- Email: [email protected]
The difficult airway: Mechanisms for effective dissemination of critical information
The Difficult Airway: Mechanisms for Effective Dissemination of Critical Information
Lynette J. Mark, MD,* Charles Beattie, PhD, MD,? C. Lee Ferrell, MD,+ Gregory Trempy, MD,$ Todd Dorman, MD,11 James F. Schauble, MD”f Department of Anesthesiology and Critical Care Medicine, Johns versity School of Medicine, Baltimore, MD. The perioperative management and dissemination of critical information regarding a patient with an unexpected difficult intubation, including successful ap@ication of a dzfficult airway algorithm (Figure l), are described. Documentation and di.rsemination of critical information include entry of patient data into an in-hospital computerized Difficult Airwayllntubation Registry, simultaneous application of a highly uisible D$fjficult Airwayllntubation Patient Wrist Band (codedfor access to computer regi&y), summary reports distributed to health care providers, and enrollment of the patient in the Medic Alert Foundation International’s newly established category difficult airwaylintubation for 24-hour access. We postulate that the widespread use of the procedures described in this report may
*Assistant Professor TAssociate Professor /Resident OFellow, Cardiac Anesthesia I(Assistant Chief of Service Address reprint requests to Dr. Mark at the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital, 600 N. Wolfe Street/Tower 711, Baltimore, MD 21205, USA. This study was supported in part by an educational research grant from the Foundation for Anesthesia Education Research, Baltimore, MD. Received for publication December 17, 1991; revised manuscript accepted for publication January 7, 1992. 0 1992 Butterworth-Heinemann
J. Clin. Anesth. 4:247-251,
1992.
Hopkins Uni-
reduce the contribution of unexpected difficult airwayiintubation to anesthetic morbidity and mortality. Keywords: Airway, difficult; intubation, endotracheal, difficult; Difficult Airway/Intubation Kegistry; medical record linkage; information retrieval systems, Medic Alert Foundation International.
Introduction Failed airway maintenance and/or endotracheal intubation is an ever-present hazard in anesthetic practice. The American Society of Anesthesiologists (ASA) Committee on Professional Liability’ stated that adverse outcomes associated with respiratory events constitute the largest class of injury in the ASA Closed Claims Project and listed difficult endotracheal intubation as one of the preventable causes. The ASA responded to this concern regarding airway management by establishing a task force and preparing a patient safety videotape.’ At the Johns Hopkins University, we have instituted the following steps to address this issue: (1) Document the frequency ofdifficult airway/intubation cases and apply the existing Difficult Airway Management Algorithm of the ASA videotape (Figure 1) with certain modifications based on our personal experiences. (2) Establish a Difficult Airway/ Intubation Registry with in-hospital identification of such patients via a highly visible Difficult AirwayOntubation Patient Wrist Band coded to link the patient to our registry. (3) Disseminate critical airway and perioperative management information to the patient and future health care providers via our investigational Anesthesiology Consultant Report (ACR).3 The ACR is a two-page dic.J. Clin. Anesth.,
vol. 4, May/June
1992
247
Case Reports
DIFFICULT AIRWAY
UNRECOGNIZED
RECOGNIZED
INDUCE GENERAL ANESTHESIA
ONE ATTEMPT AT DIRECT VISION INTUBATION (bryngeal Mask Altway 7)
FAIL TO INTUBATE
CALL FOR HELP
FAIL
NO 4
CRICOTHYROIDOTOMY
TRANSTAACHEAL
ADEQUATE 7
FAIL AFlER MULTIPLE AlTEMPTS
TO FlNlSH CASE -I-
.
VENTILATION WITH ET Ce, BaO2 and OTHER TESTS
WHEN APPROPRIATE
*
EXTUBATION (SVER JET STYLET)
Figure 1. ‘l‘his figure shows the diil’icult ail-w) algorithm propsed h? the XL\ videotape that we generally fitllou ONI. intubation choices ( + + ) include the fiber-optic technique briefI>. described in this report. Alternatively, we use rigid hronchoscopic or suspension laryngoscopic equipment.
tation by the anesthesiologist that describes preoperative intraoperative techniques evaluation and preparation, and management, and recommendations for future anesthetics and is distributed to OUI‘medical, surgical, and anesthetic colleagues. (4) Enroll selected patients in the nonprofit Medic Alert Foundation International (Medic Alert, Turlock, G4) under the category difficult airway/ intubation for 24-hour international access. This case report illustrates how the above procedures were implemented for a patient scheduled for cardiac surgery who presented serious difficulty with endotracheal intubation.
