This document summarizes the findings of a study examining major airway complications occurring in intensive care units (ICUs) and emergency departments (EDs) in the UK. 184 events met the inclusion criteria of leading to death, brain damage, need for emergency surgical airway, unanticipated ICU admission, or prolonged ICU stay. Of these, 36 occurred in ICUs and 15 in EDs. Events in ICUs and EDs were more likely to occur out of hours, be managed by less experienced doctors, and lead to permanent harm compared to events during anesthesia. Failure to use capnography contributed to 74% of cases of death or brain damage. The outcomes of airway events in ICUs and EDs were
Day care surgery was started as money saving modality. It has picked up momentum even in India. In last one decade due to innovations in surgical techniques and advances in anaesthesia, the positive feedback from the patients and their relations has enhanced the popularity of day care surgery. There is an immense opportunity for expansion of day care surgery in India to ensure faster, safer, cost-effective and patient turnover. Retrospective and Prospective day care surgery is being performed on general surgery patients at National Institute of Medical Science and Hospital (NIMS), Jaipur from 2014 to 2017. During this period, 4547 day care surgical procedures and 2757 OPD procedures were performed. Only 212 day care surgery patients (2.9%) were transferred to day care unit as in-patient admission. We found the day care surgery as safe and effective means of fast track surgery, which was economical also. In-patient admission following day surgery can be reduced by improved out-patient selection of cases by introducing a pre-admission assessment form filled in at the out-patient clinic, operating early on day care by using separate day care theatre. Anaesthetic complications were reduced by increased use of local anaesthetic techniques.
Key-words: Day care surgery, Ambulatory surgery, Anaesthesia, Early Ambulation, Post-Operative, Laparoscopy
Background: The transition from resident physician to independent practitioner is an important period for young physicians.Optimally, they would feel well prepared to independently care for all patients presenting to them for anesthesia, however, this is unlikely Methods: A survey was emailed to all accredited anesthesiology residency program coordinators in April 2018 for further distribution to their CA3 residents. The survey collected data on the resident’s perception of his or her preparedness to manage a variety of anesthesia cases, patients with comorbid conditions, and ethical issues as well as perform various procedures.
Content server (10)A randomized, controlled, double-blind prospective trial w...Missing Man
A randomized, controlled, double-blind prospective trial
with a Lipido-Colloid Technology-Nano-OligoSaccharide
Factor wound dressing in the local management of
venous leg ulcers
The assessment, diagnosis and treatment of critically ill patients is extremely challenging. Patients often deteriorate whilst being
reviewed and their rapidly changing pathophysiology barrages healthcare professionals with new data. Furthermore, comprehensive assessments must be postponed until the patient has been stabilised. So, important data and interventions are often missed in the heat of the moment. In emergency situations, suboptimal management decisions may cause signifi cant morbidity and mortality. Fortunately, standardisation and careful design of documentation (i.e. proformas and checklists) can enhance patient safety. So, I have developed a series of checklist proformas to guide the assessment of critically ill patients. These proformas also promote the systematic recording and presentation of information to facilitate the retrieval of the precise data required for the management for critically ill patients. The proformas have been modifi ed extensively over the last twenty years based on my personal experience and extensive consultation with colleagues in several world-renowned centres of excellence. The proformas were originally developed for use in the intensive therapy unit
or high dependency unit. However, they have been adapted for use by outreach teams reviewing patients admitted outside of critical care areas. The use of these tools can direct eff orts to provide appropriate organ support and provides a framework for diagnostic reasoning.
Day care surgery was started as money saving modality. It has picked up momentum even in India. In last one decade due to innovations in surgical techniques and advances in anaesthesia, the positive feedback from the patients and their relations has enhanced the popularity of day care surgery. There is an immense opportunity for expansion of day care surgery in India to ensure faster, safer, cost-effective and patient turnover. Retrospective and Prospective day care surgery is being performed on general surgery patients at National Institute of Medical Science and Hospital (NIMS), Jaipur from 2014 to 2017. During this period, 4547 day care surgical procedures and 2757 OPD procedures were performed. Only 212 day care surgery patients (2.9%) were transferred to day care unit as in-patient admission. We found the day care surgery as safe and effective means of fast track surgery, which was economical also. In-patient admission following day surgery can be reduced by improved out-patient selection of cases by introducing a pre-admission assessment form filled in at the out-patient clinic, operating early on day care by using separate day care theatre. Anaesthetic complications were reduced by increased use of local anaesthetic techniques.
Key-words: Day care surgery, Ambulatory surgery, Anaesthesia, Early Ambulation, Post-Operative, Laparoscopy
Background: The transition from resident physician to independent practitioner is an important period for young physicians.Optimally, they would feel well prepared to independently care for all patients presenting to them for anesthesia, however, this is unlikely Methods: A survey was emailed to all accredited anesthesiology residency program coordinators in April 2018 for further distribution to their CA3 residents. The survey collected data on the resident’s perception of his or her preparedness to manage a variety of anesthesia cases, patients with comorbid conditions, and ethical issues as well as perform various procedures.
Content server (10)A randomized, controlled, double-blind prospective trial w...Missing Man
A randomized, controlled, double-blind prospective trial
with a Lipido-Colloid Technology-Nano-OligoSaccharide
Factor wound dressing in the local management of
venous leg ulcers
The assessment, diagnosis and treatment of critically ill patients is extremely challenging. Patients often deteriorate whilst being
reviewed and their rapidly changing pathophysiology barrages healthcare professionals with new data. Furthermore, comprehensive assessments must be postponed until the patient has been stabilised. So, important data and interventions are often missed in the heat of the moment. In emergency situations, suboptimal management decisions may cause signifi cant morbidity and mortality. Fortunately, standardisation and careful design of documentation (i.e. proformas and checklists) can enhance patient safety. So, I have developed a series of checklist proformas to guide the assessment of critically ill patients. These proformas also promote the systematic recording and presentation of information to facilitate the retrieval of the precise data required for the management for critically ill patients. The proformas have been modifi ed extensively over the last twenty years based on my personal experience and extensive consultation with colleagues in several world-renowned centres of excellence. The proformas were originally developed for use in the intensive therapy unit
or high dependency unit. However, they have been adapted for use by outreach teams reviewing patients admitted outside of critical care areas. The use of these tools can direct eff orts to provide appropriate organ support and provides a framework for diagnostic reasoning.
IOSR Journal of Mathematics(IOSR-JM) is an open access international journal that provides rapid publication (within a month) of articles in all areas of mathemetics and its applications. The journal welcomes publications of high quality papers on theoretical developments and practical applications in mathematics. Original research papers, state-of-the-art reviews, and high quality technical notes are invited for publications.
The Evaluation of Time Performance in the Emergency Response Center in Kerman...Emergency Live
The Evaluation of Time Performance in the Emergency Response
Center to Provide Pre-Hospital Emergency Services in Kermanshah
http://www.ccsenet.org/journal/index.php/gjhs/article/view/38288
KNOWLEDGE AND PRACTICES AMONG SURGEONS REGARDING CROSS INFECTION CONTROL PROC...Anil Haripriya
The study revealed good knowledge of infection control procedures but there were problems in practices of
sterilization. Most of them did not separate the needle from the syringe prior to disposal therefore needle
prick injuries were common. So more intensive and regular training programs to surgeons must be included
in the plans of quality control in all hospital and regular inspection from the ministry of health guarantees
good infection control practices
Ochsner Sherren regimen Vs Appendectomy in Adults with Acute Appendicitis.QUESTJOURNAL
ABSTRACT: The main Objective of this study is to examine whether Ochsner Sherren regimen in adult patients with acute appendicitis is safe by correlating the interval from onset of symptoms to operation (total interval) with the degree of pathology and incidence of postoperative complications. Prompt appendectomy has long been the standard of care for acute appendicitis because of the risk of progression to advanced pathology. This time-honored practice has been recently challenged by studies in pediatric patients, which suggested that acute appendicitis can be managed in an elective manner once antibiotic therapy is initiated. No such data are available in adult patients with acute appendicitis. A retrospective review of 480 patients who underwent an appendectomy for acute appendicitis between November2012 and October 2015 was conducted. The following parameters were monitored and correlated: demographics, time from onset of symptoms to arrival at the emergency room (patient interval) and from arrival to the emergency room to the operating room (hospital interval), physical, computed tomography (CT scan) and pathologic findings, complications, length of stay, and length of antibiotic treatment. Pathologic state was graded 1 (G1) for acute appendicitis, 2 (G2) for gangrenous acute appendicitis, 3 (G3) for perforation or phlegmon, and 4 (G4) for a periappendicular abscess. The risk of advanced pathology, defined as a higher pathology grade, increased with the total interval. When this interval was <12>71 hours group compared with total interval<12 hours. Although both prolonged patient and hospital intervals were associated with advanced pathology, prehospital delays were more profoundly related to worsening pathology compared with in-hospital delays . Advanced pathology was associated with tenderness to palpation beyond the right lower quadrant , guarding , rebound , and CT scan findings of peritoneal fluid , fecalith , dilation of the appendix , and perforation . Increased length of hospital stay and antibiotic treatment as well as postoperative complications also correlated with progressive pathology. In adult patients with acute appendicitis, the risk of developing advanced pathology and postoperative complications increases with time; therefore, delayed appendectomy is unsafe. As delays in seeking medical help are difficult to control, prompt appendectomy is mandatory. Because these conclusions are derived from retrospective data, a prospective study is required to confirm their validity
Vietnam’s Tech Boom A look inside Southeast Asia’s Silicon Valley.Hán Văn Thắng
More than four decades after choppers lifted the last U.S. troops back
across the world, Vietnam’s Da Nang Hi-Tech Park hums with
activity. The park, one of several established as part of Vietnam’s
2020 IT Master Plan, houses offices and factories for a growing number of
international IT and software companies, hardware manufacturers, and
infrastructure plants powering the central Vietnamese city at the heart of a
tech boom.
