Video laryngoscopy in pre-hospital critical care - a quality improvement study.

Marianne Grønnebæk Rhode,Leif Rognås,Mads Partridge Vandborg,Vibeke Bladt

doi:10.1186/s13049-016-0276-6

Abstract

BackgroundPre-hospital endotracheal intubation is challenging and repeated endotracheal intubation is associated with increased morbidity and mortality.We investigated whether the introduction of the McGrath MAC video laryngoscope as the primary device for pre-hospital endotracheal intubation could improve first-pass success rate in our anaesthesiologist-staffed pre-hospital critical care services. We also investigated the incidence of failed pre-hospital endotracheal intubation, the use of airway adjuncts and back-up devices and problems encountered using the McGrath MAC video laryngoscope.MethodsProspective quality improvement study collecting data from all adult pre-hospital endotracheal intubation performed by four anaesthesiologist-staffed pre-hospital critical care teams between December 15th 2013 and December 15th 2014.ResultsWe registered data from 273 consecutive patients. When using the McGrath MAC video laryngoscope the overall pre-hospital endotracheal intubation first-pass success rate was 80.8 %. Following rapid sequence intubation (RSI) it was 88.9 %. This was not significantly different from previously reported first-pass success rates in our system (p = 0.27 and p = 0.41). During the last nine months of the study period the overall first-pass success rate was 80.1 (p = 0.47) but the post-RSI first-pass success rate improved to 94.4 % (0.048).The overall pre-hospital endotracheal intubation success rate with the McGrath MAC video laryngoscope was 98.9 % (p = 0.17). Gastric content, blood or secretion in the airway resulted in reduced vision when using the McGrath MAC video laryngoscope.ConclusionIn this study of video laryngoscope implementation in a Scandinavian anaesthesiologist-staffed pre-hospital critical care service, overall pre-hospital endotracheal first pass success rate did not change. The post-RSI first-pass success rate was significantly higher during the last nine months of our 12-month study compared with our results from before introducing McGrath MAC video laryngoscope. The implementation of the Standard Operating Procedure and check list for pre-hospital anaesthesia during the study period may have influenced the first-pass success rate and constitutes a potential confounder.The potential limitations of the McGrath MAC video laryngoscope when there are gastric content, blood and secretions in the airways need to be further investigated before the McGrath MAC video laryngoscope can be recommended as the primary device in all pre-hospital endotracheal intubations.Electronic supplementary materialThe online version of this article (doi:10.1186/s13049-016-0276-6) contains supplementary material, which is available to authorized users.

Highlights

Pre-hospital endotracheal intubation is challenging and repeated endotracheal intubation is associated with increased morbidity and mortality
Pre-hospital endotracheal intubation first-pass success rates The overall first-pass success rate for the entire 12-month study period was 80.8 % (n = 207). This is not significantly different (p = 0.27) from the 77.6 % pre-video laryngoscope (VL) first-pass success rate in our system [10]. During these 12 months, rapid sequence intubation (RSI) was performed in 42.2 % (n = 108) of the patients and with a first-pass success rate of 88.9 %, (n = 96) (p = 0.41 compared to pre-VL results)
Problems encountered when using the McGrath MAC video laryngoscope The physicians participating in our study reported that the McGrath MAC VL had limitations if there was gastric content, blood or secretion in the airway

Summary

Introduction

Pre-hospital endotracheal intubation is challenging and repeated endotracheal intubation is associated with increased morbidity and mortality. Limited access to the patient and certain biophysical conditions (e.g. obesity, short neck, face- and neck injuries, and anatomical restrictions) are predicting conditions for difficult airway management and difficult endotracheal intubation (DETI) and may complicate pre-hospital endotracheal intubation (PHETI) [1, 4, 5]. In both the template for uniform reporting data from pre-hospital advanced airway management by Sollid et al [6] and the “Practical guidelines for management of difficult airway” by the American Society of Anaesthesiologists [7], difficult endotracheal intubation is defined as more than one attempt needed to successfully perform endotracheal intubation. A metaanalysis by Lossius et al reported significantly increased PHETI success rates by physicians compared with non-physicians [11]

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