Refraining from pre-hospital advanced airway management: a prospective observational study of critical decision making in an anaesthesiologist-staffed pre-hospital critical care service

Leif Rognås,Troels Martin Hansen,Else Tønnesen,Hans Kirkegaard

doi:10.1186/1757-7241-21-75

Abstract

IntroductionWe report prospectively recorded observational data from consecutive cases in which the attending pre-hospital critical care anaesthesiologist considered performing pre-hospital advanced airway management but decided to withhold such interventions.Materials and methodsAnaesthesiologists from eight pre-hospital critical care teams in the Central Denmark Region (a mixed rural and urban region with 1.27 million inhabitants) registered data from February 1st 2011 to October 31st 2012. Included were patients of all ages for whom pre-hospital advanced airway management were considered but not performed. The main objectives were to investigate (1) the pre-hospital critical care anaesthesiologists’ reasons for considering performing pre-hospital advanced airway management in this group of patients (2) the pre-hospital critical care anaesthesiologists’ reasons for not performing pre-hospital advanced airway management (3) the methods used to treat these patients (4) the incidence of complications related to pre-hospital advanced airway management not being performed.ResultsWe registered data from 1081 cases in which the pre-hospital critical care anaesthesiologists’ considered performing pre-hospital advanced airway management. The anaesthesiologists decided to withhold pre-hospital advanced airway management in 32.1% of these cases (n = 347). In 75.1% of these cases (n = 257) pre-hospital advanced airway management were withheld because of the patient’s condition and in 30.8% (n = 107) because of patient co-morbidity. The most frequently used alternative treatment was bag-mask ventilation, used in 82.7% of the cases (n = 287). Immediate complications related to the decision of not performing pre-hospital advanced airway management occurred in 0.6% of the cases (n = 2).ConclusionWe have illustrated the complexity of the critical decision-making associated with pre-hospital advanced airway management. This study is the first to identify the most common reasons why pre-hospital critical care anaesthesiologists sometimes choose to abstain from pre-hospital advanced airway management as well as the alternative treatment methods used.

Highlights

We report prospectively recorded observational data from consecutive cases in which the attending pre-hospital critical care anaesthesiologist considered performing pre-hospital advanced airway management but decided to withhold such interventions
Immediate complications related to the decision of not performing pre-hospital advanced airway management occurred in 0.6% of the cases (n = 2)
We have recently reported the incidences of different Pre-hospital Advanced Airway Management (PHAAM)-related complications in our anaesthesiologist-staffed pre-hospital critical care system [9] but the incidences of complications related to not performing PHAAM in a physician-staffed prehospital critical care system are unknown

Summary

Introduction

We report prospectively recorded observational data from consecutive cases in which the attending pre-hospital critical care anaesthesiologist considered performing pre-hospital advanced airway management but decided to withhold such interventions. Background Pre-hospital Advanced Airway Management (PHAAM) continues to be one of the main controversies in prehospital critical care and an international group of experts have selected the topic as one of the top five research priorities in pre-hospital care [1]. Little attention has been paid to the critical decision making process involved in PHAAM These decisions can be challenging even to pre-hospital critical care physicians [14,15]. Both we [9] and other authors [6,16] have reported pre-hospital critical care physicians’ reasons for performing PHAAM.

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