The Obstetric difficult airway guidelines - OAA · PDF fileThe Obstetric Difficult Airway...

The Obstetric Difficult Airway Guidelines

Dr Mary Mushambi

Chair OAA/DAS obstetric difficult airway guidelines group

Consultant Anaesthetist

Leicester Royal Infirmary

The OAA/DAS Obstetric

Difficult Airway Guidelines

The purpose of my lecture

1. Discuss the work that the group has been doing

2. Highlight difficulties of formulating evidence based guidelines

3. Consultation process with you as members of OAA

Who we are

OAA/DAS combined group

Members

Mary Mushambi (Chair) - Leicester

Mansukh Popat - Oxford

Mike Kinsella - Bristol

Hilary Swales - Southampton

Audrey Quinn - Leeds

KK Ramaswamy - Northampton

Anoushka Winton - Trainee

representative

Steve Robson - Obstetrician

Malachy Columb - Statistician

The rest of this presentation

is on behalf of the work done

by the group

OAA/DAS obstetric

guidelines plan

Meeting since May 2012

Funding – DAS & OAA

Gather evidence/literature

search (>6,000 abstracts

and >600 papers)

Librarian support from

Leicester

Review of literature

Airway management in the pregnant woman

• Why airway is difficult

• How to assessment airway

• GA in the pregnant woman

- Pre-oxygenation

- Position

- RSI drugs

- Cricoid pressure

• Unanticipated difficult airway

• Anticipated difficult airway

• Teaching and training

What other guidelines are there

and what can we learn from them?

Plan A:

Initial tracheal

intubation plan

Plan B:

Secondary tracheal

intubation plan

Plan C:

Maintenance of

oxygenation, ventilation,

postponement of

surgery and awakening

Plan D:

Rescue techniques

for "can't intubate,

can't ventilate" situation

Direct laryngoscopy

failed intubation

succeed

succeed

succeed

Tracheal intubation

ILMATM or LMATM

failed oxygenation

failed oxygenation

Revert to face mask

Oxygenate & ventilate

LMATM

increasing hypoxaemia

or

fail

Cannula

cricothyroidotomy

Surgical

cricothyroidotomy

improved

oxygenationAwaken patient

Confirm - then

fibreoptic tracheal

intubation through

ILMATM or LMATM

Postpone surgery

Awaken patient

failed intubation

ASA

Italian

UK

Canadian

Success of the DAS unanticipated guidelines

- Step-by-step approach

- Simple flow charts

- Standardised teaching

- Standardised equipment

Plan A:

Initial tracheal

intubation plan

Plan B:

Secondary tracheal

intubation plan

Plan C:

Maintenance of

oxygenation, ventilation,

postponement of

surgery and awakening

Plan D:

Rescue techniques

for "can't intubate,

can't ventilate" situation

Direct laryngoscopy

failed intubation

succeed

succeed

succeed

Tracheal intubation

ILMATM or LMATM

failed oxygenation

failed oxygenation

Revert to face mask

Oxygenate & ventilate

LMATM

increasing hypoxaemia

or

fail

Cannula

cricothyroidotomy

Surgical

cricothyroidotomy

improved

oxygenationAwaken patient

Confirm - then

fibreoptic tracheal

intubation through

ILMATM or LMATM

Postpone surgery

Awaken patient

failed intubation

OAA guidelines group

Failed intubation guidelines

Selected GUIDELINE examples Dated

•Ipswich Hospital March 2008

•North Bristol NHS Trust August 2008

•Poole Hospital NHS Foundation Trust June 2009

•Queen Charlotte's Hospital London July 2010

•Sandwell & West Birmingham Hospitals NHS Trust March 2009

•Southampton University Hospitals NHS Trust March 2010

(These guidelines first displayed in September 2009)


General/good points

Correct patient

position

Avoid 2nd dose of sux

and multiple attempts

Reducing cricoid

pressure

Easy to follow

flowcharts

Rescue airway

devices


General/good points

Correct patient

position

Avoid 2nd dose of sux

and multiple attempts

Reducing cricoid

pressure

Easy to follow

flowcharts

Rescue airway

devices

Grading of decision

to continue/wake up

Call for help and

who to call for help

Continue with CS as

part of CPR

Follow up and

airway alerts


Poor points

Multiple flow charts with no overall all-in-

one

Inserting Proseal LMA before sux wears

off

No mention or option about whether to

proceed or not

Not having a flow chart


Unsure

Proceed to Proseal LMA before

attempting mask ventilation

All Guidelines mentioned continuing

with SV – Why not IPPV?

