Embed Size (px)
Citation preview
Pr Olivier Langeron
Département d ’Anesthésie-Réanimation Unité de Surveillance Post-Interventionnelle et
d’Accueil des Polytraumatisés Hôpital de la Pitié-Salpêtrière - Paris
Gestion des voies aériennes en urgence
Conflits d’intérêt
Ambu Cook Medical
Teleflex
Ges$on des voies aériennes en urgence
o Est-‐ce plus difficile ?
o La préoxygénaBon, quels enjeux ?
o Quelle(s) stratégie(s), quelle(s) technique(s) ?
ComplicaBons de l’intubaBon trachéale hors bloc opératoire
Schwartz DE et al. Anesthesiology 1995
Programmé (bloc) : IDS > 5 : 6% vs
Urgence (préhospitalier) : IDS > 5 : 16%
L’urgence accroît la difficulté de l’intubaBon
trachéale
SPECIAL ARTICLES
Major complications of airway management in the UK: resultsof the Fourth National Audit Project of the Royal College ofAnaesthetists and the Difficult Airway Society. Part 1:Anaesthesia†
T. M. Cook 1*, N. Woodall 2 and C. Frerk 3, on behalf of the Fourth National Audit Project1 Department of Anaesthesia, Royal United Hospital, Combe Park, Bath BA1 3NG, UK2 Department of Anaesthesia, Norfolk and Norwich University NHS Foundation Trust, UK3 Department of Anaesthesia, Northampton General Hospital, Northampton, UK
* Corresponding author. E-mail: [email protected]
Background. This project was devised to estimate the incidence of major complications of airway management duringanaesthesia in the UK and to study these events.
Methods. Reports of major airway management complications during anaesthesia (death, brain damage, emergency surgicalairway, unanticipated intensive care unit admission) were collected from all National Health Service hospitals for 1 yr. Anexpert panel assessed inclusion criteria, outcome, and airway management. A matched concurrent census estimated adenominator of 2.9 million general anaesthetics annually.
Results. Of 184 reports meeting inclusion criteria, 133 related to general anaesthesia: 46 events per million general anaesthetics[95% confidence interval (CI) 38–54] or one per 22 000 (95% CI 1 per 26–18 000). Anaesthesia events led to 16 deaths andthree episodes of persistent brain damage: a mortality rate of 5.6 per million general anaesthetics (95% CI 2.8–8.3): one per180 000 (95% CI 1 per 352–120 000). These estimates assume that all such cases were captured. Rates of death and braindamage for different airway devices (facemask, supraglottic airway, tracheal tube) varied little. Airway management wasconsidered good in 19% of assessable anaesthesia cases. Elements of care were judged poor in three-quarters: in only threedeaths was airway management considered exclusively good.
Conclusions. Although these data suggest the incidence of death and brain damage from airway management during generalanaesthesia is low, statistical analysis of the distribution of reports suggests as few as 25% of relevant incidents may have beenreported. It therefore provides an indication of the lower limit for incidence of such complications. The review of airwaymanagement indicates that in a majority of cases, there is ‘room for improvement’.
Keywords: airway; audit; brain damage; complications; cricothyroidotomy; death; emergency department; intensive care,tracheostomy
Accepted for publication: 15 February 2011
Airway management is fundamental to safe anaestheticpractice and in most circumstances is uncomplicated, but ithas been recognized for many years that complications ofairway management occur with serious consequences.1 2
Good-quality information on the frequency and nature ofmajor adverse events related to anaesthetic airway manage-ment is incomplete. Litigation-based analyses add someinsight into the severity of such events and have drivenchanges in practice.3 – 6 These indicate that airway and respir-atory complications leading to litigation are a smallproportion of all claims against anaesthetists but are associ-ated with notably high rates of death and brain damage,high rates of ‘less than appropriate care’, and high costs.
Owing to the complexity of the relationship between compli-cations and litigation, and the lack of denominators, they donot add information about prevalence or incidence of com-plications.7 8 Analyses of critical incident reports in the UKhave also added useful information, but these reportslargely focus on minor incidents and are likely to miss a con-siderable proportion of major events.9
Knowledge of the incidence of such complications shouldbe an important component of clinical decision-making, riskmanagement, and the consent processes. Information onserious and common complications should guide the specialtyinto appropriate areas for research by demonstrating areas inwhich our current practice or performance can improve.
† This article is accompanied by the Editorial.
British Journal of Anaesthesia 106 (5): 617–31 (2011)Advance Access publication 29 March 2011 . doi:10.1093/bja/aer058
& The Author [2011]. Published by Oxford University Press on behalf of the British Journal of Anaesthesia. All rights reserved.For Permissions, please email: [email protected]
at REDAR on July 19, 2013http://bja.oxfordjournals.org/
Downloaded from
complicated another primary event: eight of these patientsdied and two suffered brain damage.
Primary airway problem during anaesthesia
Problems with tracheal intubation were the most frequentlyrecorded primary airway problem (Fig. 1). Difficult ordelayed intubation, failed intubation, and ‘can’t intubatecan’t ventilate’ (CICV) accounted for 39% of all events andevents during anaesthesia. Aspiration then extubation pro-blems followed tracheal intubation in frequency of reportedcomplications. For anaesthesia events, aspiration, CICV, andproblems during use of a supraglottic airway, iatrogenicairway trauma, and failed mask ventilation were the nextmost prominent complications.
Primary airway device during anaesthesia
For anaesthesia events, the airway in use or intended formaintenance was: tracheal tube of any sort (91), supraglotticairway device (35), and facemask (7) (Table 6).
Incidence of incidents
The total number of events reported in relation to anaes-thesia was 133. The number of anaesthetics administeredin the same period derived from the census phase ofNAP4 was 2.9 million (2 872 600),12 giving a minimum inci-dence (point estimate) of 133/2 872 600: i.e. 46 per millionor approximately one per 22 000 general anaesthetics.Using binomial statistics, we can estimate an upper 95%confidence limit of 54 per million and a lower CI of 38per million (although as the actual event rate in our
population cannot be lower than that we observed, somemight omit this value).
Using the same methodology, we can calculate the pointestimate and CIs for incidence of death (or death and braindamage) from an airway event during general anaesthesia(Table 7). The census data also provided estimates of fre-quency of use of airway devices (tracheal tube, supraglotticairway device, and facemask) and estimates of the risk ofevents and poor outcomes with these devices can bederived (Table 7).
