Why do we use a pre-anesthetic checklist?

!

And how do we use it?

Do we need to improve our RSI systems? - Yes!

• Complication rate varies internationally.

• Hypoxia 19 (UK)1%

• Hypotension 17.8 (UK)1

• Arrhythmia 3.4 % (UK)1

• Cannot intubate 1/300 - 1/800

• Cannot intubate + cannot ventilate 1/200 in all cases

• Difficult intubation up to 9% in ED (UK)3

• Surgical airway up to 0.6 (UK)4 -0.9%

(USA) in ED2

What is our experience locally?

• Little provincial safety data

• Recent needs assessment in NB - Only 54% of 56 physician respondents were confident with RSI

• <50% perform RSI more than once per month

• A growing number of significant events reported secondary to failed or complicated airway management.

NAP44 and other Airway Research Errors show Recurrent themes

• Poor airway risk assessments. • Poor Planning for the initial

approach. • Poor Planning for rescue

approaches. • Repeated attempts at intubation

making things worse. • Missing or broken equipment. • Failure to use Capnography. • Aspiration. • Poor judgement. • Poor education.

So how many do I need to do?

• Single centre in UK, 5 years, 329 RSIs.

• Complication rates drop after a total of 30.

• At least 7/year to achieve an acceptable complication rate.

• + Simulator based in situ training , monthly refresher + case reconstruction + audit

a. ongoing independent RSI practice;b. confidence to make the decision to proceed with RSI and

perform independently at the end of training;c. confidence to perform pre-hospital RSI;d. amount of anaesthetic experience prior to completion of

training;e. suggestions of how training could be improved.

RESULTSRSI patient populationTable 1 presents results of the intubation registry. RSI wasperformed on a total of 329 patients (207 male/122 female)during the study period. This equates to approximately 77patients annually. Forty-five (14%) patients received RSI in thepre-hospital environment. Mean patient age was 41 years; 10patients in the study were children (age #14).

RSI case-mixThe primary reason for RSI was trauma, 134 (41%) patients,toxicology 83 (25%), neurological disease 66 (21%), cardio-respiratory disease 39 (12%) and other reason 7 (2%).

RSI Operator ExperienceRSI was performed by emergency physicians in 288 (88%)patients. ED registrars were the predominant RSI operator, with206 patients (63%). ED consultants performed RSIs on 82 (25%)patients, anaesthetic registrars on 31 (9.4%) patients, and anaes-thetic consultants on 8 (2.4%) patients. Figure 1 shows annualoperator trend. An ED consultant was present during every RSIperformed and an anaesthetist was present during 72 (22%). Theaverage number of ED registrars during this period of training was8. This equates to each ED trainee performing approximately 26ED RSIs (6.5 RSIs/year). On average, ED consultants performed14 RSIs during this period (approx 3.5 RSIs/year).

Pre-hospital RSIForty-five (14%) RSIs were performed in the pre-hospital envi-ronment. Fifteen (33%) of these were performed by ED registrarsunder the supervision of the ED consultant. The remaining 30RSIs were performed by the duty ED consultant. Road trafficcollision victims were the predominant patient population (39,87%). Other reasons for pre-hospital RSI included: strangulation,foreign body aspiration, shotgun injury to the chest, lifethreatening asthma, and spontaneous intra-cerebral haemor-rhage in a paediatric patient.

Postal survey responseSeventeen doctors were identified that had completed EDregistrar training in Ninewells Hospital, Dundee. Twelve (71%)completed questionnaires were returned. Figures 1 and 2 presentgraphs showing the responses to questions (a)e(c) and (d),respectively.

A number of suggestions were made to improve ED registrartraining. These included: monthly access to an anaesthetic list;refresher training in theatre if >2 months since last RSI; regularmoulage for RSI and failed intubation drills; in accordance withcurrent training, a full anaesthetic training post for a year andnot a supernumerary 12-week secondment; and Great North AirAmbulance pre-hospital anaesthesia course, standardised as partof training.

DISCUSSIONThe case-mix of patients requiring RSI in this study is compa-rable with previous reports from other Scottish hospitals.5 6

Trauma remains the most common reason for RSI. Eighty-eight

per cent of the RSIs during this observed period were performedby emergency physicians (EPs). ED specialist registrars were themost frequent operator, supervised by an ED consultant. This isthe highest frequency of EP RSI practice documented in the UK

Table 1 Results of intubation registryRSI population

Total no of RSI performed 329 (207 men/122 women)

Pre-hospital RSI 45 (14%)

Paediatric RSI (age<14) 10 (3%)

Mean age 41 years

Median time to intubation 20 min (mean 53)

Primary reason for RSI

Trauma 134 (41%)

Neurological 66 (21%)

Toxicology 83 (25%)

Cardiorespiratory 39 (12%)

Other 7 (2%)

RSI operator

ED consultant 82 (25%)

ED registrar 206 (63%)

Anaesthetic consultant 8 (2.4%)

Anaesthetic registrar 31 (9.4%)

Urgency of intubation

Immediate 111 (34%)

Urgent 204 (62%)

Semi-elective 14 (4%)

Anticipated problems

Cervical spine immobilisation 100 (30%)

Obesity 28 (8.5%)

Difficult airway 21 (6%)

Physiology pre-RSI

Pulse <40>140 29 (8.8%)

RR <10>29 74 (22.5%)

GCS 8 or less 251 (76%)

Systolic<90 mm Hg 37 (11%)

Saturation<90% 63 (19%)

None of above 31 (9.4%)

Anaesthetic induction agents

Thiopentone 195 (59%)

Etomidate 94 (29%)

