2017-18 HSC Section 3 Green Book

Darby et al

Airway Management Methods employed in airway management prior to undergoing ESA and related complexities of management are shown in Table 3. The GlideScope video laryngoscope was unavailable to the DAMT for 7 events where endotracheal intubation (ETI) was attempted prior to ESA. Standard direct laryngoscopy (DL; n ¼ 14) or DL with bougie (n ¼ 1) was chosen as the initial method of intubation in the vast majority of patients where ETI was attempted. In 10 patients, multiple methods of intubation were attempted prior to ESA, which included DL þ bougie (n ¼ 5), GlideScope (n ¼ 3), LMA-guided bronchoscopy (n ¼ 2), blind LMA guided (n ¼ 2), bronchoscopy (n ¼ 1), Airtraq (n ¼ 1), and digital (n ¼ 1). Detailed information on airway operators attempting ETI prior to ESA was limited in retrospect; however, the majority (84 % ) of operators providing initial airway management were documented to be ICU fellows or attending-level physicians. Of the 19 patients who under- went ESA following failed intubation attempts, 13 (68 % ) underwent 3 or more attempts to intubate prior to proceeding to ESA. Neuromuscular blockers were documented to have been administered in 12 (63 % ) patients undergoing attempts at ETI, with the proportion increasing to 75 % when arrested patients are excluded. Ineffective bag valve mask as evidenced by persistent arterial desaturation was documented in most cases (89 % ), whereas ineffective LMA-assisted ventilation was documented in 26 % . A number of variables potentially affecting the complexity of airway management were present, with the most common being impaired visualization of the glottis in 18 (95 % ) patients who underwent an attempt at ETI prior to ESA. Formal grading of the glottic view was absent in most cases; however, there were 7 (37 % ) patients with a documented Cormack-Lehane grade III and IV view. The glottic view was obscured by vomi- tus in 2 patients and by blood in 3 other patients. Airway pathology was present in 11 (58 % ) at the time of DAMT events, with airway edema described in 8 (42 % ) of all cases where there was an attempt at ETI. One patient had a tumor of the upper airway, whereas another had undergone recent resec- tion of the base of the tongue for carcinoma. Tracheal stenosis was present in 1 patient with scleroderma. A number of other anatomical and physiological variables were present adding to the complexity of airway management and included limitations in neck mobility, restricted mouth opening, macroglossia, arterial desaturation, bradycardia, and ongoing cardiopulmon- ary resuscitation (CPR). Emergency Surgical Airways The majority of ESAs in this series occurred in ‘‘can’t intubate can’t ventilate’’ scenarios, whereas 3 (14 % ) patients underwent ESA without any attempt at ETI. Two of these patients had malignancies involving the tongue associated with acute oro- pharyngeal bleeding, whereas a third patient with a cervical spine fracture and limited mouth opening underwent ESA when initial manual ventilation was ineffective and CPA was

Surgical airways that were performed in the operating room (OR) following DAMT activation on patients who did not have a need for immediate airway control were classified as urgent surgical airways and excluded from analysis. Emergency sur- gical airway events occurring in the ED or the OR were also excluded since these locations are clinical environments that usually manage patients in need of ESA without the assistance of our DAMT. Data Collection and Analysis For each patient in this series who underwent ESA, electronic medical records were reviewed in detail and data extracted by one of the authors (J.M.D.). Demographics, event-related clin- ical data, airway complexity variables, and airway manage- ment–related details were tabulated. Specific outcomes of interest included ESA event frequency, complications related to ESA, event mortality, and all-cause hospital mortality. Data were summarized using simple descriptive statistics, with con- tinuous data presented as mean + standard deviation (SD) and categorical variables expressed as frequencies. Where appro- priate, Fisher exact test was used for comparisons of categori- cal variables. During the study period, there were a total of 266 DAMT activations. After a number of exclusions, there were 207 native airway events, with 22 (10.6 % ) events culminating in ESA (Figure 1). A robust airway registry was not available, but based on a review of airway kit utilization data from our hos- pital central supply, we derived an estimate of the frequency of ESA to be in the range of 0.2 % of all native airway intubations occurring during the study period. Patient and DAMT Event Characteristics The majority of patients in this cohort were male (77 % ), obese (64 % ), and had comorbid conditions (86 % ; Table 1). A history of DA was present in 9 (41 % ), with prior head and neck surgery in 6 (27 % ) patients. The DAMT events culminating in ESA were more commonly activated for patients in ICU locations (59 % ) than for non-ICU locations (Table 2). Activations for ICU patients occurred most commonly in the context of a planned (n ¼ 4) or unplanned (n ¼ 4) extubation, whereas activations in non-ICU locations occurred mainly in the context of bleeding originating from the respiratory tract (n ¼ 4) or CPA (n ¼ 3). Cardiopulmonary arrest occurred in 7 (32 % ) patients prior to establishing a secure ESA. Three of these arrests occurred prior to any attempts to intubate, whereas 1 occurred in the OR prior to ESA without any attempt to intu- bate. Three other patients arrested during attempts to intubate and prior to ESA. Results Event Frequency

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