Emergency airway management in the critically ill: a 1 yr review of practice within a London teaching hospital

Abstract

Emergency airway management in the critically ill is complex and potentially hazardous.1 The Difficult Airway Society (DAS) is developing a critical care intubation guideline.2 Our aims were to examine local practice in relation to intubations performed in the critically ill outside of the operating theatre, and to identify ways to improve care. All critical care intubations from February 2016 to 2017 were reviewed retrospectively. Patients were identified from the electronic patient database (AcuBase) and data analysed from medical records. Patients were excluded if intubated in theatre for emergency surgery, not admitted to the intensive care unit (ICU), and had a tracheostomy in situ. The project was registered with the trust governance team. Ninety intubation events were identified, with 16 (18%) defined as difficult (more than two attempts/more than 10 min to intubate/other features defined as difficult by a senior anaesthetist). Table 2 demonstrates our key results.Table 2Characteristics of intubation events. DA, Difficult Airway; ICU, Intensive Care Unit; ED, Emergency Department; HFNC, High Flow Nasal Cannula.Intubation events (n=90)Senior operator, n (%)Consultant, 27 (30)ST5+, 30 (33)ST3-4, 27 (30)Not recorded, 7 (7)Difficult airway (DA) cohort5 (31)6 (38)5 (31)0 (0)Location, n (%)ICU, 47 (52)ED, 21 (23)Ward, 16 (18)Theatre, 6 (7)DA cohort8 (50)5 (31)2 (13)1 (6)Preoxygenation, n (%)Waters, 35 (39)BiPAP, 5 (6)HFNC, 4 (4)Not recorded, 46 (51)DA cohort7 (44)1 (6)1 (6)7 (44)Positioning, n (%)Sitting, 7 (8)20–40 deg, 4 (4)Oxford pillow, 1 (1)Not recorded, 78 (87)DA cohort1 (6)1 (6)1 (6)13 (81)ApOx, n (%)Yes, 5 (6)No, 2 (2)Not recorded, 83 (92)DA cohort1 (6)0 (0)15 (94)Bagged electively, n (%)Yes, 11 (12)No, 1 (1)Not recorded, 78 (87)DA cohort6 (36)0 (0)10 (64)Airway operators, n (%)Two, 51 (57)One, 32 (36)Not recorded, 7 (7)DA cohort9 (56)7 (44)0 (0)First laryngoscopic attempt, n (%)DL, 50 (55)VL, 17 (19)Not recorded, 23 (26)DA cohort7 (44)6 (38)3 (18) Open table in a new tab Only 57% of intubations were performed with two airway operators, and the senior operator was often relatively junior (consultant, 30%). The use of nasal oxygenation to prolong time to desaturation was only used in 6%, suggesting a lack of familiarity. In the difficult airway group, a video laryngoscope was used for the first intubation attempt in 38% patients, likely reflecting changing practice amongst anaesthetists. There were an equal number of cases (two vs two) where video and direct laryngoscopy rescued each other after failure with the first technique; hence, competence in both is essential. The documentation of airway interventions was poor and sometimes not performed. Grade of intubation was often recorded, but lacked context (e.g. positioning). After these results, we have developed a local intubation checklist, which addresses human factors and multidisciplinary team working, and acting as a standardised form for documenting airway interventions outside of theatre. It is being tested within our in situ simulation programme before its launch in late 2017. This checklist complements our system of highlighting ICU patients with difficult airways (identified from theatre or outwith) with a bedside warning, documented airway management plan, and discussion at operational handover. All of these have been well received by the multidisciplinary team and aim to complement future DAS guidelines for critical care. 1.Cook TM, Woodall N, Frerk C. On behalf of the Fourth National Audit Project. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 2: intensive care and emergency departments. Br J Anaesth 2011; 106: 632–422.Higgs A, et al. Br J Anaesth 2016; 117: i5–9