Propofol 5 (1.5%)

Gas 3 (1%)

Midazolam 4 (1%)

Ketamine 11 (3%)

Intubation attempts

1st attempt 289 (87%)

2nd attempt 36 (11.5%)

3rd attempt 4 (1.5%)

Grade of view (1st attempt)

Grade 1 233 (71%)

Grade 2 52 (16%)

Grade 3 21 (6.4%)

Grade 4 10 (3%)

Adverse events related to RSI

Desaturation 11 (3%)

Cardiac arrest 1 (0.3%)

Hypotension (requiring fluids/pressors) 13 (4%)

Trauma 1 (0.3%)

Failed intubation 2 (0.6%)

Surgical airway 2 (0.6%)

Aspiration 1 (0.3%)

Recognised oesophageal intubations 8 (2%)

Total 39 (11%)

ED, emergency department; GCS, Glasgow coma score; RR, respiratory rate; RSI, rapidsequence intubation.

776 Emerg Med J 2011;28:775e777. doi:10.1136/emj.2010.096396

Original article

group.bmj.com on February 7, 2014 - Published by emj.bmj.comDownloaded from

Checklists in Medicine

Checklist Risk Reduction

WHO Surgical Safety Checklist

Mortality decreased by 3.13%

Central Line Insertion 66% reduction in Catheter related infection

RSI 50% reduction in Errors

Plan D Cricothyrotomy

RSI KIT DUMP

HME Filter

EtCO2

Glidescope, McCoy, Macintosh, Miller or Air Q can be Primary or back-up Blade. LMA for Plan B

RSI Checklist

Plan C OPA + 2 NPA + HFNC

+BVM + EtCO2

+ 2 Person

Plan B LMA

Bougie

LMA

Plan A Intubate

Plan A 1st B

lade

10ml

Pla

n A

2nd

Bla

de

EasyCap and EtCO2

Plan

C

Plan

A

Plan

A

Plan

C

Plan B LMA

Size 4 F

Bougie/Stylet

Emergency RSI Checklist.Stabilize the Patient Prior to giving the drugs.1. Have Patient ABCs been stabilized?

2. Is oral intubation difficult or impossible?

2. BVM and Hi-flo Nasal Cannula Pre Oxygenation on 15 Litres in progress?

3. Has Levitan’s Line Achieved? (not in trauma)

4. Suction turned on and under the pillow?

5. Has NIBP (on a 3 minute cycle), 3 Lead ECG, SpO2 been attached?

6. Is fluid running easily in the IV/IO line?

Calculate Drug Doses Based on Weight and Stability.1. Who is giving the drugs?

2. Patient weight?

3. Patient shocked or stable?

4. Best dose of Ketamine (or Etomidate)?

5. Best dose of Succinylcholine (or Rocuronium)?

Drug! Stable Dose ( 70 kg adult dose)

Shocked Dose ( av 70 kg adult dose)

Ketamine (10mg/ml) !Draw up 20 mls 2.0mg/kg (give 14mls) 1.0mg/Kg (give 7mls)

Etomidate (2mg/ml)!Draw up 10 mls 0.3mg/Kg (give 10mls) 0.1/mg/Kg (give 3.5

mls)

Succinylcholine (20mg/ml) DRAW up 10mls

1.5 mg/Kg = 105mg = 5mls (wait 45 secs)

Rocuronium (10mg/ml)!Draw up 10mls 1.2 mg/kg = 84mg = 9 mls (wait 45-60 secs)

Make a Plan 1.Which blades for Plan A (1. Direct with bougie or 2. Video with Stylet?)

2. What size LMA for Plan B?

3. Are all kit dump items present?

4. Surgical Airway Kit in Airway Cart?

5. Is the EasyCap EtCO2 on the kit dump?

6. Is the C-Collar un-done and is someone doing stabilization from below?

7. Checks Complete - Anesthetize! Ketamine push then Rocuronium push.

8. Bag ventilate slowly if SpO2 approaches 93%.

References and Other Resources

1. Emerg Med J. 2004 May;21(3):296-301. The who, where, and what of rapid sequence intubation: prospective observational study of emergency RSI outside the operating theatre. Reid C, Chan L, Tweeddale M. !2.Airway management by US and Canadian emergency medicine residents: a multicenter analysis of more than 6,000 endotracheal intubation attempts. Sagarin MJ, Barton ED, Chang YM, Walls RM, National Emergency Airway Registry Investigators. Ann Emerg Med. 2005;46(4):328. !3. Training and competency in rapid sequence intubation: the perspective from a Scottish teaching hospital emergency department. Emerg Med J 2011;28:775 - 777. !4. Cook TM, Woodall N, Frerk C; 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 1: anaesthesia. Br J Anaesth 2011;106:617-631. all available at http://www.rcoa.ac.uk/nap4

5. Annals of Surgery, January 2012 - Volume 255 - Issue 1 - p 44–49. Effects of the Introduction of the WHO “Surgical Safety Checklist” on In-Hospital Mortality: A Cohort Study. van Klei, W. A., Hoff et al.

6. The New England Journal of Medicine. December 28, 2006. 355(26)An Intervention to Decrease Catheter-Related Bloodstream Infections in the ICU. Peter Pronovost et al. http://www.nejm.org/doi/pdf/10.1056/NEJMoa061115

7. Mackenzie R., French J., Lewis S. & Steel A. (2009) A pre-hospital emergency anaesthesia pre-procedure checklist SJTREM 2009 17 (supp 3) O26

http://kidocs.org/2014/03/real-airway-doctors-use-checklists/ a great bog run by a colleague in retreival medicine that discusses checklists, human factors and much more.

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