Major Complications Of Airway Management Research Articles

Creating an easy to construct, low-cost aspiration simulator for airway training

Aspiration of gastric contents remains the commonest cause of death during anaesthesia, accounting for 50% of deaths and occurring more frequently than cannot intubate, cannot oxygenate (CICO) events [1]. Despite this, training for CICO is ubiquitous while rehearsal of aspiration management is rare. Soiled airway simulation has been shown to reduce the time to intubation with less volume entering the lungs, a factor known to correlate with the severity of aspiration [2]. Initially developed by Dr DuCanto, high-fidelity vomit simulators have existed since 2014 however cost (£1,595) precludes their widespread use. Low-cost models have since been described, however, the materials are sourced from hardware stores, relatively expensive, require skills to construct, utilise noisy pumps, and some even require electrical safety considerations [3]. We aimed to improve access to aspiration training by designing an aspiration simulator that is easy to construct and low-cost. Employing an iterative design process we created an aspiration simulator using materials readily available in the operating theatre. The final model requires an intubatable manikin with an oesophagus, such as the Laerdal Airway Management Trainer The setup silently produces a titratable flow of up to 250 ml per minute, sufficient to flood the oropharynx within 30 seconds. The simulation itself can be set up in under 10 minutes, used several times before requiring refilling, and is easily transported between theatres as a part-task trainer or concealed for a multi-disciplinary simulation (Figure 1, bottom left). All parts are reusable and the total cost equals £9.90 (excluding the manikin, which is undamaged). Our simulator was tested on a cohort of 16 middle-grade anaesthetic trainees and its performance was evaluated using pre and post-course questionnaires (scale 0–10). All successfully intubated the simulator. Average user-rating scores for realism were 8.4/10 while confidence in managing soiled airways improved from 6.2/10 to 8.9/10 after exposure to the simulation. Soiled airway simulation can be simple and affordable, creating a realistic environment to practise the unique skills necessary to manage this important yet under-rehearsed cause of death during anaesthesia. 1. Cook T, Woodall N, Frerk C. 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 1: Anaesthesia †. British Journal of Anaesthesia. 2011;106(5):617–631 2. Jensen M, Louka A, Barmaan B. Effect of Suction Assisted Laryngoscopy Airway Decontamination (SALAD) Training on Intubation Quality Metrics. Air Medical Journal. 2019;38(5):325. 3. Sampson C, Pauly J, Horner J. Low-cost Portable Suction-Assisted Laryngoscopy Airway Decontamination (SALAD) Simulator for Dynamic Emesis. Journal of Education and Teaching in Emergency Medicine. 2019;4(2).

Major complications of airway management: a prospective multicentre observational study.

We conducted an observational study of serious airway complications, using similar methods to the fourth UK National Audit Project (NAP4) over a period of 1 year across four hospitals in one region in the UK. We also conducted an activity survey over a week, using NAP4 methods to yield an estimate for relevant denominators to help interpret the primary data. There were 17 serious airway complications, defined as: failed airway management leading to cancellation of surgery (eight); airway management in recovery (five); unplanned intensive care admission (three); and unplanned emergency front of neck access (one). There were no reports of death or brain damage. This was an estimate of 0.028% (1 in 3600) complications using the denominator of 61,000 general anaesthetics per year in the region. Complications in patients with 'predicted easy' airways were rare (approximately 1 in 14,200), but 45 times more common in those with 'predicted difficult' airways (approximately 1 in 315). Airway management in both groups was similar (induction of anaesthesia followed by supraglottic airway or tracheal tube). Use of awake/sedation intubation, videolaryngoscopy and high-flow nasal oxygenation were uncommon even in the predicted difficult airway patients (in 2.7%, 32.4% and 9.5% of patients, respectively). We conclude that the incidence of serious airway complications is at least as high as it was during NAP4. Despite airway prediction being used, this is not informing subsequent management.

O.10 Morbid obesity and caesarean section: The impact of BMI on anaesthesia and surgical duration

Introduction: Obesity is associated with increased operative time at caesarean section (CS). [1] Girsen A, Osmundson S, Naqvi M et al. Body Mass Index and Operative Times at Caesarean Delivery. Obstet Gynecol 2014; 124: 684 –9. Google Scholar Obesity, pregnancy and emergency surgery all increase the risk of general anaesthesia (GA). [2] Cook T, Woodall N, Frerk C. 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 1: Anaesthesia, Br J Anaesth 2011;106:617 –31. Google Scholar On labour ward, urgency to deliver is challenged by raised body mass index (BMI). Conversion to GA during CS is challenging and potentially distressing for the mother. The study aims were to quantify how surgical time (ST) and anaesthesia time (AT), at CS, vary by BMI.

