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NAP4UK Indian perspective Dr Amit Shah

REVIEW OF AUDIT REPORT OUR PERSPECTIVE
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dr amit shah

on 13 October 2014

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Transcript of NAP4UK Indian perspective Dr Amit Shah

Management of the ‘can’t intubate can’t ventilate’ situation and the
emergency surgical airway 133 serious complications of airway management
which occurred during anaesthesia 58 (43%) involved an
attempt at a cricothyroidotomy or urgent tracheostomy This life saving
procedure was associated with a significant failure rate. Cannula
cricothyroidotomy attempted by anaesthetists had a
particularly low success rate. What we already know ‘can’t intubate, can’t ventilate’ (CIC V) scenario
describes the situation where attempts to manage the
airway by facemask, (usually also Supraglottic Airway
Device – SAD ) and by placing a tracheal tube have failed cardiac arrest will typically occur within 5–10 minutes
of complete airway obstruction. Many countries have national guidelines for the
management of CIC V at induction of general anaesthesia;
in the UK guidelines from the Difficult Airway Society
(DAS ) were published in 2004.1

The final step in these
guidelines is emergency cricothyroidotomy. DAS
guidance offers the choice of narrow bore (needle)
cricothyroidotomy or surgical cricothyroidotomy. Where
needle cricothyroidotomy fails surgical cricothyroidotomy
is recommended incidence of CICV during anaesthesia is often quoted
as one in 10,0002 although Kheterpal’s more recent work identified just one case in 50,000 anaesthetics -N agaro T et al. Survey of patients whose lungs could not be ventilated and whose trachea could not be intubated in university hospitals in Japan. J Anesthesia 003;17:232–240.

-Kheterpal S et al. Prediction and Outcomes of Impossible
Mask Ventilation. Anesthesiology 2009;110:891–897. Langeron showed that patients who
are difficult to mask ventilate are four-fold more likely to be difficult to intubate
and 12-fold more likely to beimpossible to intubate than those in whom mask ventilation is easy. Langeron O et al. Prediction of difficult mask ventilation.
Anesthesiology 2000;92:1229–1236. Simple strategies to reduce the risks of CIC V include:
1 assessing the airway. Assessment enables the formation of a strategy (i.e. a co-ordinated series of plans, not just one) for dealing with failure of any part of the airway plan

2 performing effective pre-oxygenation. Pre-oxygenation including anaesthetising patients in a head up position
increases the time available to move through a failed
intubation drill before hypoxia develops

3 limiting the number of attempts at intubation.
This considerably decreases the likelihood of poor
outcomes.13 In a hypoxic patient where prompt
awakening is not possible, if oxygenation is not
improving after four attempts at intubation and two
attempts at placing a supraglottic airway, a surgical
airway should be performed

4 act before it is too late. Making the decision to
perform an emergency surgical airway is difficult and
it is important to make the most of the extra time
available from pre-oxygenation to work through all the
alternative options before dangerous hypoxia occurs.
Anaesthesia Cases

Of the 58 anaesthetic patients who had emergency surgical
airways six died. Five of the deaths were in patients with
advanced laryngeal or tracheal tumours, three died from
failed emergency airway access and two died later from
complications of their primary disease. The sixth patient
died as a result of surgical complications.

Planning issues

There was a history indicative of airway problems in half
of cases: previous difficult or failed intubation in eight
and worrying pathology or stridor in 13. In all cases the
anaesthetist was aware of the history but this did not
always seem to have been taken into account when
devising the airway management plan. Risks appeared to
be underestimated despite the presence of often multiple
risk factors. Case Review Difficulty with airway management had been anticipated in 46 of the 58 anaesthetic cases. This included difficulty with mask ventilation in 15, laryngoscopy in 40 and SAD placement in seven. Access via the front of neck was anticipated to be difficult in 15.

