- Email: [email protected]
G-1 Predictors of difficult mask ventilation and difficult intubation in morbidly obese surgical patients
94
Abstracts
general anesthesiologists. Use of ultrasound to guide cannula cricothyroidotomy in cannot intubate, cannot ventilate (CICV) situation must be cautious. http://dx.doi.org/10.1016/j.jclinane.2014.11.009
F-1 Implementation of a threatened adult airway response program at an academic medical center William Rosenblatt MD, Nathan Clendenen MD Yale University, New Haven, CT, USA
Abstract: Patients who require urgent and complex airway management outside the operating room are at risk for substantial morbidity and mortality, when trained personnel with adequate equipment are not immediately available. A comprehensive difficult airway program has been shown to reduce the number of emergency surgical airways performed outside the operating room at a large academic hospital in a retrospective study [1]. We present a summary of the development of a threatened adult airway response program to facilitate access to necessary personnel and equipment, when a patient with a difficult airway is in respiratory failure. The program was proposed in October 2010, and the first threatened adult airway team code (TAART) was called in July 2012. A TAART code may be initiated by a rapid response team hospitalist, airway response trained nurse trained nurse, respiratory therapist, anesthesia resident or attending, surgical resident, otorhinolaryngologist (ENT) resident, or trauma attending. Initiating a TAART code notifies the on-call anesthesiologist, trauma surgeon, ENT surgeon, SWAT nurse, and respiratory therapist. A dedicated equipment tower is brought to the bedside. Criteria for a TAART code include a patient with tachypnea, apnea, stridor, low or falling oxygen saturation, or initial failed intubation and a difficult airway (super morbid obesity, obvious anatomic distortion, failed intubation, or history of a difficult airway). Over 2 years, there have been 29 TAART codes called with 23 meeting the established criteria. Table 1 summarizes the characteristics of the patient and the outcome of the TAART code. Figure displays the number of TAART codes by year. Correspodence to [email protected]
Reference [1] Berkow LC, Greenberg RS, Kan KH, Colantuoni E, Mark LJ, Flint PW, et al. Need for emergency surgical airway reduced by a comprehensive difficult airway program. Anesth Analg 2009;109(6):1860-9. http://dx.doi.org/10.1016/j.jclinane.2014.11.010
G-1 Predictors of difficult mask ventilation and difficult intubation in morbidly obese surgical patients Mercedeh Vaez ⁎, David T. Wong MD, Waleed Riad Solima MD, Ravi Raveendran MD, Frances F. Chung MD Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada ⁎Corresponding author. E-mail: [email protected]
Background: Neck circumference was suggested to be a predictor of difficult intubation in the surgical population. The purpose of the study was to determine if neck circumference was a predictor of difficult mask ventilation (DMV) and difficult intubation (DI) in morbidly obese surgical patients. Methods: Institutional review board was obtained. Morbidly obese patients (BMI, ≥ 40) undergoing elective surgery requiring tracheal intubation were prospectively studied. Exclusions were known difficult airway and emergency surgery. Preoperative history, airway examination, neck, and waist circumference were collected. Patients were preoxygenated and induced. Mask ventilation was grade [1] as easy or difficult (inadequate, desaturation, 2 hand, or impossible). Intubation was performed using MacIntosh direct laryngoscopy. Intubating adjuncts or alternatives were permitted. Intubation difficult scale (IDS) was derived using 7 parameters as per Adnet [2]. Difficult intubation was defined as IDS ≥ 5. Univariate analyses were done to determine association with DMV/ DI, whereas multiple logistic regressions were done to determine independent predictors of DMV/DI. Results: (Table) One hundred four patients were studied. Age was 44 ± 11; 84% female; BMI, 48.4 ± 7.5; 54% had sleep apnea; Mallampati 1/2/3/4:32/28/33/10; and neck circumference, 42.3 ± 4.4 cm. Eleven (11%) had DMV, and 13 (13%) had DI. Univariate analyses showed that DMV was associated with males, BMI ≥ 50, sleep apnea, thyromental distance, and neck circumference; and DI with males, weight, BMI ≥ 50, waist, and neck circumference. Logistic regression showed that independent predictors of DMV were males and BMI ≥ 50 and of DI, neck circumference N 42 cm and BMI ≥ 50. Discussion: In morbidly obese surgical patients, predictors of DMV were male sex and BMI ≥ 50. Predictors of DI were BMI ≥ 50 and neck circumference N 42 cm.