Today’s Vietnam—with a population of over 93.5 million and a median age
of 30.3 years old—is defined by a growing population of young coders,
engineers, entrepreneurs, and students driving economic growth and
technological innovation. For them, the country’s war-torn past is a history
lesson, not a memory.
IOSR Journal of Mathematics(IOSR-JM) is an open access international journal that provides rapid publication (within a month) of articles in all areas of mathemetics and its applications. The journal welcomes publications of high quality papers on theoretical developments and practical applications in mathematics. Original research papers, state-of-the-art reviews, and high quality technical notes are invited for publications.
The Evaluation of Time Performance in the Emergency Response Center in Kerman...Emergency Live
The Evaluation of Time Performance in the Emergency Response
Center to Provide Pre-Hospital Emergency Services in Kermanshah
http://www.ccsenet.org/journal/index.php/gjhs/article/view/38288
KNOWLEDGE AND PRACTICES AMONG SURGEONS REGARDING CROSS INFECTION CONTROL PROC...Anil Haripriya
The study revealed good knowledge of infection control procedures but there were problems in practices of
sterilization. Most of them did not separate the needle from the syringe prior to disposal therefore needle
prick injuries were common. So more intensive and regular training programs to surgeons must be included
in the plans of quality control in all hospital and regular inspection from the ministry of health guarantees
good infection control practices
Ochsner Sherren regimen Vs Appendectomy in Adults with Acute Appendicitis.QUESTJOURNAL
ABSTRACT: The main Objective of this study is to examine whether Ochsner Sherren regimen in adult patients with acute appendicitis is safe by correlating the interval from onset of symptoms to operation (total interval) with the degree of pathology and incidence of postoperative complications. Prompt appendectomy has long been the standard of care for acute appendicitis because of the risk of progression to advanced pathology. This time-honored practice has been recently challenged by studies in pediatric patients, which suggested that acute appendicitis can be managed in an elective manner once antibiotic therapy is initiated. No such data are available in adult patients with acute appendicitis. A retrospective review of 480 patients who underwent an appendectomy for acute appendicitis between November2012 and October 2015 was conducted. The following parameters were monitored and correlated: demographics, time from onset of symptoms to arrival at the emergency room (patient interval) and from arrival to the emergency room to the operating room (hospital interval), physical, computed tomography (CT scan) and pathologic findings, complications, length of stay, and length of antibiotic treatment. Pathologic state was graded 1 (G1) for acute appendicitis, 2 (G2) for gangrenous acute appendicitis, 3 (G3) for perforation or phlegmon, and 4 (G4) for a periappendicular abscess. The risk of advanced pathology, defined as a higher pathology grade, increased with the total interval. When this interval was <12>71 hours group compared with total interval<12 hours. Although both prolonged patient and hospital intervals were associated with advanced pathology, prehospital delays were more profoundly related to worsening pathology compared with in-hospital delays . Advanced pathology was associated with tenderness to palpation beyond the right lower quadrant , guarding , rebound , and CT scan findings of peritoneal fluid , fecalith , dilation of the appendix , and perforation . Increased length of hospital stay and antibiotic treatment as well as postoperative complications also correlated with progressive pathology. In adult patients with acute appendicitis, the risk of developing advanced pathology and postoperative complications increases with time; therefore, delayed appendectomy is unsafe. As delays in seeking medical help are difficult to control, prompt appendectomy is mandatory. Because these conclusions are derived from retrospective data, a prospective study is required to confirm their validity
Vietnam’s Tech Boom A look inside Southeast Asia’s Silicon Valley.Hán Văn Thắng
More than four decades after choppers lifted the last U.S. troops back
across the world, Vietnam’s Da Nang Hi-Tech Park hums with
activity. The park, one of several established as part of Vietnam’s
2020 IT Master Plan, houses offices and factories for a growing number of
international IT and software companies, hardware manufacturers, and
infrastructure plants powering the central Vietnamese city at the heart of a
tech boom.
Today’s Vietnam—with a population of over 93.5 million and a median age
of 30.3 years old—is defined by a growing population of young coders,
engineers, entrepreneurs, and students driving economic growth and
technological innovation. For them, the country’s war-torn past is a history
lesson, not a memory.
Assessment of the Implementation of Ventilator-associated Pneumonia Preventiv...IOSR Journals
Background: Pneumonia associated with mechanical ventilation (VAP) is one of the important
causes of nosocomial infections in pediatric intensive care units (PICU). VAP is the leading cause of morbidity
and mortality in PICUs. Aim: To assess the compliance to ventilator bundle components: elevation of the head
of bed >30, sedation interruption, spontaneous breathing trial, peptic ulcer prophylaxis and its effect on the
prevention of VAP. Subjects and Methods: A case control study at PICU of Abo EL Reish El Moneira Hospital,
including all mechanically ventilated patients admitted over a period of one year. The study tested the effect of
implementation of this bundle as regard the rate of VAP in both group, compliance to bundle and most affecting
component of it. Results: There was decrease incidence of VAP after implementation of the bundle, from (50%)
to (14%). Development of VAP was mostly affected by being in supine position, long duration of mechanical
ventilation and presence of pump failure. (p<0.05) The compliance to bundle components was statistically
significant, p= 0.001. Conclusion: VAP rate decreased after implementation of this bundle. Elevation of the
head of bed was the most compliant component of bundle in the PICU.
Laparoscopic Gynecologic Surgery Under Regional Neuraxial Anaesthesia: the be...semualkaira
At present, most laparoscopic
interventions are performed under general anesthesia. In literature
we have few retrospective studies, with few cases, that show just
minor laparoscopic proceduresperformed under regional anesthesia.
Laparoscopic Gynecologic Surgery Under Regional Neuraxial Anaesthesia: the be...semualkaira
At present, most laparoscopic
interventions are performed under general anesthesia. In literature
we have few retrospective studies, with few cases, that show just
minor laparoscopic proceduresperformed under regional anesthesia.
The 2019 Diagnostic Summit brought together diagnostic developers in academia and industry as well as end-users in the pharmaceutical and healthcare sector to gain a comprehensive picture of diagnostics in prenatal, oncology, infectious disease, point-of-care, and liquid biopsy.
This important Summit enabled delegates to learn what novel technologies, platforms and applications are emerging that will impact future healthcare delivery and pharmaceutical research.
Bringing together European leading experts via presentations, workshops and case studies the Summit was a must attend event! We explored:
Current diagnostic testing in GP surgeries and Pharmacies
How Diagnostics can be funded and funding barriers
Advances in Prenatal Molecular Diagnostics
Diagnostic Regulations
Point of care testing
Advanced Diagnostics for infectious diseases
Adapting and evaluating Innovation
Education on testing and accuracy
Patient and Clinical pathways
Key health areas examined in the Summit included:
Sexual Health
Diabetes
Cancer
Antibiotic Resistance
Sepsis
Obesity
Urinary Infections
Video Vs direct laryngoscopy for tracheal intubation of critically ill adults...Ahmed Lotfy
In this trial (The DEVICE Trial), among critically ill adults undergoing tracheal intubation in an emergency department or ICU, the use of a video laryngoscope resulted in a higher incidence of successful intubation on the first attempt than the use of a direct laryngoscope.
