DAS guidelines for icu intubation

1. INTUBATION IN CRITICAL
CARE SETTING
DR.MALAKA MUNASINGHE
2018.11.29

2.  6% of ICU patients- predicted difficult airways
 Severe hypoxaemia( SPO2< 80%)- 25% during ICU intubations
 NAP 4 STUDY - 60% of air way incidents in ICU
DEATH OR PERMANENT NEUROLOGICAL INJURY

3. Increased airway difficulty in ICU???
Multifactorial!!!
 Patient related
 Environment related
 Staff related

4. Staff related
 lack of patient preparation
 equipment check failure
 protocol deviation
 poor decision-making
 loss of situation awareness
 Lack of experience in airway management
 Lack of senior help( out of hour intubations)
 Poor team work

5. Patient related
 physiologically and /or Anatomically difficult airways- burns/ cervical spine injuries
 Physiologically difficult airways
 Increased risk of aspiration
 Airway assessment difficult-
 Poor cooperation/low GCS
 Collars/masks
 Limited time

6. Environment related
 Limited access to the patient( monitors/ equipment)
 Monitors in head end
 Suboptimal lighting
 Access to advanced airway devices/ monitoring( Capnography/ End tidal O2)
limited
 Complex equipment or devices - cognitive overload and poor decision making
 Non-availability of surgical staff

7. Predicting difficult airway in ICU
 Only validated assessment tool available currently- MACOCHA score
 SCORE 0- EASY
 >3-DIFFICULT AIRWAY
2017 American Thoracic Society. De Jong et al.54
Factors Points
Factors related to patient
Mallampati class III or IV 5
Obstructive sleep
Apnoea
syndrome
2
Reduced mobility
of
Cervical spine
1
Limited mouth
Opening <3
cm
1
Factors related to pathology
Coma 1
Severe
Hypoxaemia
(SpO2 <80%)
1
Factor related to operator
Non-
Anaesthetist 1
Total 12

8. Difficult Airway Society( DAS) guidelines

9. DAS guidelines
 Team

10. Intubation check list

11. Patient preparation

12. Preparation of equipment

13. Preparation of the team

14. Preparation for difficulty

15. Air way management plan

16. PLAN A

17. PLAN B/C

18. PLAN D

19. FRONT OF NECK ACCESS( FONA)

20. Priming of FONA
 Getting the FONA set to the bedside after one failed intubation attempt
 Opening the FONA set after one failed attempt at facemask or SGA oxygenation
 Immediate use of the FONA set at CICO declaration

21. ISSUES
 AWAKE INTUBATION in ICU?
 WHAT TO USE DURING INDUCTION?
 WHAT IS DELAYED SEQUENCE INDUCTION?
 Can you wake up the patient if intubation fails?

22. Post intubation
 Complications are common- 80% of airway problems occur after intubation
 Continuous monitoring continued
 Care of the tube/ adequate sedation/ physiotherapy
 CXR- to exclude endobronchial intubation/aspiration
 If patient haemodynamically stable but hypoxaemic- recruitment maneuvers
performed

23. SUMMARY
 Morbidity and mortality during ICU intubations are significantly high compared to
elective surgical intubations
 Patient related, staff and environment related factors are contributory factors
 Simplified, protocolized approach would reduce detrimental outcomes during
these airway interventions