Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 2: intensive care and emergency departments.
01 May 2011-BJA: British Journal of Anaesthesia (Oxford University Press)-Vol. 106, Iss: 5, pp 632-642
TL;DR: The project findings suggest avoidable deaths due to airway complications occur in ICU and the ED, and repeated gaps in care that include poor identification of at-risk patients, poor or incomplete planning, inadequate provision of skilled staff and equipment to manage these events successfully are identified.
Abstract: Background The Fourth National Audit Project of the Royal College of Anaesthetists and Difficult Airway Society (NAP4) was designed to identify and study serious airway complications occurring during anaesthesia, in intensive care unit (ICU) and the emergency department (ED). Methods Reports of major complications of airway management (death, brain damage, emergency surgical airway, unanticipated ICU admission, prolonged ICU stay) were collected from all National Health Service hospitals over a period of 1 yr. An expert panel reviewed inclusion criteria, outcome, and airway management. Results A total of 184 events met inclusion criteria: 36 in ICU and 15 in the ED. In ICU, 61% of events led to death or persistent neurological injury, and 31% in the ED. Airway events in ICU and the ED were more likely than those during anaesthesia to occur out-of-hours, be managed by doctors with less anaesthetic experience and lead to permanent harm. Failure to use capnography contributed to 74% of cases of death or persistent neurological injury. Conclusions At least one in four major airway events in a hospital are likely to occur in ICU or the ED. The outcome of these events is particularly adverse. Analysis of the cases has identified repeated gaps in care that include: poor identification of at-risk patients, poor or incomplete planning, inadequate provision of skilled staff and equipment to manage these events successfully, delayed recognition of events, and failed rescue due to lack of or failure of interpretation of capnography. The project findings suggest avoidable deaths due to airway complications occur in ICU and the ED.
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TL;DR: The incidence of death and brain damage from airway management during general anaesthesia is low, and statistical analysis of the distribution of reports suggests as few as 25% of relevant incidents may have been reported, providing an indication of the lower limit for incidence of such complications.
Abstract: Results. Of 184 reports meeting inclusion criteria, 133 related to general anaesthesia: 46 events per million general anaesthetics [95% confidence interval (CI) 38 ‐54] or one per 22 000 (95% CI 1 per 26‐ 18 000). Anaesthesia events led to 16 deaths and three episodes of persistent brain damage: a mortality rate of 5.6 per million general anaesthetics (95% CI 2.8‐ 8.3): one per 180 000 (95% CI 1 per 352‐120 000). These estimates assume that all such cases were captured. Rates of death and brain damage for different airway devices (facemask, supraglottic airway, tracheal tube) varied little. Airway management was considered good in 19% of assessable anaesthesia cases. Elements of care were judged poor in three-quarters: in only three deaths was airway management considered exclusively good. Conclusions. Although these data suggest the incidence of death and brain damage from airway management during general anaesthesia is low, statistical analysis of the distribution of reports suggests as few as 25% of relevant incidents may have been reported. It therefore provides an indication of the lower limit for incidence of such complications. The review of airway management indicates that in a majority of cases, there is ‘room for improvement’.
1,610 citations
Cites methods from "Major complications of airway manag..."
...introduction The Fourth National Audit Project (NAP4) collected data on airway management techniques in use throughout the UK, and case reports of adverse incidents (inclusion criteria table 1) occurring in the Emergency Department, ICU or during anaesthesia over one year (1,2,3,4)....
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Heart of England NHS Foundation Trust1, University of Warwick2, University of Helsinki3, Oslo University Hospital4, Ghent University5, University of Antwerp6, Innsbruck Medical University7, Mario Negri Institute for Pharmacological Research8, Southmead Hospital9, The Catholic University of America10, Imperial College Healthcare11, Royal United Hospital12, Imperial College London13, University of Bern14
TL;DR: This chapter contains guidance on the techniques used during the initial resuscitation of an adult cardiac arrest victim and the use of an automated external defibrillator (AED).
1,104 citations
TL;DR: Anaesthesia and Intensive Care Medicine, Southmead Hospital, Bristol, UK Anaesthesia and intensive care Medicine, Royal United Hospital, Bath, UK School of Clinical Sciences, University of Bristol, United Kingdom, UK Department of Anesthesiology, and intensive care medicine, The National Institute for Mental Health (NIMH), London, UK NHS Foundation Trust, Coventry, UK The National Health Service (NHS), Coventry and Birmingham, UK Heart of England (HSE), Birmingham, Birmingham and The Royal National Institute of Neurological and Women's Health Service
919 citations
TL;DR: The Pediatric Basic and Advanced Life Support Collaborators aim to provide real-time information and guidance to parents and clinicians on how to care for their children during the neonatal intensive care unit and beyond.
