Airway management – it’s a team sport, not a technical skill
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Airway management – it’s a team sport, not a technical skill
Jan. 20, 2020•0 likes•1,928 views
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Adam gives practical pearls about managing the unexpected difficult airway. He uses a good example, emphasises the importance of effective teamwork and draws from the Vortex approach and the DAS guidelines. Watch out for more from Adam via the Safe Airway Society.
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Airway management – it’s a team sport, not a technical skill
- Airway Mx of the Critically Ill… A team sport, not a technical skill Dr Adam Rehak
- Acknowledgements
- Declarations
- Airway Mx of the Critically Ill… A team sport, not a technical skill Dr Adam Rehak FANZCA
- Rationale/Background • Delayed/failed intubations • CICO events where FMV/SGA omitted or poorly optimised • Excessive no. intubation attempts • Poor recognition/ agreement when to “transition” to CICO Rescue
- Objectives Barriers Goals Utilise existing tools/models
- Case Study • 69y/o BIBA with severe SOB • Suspected cardiogenic pulmonary oedema • PHx IHD/AMI/Poor LVEF • BMI 35 • SpO2 92% on non-rebreather • Confused and combative, removing mask • Refusing NIV/CPAP/BiPAP • Plan to intubate
- Airway Plan Delayed sequence induction (ketamine) RSI with CP • Plan A • CMac #4 blade • CMac D blade • 3rd attempt only If anaesthestic help arrives • Plan B • iGel • Plan C • FMV w OPA/NPA & two-hands • Plan D • CICO Rescue scalpel technique
- Case Study Delayed Sequence Induction • 150mg Ketamine given IV • SpO2 falls to 85%. Apnoeic What now?
- Case Study Airway Rescue • FMV attempted but big leak due to beard • Unable to get iGel into mouth • 100mg Sux given • SpO2 76% when fasciculations end • Grade IV larynx with standard #4 Macintosh blade laryngoscope • Grade IV larynx with cMac #4 blade • Grade IIIb larynx with CMac D blade (CP removed, BURP attempted) • SpO2 68% Is this CICO?
- Case Study Return to FMV • FMV with OPA and two hands produces some chest movement • Poor capnograhy trace • SpO2 steady at 84% What now?
- Case Study Anaesthetic Registrar Arrives • A.R. - “What have you tried?” • FACEM – “We’ve tried everything…can barely ventilate with FMV and LMA didn’t work. Couldn’t intubate with cMac. Do you want to have a look?” What now?
- Case Study Anaesthetic Registrar • Attempts intubation with Mac #4 blade – Grade IV view • SpO2 70% • cMac #4 blade – Grade IV view • Returns to FMV – impossible • SpO2 58% • cMac D-blade – Grade IIIb view, blind insertion = No ETCO2 • SpO2 unrecordable • Returns to FMV – impossible…”I think this is CICO” Is it? Who? How?
- Case Study CICO Rescue • FACEM – “Do you want to do it?” • A.R. – “Ok. Give me a 14G cannula” • 2 mins - Cannula inserted • A.R. – “Have you got a Rapid- O2?....What about an ENK?” • (Silence).... • 3 mins - FACEM performs scalpel-bougie • 5 mins – O2 delivered, SpO2 90%
- The Unanticipated Difficult Airway Management Goals • Try all three lifelines • Optimise all three lifelines • Do it quickly (minimum no. of attempts) • Don’t repeat anything • Recognise and exploit opportunities of the GZ • Know when to declare CICO • Be ready to perform CICO Rescue
- • Try all three lifelines • Optimise all three lifelines • Do it quickly (minimum no. of attempts) • Don’t repeat anything • Recognise and exploit opportunities of the GZ • Know when to declare CICO • Be ready to perform CICO Rescue The Unanticipated Difficult Airway Management Goals
- The Unanticipated Difficult Airway Management Goals • Try all three lifelines • Optimise all three lifelines • Do it quickly (minimum no. of attempts) • Don’t repeat anything • Recognise and exploit opportunities of the GZ • Know when to declare CICO • Be ready to perform CICO Rescue The Unanticipated Difficult Airway Management Goals
- • Try all three lifelines • Optimise all three lifelines • Do it quickly (minimum no. of attempts) • Don’t repeat anything • Recognise and exploit opportunities of the GZ • Know when to declare CICO • Be ready to perform CICO Rescue The Unanticipated Difficult Airway Management Goals
- • Try all three lifelines • Optimise all three lifelines • Do it quickly (minimum no. of attempts) • Don’t repeat anything • Recognise and exploit opportunities of the GZ • Know when to declare CICO • Be ready to perform CICO Rescue The Unanticipated Difficult Airway Management Goals
- Why? The Unanticipated Difficult Airway Management Goals
- Fundamental airway errors – Why?
