Airway research: the current status and future directions.

We highlight the areas we think important for future development of the subspeciality. The ultimate goal is to improve patient care and safety and to do this, we need to identify how and where episodes of harm arise. Simply continuing with current practice does not represent the best path towards our ultimate goal; objective evidence is needed to inform changes in practice.

The effects of forced-air warming on postbypass central and skin temperatures and shivering activity.

STUDY OBJECTIVE: To test the hypothesis that forced-air skin-surface warming used prophylactically after hypothermic cardiopulmonary bypass (CPB) would: (1) decrease the incidence and severity of postbypass shivering, (2) rapidly increase skin-surface temperatures when compared with standard warmed cotton blankets, and (3) not contribute to excessive central temperature elevation. DESIGN: Prospective, randomized, nonblinded comparison of two rewarming techniques. SETTING: Multidisciplinary intensive care unit at a tertiary care, private teaching hospital. PATIENTS: Following hypothermic CPB, 47 patients underwent postoperative rewarming by using either conduction (warmed cotton blankets) or convection (forced-air cover) techniques. MEASUREMENTS AND MAIN RESULTS: Central and skin temperatures were measured at 30-minute intervals for 5.5 hours postoperatively. Four lead electromyographic recordings were used to objectively document shivering activity. Antihypertensives, opioids, sedatives, and muscle relaxants were administered per patient need and recorded. The forced-air cover markedly decreased the overall incidence, duration, and magnitude of significant shivering compared with the warmed cotton blankets. Forced-air therapy produced clinically significant increases in skin surface temperatures, but avoided excessive central temperature elevation when compared with passive rewarming with cotton blankets. CONCLUSION: Convection warming, when compared with conductive warming with cotton blankets, limited the incidence, magnitude, and duration of shivering following hypothermic cardiac surgery. This suggests an important role of cutaneous thermal input in the mediation of the shivering response. The central tissue compartment is buffered from the effects of skin-surface warming and, thus, forced-air therapy will not lead to excessive central temperature elevation in this patient population when compared with cotton blanket rewarming.

Unplanned tracheal extubation outside the operating room: a quality improvement audit of hemodynamic and tracheal airway complications associated with emergency tracheal reintubation.

UNLABELLED: The incidence of hemodynamic and airway complications associated with tracheal reintubation after an unplanned extubation has not been established. Patients whose tracheas were emergently intubated outside the operating room were reviewed over a 27-mo period via a quality improvement vehicle to evaluate hemodynamic and airway complications. Data from a subset of patients (n = 57) who underwent tracheal reintubation after unplanned (self-) extubation were collected for analysis. Of the reintubations, 93% took place within 2 h of self-extubation. Of the patients, 72% had hemodynamic alterations and/or airway-related complications, including hypotension (35%), tachycardia (30%), hypertension (14%), multiple laryngoscopic attempts (22%), difficult laryngoscopy (16%), difficult intubations (14%), hypoxemia (14%), and esophageal intubation (14%). In addition, one surgical airway and one case of "cannot ventilate, cannot intubate" leading to cardiac arrest and death were recorded. These findings suggest that patients requiring reintubation will likely do so soon after self-extubation and that reintubation can be fraught with significant hemodynamic and airway complications. Less than one third of patients undergo a mishap-free reintubation. Strategies to decrease the self-extubation rate in the intensive care unit are needed to improve patient safety and to lessen the potential impact of emergency airway management. IMPLICATIONS: Self-extubation by patients requiring mechanical ventilation can be life-threatening, and replacing the breathing tube often leads to hemodynamic and airway complications. Using this quality improvement audit, 57 self-extubating patients and the complications associated with replacing the breathing tube, which are numerous and can lead to significant morbidity and mortality, were analyzed.

The relationship of pre mortem diagnoses and post mortem findings in a surgical intensive care unit.

OBJECTIVE: To evaluate pre- and post mortem diagnoses and determine their relationship and the discrepancy rate. DESIGN: Retrospective, descriptive chart review. SETTING: A 36-bed surgical intensive care unit (ICU) of an academic, tertiary care center. PATIENTS: 149 adults who died in the ICU and had an post mortem examination. INTERVENTIONS: Review of the medical record for the ICU course, hospital discharge/death summary, major and minor clinical diagnoses, and the cause of death were directly compared with the major and minor diagnoses and cause(s) of death determined by post mortem examination. MEASUREMENTS AND MAIN RESULTS: Major and minor clinical diagnoses were categorized by the Goldman method and compared with post mortem findings to determine the discrepancy rate. Patients were categorized by the primary surgical service that provided medical and surgical care. Sixty-one (41%) patients had discrepancies uncovered at post mortem examination, of which 20 had two discrepancies. Twenty-three percent of the 149 patients had errors categorized as major and 18% as minor. Overall, 85% of the major errors were undiagnosed infectious processes. Complete agreement between the pre and post mortem diagnoses was present in 58% and varied with the surgical population: trauma group (86%) and cardiac surgery (69%) vs. the transplantation group (17%). Those with longer lengths of stay in the ICU were more likely to develop and, subsequently, have a major error discovered post mortem. Conversely, those who died early (<48 hrs), were less likely to have an undiagnosed disease at post mortem examination and, thus, more likely to have complete agreement between pre and post mortem findings. CONCLUSIONS: The overall discrepancy rate as well as the infectious discrepancy rate between pre mortem clinical diagnoses and post mortem findings were substantially higher in a surgical ICU compared with a hospital-wide population. The majority of these discrepancies were undiagnosed infections. The length of time spent in the ICU before death appeared to influence the rate of errors uncovered at the post mortem examination, suggesting that a longer ICU course, as well as the particular type of surgical patient population, may increase the chance of developing an infectious process, only to be uncovered at post mortem examination.