Non-operative Treatment Compared to Surgery in the Management of Uncomplicate...asclepiuspdfs
Purposes: We are aiming to investigate the safety and efficacy of the non-operative treatment (NOT) for the management of acute appendicitis (AA), to avoid the risk of unnecessary surgery. Methods: The study includes 400 consecutive patients who were diagnosed as AA. The study involved patients with symptoms <72 h and the first attack of AA. Patients divided into two equal groups using the “alternation” method. In the first group, patients were hospitalized and received medical treatment, while in the second group, appendectomy was done. After discharge, follow-up was done in all cases for 2 years. Data collected and statistically analyzed.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
Adv. biopharm. APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMSAkankshaAshtankar
MIP 201T & MPH 202T
ADVANCED BIOPHARMACEUTICS & PHARMACOKINETICS : UNIT 5
APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMS By - AKANKSHA ASHTANKAR
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
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Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Triangles of Neck and Clinical Correlation by Dr. RIG.pptx
Via aerea complicaciones2
1. BJA Advance Access published March 29, 2011
British Journal of Anaesthesia Page 1 of 11
doi:10.1093/bja/aer059
Major complications of airway management in the UK: results
of the Fourth National Audit Project of the Royal College of
Anaesthetists and the Difficult Airway Society. Part 2:
intensive care and emergency departments
T. M. Cook 1*, N. Woodall 2, J. Harper 3 and J. Benger 4, on behalf of the Fourth National Audit Project
1
Department of Anaesthesia and Intensive Care, Royal United Hospital, Combe Park, Bath, UK
2
Department of Anaesthesia, Norfolk & Norwich University NHS Foundation Trust, Norwich, UK
3
Department of Anaesthesia and Intensive Care, Royal Liverpool University Hospital, Liverpool, UK
4
University of the West of England, Bristol, UK
* Corresponding author. E-mail: timcook007@googlemail.com
Background. The Fourth National Audit Project of the Royal College of Anaesthetists and Difficult Airway Society (NAP4) was
designed to identify and study serious airway complications occurring during anaesthesia, in intensive care unit (ICU) and
the emergency department (ED).
Methods. Reports of major complications of airway management (death, brain damage, emergency surgical airway,
unanticipated ICU admission, prolonged ICU stay) were collected from all National Health Service hospitals over a period of
1 yr. An expert panel reviewed inclusion criteria, outcome, and airway management.
Results. A total of 184 events met inclusion criteria: 36 in ICU and 15 in the ED. In ICU, 61% of events led to death or persistent
neurological injury, and 31% in the ED. Airway events in ICU and the ED were more likely than those during anaesthesia to occur
out-of-hours, be managed by doctors with less anaesthetic experience and lead to permanent harm. Failure to use capnography
contributed to 74% of cases of death or persistent neurological injury.
Conclusions. At least one in four major airway events in a hospital are likely to occur in ICU or the ED. The outcome of these
events is particularly adverse. Analysis of the cases has identified repeated gaps in care that include: poor identification of
at-risk patients, poor or incomplete planning, inadequate provision of skilled staff and equipment to manage these events
successfully, delayed recognition of events, and failed rescue due to lack of or failure of interpretation of capnography. The
project findings suggest avoidable deaths due to airway complications occur in ICU and the ED.
Keywords: airway; audit; brain damage; complications; cricothyroidotomy; death; emergency department; intensive care;
tracheostomy
Accepted for publication: 15 February 2011
Active airway management takes place most frequently in complications of airway management during anaesthesia. At
anaesthetic practice, but is often required outside the operat- an early stage in planning NAP4, it was decided that it would
ing theatre. Several studies of airway management outside be important to study similar complications in the environ-
the operating theatre have identified higher rates of compli- ments of ICUs and EDs for the reasons stated above. This
cations, including failed intubation, oesophageal intubation, paper describes the major findings of this section of the
hypoxia, and cricothyroidotomy. These include studies in NAP4 project.
intensive care units (ICU)1 – 4 and emergency departments For reasons of space, this paper cannot explore many
(EDs).4 – 8 Differences in factors such as case mix, availability facets of events that were reported. This paper should be
of skilled and trained staff, levels of assistance, and working read in conjunction with the accompanying paper11 and
environment all likely contribute. Recent data from analysis the full report of the project is available on http://www.rcoa.
of the National Reporting and Learning System (NRLS) of the ac.uk/index.asp?PageID=1089.
National Patient Safety Agency (NPSA) indicated that ICU
may be an area where airway complications are relatively fre-
quent,9 but the data were limited by the nature of NRLS report- Methods
ing, which numerically focuses on low impact events.9 10 The full methodology of the NAP4 project is described in the
The Fourth National Audit Project of the Royal College of accompanying paper.11 In brief, a multi-speciality group was
Anaesthetists and Difficult Airway Society (NAP4) had the established to plan delivery of NAP4 (see Supplementary
primary aim of identifying the incidence of major Appendix). The project leads established a network of local
& The Author [2011]. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved.
For Permissions, please email: journals.permissions@oup.com
2. BJA Cook et al.
reporters in all anaesthetic departments in UK National of the care were analysed for learning points and pertinent
Health Service (NHS) hospitals believed to be performing cases were selected to act as illustrations of clinical care for
surgery. Efforts were made to also recruit a local reporter inclusion in a detailed report of the project. Airway manage-
in every ICU and ED. The local reporters were tasked with ment was classified as good, poor, mixed (i.e. elements of
supporting the project at the local level and assisting in both good and poor management), or unclassifiable.
ensuring all cases meeting inclusion criteria were identified
and fully reported to the project. Incidence calculations
For patients in ICU and EDs, the main aim of the project No attempt was made to calculate the incidence of events in
was to study the nature of major airway events in the two the ICU and EDs due to both lack of denominators and the
identified non-anaesthetic environments. No formal census fact that not all hospitals had specific local reporters for
was planned to identify a denominator for such events. the ICU and ED.
However, during the project, such a census for ED activity
was completed by one of the authors of this paper.12 Missing reports
A registry of the major complications of airway manage- No formal attempt was made to identify the extent of
ment was established to collect detailed reports on such missing cases, as it was never the expectation of this part
cases over a 12 month period. Discussions with the National of the project that all cases meeting inclusion criteria
Research Ethics Service indicated that ethics committee would be reported.
approval was not required. The project was examined by
the Patient Information Advisory Group of the Department Results
of Health and a methodology was agreed that ensured
patient confidentiality. Data were not sought from private Agreement to participate and appointment of a local repor-
hospitals or Independent Sector Treatment Centres (ISTCs), ter was confirmed in all 309 hospitals by September 2008. In
but were collected from treatment centres attached to NHS total, 286 anaesthesia local reporters were appointed with
hospitals. The project was widely advertised. some representing more than one hospital. In addition,
Inclusion criteria for complications in ICU and the ED were 118 ICU local reporters (for 253 UK ICUs: 47%) and 115 ED
the same as for complications during anaesthesia. ‘A compli- local reporters (for 239 major UK EDs: 48%) were recruited.
cation of airway management that led to death, brain Anaesthesia local reporters were encouraged to report
damage, the need for an emergency surgical airway (including cases from ICU and the ED when there were no additional
a needle, cannula, open cricothyroidotomy or tracheostomy), local reporters.
unanticipated ICU admission or prolongation of ICU admission’.