Major Complications of Airway Management in Thames Valley

Major Complications of Airway Management in Thames Valley

Is rapid sequence spinal anaesthesia a valid alternative for an emergency caesarean?

British Journal of Hospital MedicineVol. 80, No. 9 Anaesthetic and Critical Care DilemmaIs rapid sequence spinal anaesthesia a valid alternative for an emergency caesarean?Frances YoungFrances Young(E-mail Address: [email protected])Specialist Trainee in Anaesthesia, Department of Anaesthesia, Manchester University NHS Foundation Trust – Wythenshawe, Manchester M23 9LTSearch for more papers by this authorFrances YoungPublished Online:9 Sep 2019https://doi.org/10.12968/hmed.2019.80.9.554AboutSectionsView articleView Full TextPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareShare onFacebookTwitterLinked InEmail View article References Afolabi BB, Lesi FEA. Regional versus general anaesthesia for caesarean section. Cochrane Database Syst Rev. 2012 Oct 17;10:CD004350. https://doi.org/10.1002/14651858.CD004350.pub3 Medline, Google ScholarColven J, Peden C. 2012. Section 8: Obstetrics. In: Audit Recipe Book. 3rd edn. London: Royal College of Anaesthetists. Google ScholarCook T, Woodall N, Frerk C. 2011. Major complications of airway management in the United Kingdom. 4th National Audit Project of The Royal College of Anaesthetists and The Difficult Airway Society. (accessed 14 April 2019) https://www.nationalauditprojects.org.uk/NAP4-Report Google ScholarKinsella SM, Girgirah K, Scrutton MJL. Rapid sequence spinal anaesthesia for category-1 urgency caesarean section: a case series. Anaesthesia. 2010 Jul;65(7):664–669. https://doi.org/10.1111/j.1365-2044.2010.06368.x Crossref, Medline, Google ScholarNational Institute for Health and Care Excellence. 2019. Caesarean section. (accessed 14 April 2019) https://www.nice.org.uk/guidance/cg132 Google ScholarPandit JJ, Cook TM. 2014. Accidental Aawareness during General Anaesthesia in the United Kingdom and Ireland. 5th National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. (accessed 15 June 2019) https://www.nationalauditprojects.org.uk/NAP5report Google ScholarRucklidge MWM, Paech MJ, Yentis SM. A comparison of the lateral, Oxford and sitting positions for performing combined spinal-epidural anaesthesia for elective Caesarean section. Anaesthesia. 2005 Jun;60(6):535–540. https://doi.org/10.1111/j.1365-2044.2005.04178.x Crossref, Medline, Google Scholar FiguresReferencesRelatedDetails 2 September 2019Volume 80Issue 9ISSN (print): 1750-8460ISSN (online): 1759-7390 Metrics History Published online 9 September 2019 Published in print 2 September 2019 Information© MA Healthcare LimitedPDF download

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

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

The United Kingdom National Audit Projects: a narrative review

The Royal College of Anaesthetists’ National Audit Project (NAP) programme has been running in its current form since 2006. Since NAP3 was commissioned the NAPs have examined rare but important complications of anaesthesia and related sub-specialties. The topics covered include major complications of central neuraxial block (NAP3), major complications of airway management in hospitals (NAP4) and accidental awareness during general anaesthesia (NAP5). NAP6 is currently studying severe perioperative anaphylaxis. The NAPs have shed new light on the major complications of anaesthesia, providing both quantitative (frequencies, prevalence, incidence, risk factors) and qualitative (themes, patient stories, human factors) knowledge that has led to new learning, recommendations and changes in practice. This article describes the background, nature and processes of the NAPs.

Extubation of the perioperative patient with a difficult airway

A considerable amount of literature has been dedicated to the topic of difficult airway management and a number of algorithms and recommendations have been established to safely manage patients at risk for difficult intubation. Only recently, however, has extubation of the difficult airway gained more awareness since this procedure, although elective, is often fraught with complications. The importance of developing pre-planned strategies for extubation of the difficult airway to improve patient safety and outcomes is apparent from data from both the ASA Closed Claims Analysis and the UK's recent Fourth National Audit Project of major complications of airway management. The key to successful management of patients at risk for difficult extubation is accurate risk assessment, application of appropriate strategies, and preparedness by both the individual practitioner and the institution.

