Report of the 2022 Perfusion Perspectives of Waste Anesthetic Gas Exposure Survey.

OBJECTIVES: To describe perfusionist perspectives regarding waste anesthetic gas (WAG) management during cardiopulmonary bypass (CPB) and compare results to existing American Society of Extracorporeal Technology (AmSECT) guidelines and the 2016 National Institute of Occupational Safety and Health Survey of healthcare workers and anesthesia care providers. DESIGN: We developed a questionnaire with 26 questions covering institutional demographics, use of anesthetic gases, scavenging systems, and air monitoring practices. SETTING: Web-based survey. PARTICIPANTS: Self-identified board-eligible perfusionist members of AmSECT, the American Academy of Cardiovascular Perfusion, and the Maryland and Wisconsin State Perfusion Societies in 2022. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Of the 4,303 providers sent the survey, 365 (8.5%) participated. Although 92% of the respondents (335/364) routinely administered inhaled anesthetics via the oxygenator, only 73.2% (259/354) routinely scavenged WAG during CPB cases. Only 6.6% of the respondents (22/336) conducted environmental monitoring for WAG levels. Cited reasons for not scavenging waste gases included a lack of applicable protocols and waste gas scavenging systems, excessive cost, and no need for scavenging. CONCLUSIONS: Our findings identify a gap between AmSECT guidelines and current perfusionist behavior and suggest potential strategies for reducing WAG leakage during CPB. Effective management should incorporate hazard awareness training, availability of standard procedures to minimize exposure, scavenging systems, regular equipment inspection, and prompt attention to spills and leaks. In high-risk environments, environmental surveillance for waste gas levels would also contribute to waste gas safety. A comprehensive approach to managing waste anesthetic gases will reduce WAG leakage, help improve health care worker safety, and prevent potential adverse effects of exposure.

Tracheal intubation in critically ill adults with a physiologically difficult airway. An international Delphi study.

PURPOSE: Our study aimed to provide consensus and expert clinical practice statements related to airway management in critically ill adults with a physiologically difficult airway (PDA). METHODS: An international Steering Committee involving seven intensivists and one Delphi methodology expert was convened by the Society of Critical Care Anaesthesiologists (SOCCA) Physiologically Difficult Airway Task Force. The committee selected an international panel of 35 expert clinician-researchers with expertise in airway management in critically ill adults. A Delphi process based on an iterative approach was used to obtain the final consensus statements. RESULTS: The Delphi process included seven survey rounds. A stable consensus was achieved for 53 (87%) out of 61 statements. The experts agreed that in addition to pathophysiological conditions, physiological alterations associated with pregnancy and obesity also constitute a physiologically difficult airway. They suggested having an intubation team consisting of at least three healthcare providers including two airway operators, implementing an appropriately designed checklist, and optimizing hemodynamics prior to tracheal intubation. Similarly, the experts agreed on the head elevated laryngoscopic position, routine use of videolaryngoscopy during the first attempt, preoxygenation with non-invasive ventilation, careful mask ventilation during the apneic phase, and attention to cardiorespiratory status for post-intubation care. CONCLUSION: Using a Delphi method, agreement among a panel of international experts was reached for 53 statements providing guidance to clinicians worldwide on safe tracheal intubation practices in patients with a physiologically difficult airway to help improve patient outcomes. Well-designed studies are needed to assess the effects of these practice statements and address the remaining uncertainties.