Complications reported
Events occurring during transfer to or from the ICU or ED
were included. A total of 286 cases were reported to the RCoA-lead or dis-
The process of notification, confirmation of inclusion cri- cussed with the moderator. Seventy-nine reports were with-
teria, submission, and case review was identical to that for drawn after discussion with the moderator or the reporter
anaesthesia cases: see accompanying paper.11 As with reviewed the inclusion criteria sent by the RCoA-lead: 207
anaesthesia cases, the NAP4 moderator was available to cases were reviewed by the review panel. During the review
discuss cases where a clinician was uncertain about inclusion process, additional information, using the methods described
criteria. The same high levels of data protection and confi- in the accompanying paper,11 was requested from the repor-
dentiality that applied to all of the NAP4 project were ters of 12 of the cases. After final review, 184 reports met the
applied to cases submitted from ICU and the ED. inclusion criteria. Of the 184 reports, 133 complicated the
An event was included if it occurred in the period from management of anaesthesia, 36 occurred in patients on
September 1, 2008, to August 31, 2009. Notification of ICU, and 15 in the ED. The results of the anaesthesia cases
events was accepted until June 2010. are presented in the accompanying article.11
Patient characteristics
Case review panel Of the ICU cases, the male:female ratio was 21:15 (58%
An expert review panel examined each submitted clinical males), 22% were ASA grade I– II, and 61% aged ,60
report. The panel incorporated representatives from all (Table 1). In ICU, 19 patients were receiving invasive venti-
specialities involved in the project including the College of lation, eight non-invasive ventilation, eight were not receiv-
Emergency Medicine and the Intensive Care Society. Case ing mechanical ventilation before the airway event: in one
review was a structured process; the review panel specifically case, this information was not provided. Supplemental
considered cases under the categories described (Supplemen- oxygen was being given in 94% before the event and in
tary Table S1). Contributory or causative factors were identified 35% the FIO2 was ≥0.6. Thirteen had organ failure other
as were factors considered to have had a positive effect. The than respiratory and nine were receiving vasoactive drugs or
degree of harm caused was graded using the National continuous renal replacement therapy. A BMI of .30 kg m22
Patient Safety Agency (NPSA) severity of outcome scale for was recorded in 47% of ICU cases and a BMI of ,20 kg m22
patient safety incidents (Supplementary Table S2).13 Aspects in 6%. In the ICU, 46% of events for which a time was
Page 2 of 11
3. Major complications of airway management in the UK BJA
Table 1 Incident reports classified: by ASA grade and type of Table 2 Final outcome: Narrative outcome and NPSA
event; by age and type of event; and by inclusion criteria provided classification (see Supplementary Table S2)
by the reporter. More than one inclusion criterion could be chosen.
Note that some deaths were considered by the review panel not ICU (n536) Emergency
to be causally related to the event, in other cases patients department (n515)
reported with an inclusion criterion of brain damage either made Final outcome (narrative)
a full recovery at the time of reporting or died. Therefore, figures in Death 18 4
this table do not exactly match final outcomes in Table 2.
Brain damage 4 1
*Prolongation of stay in the case of patients already in ICU
Other partial recovery 3 1
ICU (n536) Emergency Full recovery 9 9
department Unrelated death 2 0
(n515) Final outcome (NPSA definitions)
ASA Death 18 4
I 1 2 Severe 5 0
II 7 4 Moderate 12 11
III 14 5 Low 1 0
IV 13 3 None 0 15
V 1 0
Not recorded 0 1
Age Common Stem trainee with 5 months anaesthetic experi-
,10 1 1 ence. In a further three cases, the anaesthetist present at
11 –20 2 0 the start of the airway event was a year 3 specialist
21 –40 6 7 trainee, and in eight events, no consultant was present at
41 –60 11 4 the start of the airway event.
61 –80 14 2
.80 2 1 Inclusion criteria and event outcomes
Not recorded 0 0 The inclusion criteria indicated by reporters are presented in
Reporter provided inclusion criteria Table 1. The final outcome of events is presented, both focus-
Death 16 3 ing on outcomes of death and brain damage and by NPSA
Brain damage 6 1 classification of severity of harm (Table 2).
ESA 10 11 Death resulting from an airway problem was the inclusion
ICU admission* 12 10 criterion for 33 reports: 16 occurred in ICU and three in the
Sum 44 25 ED (Table 1). Three further cases resulted in late deaths,
two in ICU, and one in the ED. In total, there were 38
deaths attributable to an airway event, 18 on ICU, and four
recorded took place out-of-hours (18:01 – 08:00). Although
in the ED. Hypoxia was the common theme in deaths
consultants were present for 58% of all events, there was a
caused by an airway problem in both ICU and the ED.
notable difference between events in hours (80%) and
Death rate for cases in ICU was 18/36 (50%) and in the ED
out-of-hours (36%). Several events were managed by
4/15 (27%).
doctors who would not be expected to have airway expertise
because of lack of seniority [e.g. specialist trainee (ST) year 2]
Brain damage
or primary speciality (e.g. ST2 in medicine).
Of the ED cases, the male:female ratio was 10:5 (67% In 13 patients, brain damage was recorded as an inclusion
males), 40% were ASA grade I– II, and 80% aged ,60 criterion, six in reports of events on ICU, and one in the ED
(Table 1). A BMI of .30 kg m22 was recorded in 46% and (Table 1). After excluding those who died or recovered,
,20 kg m22 in 7%. Fifty-three per cent of events took there were four cases of persistent non-fatal brain damage
place ‘out of hours’. All but three cases involved attempts in ICU and one in the ED. The combined rate of death and
at tracheal intubation, the exceptions being facemask anaes- brain damage for ICU cases was 22/36 (61%) and in the ED
thesia for cardioversion and two surgical airways for airway 5/15 (33%).
obstruction. In 11 cases (73%), airway management was
performed by an anaesthetist and in eight (53%) a consult- Emergency surgical airway
ant. Anaesthetist involvement decreased from 6/7 during An attempt at emergency surgical airway, either tracheost-
the day (08:01 –18:00) to 5/8 out-of-hours and consultant omy or cricothyroidotomy, was reported as an inclusion cri-
involvement was 4/7 in-hours and 4/8 out-of-hours. Several terion in 75 cases (Table 1). Twelve attempts took place on
events were managed by doctors who would not be expected ICU (33% of all ICU cases), with three failing to rescue the
to have airway expertise, including two ICU trainees with airway, a failure rate of 25%. Five needle cricothyroidotomies
minimal anaesthetic experience and one Acute Care were attempted on ICU, three of which failed. One patient
Page 3 of 11
4. BJA Cook et al.
with successful surgical airway died and one suffered persist- unrecognized oesophageal intubations and two led to death
ent brain damage; two patients with failed placement of an (there was also one fatal oesophageal intubation as a second-
emergency surgical airway died. ary event). Displacement or obstruction of a tracheostomy and
Ten emergency surgical airways were placed in the ED difficult intubation required a fibrescope on several occasions
(67% of ED cases) with no total failures. However, in all and delays in accessing one was a recurrent problem.
three cases where a needle cricothyroidotomy was Events in the ED were predominantly related to tracheal
attempted, this failed and had to be replaced by a surgical intubation and included delayed or failed intubation, unrec-
or percutaneous technique. Of the 10 patients requiring a ognized oesophageal intubation, the cannot intubate,
surgical airway in the ED, two died and one suffered persist- cannot ventilate (CICV) scenario, aspiration, and perforation
ent brain damage. of the trachea with a bougie. The two unrecognized oesopha-
geal intubations led to death. Airway management in both of
ICU admission these cases was undertaken by a non-anaesthetist intensive
Of 122 cases included in NAP4 because of ICU admission or care doctor, one junior and one senior, the latter with limited
prolongation of ICU stay, 12 arose in patients already on anaesthetic experience. The case of significant airway
ICU and 10 in ED cases. The most common reasons for pro- trauma occurred during an uneventful intubation by an
longation of stay on ICU after an airway event were failure to emergency physician.
awaken in five, aspiration of gastric contents or blood in four,
Paediatrics and obstetrics
and airway swelling in two. The most common reasons for ED
cases to be admitted to ICU were management of airway There were no cases reported from ICU or the ED that
swelling/trauma in four, failure to awaken in three, and involved pregnant women.
aspiration in two. One event occurred in ICU in a child under 10 yr: a dys-
morphic neonate required multiple attempts to intubate
Primary airway problem and the tracheal tube was then repeatedly displaced. Intuba-
tion became impossible and attempts were made to transfer
In the ICU, tracheostomy-related events were the most fre-
the patient to theatre for a surgical tracheostomy, but the
quently occurring problem (n¼18, 50%) (Table 3). Next most
airway was again lost during transfer and the patient died.
frequent was failed intubation or tracheal tube misplacement
There was one paediatric event reported from the ED: a
(including unrecognized oesophageal intubation and inadver-
case of inadvertent oesophageal intubation in an infant.
tent extubation). Displacement of an existing tracheostomy or
During cardiac arrest, a flat capnography trace was not
standard tracheal tube combined accounted for 18 events
recognized as indicating ‘non-intubation’. The patient died.
and half of all cases of death or brain damage. These
events occurred most frequently in obese patients and
Review panel analysis
during patient movement, sedation holds (e.g. sudden awa-
kening and coughing or manually removing a tube) or Degree of harm
airway interventions (e.g. tracheal suction or nasogastric The outcomes ascribed to all ICU and ED cases by the review
tube placement). Of all tubes that became dislodged, 13 panel are presented in Table 2.
were recorded as taped (ties, Velcro straps), two sutured,
and three both taped and sutured. There were three Causal, contributory and positive aspects of care
Causal and contributory factors were identified in all 36 ICU
cases (Table 4). The most frequent causal and contributory
Table 3 Primary reported airway event
factors were patient-related (69% of cases), followed by edu-
ICU (n¼36) cation/training (58%), judgement (50%), equipment/resource
Tracheostomy-related problems 14 (36%), and communication (31%). Positive factors were
Tracheal tube misplacement/displacement 7 identified in 19 cases (54%): the most frequent positive
Failed intubation 7 factors were communication (36% of cases) and organiz-
Oesophageal intubation 3 ation/strategic (19%).
