Incidence, causes, and management of failed awake fibreoptic intubation-A retrospective study of 833 procedures.

Awake fibreoptic intubation has been considered a gold standard in the management of the difficult airway. However, failure may cause critical situations. The aim of this study was to investigate the incidence and causes of failed awake fibreoptic intubation at a tertiary care hospital. The study was conducted at St. Olav University Hospital in Trondheim, Norway. Problems occurring during anaesthesia are routinely recorded in the electronic anaesthesia information system (Picis Clinical Solutions Inc.), including difficult intubations. We applied text search on all anaesthesia records between 2011 and 2021 and identified 833 awake fibreoptic intubations. The anaesthesia records were examined to identify failed awake fibreoptic intubations, the cause of failure and how the airway ultimately was secured. Among 233,938 patients who received anaesthesia, 90,397 received tracheal intubation and 833 received awake fibreoptic intubation. Twenty-nine of the procedures failed. In nine patients the failure caused loss of airway control with desaturation and hypoventilation. The major causes of failure were dislodged tube after induction of general anaesthesia (n = 8), patient distress (n = 5), tube not able to pass (n = 5), and airway bleeding (n = 3). The situations were primarily solved using direct laryngoscopy, with or without bougie, or with video laryngoscopy. Tracheostomy was performed in four patients. Awake fibreoptic intubation failed in 3.5% of patients, most often due to dislocation, problems passing the tracheal tube, or patient discomfort. The failure rate was higher than in previous studies.

Pediatric hypothermic submersion incident - should we do chest compressions on a beating heart?

BACKGROUND: Drowning is the third leading cause of unintentional injury death worldwide, with the highest rates of fatality among young children. To decide how to treat these patients prehospitally could be challenging in certain situations when uncertain about the adequacy of the patent's circulation. METHODS/CASE REPORT: We describe a 2 year old boy surviving a 15 min hypothermic submersion in a cold river. In spite of the presence of some vital signs, we decided to do full cardiopulmonary resuscitation to the hospital. The main reason was that we were uncertain about the adequacy of the spontaneous circulation, and the transport to hospital was fairly long. The patient suffered no obvious harm and the outcome was good. DISCUSSION: What is regarded as adequate circulation when accidentally hypothermic between 24 and 250 C? A weak pulse was felt in the femoral artery with a rate of about 40-50 per minute. There were shallow, but regular respiration, and point of care ultrasound revealed a slightly dilated left ventricle and weak, but organised cardiac contractions. Despite these findings a decision was made to continue ventilations and chest compressions during helicopter transport to the University hospital. CONCLUSION: In an accidentally hypothermic pediatric submersion incident we decided to do full cardiopulmonary resuscitation to the hospital despite there were signs of circulation. We did no harm to the patient. Future guideline revisions should try to clarify how to handle situations with severly accidentally hypothermic patients like this, so the good outcome that is often seen in these patients could be even better.

How do we know that we are doing a good job - can we measure the quality of our work?

There is an increasing demand for systems for measuring the quality of our medical work. In this article, we present a suggestion for how one can attempt to do this in a department of anaesthesia. It would be desirable to measure real clinical outcomes such as morbidity and mortality. However, such events are rare and not suitable for routine recording of work quality. Instead, we propose a system based on indicators of process quality and surrogate clinical outcomes. Surrogates may provide useful information if chosen carefully and checked for validity. We further suggest that such indicators be recorded routinely on every anaesthesia chart. The rate of the indicator can then be followed over time with the use of statistical process control methods. The foundation for such a system for measuring quality is the presence of a good quality culture in the department, with a good team spirit, communication and cooperation.

[Emergency in-hospital anaesthesia assistance]. / Anestesiologisk akutthjelp i sykehus.

BACKGROUND: Anesthesiologists and nurse anaesthesists have important roles in the management of in-hospital medical emergencies, and in trauma management. We investigated the extent of these services provided by the department of anaesthesiology at St. Olav University Hospital in Trondheim in the year 2002. MATERIAL AND METHODS: Missions involving emergency medical assistance were identified by a computer search in the department's database. We assessed medical aspects, place, time, and type of intervention. RESULTS: We identified a total of 646 missions, of which 501 occurred in the emergency department and 145 on the general wards. The majority (64%) occurred during on-call hours (4 pm-8 am). We found that as many as 4 to 7 missions occurred on any single day 40 times (i.e. days) during the year; which fits in with a Poisson statistical model. Trauma (50 %) and cardiac arrest (20%) dominated the material. Other medical emergencies included seizures, cerebrovascular events, intoxication, respiratory arrest, cardiac arrhythmias, internal bleeding, pulmonary oedema and loss of consciousness. Airway management was important, as 61 patients received bag-valve-mask ventilation and 164 were intubated and ventilated. INTERPRETATION: Staffing of anaesthesiology departments must take into account the possibility of sudden medical emergencies.