1. “Dirty Laundry” of Airway Management Ashley Grace Piper SRNA

3. Review the design and results of… ASA Closed Claims Project NAP4 Project OBJECTIVE

4. ASA Closed Claims Project: DESIGN Examined closed claim files from 35 US professional liability insurance companies 5,480 claims entered in the database (1961-1999) Reviewing process: – 1+ trained/practicing MDs periodically review/collect claim files on site at each insurance company – Standardized information collection forms completed – Reviewer assigns severity score – Data forms further reviewed by a Closed Claims Project committee

5. ASA Closed Claims Project: RESULTS

10. NAP4: Design Phase One: census of airway management techniques used in the UK National Health Service (309 hospitals) Phase two: identify all cases of major complications of airway management in the same population as in phase one.

11. NAP4: Results What types of airway device are used during anesthesia and how often? 30% _____ 65% ___________ 5%

12. NAP4: Results How often do major complications, leading to serious harm, occur in association with airway management in anesthesia, in the intensive care units and in the emergency departments of the UK? 15% 2008

13. NAP4: Results What is the nature of these events and what can we learn from them, in order to reduce their frequency and consequences? 39% 16% 4% 17%

14. NAP4: Results What is the nature of these events and what can we learn from them, in order to reduce their frequency and consequences? # of EVENTS # of annual GAs EVENTS 133 46.3 1 __________________________ _______________________________ ______________________________ _______________________ GAs 2,872,600 1,000,000 21,598

15. NAP4: Results What is the nature of these events and what can we learn from them, in order to reduce their frequency and consequences? !?!?!?! 18% 41% 33% 53% 21% 15% 18% 25% 50% 8% 7% 11%

16. NAP4: Results What is the nature of these events and what can we learn from them, in order to reduce their frequency and consequences? Clinical Themes & Recommendations: Anesthesia induction and maintenance End of anesthesia and recovery Airway devices Management of the CVCI situation Fiberoptic intubation Obesity Pediatrics Obstetrics

17. Anesthesia Induction and Maintenance Clinical ThemesRecommendations Aspiration Most common C.O.D. Always assess aspiration risk Tracheal tubes= highest protection…ONCE PLACED Difficult or failed tracheal intubation Most common problem on induction Multiple attempts with single plan All anesthesia departments should have an explicit policy for difficult/failed intubation that limits number of DL attempts Have a strategy, not a plan prior to induction Perform awake fibreoptic intubation when necessary Difficulties with ventilation Most determined to be due to light anesthesia Prompt deepening of anesthesia with/without NMBs Call for help early Missed esophageal intubations Poor ETCO2 interpretation Flat capnographs seen after tracheal intubation should be promptly investigated to rule out esophageal intubation (or absolute airway obstruction)

18. End of Anesthesia & Recovery Clinical ThemesRecommendations Upper airway obstruction Laryngospasm= root cause Assess risk (ENT surgery, trendelenburg, spasm on induction, reactive airway disease, etc) Bite blocks for ETT and SAD Unanticipated problems Limited evaluation/ preparation of pt for extubation Evaluate and optimize pts prior to extubation (NMB reversal, PreO2, pulm. toileting, etc) Have a reintubation strategy and equipment readily available Transfer & Recovery DIs, Obese, COPD/asthma, OSA, ENT surgery Always use supplementary O2 during transfer High risk pts should be reassessed prior to discharge Convey an airway management plan to recovery room staff in high risk pt Full range of equipment readily accessible in recovery

19. Airway Devices: SADs Clinical ThemesRecommendations Aspiration : most common problem during maintenance Non aspiration: due poor pt/operation selection, poor insertion Obesity, high aspiration risk, predicted DI, urgent surgeries If intubation not indicated but concern for regurgitation, positioning, pt size, airway access= USE a 2 nd generation SAD SADs deserve as much academic attention as tracheal intubation Still establish a airway strategy in the event the airway is lost (esp if SAD placed in a DI) Do not continue with a suboptimal airway

20. Airway Devices: Tracheal intubation Clinical ThemesRecommendations Failed/Difficult intubation 12 unanticipated DI + 42 predicted DI = 54 failed intubations Perform and document thorough airway assessment on every pt Have airway strategy for DL and rescue Blind intubation Recognize the potential value, respect the potential damage Concern for “blind”/anterior view may be best approached with fibreoptic intubation or videolaryngoscopes

21. Management of the CVCI situation Clinical Themes Recommendations Emergency Airways Omission of back up: plans, equipment, skills >60% failure rate for anesthesia providers Recognize high risk CVCI pts: difficult airway history and airway tumors Develop a comprehensive airway strategy prior to induction; strongly consider awake fibreoptic or awake tracheostomy All anesthetists must be trained and keep skills up to date for emergency/cannula and surgical cricothyroidotomy Behavior trends Task fixation= delayed recognition of CVCI situations, delayed rescue methods, etc Limit attempts at DL Attempt a rescue SAD early in the management of a CVCI situation If unable to wake a CVCI pt, administer NMB before proceeding to surgical airway Do NOT inappropriately delay establishing an emergency surgical airway

22. Fiberoptic Intubation Clinical Themes Recommendations Omission Failure to use where strongly indicated Low provider competence and confidence AFOI is the optimal method of securing a difficult airway All anesthetists should be adequately trained and have continued competence training Anesthesia departments should provide a service where skills and equipment are readily available for AFOI Failure Awake vs asleep Oversedation: apnea and obstruction Both asleep and awake fiberoptic intubations fail, so back up strategy still required Use strong consideration in delegating administration and supervision of sedation to another anesthetist

23. Obesity Clinical Themes Recommendations Assessment Assessments: not recorded or DI indicators ignored Aspiration risk Obese pts should have a thorough assessment of airway, aspiration risk, and co-morbidities Anesthesia Strategies Poor GA airway management Failure of RA Do AFOI for pts whom rescue oxygenation or emergency airways are predicted difficult Establish an airway strategy, emphasizing rescue techniques for all obese pts regardless if undergoing GA or RA Emergence and Postop High risk time periods High quality pre-oxygenation on induction AND emergence Be prepared for airway management failure

24. Pediatrics Clinical Themes Recommendations Difficult intubation Limited recorded assessments Repeated attempts to intubate Congenital abnormalities= high potential for extreme difficulty Formal airway assessment should be done on all pediatric pts Airway strategy formulated including rescue devices easily accessible Predicted difficult airway should consider early consultation of ENT Children with congenital abnormalities may have airways that can ONLY be managed with a tracheostomy Events common at end of surgery in recovery Blood in airway Transfer is a crucial time Thoroughly suction pediatric pts; esp ENT surgery Ensure immediate availability of facemask and intubation equipment in the OR, during transfer, and in recovery Training Hypoxia= bradycardia and cardiac arrest Anesthetists involved in pediatric airway management should also be competent and confident in pediatric advanced life support

25. Obstetrics Clinical Themes Recommendations Failed airway/intubation GA often not “plan A” Rescue techniques often failed Despite the infrequency of GA for C- sections, OB anesthetists need to maintain their airway skills; especially rescue strategies to manage difficult intubation, failed intubation, and CVCI situations Best to utilized 2 nd generation if using an SAD Waking the pt up is an appropriate rescue technique in the face of severe maternal hypoxia

26. “There is one skill above all else that an anesthetist is expected to exhibit and that is to maintain the airway impeccably” M Rosen, IP Latto 1984

27. In short…. Questions/Comments References available upon request