Bill Howie DNP, CRNA University of Maryland Medical Center/Shock Trauma Center Uniformed University of the Health Sciences Catholic University of America 08 March 2014 MANA Following this presentation the participant will: ◦ Discuss strategies to prevent adverse patient outcomes when faced with: An unrecognized difficult airway; an acutely injured trauma patient; a patient at risk for aspiration; a patient at risk for an airway fire ; a patient with an airway obstruction; and an unintended endobronchial intubation. Complications arising from difficult or failed tracheal intubation remain a leading cause of anesthetic morbidity and mortality, despite the advent of recent developments in airway management strategies (Langeron et al. 2006; Malik, et al. 2009; Hagberg 2013) Physical exam: mouth opening, teeth (or tooth) configuration? neck mobility , thyromental distance, jaw mobility, tongue size, length of neck, neck scars (old trach, neck surgeries?), evidence of previous radiation therapy or a history of such? History : no prior radical head and neck surgeries? No history of obstructive sleep apnea (redundant tissue) Preop exam written by others? Always do your own airway exam on all patients! ASA Practice Guidelines for management of the difficult airway (2013) Anesthesiology: 118(2) pp 1-20. Berkow, L. What’s new in airway management (2013) ASA Refresher Course: 41(1) pp 31-37. Berkow, L. What’s new in airway management (2013) ASA Refresher Course: 41(1) pp 31-37 It has been defined as the clinical situation in which a conventionally trained anesthetist experiences difficulty with face mask ventilation , difficulty with tracheal intubation, or both ( ASA 2003) Much study has been conducted to identify strategies to deal with this significant anesthesia and critical care problem (Airway examination techniques , airway adjuncts, airway rescue devices, airway practice simulators, emergency surgical airways, difficult airway workshops and the like) An observational study of 94,630 anesthetics performed 2004 to 2008 was completed 53,041 operations included an attempt at mask ventilation. 77 patients (0.15%) were noted to be impossible to ventilate (incidence of 1: 690) 19 (25%) of the patients were noted to be a difficult intubation 15 of these were intubated 4 were not (2 surgical airways and 2 were awakened and a fiberoptic was done) Factors linked to the difficulties were: ◦ Neck radiation changes (the most significant clinical predictor in this review) ◦ Male sex ◦ Sleep apnea ◦ Mallampati III or IV ◦ Presence of a beard Kheterpal S., et al. (2009) Prediction and outcomes of impossible mask ventialtion. Anesthesiology 110(4): pp 891-897. The most frequent cause of maternal death in the UK was failed intubation (50 of 103 reported deaths from 1976-2005) The authors collected data from 2000-2007 and reported a total of 55,057 deliveries Difficult intubation was reported in 23 of 3430 patients (1:156 patients) 14 cases (61%) were unanticipated difficult intubations Risk factors to explain the unrecognized difficult intubation were noted to be due to an inadequate preop assessment: ◦ no recorded assessment (6 cases) ◦ poorly documented airway exam(8 cases) ◦ 7 patients were overweight ◦ 2 of the patients had a BMI > 35 All patients were successfully intubated primarily with a bougie The authors noted that the low rate of general anesthetic in OB does not allow providers adequate experience in airway management. And, a thorough airway exam is essential to provide a safe anesthetic Djabatey EA., & Barclay PM. (2009) Difficult of failed intubation in 3430 general anesthetics. Anaesthesia 64(11) pp 1168-1171 When applied in accordance with a predefined algorithm, the gum elastic bougie and the ILMA™ are effective to solve most problems occurring during unexpected difficult airway management (Combes et al. 2004) Other studies have noted potential improved success using alternative adjuncts (Bullard , retrograde wire, LMA Ctrach, Airtraq Laryngoscope, LMA-Fastrach, and the Glidescope) (Rich 2005; Malik et al 2009) An algorithm for airway management that incorporates Gum Elastic Bougie (GEB), LMA-CT, and AQ-L devices was used in 12,225 anesthetized, paralyzed patients. Successful tracheal intubation under visual control was achieved in all patients with difficult airways. The Pentax AWSw laryngoscope demonstrated more advantages over the Macintosh laryngoscope than either the Truview EVO2w or the Glidescope w laryngoscope, when used by experienced anaesthetists in difficult tracheal intubation scenarios (Malik et al 2009) Who in the audience has ever faced an unrecognized difficult airway? What strategy worked the best for you? When faced with the acutely injured trauma patient the provider must