CICV—the cannot intubate, cannot ventilate scenario 2 Causal and contributory factors were identified in all 15 ED
Latrogenic airway trauma 2 cases (Table 4). The most frequent causal and contributory
Problems at the time of extubation 1 factors were patient-related (73% of cases), followed by judge-
Emergency department (n¼15) ment (57%), education/training (40%), and task (33%). Positive
Failed intubation 7 factors were identified in eight cases (53%), the most frequent
Aspiration of gastric contents 2 positive factor being communication (33% of cases).
Oesophageal intubation 2
CICV—the cannot intubate, cannot ventilate scenario 2 Quality of airway management conduct
Iatrogenic airway trauma 1 Reviewers assessed airway management in ICU cases as
Difficult or delayed intubation 1 good in 11% of cases (n¼4), mixed in 52% (n¼19), and
poor in 36% (n¼13) (Table 5). In the ED, airway management
Page 4 of 11
5. Major complications of airway management in the UK BJA
Table 4 Factors assessed by review panel to contribute or cause events and factors indicating good practice. For definitions of factors listed, see
Supplementary Table S2
Factors ICU (n536) ED (n515)
Causal Contributory Positive Causal Contributory Positive
Communication 2 9 13 0 3 5
Education and training 2 19 2 0 6 2
Equipment and resources 0 13 4 0 4 1
Medicines 0 7 0 0 4 0
Organization and strategic 0 7 7 0 0 0
Patient 6 19 0 3 8 0
Task 0 6 2 2 3 1
Team and social 0 7 1 0 3 1
Work and environment 0 4 0 0 1 0
Judgement 3 15 4 0 8 1
Other 0 3 0 0 2 0
There is much that could be discussed, but this discussion
Table 5 Airway management and degree of harm number of is structured in three sections.
cases: n (includes all reported cases—anaesthesia, ICU, and ED)
† What have we observed?
Clinical area Airway management
† What do we learn from these observations?
Good Good Poor Not Sum † What can be done to improve airway management in
and classified
poor
the environments of ICU and the ED?
All 30 79 65 10 184 Space limits the extent of these discussions and the reader is
All deaths 3 14 20 1 38 referred to a full report of the project available at http://www.
All death and brain 3 16 27 2 48 rcoa.ac.uk/index.asp?PageID=1089.
damage
ICU 4 19 13 0 36 What have we observed?
ICU death 0 10 8 0 18
We have observed that although ICU was the setting for
ICU death and brain 0 11 11 0 22
damage fewer than 20% of notified events almost half of deaths
Emergency 2 5 7 1 15 occurred there. More than 60% of events reported from ICU
department led to death or brain damage (compared with 14% in anaes-
Emergency 0 0 4 0 4 thesia). While it is not surprising that ICU patients frequently
department death had a high ASA grading, multi-organ failure, and were receiv-
Emergency 0 1 4 0 5 ing high inspired oxygen fractions, the high rate of obesity
department death and (approaching 50%) of patients experiencing major airway
brain damage
complications is a new and notable finding. Events in the
ICU in obese patients led to death or permanent brain
damage more often than events in non-obese patients
(12 of 17 obese and 10 of 19 non-obese). This is in contrast
was assessed as good in 13% (n¼2) cases, mixed in 33% to anaesthesia, where events in obese patients were not
(n¼5), and poor in 46% (n¼7) (Table 5). Airway management associated with poorer outcomes than in non-obese patients.
was assessed as poor in almost half of ICU deaths and all ED Primary events leading to complications were more likely
deaths. than anaesthesia events to involve failed intubation or prob-
lems with tracheostomies. These events were more likely
than anaesthesia events to occur out-of-hours and to be
Discussion managed by inexperienced staff. NAP4 identified several
This project has performed a prospective study of major cases where management of intubation was by staff who
airway events occurring throughout the UK during anaesthe- were not adequately experienced and when problems
sia, in ICU and the ED for the first time. In-depth structured arose, they were not managed in a logical or recognized
review of these cases has identified specific issues and recur- manner. Issues with equipment arose frequently and
rent themes. While such a study will be ranked low in a hier- included non-availability, lack of training in the use of equip-
archy of research quality, it is likely to have considerable ment, and failure to consider using the right equipment.
clinical relevance and importance. When rescue techniques were used (facemask ventilation,
Page 5 of 11
6. BJA Cook et al.
laryngeal mask ventilation, and cricothyroidotomy), these all more likely to occur in obese patients. Tracheal tube and tra-
had relatively high rates of failure. Issues of preparedness cheostomy displacement in ICU was repeatedly reported
were also identified and included failures to identify patients after patient movement or patient interventions and this
at risk of complications, failures to formulate a plan for criti- has been reported before.9 Similarly, delayed diagnosis of
cal events in these patients and failure to ensure that such a displacement, in the absence of capnography, has been
plan could be carried out. The assessors judged airway man- reported before9 and was reported repeatedly in this project.
agement in the ICU to be good less frequently than in either Failed intubation or difficult intubation contributed to
anaesthesia or the ED. many events on ICU and the ED. Failure to identify potential
Observations in the ED were similar, with a high pro- difficulty, to have a strategy for failure (plan B, plan C), to
portion of events occurring out-of-hours and without con- assemble the correct equipment, and intubation by inappro-
sultants present; the primary airway problem was priately inexperienced personnel contributed to numerous
predominantly failed or problematic intubation and out- events. These observations also applied to patients specifi-
comes were similar to those in ICU, although less severe. cally admitted to a critical care unit for airway monitoring
Several reports suggested failure of preparation, failure to and management. Reviewer assessments frequently ident-
follow standard practices for airway protection, or airway ified system, organizational, and human factor deficiencies.
rescue in cases of difficulty. Emergency surgical airway was In a recent study, implementation of a 10-point ICU intuba-
required in two-thirds of cases, higher than during anaesthe- tion management protocol (‘care bundle’) led to a 30 –60%
sia or in ICU, and in all cases was ultimately successful, also reduction in complications.14 There are various interpret-
higher than other settings. ations of this study, but it is notable that the bundle included
An observation in both ICU and the ED was of unrecog- preoxygenation with continuous positive airways pressure,
nized oesophageal intubation. In total, there were six presence of two operators, rapid sequence induction (RSI),
leading to five deaths (23% of deaths in these areas). All capnography, and early administration of vasopressors if
were performed by clinicians with very limited airway experi- needed. Such a protocol, supported by a checklist is attractive
ence. Capnography was not used in five cases and in one in the light of this study and other checklist-driven successes
case, it was used, but a flat capnograph trace was misinter- in ICU.15
preted as being ‘due to cardiac arrest’. In the ED, predictable airway emergencies include trauma
In both groups, there was a high failure rate of needle cri- intubations, stridor, inhaled foreign bodies, and other causes
cothyroidotomy. Of eight attempted in ICU and the ED, six of airway obstruction. The rate of difficult intubation in the
failed (75%) and the airway was rescued either with a surgi- ED may be as high as 8.5%, and the need for an emergency
cal approach (open or percutaneous tracheostomy) or with surgical airway as high as 0.5%.5 – 8 Knowledge of likely scen-
other non-invasive techniques. Direct surgical approaches arios should drive preparedness of personnel, equipment,
to the trachea had high success rates. communication channels, and policies. A survey12 identified
that 20 000 RSIs of anaesthesia are performed in UK EDs
per year and therefore an average size ED will perform RSI
What do we learn from these observations? approximately every 4 or 5 days with 80% of these per-
In both settings, it must be accepted that patients may formed by anaesthetists, many of whom are trainees. In
present with complex conditions which are intrinsically this project, we identified avoidable harm, including death,
‘high risk’: in ICU because of critical illness and oxygen caused by airway trauma or oesophageal intubation that
dependency and in the ED because of underling pathology occurred during airway management by clinicians with
or injury that has precipitated their admission. An American limited airway management experience. The implications
Society of Anesthesiologists’ Closed Claims Project (ASACCP) are that emergency physicians undertaking these procedures
study identified claims related to difficult airway manage- need specific training to establish and maintain their skills,
ment outside the operating theatre to be considerably that anaesthetists and intensive care doctors need to under-
more likely to lead to fatal outcomes than in the operating stand the particular requirements and difficulties of airway
theatre.4 A study of more than 10 000 emergency intuba- management in the ED, and that channels of communication
tions outside the operating theatre found multiple attempts between the ED and anaesthesia or ICU departments need
at intubation to be associated with dramatic increases and to be well established to ensure prompt attendance by an
high rates of hypoxaemia (11.8% vs 70%), regurgitation of appropriately skilled senior clinician.