Case-mix
Aspiration of gastric contents
Aspiration of gastric contents was the primary event in 23anaesthesia cases, two emergency department cases, andno ICU cases. It was the most common cause of death inthe anaesthesia group accounting for eight deaths and twocases of brain damage. Aspiration occurred most frequentlyin patients with risk factors (.90%), at induction of anaes-thesia or during airway instrumentation (61%). Plannedairway management was as follows: laryngeal mask 13,i-gel 1, tracheal tube 8, and none 1. Aspiration occurredbefore airway instrumentation in five cases and duringairway placement in two. Two cases had clear indicationsfor rapid sequence induction (RSI) and in several others, itsuse could be argued, one case occurred during RSI laryngo-scopy. Management of the cases was judged good in four,mixed in seven, and poor in eight, with managementjudged poor in four deaths. Aspiration also complicated
0 10 20 30 40
Failed intubation
Aspiration of gastric contents
Extubation related problems
Difficult or delayed intubation
CICV—(can't intubate can't ventilate)
LMA or supraglottic airway related problem
Iatrogenic airway trauma
Tracheostomy related problems
Failed mask ventilation
Tracheal tube misplacement
Obstruction of tracheal tube or circuit
Other
All cases
Anaesthesia
Fig 1 Primary airway problem
Major complications of airway management in the UK BJA
623
at RE
DA
R on July 19, 2013
http://bja.oxfordjournals.org/D
ownloaded from
National Institute for Health and Clinical Excellence (NICE) Audit pendant 1 an 2,9 millions d’AG
184 évènements (ICU+ED/anesthésie) : 28%(72%) des évènements, 54 % (14%) de la mortalité
Emergency Tracheal Intubation: Complications Associatedwith Repeated Laryngoscopic AttemptsThomas C. Mort, MD
Department of Anesthesiology, Hartford Hospital, University of Connecticut School of Medicine
Repeated conventional tracheal intubation attemptsmay contribute to patient morbidity. Critically-ill pa-tients (n ! 2833) suffering from cardiovascular, pulmo-nary, metabolic, neurologic, or trauma-related deterio-ration were entered into an emergency intubationquality improvement database. This practice analysiswas evaluated for airway and hemodynamic-relatedcomplications based on a set of defined variables thatwere correlated to the number of attempts required tosuccessfully intubate the trachea outside the operatingroom. There was a significant increase in the rate ofairway-related complications as the number of laryngo-scopic attempts increased (!2 versus "2 attempts): hy-poxemia (11.8% versus 70%), regurgitation of gastric
contents (1.9% versus 22%), aspiration of gastric con-tents (0.8% versus 13%) bradycardia (1.6% versus 21%),and cardiac arrest (0.7% versus 11%; P # 0.001). Al-though predictable, this analysis provides data thatconfirm the number of laryngoscopic attempts is asso-ciated with the incidence of airway and hemodynamicadverse events. These data support the recommenda-tion of the ASA Task Force on the Management of theDifficult Airway to limit laryngoscopic attempts tothree in lieu of the considerable patient injury that mayoccur.
(Anesth Analg 2004;99:607–13)
Emergency airway management can be fraughtwith complications related to hemodynamic al-terations and difficulty with oxygenation and
ventilation (1,2). Esophageal intubation, pneumo-thorax, and pulmonary aspiration, as well as othermajor complications, were reported by Schwartz etal. (1) to occur relatively frequently during emer-gency tracheal intubation outside of the operatingroom (OR). However, the severity and frequency ofcomplications were not correlated with the numberof intubation attempts. Another anesthesia-basedstudy of emergency intubation reported that 1 in 10airway encounters required 3 or more intubationattempts and suggested that multiple attempts wereassociated with an increased incidence of hypox-emia, regurgitation, and esophageal intubation (2).Our emergency department (ED) colleagues havepublished many studies, but none has quantified anassociation of increasing complications with repeti-tive laryngoscopic attempts (3– 8). The ASA TaskForce on the Management of the Difficult Airway
has made a recommendation, based on the consult-ant’s consensus opinion, that an alternative methodshould be pursued to secure the airway when diffi-culty with intubation is encountered (9,10). As dif-ficulty arises with securing the airway and the num-ber of laryngoscopic attempts increases, theoccurrence of hypoxemia, esophageal intubation, re-gurgitation, airway trauma, and cardiac arrestshould be more common (11–15). Despite the con-sequences of repetitive conventional intubation at-tempts, there is little published evidence directlysupporting the ASA’s recommendation to limit con-ventional intubation attempts to three (multiple)with subsequent use of accessory airway devices oralternative techniques (tracheal tube introducer[bougie], laryngeal mask airway (Laryngeal MaskCompany, Henley-on-Thames, UK), Combitube®,[Kendall-Sheridan, Argyle, NY] fiberoptic bron-choscopy, and cricothyrotomy/tracheotomy). Thisquality improvement database was analyzed: (a) todetermine the incidence of airway and hemody-namic complications during emergency tracheal in-tubation outside the OR based on a predeterminedset of defined criteria and (b) to determine if there isany relationship between the number of conven-tional intubation attempts and the incidence ofcomplications.
Accepted for publication February 3, 2004.Address correspondence and reprint requests to Thomas C. Mort,
MD, Senior Associate, Anesthesiology, Hartford Hospital, 80Seymour Street, Hartford, CT 06102. Address e-mail to [email protected].
DOI: 10.1213/01.ANE.0000122825.04923.15
©2004 by the International Anesthesia Research Society0003-2999/04 Anesth Analg 2004;99:607–13 607
Emergency Tracheal Intubation: Complications Associatedwith Repeated Laryngoscopic AttemptsThomas C. Mort, MD
Department of Anesthesiology, Hartford Hospital, University of Connecticut School of Medicine
Repeated conventional tracheal intubation attemptsmay contribute to patient morbidity. Critically-ill pa-tients (n ! 2833) suffering from cardiovascular, pulmo-nary, metabolic, neurologic, or trauma-related deterio-ration were entered into an emergency intubationquality improvement database. This practice analysiswas evaluated for airway and hemodynamic-relatedcomplications based on a set of defined variables thatwere correlated to the number of attempts required tosuccessfully intubate the trachea outside the operatingroom. There was a significant increase in the rate ofairway-related complications as the number of laryngo-scopic attempts increased (!2 versus "2 attempts): hy-poxemia (11.8% versus 70%), regurgitation of gastric
contents (1.9% versus 22%), aspiration of gastric con-tents (0.8% versus 13%) bradycardia (1.6% versus 21%),and cardiac arrest (0.7% versus 11%; P # 0.001). Al-though predictable, this analysis provides data thatconfirm the number of laryngoscopic attempts is asso-ciated with the incidence of airway and hemodynamicadverse events. These data support the recommenda-tion of the ASA Task Force on the Management of theDifficult Airway to limit laryngoscopic attempts tothree in lieu of the considerable patient injury that mayoccur.
(Anesth Analg 2004;99:607–13)
Emergency airway management can be fraughtwith complications related to hemodynamic al-terations and difficulty with oxygenation and
ventilation (1,2). Esophageal intubation, pneumo-thorax, and pulmonary aspiration, as well as othermajor complications, were reported by Schwartz etal. (1) to occur relatively frequently during emer-gency tracheal intubation outside of the operatingroom (OR). However, the severity and frequency ofcomplications were not correlated with the numberof intubation attempts. Another anesthesia-basedstudy of emergency intubation reported that 1 in 10airway encounters required 3 or more intubationattempts and suggested that multiple attempts wereassociated with an increased incidence of hypox-emia, regurgitation, and esophageal intubation (2).Our emergency department (ED) colleagues havepublished many studies, but none has quantified anassociation of increasing complications with repeti-tive laryngoscopic attempts (3– 8). The ASA TaskForce on the Management of the Difficult Airway
has made a recommendation, based on the consult-ant’s consensus opinion, that an alternative methodshould be pursued to secure the airway when diffi-culty with intubation is encountered (9,10). As dif-ficulty arises with securing the airway and the num-ber of laryngoscopic attempts increases, theoccurrence of hypoxemia, esophageal intubation, re-gurgitation, airway trauma, and cardiac arrestshould be more common (11–15). Despite the con-sequences of repetitive conventional intubation at-tempts, there is little published evidence directlysupporting the ASA’s recommendation to limit con-ventional intubation attempts to three (multiple)with subsequent use of accessory airway devices oralternative techniques (tracheal tube introducer[bougie], laryngeal mask airway (Laryngeal MaskCompany, Henley-on-Thames, UK), Combitube®,[Kendall-Sheridan, Argyle, NY] fiberoptic bron-choscopy, and cricothyrotomy/tracheotomy). Thisquality improvement database was analyzed: (a) todetermine the incidence of airway and hemody-namic complications during emergency tracheal in-tubation outside the OR based on a predeterminedset of defined criteria and (b) to determine if there isany relationship between the number of conven-tional intubation attempts and the incidence ofcomplications.