Abstract: Alexis A. Topjian, MD, MSCE, Chair; Tia T. Raymond, MD, Vice-Chair; Dianne Atkins, MD; Melissa Chan, MD; Jonathan P. Duff, MD, Med; Benny L. Joyner Jr, MD, MPH; Javier J. Lasa, MD; Eric J. Lavonas, MD, MS; Arielle Levy, MD, Med; Melissa Mahgoub, PhD; Garth D. Meckler, MD, MSHS; Kathryn E. Roberts, MSN, RN; Robert M. Sutton, MD, MSCE; Stephen M. Schexnayder, MD; On behalf of the Pediatric Basic and Advanced Life Support Collaborators
567 citations
TL;DR: These guidelines describe a comprehensive strategy to optimize oxygenation,Airway management, and tracheal intubation in critically ill patients, in all hospital locations, and stress the role of the airway team, a shared mental model, planning, and communication throughout airway management.
Abstract: These guidelines describe a comprehensive strategy to optimize oxygenation, airway management, and tracheal intubation in critically ill patients, in all hospital locations. They are a direct response to the 4th National Audit Project of the Royal College of Anaesthetists and Difficult Airway Society, which highlighted deficient management of these extremely vulnerable patients leading to major complications and avoidable deaths. They are founded on robust evidence where available, supplemented by expert consensus opinion where it is not. These guidelines recognize that improved outcomes of emergency airway management require closer attention to human factors, rather than simply introduction of new devices or improved technical proficiency. They stress the role of the airway team, a shared mental model, planning, and communication throughout airway management. The primacy of oxygenation including pre- and peroxygenation is emphasized. A modified rapid sequence approach is recommended. Optimal management is presented in an algorithm that combines Plans B and C, incorporating elements of the Vortex approach. To avoid delays and task fixation, the importance of limiting procedural attempts, promptly recognizing failure, and transitioning to the next algorithm step are emphasized. The guidelines recommend early use of a videolaryngoscope, with a screen visible to all, and second generation supraglottic airways for airway rescue. Recommendations for emergency front of neck airway are for a scalpel–bougie–tube technique while acknowledging the value of other techniques performed by trained experts. As most critical care airway catastrophes occur after intubation, from dislodged or blocked tubes, essential methods to avoid these complications are also emphasized.
522 citations
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TL;DR: The incidence of death and brain damage from airway management during general anaesthesia is low, and statistical analysis of the distribution of reports suggests as few as 25% of relevant incidents may have been reported, providing an indication of the lower limit for incidence of such complications.
Abstract: Results. Of 184 reports meeting inclusion criteria, 133 related to general anaesthesia: 46 events per million general anaesthetics [95% confidence interval (CI) 38 ‐54] or one per 22 000 (95% CI 1 per 26‐ 18 000). Anaesthesia events led to 16 deaths and three episodes of persistent brain damage: a mortality rate of 5.6 per million general anaesthetics (95% CI 2.8‐ 8.3): one per 180 000 (95% CI 1 per 352‐120 000). These estimates assume that all such cases were captured. Rates of death and brain damage for different airway devices (facemask, supraglottic airway, tracheal tube) varied little. Airway management was considered good in 19% of assessable anaesthesia cases. Elements of care were judged poor in three-quarters: in only three deaths was airway management considered exclusively good. Conclusions. Although these data suggest the incidence of death and brain damage from airway management during general anaesthesia is low, statistical analysis of the distribution of reports suggests as few as 25% of relevant incidents may have been reported. It therefore provides an indication of the lower limit for incidence of such complications. The review of airway management indicates that in a majority of cases, there is ‘room for improvement’.
1,610 citations
TL;DR: This work states that Neonatal Resuscitation and Emergency Cardiovascular Care Science With Treatment Neonatal resuscitation: 2010 International Consensus on Cardiopulmonary is the most likely cause of sudden death in newborns aged under six weeks.