Case Report A 64-year-old, ASA physical status IV, 70 kg, 175 cm male with a diagnosis of unstable angina was admitted to the coronary care unit for coronary artery bypass surgery. Cardiac catheterization revealed a high-grade lesion of the left anterior descending coronarv artery. His 248
J,
Clin.
Anesth.,
vol.
4, Mayljune 1992
significant past medical history included hypertension treated with nifedipine; diet-controlled, non-insulindependent diabetes mellitus; and a remote history 01‘ tobacco use. The patient had no history of intubation, his only previous surgery being a transurethral resection of the prostate under spinal anesthesia. There was no family history of difficult intubation. Physical examination showed a well-developed male with stable hemodynamic parameters. His airway examination, weight, head and neck movement, jaw movement, mandibular profile, and dentition were consistent with a Wilson risk-sum of zero (no difficulty anticipated).’ Faucial pillars and soft palate were seen, and the uvula was visible with phonation (Mallampati Class 2).: He was assessed to be a candidate for conventional, asleep oral laryngoscopy and intubation. The patient was premeditated with morphine sulfate 0.1 mg/kg intramuscularly (IM) and scopolamine 0.3 mg IM. He was transported to the operating room with supplemental oxygen via a face mask. Monitors were ap-
Difficult aimaylintubation registry: Mark et al.
plied, and central and arterial access (right radial artery catheter, right internal jugular catheter, and pulmonary artery catheter) was accomplished without problems. The patient was preoxygenated by face mask and induced with midazolam 0.3 mg/kg. Controlled mask ventilation was established, and he was paralyzed with vecuronium 0.15 mg/kg. Fentanyl 15 pg/kg was titrated with stable hemodynamics in anticipation of intubation. Attempts at oral laryngoscopy with Macintosh #3 and #4 and Miller #2 and #3 blades failed to expose the glottic opening (Mallampati Glottic Exposure Grade 4; Wilson risk-sum laryngeal view 4).4.9 Attempts to blindly place styletted #8 and #7 endotracheal tubes were unsuccessful. Interposed episodes of mask ventilation were adequate. We decided to proceed with other techniques to secure the airway, rather than awakening the patient, because of our choice of induction drugs. At this juncture, one wing of our clinical algorithm (Figure 1) was instituted. It involved the transition from conventional hand-bag-mask ventilation to hand-bagnasopharyngeal ventilation using an endotracheal tube connector inserted into the nasopharyngeal airway (with manual oral seal). Adequate ventilation [end-tidal partial pressure of carbon dioxide (PE,COn) 25 to 40 mmHg] and oxygenation [oxygen saturation (SaO,) greater than 95%~] were achieved. Asleep fiber-optic intubation was accomplished using a 4.5 mm fiber-optic bronchoscope through a #7.5 endotracheal tube placed in the opposite nares, while hand-bag-nasopharyngeal positive-pressure ventilation was continued.fi.7 Endotracheal tube position was confirmed by bronchoscopy, the presence of P,, CO,, and bilateral breath sounds. SaO, was greater than 95% throughout the procedure. The case proceeded without incident. The patient was extubated without problems on the first postoperative day in the presence of an anesthesiologist (with airway management/fiber-optic technology available). The patient was informed of the operative events. Dissemination of this information to the medical record, surgeon, referring physician(s), patient, and Medic Alert is discussed in the following section.