References [1] Kheterpal-Anesthesiol 2009;110:891. [2] Adnet-Anesthesiology 1997;87:1290. http://dx.doi.org/10.1016/j.jclinane.2014.11.011
Figure Number of TAART codes by year.
Abstracts
95
Table Top: Univariate analysis of the variables associated with DMV and DI. Bottom: Multiple logistic regressions showing predictors of DMV and DI Top: Univariate analysis Variables
Male sex BMI (kg/m2) BMI (≥ 50) Obstructive sleep apnea Thyromental distance (cm) Neck circumference (cm)
Easy mask vent
Difficult mask vent
P
n = 93
n = 11
10 (10.7%) 48 ± 7 27 (29.3%) 46 (50.6%) 9±1 42 ± 4
6 (54.6%) 53 ± 10 7 (63.6%) 9 (81.8%) 10 ± 2 45 ± 5
.002⁎ .034⁎ .038⁎ .049⁎ .012⁎ .014⁎
Easy intubation (IDS b 5) n = 91
.028⁎ .016⁎ .008⁎ .004⁎ .001⁎ .009⁎
Male sex Weight (kg) BMI (≥ 50) Waist circumference (cm) Neck circumference (cm) Neck circumference (N 42 cm)
11 (12.1%) 132 ± 23 25 (27.5%) 134 ± 13 42 ± 4 42 (46.2%)
DI (IDS ≥ 5) n = 13 5 (38.5%) 150 ± 32 9 (69.2%) 146 ± 8 45 ± 5 11 (84.6%)
Bottom: Multiple logistic regression analysis Difficult mask vent Male sex BMI ≥ 50 Obstructive sleep apnea
OR 8.55 5.23 5.08
95% CI 1.95-37.49 1.16-23.58 0.86-30.10
P .004⁎ .031⁎ .073
Difficult intubation (IDS ≥ 5) Neck circumference (N 42 cm) BMI ≥ 50
5.17 4.88
1.05-25.5 1.33-17.9
.044⁎ .017⁎
Abbreviations: OR, odds ratio; CI, confidence interval
G-2 A preliminary report of the extubation safety quality improvement project: correctly identifying patients at highest risk for extubation failure Aaron M. Joffe DO⁎, Jacob Sunshine MD, David Dorsey MD, N. David Yanez MD, Miriam M. Treggiari MD University of Washington, Harborview Medical Center, Seattle, WA ⁎Corresponding author. E-mail: [email protected]@uw.edu
Background: Extubation failure in the intensive care unit is associated with significant morbidity. We implemented a planned intensive care unit extubation safety algorithm (see Figure) with the goal to identify patients at high risk for extubation failure and reduce complications related to extubation and reintubation. Methods: The extubation safety quality improvement project was a before and after quality improvement project conducted at a large urban teaching hospital from 3/2012-2/2013. The project included baseline data collection (first 6 months), an educational component with bedside signage specific to airway risk classification, distribution of laminated pocket cards illustrating the decision algorithm, and data collection during the intervention period (6 months). Performance of the screening algorithm in identifying
patients at high risk for reintubation was estimated using frequency distributions in each of the risk category groups. Results: One thousand eight hundred three mechanically ventilated patients were included, 981 patients in the baseline period and 822 patients in the intervention period. Overall, 96 (5%) patients were at high risk for immediate extubation failure, 376 (20%) high risk of delayed failure, and 1396 (75%) at low risk of failure (LR). The risk of reintubation was 65% in the high risk for immediate extubation failure group (odds ratio = 8.6; 95% confidence interval, 5.6-13.3), 21% for high risk of delayed failure (odds ratio = 1.6; 95% confidence interval, 1.2-2.1), and 16% in the LR group (P b .01 vs LR group). Risk of reintubation was reduced by 12% in the intervention group. Conclusions: A screening algorithm such as what we describe can correctly identify patients at highest risk for extubation failure allowing opportunity to avoid of airway-related morbidity. Conflict of interest: None of the authors has any conflicts to disclose. The study was supported with funds from the Anesthesia Patient Safety Foundation/American Society of Anesthesiologists Endowed Research Award. http://dx.doi.org/10.1016/j.jclinane.2014.11.012
Abstracts
general anesthesiologists. Use of ultrasound to guide cannula cricothyroidotomy in cannot intubate, cannot ventilate (CICV) situation must be cautious. http://dx.doi.org/10.1016/j.jclinane.2014.11.009
F-1 Implementation of a threatened adult airway response program at an academic medical center William Rosenblatt MD, Nathan Clendenen MD Yale University, New Haven, CT, USA