gastric contents (1.9% vs 22%), aspiration (0.8% vs 13%), Diagnosis of oesophageal intubation was hampered by
bradycardia (1.6% vs 21%), and cardiac arrest (0.7% vs lack of capnography. The current situation in ICU and the
11%).3 For these reasons, the staffing and equipment in ED can be compared with the 1980s when capnography
both settings must be such that airway management can was not universally used for intubation in anaesthesia. The
be timely, skilled, and where necessary utilize highly ASACCP identified numerous cases of litigation after oeso-
advanced techniques. This requires planning and communi- phageal intubation:16 delays in diagnosis of more than 5
cation. In ICU, planning should recognize that intubation min were almost universal, auscultation routinely gave
sometimes fails, that tracheal tubes and tracheostomies false positives, cyanosis was often absent, and it was cardio-
will inadvertently fall out, and that all these events are vascular disturbance or collapse that alerted clinicians to the
Page 6 of 11
7. Major complications of airway management in the UK BJA
problem in more than 80% of cases. The authors commented addition to clinical assessment . . . if not available, a non-
on ‘preconceived notions of likelihood’, ‘reflex clinical beha- waveform carbon dioxide detector or oesophageal detector
viours’, ‘conflicting environmental data’, ‘the inherent limit- device in addition to clinical assessment is an alternative’.19
ations of diagnostic tests’, and ‘the potential for a rapid Capnography, or rather the failure to use it, likely contrib-
and poorly reversible clinical cascade’. These comments act uted to 17 outcomes of death or brain damage on ICU,
as a potent reminder of the problem and the potential for including four oesophageal intubations and 14 inadvertent
human factors to impede correct clinical diagnosis. A more tube displacements: these account for 82% of events
recent study of emergency intubation outside the operating leading to death or brain damage in ICU.
theatre noted that reliance on indirect clinical tests for diag- In the ED, capnography use was higher, being definitely
nosing oesophageal intubation during emergency tracheal used 50% of intubation attempts, although this question
intubation led to more hypoxaemia, severe hypoxaemia, was poorly completed. Despite this, its use was not universal
regurgitation, aspiration, cardiac dysrhythmia, and cardiac and failure to use, or misinterpretation of, capnography led
arrest.17 to two fatal unrecognized oesophageal intubations in the
An important recurrent finding was misinterpretation of ED. Correct use and interpretation of capnography would
capnography when oesophageal intubation occurred during have prevented half of the deaths in the ED.
cardiac arrest or cardiac arrest occurred as a consequence The contrast between rates of use of capnography in
of it. This was also noted in anaesthesia cases. Clinicians, anaesthesia and in ICU and the ED is stark and is reinforced
mostly anaesthetists, failed to recognize that a flat capno- by this project’s findings. The use of capnography in ICU
graph trace indicated absence of ventilation and a misplaced has been recommended by various authors and organiz-
tracheal tube. Nevertheless, it has been recognized for many ations.9 14 31 – 35 The breadth of these recommendations
years that during cardiopulmonary resuscitation (CPR) cap- has ranged from that it should be available for intubation
nography is not flat but indicates a low concentration of to recommending its routine use ‘from intubation to extuba-
expired gas (Fig. 1).18 The 2010 International Consensus tion’. Surveys repeatedly show current use fails even to meet
guidelines on Cardiopulmonary Resuscitation specifically the narrowest recommendation. This project has shown that
addressed the use of capnography to confirm advanced full implementation would save lives.
airway placement during CPR.19 The report describes two In both areas, needle cricothyroidotomy had an unex-
studies which included 21 oesophageal intubations in 297 pectedly high failure rate. It has been widely discussed as
patients at cardiac arrest and in which waveform capnogra- to whether needle or Seldinger or surgical approaches to
phy was 100% sensitive and 100% specific in identifying direct tracheal access are best and it may be argued that
correct tracheal tube placement.20 21 In contrast, studies of this project provides evidence that needle cricothyroidot-
colorimetric expired carbon dioxide detectors, non-waveform omy has a high failure rate and therefore should be aban-
expired capnometers, and oesophageal detector devices doned, particularly as surgical approaches were generally
(both syringe aspiration and self-inflating bulb types) had successful (even when following failed needle cricothyroi-
similar accuracy to clinical assessment for confirming the dotomy). There are several reasons to be cautious about
tracheal tube position during cardiac arrest.22 – 30 The report such a conclusion. The NAP4 project specifically studied
concludes that ‘waveform capnography is recommended to events with poor outcomes and although we did seek
confirm and continuously monitor the position of a tracheal reports of all airway complications requiring emergency
tube in victims of cardiac arrest . . . it should be used in surgical airway, it is possible that a disproportionate
Fig 1 Capnograph trace during cardiac arrest with on-going CPR. The positive trace is an indicator of correct (i.e. tracheal) placement of the
tracheal tube.
Page 7 of 11
8. BJA Cook et al.
number of successful rescue needle cricothyroidotomies Intubation
were not reported. Even if this explanation is not correct, † An intubation checklist should be developed and used
it is not reasonable to abandon the needle cricothyroidot- for all intubations of critically ill patients. A checklist
omy technique without a much more robust explanation might usefully identify preparation of patent, equip-
of failures, which may have been due to failures of training, ment, drugs, and team. A checklist should include
use of inappropriate equipment, design problems with identification of back-up plans.
appropriate equipment, or technical failures during use.
Examples of each of these observed in NAP4 include cepha-
lad placement of the device, use of an i.v. cannula for cri- Recognition of difficulty and back-up planning
cothyroidotomy, mechanical failures of a Ravussin † Every ICU should have algorithms for management of
cannula, and successful passage of a fine bore needle fol- intubation, extubation, and re-intubation. National
lowed by unsuccessful (and inappropriate) attempts to ven- efforts should be made to develop evidence-based
tilate with a low-pressure gas source. algorithms for ICU.
Emergency surgical airway is the ‘final common pathway’ † Patients at risk of airway events (i.e. those patients at
for all difficult airway algorithms. While much emphasis is increased risk of problems or for whom the standard
placed on the choice of device and technique, there is rela- algorithms are not appropriate) should be identified
tively little written about the decision-making process and and clearly identifiable to those caring for them.
timing of emergency surgical airway. An anaesthetic litiga- † A plan for such patients should be made and documen-
tion review found that 42% of 179 difficult airway cases ter- ted. The planning should identify primary and back-up
minated in CICV.4 Errors of technique were frequent causes plans. The plan should also identify any additional
of failure, particularly failure to ventilate with a high-pressure equipment and skills necessary to carry out the plan.
source when a narrow cricothyroid cannula was inserted.36 The plan should be communicated to on-coming staff
Of equal importance, persistent attempts at intubation at each staff handover, including confirmation that
occurred before rescue techniques and the authors noted the plans can still be carried out.
that ‘our data suggest the rescue ability of (supraglottic
airways) may have been reduced by the effects of multiple
preceding attempts at conventional intubation’ and that ‘in Tube displacement
2/3 of the claims where CICV occurred a surgical airway † Staff education should recognize and emphasize the
was obtained but was too late to avoid poor outcomes’. In risks of airway displacement. Airway displacement
NAP4, there were also cases, in anaesthesia and also in the may occur at any time but is more frequent in obese
ICU and ED, where persistent attempts at intubation patients, in patients with tracheostomy, during or
perhaps precipitated CICV, likely led to failure of rescue tech- after patient movement, and during sedation holds.
niques and definitely delayed emergency surgical airway.