Discussion Unanticipated difficult airway management continues to be a potentially disastrous problem.‘,* Several published reports suggest that difficulty with airway/intubation is more common than generally supposed (1% to 3%).2.4,i,x The difficult airway contribution to anesthetic morbidity and mortality is probably becoming even more important as other causes of morbidity and mortality are reduced by improved monitoring and pharmacologic techniques.“-” Although 90% of difficult intubations should be anticipated with careful, routine examination of the airway in all patients requiring anesthesia,12 unexpected problems with difficult airway/intubation continue to occur. Several investigators have proposed preoperative characteristics that predict difficult intubation; however, limited sensitivity and specificity have prevented their general acceptance.13-15
Patients with documented difficult airways should be identified to future health care providers to help decrease adverse respiratory outcomes.‘,* Unfortunately, the patient may not be aware of his or her previous experience (or details) or may be unable to communicate the problem. Although the anesthesia record will probably note any difficulty with airway management, to date to be made it has not been common for this information known to other health care professionals. Thus, should the patient require postoperative reintubation (or other airway manipulation), disastrous (potentially avoidable) complications could ensue. Furthermore, airway difficulties are rarely noted on discharge summaries, and this vital fact remains buried within the arcane notation of anesthetic records. To address these issues, we have initiated several procedures that make critical information available to health care providers during the patient’s hospitalization (when the problem was identified) and for subsequent medical encounters. Patients identified as having a difficult airwayiintubation are entered into an ongoing “Anesthesia-Medical Alert” investigation. I6 This involves immediate application of a temporary patient wristband* and subsequent enrollment in an in-house registry. For our patient, the wristband was inscribed “Difficult Intubation: Mask airway OK. Glottic opening not visualized with Mac #3,4, Miller #2,3. Asleep, nasal fiberoptic #7.5 ETT. JHU Registry #__ .” The highly visible nature of the wristband and its attendant information alerted health care providers to the patient’s special requirements for the duration of his hospitalization. After the anesthetic/surgical procedure, patients are enrolled in a Difficult AirwayiIntubation Registry. This data base identifies categories of airway-related history, physical characteristics, designated techniques, decision tree and clinically applied airway algorithm, complications, immediate disposition, and final disposition. The data base will ultimately be accessible from a computerized medical record via terminals already strategically located throughout the hospital. The registry number on the patient wristband links this additional information as needed. Using this data base, we have initiated a collaborative effort with the Johns Hopkins Department of Otolaryngology-Head and Neck Surgery to develop and modify airway management techniques and clinical algorithms. Dissemination of pertinent details of patient management and outcome also is available from our Anesthesiology Consultant Report (ACR).” This summary report is dictated following selected anesthetics/procedures and transcribed by the hospital clinical documentation service, with copies to the medical record, surgeon, and referring physician. In this case, the ACR highlighted the *The Joint Committee on Clinical Investigations issued a waiver to written informed consent to place wristbands on identified patients. Health care personnel and patients recognize the tremendous implications to patient safety (VS.breach of confidentiality) as modeled in existing in-hospital “allergy alert” temporary wristbands and outof-hospital permanent medical alert bracelets.
J. Clin. Anesth.,
vol. 4, May/June
1992
249
Case Reports
clinical airway algorithm applied, including specific anesthesia technical information, and recommended awake fiber-optic intubation techniques should future anesthetics be required. This document becomes part of the patient’s official medical record and is available to inhospital personnel. Medic Alert is a charitable, nonprofit organization that provides comprehensive 24-hour emergency medical identification service for its members. In 1979, Medic Alert was officially endorsed by the ASA House of Delegates.” Although patients with prior laryngeal surgery/ tracheostomy had been enrolled in Medic Alert, there had not been a formally designated category (difficult airwayiintubation). We have created this category with Medic Alert, and any physician or institution can easily access or enter patients as they are identified. Seventyfive lines of information can be entered into the patient’s Medic Alert computer record and backup wallet card. We identified critical wall~~rinformation to include the (2) institutional following: ( 1) difficult airwayiintubation; Difficult AirwayiIntubation Registry and medical record number; (3) clinical airway algorithm; (4) surgical procedure (medical intervention) and date. ‘l‘he Medic Alert wallet card and engraved bracelet for the patient described in this case report are shown in ~;@UYS 2 and 3.
