2017-18 HSC Section 3 Green Book

Darby et al

was performed. Notably, 3 patients with airway bleeding had undergone surgery involving the upper airway for malignancy or were complications related to malignancy highlighting a population of patients where airway management would be predictably difficult because of distorted anatomy and/or visual obscuration. Finally, the high proportion of patients with neu- rological disease in our study (45 % ) may be a reflection of potential difficulty in airway management associated with impaired arousal. 27 The overall complication rates associated with ESA as reported in the literature are variable and range from 12 % to 54 % . 30-37 Not unexpectedly, complications in our study were common (68 % ) and similar to those reported in the literature. While most ESA procedures were successful on initial attempts, malpositioned tubes and multiple attempts to cannu- late the airway necessarily resulted in a delay in securing the airway and may have contributed to CPA in 3 (13.6 % ) patients while undergoing ESA. Technical factors may also have con- tributed to complications include ESA performed without the adjunctive use of an intubating stylettes 38,39 the use of larger sized ETTs, and the performance by inexperienced operators in some cases. Obesity that was present in 64 % and ongoing CPR in 41 % are yet other factors potentially contributing to observed complications. Although ESAs were successfully secured in all cases, ini- tial attempts at emergency CRIC did fail in 2 (10 % ) patients where CRIC was chosen as the initial method, while there were no failures with emergency TRACH as an initial method (n ¼ 2) or as a rescue method following failed CRIC (n ¼ 2). Our success rates for emergency CRIC are consistent with those reported in the literature ranging from 88 % to 100 % . 33,34,36,40,41 Fewer data are available on the success rates of emergency TRACH, but data from several reports of ESA performed in hospital settings by otolaryngologists or general surgeons indicate success rates of 100 % . 11,32,41 Notwithstand- ing our success rate in initially securing the airway with CRIC, 12 patients who underwent CRIC were taken emergently to the OR for planned revision to TRACH. Nine of these patients eventually underwent revision to TRACH, whereas the other 3 could not be revised because of respiratory instability or bleeding complications. Revision of emergency CRIC to TRACH is routine at many institutions, but it may be unneces- sary and is associated with significant risk. 32,42-44 The decision to revise emergency CRIC to TRACH therefore should be individualized taking into consideration such things as stability of the patient, the risks of transport, the anticipated duration of mechanical ventilation, the need to address surgical complica- tions, and the stability of the ESA itself. In some cases, ETI may still be a viable option and should be considered once the patient’s clinical condition has stabilized after ESA. Not unexpectedly, overall mortality for patients requiring ESA was high (59 % ) and within the range reported by others (32 % -85 % ). 30-32,36,42,45,46 Risk factors for mortality in patients undergoing ESA are poorly defined; however, there was 100 % mortality in 47 (49.5 % ) trauma patients who underwent CPR prior to or during emergency CRIC. 42 The high ESA event

mortality and high mortality rate observed in patients who had CPR in our series emphasize the importance of early recogni- tion of patients with challenging airways or DAs in an effort to prevent CPA as well as the need for experienced teams in preventing CPA during the course of emergency airway management. While the concept of a DAMT as an integral component of our RRS emerged late in 2005, focused attention to process improvement was slow until 2008 when our case reviews high- lighted a number of system vulnerabilities. We were impressed that many ESA cases in which there was an adverse outcome seemingly were related to failures in identifying patients with previously known DAs, delayed notification of the DAMT, and/or an excessive number of intubation attempts prior to calling for help. Although we have subsequently introduced many changes to the system, our primary intervention was the development and wide distribution of DAMT activation cri- teria. Based on our detailed review of all DAMT activations occurring from 2008 to 2012, we revised our original DAMT triggers to include provisions for criteria-based mandatory acti- vation of the team (Table 5). In the latest iteration of our trig- gering criteria, we have also included DAMT activation for pediatric RRT events where ETI is needed since most airway providers at our institution are inexperienced in pediatric air- way management. Changes in institutional culture have occurred over the course of time mainly through greater awareness and attention to DAMT activation criteria, prominently displayed electronic health record alerts for patients with known DAs, and most importantly through more frequent activation of the DAMT itself. Reluctance to call for help by physicians and nursing staff alike has palpably waned, while events themselves have become less chaotic. Concomitant with an evolving culture of patient safety, dedicated and required educational programs focused on DA management and ESA training for CCM fel- lows and surgical residents have matured over the course of the last 5 years or so. Morbidity and mortality conferences in the Department of Critical Care Medicine now routinely present and discuss DA cases as an opportunity to learn and improve upon emergency airway management. The value and utility of video laryngoscopy in DA management as demonstrated by our DAMT prompted the acquisition and widespread availability of these devices in our ICUs and are now in common use. Stimu- lated by a number of ESA events in their patients, we have also engaged and recruited leaders from the otolaryngology service to further guide and improve our efforts to improve outcomes. Finally, the efforts of our DAMT have motivated substantial interest and activity in QI projects that are focused on the DA problem. We believe that our QI efforts have had a positive impact on the DA problem in general and specifically on ESA outcomes as suggested in our data. That a dedicated DA team is influen- tial in reducing the frequency of ESAs in hospitalized patients has also been shown by the group at Johns Hopkins where their DA system reduced the frequency of ESAs in the OR/perio- perative environment. 47 Likewise, after implementation of

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