have: ◦ All necessary airway and anesthesia equipment immediately available and checked for function ◦ An understanding of the basic “rules of trauma” (full stomach, potentially hypovolemic, potentially closed head injured, potentially c-spine injured, potentially premedicated, etc) ◦ Enough help immediately available to handle the airway (how many people do you need?) ◦ A clear plan regarding management of the airway (Bailitz et al 2011) 6088 patients admitted to the STC required intubation within the first hour, 21(0.3%) received a surgical airway. During the first 24 h, 10 more patients (n=31), received a surgical airway, during approximately 32,000 attempts (0.1%). Unanticipated difficult upper airway anatomy was the leading reason for a surgical airway. Four of the 31 patients died of their injuries but none as the result of failed intubation. (Stephens et al: 2009) Rapid sequence induction followed by direct laryngoscopy is a remarkably effective approach to emergency airway management. An algorithm designed around this approach can achieve very high levels of success (Stephens et al: 2009) Difficult mask ventilation: presents as the inability to provide adequate face mask ventilation due to inadequate mask seal, excessive gas leak, or excessive resistance to gas flow There are five independent predictors for difficult mask ventilation: age > 55, BMI > 26, presence of a beard, edentulous , and a history of snoring (Bhavani et al, 2011) The inability to adequately ventilate your patient makes this a true life threatening emergency Uniform application of a difficult airway algorithm might decrease the incidence of hypoxic brain damage during anesthesia induction (Amathieu 2011) Uniform application of a clear algorithm might decrease patient injury or death in any situation where airway management turns difficult Experience in surgical airway techniques is essential (cricothyroidotomy). Training in such techniques is mandatory for any organization with a safety culture. These techniques should be practiced in workshops and their daily use in certain ENT and trauma situations is good practice that provides further experience (Heidegger et al. 2005) Your facility should have a mechanism to deal with a failed airway scenario (emergency surgical airway team? Or just the closest podiatric surgeon?) Difficult airway cases brought to lawsuit were reviewed in the ASA Closed Claims Data Base (n=179 from 1985-1999) The analysis found that the difficult airway sentinel events occurred : 67% upon induction, 15% during surgery, 12% at extubation, and 5% during recovery (Peterson et al. ASA 2005) Persistent attempts to instrument the airway with the same unsuccessful technique waste valuable time A preset difficult airway algorithm is critical. Do you have the necessary equipment on hand, and are you comfortable using it? Call for help early. (The airline industry has pointed to countless crashes attributed to failure of crew members to speak-up and note a problem. Lack of a “safety culture”) (Bhavani et al 2011) Rapid Sequence Induction: A technique of inducing general anesthesia to quickly secure the airway to reduce the risk of pulmonary aspiration of gastric contents ◦ Indications: Emergency surgery/non-fasting patients/acute abdomen/paralytic ileus/ reflux/obesity/diabetes/pregnancy ◦ Airway management is the most important skill for an emergency practitioner to master because failure to secure an adequate airway can quickly lead to death or disability Contraindications: Patients with anticipated difficult airway Situations where laryngeal injury suspected Which muscle relaxant should be used? (Sux, Roc, Vec, Cisatracurium- or does it matter?) Roc vs Sux for RSI: Cochrane Review found Sux created superior intubating conditions (perceived as excellent. But when less stringent clinically acceptable conditions used, there were not statistically significant differences found when propofol was used to induce (Perry et al 2008) Rapid Sequence Induction includes specific separate actions to reduce risk of pulmonary aspiration: ◦ Administration of a rapid acting IV induction agent and muscle relaxant simultaneously (classic RSI) ◦ No mask ventilation (classic versus modified?) ◦ Cricoid pressure ◦ Smooth and skillful laryngoscopy (trainees?) ◦ Provision of optimal pre-oxygenation clearly is recommended whenever possible. It is key that the provider remembers : ◦ Prepare (assess the airway/have primary and backup equipment assembled) ◦ Preoxygenate ◦ Paralysis and induction drugs at the same time ◦ Protection (cricoid) (zantac/reglan/bicitra ?)and positioning (head up or head slightly down?) ◦ Placement of cuffed ETT with proof of ETC02 ◦ Post-intubation management (sedation/vent) The 2008 National