Nasal airway or blind nasal intubations

OAA/DAS obstetric guidelines

Brain storming

Questions to address

Brainstorming

Team briefing / ?

Include backup plan

Face mask ventilation

during RSI

Which laryngoscopes

Oxygen insufflation

during laryngoscopy

Max. no. of attempts

STP vs Propofol

Sux vs Roc and

sugammadex

Questions to address

Brainstorming

Team briefing / ? Include

backup plan

Face mask ventilation

during RSI

Which laryngoscopes

Oxygen insufflation

during laryngoscopy

Max. no. of attempts

STP vs Propofol

Sux vs Roc and

sugammadex

Supraglottic devices

How to continue with

GA

How to wake up/position

after FI

Experience of

anaesthetist vs continue

Technique for a known

difficult airway

Help / who and when

OAA/DAS obstetric guidelines plan

Background papers/projects

1. All reported cases/series of failed

intubations

2. Neonatal outcome

3. National OAA survey

4. Anticipated difficult airway

5. Final paper and algorithms

Case Series

Total no of GAs

Number of FI

Incidence of FI

Woken/continue

Airway devices

Morbidity/mortality

Year Case Series1978 Lyons

1979

1980 Glassenberg

1981

1982 Samsoon

1983

1984 Hawthorne McKeen

1985

1986

1987

1988 Saravankumar

1989

1990 Tsen

1991 Rocke Enohumah

1992 Ajmal

1993 Barnardo Nze

1994

1995

1996

1997 Shibli

1998

1999 Rahman

2000 Djabatey Palanisamy

2001 Tao

2002 Kan

2003 Bullough

2004 Teoh

2005 McDonnell

2006 Kirodian

2007

2008 Pujic Kessack Quinn Davies

2009 Keen NOAD 09

2010 NOAD 10

2011 NOAD 11

2012

Failed intubation series1

97

8

19

79

19

80

19

81

19

82

19

83

19

84

19

85

19

86

19

87

19

88

19

89

19

90

19

91

19

92

19

93

19

94

19

95

19

96

19

97

19

98

19

99

20

00

20

01

20

02

20

03

20

04

20

05

20

06

20

07

20

08

20

09

20

10

20

11

20

12

Lyons

Hawthorne

Glassenberg

Samsoon

McKeen

Saravankumar

Tsen

Rocke

Enohumah

Ajmal

Nze

Barnardo

Shibli

Rahman

Djabatey

Palanisamy

Tao

Kan

Bullough

Teoh

McDonnell

Kirodian

Davies

Quinn

Pujic

Kessack

Keen

NOAD 09

NOAD 10

NOAD 11

Number of reports 30

Number of Obs GAs 133,209

Total Failed intubations 330

Median FI rate

CS GAs 1:463

Total GAs 1:411

Case Reports

Urgency

BMI/Weight if available

Airway assessment

Number of attempts

Mask ventilation

Airway device

Cricoid pressure

Continue or wake up

SV or IPPV

Maternal/neonatal outcome

47 case reports

Main findings (case reports and series)

1. Failed intubation rates

2. Wake up or continue - majority continue - from 1990’s

3. Which SAD - majority in literature cLMA

4. 2nd generation LMA - orogastric tubes passed in majority

5. Cricoid pressure - Continued in 50% of cases

? With 2nd generation LMA

6. IPPV vs SV - not clear

7. Maintaining anaesthesia - majority used volatile

Number of failed intubations -

continued or woken up

Wake up vs continue data

F a ile d In tu b a t io n s P ro c e e d in g

Y e a r

Pro

po

rti

on

pro

ce

ed

ing

1 9 8 0 1 9 8 5 1 9 9 0 1 9 9 5 2 0 0 0 2 0 0 5 2 0 1 0

0 .0 0

0 .2 5

0 .5 0

0 .7 5

1 .0 0S lo p e 3 .4 % /y r (9 5 % C I 1 .4 -4 .9 )