MtNnberID: Issued:
05 NOV 1991
DIFFICULT AIRWAY INTUBATION REGlBTRY UNIVERSITY YBMBRR ?? MABR VRNllLAllON OR. MULTIPLE FAILED AllBMPTS. DIRBCT LARYNGOBCOPY (MAC/MILLBR). GLOlTlC OPBNING NOT VIBIJAL. NABAL FIBER OPTIC INTUBATION SUCCEBBNL. CORONARY ARTERY BYPASS GRAFT 1091. . PERSONS TO NOTIFY Dr
(301) (301) ml)
MEMBER INFORMATlON 5%: Born: SSN:
Moms Since:
Figure 2. Medic Alert Foundation International wallet card. Specific documentation includes (1) category: difficult airwayiintubation; (2) institution registry; (3) clinical airway algorithm; and (4) surgical procedure and date. *The MAC/MILLER should specify MAC #3, #4, MILLER #3.
250
J. Clin. Anesth., vol. 4, May/-June 1992
Figure
3. Medic Alert Foundation
International
bl-acrlet.
fee is acquired through a I‘he basic lifetime membership one-time fee of $35.00. The Medic Alert system readilk accommodates updates or entry of new i&rmation regarding the patient’s condition for a nominal fee (currently $7). There are other considerations when individuals are categorized as having a difficult airway. Techniques to facilitate endotracheal intubation in patients whose glottic opening cannot be visualized by convenrional direct laryngoscopy (anticipated or unanticipated difficult illtubations) continue to improve. In addition, patients’ physical characteristics change and anesthesiologists’ level of expertise vary. ‘l‘herefore, a patient’s status as having a difficult airway/intubation may change with time and circumstance. Subsequent clinicians can be alerted to the patient’s airway problem so they may implement their techniques of choice for a successful intubation. We believe that the patient described in this report underwent an appropriate preoperative evaluation. His difficult intubation was unanticipated, with management options limited by the induction technique. Our prospectively organized approach resulted in a secured airway and minimal tissue trauma. Health care professionals who subsequently encomtered this patient during his hospitalization were made aware of his airway problem via his wristband. His enrollment in the in-hospital airway registry ensures that future admissions to the Johns Hopkins Hospital will include fully informing personnel about his airway problem. His enrollment in Medic Alert (for which he receives a computerized record, wallet card, and permanent bracelet/necklace) enables immediate access to the details surrounding his condition for authorized medical personnel throughout the world. The details of his anesthetic management are made available to his current care givers via a dictated report, a copy of which is included in the Medic Alert computer record. Future health care providers can access this report directly through Medic Alert or Johns Hopkins University.
Difficult
Widespread dissemination of specific information concerning difficult airways could change airway management practices and improve patient outcomes.
6.
Acknowledgments
7.
We gratefully acknowledge Joyce Drake, Chicago Regional Director, Medic Alert Foundation International, and Kathy Mulford, medical record coordinator for the development of the Anesthesiology Consultant Report. Additionally, we would like to thank our chairman, Dr. Mark C. Rogers, for his support in this endeavor.
8.
9. IO.
References American Society of Anesthesiologists, Committee on Professional Liability: Preliminary study of closed claims. ASA Nmlrttvr 1988;52:8-10. ASA Committee on Patient Safety and Risk Management’s Task Force on the Difficult Airway: ASA Patient Safety Videotap No. 15, Thr Lhffidt ,4inq, Pnrt One. EC Pierce Jr, executive producer. Hurroughs Wellcome, Research Triangle Park, NC, 199 1. Mark L, Beattie C, Fisher Q: The Consultant Anesthr.tinlog~.~t: A Nm t’rofzle Jbr the Prc$es.rion of Anesthesiology. Baltimore, MD: Foundation fbr Anesthesia Education and Research, Educational Research Grant, 1991-92. Wilson ME, Spiegelhalter D, Robertson JA, Lesser P: Predicting dif.ficult intubation. BrJ Am& 1988;61:21 1-6. Mallampati SK, Gatt SP, Gugino LD, et al: A clinical sign to
11. 12.
13.
14. 15. 16.
