2017-18 HSC Section 3 Green Book

Darby et al

Table 1. Demographics and Characteristics of Patients Undergoing Emergency Surgical Airways.

Table 3. Airway Management and Complexity in Patients Undergoing Emergency Surgical Airways.

Patients, n

22

Intubation methods, n (%) No ETI attempted Direct laryngoscopy alone Video laryngoscopy alone

Male sex, n (%)

17 (77)

3 (14) 7 (32)

Age, mean + SD (range), years Obese (BMI > 30 kg/m 2 ), n (%) BMI, mean + SD (range), kg/m 2 Emergency hospital admission, n (%) Admitting hospital service, n (%) Neurosurgery and neurology

61 + 11 (37-83)

2 (9)

14 (64)

31.4 + 7.1 (19.9-45.0)

Multiple intubation methods

10 (45)

Initial airway operator, n (%) Attending

15 (68)

5 (26)

Fellow

11 (58)

10 (45)

Resident

1 (5)

Internal medicine

5 (23) 4 (18)

Indeterminate

2 (11)

Otolaryngology and plastic surgery

Three or more intubation attempts, n (%)

13 (68) 12 (63) 17 (89)

Trauma–general surgery Cardiothoracic surgery Comorbid conditions, n (%)

2 (9) 1 (5)

NMB use documented, n (%)

Ineffective BVM, n (%)

19 (86)

Charlson index, mean + SD (range)

2.2 + 2.0 (0-8)

Ineffective LMA ventilation, n (%)

5 (26)

Initial airway management complexity, n (%) Impaired glottic view

ICU location, n (%)

13 (59)

18 (95)

Airway history, n (%) History of difficult airway Prior head and neck surgery

Bleeding or vomitus Airway pathology Limited neck mobility

5 (26)

9 (41) 6 (27) 3 (14) 3 (14)

11 (58)

5 (26) 2 (11) 4 (21)

Prior tracheostomy

Restricted mouth opening

Obstructive sleep apnea

Macroglossia

Tracheal stenosis

1 (5)

Hospital LOS, mean + SD (range), days

11 + 10 (1-35)

SaO 2

< 80%

15 (79)

Hospital mortality, n (%)

13 (59)

Bradycardia

7 (37) 6 (32)

Cardiopulmonary resuscitation

Abbreviations: BMI, body mass index; ICU, Intensive care unit; LOS, length of stay; SD, standard deviation.

Abbreviations: BVM, bag valve mask; ETI, endotracheal intubation; LMA, laryn- geal mask airway; NMB, neuromuscular blockers; SaO 2 , arterial saturation.

Table 2. Difficult Airway Management Team Event Characteristics.

(n ¼ 3). Including CPA events prior to ESA, 9 (41 % ) patients were undergoing CPR at the time of the ESA, potentially con- tributing to observed complications. Of the 22 patients who underwent ESA, 15 (68 % ) patients were emergently trans- ported to the OR, including 1 patient with prior major complex head and neck surgery with an acutely bleeding upper airway in need of emergency TRACH. Of the 12 patients transported to the OR following emergency CRIC, 9 underwent surgical revi- sion to TRACH. Plans for CRIC revision were aborted in 3 patients after arrival to the OR. Instability in respiratory status following reintubation in the OR occurred in 2 patients, whereas ongoing bleeding related to prior ESA occurred in another patient prompted abandonment of revision plans with surgeons opting instead to exchange the in situ ETT for a standard TRACH tube. Mortality Overall hospital mortality for patients undergoing ESA in this case series was 59 % . Of the 13 hospital deaths, 5 (23 % ) occurred in the context of the airway event itself, constituting 38 % of all hospital mortality. Anoxic brain injury was present in 5 of the deaths remote from the airway event. Cardiopul- monary arrest occurred during the course of airway manage- ment for which the DAMT was activated in 13 (59 % ) patients undergoing ESA. Only 2 (15 % ) of these patients survived hos- pitalization without anoxic brain injury, whereas 88 % of patients undergoing ESA without CPA survived to hospital discharge without anoxic brain injury. The influence of CPA

Patient location, n (%) ICU

13 (59)

Non-ICU

9 (41)

ICU airway event context, n (%) Planned extubation

4 (31) 4 (31) 4 (31)

Unplanned extubation Respiratory failure Upper airway bleeding

1 (8)

Non-ICU event context, n (%) Upper or lower airway bleeding

4 (44) 3 (33) 2 (22) 4 (18) 3 (14) 5 (23)

Cardiopulmonary or respiratory arrest

Respiratory failure

Cardiopulmonary arrest, n (%) Prior to any airway interventions

During ETI attempts Event mortality, n (%)

Abbreviations: ETI, endotracheal intubation; ICU, intensive care unit.

attempts to secure the airway following surgical exposure. Endotracheal intubation subsequent to ESA was performed in 7 (32 % ) patients, with 6 of these performed in the OR in the context of planned CRIC revision. One patient with ARDS undergoing prone ventilation had an unplanned extubation and was reintubated in the ICU after ESA. Complications associated with the performance of the ESA occurred in the majority (68 % ) of patients. Cardiopulmonary arrest occurred in 6 (27 % ) patients, with 3 occurring during the ESA procedure itself (n ¼ 3) or following ESA in the OR

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