Emergency Medical Services Information System (NEMSIS) Public-Release Data Set containing data from 16 states was utilized ◦ Among 4,383,768 EMS activations, there were 10,356 Endotrachial Intubations, 2246 alternate airways, and 88 cricothyroidotomies. ETI success rates were: overall 6482/8418 (77.0%) ◦ Alternate airway success was 1564/1794 (87.2%). Major complications included: bleeding 84 (7.0 per 1000 interventions), vomiting 80 (6.7 per 1000) and esophageal intubation 12 (1.0 per 1000) Data were collected prospectively for all ETIs performed by the fire department from 2001– 2005, and included demographics, number of laryngoscopy attempts, airway procedures, complications, and outcomes Of 80,501 ALS patient contacts, 4091 (5.1%) underwent attempted oral ETI, with a 96.8% success rate in four or fewer attempts The difficult airway cohort included 130 patients (3.2%), whose airway management consisted of oral ETI after more than four attempts (46%), bag-valve-mask ventilation (33%), cricothyroidotomy (8%), retrograde ETI (5%), and digital ETI (1%) Procedural success rates ranged from 14% (digital ETI) to 91% (cricothyroidotomy). Nine patients (7%) had failed airway management, of whom 5 were found in cardiac arrest The two most common reasons reported by ALS providers for airway difficulty were anterior trachea (39%) and small mouth (30%). Overall mortality for the difficult airway cohort was 44% Patient anatomy was a primary factor in failed ETI Among the advanced procedures utilized, cricothyroidotomy had the highest success rate and should not be delayed by other interventions A systematic review was done (184 clinical trials) The overall conclusion was that: ◦ There was an absence of evidence to either support or discourage the use of the RSI technique for the prevention of aspiration ◦ The use of a modified RSI that permits ventilation with cricoid after induction may be appropriate in some situations ◦ Available studies support use of sux due to its speed of offset since it gives the fastest and best early intubation conditions (less coughing with early instrumentation) (Sluga et al 2005). However, higher dose Roc or Vec provide clinically similar results to sux ◦ Controlled trials are necessary to provide more evidence to strongly recommend the RSI technique. (Which drugs are best? (Etomidate vs STP vs Propofol vs Ketamine; Fentanyl vs Lidocaine to blunt laryngoscopy stimulation) Bag valve mask ventilation while waiting for agents to take effect? ◦ (Neilipovitz et al 2007) Aspiration: Inhalation of material into the airway below the level of the true vocal cords The incidence of aspiration in adults is: ◦ ◦ ◦ ◦ ◦ 1 1 1 1 1 in in in in in 3000 anesthetics 600-800 emergency surgeries 400-900 C-sections under general anesthesia 2600 for children 400 or emergency surgery in children Risk Factors: Trauma/Emergency surgeries, gastroparesis (multiple causes), head injured /CVA patients (altered gag/swallow/LOC), GERD, Obesity, Pregnancy, obstruction, lied about PO intake preoperatively, extremes of age, impaired LOC due to illicit drugs and or ETOH, lithotomy and occurrence of a difficult intubation/difficult airway (Kalinowski 2004; Sekar et al 2011) The consequences of aspiration can lead to situations where patients need > 48 hours of ventilator/ICU support Acute lung injury associated with aspiration produces impaired arterial oxygenation with a Pa02/Fi02 ratio of < 300 Extreme lung injury may progress to ARDS and a Pa02/Fi02 ratio of < 200 There is a 50% mortality (Kalinowski & Kirsch 2004) Provider related risk factors: ◦ Poor induction technique (Failure to push induction agents in rapid order if RSI); administration of large tidal volumes or airway pressure greater than 20cm H20 during induction (gas insufflation into the stomach); difficult airway or repeated laryngoscopies (how many attempts should be taken to secure the airway? When should trainees be permitted to manage the airway of actual patients?) Provider related risk factors: ◦ Manipulation of the airway during a light stage of anesthesia leading to gagging/coughing/vomiting ◦ Patient positioning (T-Berg/Lithotomy) ◦ Topicalization of the airway during awake procedures leading to loss of airway protection ◦ Improper application of cricoid pressure ◦ Administration of ongoing doses of opioids (anesthesia pain management service) ◦ Inadequate preoperative assessment (forgot to ask NPO status, or did not appreciate risk factors such as diabetes, obesity, GERD, etc) Presentation: ◦ Particulate matter or liquids found in the oropharynx ◦ Wheezing ◦ Elevated airway pressure ◦ Decreased 02 saturations ◦ Infiltrates on CXR ◦ Signs and symptoms of ARDS A recent retrospective study looked at 99,441 anesthetic in patients over 18 years of age from January 2001 through December 2004. 