2017-18 HSC Section 3 Green Book

Journal of Intensive Care Medicine

Table 4. Methods and Complications Associated With Emergency Surgical Airways.

ESA Event Rate and Mortality

1.2

Final surgical airway method, n (%) Cricothyrotomy

18 (82)

1.0

Tracheostomy

4 (18)

2008-2012 2013-2014

ESA operator service, n (%) Trauma/acute care surgery

0.8

19 (86)

Critical care medicine

2 (9) 1 (5)

0.6

Indeterminate

Incision type, n (%) Vertical

16 (73)

0.4

Horizontal

2 (9)

Indeterminate

4 (18)

0.2

Cricothyrotomy ETT tube size, n (%), mm 5.0 ID

Number Per 10 DAMT AcƟvaƟons

2 (11)

0.0

6.0 ID

13 (72)

ESA Events

ESA Hospital Deaths ESA Event Deaths

>6.0 ID

3 (17)

First attempt ESA success, n (%)

14 (64)

Reintubation following cricothyrotomy, n (%)

7 (39)

recommended when these methods fail; however, there are few studies, if any, that have systematically examined the fre- quency, complications, and outcomes of ESA in hospitalized patients. The frequency of ESA in our study is similar to a report of a population of patients that closely approximates ours, where the frequency of ESA was 0.26 % of 3423 emer- gency intubations. 26 Studies on the frequency of ESA in the ICU environment are limited to 1 large multicenter study where only 1 (0.07 % ) ESA was reported in 1400 ICU intubations. 27 These data corroborate our experience whereby the relatively low frequency of ESA in our ICUs and on hospital wards may be attributable to the ready availability of experienced airway managers in our ICUs, a mature RRT, and an organized DAMT. Although patients with known or predictably DAs are at obvious risk for ESA, other less predictable variables including clinical context, event location, operator experience, equip- ment availability, and number of ETI attempts may interact and culminate in the need for ESA. Risk factors predictive of ESA have not been defined in the literature, but our findings generally align with those that have been defined for DAs in general including obesity, obstructive sleep apnea, airway pathology, limitations in airway visualization, and CPA. 15,27,28 Planned or unplanned extubation preceded ESA in 61 % of ICU patients, an observation not previously considered as a primary risk factor for DA. Complications associated with extubation and extubation management guidelines including those with potentially DAs have been published in the anesthesia litera- ture, with general principles applicable to the critically ill patient including inclusion of an extubation strategy for at- risk patients. 29 For events occurring outside the ICU, unantici- pated catastrophic problems such as airway bleeding or CPA were antecedents to ESA in the majority of cases where ESA Figure 2. Comparison of emergency surgical airway (ESA) events, hospital mortality, and event mortality between the study group (2008-2012) and the subsequent 2-year interval (2013-2014). Emer- gency surgical airway event rates and mortality are represented as the ratio of the number of patients per 10 difficult airway management team (DAMT) events.

Complications, n (%)

15 (68) 11 (50)

Bleeding

Multiple cannulation attempts

8 (36) 7 (32) 6 (27)

Malpositioned tubes

Cardiopulmonary arrest

Pneumothorax

2 (9) 1 (5) 2 (9)

Cricoid cartilage injury Failed cricothyrotomy

Transports to operating room, n (%)

15 (68)

Emergency tracheostomy Cricothyrotomy revision

1 (7)

9 (60) 3 (20) 2 (13)

Replace ETT with tracheotomy tube

Reintubation only

Abbreviations: ID, Inner diameter; ESA, emergency surgical airway; ETT, endotracheal tube.

on overall hospital mortality is reflected in an 84.6 % hospital mortality rate in those patients who had an event-associated arrest versus 22.2 % in patients who survived the event without arrest ( P ¼ .007). Quality Improvement Outcomes To evaluate the potential impact of our continuous QI efforts, we reviewed DAMT outcomes for the 2 years following the inclusive time frame of our study. Compared to 2008 to 2012, there was an increase in DAMT activations for native airway events from 41/year to 48/year during the 2013 to 2014 period. Because the outcomes of interest were relatively infrequent, we indexed ESA event rate and mortality as a proportion of the number of DAMT activations. Compared to the study group, there appears to be favorable trends in the reduction of ESAs and mortality (Figure 2). Discussion Few circumstances in acute care medicine are as challenging as securing an airway in a patient who cannot be intubated, ventilated, or oxygenated using conventional methods of airway management. Emergency surgical airway is widely

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