Extubación del paciente perioperatorio con una vía aérea difícil

A considerable amount of literature has been dedicated to the topic of difficult airway management and a number of algorithms and recommendations have been established to safely manage patients at risk for difficult intubation. Only recently, however, has extubation of the difficult airway gained more awareness since this procedure, although elective, is often fraught with complications. The importance of developing pre-planned strategies for extubation of the difficult airway to improve patient safety and outcomes is apparent from data from both the ASA Closed Claims Analysis and the UK's recent Fourth National Audit Project of major complications of airway management. The key to successful management of patients at risk for difficult extubation is accurate risk assessment, application of appropriate strategies, and preparedness by both the individual practitioner and the institution.

Needle, knife, or device – which choice in an airway crisis?

Needle, knife, or device – which choice in an airway crisis?

Reply to

Editor, Thank you for the opportunity to respond to the comments of Sorbello et al.1 made with respect to our article investigating the use of ultrasound to guide life-saving cannula tracheotomy.2 First, we support their suggestion that anaesthetists must take all reasonable steps to prevent ‘cannot intubate, cannot ventilate’ (CI–CV) scenarios. In situations wherein a difficult airway is predicted, then in many cases, awake fibreoptic intubation or awake tracheostomy will be the safest management plan and should be used. This is just one message from the recent fourth UK National Audit Project (NAP4) that investigated major complications of airway management.3 The report also highlighted that preemptive cannula cricothyroidotomy prior to induction of general anaesthesia is another potentially valuable technique. However, although the anaesthetist must try and avoid CICV scenarios, he should nevertheless still be prepared should they occur. Predictive tests will not identify all difficult airways and in one in five of the anaesthetic cases of CI–CV in NAP4, no difficulty in airway management was predicted.3 Furthermore, CI–CV events may occur in spite of attempts to prevent them and there are multiple case reports of complete airway obstruction precipitated by the process of awake fibreoptic intubation.3–5 Second, Sorbello et al. make a valid observation that our model had largely muscle overlapping the airway as opposed to fat, as would be the case in an obese patient. However, although the sonographic characteristics of these tissues may not be the same, we would expect to be able to identify a trachea at a depth of at least 3–4 cm whether it was under fat or muscle. This will vary depending on the frequency of the ultrasound probe used and the experience of the operator. Ezri et al.6 used ultrasound to identify tracheas that were at least as deep as 35 mm in a morbidly obese population. Although the cartilages of the larynx and trachea are relatively hyperechoic,7 it is conceivable that if the airway is compressed or occluded, it could be difficult to visualise. Finally, based on our extensive experience of their use in an animal model, we would disagree with the suggestion that cannulation might be quicker with a Cook emergency transtracheal airway catheter (Cook, Bloomington, USA) than the 14-G Insyte cannula (Becton Dickinson UK Ltd, Oxford, UK) that we used in our study. Due to its larger diameter trocar, greater wall thickness and ribbed design, the Cook ETAC requires considerably more force to insert (our own unpublished laboratory data) and so the procedure is more difficult and unlikely to be faster.

Airway Management in Critical Care - New Guidelines, Old Problems

Intensive care training in the UK is undergoing change. Traditionally, the majority of intensive care medicine (ICM) clinicians were from an anaesthetic background with trainees and consultants receiving specific training and experience in basic and advanced airway management. As ICM becomes a stand-alone specialty with intake of trainees from other acute medical backgrounds, these airway skills can no longer be taken for granted. Advanced ICM trainees require only six months of training in anaesthesia, which could mean that the management of the difficult airway from intubation through to successful extubation will become increasingly challenging for those without advanced airway skills. The recent Royal College of Anaesthetists NAP4 audit aimed to identify and study major complications of airway management in the UK. It described many of these events as likely to have been avoidable, with a disproportionately high number of adverse airway incidents occurring in the intensive care unit (ICU) and emergency department. 1 When compared with ‘anaesthetic’ airway incidents, ICU airway events were more likely to be managed by doctors with less airway experience, occur out of hours and lead to more frequent permanent harm and death. Similar findings are echoed in the report written on behalf of the UK National Patient Safety Agency. 2

4th National Audit Project of the Royal College of Anaesthetists and The Difficult Airway Society: Major Complications of Airway Management in the United Kingdom: Report and Findings

4th National Audit Project of the Royal College of Anaesthetists and The Difficult Airway Society: Major Complications of Airway Management in the United Kingdom: Report and Findings

Book Review: NAP4. 4th National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Major Complications of airway management in the United Kingdom. Report and Findings March 2011.