Accepted for publication February 3, 2004.Address correspondence and reprint requests to Thomas C. Mort,
MD, Senior Associate, Anesthesiology, Hartford Hospital, 80Seymour Street, Hartford, CT 06102. Address e-mail to [email protected].
DOI: 10.1213/01.ANE.0000122825.04923.15
©2004 by the International Anesthesia Research Society0003-2999/04 Anesth Analg 2004;99:607–13 607
Augmentation des complications en fonction du nombre de tentatives d’intubation trachéale
SPECIAL ARTICLE
The difficult airway with recommendations for management –Part 1 – Difficult tracheal intubation encounteredin an unconscious/induced patient
Prise en charge des voies aeriennes – 1re partie –Recommandations lorsque des difficultes sont constatees chez lepatient inconscient/anesthesie
J. Adam Law, MD • Natasha Broemling, MD • Richard M. Cooper, MD • Pierre Drolet, MD •
Laura V. Duggan, MD • Donald E. Griesdale, MD • Orlando R. Hung, MD •
Philip M. Jones, MD • George Kovacs, MD • Simon Massey, MBBCh • Ian R. Morris, MD •
Timothy Mullen, MD • Michael F. Murphy, MD • Roanne Preston, MD • Viren N. Naik, MD •
Jeanette Scott, MBChB • Shean Stacey, MD • Timothy P. Turkstra, MD • David T. Wong, MD •
for the Canadian Airway Focus Group
Received: 28 February 2013 / Accepted: 13 August 2013! The Author(s) 2013. This article is published with open access at Springerlink.com
AbstractBackground Previously active in the mid-1990s, the
Canadian Airway Focus Group (CAFG) studied theunanticipated difficult airway and made recommendations
on management in a 1998 publication. The CAFG has
since reconvened to examine more recent scientificliterature on airway management. The Focus Group’s
mandate for this article was to arrive at updated practice
recommendations for management of the unconscious/induced patient in whom difficult or failed tracheal
intubation is encountered.
Methods Nineteen clinicians with backgrounds inanesthesia, emergency medicine, and intensive care
joined this iteration of the CAFG. Each member was
assigned topics and conducted reviews of Medline,EMBASE, and Cochrane databases. Results were
presented and discussed during multiple teleconferences
and two face-to-face meetings. When appropriate,
evidence- or consensus-based recommendations were
made together with assigned levels of evidence modelled
after previously published criteria.Conclusions The clinician must be aware of the potential
for harm to the patient that can occur with multiple
attempts at tracheal intubation. This likelihood can beminimized by moving early from an unsuccessful primary
intubation technique to an alternative ‘‘Plan B’’ technique
if oxygenation by face mask or ventilation using asupraglottic device is non-problematic. Irrespective of the
technique(s) used, failure to achieve successful tracheal
intubation in a maximum of three attempts defines failedtracheal intubation and signals the need to engage an exit
strategy. Failure to oxygenate by face mask or supraglottic
device ventilation occurring in conjunction with failedtracheal intubation defines a failed oxygenation, ‘‘cannot
intubate, cannot oxygenate’’ situation. Cricothyrotomy
must then be undertaken without delay, although if notalready tried, an expedited and concurrent attempt can be
made to place a supraglottic device.
ResumeContexte Actif au milieu des annees 1990, le Canadian
Airway Focus Group (CAFG), un groupe dedie a l’etudedes difficultes imprevues dans la prise en charge des voies
aeriennes, a emis des recommandations sur ce sujet dans
une publication datant de 1998. Le CAFG s’est reuni anouveau pour passer en revue la litterature scientifique
(Please see Appendix 2 for authors’ affiliations, attributions, anddisclosures).
This article is accompanied by an editorial. Please see Can J Anesth2013; 60: this issue.
J. A. Law, MD (&)Department of Anesthesia, Queen Elizabeth II Health SciencesCentre, Dalhousie University, Halifax Infirmary Site, 1796Summer Street, Halifax, NS B3H 3A7, Canadae-mail: [email protected]
123
Can J Anesth/J Can Anesth
DOI 10.1007/s12630-013-0019-3
recente concernant la prise en charge des voies aeriennes.
Dans cet article, le CAFG s’est donne pour mission
d’emettre des recommandations visant la prise en chargedu patient inconscient ou anesthesie qui presente des
difficultes d’intubation significatives.
Methode Dix-neuf cliniciens ayant une formation enanesthesie, en medecine d’urgence ou en soins intensifs
composent le CAFG actuel. Les participants ont passe en
revue des sujets precis en consultant les bases de donneesMedline, EMBASE et Cochrane. Les resultats de ces revues
ont ete presentes et discutes dans le cadre de teleconferences
et de deux reunions en personne. Lorsqu’indique, desrecommandations fondees sur des donnees probantes ou
sur un consensus ont ete emises. Le niveau de confiance
attribue a ces recommandations a aussi ete defini.Conclusion Le clinicien doit avoir conscience des lesions
qu’il peut infliger lors de tentatives multiples d’intubation
tracheale. Il est possible d’eviter de telles lesions enabandonnant rapidement une technique d’intubation
infructueuse afin d’opter pour une methode alternative
(ou ‘plan B’) a condition que l’oxygenation par masquefacial ou par l’utilisation d’un dispositif supraglottique
s’avere possible. Nonobstant la ou les techniques choisies,
un maximum de trois tentatives infructueuses mene a laconclusion qu’il s’agit d’un echec d’intubation et devrait
inciter le clinicien a adopter une strategie de retrait. Une
situation dans laquelle il est impossible de proceder al’oxygenation du patient a l’aide d’un masque facial, d’un
dispositif supraglottique ou de l’intubation endotracheale
est qualifiee de scenario cannot intubate, cannot ventilate.Il est alors imperatif de proceder sans delai a une
cricothyrotomie, a moins que l’insertion d’un dispositif
supraglottique n’ait ete tentee. Celle-ci peut alors etreeffectuee rapidement et parallelement a la realisation de la
cricothyrotomie.
What other statements of recommendation areavailable on this topic?
In 1998, Canadian recommendations were published onmanagement of the unanticipated difficult airway. More
recent national recommendations and guidelines on
difficult airway management have been published in theUSA, the United Kingdom, and other western European
countries.
Why were these recommendations developed?
Canadian recommendations were overdue for an update.
Since the last review, many new devices useful in difficult
airway management have been introduced. In addition,
the Anesthesia Closed Claims Project and other
observational studies have highlighted potential areas forimprovement in management of the difficult and failed
airway.
How do these statements differ from existingrecommendations?These statements reflect current evidence and thinking on
an appropriate response to difficult airway managementencountered in the unconscious/induced patient. The
importance of engaging an exit strategy after a limited
number of attempts at tracheal intubation is emphasized, asis a simplified response to a failed oxygenation, ‘‘cannot
intubate, cannot oxygenate’’ situation.
Why do these statements differ from existingrecommendations?These statements differ from existing recommendations in
order to simplify decision-making when failed trachealintubation or failed oxygenation is encountered in the
unconscious/induced patient.