Multiple unsuccessful attempts at direct laryngoscopy were seen both after intravenous induction of anaesthesia and muscle relaxation and after inhalational induction In 35 cases it was acknowledged in the reports that an alternative technique had been available for airway management and in 14 this alternative was not discussed before embarking on the case. unwanted pages For Airway management we are either overconfident or ignorant ‘The most compelling educational effort for the anaesthesia community should be to reduce the frequency and severity of complications related to managing the airway’
Jonathan Benumof 1995 It is generally accepted that airway mg may be sometimes problematic, but it is not known how frequently and nature of this events NAP4 set out to address this It was designed to find out:
what type of airway devices are used
How often major complication in association of airway mg occurs
what is nature and what we can learn from this event this project is based on review of reports of series of 184 major airway related events occurring in the UK over a period of 1 year. The project team has identified the themes and combining this with previous knowledge, extracted lessons that might be learn t before outlining a series of recommendations that may guide improvement in the care.
It is certain that all cases are not reported, they anticipate that up to 3/4 cases may not have been reported three areas of clinical practice were identified and considered seprately
airway management during anesthesia
airway management during ICU
airway management during Emergency Department two weeks data collected from each of NHS hospital for all anesthetics and extrapolated for entire year Evidence-based medicine and airway management:
are they incompatible? Randomised controlled trials, RCTs, (the benchmark of high quality research) are often not a suitable methodology for
such studies major events are infrequent
these events are unpredictable
Where events are predictable, considerable effort is usually made to use alternative techniques so that the event does not occur
clinicians who attend these emergencies need to act swiftly and decisively to minimize harm and likely have little or no time to consider the possibility of performing research
success of any technique is very much based on user experience and preference NAP4 is the synthesis of learning extracted from a large series of major airway events collected in a systematic manner, prospectively, from a large area (the whole of the UK) over a relatively long period (one year) and with 100% participation. Results of the second phase of NAP4: overall results and anesthesia A total of 286 cases were reported to the RCoA lead or discussed with the moderator

After final review 184 reports met the inclusion criteria. Of the 184 reports 133 complicated the management of anaesthesia, 36 occurred in patients on ICU and 15 in the emergency department Incidence of grave event per anesthesia induced:
optimistic view- 1 / 1,80,000
pessimistic view- 1 / 45,000 considering the number of anesthetist practicing in UK:
approximately one event for consultant every 6 years It is a
tribute to the specialty that so few patients came to serious harm and few died
but these were still very serious events and to individual anaesthetists these will probably be events that they will never forget. More than half of patients were male, ASA 1–2, aged
under 60 and most events occurred during elective
surgery under the care of anaesthetic consultants. This does confirm the our belief that catastrophe always comes from no where
and most unexpected circumstances Aspiration was the most frequent cause of anesthesia airway- related mortality Aspiration of gastric contents was the primary event in 23 anaesthesia cases
It was the commonest cause of death in the
anaesthesia group accounting for eight deaths and two cases of brain damage.
Aspiration occurred most frequently in patients with risk factors (>90%),
at induction of anaesthesia or during airway instrumentation (61%).
Planned airway management was as follows:
laryngeal mask 13,
i-gel 1,
tracheal tube 8,
none 1
Aspiration occurred
before airway instrumentation in five cases
and during airway placement in two.
Two cases had clear indications for rapid
sequence induction (RSI) and in several others its use could be argued,
one case occurred during RSI laryngoscopy several cases were classic LMA was used
when clear indication for
RSI
or atleast use of
second generation supraglottic airway was warrented Obese patients were disproportionately represented 42% of all patients notified to NAP4 were obese.
Obesity was identified in 40% of anaesthesia cases.
The incidence of adult obesity in the UK in 2008 was reported to be 24.5% Our obesity population is rising
we need to be more carefull we need to be more carefull in choice of airway in high risk for aspiration cases Head and neck cases
Seventy-two reported cases (39%) involved an airway
problem in association with an acute or chronic disease
process in the head, neck or trachea.
Approximately 70% of these reports were associated with obstructive lesions within the airway Obstructing airway lesions generated a large number of
complications, many reports showed evidence of poor
planning of primary and rescue techniques Issues of
assessment, planning and communication within teams were prominent in these cases. Approximately 42% of anaesthesia events reported had a CICV. Cricothyroidotomy was the rescue technique
of choice for anaesthetists but approximately 65% of
these attempts failed to secure the airway when emergency surgical airway was required this was performed most frequently by ENT surgeons performing a rescue tracheostomy, all of which were successful The technique of cannula cricothyroidotomy needs to be taught and performed to the highest standards



