Safety and Risk in Airway Management During Bariatric Air Medical Retrieval.

OBJECTIVE: Bariatric anatomy and physiology present added clinical challenges to the provision of safe critical care and patient transport. LifeFlight Retrieval Medicine provides air medical retrieval services in Queensland, Australia, and performs over 6,000 retrieval missions annually using rotary wing, fixed wing, and ground ambulance platforms. METHODS: Bariatric patient retrievals were identified from the LifeFlight Retrieval Medicine electronic patient database. These cases were interrogated to quantify and describe adverse events during patient transport. RESULTS: Over the study period from July 2019 to December 2021 11,096 patient retrievals were completed. Of these patients, 816 (7.3%) had a body weight ≥ 120 kg (range, 120-246 kg; median = 146 kg). Bariatric patients were more likely to be male (70%) and to require critical care interventions than nonbariatric patients (25.9% vs. 19.9%). There was an absolute 1.5% increase of high-interest events during patient retrieval, corresponding to a 1.9-fold increased relative risk. Five hundred eleven of 11,096 patients were intubated by the retrieval team, and 61 of these weighed ≥ 120 kg. Bariatric patients undergoing intubation were of similar age and sex, weighed significantly more, had nonsignificant trends toward poorer airway visualization by Cormack-Lehane laryngoscopic grade, and tended toward reduced first-attempt success compared with nonbariatric patients. Rates of airway adverse events (AAEs) were significantly increased for the bariatric group (30/61, 49.2%) compared with the nonbariatric group (135/450, 30.0%) (χ2 likelihood ratio, P = .004). Postintubation desaturation was the most common AAE and was the only criterion significantly increased when comparing bariatric (26%) versus nonbariatric (12%) patients (χ2 likelihood ratio, P = .005). Using patient weight as a continuous variable, nominal logistic regression revealed a significant effect of increasing weight on AAEs (χ2 = 12.9, P = .0003) with a threshold of 105 kg providing an optimal 88% sensitivity for predicting AAEs. The odds of AAEs were increased significantly for those weighing 105 to 119 kg versus those weighing < 105 kg (odds ratio [OR] = 3.4; 95% confidence interval [CI], 1.6-7.5) and for those weighing ≥ 120 kg versus those weighing < 105 kg (OR = 2.5; 95% CI, 1.4-4.3). There was no difference between those weighing ≥ 120 kg versus those weighing 105 to 119 kg (OR = 0.73; 95% CI, 0.3-1.8). CONCLUSION: Air medical retrieval of bariatric patients is safe despite an increased risk of adverse events. Strategies to optimize emergency anesthesia should be used to maximize safe intubation in bariatric patients.

Safety of pre-hospital peripheral vasopressors: The SPOTLESS study (Safety of PrehOspiTaL pEripheral vaSopreSsors).

OBJECTIVE: To assess the safety and effectiveness of peripheral vasoactive drugs initiated during pre-hospital care and retrieval missions, in Queensland, Australia. METHODS: Three years of retrospective data was gathered from two sources. Medical notes were reviewed using a search for any patient having 'inotrope' recorded on an electronic medical record. Each case was reviewed to include only peripheral infusions of adrenaline or noradrenaline. Clinical Governance records were searched for adverse events related to vasoactive drugs, alerted for review to ensure complete capture. RESULTS: A total of 418 patients received peripheral infusions of adrenaline and noradrenaline over the 3-year period. No major complications were recorded either immediately or at Clinical Governance review. Minor complications were recorded in 4.7% of the cases, of which 3.5% occurred with peripheral vasoactives during the presence of the retrieval team. The frequency of use of peripheral vasoactives increased over the study period. CONCLUSIONS: In this retrospective data set there were no major complications of peripheral vasoactive drugs. Minor complications were similar to in-hospital use and related to vascular access and drug delivery.

Rural and Remote Intubations in an Australian Air Medical Retrieval Service: A Retrospective Cohort Study.

OBJECTIVE: Critically unwell patients in rural and remote areas of Queensland, Australia, often require airway management with rapid sequence intubation before retrieval to a tertiary center. Retrieval Services Queensland coordinate retrievals and support rural hospitals, including via telehealth. This study compared the demographics of patients intubated by a retrieval team including a LifeFlight Retrieval Medicine doctor with those intubated by the local hospital team. METHODS: This was a retrospective cohort study of patients intubated in hospitals in Queensland, Australia, requiring subsequent air medical retrieval between January and December 2019. The data collected included the time of day, mission priority, geographic location, diagnosis, and failure/assistance with intubation. Descriptive statistics were complemented by regression analyses. RESULTS: In 2019, 684 patients were intubated in hospitals in Queensland, Australia, requiring air medical retrieval by a team including a LifeFlight Retrieval Medicine doctor. One hundred thirty-one (19.2%) were intubated by the retrieval team, and 553 (80.8%) were intubated by the hospital team. In the most rural and remote areas, 64 (43.2%) of the patients were intubated by the retrieval team compared with 84 (56.8%) by the hospital team. CONCLUSION: A retrieval team is more likely to intubate patients in remote hospitals in Queensland, Australia. Remote hospitals should be given preference for dispatch of the retrieval team for assistance with critical patients.

Successful endotracheal intubation following a failed first attempt during aeromedical retrieval.

INTRODUCTION: First attempt intubation success is used by many prehospital services as a marker of quality and safety. An increasing complication rate is associated with repeated intubation attempts. The aim of this study was to identify changes to intubation technique following a failed intubation attempt. METHODS: LifeFlight Retrieval Medicine provides aeromedical retrieval services in Queensland, Australia. This retrospective study identified cases of failed intubation attempts from an electronic database registry over a 41-month period from March 2015 to July 2018. These data were analysed using descriptive statistics. RESULTS: Of the 762 patients who required intubation 758 (99.5%) were successfully intubated, with 684 intubated at the first attempt (89.8%; 95% CI: 0.87 to 0.92). There was no difference in first attempt success between direct and video laryngoscopy (511/563 (90.8%) vs 172/194 (88.6%) p=0.38), trauma or medical (374/419 (89.3%) vs 310/343 (90.4%), p=0.61), primary or interhospital missions (329/370 (88.7%) vs 355/392 (90.8%), p=0.33). 78 cases of failed first attempt intubations were identified. In 65 of these cases, intubation was successful at the second attempt. A single change was made to the intubation procedure prior to a second successful attempt in 28/78 cases (35.9%), and more than one change was made in 41/78 (52.6%). The changes included the operator, intubation device, patient position, intubating aid and external laryngeal manipulation. No change between attempts was recorded in 9/78 (11.5%). 9 cases were successfully intubated at the third attempt, and changes prior to the third attempt included operator, device and intubating aid. CONCLUSION: Although a high overall intubation success was found, one in ten patients who were intubated had a failed first attempt. The majority of successful subsequent attempts were preceded by at least one change to intubating technique. Intubating clinicians need the ability to identify and correct issues leading to a failed first attempt.