Contents
MethodsDefinitionsIncidence and scope of the problemManagement of the difficult and failed airway in theunconscious/induced patient
The primary approach to tracheal intubation: ‘‘Plan A’’RESPONSE TO DIFFICULTY ENCOUNTERED IN THE
UNCONSCIOUS PATIENT
UNSUCCESSFUL PRIMARY APPROACH TO TRACHEAL
INTUBATION
The alternative approach to tracheal intubation:‘‘Plan B’’ in the adequately oxygenated patient
Failed tracheal intubation in the adequately
oxygenated patientLIMITS TO ATTEMPTS AT TRACHEAL INTUBATION
FAILED INTUBATION: EXIT STRATEGIES
Failed oxygenation: the emergency strategyTracheal intubation confirmationThe obstetric airway: special considerationsThe pediatric airway: special considerationsDocumentation following an encounter with adifficult airwayEducation in the management of a difficult airwaySummary of recommendationsReferencesAppendices
J. A. Law et al.
123
Signes prédictifs d’une intubation difficile chez l’adulte SFAR 2006
" Antécédents d’ID +++++
" Critères recommandés (grade C)
Classe de MallampaB >II
DTM <65mm
Ouverture de bouche <35mm
" Critères conseillés (grade E)
Mobilité mandibulaire (morsure de lèvre sup)
Mobilité rachis cervical (extension max-‐flexion max >90°)
" Autres critères à rechercher selon le contexte
IMC>35kg/m2
SAOS avec périmètre cou >45,6cm
Pathologie cervico-‐faciale
État pré éclampBque
PrédicBon de l’ID en situaBon d’urgence
Essen$ellement liée au contexte : TraumaBsme facial ou cervical +++
Brûlure +++
Hémoptysie
Epiglohte, corps étranger des VAS
Difficultés d’environnement (incarcéraBon …)
Ges$on des voies aériennes en urgence
o Est-‐ce plus difficile ?
o La préoxygénaBon, quels enjeux ?
o Quelle(s) stratégie(s), quelle(s) technique(s) ?
OUI
12
AG et conséquences sur les échanges gazeux
Avant l’induction
Après l’induction
Rothen HU, Sporre B, Engberg G, Wegenius G, Hedenstierna G. Airway closure, atelectasis and gas exchange during general anaesthesia. Br J Anaesth 1998;81:681-6
Modèle tricompartimental
Anesthésie et échanges gazeux
Facteurs de risque de désaturaBon pendant l’intubaBon
o IntubaBon en urgence avec ISR o Difficulté de venBlaBon au masque prévisible o IntubaBon présumée difficile o Obésité et grossesse o Enfant
• <1an • ASA classe 3 ou 4 • Syndrome apnée du sommeil • InfecBon des VAS
o Sujet âgé o Broncho-‐pneumopathie obstrucBve
Stocks en O2 (en ml)
Compar4ments FiO2 = 0,21 FiO2 = 1 Poumons 630 2850 Sang : Plasma 7 45 Globules 798 804
Myoglobine 200 200 Tissu inters44el 25 160 Total des réserves 1650 4059 dont mobilisables 1425 3699 x 2,6
Qui préoxygéner ?
Tous les paBents et plus parBculièrement:
" ID ou VMD prévus (grade C)
" Dans cadre de l’urgence (grade E)
" PaBents avec risque de désaturaBon pendant
l’intubaBon (grade E)
Comment réaliser une préoxygénaBon ?
o Les manœuvres de préoxygénaBon doivent être réalisées rigoureusement (grade D)
• Étanchéité du masque ( FiO2) • Débit adéquat gaz • Ballon capacité adaptée
o Surveillance par monitorage de la FeO2 est recommandée en anesthésie (grade E)
o Monitorage SpO2 est recommandé (grade E)
Variations SpO2 pendant la préoxygenation et l’intubation tracheale
Valeurs Minimales de SpO2 enregistrées lors de l’IT
C Baillard et al. American Journal of Respiratory and Critical Care Medicine 2006, 174 : 171-177
VS 15l/min vs PSV 7-10ml/kg
Ges$on des voies aériennes en urgence
o Est-‐ce plus difficile ?
o La préoxygénaBon, quels enjeux ?
o Quelle(s) stratégie(s), quelle(s) technique(s) ?
OUI
Capitaux
Critères de choix d’une technique
o Situa4on clinique
o L’expérience de l’opérateur
o Rapidité de la réalisa4on de la technique
o Pourcentage aWendu de réussite de la technique
o Caractère invasif de la technique
Choix des lames
Lame métallique réuBlisable: démonstraBon d’une meilleure efficacité par rapport aux lames plasBques jetables en situaBon d’urgence
Augmentation du risque d’échec avec les lames plastiques 17 vs. 3%; P < 0.01
Choix des lames
Sellick, Lancet, 1961
Manœuvre de Sellick
Manœuvre de Sellick
Contre indicaBons Vomissements Lésions du rachis cervical
Efficacité non établie
NS
CRITICAL CARE MEDICINE
Unanticipated Difficult Airway Management in thePrehospital Emergency Setting
Prospective Validation of an Algorithm
Xavier Combes, M.D.,* Patricia Jabre, M.D., Ph.D.,† Alain Margenet, M.D.,* Jean Claude Merle, M.D.,*Bertrand Leroux, M.D.,* Michel Dru, M.D.,* Eric Lecarpentier, M.D.,‡ Gilles Dhonneur, M.D., Ph.D.§
ABSTRACT
Background: Difficult intubation management algorithmshave proven efficacy in operating rooms but have rarely beenassessed in a prehospital emergency setting. We undertook aprospective evaluation of a simple prehospital difficult intu-bation algorithm.Methods: All of our prehospital emergency physicians andnurse anesthetists were asked to adhere to a simple algorithmin all cases of impossible laryngoscope-assisted tracheal intu-bation. They received a short refresher course and training inthe use of the gum elastic bougie (GEB) and the intubatinglaryngeal mask airway (ILMA), which were techniques to beused as a first and a second step, respectively. In cases ofdifficult ventilation with arterial desaturation, IMLA was tobe used first. Cricothyroidotomy was the ultimate rescuetechnique when ventilation through ILMA failed. Patientcharacteristics, adherence to the algorithm, management ef-ficacy, and early complications were recorded (August 2005–December 2009).
Results: An alternative technique to secure the airway wasneeded in 160 of 2,674 (6%) patients undergoing intuba-tion. Three instances of nonadherence to the algorithm wererecorded. GEB was used first in 152 patients and was suc-cessful in 115. ILMA was used first in 8 patients and secondin the 37 GEB-assisted intubation failures. Forty-five pa-tients were successfully mask-ventilated, and 42 were blindlyintubated before reaching the hospital. Cricothyroidotomywas used successfully in a patient with severe upper airwayobstruction as a result of pharyngeal neoplasia. Early intuba-tion-related complications occurred in 52% difficult cases.Conclusion: Adherence to a simple algorithm using GEB,ILMA, and cricothyroidotomy solved all difficult intubationcases occurring in a prehospital emergency setting.
U NANTICIPATED difficult intubation is a com-mon, potentially life-threatening problem in several
settings (operating room, intensive care unit, and prehos-pital). Several experts and national anesthesiology societ-ies have proposed algorithms using different techniques
* Anesthesiologist, CHU H. Mondor (AP-HP), Creteil, France,† Emergency Physician, Centre de Recherche Cardiovasculaire deParis, France, and Department of Health Sciences Research, MayoClinic, Rochester, Minnesota, ‡ Emergency Physician, CHU H. Mon-dor (AP-HP), § Professor and Head, Department of Anesthesia andIntensive Care Medicine, CHU Jean Verdier (AP-HP), Bondy,France.
