National audit project -(NAP 4)- findings and recommendations

NAP4 project

1. Airway Management's Dirty Laundry – Lessons From The NAP4 Study Dr.Shanawaz Abdul Rasheed, Consultant Anaesthesiologist , King’s College Hospital,Dubai .

2. 4th National Audit Project of the Royal College of Anaesthetists (NAP4) Major complications of airway management in the UK March 2011 http://www.rcoa.ac.uk/nap4

3. National Audit Project 4 RCoA & DAS Sept 08-Aug 09 Report March 2011

4. NAP4

5. Airway complications d uring Anaesthesia Total Reports : 184 adverse incidents reported. 133 incidents from anaesthesia. Outcomes : 16 deaths . 3 patients  with persistent neurological deficits. 58 attempted surgical airways . Incidence : 1 death  per  180,000  general anaesthetics (likely an underestimate). ICU and ED complications were generally more adverse. Involvement : On average,  2.9 anaesthetists  involved per incident. Risk  of encountering a complication 3x higher for an anaesthetist than for a patient.

6. Incide n ce Major complications Brain damage. Emergency surgical airway. Unanticipated ICU admission. Death Events Numerator Denominator 1:n cases Major compl* 133 2.9 M 1: 22,000

7. Key Findings of NAP4

8. Airway management strategy Objective : Maintain  oxygenation . Prevent  aspiration . Avoid  airway trauma . Challenges : Lack of anticipation of failure. Some strategies poorly suited to patient needs. Equipment or personnel not always available.

9. Airway assessment Often poorly performed or not recorded. Key areas of difficulty: Mask ventilation LMA insertion Tracheal intubation Direct tracheal access Aspiration risk and patient cooperation often not assessed adequately. When potential difficulty with airway management is identified a strategy is required. An airway plan suggests a single approach to management of the airway. An airway management strategy requires a logical sequence of plans or techniques aimed at; maintaining oxygenation, preventing aspiration and avoiding airway trauma.

10. Airway management The authors suggest that choosing the safest technique for airway management may not necessarily be the anaesthetist’s most familiar and it may be necessary to seek the assistance of colleagues with specific skills.

11. Airway management The authors also suggest that obesity needs to be recognized as a risk factor for airway difficulty and strategies modified accordingly.

12. The authors also suggest that obesity needs to be recognized as a risk factor for airway difficulty and strategies modified accordingly. http://www.anaesthesiacases.com.au/cpd/dr_maryannes_journal_watch/may_2011_journal_watch

13. Aspiration - The commonest c ause of death Aspiration Risk : Poor assessment in patients at risk. High-Risk Patients : No precautions  like gastric drainage or tracheal intubation in some cases. Omission of rapid sequence induction in high-risk cases. Low-Risk Patients : Steps like pharmacological intervention or 2nd generation  Supra-Glottic Airway (SAD)  often  not taken . Trauma and Opiates : Gastric stasis from these factors was  overlooked , leading to aspiration.

14. Supra-Glottic Airway Devices (SADs) Inappropriate Use : Reported  deaths  when SADs were used in  morbidly obese patients   (lithotomy position) and  high-risk aspiration patients . SADs were sometimes used  without a backup plan , leading to dangerous complications when displaced. Risks : Prolonged ventilation via SAD  increased risks of aspiration and fatal airway obstruction. Recommendations : SADs can be a useful conduit for  tracheal intubation  using a  fibrescope  and  Aintree catheter . Proper use and timely conversion to intubation could have  prevented aspiration  and the need for  surgical airways .

15. Known or anticipated difficult airways Awake intubation and awake tracheostomy were under-utilised In others, where awake fibreoptic intubation (AFOI) was attempted, the airway became obstructed; notably sedation led to complications with AFOI. Awake intubation may fail, its safety relies upon the fact that spontaneous ventilation is maintained and the option of regrouping or abandonment is available. Complicated sedation techniques or difficult patients are best managed by a 2nd anaesthetist with sole responsibility for maintaining oxygenation and sedation. Unnecessary selection of the nasal route led to failures of awake intubation. All departments of anaesthesia should ensure patients have access to skilled awake intubation if needed

16. Considerations for Regional Anaesthesia & Airway management  Regional Anaesthesia: Could have prevented complications seen under general anaesthesia. Challenges arise during conversion to general anaesthesia in patients with a difficult airway. Block failure plans must be communicated to the theatre team, and the block must be confirmed effective before surgery. Airway Management Devices: Supra-glottic airway devices were used as an alternative in difficult airway cases. Failures occurred due to displacement or obstruction, leading to deaths when rescue techniques were unsuccessful. Key Actions: Departments must ensure availability of skilled awake intubation. Support systems should be in place to assist anaesthetists during high-risk cases.

17. Abnormal BMI Obese & Morbidly Obese Patients Reported 2x and 4x more often, respectively, than their prevalence in the UK population. Normal BMI Patients Underrepresented in NAP4 reports. Airway Rescue Options Complexities in Obese Patients Requires careful evaluation. Awake Intubation or Regional Anaesthesia may be needed. Extra Time for Assessment Morbidly obese patients need more time for proper assessment and discussion of anaesthetic options. Operational Planning Considerations Even minor surgeries require additional time and resources for safe assessment and anaesthesia in morbidly obese patients.

