G-1 Predictors of difficult mask ventilation and difficult intubation in morbidly obese surgical patients

Abstract

Patients who require urgent and complex airway management outside the operating room are at risk for substantialmorbidity and mortality, when trained personnel with adequate equipment are not immediately available. A comprehensive difficult airway program has been shown to reduce the number of emergency surgical airways performed outside the operating room at a large academic hospital in a retrospective study [1]. We present a summary of the development of a threatened adult airway response program to facilitate access to necessary personnel and equipment, when a patient with a difficult airway is in respiratory failure. The program was proposed in October 2010, and the first threatened adult airway team code (TAART) was called in July 2012.ATAARTcodemaybe initiated by a rapid response team hospitalist, airway response trained nurse trained nurse, respiratory therapist, anesthesia resident or attending, surgical resident, otorhinolaryngologist (ENT) resident, or trauma attending. Initiating a TAART code notifies the on-call anesthesiologist, trauma surgeon, ENT surgeon, SWAT nurse, and respiratory therapist. A dedicated equipment tower is brought to the bedside. Criteria for a TAARTcode include a patient with tachypnea, apnea, stridor, low or falling oxygen saturation, or initial failed intubation and a difficult airway (super morbid obesity, obvious anatomic distortion, failed intubation, or history of a difficult airway). Over 2 years, there have been 29 TAART codes called with 23 meeting the established criteria. Table 1 summarizes the characteristics of the patient and the outcome of the TAART code. Figure displays the number of TAART codes by year. Correspodence to will.rosenblatt@yale.edu Figure Number of TAART codes by year. Reference [1] BerkowLC,GreenbergRS,KanKH,Colantuoni E,MarkLJ, Flint PW, et al. Need for emergency surgical airway reduced by a comprehensive difficult airway program. Anesth Analg 2009;109(6):1860-9. http://dx.doi.org/10.1016/j.jclinane.2014.11.010 G-1 Predictors of difficult mask ventilation and difficult intubation in morbidly obese surgical patients Mercedeh Vaez ⁎, David T. Wong MD, Waleed Riad Solima MD, Ravi Raveendran MD, Frances F. Chung MD Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada ⁎Corresponding author. E-mail: vaez4910@mylaurier.ca Background: Neck circumference was suggested to be a predictor of difficult intubation in the surgical population. The purpose of the study was to determine if neck circumference was a predictor of difficult mask ventilation (DMV) and difficult intubation (DI) in morbidly obese surgical patients. Methods: Institutional review board was obtained. Morbidly obese patients (BMI, ≥40) undergoing elective surgery requiring tracheal intubation were prospectively studied. Exclusions were known difficult airway and emergency surgery. Preoperative history, airway examination, neck, and waist circumference were collected. Patients were preoxygenated and induced. Mask ventilation was grade [1] as easy or difficult (inadequate, desaturation, 2 hand, or impossible). Intubation was performed using MacIntosh direct laryngoscopy. Intubating adjuncts or alternatives were permitted. Intubation difficult scale (IDS) was derived using 7 parameters as per Adnet [2]. Difficult intubation was defined as IDS ≥5. Univariate analyses were done to determine association with DMV/ DI, whereas multiple logistic regressions were done to determine independent predictors of DMV/DI. Results: (Table) One hundred four patients were studied. Age was 44 ± 11; 84% female; BMI, 48.4 ± 7.5; 54% had sleep apnea; Mallampati 1/2/3/4:32/28/33/10; and neck circumference, 42.3 ± 4.4 cm. Eleven (11%) had DMV, and 13 (13%) had DI. Univariate analyses showed that DMV was associated with males, BMI≥50, sleep apnea, thyromental distance, and neck circumference; and DI with males, weight, BMI ≥50, waist, and neck circumference. Logistic regression showed that independent predictors of DMV were males and BMI ≥50 and of DI, neck circumference N42 cm and BMI ≥50. Discussion: In morbidly obese surgical patients, predictors of DMV were male sex and BMI ≥50. Predictors of DI were BMI ≥50 and neck circumference N42 cm.