Book Review: NAP4. 4th National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Major Complications of airway management in the United Kingdom. Report and Findings March 2011.

4th National Audit Project of The Royal College of Anaesthetists and The Difficult Airway Society (NAP4) Major Complications of Airway Management in the United Kingdom

4th National Audit Project of The Royal College of Anaesthetists and The Difficult Airway Society (NAP4) Major Complications of Airway Management in the United Kingdom

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 1: Anaesthesia

This project was devised to estimate the incidence of major complications of airway management during anaesthesia in the UK and to study these events. Reports of major airway management complications during anaesthesia (death, brain damage, emergency surgical airway, unanticipated intensive care unit admission) were collected from all National Health Service hospitals for 1 yr. An expert panel assessed inclusion criteria, outcome, and airway management. A matched concurrent census estimated a denominator of 2.9 million general anaesthetics annually. Of 184 reports meeting inclusion criteria, 133 related to general anaesthesia: 46 events per million general anaesthetics [95% confidence interval (CI) 38-54] or one per 22,000 (95% CI 1 per 26-18,000). Anaesthesia events led to 16 deaths and three episodes of persistent brain damage: a mortality rate of 5.6 per million general anaesthetics (95% CI 2.8-8.3): one per 180,000 (95% CI 1 per 352-120,000). These estimates assume that all such cases were captured. Rates of death and brain damage for different airway devices (facemask, supraglottic airway, tracheal tube) varied little. Airway management was considered good in 19% of assessable anaesthesia cases. Elements of care were judged poor in three-quarters: in only three deaths was airway management considered exclusively good. Although these data suggest the incidence of death and brain damage from airway management during general anaesthesia is low, statistical analysis of the distribution of reports suggests as few as 25% of relevant incidents may have been reported. It therefore provides an indication of the lower limit for incidence of such complications. The review of airway management indicates that in a majority of cases, there is 'room for improvement'.

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

The Fourth National Audit Project of the Royal College of Anaesthetists and Difficult Airway Society (NAP4) was designed to identify and study serious airway complications occurring during anaesthesia, in intensive care unit (ICU) and the emergency department (ED). Reports of major complications of airway management (death, brain damage, emergency surgical airway, unanticipated ICU admission, prolonged ICU stay) were collected from all National Health Service hospitals over a period of 1 yr. An expert panel reviewed inclusion criteria, outcome, and airway management. A total of 184 events met inclusion criteria: 36 in ICU and 15 in the ED. In ICU, 61% of events led to death or persistent neurological injury, and 31% in the ED. Airway events in ICU and the ED were more likely than those during anaesthesia to occur out-of-hours, be managed by doctors with less anaesthetic experience and lead to permanent harm. Failure to use capnography contributed to 74% of cases of death or persistent neurological injury. At least one in four major airway events in a hospital are likely to occur in ICU or the ED. The outcome of these events is particularly adverse. Analysis of the cases has identified repeated gaps in care that include: poor identification of at-risk patients, poor or incomplete planning, inadequate provision of skilled staff and equipment to manage these events successfully, delayed recognition of events, and failed rescue due to lack of or failure of interpretation of capnography. The project findings suggest avoidable deaths due to airway complications occur in ICU and the ED.

National census of airway management techniques used for anaesthesia in the UK: first phase of the Fourth National Audit Project at the Royal College of Anaesthetists

BackgroundThe first stage of the Royal College of Anaesthetists Fourth National Audit Project (NAP4) (to determine the incidence of major complications of airway management in the UK) required a national census of airway management techniques currently in use. MethodsA network of local reporters (LRs) was established, with a link to each of the 309 National Health Service hospitals believed to undertake surgery. LRs were requested to report the primary airway management technique used for all general anaesthetics performed in their hospital during a specified 2 week period. Individual unit’s data for the survey period were extrapolated using a multiplier of 25 to provide an estimated annual usage. ResultsData were received from all 309 hospitals. The number of general anaesthetics reported in the 2 weeks was 114 904 giving an estimate of 2.9 million annually. Eighty-nine per cent of returns were reported by the LR to be ‘accurate’ or ‘a close estimate’ (an error of <10%). The primary airway management device for general anaesthesia was a supraglottic airway in 64 623 (56.2%), a tracheal tube in 44 114 (38.4%), and a facemask in 6167 (5.3%). ConclusionsThe second stage of NAP4 is designed to register and collect details of each major airway complication from the same hospitals over a 12 month period. The individual case reports will produce the numerator to calculate the incidence of airway complications associated with general anaesthesia in the UK. The results of the census presented here will provide the denominator.