14 cases of confirmed aspiration occurred. 6 of the patients required ICU care. One of these patients died Approximately 70% of the cases of aspiration were the attributed to improper anesthetic technique All of the patients had one or more risk factors for aspiration : esophageal pathology, previous esophageal surgery, continuous opioid administration, GI obstruction, recent PO intake, trauma surgery , impaired gag/swallowing reflexes, obesity, depressed LOC The incidence of perioperative pulmonary aspiration was 1 in 7103 anesthetics with a morbidity rate of 1 in 16,573 and a mortality rate of 1 in 99,441 (Sakai et al 2006) Patients who aspiration were typically older and sicker than other patients They more often underwent emergency surgeries or abdominal procedures Death was twice as common in in aspiration claims as compared to other closed claims Aspiration typically occurred on induction despite the use of RSI with cricoid pressure in half of the claims (raising questions if this technique is effective to prevent aspiration) (Bailie et al 2010) Immediate management: Increase Fi02 to 100% Position patient head down-suction intraoral Maintain cricoid pressure? Intubate with cuffed ETT (if you have not done so already) ◦ Suction the ETT ◦ Mechanical ventilation with at least 5cm peep ◦ Perform bronchoscopy (diagnostic and therapeutic) ◦ ◦ ◦ ◦ Routine use of steroids not recommended Antibiotics not recommended unless diagnosis of pneumonia made Antacids and prokinetics not shown to improve outcomes after the aspiration has occurred Defer elective surgeries until patient stable ? Ventilator therapy/ICU care Prevention: ◦ Stress importance of NPO guidelines ◦ Control and secure the airway of any patients with poor gag reflex or decreased LOC early ◦ Appropriately apply RSI principles (correct drugs in correct sequence, correct cricoid pressure) ◦ Consider H2 blockers/prokinetics/bicitra and the like for patients at high risk ◦ Consider awake intubation if difficult airway anticipated ◦ Effects of Metoclopramide and Ranitidine on Preoperative Gastric Contents in Day-Case Surgery (Laproscopic outpatient GYN procedures) ◦ 15 minutes prior to induction of anesthesia 20 patients were given 50mg ranitidine and 10mg metoclopramide. The pH was on average 6.8 in the study group vs 1.6 in the control group. The gastric volume was on average 11ml in the control group and 4.5ml in the study group (Hong 2006) A Cochrane review found that drinking clear fluids as recently as a few hours prior to surgery did not increase he risk of regurgitation during or after surgery (Brady et al. 2003)(Does it actually promote emptying?) Clearly traumatic injury after eating, obesity, diabetes, pregnancy, the elderly, and people with various stomach disorders are still at greater risk for aspiration ASA Closed Claims Intraoperative Fires : Kressin 2004 Operating room fires are infrequent but potentially catastrophic . Early signs of a fire include: Seeing a flame, flash, or smoke, unusual sounds, odors, or feeling actual heat Communication is vital between anesthesia and the surgeon regarding use of cautery, placing drapes over the face/adequate use of suction to clear the environment of potential fuel sources and careful titration of oxygen and N20 . (should N20 be used for surgeries near face and airway?) “Death by anesthetic explosion is given heavy emphasis in the media of public information…it is the most dramatic of all surgical fatalities” Rare back in the late 1950s (1 in 100,000 anesthetics)…in the late 1950s ethylene, cyclopropane, diethyl ether and divinyl ether were used Halothane used in the United States 1958 (the first non-flammable anesthetic agent) It has been virtually obsolete since 1988 due to concerns of hepatitis necrosis in some patients as well as myocardial depression (particularly in pediatrics) (Giesecke 2008 Bulletin of anesthesia history: 26(2) First use of Halothane in the United States Thomas GJ Fire and explosion hazards with flammable anesthetics and their control. 1960 Journal National Medical Association: 10(6) 397-403 Ignition of combustible materials ( plastic tracheal tube) in the airway. Any fire requires three components : Fuel source (alcohol prep, plastic tracheal tube); Oxygen, and a source of ignition (cautery, laser) (approx 50 to 200 OR reported fires/year in US. 33% in the airway, 28% the face, 39% elsewhere on patient . 