P < 0 .0 0 0 1

Case reports – Airway device

cLMA - 23 cases

- 17 (74%) successful

- 12 cases completed on LMA

- 13 (76%) continued CP

2nd generation LMA

- All after 2004

- 8 cases

- All surgery continued

- 7/8 passed OG tubes

Rescue procedures for FI in UKOSS

Rescue Number of cases N = 57

_____________________________________________________

cLMA 39

Intubating LMA 4

Proseal LMA 3

I-gel 3

Bag and mask 2

Smaller ETT 1

Re-intubation attempt 3

2nd dose Suxamethonium 1

Tracheostomy 1

Woken up 4

Sedation and LA 1

Spinal 3

Quinn BJA 2013:110:74-80 (UKOSS 2008-10)

Neonatal outcome data

UKOSS Data

Index Cases

(n=57)

Controls

(n=106)

Odds Ratio 95%CI P value

Maternal

morbidity

8 (14.0%) 7 (6.6%) 2.29 0.78 – 6.67 0.13

Maternal ICU 15 (26.3%) 7 (6.6%) 5.05 1.92 – 13.28 0.001

Neonatal

morbidity

2 (3.5%) 8 (7.5%) 0.44 0.04 – 2.33 0.50

Neonatal ICU 20 (35.0%) 23 (21.7%) 1.93 0.94 – 3.94 0.072

Neonatal

mortality

0 (0.0%) 3 (2.8%) 0.00 0.00 – 4.50 0.55

Maternal and neonatal morbidity and mortality

Variable Odds Ratio 95%CI P value

Failed tracheal Intubation 2.72 1.03 – 7.42 0.043

Lowest SpO2 0.964 0.932 – 0.998 0.037

Gestation (weeks) 0.71 0.59 – 0.83 <0.0001

Birth weight (g) 0.9986 0.9979 – 0.993 <0.0001

Apgar score 1 min 0.77 0.62 – 0.94 0.0083

Maternal morbidity 3.39 0.76 – 15.8 0.12

Current pregnancy problems

1.61 0.48 – 5.47 0.44

Variables were entered at P<0.15 after univariate analyses. Multivariate models include failed tracheal intubation or lowest maternal SpO2 and gestation or birth weight to avoid collinearity leaving five variables per model.

Multivariate exact logistic regression results

for factors influencing neonatal ICU admission


Failed tracheal Intubation 2.72 1.03 – 7.42 0.043

Lowest SpO2 0.964 0.932 – 0.998 0.037

Gestation (weeks) 0.71 0.59 – 0.83 <0.0001

Birth weight (g) 0.9986 0.9979 – 0.993 <0.0001

Apgar score 1 min 0.77 0.62 – 0.94 0.0083

Maternal morbidity 3.39 0.76 – 15.8 0.12

Current pregnancy problems

1.61 0.48 – 5.47 0.44

Variables were entered at P<0.15 after univariate analyses. Multivariate models include failed tracheal intubation or lowest maternal SpO2 and gestation or birth weight to avoid collinearity leaving five variables per model.

Multivariate exact logistic regression results for factors influencing neonatal ICU admission

Neonatal outcome data

(Cases reports and series, UKOSS, CESDI)

Message

• Outcome of baby may be related to reason for the CS

• Prevention of hypoxia reduces NICU admission

• Need neonatologists when failed intubation occurs

• Continue in-utero fetal resuscitation

Management of failed intubation and difficult airways in

UK Obstetric Units - an OAA survey

H Swales, M Mushambi, A Winton, K Ramaswamy, A Quinn, M Popat, M Kinsella OAA Dublin 2014

1. Number of failed intubations occurring within the last year with details of how the case(s) was managed.

2. Availability and use of difficult airway equipment

3. Training of anaesthetists in obstetric anaesthesia

Management of failed intubation in

UK Obstetric Units - an OAA survey

No. of FI 55 (41 case details available)

Continued after FI 28/41 (68%)

SAD 30/41 (73%)

2nd generation SAD 18/30 (60%)

IPPV 18/28 (64%)