Received from Hopital Henri Mondor, Creteil cedex, France.Submitted for publication April 1, 2010. Accepted for publicationSeptember 1, 2010. Support was provided solely from institutionaland/or departmental sources. This work was carried out in theServices de Medecine d’Urgence et de Reanimation (SMUR) ofHenri-Mondor University Hospital, Creteil, France.
Address correspondence to Dr. Combes: SAMU 94, HopitalHenri Mondor, 51 Avenue du Marechal de Lattre-de-Tassigny, 94010Creteil cedex, France. [email protected]. Information onpurchasing reprints may be found at www.anesthesiology.org or onthe masthead page at the beginning of this issue. ANESTHESIOLOGY’sarticles are made freely accessible to all readers, for personal useonly, 6 months from the cover date of the issue.
Copyright © 2010, the American Society of Anesthesiologists, Inc. LippincottWilliams & Wilkins. Anesthesiology 2011; 114: 105–10
What We Already Know about This Topic
• Airway management in the emergency prehospital setting isoften more difficult than that in the operating room
What This Article Tells Us That Is New
• In more than 2,500 patients in a single emergency unit, asimple airway algorithm using gum elastic bougie, intubatinglaryngeal mask airway, and cricothyroidotomy was uniformlyadopted (adherence 98%) and successfully managed 160 dif-ficulty airway situations encountered
! This article is accompanied by two Editorial Views. Pleasesee: Schmidt U, Eikermann M: Organizational aspects of dif-ficult airway management: Think globally, act locally. ANESTHE-SIOLOGY 2011; 114:3–6; Isono S, Ishikawa T: Oxygenation,not intubation, does matter. ANESTHESIOLOGY 2011; 114:7–9.
Anesthesiology, V 114 • No 1 January 2011105
CRITICAL CARE MEDICINE
Unanticipated Difficult Airway Management in thePrehospital Emergency Setting
Prospective Validation of an Algorithm
Xavier Combes, M.D.,* Patricia Jabre, M.D., Ph.D.,† Alain Margenet, M.D.,* Jean Claude Merle, M.D.,*Bertrand Leroux, M.D.,* Michel Dru, M.D.,* Eric Lecarpentier, M.D.,‡ Gilles Dhonneur, M.D., Ph.D.§
ABSTRACT
Background: Difficult intubation management algorithmshave proven efficacy in operating rooms but have rarely beenassessed in a prehospital emergency setting. We undertook aprospective evaluation of a simple prehospital difficult intu-bation algorithm.Methods: All of our prehospital emergency physicians andnurse anesthetists were asked to adhere to a simple algorithmin all cases of impossible laryngoscope-assisted tracheal intu-bation. They received a short refresher course and training inthe use of the gum elastic bougie (GEB) and the intubatinglaryngeal mask airway (ILMA), which were techniques to beused as a first and a second step, respectively. In cases ofdifficult ventilation with arterial desaturation, IMLA was tobe used first. Cricothyroidotomy was the ultimate rescuetechnique when ventilation through ILMA failed. Patientcharacteristics, adherence to the algorithm, management ef-ficacy, and early complications were recorded (August 2005–December 2009).
Results: An alternative technique to secure the airway wasneeded in 160 of 2,674 (6%) patients undergoing intuba-tion. Three instances of nonadherence to the algorithm wererecorded. GEB was used first in 152 patients and was suc-cessful in 115. ILMA was used first in 8 patients and secondin the 37 GEB-assisted intubation failures. Forty-five pa-tients were successfully mask-ventilated, and 42 were blindlyintubated before reaching the hospital. Cricothyroidotomywas used successfully in a patient with severe upper airwayobstruction as a result of pharyngeal neoplasia. Early intuba-tion-related complications occurred in 52% difficult cases.Conclusion: Adherence to a simple algorithm using GEB,ILMA, and cricothyroidotomy solved all difficult intubationcases occurring in a prehospital emergency setting.
U NANTICIPATED difficult intubation is a com-mon, potentially life-threatening problem in several
settings (operating room, intensive care unit, and prehos-pital). Several experts and national anesthesiology societ-ies have proposed algorithms using different techniques
* Anesthesiologist, CHU H. Mondor (AP-HP), Creteil, France,† Emergency Physician, Centre de Recherche Cardiovasculaire deParis, France, and Department of Health Sciences Research, MayoClinic, Rochester, Minnesota, ‡ Emergency Physician, CHU H. Mon-dor (AP-HP), § Professor and Head, Department of Anesthesia andIntensive Care Medicine, CHU Jean Verdier (AP-HP), Bondy,France.
Received from Hopital Henri Mondor, Creteil cedex, France.Submitted for publication April 1, 2010. Accepted for publicationSeptember 1, 2010. Support was provided solely from institutionaland/or departmental sources. This work was carried out in theServices de Medecine d’Urgence et de Reanimation (SMUR) ofHenri-Mondor University Hospital, Creteil, France.
Address correspondence to Dr. Combes: SAMU 94, HopitalHenri Mondor, 51 Avenue du Marechal de Lattre-de-Tassigny, 94010Creteil cedex, France. [email protected]. Information onpurchasing reprints may be found at www.anesthesiology.org or onthe masthead page at the beginning of this issue. ANESTHESIOLOGY’sarticles are made freely accessible to all readers, for personal useonly, 6 months from the cover date of the issue.
Copyright © 2010, the American Society of Anesthesiologists, Inc. LippincottWilliams & Wilkins. Anesthesiology 2011; 114: 105–10
What We Already Know about This Topic
• Airway management in the emergency prehospital setting isoften more difficult than that in the operating room
What This Article Tells Us That Is New
• In more than 2,500 patients in a single emergency unit, asimple airway algorithm using gum elastic bougie, intubatinglaryngeal mask airway, and cricothyroidotomy was uniformlyadopted (adherence 98%) and successfully managed 160 dif-ficulty airway situations encountered
! This article is accompanied by two Editorial Views. Pleasesee: Schmidt U, Eikermann M: Organizational aspects of dif-ficult airway management: Think globally, act locally. ANESTHE-SIOLOGY 2011; 114:3–6; Isono S, Ishikawa T: Oxygenation,not intubation, does matter. ANESTHESIOLOGY 2011; 114:7–9.
Anesthesiology, V 114 • No 1 January 2011105
resort to an alternative intubation technique in 6% of pa-tients, whereas in the operating room, this was the 1% in ourprevious study.1 There are several reasons for this higherincidence: operators are not anesthesiologists with specificskills in airway management, patients may be in vital distress,overall circumstances are more hostile (e.g., patient lying onthe ground, cramped space, frequent presence of blood orgastric fluid in the pharynx, or uncooperative patient), andarterial oxygen desaturation occurs more often.12
For all of these reasons, we had to adapt our operatingroom algorithm to the prehospital setting. We recom-mended GEB after just one intubation attempt under directlaryngoscopy for a class IV laryngeal view, according to theCormack and Lehane classification. In addition, we recom-mended cricothyroidotomy rather than percutaneous tran-stracheal jet ventilation in cannot intubate, cannot ventilatesituations. Although transtracheal jet ventilation is a highlyeffective rescue technique when prompt surgical tracheot-
omy is possible, it is unrealistic in a prehospital setting. Wethought that a technique such as cricothyroidotomy, allow-ing inspiration and expiration through the same tube, wasmore appropriate because of the time that may elapse be-tween tracheal access and arrival at the hospital. In fact, weused cricothyroidotomy only once in a patient with severerespiratory distress as a result of a malignancy obstructing theupper airway and in whom direct tracheal access was man-datory for rescue oxygenation.
