: Do patients perceive different levels of importance among their medications? What factors influence perceptions of medication importance? Is perceived importance associated with perceived worth of medications, and does expense impact on that association?

METHODS

Study participants included individuals aged >or=60 years who were taking three or more prescription drugs. Semi-structured, in-person interviews were conducted to measure how patients rated their medications in terms of importance, expense and worth. Factors that influenced medication importance were identified using qualitative analysis. Ordinal logistic regression analyses were employed to examine the association between perceived importance and perceived worth of medications, and the impact of expense on that association.

RESULTS

For 143 prescription drugs reported by 20 participants, the weighted mean rating of medication importance was 8.2 (SD 1.04) on a scale from 0 (not important at all) to 10 (most important). Patients considered 38% of these medications to be expensive. The weighted mean rating of worth was 8.4 (SD 1.46) on a scale from 0 (not worth it at all) to 10 (most worth). Three major factors influenced medication importance: drug-related (characteristics, indications, effects and alternatives); patient-related (knowledge, attitudes and health); and external (the media, healthcare and family caregivers, and peers). Regression analyses showed an association between perceived importance and perceived worth for inexpensive medications (odds ratio [OR] 2.23; p = 0.002) and an even greater association between perceived importance and perceived worth for expensive medications (OR 4.29; p < 0.001).

DISCUSSION

This study provides preliminary evidence that elderly patients perceive different levels of importance for their medications based on factors beyond clinical efficacy. Their perception of importance influences how they perceive their medications' worth, especially for medications of high costs. Understanding how patients perceive medication importance may help in the development of interventions to reduce cost-related non-adherence.