NDMR 10/18 (56%)

Volatile agent all except one

Videolaryngoscopes – 90% of units and Airtraq most common

Anticipated difficult airway review

80 case reports

0

5

10

15

20

25

30

35

40

Failures

Numbers

Be prepared for failure of plan A – Have a Plan B/C

Anticipated difficult airwayAssessment and planning

1. Assess the nature of airway

difficulties

2. Formulate anaesthetic and

obstetric plan

3. Communicate with teams

and patient

4. Vaginal delivery /operative

delivery (awake or GA)

5. Plan for unplanned

emergency admission

Algorithms/Tables

1. Performing a safe GA

2. Failed intubation drill

3. Decision making table

4. Continue/wake up plan

5. Can’t intubate can’t oxygenate (CICO)

6. Anticipated difficult airway

Safe airway environmentEquipmentTrained primary anaesthetistTrained assistantSenior help identified

Planning, Preparation and Performing

Pre-theatre preparationAirway assessmentExplanation & consentAntacid prophylaxisStarvation

Team Safety CheckWHO checklistPre plan – wake up Vs continuePre plan equipment

Safe Obstetric General Anaesthesia

Rapid sequence inductionPatient positionPre oxygenationInduction agent – adequate dose Cricoid pressure Muscle relaxant – adequate doseGood laryngoscopy technique

Vaginal delivery Caesarean Section

Antenatal anaesthetic assessment

Multidisciplary planning (severe cases)

Primary and back up plans

Documentation of plan (s)Decision: Mode of delivery

MODE OF DELIVERY

Communication(obstetrician, anaesthetist, midwife, patient)

Review management plans

Alert senior personnel

Aspiration prophylaxis

Early working epidural

Airway avoidance

Central neuraxial blockClinical judgement: Spinal, Epidural, CSE, CSA

Fail

Contraindicated

Airway manipulation

Awake (fibreoptic) intubation

Awake tracheostomy

GA

EMERGENCY ELECTIVE

Management of obstetric patient with anticipated difficult airway

Other things to address

List of recommended equipment

Section on training and human factors

Liaise with the DAS unanticipated

guidelines group on RSI and CICO

Level of evidence

No randomised trials to support the majority of our

work.

Most of evidence is by way of case reports/series

and consensus.

Therefore we shall not grade the guidelines

according to level of evidence.

Thanks to

1. Members of the group

2. Steve Robson and

Malachy Columb

3. UKOSS – Neonatal data

4. Sheffield and Manchester

teams for allowing us to use

their data

5. OAA and DAS for paying

our expenses

Anaesthesia 1982

The rapid induction technique for Caesarean section

Why do we still use Suxamethonium?

Young anaesthetists in this country are taught that the use of this drug to facilitate intubation in CS is virtually mandatory….

I have used a technique for 5yrs which avoids both sux and atropine but permits equally rapid intubation ..and there has not been a single case of regurgitation.

Pt is pre-oxygenated with a tilt 10 degrees to the left, cricoid pressure is then applied by a trained assistant and alcuronium 0.25 mg/Kg injected into the iv infusion set port and this is immediately followed by a sleep dose of methohexitone

Letter in Anaesthesia 1982


Inflation of the lungs is gently begun in time with the

patient’s own inspiration efforts which usually cease

shortly after the injection of methohexitone, so that,

between 10 and 20 seconds after methohexitone has

been given, intubation is easily accomplished and a

conventional maintenance regime instituted.



Should it prove impossible to intubate the patient, atropine is given, oropharyngeal toilet carried out and ventilation is maintained by mask with an airway inserted if necessary. Cricoid pressure is maintained throughout the procedure using a mechanical device which I have developed partly for this eventuality, which will be described in a paper which is in preparation.



Should it prove impossible to intubate the patient, atropine is given, oropharyngeal toilet carried out and ventilation is maintained by mask with an airway inserted if necessary. Cricoid pressure is maintained throughout the procedure using a mechanical device which I have developed partly for this eventuality, which will be described in a paper which is in preparation.