20% result in serious injury or death- ASA 2008, Daane, 2005) Burn injuries represent 20% of MAC related malpractice claims, 95% of which involved head/neck surgeries (Rinder 2008) Disconnect the circuit (Oxygen supply) Inform the surgeon (they probably already know) Remove the ETT/Trach ? Stop flow of all airway gases (especially Nitrous Oxide) Flood the area with fluid (saline or sterile water) Reintubate (even if injury to airway not immediately evident) Duraprep and the Risk of Fire During Tracheostomy (Weber, Hargunani, & Wax: 2006. Head and Neck: 28(7); 649-652. Duraprep is a surgical prep that contains 0.7% iodine in a 74% alcohol base. It takes 3 minutes to dry. The solution accumulated in sufficient amounts to ignite on a 62 year old man with copious amounts of body hair posted for a tracheostomy Weber et al. Duraprep and the risk of fire during tracheostomy 2006: Head and Neck: 28. 649-652. Should you extubate the patient for a presumed airway fire? Does it matter if it occurs with an ETT in place or during a tracheostomy? Special considerations regarding fires involving tracheostomies require consideration of where the fire was/is (in airway; on ETT, in superficial tissue?) is ETT backed out to area waiting for tracheostomy to be inserted? Must consider how sick and how difficult to intubate the patent is (ICU vent dependent, short neck, morbidly obese, etc) Consider use of a tube exchanger if suspect ETT damaged prior to insertion of the Trach (Chee, Benumof 1998 Airway Fire during Tracheostomy: Extubation may be contraindicated. Anesthesiology: 89(6). 1576-1578. Avoid situations that increase fire risk (alcohol preps/use holsters for cautery/keep audibles tuned up on cautery devices/keep surgeons aware of where foot switches are, do not turn off audible that device is being used) Always have plan of action if fire occurs(have written plan of action displayed in all ORs) Periodically discuss prevention of operating room fire strategies (staff meetings/ inservices) Prevention of surgical fires requires understanding of the risks and effective communication between surgeons, anesthesia, and OR nursing and non-nursing staff (Bruley 2004) Watch for pooling of potentially flammable liquids in drapes and on the patient ASA: Anesthesiology 2008; 108:786–801 Airway obstruction in the spontaneously breathing patient: (IV sedation/MAC/ immediate post-operative) Presentation depends on the severity of obstruction: Dyspnea, hypercarbia (can lead to obtundation) , hypoxemia (can lead to obtundation), snoring (OSAS-diagnosed or undiagnosed), wheezing, stridor, use of accessory muscles, tracheal tug, apnea, agitated patient Increase Fi02 (100%) Open the airway (nasal trumpet, oral airway, jaw thrust, LMA, etc) Lighten the anesthesia-(titrate to desired effect…should a heavy mac be done with hand boluses of propofol, or should a pump be used?) Was the patient extubated in stage 2? Should a patient be taken to the PACU with an oral airway in? (should all patients,not just the obstructed ones, be taken to the PACU with oxygen on?) Positive pressure ventilation to break laryngospasm Inhaled bronhodilator for suspected bronchospasm. Racemic Epi also worth considering Nasal CPAP-for OSAS in PACU. The so called Non-invasive ventilation (NIV) has been used successfully in both the ICU and PACU to reduce length of PACU or ICU stay and negates the need to place an endotracheal tube (Battist et al 2005: Scalea et al. 2008: Schonhofer et al 2008) i Perhaps an ETT was the best choice in the first place (depends on case, patient comorbidities-OSAS, IDDM, obesity, current ETOH and or other premedication on board) Careful titration of anesthetic agents-use of pumps as opposed to hand bolusing? Make sure extubated patients meet extubation criteria prior to extubation Do all patients who receive moderate sedation require continuous ETc02 monitoring? Failed Extubation (in post surgical patients as opposed to ICU patients who required ventilatory support): Postoperative respiratory failure (requiring re-intubation) is among the most serious of post-op pulmonary complications. The literature typically defines this as inability to tolerate removal of an endotracheal tube in the early post-operative period Development and Implementation of Evidenced Based Guidelines for the Extubation of Adult Trauma Patents in the Early Postoperative Period. William Howie University of Maryland Medical Center R Adams Cowley Shock Trauma Center The Johns Hopkins School of Nursing 2010 Clinical Question Translation Framework Further exploration is required to determine which patient risk factors play significant roles in patients who fail an elective extubation despite meeting standard extubation criteria. Because the process of reintubation and mechanical ventilation places patients at an increased risk for airway misadventures, prolonged hospitalization/ICU stay, ventilator acquired pneumonia, and higher levels of morbidity and mortality. What are the predictors of extubation failure in the adult trauma patient who meet