18. Airway Management in Patients with Head & Neck Pathology High Risk of CICV (Can't Intubate, Can't Ventilate) Airway Obstruction  in head & neck pathology patients presented the  highest risk . Poor Preassessment & Planning Inadequate planning and communication during: Induction  and  Recovery Period Led to adverse outcomes. Thorough Airway Assessment Patients with airway tumours or obstruction require: Airway Radiological Investigations Nasendoscopy Team-based Approach  with prior discussion. Underutilised Awake Tracheostomy Awake Tracheostomy  was not used enough but could have: Prevented serious complications  in cases of severe airway obstruction and stridor.

19. Complications in Emergence and Recovery Complications at Emergence 25%  of complications occurred at the end of anaesthesia. All cases involved  airway obstruction . Particularly frequent in operations involving the airway (e.g., bleeding). Poor Anticipation of Problems Lack of anticipation, even when issues arose at induction. Controlled Extubation & Observation Some patients managed well with: Controlled extubation  in the OR. Observation before transfer to PACU. Improved communication  with recovery staff could enhance patient care.

20. Complications in Emergence and Recovery Post-Operative Plan for Difficult Airways For difficult airway patients, ensure: Clear instructions  on warning signs. Management plan, necessary equipment, and location of skilled personnel are communicated to recovery or ICU staff. Post-Obstructive Pulmonary Oedema Occurred in  13 cases (10%) , linked to  1 death . Preventive measures: Use of  bite block  or  2nd generation SAD  to prevent airway occlusion from biting.

21. Airway Trauma and CICV Risk Repeated Intubation Attempts → CICV Repeated attempts at tracheal intubation led to the development of Can't Intubate, Can't Ventilate (CICV). Swelling After Difficult Intubation Swelling following previous  difficult but successful intubations  complicated subsequent airway management. Ignored Warning Signs Previous difficulty by a  trainee  was ignored by seniors, leading to similar complications. Airway Trauma at Induction Trauma, combined with  extreme Trendelenburg position , led to: Postoperative airway obstruction  requiring intubation or tracheostomy. Complications from Airway Management Tools High-pressure oxygenation  via airway exchange catheter resulted in: Bilateral pneumothoraces . Blind bougie use  resulted in: Tracheal tear  and  severe airway haemorrhage .

22. Capnography in Airway Management  Capnography  was used in all anaesthesia cases. Misinterpretation Leading to Deaths Several deaths occurred when  absence of detectable CO₂  was mistakenly attributed to: Cardiac arrest , delaying recognition of: Tracheal tube obstruction  or Oesophageal intubation . Absence of CO₂ = Non-Ventilation Absence of detectable CO₂  signals: Misplaced tracheal tube  or Total airway obstruction  preventing lung ventilation.

23. Emergency Surgical Airway Emergency Surgical Airway Cases 80 cases reviewed , 58 during anaesthesia. Needle Cricothyroidotomy Favoured by anaesthetists, but  60% failure rate . Fine bore techniques  had the  highest failure rate . Reasons for Failure Failures were due to: Misplacement Device malfunction Misuse Success with Surgical Tracheostomy or Cricothyroidotomy These carried the  highest success rate . Alternatives Before Surgical Airway Insertion of a  supra-glottic airway  or use of a  muscle relaxant  could enable ventilation and should always precede an emergency surgical airway in CICV management.

24. ICU and ED Airway Management 184 total reports : 36  from ICU. 15  from Emergency Departments (ED). Increased Risk of Major Complications Airway management interventions in: ICU  were  56 times  more likely to result in major complications than during anaesthesia. ED  were  36 times  more likely to result in major complications than during anaesthesia.

25. ICU Airway Management  Major Causes of Morbidity and Mortality Displaced tracheostomy tubes  were the leading cause. Displaced tracheal tubes  were a lesser but significant cause. Poor Planning for Airway Management Especially in patients: Admitted for prior airway issues. With prior airway problems on the ICU. Re-intubation Plan Needed All patients with an artificial airway should have: A clear  re-intubation plan . Appropriate equipment  readily available. Importance of Continuous Capnography Continuous capnography could have: Facilitated earlier detection of airway events or failed rescue attempts. Its absence contributed to  70% of ICU-related deaths .

26. Emergency Department Airway Management Factors Contributing to Complications Inexperienced practitioners Unfamiliar or absent equipment Poor access to skilled help Missed Oesophageal Intubations Missed due to the failure to use capnography.

27. Contributing Factors: Human factors:  Decision-making errors, miscommunication, and inadequate airway assessment. Equipment issues:  Lack of availability or inappropriate use of airway equipment. Delayed recognition:  Delays in recognizing airway difficulties or deterioration led to poor outcomes. Guideline adherence:  Failure to follow established airway management protocols was a common theme in many incidents.