The techniques used in steps 1 and 2 of our algorithm(GEB and ILMA) do not take long to learn.16,17 A shortlearning curve is essential when operators perform few intu-bations. Our emergency physicians intubate, on average, 14patients per year, whereas anesthesiologists intubate severalhundreds. Despite their lesser experience, their success ratesfor GEB and ILMA use were similar to those reported inoperating room studies. Minimal initial skill was required fornonanesthesiologist training to apply these alternative tech-niques within the framework of our algorithm. We have topoint out that our algorithm was applied by senior operatorsand was regularly brought up at daily staff meetings to all thestaff. We believe that these two keys points enhanced theadherence to the program and resulted in the success rate weobserved with our algorithm.
Our intubation-related complications rate was high(52%). Most of our patients underwent more than two in-tubation attempts, and thus were exposed to a high risk ofarterial oxygen desaturation. The most common complica-tions we encountered were esophageal intubation (36%) andarterial oxygen desaturation (26%). Mort18,19 reported up to
695 First intubation attempt failures
569 Cormack < IV17 Cormack IV
2nd intubation attempt 435 successes
151 GEB
(8+37) ILMA
1 Cricothyrotomy
45 Success (42 ventilation andintubation through the ILMA. 3ventilation without intubationthrough the ILMA)
114 successes(111 within 2 attempts)
9 patients with difficult mask ventilation and arterial desaturation
686 patients with no mask ventilation difficulty
1 Contraindication to ILMA
2,674 intubations
Fig. 1. Flowchart of the patients intubated during the study period. GEB ! gum elastic bougie; ILMA ! intubating laryngealmask airway.
0
5
10
15
20
25
30
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20
Intu
batio
ns (
n)
IDS score
Fig. 2. Distribution of the IDS values of the 160 difficultintubations recorded during the study period. IDS ! intuba-tion difficulty scale.
Algorithm for Prehospital Difficult Airway Management
Anesthesiology 2011; 114:105–10 Combes et al.108
Long mandrin
MLI-‐Fastrach®
Cricothyrotomie
160 paBents ID/VMD
71,2 %
28,2 %
0,6 %
= 100 %
Pa4ents avec Cormack 3 " Bougie glissée à l ’aveugle sous épigloWe " Placement confirmé par :
-‐ froWement passage des anneaux ++ -‐ rota4on passage bronche souche + -‐ arrêt progression +++ -‐ Toux si pa4ent non curarisé
" Sonde glissée sur bougie -‐ rota4on si résistance passage gloWe -‐ laisser laryngoscope en place +++
" Retrait bougie et confirmer intuba4on
U4lisa4on du long mandrin béquillé
Principe : connec4on 3 bars + gacheWe
Jet ven4la4on : système
ManujetTM
(vérifier l’expira4on +++)
« + » : simple et rapide d’u4lisa4on, faible coût « -‐ » : injec4on manuelle, pas de mesure de la pression intratrachéale
Fastrach et mobilité rachis cervical Brimacombe et al Anesth Analg 2001
moy (DS) Déplacement Rota4on maximale maximal (C3, mm) sagiWale (C2-‐C3, °)
Ven4la4on masque 1,9 (1,2)* 2,7 (3,2)
Intuba4on-‐laryngoscope 2,6 (1,6)* 2,7 (3,3)
Intuba4on-‐Fastrach 1,7 (1,3)* 1,1 (5,5)
Inser4on-‐Masque Laryngé 1,7 (1,3)* 2,4 (4)
* P < 0,01 versus contrôle
Intuba4on Naso-‐trachéale 0,1 (0,7) 0,2 (3,2)
Fibroscope
Samir JaberBoris JungPhilippe CorneMustapha SebbaneLaurent MullerGerald ChanquesDaniel VerzilliOlivier JonquetJean-Jacques EledjamJean-Yves Lefrant
An intervention to decrease complicationsrelated to endotracheal intubationin the intensive care unit: a prospective,multiple-center study
Received: 26 July 2009Accepted: 11 October 2009Published online: 17 November 2009! Copyright jointly hold by Springer andESICM 2009
Presented in part at the at the 2007 AnnualMeeting of American Society ofAnesthesiology (San Francisco, CA,October 13–17, 2007).
Electronic supplementary materialThe online version of this article(doi:10.1007/s00134-009-1717-8) containssupplementary material, which is availableto authorized users.
S. Jaber ()) ! B. Jung ! M. Sebbane !G. Chanques ! D. Verzilli ! J.-J. EledjamIntensive Care Unit, Anesthesia and CriticalCare Department B: DAR B,CHU de Montpellier, Saint Eloi TeachingHospital, Universite Montpellier 1,80 avenue Augustin Fliche,34295 Montpellier Cedex 5, Francee-mail: [email protected].: ?33-467-337271
B. Jung ! P. Corne ! O. JonquetService de Reanimation MedicaleAssistance Respiratoire,CHU de Montpellier,Hopital Gui-de-Chauliac,80 avenue Augustin Fliche,34295 Montpellier Cedex 5, France
L. Muller ! J.-Y. LefrantFederation Anesthesie-Douleur-Urgences-Reanimation,Groupe Hospitalo-Universitaire Caremeau,Centre Hospitalier Universitaire Nımes,Place du Professeur Robert Debre,30029 Nımes Cedex 9, France
Abstract Objective: To deter-mined whether the implementation ofan intubation management protocolleads to the reduction of intubation-related complications in the intensivecare unit (ICU). Design: Two-phase, prospective, multicenter con-trolled study. Setting: Threemedical-surgical ICUs in two uni-versity hospitals. Patients: Twohundred three consecutive ICUpatients required 244 intubations.Interventions: All intubations per-formed during two consecutivephases (a 6-month quality controlphase followed by a 6-month inter-vention phase based on theimplementation of an ICU intubationbundle management protocol) wereevaluated. The ten bundle compo-nents were: preoxygenation withnoninvasive positive pressure venti-lation, presence of two operators,rapid sequence induction, cricoidpressure, capnography, protectiveventilation, fluid loading, preparationand early administration of sedationand vasopressor use if needed.
Measurements and main results:The primary end points were theincidence of life-threatening compli-cations occurring within 60 min afterintubation (cardiac arrest or death,severe cardiovascular collapse andhypoxemia). Other complications(mild to moderate) were also evalu-ated. Baseline characteristics,including demographic data and rea-son for intubation (mainly acuterespiratory failure), were similar inthe two phases. The intubation pro-cedure in the intervention phase(n = 121) was associated with sig-nificant decreases in both life-threatening complications (21 vs.34%, p = 0.03) and other complica-tions (9 vs. 21%, p = 0.01) comparedto the control phase (n = 123). Con-clusions: The implementation of anintubation management protocol canreduce immediate severe life-threat-ening complications associated withintubation of ICU patients.