17.
aimaylintubation
registry: Mark
et al.
predict difficult intubation: a prospective study. Can Anaesth socj 1985;32:429-34. Stella JP, Kageler WV, Epker BN: Fiberoptic endotracheal intubation in oral and maxillofacial surgery. J Oral Mwcillofac Surg 1986;44:923. Benumof J: Management of the difficult adult airway. Anestheszology 1991;75:1087-1110. Caplan RA, Posner K, Ward RJ, Cheney W: Adverse respiratory events in anesthesia: a closed claims analysis. Anesthe\ZOlOg$ 1990;72:828-33. Keats AS: Anesthesia mortality in perspective. Anesth An& 1Y90;7 1: 113-g. Eichhorn JH: Documenting improved anesthesia outcome. ,] Clin An&h 1991;3:351-3.
J. Clin.
Anesth.,
vol. 4, May/June
1992
251
Lynette J. Mark, MD,* Charles Beattie, PhD, MD,? C. Lee Ferrell, MD,+ Gregory Trempy, MD,$ Todd Dorman, MD,11 James F. Schauble, MD”f Department of Anesthesiology and Critical Care Medicine, Johns versity School of Medicine, Baltimore, MD. The perioperative management and dissemination of critical information regarding a patient with an unexpected difficult intubation, including successful ap@ication of a dzfficult airway algorithm (Figure l), are described. Documentation and di.rsemination of critical information include entry of patient data into an in-hospital computerized Difficult Airwayllntubation Registry, simultaneous application of a highly uisible D$fjficult Airwayllntubation Patient Wrist Band (codedfor access to computer regi&y), summary reports distributed to health care providers, and enrollment of the patient in the Medic Alert Foundation International’s newly established category difficult airwaylintubation for 24-hour access. We postulate that the widespread use of the procedures described in this report may
*Assistant Professor TAssociate Professor /Resident OFellow, Cardiac Anesthesia I(Assistant Chief of Service Address reprint requests to Dr. Mark at the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Hospital, 600 N. Wolfe Street/Tower 711, Baltimore, MD 21205, USA. This study was supported in part by an educational research grant from the Foundation for Anesthesia Education Research, Baltimore, MD. Received for publication December 17, 1991; revised manuscript accepted for publication January 7, 1992. 0 1992 Butterworth-Heinemann
J. Clin. Anesth. 4:247-251,
1992.
Hopkins Uni-
reduce the contribution of unexpected difficult airwayiintubation to anesthetic morbidity and mortality. Keywords: Airway, difficult; intubation, endotracheal, difficult; Difficult Airway/Intubation Kegistry; medical record linkage; information retrieval systems, Medic Alert Foundation International.
Introduction Failed airway maintenance and/or endotracheal intubation is an ever-present hazard in anesthetic practice. The American Society of Anesthesiologists (ASA) Committee on Professional Liability’ stated that adverse outcomes associated with respiratory events constitute the largest class of injury in the ASA Closed Claims Project and listed difficult endotracheal intubation as one of the preventable causes. The ASA responded to this concern regarding airway management by establishing a task force and preparing a patient safety videotape.’ At the Johns Hopkins University, we have instituted the following steps to address this issue: (1) Document the frequency ofdifficult airway/intubation cases and apply the existing Difficult Airway Management Algorithm of the ASA videotape (Figure 1) with certain modifications based on our personal experiences. (2) Establish a Difficult Airway/ Intubation Registry with in-hospital identification of such patients via a highly visible Difficult AirwayOntubation Patient Wrist Band coded to link the patient to our registry. (3) Disseminate critical airway and perioperative management information to the patient and future health care providers via our investigational Anesthesiology Consultant Report (ACR).3 The ACR is a two-page dic.J. Clin. Anesth.,
vol. 4, May/June
1992
247
Case Reports
DIFFICULT AIRWAY
UNRECOGNIZED
RECOGNIZED
INDUCE GENERAL ANESTHESIA
ONE ATTEMPT AT DIRECT VISION INTUBATION (bryngeal Mask Altway 7)
FAIL TO INTUBATE
CALL FOR HELP
FAIL
NO 4
CRICOTHYROIDOTOMY
TRANSTAACHEAL
ADEQUATE 7
FAIL AFlER MULTIPLE AlTEMPTS
TO FlNlSH CASE -I-
.