Anaesthetists should be trained to
perform a surgical airway. to maximise the chances of success but the possibility that it is intrinsically inferior to a surgical technique should
also be considered. Inclusion criteria
Triggers for inclusion and notification to the project were complications of airway management that led to
■■ death
■■ brain damage
■■ need for an emergency surgical airway
■■ unanticipated ICU admission or prolongation of
ICU stay. One in four events occurred at the end of anaesthesia or in the early recovery room same extensive planning is needed for extubation of anticipated difficult airway
supplemental oxygenation should given throughout recovery phase
all paramedical staff should know the signs of airway obstruction THANK YOU Clinical Themes Poor airway assesment poor planning contributed to poor airway outcome in some circumstances when airway for unexpectedly difficult the response was unsturctured There were numerous instances where awake FOI was indicated but was not used Problem arose when difficult intubation was
managed by multiple repeat attempts at intubation Supra glottic airway was used to avoid intubation in recognized difficulty failure to correctly interpret a capnograph trace led to several oesophageal intubations going unrecognized in anesthesia commonest cause of events reported to NAP4 ,
as identified by both reporter and reviewers ,
appeared to be
POOR JUDGMENT,
EDUCATION,
TRAINING Only in one fifth of cases
the management was considered good,
rest of cases it was considered poor Results of first phase of NAP4: CENSUS For Airway management we are either overconfident or ignorant ‘The most compelling educational effort for the anaesthesia community should be to reduce the frequency and severity of complications related to managing the airway’
Jonathan Benumof 1995 It is generally accepted that airway mangement may be sometimes problematic, but it is not known how frequently and nature of this events NAP4 set out to address this It was designed to find out: All NHS hospital took part in survey

First phase - airway audit was done

Second phase- over one year reported airway events were reviewed - total 184 major airway events were included in survey

Faults identified and recommendations are the made to improve outcome Three areas of clinical practice were identified and considered separately
airway management during two weeks data collected from each of NHS hospital for all anesthetics and extrapolated for entire year Evidence-based medicine and airway management:
are they incompatible? Randomised controlled trials, RCTs, (the benchmark of high quality research) are often not a suitable methodology for
such studies Major events are infrequent & unpredictable

If you predict - need to change plan.

In emergencies - you act swiftly and decisively.

little or no time to consider the possibility of performing research.

performance vary with experience and preference. We rely on prospective studies.

NAP4 is the synthesis of learning extracted from a large series of major airway events collected in a
systematic manner,
prospectively,
from a large area (the whole of the UK)
over a relatively long period (one year) and
with 100% participation. Results of the second phase of NAP4: overall results and anesthesia A total of 286 cases were reported to the RCoA lead or discussed with the moderator

After final review 184 reports met the inclusion criteria. Of the 184 reports 133 complicated the management of anaesthesia, 36 occurred in patients on ICU and 15 in the emergency department Incidence of grave event per anesthesia induced:
optimistic view- 1 / 1,80,000
pessimistic view- 1 / 45,000 considering the number of anesthetist practicing in UK:
approximately one event for consultant every 6 years It is a
tribute to the specialty that so few patients came to serious harm and few died
but these were still very serious events and to individual anaesthetists these will probably be events that they will never forget. More than half of patients were male, ASA 1–2, aged
under 60 and most events occurred during elective
surgery under the care of anaesthetic consultants. This does confirm the our belief that catastrophe always comes from no where
and most unexpected circumstances Aspiration was the most frequent cause of anesthesia airway- related mortality Aspiration of gastric contents was the primary event in 23 anaesthesia cases
It was the commonest cause of death in the
anaesthesia group accounting for eight deaths and two cases of brain damage.
Aspiration occurred most frequently in patients with risk factors (>90%),
at induction of anaesthesia or during airway instrumentation (61%).
Planned airway management was as follows:
laryngeal mask 13,
i-gel 1,
tracheal tube 8,
none 1
Aspiration occurred
before airway instrumentation in five cases
and during airway placement in two.
Two cases had clear indications for rapid
sequence induction (RSI) and in several others its use could be argued,
one case occurred during RSI laryngoscopy several cases were classic LMA was used
when clear indication for
RSI
or atleast use of
second generation supraglottic airway was warrented Obese patients were disproportionately represented 42% of all patients notified to NAP4 were obese.
Obesity was identified in 40% of anaesthesia cases.
The incidence of adult obesity in the UK in 2008 was reported to be 24.5% Our obesity population is rising
we need to be more carefull we need to be more carefull in choice of airway in high risk for aspiration cases Head and neck cases
Seventy-two reported cases (39%) involved an airway
problem in association with an acute or chronic disease
process in the head, neck or trachea.
Approximately 70% of these reports were associated with obstructive lesions within the airway Obstructing airway lesions generated a large number of
complications, many reports showed evidence of poor
planning of primary and rescue techniques Issues of
assessment, planning and communication within teams were prominent in these cases. Approximately 42% of anaesthesia events reported had a CICV. Cricothyroidotomy was the rescue technique
of choice for anaesthetists but approximately 65% of
these attempts failed to secure the airway when emergency surgical airway was required this was performed most frequently by ENT surgeons performing a rescue tracheostomy, all of which were successful The technique of cannula cricothyroidotomy needs to be taught and performed to the highest standards