standard extubation criteria? Application of the Agency for Healthcare Research and Quality (AHRQ) Model to Extubation Failure in Adult Trauma Patients at Shock Trauma Center (STC) Search Methods The literature search for this systematic review was performed during December of 2008 using Pubmed, Medline, CINAL, Cochrane Database, Googlescholar, and a selective handsearch. Approximately 110 articles that were written in English and contained the search terms: “reintubation”, “failed extubation”, “extubation failure”, “respiratory failure”, “postoperative”, “perioperative”, “trauma”, “post-surgical”, “multiple trauma”, “poly trauma”, “trauma patient”, “extubation criteria”, “adult”, “anesthesia”, “complications”, and “adverseMethod events”. of .Grading Evidence The articles were reviewed for relevance, and a total of 13 articles published between 1996 and 2008 were selected for in-depth review (Table 1), including 1 randomized control trial (RCT), 4 prospective record reviews, and 8 retrospective reviews. Such studies have generally been setting-specific (neurological ICU, teaching hospital, pediatric intensive care unit). For this template we use the Arial font family at several recommended text sizes. You can use any typeface you like and at any size but try to stay close to the suggested limits. Figure 4 gives a visual reference of what different font sizes look like when printed at 100% and at 200%. Due to a page size limitation in PowerPoint and unless your poster is going to be less than 56” in length, all the work done on this template is at half the size of the final poster. For example, if you choose a 21 point font for this poster, the actual printed size will appear as 42 points. . 1 Translational Framework Framework appears to be appropriate. Process Synthesis of Findings Factors predictive of extubation failure gleaned from quality assurance and medico-legal sources serve to clearly define many key factors that commonly lead to failed extubation. Residual neuromuscular blockade, excessive narcotics, over sedation, failure to employ standard intubation guidelines, or inadequate use of basic extubation criteria were the most likely causes of the extubation failure. Available evidence supports adherence to standardized extubation guidelines (awake, follows commands, reversal of muscle relaxant) and taking appropriate steps to secure the airway (ASA airway algorithm) minimizes airway misadventures SUMMARY OF RESEARCH Factors predictive of extubation failure Level of consciousness (does not follow commands) GCS < 8 (69 % failure rate) Not able to protect the airway (inadequate cough) Abundant secretions (16 times more likely to fail extubation) Hemoglobin level < 10 ( 5 times more likely to fail) Does not follow commands, abundant secretions and ineffective cough strength (close to 100% fail) Advancing age (> 60), higher ASA classification, low albumen levels, emergency surgery, abdominal surgery, thoracic surgery, more complicated surgery. Smoking history, COPD or debilitating Knowledge/ Dissemination Sources Actors Target Audience Projected Project Timeline Knowledge Creation and Distillation 2 Diffusion and Dissemination 3 Adoption, Implementation and Institutionalization 1a. Creation of a new knowledge on factors related to extubation failure in adult trauma patients. 1b. Distillation of key knowledge on extubation in adult trauma patients 2a. Creation of dissemination partnerships/know ledge transfer teams at STC Quality Assurance Committee 2b. Mass diffusion of key knowledge related to extubation failure to STC anesthesia providers. 2c. Targeted dissemination/pers uation in OR and PACU. 3a. Development of extubation criteria. 3b. implemention of standardized extubation criteria. 3c. Confirmation, adaption and internal institutionalIzation of extubation criteria on patient record. 3d. External routinization of extubation criteria in all adult trauma patients. Extubation QA Committee, Guidelines Educational QA Committee, Committee AHRQ anesthesia experts National Patient ASA, AANA Safety Foundation Guidelines for The Joint Extubation Commission Adult post-op ASA, AANA patients requiring Journals, extubation Anesthesia Anesthesia Conferences andis tables, charts and graphs providers Inservices, Dissermination partnerships with other trauma centers Anesthesia and critical care providers in OR, PACU IOM, AANA, MD. Cost Review Commission, easier than Insurers Relevant Standards and Guidelines Importing importing photos. To import charts and Training graphs Record review of Publications and on from Excel, Word or other conference applications, go to STC Quality extubation Data presentations Culturally sensitive EDIT>COPY,Assurance copy your chart and come back to Base and patient