A I Brain, Anaesthesia:1982

Any comments and questions

[email protected]


Failed Tracheal Intubation 1.93 0.94 – 3.94 0.072

Maternal Age (years) 1.49 0.29 – 7.52 0.63

Apgar Score 1 minute 0.50 0.38 – 0.66 <0.0001

Urgency Grade 0.81 0.56 – 1.17 0.27

Birth Weight (g) 0.9989 0.9984 – 0.9995 0.0005

Lowest SpO2 (%) 0.972 0.946 – 0.998 0.036

Gestation (weeks) 0.65 0.55 – 0.77 <0.0001

BMI (kg m-2) 1.01 0.96 – 1.07 0 .60

Ethnicity (white) 1.83 0.80 – 4.21 0.30

Maternal Morbidity 3.76 1.27 – 11.14 0.017

Current Pregnancy Problems 4.37 2.06 – 9.27 0.00012

Smoking history 1.20 0.55 – 2.60 0.65

Univariate logistic regression for factors influencing neonatal ICU admission

Anticipated difficult airwayfailures and solutions

Epidurals (64%)

Dural tap (3) - CSA (High BMI 62 and 83)

Failed to top up - Failed AFI – ILMA and intub through ILMA

- GA with glidescope

- Spinal – failed – AFI

CSE (33%)

Dural tap - CSA

Intra-op pain - Remifentanil

Spinal(29%)

Failed spinal - GA - FI – Glidescope

GA (MOH) - Inhalational and size 5 ETT

OAA/DAS obstetric guidelines

planConsultation period in 2014

Publish end 2014 (?2015)

Where- submit to:

Background papers – IJOA

Guideline paper – Anaesthesia

Algorithms – (? copyrights to DAS and OAA)

IJOA & OAA/DAS website

Links to DAS/OAA website for extra papers or information

Why do we need national obstetric

difficult airway guidelines?

1. Reduced GA rates &

reduced number of

GAs per trainee

2. Morbidity/mortality

related to GA

3. DAS guidelines

4. National survey of

obstetric guidelines in 2009

5. Coroners Rules and

preventable deaths

6. Request from DAS

and OAA members

7. Pregnant woman

- Physiological

- Anatomical

- Foetus

8. Labour ward

environment

Why do we need national obstetric guidelines? –

Training issues

Number of C/S under GAs ↓

1982 - 425

1998 - 68

2006 - 41

Number of GAs per trainee ↓

1982 - 18

1998 - 4

2006 - 1

Johnson Anaesthesia 2000Searle IJOA 2008

Total LSCS

GA LSCS

GAs per trainee

Why do we need national

obstetric guidelines


reduced number of

GAs per trainee


related to GA

3. DAS guidelines

4. Survey 2009

• CEMACE – 3 airway deaths

- Aspiration on emergence ?use of orogastric tube

- Unrecognised oesophageal intubation

• NAP4 - 4 cases - all alive

- Failed AFI- Failed needle FON (obese)- Failed proseal/Bonfils

success with McCoy

Preventable deaths (CMACE) and advanced airway skills (NAP4)

Why do we need national

obstetric guidelines


reduced number of

GAs per trainee


related to GA

3. DAS guidelines

4. Survey 2009

National survey of obstetric difficult airway guidelines and equipment

A Joseph, J Dedhia, M. Mushambi

Anaesthetics, University Hospitals of Leicester Leicester, UK

IJOA 2009;18:S40

Guidelines used in 131 hospitals

Guidelines

DAS guidelines 21 (16%)None 3 (0.2%)

Methods to improve laryngoscopy

33% did not advice change in head/neck position.

38% did not advice change of blade

32% did not advice use of bougie

Methods for oxygenation

Nasopharyngeal airway 21 (16%)

Proceed or wake up

Most units did not mention indications for continuing

Joseph IJOA 2009;18:S40

Survey findings

16% using unmodified DAS guidelines

Maximum attempts of laryngoscopy

Methods to improve laryngoscopy

Methods of oxygenation following failed laryngoscopy

Most units did not mention indications for continuing

Exclusion of Obstetrics in the RSI algorithm

The Obstetric difficult airway guidelines - OAA · PDF fileThe Obstetric Difficult Airway...

Documents

Transcript of The Obstetric difficult airway guidelines - OAA · PDF fileThe Obstetric Difficult Airway...