Obesity
† Obese patients on ICU should be recognized as at
What can be done to improve airway management in increased risk of airway complications and at increased
the environments of ICU and the ED? risk of harm from such events. Plans to manage the
Intensive care unit airway should be particularly meticulous.
† Responsible bodies (e.g. Royal College of Anaesthetists,
Capnography Intensive Care Society) should work with other stake-
† Capnography should be used for intubation of all criti- holders and manufacturers to explore two aspects of
cally ill patients irrespective of location. tracheostomies for obese patients. (i) Can design be
† Continuous capnography should be used in all ICU improved to reduce risk of displacement? (ii) Can the
patients with tracheal tubes (including tracheostomy) optimal mode of fixation be determined?
who are intubated and ventilator-dependent. Cost and
technical difficulties may be practical impediments to
the rapid introduction of routine capnography. Airway equipment
However, these need not prevent its implementation. † Every ICU should have immediate access to a difficult
† Where capnography is not used, the clinical reason for not airway trolley. This should have the same content and
using it should be documented and reviewed regularly. layout as the one used in that hospital’s operating
† Training of all clinical staff who work in ICU should department.
include interpretation of capnography. Teaching † The airway trolley needs regular checking, mainten-
should focus on identification of airway obstruction or ance, and replacement of equipment after use which
displacement. In addition, recognition of the abnormal should be appropriately documented.
(but not flat) capnograph trace during CPR should be † A fibrescope should be immediately available for use on
emphasized. ICU.
Page 8 of 11
9. Major complications of airway management in the UK BJA
Cricothyroidotomy † An intubation checklist should be developed and used
† Training of staff who might be engaged in advanced for all intubations of ED patients. A useful checklist
airway management of these potentially difficult may identify preparation of patient, equipment, drugs
patients should include regular, manikin-based practice and team, and also back-up plans.
in the performance of cricothyroidotomies. Correct † EDs should perform a risk assessment to identify the
identification of the landmarks, especially on obese type of patients and their airway problems that they
patients, should be encouraged. can anticipate receiving. Equipment, training, and strat-
† Research is required to identify the equipment and egies should be planned around, although not
techniques most likely to be successful for direct tra- restricted to, the anticipated patient groups.
cheal access in critically ill patients. This research † Every ED should have the airway equipment necessary
should specifically address whether the same solutions to manage the anticipated clinical scenarios. This
are effective in obese patients. needs regular checking, maintenance, and replacement
of equipment after use.
Transfers † Every ED should also have a difficult airway trolley. This
should have the same content and layout as the one
† Recognizing that transfers, whether inter- or intra- used in that hospital’s operating department and also
hospital, are high-risk episodes, an airway assessment needs regular checking, maintenance, and replacement
that includes patient, equipment, back-up, and staff of equipment after use.
skills should be made before transfers. † In cases of airway compromise, it is generally preferable
to secure the airway before moving the patient out of
Staffing the ED, but local considerations apply. Any decision to
† Trainee medical staff who are immediately responsible move a patient with a threatened airway should be
for management of patients on ICU need to be profi- made by a senior clinician.
cient in simple emergency airway management. They † Robust processes should be established to ensure the
need to have access to senior medical staff with prompt availability of appropriately skilled and senior
advanced airway skills at all hours. staff at any time to manage the airway within a reason-
† Where senior intensivists do not have an anaesthetic able timeframe.
background with advanced airway management skills, † Joint training of emergency physician and anaesthesia/
it is recommended that specific protocols are in place ICU staff is recommended—as described above.
to ensure experienced anaesthetic cover can be called † Staff training should focus on the anticipated clinical
on to assist in management of difficult cases. Trust presentations. Training should also include manage-
management should support the financial implications. ment of failed intubation and emergency surgical
airway techniques using the airway equipment avail-
Education/training able in the ED.
† Junior medical staff who are to be immediately respon- † Strong links and good communication between senior
sible for management of patients on ICU need airway clinicians in the ED, anaesthesia, ICU, ear, nose, and
training. This should include basic airway management, throat surgery, and other relevant specialities are
familiarization with algorithms for management of pre- essential in planning for, and managing, the emergency
dictable airway complications, and use/interpretation of airway problems that present to the ED. Consideration
capnography. Training should identify the point at should be given to designating consultant leads from
which trainees reach the limit of their expertise and each involved speciality to agree and oversee the man-
mechanisms for summoning more experienced clini- agement of emergency airway problems presenting to
cians. Such training is likely to include simulation and the ED.
team training. † Regular audit should take place of airway management
† Regular audit should take place of airway management problems or events in the ED.
problems or critical events in the ICU.
Research
Emergency department † NAP4 has identified numerous areas of concern and
Many of the above recommendations apply equally to the ED. potential improvement in airway management in ICU
To these are added: and EDs. Airway management on ICU and in the ED is
as suitable an area for future research as many other
† Capnography should be used for all intubations in the
interventional areas. It is currently under-explored.
ED.
Grant awarding bodies should recognize this. Several
† Capnography should be used for all anaesthetized
areas of potential research are indicated above.
patients in the ED.
† Capnography should be used for intubated patients The main limitations of the NAP4 project are described in the
during transfers from the ED to other departments. accompanying paper.11 In contrast to the anaesthesia
Page 9 of 11
10. BJA Cook et al.
events where every UK NHS hospital had a local reporter, our discussions about inclusion criteria. We thank the following
network of local reporters for ICU and EDs likely covered only statisticians for advice: Rosemary Greenwood and Hazel
50% of hospitals. Although many cases in these areas will Taylor (Research Design Service, South West, Bristol) and
have been reported by anaesthesia local reporters, it is Gordon Taylor (University of Bath). Finally, we are particularly
likely that a higher proportion of events arising in ICU and indebted to Ms Shirani Nadarajah at the Royal College of
EDs were not notified. We cannot quantify these, but it is cer- Anaesthetists for her major contribution to the prompt col-
tainly possible that the cohort of patients we studied rep- lection and accurate collation of census data and for
resent only the ‘tip of the iceberg’ of such cases in ICU and project administration. The project was also endorsed/sup-
EDs. ported by the Chief Medical Officers of England (Sir Liam
Before surgery, airway management is generally a necess- Donaldson), Northern Ireland (Dr Michael McBride), Scotland
ary part of the process of anaesthesia to facilitate an oper- (Dr Harry Burns) and Wales (Dr Tony Jewell), the Medical Pro-
ation, while in both ICU and the ED, the primary aim may tection Society and Medical Defence Union.
be securing the patient’s airway, with anaesthesia a neces-
sity for that. Owing to preceding patho-physiological disturb- Conflict of interest
ance, it may be difficult in these patients to determine to T.M.C. has been paid by Intavent Orthofix and the LMA
what extent an adverse airway event was the cause of a Company (manufacturers of laryngeal mask airways) for lec-
poor outcome and this was relevant to several cases in turing. He has never had and has no financial interest in
NAP4. At the reviewing stage, we aimed only to include these or any anaesthetic equipment companies.
those cases where the outcome was judged likely to be
related to the airway event.
Funding
In conclusion, at least one-quarter of major complications
of airway management in hospitals are likely to occur in the The project was funded by three organizations: the Royal
ICU and ED. These complications are more likely to lead to College of Anaesthetists, the Difficult Airway Society, and
permanent harm or death than events in anaesthesia. Case the National Patient Safety Agency.
review has identified avoidable deaths and areas of care
that need improvement. We have outlined recommendations References
on which to base such improvements. 1 Schwartz DE, Matthay MA, Cohen NH. Death and other compli-
cations of emergency airway management in critically ill
patients: a prospective investigation of 297 tracheal intubations.