relevant to teaching PowerPoint. records Go to EDIT>PASTE and pasteSTCthe chart anesthesia Inservices, Synthesis of providers on the poster. You can scale your chartsgrand androunds, literature on Inservices, Intranet posting of tables proportionally by holding down the Shift extubation failure workshops, and guidelines Consensus of QA to Compare costs of key and dragging in or outwebcasts one of the corners. Committee and surrounding using new Process expert anesthesia providers trauma centers guidelines with costs of extubation failures in the past Measure decrease in extub. failure EBP policy on extubation Project Work Breakdown Structure Task 2 Meetings and discussion of the data with key individuals that will lead to the Collect retrospective data on failed development of evidenced based extubation, using existing trauma data Compare withseparate evidence from The blue headers are usedguidelines. to identify and base. Analyze data. literature and devise evidenced based the main topics of your presentation. The most set of extubation guidelines for the adult patient commonly used headers intrauma poster presentations Task 1 Task 3 are: Orient anesthesia providers on how to implement the evidenced based extubation guidelines in the form of staff in-services and placement of printed guidelines in patient care areas Task 5 Monitor frequency of failed extubation for a period of 3 months. Revise guidelines, as needed. Incorporate guidelines in practice to decide when an adult patient should be extubation. Task 4 Encourage implementation of the guidelines a part of daily practice for all anesthesia care providers Reassess Activity Time Start Time Finish Faculty approval of Comprehensive Plan 16 Mar 2009 08 May 2009 IRB Approval from UMMS and JHU 14 Feb 2009 23 May 2009 (estimated) Collect/Analyze data 24 May 2009 23 Aug 2009 Develop guidelines 24 Aug 2009 24 Sept 2009 Staff in-services 25 Sept 2009 25 Oct 2009 Implement guidelines 26 Oct 2009 15 Jan 2010 Assess for changes in reintubation rate 16 Jan 2010 17 Feb 2010 Incorporate guidelines as standard practice standard 18 Feb 2010 Indefinitely References Namen AM, Ely EW, Tatter SB, et al. Predictors of successful extubation in neurosurgical patients. Am J Respir Crit Care Med. 2001; 163(3), 658-664. Khamiees M, Raju P, DeGirolamo A, Amoatend-Adjepong Y, Manthous CV. Predictors of extubation outcome in patients who have successfully completed a spontaneous breathing trial. Chest. 2001; 1262-1270 . Salam A, Tilluckdharry L, Amoateng-Adjeppong Y, Manathous CA. Neurologic status, cough, secretions and extubation outcomes. Intensive Care Med. 2004; 30, 13341339. Lee PJ, MacLennan A, Naughton NN, O’Reilly M. An analysis of failed extubations from a quality assurance database of 152,000 cases. J of Clin Anesthesia. 2003; 15(8): 571-581. Arozullah AM, Daily J, Henderson WG, Khuri SF. Multifactorial risk index for predicting postoperative respiratory failure in men after major noncardiac surgery. Annals of Surgery 2000; 232(2), 242-253. Johnson RG, Arozullah AM, Neuramayer L, et al. Multivariable predictors of postoperative respiratory failure after general and vascular surgery: Results from the patient safety in surgery study. J of the American College of Surgeons. 2007; 204, 1188-1198. Vidotto MC, Sogame LC, Calciolari CC, et al. The prediction of extubation success of postoperative neurosurgical patients using frequency-tidal volume ratios. Neurocritical Care. 2008; 9(1), 83-89. Robriquet L, Georges H, Leroy O, et al. Predictors of extubation failure in patients with chronic obstructive pulmonary disease. J of Crit Care. 2006; 21(2), 185-190. The records of 195 patients were reviewed that required reintubation during 2000 and 2009 171 records met the basic criteria of requiring reintubation following elective extubation within 6 hours. Ten patients were dropped, which brought time until failure to 2 hours The soft tissue patients appear to be a high risk population for post-extubation failure (about 24% or 40 patients) The data was obtained from STC QA records, Hospital Patient Records The QA data comes from the sentinel events self reporting system utilized at the STC The problem of failed extubation has historically been the most frequently self reported sentinel event at the STC The time from extubation until the patient was reintubated was: ◦ ◦ ◦ ◦ ◦ ◦ 54% 65% 67% 69% 78% 94% of of of of of of the the the the the the patients patients patients patients patients patients within within within within within within 5 minutes. 10 minutes. 15 minutes. 20 minutes. 30 minutes. 