Simple steps towards improving safety in obstetric airway management: A quality improvement project.

BACKGROUND: Guidelines from the Obstetric Anaesthetists' Association and Difficult Airway Society state that 'a videolaryngoscope should be immediately available for all obstetric general anaesthetics'. OBJECTIVE: To report the incidence of videolaryngoscopy use, and other airway management safety interventions, in an obstetric population before and after various quality improvement interventions. DESIGN: Prospective data collection was undertaken over 18 months, divided into three separate 6-month periods: June to November 2019; March to August 2021; January to June 2022. These periods relate to evaluation of specific quality improvement interventions. SETTING: The project was carried out in a large tertiary referral obstetric unit. PATIENTS: We identified 401 pregnant women (> 20 weeks' gestation) and postnatal women (up to 48 h post delivery) undergoing an obstetric surgical procedure under general anaesthesia. INTERVENTIONS: To standardise practice, an intubation checklist was introduced in December 2020 and multidisciplinary staff training in August 2021. MAIN OUTCOME MEASURES: Primary outcome measures were use of a Macintosh-style videolaryngoscope and tracheal intubation success. Secondary outcome measures were use of an intubation checklist; low flow nasal oxygen; and ramped patient positioning. RESULTS: Data from 334 tracheal intubations (83.3% of cases) were recorded. Videolaryngoscope use increased from 60% in 2019, to 88% in 2021, to 94% in 2022. Tracheal intubation was successful in all patients, with 94% first pass success overall and only 0.9% requiring three attempts. Use of secondary outcome measures also increased: low flow nasal oxygen from 48% in 2019 to 90% in 2022; ramped positioning from 95% in 2021 to 97% in 2022; and checklist use from 63% in 2021 to 92% in 2022. CONCLUSIONS: We describe the successful adoption of simple safety measures introduced into routine practice. These comprised videolaryngoscopy, ramped positioning and low flow nasal oxygen. Their introduction was supported by the implementation of an intubation checklist and multidisciplinary team training.

Successful retrieval of a knotted pulmonary artery catheter trapped in the tricuspid valve apparatus.

We report the case of a 64-year-old patient in whom a pulmonary artery catheter formed a knot fixed within the right ventricle in the region of the tricuspid valve apparatus. Knot formation is a recognized complication associated with pulmonary artery catheters (PAC) insertion. This problem is usually dealt with by simply withdrawing the PAC until the knot impacts onto the introducer and after enlarging the puncture site by a small skin incision removing the introducer-PAC as one unit. However, we recently encountered a situation where the PAC was knotted around the tricuspid valve apparatus and could not be withdrawn. An interventional radiologist was able to unknot the catheter and release it from the tricuspid valve. We reviewed the literature related to this topic. We believe our experience could be of use to others.