VENTILATION WITH ET Ce, BaO2 and OTHER TESTS
WHEN APPROPRIATE
*
EXTUBATION (SVER JET STYLET)
Figure 1. ‘l‘his figure shows the diil’icult ail-w) algorithm propsed h? the XL\ videotape that we generally fitllou ONI. intubation choices ( + + ) include the fiber-optic technique briefI>. described in this report. Alternatively, we use rigid hronchoscopic or suspension laryngoscopic equipment.
tation by the anesthesiologist that describes preoperative intraoperative techniques evaluation and preparation, and management, and recommendations for future anesthetics and is distributed to OUI‘medical, surgical, and anesthetic colleagues. (4) Enroll selected patients in the nonprofit Medic Alert Foundation International (Medic Alert, Turlock, G4) under the category difficult airway/ intubation for 24-hour international access. This case report illustrates how the above procedures were implemented for a patient scheduled for cardiac surgery who presented serious difficulty with endotracheal intubation.
Case Report A 64-year-old, ASA physical status IV, 70 kg, 175 cm male with a diagnosis of unstable angina was admitted to the coronary care unit for coronary artery bypass surgery. Cardiac catheterization revealed a high-grade lesion of the left anterior descending coronarv artery. His 248
J,
Clin.
Anesth.,
vol.
4, Mayljune 1992
significant past medical history included hypertension treated with nifedipine; diet-controlled, non-insulindependent diabetes mellitus; and a remote history 01‘ tobacco use. The patient had no history of intubation, his only previous surgery being a transurethral resection of the prostate under spinal anesthesia. There was no family history of difficult intubation. Physical examination showed a well-developed male with stable hemodynamic parameters. His airway examination, weight, head and neck movement, jaw movement, mandibular profile, and dentition were consistent with a Wilson risk-sum of zero (no difficulty anticipated).’ Faucial pillars and soft palate were seen, and the uvula was visible with phonation (Mallampati Class 2).: He was assessed to be a candidate for conventional, asleep oral laryngoscopy and intubation. The patient was premeditated with morphine sulfate 0.1 mg/kg intramuscularly (IM) and scopolamine 0.3 mg IM. He was transported to the operating room with supplemental oxygen via a face mask. Monitors were ap-
Difficult aimaylintubation registry: Mark et al.
plied, and central and arterial access (right radial artery catheter, right internal jugular catheter, and pulmonary artery catheter) was accomplished without problems. The patient was preoxygenated by face mask and induced with midazolam 0.3 mg/kg. Controlled mask ventilation was established, and he was paralyzed with vecuronium 0.15 mg/kg. Fentanyl 15 pg/kg was titrated with stable hemodynamics in anticipation of intubation. Attempts at oral laryngoscopy with Macintosh #3 and #4 and Miller #2 and #3 blades failed to expose the glottic opening (Mallampati Glottic Exposure Grade 4; Wilson risk-sum laryngeal view 4).4.9 Attempts to blindly place styletted #8 and #7 endotracheal tubes were unsuccessful. Interposed episodes of mask ventilation were adequate. We decided to proceed with other techniques to secure the airway, rather than awakening the patient, because of our choice of induction drugs. At this juncture, one wing of our clinical algorithm (Figure 1) was instituted. It involved the transition from conventional hand-bag-mask ventilation to hand-bagnasopharyngeal ventilation using an endotracheal tube connector inserted into the nasopharyngeal airway (with manual oral seal). Adequate ventilation [end-tidal partial pressure of carbon dioxide (PE,COn) 25 to 40 mmHg] and oxygenation [oxygen saturation (SaO,) greater than 95%~] were achieved. Asleep fiber-optic intubation was accomplished using a 4.5 mm fiber-optic bronchoscope through a #7.5 endotracheal tube placed in the opposite nares, while hand-bag-nasopharyngeal positive-pressure ventilation was continued.fi.7 Endotracheal tube position was confirmed by bronchoscopy, the presence of P,, CO,, and bilateral breath sounds. SaO, was greater than 95% throughout the procedure. The case proceeded without incident. The patient was extubated without problems on the first postoperative day in the presence of an anesthesiologist (with airway management/fiber-optic technology available). The patient was informed of the operative events. Dissemination of this information to the medical record, surgeon, referring physician(s), patient, and Medic Alert is discussed in the following section.