Keywords Intubation ! Airwaymanagement ! Complications !Mechanical ventilation !Non-invasive ventilation !Practice guidelines
Intensive Care Med (2010) 36:248–255DOI 10.1007/s00134-009-1717-8 ORIGINAL
Introduction
Endotracheal intubation, which is one of the most com-monly performed procedures in the intensive care unit(ICU) [1–4], is associated with a high incidence ofcomplications (25 to 39%) because of the precarioushemodynamic and respiratory status of critically ill patients[1, 2, 5–8]. In anesthesia and pre-hospital practices, specificprocedures [i.e., preoxygenation, rapid sequence intubation(RSI) using the combined administration of a sedative andmuscle relaxant agent, capnography to check the correcttube placement, etc.] are included in guidelines and arerecommended to improve intubation safety [9–12]. Suchstandardized recommendations are lacking in ICU practice.Contrary to airway management performed in the operatingroom and pre-hospital conditions, few studies designed toimprove intubation safety in the ICU have been published[13]. We recently showed that non-invasive positive pres-sure ventilation (NIPPV) improved preoxygenation ofobese patients before intubation both in the ICU [1] and inthe operating room [14].
We hypothesized that associating preoxygenationNIPPV with other procedures that have been shown toimprove intubation safety according to pre-hospital andanesthesia literature may decrease the incidence of imme-diate complications after intubation in the ICU. Employinga group of evidence-based treatments related to a diseaseprocess, instituted together over a specific timeframe andtermed ‘‘a care bundle,’’ is expected to result in betteroutcomes than when the treatments are executed individ-ually. For instance, when ‘‘the care bundle’’ is implementedas rapidly as possible, it improves the management of out-of-hospital respiratory distress [15], sedation and weaningfrom the ventilator [16, 17], as well as severe sepsis [18, 19]and surgical procedures [20]. We therefore conducted aprospective before-after study to determine whether theimplementation of an intubation bundle therapy results in areduction of intubation-related complications in the ICU.
Patients and methods
The present study was performed in three ICUs. Data fromall ICU tracheal intubations were collected and analyzed.We excluded those performed for cardiac arrest. Theprotocol was approved by the local ethics committee.
Study design (see ESM)
Control phase
During a 6-month control phase, intubation procedureswere performed without the use of a protocol by theclinicians in charge of the patient.
Interphase
Prior to beginning enrollment in the intervention phase,we developed an intubation care bundle managementsystem based on a review of the ICU airway literature[1, 2, 4, 9, 11, 16, 21, 22] (Table 1). During a 4-weekphase, all physicians, residents and nurses received formaleducation and clinical training for the processes andprocedures related to the ten-point bundle management.
Intervention phase
During the 6-month intervention phase, the recommendedintubation procedure was to conform to the bundle man-agement detailed in Table 1 (see ESM).
Measurements and definitions of complications
We documented baseline characteristics, reason foradmission to ICU and status of the following before intu-bation: reason for intubation, heart rate, systolic arterialblood pressure, use of vasopressive drugs and pulse oxygensaturation level (SpO2). During the intubation procedure,we documented drug administration and the operator status(airway expert vs. non expert physician) [7].
We then recorded complications and categorized assevere life-threatening or mild to moderate complications(see ESM and Table 2) that occurred during the intubation
Table 1 Intubation care bundle management
Pre-intubation1. Presence of two operators2. Fluid loading (isotonic saline 500 ml or starch 250 ml) in
absence of cardiogenic pulmonary edema3. Preparation of long-term sedation4. Preoxygenation for 3 min with NIPPV in case of acute
respiratory failure (FiO2 100%, pressure support ventilationlevel between 5 and 15 cmH2O to obtain an expiratory tidalvolume between 6 and 8 ml/kg and PEEP of 5 cmH2O)
During intubation5. Rapid sequence induction: etomidate 0.2–0.3 mg/kg or
ketamine 1.5–3 mg/kg combined with succinylcholine1–1.5 mg/kg in absence of allergy, hyperkaliemia, severeacidosis, acute or chronic neuromuscular disease, burn patientfor more than 48 h and medullar trauma
6. Sellick maneuverPost-intubation7. Immediate confirmation of tube placement by capnography8. Norepinephrine if diastolic blood pressure remains \35 mmHg9. Initiate long-term sedation10. Initial ‘‘protective ventilation’’: tidal volume 6–8 ml/kg of
ideal body weight, PEEP \5 cmH2O and respiratory ratebetween 10 and 20 cycles/min, FiO2 100% for a plateaupressure \30 cmH2O
NIPPV non-invasive positive pressure ventilation, PEEP positiveend expiratory pressure, FiO2 inspired oxygen fraction
249
were significant differences between the two phases for sixof the ten processes, i.e., all that were recorded during thecontrol phase (Table 5). Mean pressure support leveldelivered during the NIPPV for preoxygenation was sim-ilar for the two phases (10 ± 4 cmH2O).
Intubation-related complications
The intubation procedure in the intervention phase(n = 121) was associated both with significantly lowerlife-threatening complications (21 vs. 34%, p = 0.03)(Fig. 1) and mild to moderate complications (9 vs. 21%,p = 0.01) (Fig. 2) than those in the control phase(n = 123). Severe hypoxemia and cardiovascular col-lapse, which were the main life-threatening complicationsafter intubation, were reduced by half in the interventiongroup compared to the control group (Fig. 1).
We reported 12 esophageal intubations (6 in eachgroup); 3 of them were complicated by severe hypoxemia(all in the control group, without capnography). Amongthe four esophageal intubations diagnosed by capnogra-phy, none of the patients developed severe hypoxemia,but two resulted in hemodynamic collapse. We did notfind any significant change in the rate of complications,whether capnography was used or not. Difficult intubationwas not different between the control and the interventiongroups.
Patient outcomes
There was no difference in length of mechanical venti-lation [7 (2–14) vs. 8 (4–15) days, p = 0.65], ICU
Table 5 Processes of medical care for the 244 evaluated procedures
Control(n = 121)
Intervention(n = 123)
p
Pre-procedure1. Presence of two operators 79/121 (65) 123/123 (100) \0.0013. Preparation of long-term sedation NR 98/123 (80) NA2. Fluid loading 56/115 (49) 86/115 (75) \0.0014. Preoxygenation with NIPPV 34/73 (47) 65/80 (82) \0.001During procedure5. Anesthetic drugsHypnoticsEtomidate 42/121 (35) 72/123 (58) \0.001Ketamine 0/121 (0) 22/123 (18) \0.001Others hypnotics 75/121 (62) 29/123 (24) \0.001
Muscle relaxantsSuccinylcholine 36/115 (32) 89/114 (78) \0.001Other muscle relaxant 42/121 (35) 9/123 (7) \0.001
6. Sellick maneuver 41/121 (34) 88/123 (72) \0.001Post-procedure7. Capnography use 0/121 (0) 69/123 (56) \0.0018. Early vasopressives drugs NR 14/19 (77) NA9. Initiation of long-term sedation NR 81/123 (65) NA10. Initial ‘‘protective ventilation’’ NR 74/105 (70) NA
The number for the denominator served to calculate the frequencyof succinylcholine use taking into account only the cases withoutcontraindications for succinylcholine use in both groups. Control:six contraindications to succinylcholine, no details have beenrecorded. Intervention: nine contraindications to succinylcholine:amyotrophic lateral sclerosis (one case), Guillain–Barre syndrome
(one case), spinal muscular amyotrophy (one case), acute renalfailure (one case), acute hyperkaliemia (one case), extreme bra-dycardia (one case) and anticipated difficult intubation (three cases)Data are number (%) or mean ± SDNR not recorded, NA not applicable
30%
or death
**Control (n= 121)Intervention (n= 123)
NS
**
0%
5%
10%
15%
20%
25%
Severe hypoxemia Severe collapse Cardiac arrest
**
NS
Fig. 1 Life-threatening complications occurring after all intuba-tions performed during the control (n = 121) and the intervention(n = 123) phases. *p \ 0.05 versus control phase. NS notsignificant
251
Etude avant/après 6 mois
-‐60% -‐40%
Guidelines
Difficult Airway Society Guidelines for the management oftracheal extubationMembership of the Difficult Airway Society Extubation Guidelines Group: M. Popat (Chairman),1
V. Mitchell,2 R. Dravid,3 A. Patel,4 C. Swampillai5 and A. Higgs6
1 Consultant Anaesthetist, Nuffield Department of Anaesthetics, Oxford Radcliffe Hospital NHS Trust, Oxford, UK2 Consultant Anaesthetist, University College London Hospital, London, UK3 Consultant Anaesthetist, Kettering General Hospital, Kettering, UK4 Consultant Anaesthetist, The Royal National Throat Nose and Ear Hospital, London, UK5 Anaesthetic Specialist Registrar, Lister Hospital, Stevenage, UK6 Consultant in Anaesthesia & Intensive Care Medicine, Warrington and Halton Hospitals Warrington, UK
SummaryTracheal extubation is a high-risk phase of anaesthesia. The majority of problems that occur during extubation andemergence are of a minor nature, but a small and significant number may result in injury or death. The need for astrategy incorporating extubation is mentioned in several international airway management guidelines, but the subject isnot discussed in detail, and the emphasis has been on extubation of the patient with a difficult airway. The DifficultAirway Society has developed guidelines for the safe management of tracheal extubation in adult peri-operative practice.The guidelines discuss the problems arising during extubation and recovery and promote a strategic, stepwise approachto extubation. They emphasise the importance of planning and preparation, and include practical techniques for use inclinical practice and recommendations for post-extubation care.................................................................................................................................................................