Anaesthetists should be trained to
perform a surgical airway. to maximise the chances of success but the possibility that it is intrinsically inferior to a surgical technique should
also be considered. Inclusion criteria
Triggers for inclusion and notification to the project were complications of airway management that led to
■■ death
■■ brain damage
■■ need for an emergency surgical airway
■■ unanticipated ICU admission or prolongation of
ICU stay. One in four events occurred at the end of anaesthesia or in the early recovery room same extensive planning is needed for extubation of anticipated difficult airway
supplemental oxygenation should given throughout recovery phase
all paramedical staff should know the signs of airway obstruction Clinical Themes Poor airway assesment There were numerous instances where awake FOI was indicated but was not used Problem arose when difficult intubation was managed by multiple repeat attempts at intubation Supra glottic airway was used to avoid intubation in recognized difficulty failure to correctly interpret a capnograph trace led to several oesophageal intubations going unrecognized in anesthesia commonest cause of events reported to NAP4 ,
as identified by both reporter and reviewers ,
appeared to be
POOR JUDGMENT,
EDUCATION,
TRAINING Only in one fifth of cases
the management was considered good,
rest of cases it was considered poor Results of first phase of NAP4: CENSUS It is certain that all cases are not reported, they anticipate that up to 3/4 cases may not have been reported poor planning contributed to poor airway outcome in some circumstances when airway for unexpectedly difficult the response was unsturctured Recommendations they are extensive and in depth
they are addrressed to individual, anesthesia department and societies as whole
all are appropriate - but will take one day conference Anesthesia department should have explicit policy

Anticipated difficulty- preplanned strategy is must.

Skill and equipment to deliver FOI should be available

CICV - consider use of further anesthetics or muscle relxants before surgical airway

Supraglottic airway is fundamental skill, require equal attention as intubation

All anesthetist must be trained in cricothyroidotomy and keep their skill up to date

All anesthetist should be made aware the published guidelines and to be trained to carry out them.

and so on........... Where are we? No airway audit

No established guidelines

Costly equipments are not always available

skill and training are far and few and unstructured AIDiAA is committed to make the changes

Prelimnary survey - airway audit is already started

Comprehensive audit to be done accross india with help of you

AIDiAA Website to develop a airway disaster reporting link-

Regional airway workshop to be done every year

To develop indian guidelines of diffcult airway where reporters identity can be kept secret if wished what type of airway devices are used
How often major complication in association of airway management occurs
what is nature and what we can learn from this event Thank you for your attention If you search for airway audit in india standard of anesthesia care- diversity No clear cut guidelines country specific guidelines
how many of us are using supraglottic airway routinely?

intubation through LMA ? another difficulty???

do we have access to FOB easily????

How many of us has training for cricothyrotomy?

How many of us are confident enough to do some form of surgical airway Can we accept guidelines of other country??? We do not have answers for these questions and many be many more Startling fact from only airway audit


Only 25% attended the workshop on difficult airway in previous year, Why we should take it seriously, its not a evidence based study anesthesia
ICU
Emergency Department 81% of anesthesia were GA
only 19% regional anesthesia
every consultant anesthesiologist roughly gave 323-333 GA per year though all of them show willingness to attend one if organized in nearby places scan papers If you search for airway audit in india standard of anesthesia care- diversity No clear cut guidelines country specific guidelines
how many of us are using supraglottic airway routinely?

intubation through LMA ? another difficulty???

do we have access to FOB easily????

How many of us has training for cricothyrotomy?

How many of us are confident enough to do some form of surgical airway Can we accept guidelines of other country??? We do not have answers for these questions and many be many more Startling fact from only airway audit


Only 25% attended the workshop on difficult airway in previous year, though all of them show willingness to attend one if organized in nearby places
Full transcript