Averting errors in Airway management @ emcon 17
-
Upload
drvenugopalan-poovathum-parambil -
Category
Health & Medicine
-
view
360 -
download
2
Transcript of Averting errors in Airway management @ emcon 17
Averting errors in Airway management
Venugopalan Poovathumparambil DA,DNB,MNAMS, MEM[GWU]Director Emergency Medicine
Aster DM Health care
Why ?
Where ?
• Operation theatre
• Intensive Care Units
• Emergency Room
• Pre-Hospital care
Evidence and Source of information Airway errors
• Limitation of literature
• Structured study is difficult
• RCT are unsuitable
• Date collection and analysis is a challenge
Evidence and Source of information Airway errors
Evidence based data for current airway management is low in the hierarchy
Evidence and Source of information Airway errors
• Evidence comprising
• Case reports [Level 4],
• Expert opinion [Level 5]
• Control and cohort studies are rare [Level 3]
• Expert opinions are variable grossly
Evidence and Source of information Airway errors
• Critical Incidents data base
• Litigation datasets
• Both
• Sentinel cases
Evidence and Source of information Airway errors
1. American Society of Anaethesiologists’ Closed Claim Project [ASACCP]- 1991 and 1999
2. NHS Litigation Authority [NHSLA] 1995 to 2007
Closed litigation data base
Evidence and Source of information Airway errors
• Critical incident data base
1. Australian Incident Monitoring Study [AIMS]
2. 4th National Audit Project of Royal College of Anaesthesiologist and Difficult Airway [NAP4]
NAP4 study
Critical incident data base
Incidence of failed intubation 1 in 1–2000 in the elective setting1 in 300 during rapid sequence induction (RSI) in the obstetric setting1 in 50–100 in the emergency department (ED), intensive care unit (ICU),pre-hospital setting.Rate of CICO requiring ESA may rise to 1 in 200 in the ED.
Sakles JC, Laurin EG, Rantapaa AA, Panacek EA. Airway manage- ment in the emergency department: a one-year study of
610 tracheal intubations. Ann Emerg Med 1998; 31: 325–32
The gravity of problem !!!
Incidence ,Causes and Consequences of airway difficulty and Failures
• Tracheal intubation[ DL]
• Face mask ventilation [FMV]
• Laryngeal masks and Supraglottic airways [SAD]
• Video laryngoscopy
• Fiberoptic intubation
Incidence ,Causes and Consequences of airway difficulty and Failures
• Emergency Surgical airway
• Composite failure of airway management
Major airway complications Noted
• Death
• Hypoxia
• Obesity
• Aspiration
• Unrecognised Oesophageal intubation
• Major airway trauma
Averting errors • Poor identification of at risk
patients
• Poor or inadequate planning
• Inadequate provision of skilled staff and equipment to manage these events properly
• delayed recognition of events
• Failed rescue due to lack of or failure of ETCo2
How to prevent airway errors in ED ?
Recommendations from NAP4
How to prevent airway errors in ED ? Recommendations
Capnography
• In all intubations
• All ED anethestization
• Transfers of intubated patients
• Intubation check list - use in all ED intubations[ Preparation of patient, equipment, drugs,Team and back up plans ]
One minute airway check
How to prevent airway errors in ED ? Recommendations
• ED risk assessment - Type of patients , Anticipated airway problems and Plan equipment, training and strategy
• ED equipment to manage anticipatory scenario - Need regular checking, maintenance and replacement after use
How to prevent airway errors in ED ? Recommendations
• Difficult airway trolley - Uniform layout and contents for whole hospital . Need regular checking, maintenance and replacement after use
• Airway comprise : -Secure airway before shifting out of ED, All such shifting are to be made by senior clinician
How to prevent airway errors in ED ? Recommendations
• Establish a robust process to ensure the availability of skilled and senior staff at any time with a reasonable time frame
• Joint training program - Emergency physician anaesthesia and ICU staff
How to prevent airway errors in ED ? Recommendations
• Staff training extra focus : Anticipated clinical presentations, Management of failed intubations ,Emergency surgical airway techniques and airway equipment available in ED
How to prevent airway errors in ED ? Recommendations
• Strong Communication links - Senior ED clinician, Anaesthesia, ICU, ENT surgery ,Other relevant specialities
• Designating consultant leads fro each involved speciality to agree and oversee the management of emergency airway problems in ED
How to prevent airway errors in ED ? Recommendations
• Regular audit should take place of airway management problems or events in the ED
Critical Care Unit How do reduce errors ?
