A surgical needs assessment for airway rapid responses: A retrospective observational study

Abstract

BACKGROUND:Airway rapid response (ARR) teams can be compiled of anesthesiologists, intensivists, otolaryngologists, general and thoracic surgeons, respiratory therapists, and nurses. The optimal composition of an ARR team is unknown but considered to be resource intensive. We sought to determine the type of technical procedures performed during an ARR activation to inform team composition. METHODS:A large urban quaternary academic medical center retrospective review (2016-2019) of adult ARR patients was performed. Analysis included ARR demographics, patient characteristics, characteristics of preexisting tracheostomies, incidence of concomitant conditions, and procedures completed during an ARR event. RESULTS:A total of 345 ARR patients with a median age of 60 years (interquartile range, 47-69 years) and a median time to ARR conclusion of 28 minutes (interquartile range, 14-47 minutes) were included. About 41.7% of the ARR had a preexisting tracheostomy. Overall, there were 130 procedures completed that can be performed by a general surgeon in addition to the 122 difficult intubations. These procedures included recannulation of a tracheostomy, operative intervention, new emergent tracheostomy or cricothyroidotomy, thoracostomy tube placement, initiation of extracorporeal membrane oxygenation, and pericardiocentesis. CONCLUSION:Highly technical procedures are common during an ARR, including procedures related to tracheostomies. Surgeons possess a comprehensive skill set that is unique and comprehensive with respect to airway emergencies. This distinctive skill set creates an important role within the ARR team to perform these urgent technical procedures.

Code Critical Airway: A Collaborative Solution to a Catastrophic Problem

“…3 Hynes et al described a 3% rate of bedside tracheostomies, but a 7.9% incidence of unplanned trips to the operating room, a group that included patients undergoing emergent airway procedures. 17…”

“…Critical Airway response teams have been described at a 169-bed hospital with 24 activations over 4 years(2), 789-bed hospital with 124 activations over 40 months(1), a 1059-bed facility with 360 activations over 5 years(3), a 600-bed hospital with 93 activations over 13 months, 11 and a 788-bed hospital with 345 activations over 3 years. 17 Indeed, in small and large institutions alike, airway response teams function to coordinate education, ensure the implementation of the most up-to-date guidelines, keep equipment available, and facilitate a team-approach in each encounter. 20 With the implementation of these programs, a decrease in the frequency of emergency surgical airways has been described, 12,19 as well as a trend toward a decrease in mortality.…”

“…Tracheal intubation was the most frequent intervention used by the CCA team to secure a critical airway, as has been corroborated in experiences at other institutions with similar programs. [16][17][18] Adjuncts to tracheal intubation including video laryngoscopy (16.8%), bougie-assisted intubation (0.7%), and fiberoptic bronchoscopy (18.8%), facilitated intubation in patients in whom direct laryngoscopy did not yield an adequate view of the vocal cords. In the remaining cases, a previously placed surgical airway was replaced or, less commonly, a new surgical airway was created.…”

The specialty of surgical critical care: A white paper from the American Association for the Surgery of Trauma Critical Care Committee

“…Furthermore, surgical intensivists were among the first to report on safety-related modifications to PDT and open tracheostomy in response to the COVID-19 pandemic 66 . Finally, surgical intensivists possess the capability to provide life-saving surgical interventions in response to airway emergencies throughout the hospital 67 …”

“…66 Finally, surgical intensivists possess the capability to provide life-saving surgical interventions in response to airway emergencies throughout the hospital. 67…”