2017-18 HSC Section 3 Green Book

Reprinted by permission of J Intensive Care Med. 2016 Nov 28. pii: 0885066616680594. [Epub ahead of print].

Review of a Large Clinical Series

Journal of Intensive Care Medicine 1-10

Emergency Surgical Airways Following Activation of a Difficult Airway Management Team in Hospitalized Critically Ill Patients: A Case Series

ª The Author(s) 2016 Reprints and permission:

sagepub.com/journalsPermissions.nav DOI: 10.1177/0885066616680594 jic.sagepub.com

Joseph M. Darby, MD 1 , Gregory Halenda, MD 2 , Courtney Chou, MD 3 , Joseph J. Quinlan, MD 2 , Louis H. Alarcon, MD 4 , and Richard L. Simmons, MD 4

Abstract Introduction: An emergency surgical airway (ESA) is widely recommended for securing the airway in critically ill patients who cannot be intubated or ventilated. Little is known of the frequency, clinical circumstances, management methods, and outcomes of hospitalized critically ill patients in whom ESA is performed outside the emergency department or operating room environments. Methods: We retrospectively reviewed all adult patients undergoing ESA in our intensive care units (ICUs) and other hospital units from 2008 to 2012 following activation of our difficult airway management team (DAMT). Results: Of 207 DAMT acti- vations for native airway events, 22 (10.6%) events culminated in an ESA, with 59% of these events occurring in ICUs with the remainder outside the ICU in the context of rapid response team activations. Of patients undergoing ESA, 77% were male, 63% were obese, and 41% had a history of a difficult airway (DA). Failed planned or unplanned extubations preceded 61% of all ESA events in the ICUs, while bleeding from the upper or lower respiratory tract led to ESA in 44% of events occurring outside the ICU. Emergency surgical airway was the primary method of airway control in 3 (14%) patients, with the remainder of ESAs performed following failed attempts to intubate. Complications occurred in 68% of all ESAs and included bleeding (50%), multiple cannulation attempts (36%), and cardiopulmonary arrest (27%). Overall hospital mortality for patients undergoing ESA was 59%, with 38% of deaths occurring at the time of the airway event. Conclusion: An ESA is required in approximately 10% of DA events in critically ill patients and is associated with high morbidity and mortality. Efforts directed at early identification of patients with a difficult or challenging airway combined with a multidisciplinary team approach to management may reduce the overall frequency of ESA and associated complications.

Keywords emergency surgical airway, cricothyrotomy, difficult airway, difficult airway team, critically ill

Introduction Management of the complex or difficult airway (DA) presents unique challenges for even the most experienced airway opera- tors and is associated with a multiplicity of complications including cardiopulmonary arrest (CPA), anoxic brain injury, failure to secure the airway, and death. 1-9 Direct trauma to the face, bleeding into the airway, CPA, airway obstruction, diffi- cult mask ventilation, and other circumstances may make it impossible to intubate or ventilate critically ill patients in a timely manner in a variety of clinical environments including the intensive care unit (ICU). 1,10-19 Invasive airway access including emergency cricothyrotomy (CRIC) is widely recom- mended as the rescue method of choice when basic and advanced airway management methods have failed. 20-23 The indications for and the frequency of emergency surgical airways (ESAs) in airway management are influenced by a number of complexity variables including event location,

1 Department of Critical Care Medicine, The University of Pittsburgh School of Medicine, Pittsburgh, PA, USA 2 Department of Anesthesiology, The University of Pittsburgh School of Medicine, Pittsburgh, PA, USA 3 Department of Otolaryngology, The University of Pittsburgh School of Medicine, Pittsburgh, PA, USA 4 Department of Surgery, The University of Pittsburgh School of Medicine, Pittsburgh, PA, USA

Received August 10, 2016. Received revised October 16, 2016. Accepted November 02, 2016.

Corresponding Author: Joseph M. Darby, Department of Critical Care Medicine, The University of Pittsburgh School of Medicine, 3550 Terrace Street, 610 Scaife Hall, Pittsburgh, PA 15261, USA. Email: darbyjm@upmc.edu

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