Supplementary material Anaesthesiology 1995; 82: 367–76
Supplementary material is available at British Journal of 2 Jaber S, Amraoui J, Lefrant JY. Clinical practice and risk factors for
Anaesthesia online. immediate complications of endotracheal intubation in intensive
care unit: a prospective multiple-center study. Crit Care Med 2006;
34: 2355– 61
Acknowledgements 3 Mort TC. Emergency tracheal intubation: complications associ-
The authors would like to express their thanks to the network ated with repeated laryngoscopic attempts. Anesth Analg 2004;
of local reporters who were responsible for collecting and 99: 607– 13
supplying data. Their role was difficult and demanding; this 4 Peterson GN, Domino KB, Caplan RA, Posner KL, Lee LA,
report would not have been possible without their hard Cheney FW. Management of the difficult airway: a closed claims
work, persistence and diligence. In addition to the Royal analysis. Anesthesiology 2005; 103: 33– 9
College of Anaesthetists and the Difficult Airway Society, a 5 Chang RS, Hamilton RJ, Carter WA. Declining rate of cricothyrot-
omy in trauma patients with an emergency medicine residency:
number of organizations contributed to the development of
implications for skills training. Acad Emerg Med 1998; 52: 47– 51
the audit in various ways, including being represented on
6 Sakles JC, Laurin EG, Rantapaa AA, Panacek EA. Airway manage-
its Working Group. These include the Association for Peri- ment in the emergency department: a one-year study of 610 tra-
operative Practice, Association of Anaesthetists of Great cheal intubations. Ann Emerg Med 1998; 31: 325– 32
Britain and Ireland, Association of Paediatric Anaesthetists, 7 Bair AE, Filbin MR, Kulkarni RG, Walls RM. The failed intubation
College of Emergency Medicine, College of Operating Depart- attempt in the emergency department: analysis of prevalence,
ment Practitioners, Intensive Care Society, National Patient rescue techniques, and personnel. J Emerg Med 2002; 23: 131– 40
Safety Agency, Obstetric Anaesthetists Association. We are 8 Graham CA, Beard D, Oglesby AJ, et al. Rapid sequence intubation
also indebted to the President, Council, and the Head of Pro- in Scottish urban emergency departments. Emerg Med J 2003; 20:
3–5
fessional Standards (Mr Charlie McLaughlan) at the Royal
9 Thomas AN, McGrath BA. Patient safety incidents associated with
College of Anaesthetists. We would also like to acknowledge
airway devices in critical care: a review of reports to the UK
the advice of Mrs Karen Thomson, Patient Information Advi-
National Patient Safety Agency. Anaesthesia 2009; 64: 358– 65
sory Group at the Department of Health. Dr Ian Calder per-
10 Catchpole K, Bell MD, Johnson S. Safety in anaesthesia: a study of
formed an essential role by acting as a moderator outside 12,606 reported incidents from the UK National Reporting and
of the running of the project. He used his extensive back- Learning System. Anaesthesia 2008; 63: 340–6
ground knowledge and understanding of airway manage- 11 Cook TM, Woodall N, Frerk C. Major complications of airway man-
ment and of the project to aid the local reporters in agement in the UK: results of the Fourth National Audit Project of
Page 10 of 11
11. Major complications of airway management in the UK BJA
the Royal College of Anaesthetists and the Difficult Airway 24 Anton WR, Gordon RW, Jordan TM, Posner KL, Cheney FW. A dis-
Society. Part 1: Anaesthesia. Br J Anaesth Advance Access pub- posable end-tidal CO2 detector to verify endotracheal intubation.
lished 29 March 2011; doi: 10.1093/bja/aer058. Ann Emerg Med 1991; 20: 271– 5
12 Benger J, Hopkinson S. Rapid sequence induction of anaesthesia 25 MacLeod BA, Heller MB, Gerard J, Yealy DM, Menegazzi JJ. Verifica-
in UK Emergency Departments: a national census. Emerg Med J tion of endotracheal tube placement with colorimetric end-tidal
2010, doi: 10.1136/emj.2009.085423 CO2 detection. Ann Emerg Med 1991; 20: 267–70
13 Seven Steps to Patient Safety: A Guide for NHS Staff. National 26 Schaller RJ, Huff JS, Zahn A. Comparison of a colorimetric
Patient Safety Agency, 2004. Available from http://www.nrls.npsa. end-tidal CO2 detector and an esophageal aspiration device for
nhs.uk/resources/?entryid45=59787 (accessed December 31, 2010) verifying endotracheal tube placement in the prehospital
14 Jaber S, Jung B, Corne P, et al. An intervention to decrease com- setting: a six-month experience. Prehosp Disaster Med 1997; 12:
plications related to endotracheal intubation in the intensive care 57–63
unit: a prospective, multiple-center study. Intensive Care Med 27 Bhende MS, Thompson AE. Evaluation of an end-tidal CO2 detec-
2010; 36: 248– 55 tor during pediatric cardiopulmonary resuscitation. Pediatrics
15 Berenholtz SM, Pronovost PJ, Lipsett PA, et al. Eliminating 1995; 95: 395– 9
catheter-related bloodstream infections in the intensive care 28 Li J. Capnography alone is imperfect for endotracheal tube place-
unit. Crit Care Med 2004; 32: 2014– 20 ment confirmation during emergency intubation. J Emerg Med
16 Caplan RA, Posner KL, Ward RJ, Cheney FW. Adverse respiratory 2001; 20: 223– 9
events in anesthesia: a closed claims analysis. Anesthesiology 29 Pelucio M, Halligan L, Dhindsa H. Out-of-hospital experience with
1990; 72: 828– 33 the syringe esophageal detector device. Acad Emerg Med 1997; 4:
17 Mort TC. Esophageal intubation with indirect clinical tests during 563– 8
emergency tracheal intubation: a report on patient morbidity. 30 Bozeman WP, Hexter D, Liang HK, Kelen GD. Esophageal detector
J Clin Anesth 2005; 17: 255 –62 device versus detection of end-tidal carbon dioxide level in emer-
18 Falk JA, Rackow EC, Weil MH. End-tidal carbon dioxide concen- gency intubation. Ann Emerg Med 1996; 27: 595– 9
tration during cardiopulmonary resuscitation. N Engl J Med 31 Cheifetz IM, Myers TR. Respiratory therapies in the critical care
1988; 318: 607– 11 setting. Should every mechanically ventilated patient be moni-
19 Deakin CD, Morrison LJ, Morley PT. 2010 international consensus tored with capnography from intubation to extubation? Respir
on cardiopulmonary resuscitation and emergency cardiovascular Care 2007; 52: 423–38
care science with treatment recommendations. Part 8: advanced 32 Cook TM, Haslam M. Complications of airway management in
life support. Resuscitation 2010; 81S: e93– 174 ICU—time for a closer look. Care of the Critically Ill 2008; 24:
20 Silvestri S, Ralls GA, Krauss B, et al. The effectiveness of 35–7
out-of-hospital use of continuous end-tidal carbon dioxide moni- 33 Goldhill D, Cook TM, Waldmann C. Airway incidents in critical care,
toring on the rate of unrecognized misplaced intubation within a the NPSA, medical training and capnography. ‘Every breath you
regional emergency medical services system. Ann Emerg Med take ... I’ll be watching you’. Anaesthesia 2009; 64: 354– 7
2005; 45: 497– 503 34 AAGBI Safety Statement Capnography outside the Operating
21 Takeda T, Tanigawa K, Tanaka H, Hayashi Y, Goto E, Tanaka K. Theatre. 2009. Available from http://www.aagbi.org/aboutaagbi/
The assessment of three methods to verify tracheal tube pressoffice/statements/aagbi_ safety_statement_capnography_
placement in the emergency setting. Resuscitation 2003; 56: jan09.htm (accessed January 2, 2011)
153–7 35 Standards for the care of adult patients with a temporary tracheost-
22 Ornato JP, Shipley JB, Racht EM, et al. Multicenter study of a por- omy. Intensive Care Society, 2008. Available from http://www.ics.ac.
table, handsize, colorimetric end-tidal carbon dioxide detection uk/intensive_care_professional/standards_and_guidelines/care_
device. Ann Emerg Med 1992; 21: 518 –23 of_the_adult_patient_with_a_temporary_tracheostomy_2008
23 Varon AJ, Morrina J, Civetta JM. Clinical utility of a colorimetric (accessed January 2, 2011)
end-tidal CO2 detector in cardiopulmonary resuscitation and 36 Cook TM, Nolan JP, Cranshaw J, Magee P. Needle cricothyroidot-
emergency intubation. J Clin Monit 1991; 7: 289– 93 omy. Anaesthesia 2007; 62: 289–90
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