Abstract: Patients who require urgent and complex airway management outside the operating room are at risk for substantial morbidity and mortality, when trained personnel with adequate equipment are not immediately available. A comprehensive difficult airway program has been shown to reduce the number of emergency surgical airways performed outside the operating room at a large academic hospital in a retrospective study [1]. We present a summary of the development of a threatened adult airway response program to facilitate access to necessary personnel and equipment, when a patient with a difficult airway is in respiratory failure. The program was proposed in October 2010, and the first threatened adult airway team code (TAART) was called in July 2012. A TAART code may be initiated by a rapid response team hospitalist, airway response trained nurse trained nurse, respiratory therapist, anesthesia resident or attending, surgical resident, otorhinolaryngologist (ENT) resident, or trauma attending. Initiating a TAART code notifies the on-call anesthesiologist, trauma surgeon, ENT surgeon, SWAT nurse, and respiratory therapist. A dedicated equipment tower is brought to the bedside. Criteria for a TAART code include a patient with tachypnea, apnea, stridor, low or falling oxygen saturation, or initial failed intubation and a difficult airway (super morbid obesity, obvious anatomic distortion, failed intubation, or history of a difficult airway). Over 2 years, there have been 29 TAART codes called with 23 meeting the established criteria. Table 1 summarizes the characteristics of the patient and the outcome of the TAART code. Figure displays the number of TAART codes by year. Correspodence to [email protected]
Reference [1] Berkow LC, Greenberg RS, Kan KH, Colantuoni E, Mark LJ, Flint PW, et al. Need for emergency surgical airway reduced by a comprehensive difficult airway program. Anesth Analg 2009;109(6):1860-9. http://dx.doi.org/10.1016/j.jclinane.2014.11.010
G-1 Predictors of difficult mask ventilation and difficult intubation in morbidly obese surgical patients Mercedeh Vaez ⁎, David T. Wong MD, Waleed Riad Solima MD, Ravi Raveendran MD, Frances F. Chung MD Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada ⁎Corresponding author. E-mail: [email protected]
Background: Neck circumference was suggested to be a predictor of difficult intubation in the surgical population. The purpose of the study was to determine if neck circumference was a predictor of difficult mask ventilation (DMV) and difficult intubation (DI) in morbidly obese surgical patients. Methods: Institutional review board was obtained. Morbidly obese patients (BMI, ≥ 40) undergoing elective surgery requiring tracheal intubation were prospectively studied. Exclusions were known difficult airway and emergency surgery. Preoperative history, airway examination, neck, and waist circumference were collected. Patients were preoxygenated and induced. Mask ventilation was grade [1] as easy or difficult (inadequate, desaturation, 2 hand, or impossible). Intubation was performed using MacIntosh direct laryngoscopy. Intubating adjuncts or alternatives were permitted. Intubation difficult scale (IDS) was derived using 7 parameters as per Adnet [2]. Difficult intubation was defined as IDS ≥ 5. Univariate analyses were done to determine association with DMV/ DI, whereas multiple logistic regressions were done to determine independent predictors of DMV/DI. Results: (Table) One hundred four patients were studied. Age was 44 ± 11; 84% female; BMI, 48.4 ± 7.5; 54% had sleep apnea; Mallampati 1/2/3/4:32/28/33/10; and neck circumference, 42.3 ± 4.4 cm. Eleven (11%) had DMV, and 13 (13%) had DI. Univariate analyses showed that DMV was associated with males, BMI ≥ 50, sleep apnea, thyromental distance, and neck circumference; and DI with males, weight, BMI ≥ 50, waist, and neck circumference. Logistic regression showed that independent predictors of DMV were males and BMI ≥ 50 and of DI, neck circumference N 42 cm and BMI ≥ 50. Discussion: In morbidly obese surgical patients, predictors of DMV were male sex and BMI ≥ 50. Predictors of DI were BMI ≥ 50 and neck circumference N 42 cm.