120 minutes. The patients were reintubated: ◦ ◦ ◦ ◦ 34% 64% 1% 1% of the time in the OR. of the time in the PACU. of the time in the TRU. of the time in the ICU. Cause of Failure Frequency Valid Laryngospasm 28 Airway Obstruction 27 Retained Secretions 10 Agitation 13 Respiratory Failure 57 Decreased LOC 8 Stridor 12 Apnea 4 Aspiration 4 Agitation DTs 3 Total 166 Missing System 5 Total 171 Percent 16.4 15.8 5.8 7.6 33.3 4.7 7.0 2.3 2.3 1.8 97.1 2.9 100.0 Valid Percent 16.9 16.3 6.0 7.8 34.3 4.8 7.2 2.4 2.4 1.8 100.0 53% of the time, the anesthesia provider did not document adherence to evidence-based, nationally recognized extubation criteria. Minimizing Potential Problems If the patient was Ensure adequate difficult to intubate initially, make sure they’re fully awake and cooperative Maintain normothermia Reverse neuromuscular blockade analgesia, without oversedation Don’t extubate if any suspicion of alcohol or other drugs on board Make sure support is readily available Not all trauma patients should be extubated post-operatively Make sure the patient meets basic extubation criteria Minimizing Problems If airway edema is suspected, institute the following: Elevate head of bed, if possible Evaluate tracheal swelling by the “leak test” Institute watchful waiting ? Steroids Humidified O2 Respiratory treatments Watch for over- hydration (colloid vs crystalloid) Airway exam under controlled conditions Maybe a tracheostomy is the best airway afterall Devices Used As Extubating Stylets Inadvertent endobronchial intubation: Early detection of this complication can avert serious perioperative problems such as: hypoxia, increased pulmonary pressures, bronchspasms, barotrauma/pneumothorax, and atelectasis on CXR (Bhavani et al. 2010, Mackenzie et al. 2003, Munnur et al 2001) Risk Factors: Pediatrics, size of patient (small body habitus), short neck, neck movement for surgery-flexion and extension, shared airway with surgeon/surgeon movement of ETT, surgeon movement of the head during the procedure, patient position (t-berg, lithotomy, prone, lateral, supine), laproscopic procedures , careless or inexperienced provider, any others?? Less experienced ,and even more experienced providers , do not always correctly interpret breath sounds and chest wall movement to confirm appropriate placement of the ETT (miss unintended endobronchial intubation) Rely to a greater extent on the ETT depth to avoid this preventable complication. This is particularly true in noisy environments such as Emergency Departments, Pre-hospital/Field environments and air and land transport situations 160 consecutive patients (ASA I or II) admitted for gyn or urological procedures Fiberoptics were utilized to position ETT tubes (some correctly and others endobronchially) First year anesthesia residents and experienced anesthesiologists were randomly assigned to perform bilateral auscultation of the chest, observe for equal chest expansion , and estimate the correct position of the ETT by consideration of tube depth First year residents failed to correctly determine endobronchial intubation in 55% of the cases The residents were 10 times more likely than experienced anesthesiologists to incorrectly determine if an ETT was appropriately placed The highest sensitivity/specificity for ruling out an endobronchial intubation was achieved by combining ETT depth, auscultation of bilateral (lateral lobes) breath sounds and observing for symmetrical chest expansion (Sitzwohl et al. 2010) During the period 01May 2010 though 30 Apr 2011 there were 279 patients admitted to the ICU in an University Military Hospital in Saudi Arabia who were orally intubated A majority of the patients were admitted from the ED or the OR There were 36 (12.9%) cases of inadvertent endobronchial intubation reported A policy was implemented to consider this as a reportable sentinel event Al-Qahtani et. Al. (2012) Saudi J Anesth: 6(3)pp 259-262. The general oral ETT depth should be 20 to 21cm in women and 22 to 23 in men (studies support the 20cm in women/22 cm in men: the 20/22 rule) (Sitwohl et al, 2009) Accidental endobronchial intubation should be should be considered when arterial desaturation occurs intraoperatively (McCoy et al 1997) Clearly if the capnography waveform changes consider a misplaced ETT (too far in or out) From 2000 to 2005,149 consecutive out-ofhospital tracheal intubations were performed by emergency physicians. The tracheal tube was determined by the study physician to have been in the right mainstem bronchus 10.7% (n=16) or esophagus 6.7% of the time (n=10) patients. All esophageal intubations were detected and corrected by the study physician at the scene, but 7 of these 10 patients died within the first 24 h of treatment (Timmermann et al 2007) The incidence of unrecognized esophageal intubation is frequent and is associated with a high mortality rate. 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