- Fundamental airway errors – Why?
- Dual-process theory • Default to type 1 decision-making • Biases & errors • Compounded by distractors and technical tasks Fundamental airway errors – Why?
- Role clarity? Fundamental airway errors – Why?
- Solutions?
- Solutions?
- Solutions? Safe Airway Society • Multi/interdisciplinary • Focus on universal principles, not discipline-specific • Watch this space
- Summary • High rates of morbidity including avoidable complications • Complex patients/situations require robust teamwork practices • Coordination • Shared mental models • Rehearsal and practice • Much still to learn in this area
- Thank You
Editor's Notes
- I want to begin by acknowledging Nickn Chrimes and Peter Fritz who created the Vortex tool and the overall Vortex Approach concept. I want to acknowledge Nick for the broader Vortex Aproach as outlined on the website of the same name. The presentation was originally listed as beyond vortex, which implies I somehow think it is somehow time to move past the Vortex, which is not the intention of this presentation. Instead I am encouraging all practitioners involved in airway management to move beyond the vortex tool and think about how the broader Vortex Approach can enhance team performance
- No conflicts of interest. My biggest disclosure is, however, given away by the letters after my name…
- Yep, I am from the wrong tribe…So what is an anaesthetist doing here mansplaining your jobs to you?
- I spend a fair proportion of my time in the sim lab, often teaching multidisciplinary groups. I have spent considerable time on committees looking at critical incident reports, and what I have learnt from simulation, which is backed up by studies such as the NAp4 study out of the UK and other studies, is that we make fundamental errors in judgement, descion making and communication during airway management in critically ill patients. These manifest as..
- Provide the participants with any additional info they need. 18G IV in left hand. BP 98/60. PR 95 SR. Predicted difficulty with FMV (beard). Tricky right? Anaesthesic help requested
- The airway plan (strategy) is based on the DAS ICU approach
- So how did we go? What went right? There were some good aspects. What went wrong? To really assess what went right and wriong we need to first define what theggoals of Mx are during the unanticipated difficult airway (or just difficult airway) Mx
- The the goals of Mx are all contained within the vortex tool or vortex approach. Go through these
- So, looking at these goals, which did we meet and which didn’t we meet? Were all 3 tried? Yes, but..were they optimized? LMA never attempted after NMBDs given
- Was anything repeated? Yes, just about everything
- When the patient was ventilatable (ie in the GZ), was this opportunity declared or exploited? Not really, rather than discussing options the choice was made to let the AR have a go at intubating. The GZ provides opportunity to optimize/oxygenate, gather resources, possibly move to theatre, etc, etc
- Fundamental errors – why?
- To begin with, although the vortex tool appears simple, it is actually a complex tool and covers a lot of ground. Similarly, the DAS approach is not easy to draw upon under pressure
- Then we have the issue of patient complexity – he was far from straight forward. The issues of flash teams – members arriving at random times, not necessarily familiar with each other, roles unclear. And finally, you have the problem of the airway management model existing largely in the mind of the operator – whether it be people using the vortex approach as a personal aide memiore or apttempting to follow the DAS algorithm – the moment this patient became apneic and strayed from the predetermined plan there was no shared mental model
- To understand what contributes to or exacerbates these issues it is worth mentioning the body of work pioneered by Danial Kahneman on dual process decision making. Give summary. Explain that under time critical situations we tend to defsault to Type 1 thinking which is fast easy but very prone to biases and errors. Instead of considering the question at hand we look for shortcuts which ofeten means substitutimg easy answwrs based on experience or external cues. The substitute answers might be “the D-blade always works”, or “the anaesthetic registrars will definitey solve the problem”, or “this must be CICO” even when things ahavnet been attempted. All of this is vastly exagereated when we try to perform any technical tasks while trying to make complex decisions
- On top of all of this there is often a lack of role clarity. This is some unpublished data from our hopsital
- Ok, so what are the solutions. To begin with, regardless of what airway management tool or approach we are following, we need to take it out of the realm of personal aide memoire and make it “the” shared mental model during the entire episode
- Next, in order to have, and maintain a shared mental model we need a central coordinator charged with the decision making and sharing information It is reassuring to see increasing numbers of intubation checklists encouraging/forcing allocation of a TL for airway Mx And finally, for any team to work together effectively using a specific protocol or model of care, we need multidisciplinary team training with a focus on human factors and non technical skills – simulation would be the logical vehicle for this
- The is the perfect time to plug a new initiative. The area of non-technical skills in airway management including team dynamics in multidisciplinary situations is new territory Go over process and what is in store