Discussion Unanticipated difficult airway management continues to be a potentially disastrous problem.‘,* Several published reports suggest that difficulty with airway/intubation is more common than generally supposed (1% to 3%).2.4,i,x The difficult airway contribution to anesthetic morbidity and mortality is probably becoming even more important as other causes of morbidity and mortality are reduced by improved monitoring and pharmacologic techniques.“-” Although 90% of difficult intubations should be anticipated with careful, routine examination of the airway in all patients requiring anesthesia,12 unexpected problems with difficult airway/intubation continue to occur. Several investigators have proposed preoperative characteristics that predict difficult intubation; however, limited sensitivity and specificity have prevented their general acceptance.13-15
Patients with documented difficult airways should be identified to future health care providers to help decrease adverse respiratory outcomes.‘,* Unfortunately, the patient may not be aware of his or her previous experience (or details) or may be unable to communicate the problem. Although the anesthesia record will probably note any difficulty with airway management, to date to be made it has not been common for this information known to other health care professionals. Thus, should the patient require postoperative reintubation (or other airway manipulation), disastrous (potentially avoidable) complications could ensue. Furthermore, airway difficulties are rarely noted on discharge summaries, and this vital fact remains buried within the arcane notation of anesthetic records. To address these issues, we have initiated several procedures that make critical information available to health care providers during the patient’s hospitalization (when the problem was identified) and for subsequent medical encounters. Patients identified as having a difficult airwayiintubation are entered into an ongoing “Anesthesia-Medical Alert” investigation. I6 This involves immediate application of a temporary patient wristband* and subsequent enrollment in an in-house registry. For our patient, the wristband was inscribed “Difficult Intubation: Mask airway OK. Glottic opening not visualized with Mac #3,4, Miller #2,3. Asleep, nasal fiberoptic #7.5 ETT. JHU Registry #__ .” The highly visible nature of the wristband and its attendant information alerted health care providers to the patient’s special requirements for the duration of his hospitalization. After the anesthetic/surgical procedure, patients are enrolled in a Difficult AirwayiIntubation Registry. This data base identifies categories of airway-related history, physical characteristics, designated techniques, decision tree and clinically applied airway algorithm, complications, immediate disposition, and final disposition. The data base will ultimately be accessible from a computerized medical record via terminals already strategically located throughout the hospital. The registry number on the patient wristband links this additional information as needed. Using this data base, we have initiated a collaborative effort with the Johns Hopkins Department of Otolaryngology-Head and Neck Surgery to develop and modify airway management techniques and clinical algorithms. Dissemination of pertinent details of patient management and outcome also is available from our Anesthesiology Consultant Report (ACR).” This summary report is dictated following selected anesthetics/procedures and transcribed by the hospital clinical documentation service, with copies to the medical record, surgeon, and referring physician. In this case, the ACR highlighted the *The Joint Committee on Clinical Investigations issued a waiver to written informed consent to place wristbands on identified patients. Health care personnel and patients recognize the tremendous implications to patient safety (VS.breach of confidentiality) as modeled in existing in-hospital “allergy alert” temporary wristbands and outof-hospital permanent medical alert bracelets.
J. Clin. Anesth.,
vol. 4, May/June
1992
249
Case Reports
clinical airway algorithm applied, including specific anesthesia technical information, and recommended awake fiber-optic intubation techniques should future anesthetics be required. This document becomes part of the patient’s official medical record and is available to inhospital personnel. Medic Alert is a charitable, nonprofit organization that provides comprehensive 24-hour emergency medical identification service for its members. In 1979, Medic Alert was officially endorsed by the ASA House of Delegates.” Although patients with prior laryngeal surgery/ tracheostomy had been enrolled in Medic Alert, there had not been a formally designated category (difficult airwayiintubation). We have created this category with Medic Alert, and any physician or institution can easily access or enter patients as they are identified. Seventyfive lines of information can be entered into the patient’s Medic Alert computer record and backup wallet card. We identified critical wall~~rinformation to include the (2) institutional following: ( 1) difficult airwayiintubation; Difficult AirwayiIntubation Registry and medical record number; (3) clinical airway algorithm; (4) surgical procedure (medical intervention) and date. ‘l‘he Medic Alert wallet card and engraved bracelet for the patient described in this case report are shown in ~;@UYS 2 and 3.
