Management of Difficult Tracheal Intubation

Management of Difficult Tracheal Intubation: A Closed Claims Analysis.:

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Management of Difficult Tracheal Intubation: A Closed Claims Analysis.

Anesthesiology. 2019 Oct;131(4):818-829

Authors: Joffe AM, Aziz MF, Posner KL, Duggan LV, Mincer SL, Domino KB

Abstract

WHAT WE ALREADY KNOW ABOUT THIS TOPIC: Difficult or failed intubation is a major contributor to morbidity for patients and liability for anesthesiologists.Updated difficult airway management guidelines and incorporation of new airway devices into practice may have affected patient outcomes.

WHAT THIS ARTICLE TELLS US THAT IS NEW: This article compared recent malpractice claims related to difficult tracheal intubation to historic claims using the Anesthesia Closed Claims Project database.Outcomes remained poor in recent malpractice claims related to difficult tracheal intubation. The number of claims during the induction phase of anesthesia in this report is comparable with the previous report of 1993 to 1999, but outcomes are poorer.Inadequate airway planning and judgment errors were contributors to patient harm. Almost three fourths exhibited judgment failures, which were more common in elective and urgent intubation procedures than emergency tracheal intubations.Delay in surgical airway initiation during "can't intubate, can't oxygenate" emergencies remains an issue in airway management.

BACKGROUND: Difficult or failed intubation is a major contributor to morbidity for patients and liability for anesthesiologists. Updated difficult airway management guidelines and incorporation of new airway devices into practice may have affected patient outcomes. The authors therefore compared recent malpractice claims related to difficult tracheal intubation to older claims using the Anesthesia Closed Claims Project database.

METHODS: Claims with difficult tracheal intubation as the primary damaging event occurring in the years 2000 to 2012 (n = 102) were compared to difficult tracheal intubation claims from 1993 to 1999 (n = 93). Difficult intubation claims from 2000 to 2012 were evaluated for preoperative predictors and appropriateness of airway management.

RESULTS: Patients in 2000 to 2012 difficult intubation claims were sicker (78% American Society of Anesthesiologists [ASA] Physical Status III to V; n = 78 of 102) and had more emergency procedures (37%; n = 37 of 102) compared to patients in 1993 to 1999 claims (47% ASA Physical Status III to V; n = 36 of 93; P < 0.001 and 22% emergency; n = 19 of 93; P = 0.025). More difficult tracheal intubation events occurred in nonperioperative locations in 2000 to 2012 than 1993 to 1999 (23%; n = 23 of 102 vs. 10%; n = 10 of 93; P = 0.035). Outcomes differed between time periods (P < 0.001), with a higher proportion of death in 2000 to 2012 claims (73%; n = 74 of 102 vs. 42%; n = 39 of 93 in 1993 to 1999 claims; P < 0.001 adjusted for multiple testing). In 2000 to 2012 claims, preoperative predictors of difficult tracheal intubation were present in 76% (78 of 102). In the 97 claims with sufficient information for assessment, inappropriate airway management occurred in 73% (71 of 97; κ = 0.44 to 0.66). A "can't intubate, can't oxygenate" emergency occurred in 80 claims with delayed surgical airway in more than one third (39%; n = 31 of 80).

CONCLUSIONS: Outcomes remained poor in recent malpractice claims related to difficult tracheal intubation. Inadequate airway planning and judgment errors were contributors to patient harm. Our results emphasize the need to improve both practitioner skills and systems response when difficult or failed tracheal intubation is encountered.

PMID: 31584884 [PubMed - in process]