References [1] Kheterpal-Anesthesiol 2009;110:891. [2] Adnet-Anesthesiology 1997;87:1290. http://dx.doi.org/10.1016/j.jclinane.2014.11.011
Figure Number of TAART codes by year.
Abstracts
95
Table Top: Univariate analysis of the variables associated with DMV and DI. Bottom: Multiple logistic regressions showing predictors of DMV and DI Top: Univariate analysis Variables
Male sex BMI (kg/m2) BMI (≥ 50) Obstructive sleep apnea Thyromental distance (cm) Neck circumference (cm)
Easy mask vent
Difficult mask vent
P
n = 93
n = 11
10 (10.7%) 48 ± 7 27 (29.3%) 46 (50.6%) 9±1 42 ± 4
6 (54.6%) 53 ± 10 7 (63.6%) 9 (81.8%) 10 ± 2 45 ± 5
.002⁎ .034⁎ .038⁎ .049⁎ .012⁎ .014⁎
Easy intubation (IDS b 5) n = 91
.028⁎ .016⁎ .008⁎ .004⁎ .001⁎ .009⁎
Male sex Weight (kg) BMI (≥ 50) Waist circumference (cm) Neck circumference (cm) Neck circumference (N 42 cm)
11 (12.1%) 132 ± 23 25 (27.5%) 134 ± 13 42 ± 4 42 (46.2%)
DI (IDS ≥ 5) n = 13 5 (38.5%) 150 ± 32 9 (69.2%) 146 ± 8 45 ± 5 11 (84.6%)
Bottom: Multiple logistic regression analysis Difficult mask vent Male sex BMI ≥ 50 Obstructive sleep apnea
OR 8.55 5.23 5.08
95% CI 1.95-37.49 1.16-23.58 0.86-30.10
P .004⁎ .031⁎ .073
Difficult intubation (IDS ≥ 5) Neck circumference (N 42 cm) BMI ≥ 50
5.17 4.88
1.05-25.5 1.33-17.9
.044⁎ .017⁎
Abbreviations: OR, odds ratio; CI, confidence interval
G-2 A preliminary report of the extubation safety quality improvement project: correctly identifying patients at highest risk for extubation failure Aaron M. Joffe DO⁎, Jacob Sunshine MD, David Dorsey MD, N. David Yanez MD, Miriam M. Treggiari MD University of Washington, Harborview Medical Center, Seattle, WA ⁎Corresponding author. E-mail: [email protected]@uw.edu
Background: Extubation failure in the intensive care unit is associated with significant morbidity. We implemented a planned intensive care unit extubation safety algorithm (see Figure) with the goal to identify patients at high risk for extubation failure and reduce complications related to extubation and reintubation. Methods: The extubation safety quality improvement project was a before and after quality improvement project conducted at a large urban teaching hospital from 3/2012-2/2013. The project included baseline data collection (first 6 months), an educational component with bedside signage specific to airway risk classification, distribution of laminated pocket cards illustrating the decision algorithm, and data collection during the intervention period (6 months). Performance of the screening algorithm in identifying
patients at high risk for reintubation was estimated using frequency distributions in each of the risk category groups. Results: One thousand eight hundred three mechanically ventilated patients were included, 981 patients in the baseline period and 822 patients in the intervention period. Overall, 96 (5%) patients were at high risk for immediate extubation failure, 376 (20%) high risk of delayed failure, and 1396 (75%) at low risk of failure (LR). The risk of reintubation was 65% in the high risk for immediate extubation failure group (odds ratio = 8.6; 95% confidence interval, 5.6-13.3), 21% for high risk of delayed failure (odds ratio = 1.6; 95% confidence interval, 1.2-2.1), and 16% in the LR group (P b .01 vs LR group). Risk of reintubation was reduced by 12% in the intervention group. Conclusions: A screening algorithm such as what we describe can correctly identify patients at highest risk for extubation failure allowing opportunity to avoid of airway-related morbidity. Conflict of interest: None of the authors has any conflicts to disclose. The study was supported with funds from the Anesthesia Patient Safety Foundation/American Society of Anesthesiologists Endowed Research Award. http://dx.doi.org/10.1016/j.jclinane.2014.11.012