MtNnberID: Issued:
05 NOV 1991
DIFFICULT AIRWAY INTUBATION REGlBTRY UNIVERSITY YBMBRR ?? MABR VRNllLAllON OR. MULTIPLE FAILED AllBMPTS. DIRBCT LARYNGOBCOPY (MAC/MILLBR). GLOlTlC OPBNING NOT VIBIJAL. NABAL FIBER OPTIC INTUBATION SUCCEBBNL. CORONARY ARTERY BYPASS GRAFT 1091. . PERSONS TO NOTIFY Dr
(301) (301) ml)
MEMBER INFORMATlON 5%: Born: SSN:
Moms Since:
Figure 2. Medic Alert Foundation International wallet card. Specific documentation includes (1) category: difficult airwayiintubation; (2) institution registry; (3) clinical airway algorithm; and (4) surgical procedure and date. *The MAC/MILLER should specify MAC #3, #4, MILLER #3.
250
J. Clin. Anesth., vol. 4, May/-June 1992
Figure
3. Medic Alert Foundation
International
bl-acrlet.
fee is acquired through a I‘he basic lifetime membership one-time fee of $35.00. The Medic Alert system readilk accommodates updates or entry of new i&rmation regarding the patient’s condition for a nominal fee (currently $7). There are other considerations when individuals are categorized as having a difficult airway. Techniques to facilitate endotracheal intubation in patients whose glottic opening cannot be visualized by convenrional direct laryngoscopy (anticipated or unanticipated difficult illtubations) continue to improve. In addition, patients’ physical characteristics change and anesthesiologists’ level of expertise vary. ‘l‘herefore, a patient’s status as having a difficult airway/intubation may change with time and circumstance. Subsequent clinicians can be alerted to the patient’s airway problem so they may implement their techniques of choice for a successful intubation. We believe that the patient described in this report underwent an appropriate preoperative evaluation. His difficult intubation was unanticipated, with management options limited by the induction technique. Our prospectively organized approach resulted in a secured airway and minimal tissue trauma. Health care professionals who subsequently encomtered this patient during his hospitalization were made aware of his airway problem via his wristband. His enrollment in the in-hospital airway registry ensures that future admissions to the Johns Hopkins Hospital will include fully informing personnel about his airway problem. His enrollment in Medic Alert (for which he receives a computerized record, wallet card, and permanent bracelet/necklace) enables immediate access to the details surrounding his condition for authorized medical personnel throughout the world. The details of his anesthetic management are made available to his current care givers via a dictated report, a copy of which is included in the Medic Alert computer record. Future health care providers can access this report directly through Medic Alert or Johns Hopkins University.
Difficult
Widespread dissemination of specific information concerning difficult airways could change airway management practices and improve patient outcomes.
6.
Acknowledgments
7.
We gratefully acknowledge Joyce Drake, Chicago Regional Director, Medic Alert Foundation International, and Kathy Mulford, medical record coordinator for the development of the Anesthesiology Consultant Report. Additionally, we would like to thank our chairman, Dr. Mark C. Rogers, for his support in this endeavor.
8.
9. IO.
References American Society of Anesthesiologists, Committee on Professional Liability: Preliminary study of closed claims. ASA Nmlrttvr 1988;52:8-10. ASA Committee on Patient Safety and Risk Management’s Task Force on the Difficult Airway: ASA Patient Safety Videotap No. 15, Thr Lhffidt ,4inq, Pnrt One. EC Pierce Jr, executive producer. Hurroughs Wellcome, Research Triangle Park, NC, 199 1. Mark L, Beattie C, Fisher Q: The Consultant Anesthr.tinlog~.~t: A Nm t’rofzle Jbr the Prc$es.rion of Anesthesiology. Baltimore, MD: Foundation fbr Anesthesia Education and Research, Educational Research Grant, 1991-92. Wilson ME, Spiegelhalter D, Robertson JA, Lesser P: Predicting dif.ficult intubation. BrJ Am& 1988;61:21 1-6. Mallampati SK, Gatt SP, Gugino LD, et al: A clinical sign to
11. 12.
13.
14. 15. 16.
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