Abstract: 2010;126;e1319-e1344; originally published online Oct 18, 2010; Pediatrics COLLABORATORS CHAPTER Sithembiso Velaphi and on behalf of the NEONATAL RESUSCITATION Sam Richmond, Wendy M Simon, Nalini Singhal, Edgardo Szyld, Masanori Tamura, Chameides, Jay P Goldsmith, Ruth Guinsburg, Mary Fran Hazinski, Colin Morley, Jeffrey M Perlman, Jonathan Wyllie, John Kattwinkel, Dianne L Atkins, Leon Recommendations Resuscitation and Emergency Cardiovascular Care Science With Treatment Neonatal Resuscitation: 2010 International Consensus on Cardiopulmonary http://wwwpediatricsorg/cgi/content/full/126/5/e1319 located on the World Wide Web at: The online version of this article, along with updated information and services, is rights reserved Print ISSN: 0031-4005 Online ISSN: 1098-4275 Grove Village, Illinois, 60007 Copyright © 2010 by the American Academy of Pediatrics All and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk publication, it has been published continuously since 1948 PEDIATRICS is owned, published, PEDIATRICS is the official journal of the American Academy of Pediatrics A monthly
1,072 citations
TL;DR: Inadequate ventilation was used to describe claims in which it was evident that insufficient gas exchange had produced the adverse outcome, but it was not possible to identify the exact cause.
Abstract: Adverse outcomes associated with respiratory events constitute the single largest class of injury in the American Society of Anesthesiology Closed Claims Study (522 of 1541 cases; 34%). Death or brain damage occurred in 85% of cases. The median cost of settlement or jury award was +200,000. Most outcomes (72%) were considered preventable with better monitoring. Three mechanisms of injury accounted for three-fourths of the adverse respiratory events: inadequate ventilation (196; 38%), esophageal intubation (94; 18%), and difficult tracheal intubation (87; 17%). Inadequate ventilation was used to describe claims in which it was evident that insufficient gas exchange had produced the adverse outcome, but it was not possible to identify the exact cause. This group was characterized by the highest proportion of cases in which care was considered substandard (90%). The esophageal intubation group was notable for a recurring diagnostic failure: in 48% of cases where auscultation of breath sounds was performed and documented, this test led to the erroneous conclusion that the endotracheal tube was correctly located in the trachea. Claims for difficult tracheal intubation were distinguished by a comparatively small proportion of cases (36%) in which the outcome was considered preventable with better monitoring. A better understanding of respiratory risks may require investigative protocols that initiate data collection immediately upon the recognition of a critical incident or adverse outcome.
969 citations
TL;DR: Multifaceted interventions that helped to ensure adherence with evidence-based infection control guidelines nearly eliminated CR-BSIs in the authors' surgical ICU.
Abstract: Objective To determine whether a multifaceted systems intervention would eliminate catheter-related bloodstream infections (CR-BSIs). Design Prospective cohort study in a surgical intensive care unit (ICU) with a concurrent control ICU. Setting The Johns Hopkins Hospital. Patients All patients with a central venous catheter in the ICU. Intervention To eliminate CR-BSIs, a quality improvement team implemented five interventions: educating the staff; creating a catheter insertion cart; asking providers daily whether catheters could be removed; implementing a checklist to ensure adherence to evidence-based guidelines for preventing CR-BSIs; and empowering nurses to stop the catheter insertion procedure if a violation of the guidelines was observed. Measurement The primary outcome variable was the rate of CR-BSIs per 1,000 catheter days from January 1, 1998, through December 31, 2002. Secondary outcome variables included adherence to evidence-based infection control guidelines during catheter insertion. Main results Before the intervention, we found that physicians followed infection control guidelines during 62% of the procedures. During the intervention time period, the CR-BSI rate in the study ICU decreased from 11.3/1,000 catheter days in the first quarter of 1998 to 0/1,000 catheter days in the fourth quarter of 2002. The CR-BSI rate in the control ICU was 5.7/1,000 catheter days in the first quarter of 1998 and 1.6/1,000 catheter days in the fourth quarter of 2002 (p = .56). We estimate that these interventions may have prevented 43 CR-BSIs, eight deaths, and 1,945,922 dollars in additional costs per year in the study ICU. Conclusions Multifaceted interventions that helped to ensure adherence with evidence-based infection control guidelines nearly eliminated CR-BSIs in our surgical ICU.
901 citations
TL;DR: Data support the recommendation of the ASA Task Force on the Management of the Difficult Airway to limit laryngoscopic attempts to three in lieu of the considerable patient injury that may occur and confirm the number of larygoscopic attempts is associated with the incidence of airway and hemodynamic adverse events.
Abstract: contents (1.9% versus 22%), aspiration of gastric contents (0.8% versus 13%) bradycardia (1.6% versus 21%), and cardiac arrest (0.7% versus 11%; P 0.001). Although predictable, this analysis provides data that confirm the number of laryngoscopic attempts is associated with the incidence of airway and hemodynamic adverse events. These data support the recommendation of the ASA Task Force on the Management of the Difficult Airway to limit laryngoscopic attempts to three in lieu of the considerable patient injury that may occur.
852 citations