What can be done to improve airway management in ICU?
• Capnography should be used in all intubations
• Continuous capnography should be used in all ICU patients with tracheal tubes [including tracheostomy
• If capnography is not used , reason should be documented and reviewed regularly
What can be done to improve airway management in ICU?
• Clinical staff training to interpret capnography- Identification of airway obstruction, tube displacement ,abnormal capnograph trace during CPR
What can be done to improve airway management in ICU?
Intubation check list - develop and us e in all intubations in critically ill patients
What can be done to improve airway management in ICU?
Recognition of difficulty and back up planning:
A. Algorithms for intubation, extubation and reintubation
B. Patients at risk for airway events - identification and care
C. Plan primary and back up - document ,communicate , additional equipment
D. Hand over and conformation
What can be done to improve airway management in ICU?
Tube displacement
A. Staff education to recognise and emphasis
B. Airway displacement can occur at any time
C. Frequent in Obese , Tracheostomy ,during or after movements , during sedation hold
What can be done to improve airway management in ICU?
Obesity
1. Increased risk for airway complication like tube displacement and harmful events - need meticulous plans
2. Responsible bodies can explore better tube design [Tracheostomy tubes] and optimal mode of fixation
What can be done to improve airway management in ICU?
Airway equipment
A. Immediate access to difficult airway trolly [uniform content and layout ]
B. Need regular checking, maintenance and replacement after use and proper documentation
C. Immediate access to fibroscope
What can be done to improve airway management in ICU?
Cricothyroidotomy
A. Training of staff - regular , manikin based performance, identification of landmarks [obesity ]
B. Research to identify equipment and technique [obesity ]
What can be done to improve airway management in ICU?
Transfers
A. Intra / inter hospital - high risk episode
B. Need airway assessment include patient , equipment, back-up, staff skills
C. Made before transfers
What can be done to improve airway management in ICU?
Staffing
A. Trainee medical staff - proficient in simple emergency airway management
B. Access to senior medical staff with advanced skill at all hours
C. If senior intensivist do not has anaesthesia back ground - need experienced anaesthetic cover to assist difficult cases
What can be done to improve airway management in ICU?
Education and training
A. Junior staff need to get training in basic airway skills , algorithms , predictable airway complications , interpretation of capnography , mechanism to summoning experienced clinician
B. Regular audit on airway problems and critical events
Paediatric airway Very special and unique
Avoidance of airway complications Golden tips
Avoidance of airway complications
Golden tips
• Believe the history and act on a history of previous airway difficulty
• Assess every patient for risk of airway difficulty and aspiration
• Identified risk - ensure the airway strategy- technique , devices and back up plans
Avoidance of airway complications
Golden tips
• Never fail to be prepared for failure - Full preparation involve training , institutional preparedness and personal preparedness
• Do Communicate strategies to team before undertaking
• Do what you can but do not what you cannot - seek help whenever needed , Doing your best is not good enough if your best is not the right thing for the patient
Avoidance of airway complications
Golden tips
• Do not intubate when it is not indicated
• Do intubate when indicated
• Adequate pre-oxygenation
• Know and practice a wide range of airway management skills
Avoidance of airway complications
Golden tips
• Learn techniques you think you will never use - CICO is the biggest disaster in airway management
• If one technique is not working do try different - A technique which fail twice , it is unlikely to succeed and alternative techniques have better chance of success
Avoidance of airway complications
Golden tips
• Do not ever forget the possibility of oesophageal intubation and always confirm with capnography
• Unrecognised oesophageal intubation will cause death and it is 100 percent avoidable
• Treat ICU and ED as places of danger.
Standard crash algorithm vs Vortex 4 step approach
Vortex
Vortex Difficult airway Algorithm Simple ..easy …Visually based cognitive tool
Vortex model
Vortex for failed RSI
Vortex for non RSI Intubation
Vortex for planned spontaneously breathing anaesthesia
Airway management skills-Multifactorial approach
Focused and integrated various interphases involving clinical performance
Research opportunities now open in emergency airway management
Questions??
Thank you so much !!!