Management of Difficult Tracheal Intubation

Abstract

Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New Background Difficult or failed intubation is a major contributor to morbidity for patients and liability for anesthesiologists. Updated difficult airway management guidelines and incorporation of new airway devices into practice may have affected patient outcomes. The authors therefore compared recent malpractice claims related to difficult tracheal intubation to older claims using the Anesthesia Closed Claims Project database. Methods Claims with difficult tracheal intubation as the primary damaging event occurring in the years 2000 to 2012 (n = 102) were compared to difficult tracheal intubation claims from 1993 to 1999 (n = 93). Difficult intubation claims from 2000 to 2012 were evaluated for preoperative predictors and appropriateness of airway management. Results Patients in 2000 to 2012 difficult intubation claims were sicker (78% American Society of Anesthesiologists [ASA] Physical Status III to V; n = 78 of 102) and had more emergency procedures (37%; n = 37 of 102) compared to patients in 1993 to 1999 claims (47% ASA Physical Status III to V; n = 36 of 93; P < 0.001 and 22% emergency; n = 19 of 93; P = 0.025). More difficult tracheal intubation events occurred in nonperioperative locations in 2000 to 2012 than 1993 to 1999 (23%; n = 23 of 102 vs. 10%; n = 10 of 93; P = 0.035). Outcomes differed between time periods (P < 0.001), with a higher proportion of death in 2000 to 2012 claims (73%; n = 74 of 102 vs. 42%; n = 39 of 93 in 1993 to 1999 claims; P < 0.001 adjusted for multiple testing). In 2000 to 2012 claims, preoperative predictors of difficult tracheal intubation were present in 76% (78 of 102). In the 97 claims with sufficient information for assessment, inappropriate airway management occurred in 73% (71 of 97; κ = 0.44 to 0.66). A “can’t intubate, can’t oxygenate” emergency occurred in 80 claims with delayed surgical airway in more than one third (39%; n = 31 of 80). Conclusions Outcomes remained poor in recent malpractice claims related to difficult tracheal intubation. Inadequate airway planning and judgment errors were contributors to patient harm. Our results emphasize the need to improve both practitioner skills and systems response when difficult or failed tracheal intubation is encountered.

Clinical prediction tools for rare complications: are large administrative healthcare databases the answer?

“…Mental preparation, repeated deliberate practice, equipment and team simulation are required to maintain eFONA skills. Delay in both the recognition of the need for an eFONA procedure, and delay procedure itself, has been a recurrent theme in closed claims analysis . The eFONA prediction tool may allow the clinician and team to mentally prepare for a higher risk patient.…”

Special announcement: Guidelines to the Practice of Anesthesia—Revised Edition 2020

“…• Malgré nos progrès constants en tant que spécialité, il est indubitable que la prise en charge des voies aériennes, et plus particulièrement des voies aériennes difficiles, est encore à l'origine d'une importante proportion des événements indésirables liés à l'anesthésie. 9 Les systèmes électroniques de gestion de l'information en anesthésie (SGIA) ont remplacé les dossiers anesthésiques manuscrits dans certains centres, là où les ressources nécessaires étaient disponibles. La littérature sur la sécurité des patients en anesthésie appuie fortement l'utilisation des SGIA.…”

“…• Despite the steady improvement as a specialty, it is well recognized that airway management, particularly of the difficult airway, still contributes to a significant proportion of anesthesia-related adverse events. 9 To date, the Guidelines have been silent related to airway management. The Committee has introduced a new section 5.2 Airway Management to make some initial recommendations.…”

Death and brain damage from difficult airway management: a “never event”

“…Despite differences in methodologies, the results from Crosby et al 1 are very similar to findings from the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society (NAP4) in the UK, [2][3][4] and recently published findings from the Anesthesia Closed Claims Project in the US. 5,6 These studies also show severe patient injury with difficult airway management, with a high proportion of resulting death and permanent brain damage. The US closed claims analysis 5 studied 102 claims related to difficult tracheal intubation, representing 4% of the claims during the time period.…”

“…5,6 These studies also show severe patient injury with difficult airway management, with a high proportion of resulting death and permanent brain damage. The US closed claims analysis 5 studied 102 claims related to difficult tracheal intubation, representing 4% of the claims during the time period. Similar to Crosby et al, most of the difficult airways were encountered in patients undergoing elective or urgent procedures in the operating room.…”