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Airway management – it’s a team sport, not a technical skill

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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

  1. 1. Airway Mx of the Critically Ill… A team sport, not a technical skill Dr Adam Rehak
  2. 2. Acknowledgements
  3. 3. Declarations
  4. 4. Airway Mx of the Critically Ill… A team sport, not a technical skill Dr Adam Rehak FANZCA
  5. 5. 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
  6. 6. Objectives Barriers Goals Utilise existing tools/models
  7. 7. 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
  8. 8. 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
  9. 9. Case Study Delayed Sequence Induction • 150mg Ketamine given IV • SpO2 falls to 85%. Apnoeic What now?
  10. 10. 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?
  11. 11. Case Study Return to FMV • FMV with OPA and two hands produces some chest movement • Poor capnograhy trace • SpO2 steady at 84% What now?
  12. 12. 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?
  13. 13. 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?
  14. 14. 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%
  15. 15. 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
  16. 16. • 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
  17. 17. 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
  18. 18. • 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
  19. 19. • 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
  20. 20. Why? The Unanticipated Difficult Airway Management Goals
  21. 21. Fundamental airway errors – Why?
  22. 22. Fundamental airway errors – Why?
  23. 23. Dual-process theory • Default to type 1 decision-making • Biases & errors • Compounded by distractors and technical tasks Fundamental airway errors – Why?
  24. 24. Role clarity? Fundamental airway errors – Why?
  25. 25. Solutions?
  26. 26. Solutions?
  27. 27. Solutions? Safe Airway Society • Multi/interdisciplinary • Focus on universal principles, not discipline-specific • Watch this space
  28. 28. 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
  29. 29. Thank You

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