Management of Unanticipated Difficult Intubation

[NRSKarenRN, BSN, RN]

having lived through the experience of multiple intubation attempts due to unanticipated difficult intubation, i urge all to review this info. afterwards, my letter to hospital mgmt + qi led to many changes thoughout health system where i was treated per surgeon and chief of anesthesia --even have his cell phone #. karen

from pa safety authority:

of the anesthesia events involving complications reported to the pennsylvania patient safety authority in 2009, 36 involved difficult preoperative tracheal intubation. these will be the focus of this article, although the information may also be of value in other settings.

management of unanticipated difficult intubation

pa patient saf advis 2010 dec;7(4):113-22.

abstract

airway management, ensuring uninterrupted oxygenation and ventilation, is a fundamental part of the practice of anesthesia and of emergency and critical care medicine. endotracheal intubation is an airway management technique indicated in a variety of clinical situations, most commonly for the maintenance of the upper airway during general anesthesia, but also in any situation involving the maintenance and protection of the upper airway when the airway may be compromised or positive pressure ventilation is necessary. a difficult intubation is defined by the american society of anesthesiologists as tracheal intubation requiring more than three attempts, in the presence or absence of tracheal pathology. unanticipated difficulty with endotracheal intubation may result in catastrophic outcomes, including cerebral anoxia and death. of the anesthesia events involving complications reported to the pennsylvania patient safety authority in 2009, 36 reports involved a difficult intubation. in 23 reports, difficult intubation was described as unanticipated. even the most thorough assessment of the airway may not detect the possibility of a difficult intubation, and every anesthetist should have a predetermined strategy for dealing with this situation. alternative methods of managing the airway should be initiated after two or three unsuccessful attempts at intubation. this article discusses assessment of the airway, identification of patients at risk for a difficult intubation, and risk reduction strategies, including plans for dealing with an unexpected difficult intubation. recent advances in airway management techniques and devices will be summarized.

see sidebar article sections

introduction

authority reports

evaluation of the airway

quantitative evaluation of difficult intubations

risk reduction strategies

conclusion

notes

supplemental material

lemon airway assessment method

self-assessment questions

patient safety tools

difficult intubation

[Jonesskky RN]

Great information.

[wtbcrna, MSN, DNP, CRNA]

The best thing that a patient can do is if they know they have had difficulties with intubation is to tell the anesthesia provider up front they have had past difficult intubations, and what method was used last time for intubation i.e. AFO, glidescope, Miller vs. Mac, Bougie etc.

[highlandlass1592, BSN, RN]

I think that's a great idea but how many patients would be able to remember such specific information and relay it correctly to future healthcare providers? My institution sends the patient a letter detailing the fact they were a difficult intubation and then gives the information you described. A copy is also kept in the patient's chart for future providers. I think it's a great idea...even if the patient doesn't understand the information provided, they are able to take that letter anywhere they go.

[wtbcrna, MSN, DNP, CRNA]

I think that's a great idea but how many patients would be able to remember such specific information and relay it correctly to future healthcare providers? My institution sends the patient a letter detailing the fact they were a difficult intubation and then gives the information you described. A copy is also kept in the patient's chart for future providers. I think it's a great idea...even if the patient doesn't understand the information provided, they are able to take that letter anywhere they go.

I have never had a patient forget that they had awake fiber optic and most will at least remember to tell you that they were a difficult intubation as long as they were told afterward. That is usually enough to let us know to get other prepared and in the room that are needed for difficult intubations. The letter would be nice but more often than not in most places you aren't going to have the patients old chart when doing your anesthetic. This especially true for outpatient procedures.

[loveanesthesia]

We also do the letter to the patient. A universal electronic medical record would be a great advantage in these cases.

[BCRNA]

I find most patients will remember they were told they were difficult to "put in the breathing tube." But most will no be able to remember the name of the method that was used. The ones that could name the method were highly educated, graduate level engineer usually. And the ones that were given a letter, lost it. Electronic record would be nice if it was easy to access, but records at other institutions are not easy to access at the moment.

Doing a letter is a good idea, but practically useless. At least in my area where most of the patients are in the lower economic group, they are unable to keep up with it.