Correspondence to: Dr M. PopatEmail: [email protected]*This article is accompanied by an Editorial. See page 213 of this issue
Accepted: 5 January 2012
What other guideline statements are available on this topic?The need for a strategy incorporating extubation is mentioned in several international airway management guidelines: theCanadian Airway Focus Group’s 1998 recommendations for the management of the unanticipated difficult airway; the 2003American Society of Anesthesiologists (ASA) difficult airway guidelines; the Societa Italiana Anaesthesia AnalgesiaRianimazione Terapia Intensiva (SIAARTI) recommendations for airway control and difficult airway management 2005. TheDifficult Airway Society (DAS) difficult intubation guidelines of 2004 mention the need for a pre-formulated extubation plan,but no details are given.
Why was this guideline developed?Complications are common at extubation and during recovery and may result in significant morbidity and mortality. Althoughextubation is addressed in some airway management guidelines, it has not received the same attention as intubation.
How does this statement differ from existing guidelines?These guidelines recommend that an extubation strategy should be developed before the start of anaesthesia. A stepwiseapproach is used to aid risk stratification, the practical management of routine and at-risk situations, and to highlight theimportance of continued postextubation care. Flowcharts have been produced to summarise this philosophy. The guidelinesare applicable to adult peri-operative practice; they do not address paediatric or critical care patients.
Why does this statement differ from existing guidelines?These guidelines explore the pathophysiology of problems arising during extubation and emergence. They address theimportance of planning extubation to avoid difficulties. They provide a structured framework around which extubation can bemanaged and taught and offer practical strategies for use in clinical practice.
Anaesthesia 2012, 67, 318–340 doi:10.1111/j.1365-2044.2012.07075.x
318 Anaesthesia ª 2012 The Association of Anaesthetists of Great Britain and Ireland
Step 3: perform extubationStep 3 involves the actual performance of extubation.
General considerations. Any extubation technique usedshould ensure minimum interruption in oxygen deliveryto the patient’s lungs. The following general considera-tions are relevant to extubation for both the ‘low-risk’and the ‘at-risk’ groups:
Building oxygen stores (pre-oxygenation): the peri-operative anatomical and physiological changes de-scribed above compromise gas exchange, and makepre-oxygenation before extubation vital. As for induc-tion of anaesthesia, the aim of pre-oxygenation beforeextubation is to maximise pulmonary oxygen stores byraising the FEO2 above 0.9, or as close to the FIO2 aspossible [78]. Although studies have shown that an FIO2
of 1.0 increases atelectasis, the clinical significance ofthis has yet to be determined [79, 80]. At extubation, thepriority is to maximise oxygen stores to continue oxygenuptake during apnoea, and therefore pre-oxygenationwith a FIO2 of 1.0 is recommended [81–85].
Patient position: there is no evidence to support auniversal patient position for extubation. There is anincreasing trend towards extubating in a head-up(reverse Trendelenburg) or semi-recumbent position.The head-up tilt is especially useful in the obese
population as it confers a mechanical advantage torespiration and provides more familiar conditions inwhich to monitor and manage the airway. A left-lateral,head-down position has traditionally been used for thenon-fasted patient [77, 86].
Suction: the soft tissues of the oropharynx are at riskof trauma if suction is not applied under direct vision[87, 88], ideally using a laryngoscope, particularly ifthere are concerns about oropharyngeal soiling fromsecretions, blood or surgical debris. Laryngoscopyshould be carried out with the patient in an adequatelydeep plane of anaesthesia, but may need to be repeated.Special vigilance is necessary if there is blood in theairway, as NAP4 highlighted the danger of the ‘coroner’sclot’, where aspiration of blood can lead to airwayobstruction and death [89]. Suction of the lower airwayusing endobronchial catheters, together with aspirationof gastric tubes, may also be necessary.
Alveolar recruitment manoeuvres: patientsundergoing anaesthesia develop atelectasis. Alveolarrecruitment manoeuvres, such as sustained positiveend-expiratory pressure (PEEP) and vital capacitybreaths, may temporarily reverse atelectasis, but havenot been shown to provide any benefit in the post-operative period [81, 90]. Simultaneous deflation of thetracheal tube cuff and removal of the tube at the peak of
Figure 1 DAS extubation guidelines: basic algorithm.
Anaesthesia 2012, 67, 318–340 Popat et al. | Management of tracheal extubation
324 Anaesthesia ª 2012 The Association of Anaesthetists of Great Britain and Ireland
Conclusion
o L’urgence accroît les difficultés et les risques du contrôle des voies aériennes
o La préoxgénaBon est un enjeu majeur dans le cadre de l’urgence
o Les algorithmes formalisent la disBncBon entre le premier impéraBf l’oxygénaBon et l’objecBf "secondaire", l’intubaBon trachéale…
Tout était écrit … Merci de votre ayenBon
INTUBATION DIFFICILE PREVUE
Orientation stratégique
Evaluer la difficulté prévisible de la ventilation au masque facial
SFAR 2006
Prévoir le maintien de l’oxygénation ( Masque laryngé ou MLI-Fastrach utilisables ? Abord trachéal possible ? )
Choix des techniques d’anesthésie : apnée ou ventilation spontanée ?
INTUBATION
Echec
MLI FASTRACH Masque laryngé enfant <30 kg
Echec
FIBROSCOPE
Echec
Apnée possible Ventilation Spontanée Aide prévue
Réveil Abord trachéal si réveil
impossible
ventilation au masque efficace SFAR 2006
Intubation Intubation ± fibroscope
Intubation
Réveil Réveil
Laryngoscopie 2 essais - optimisation exposition -
long mandrin béquillé
Vidéolaryngoscopes
CT
INTUBATION DIFFICILE IMPREVUE
Intubation
Echec MLI /
FASTRACH Masque laryngé enfant <30 kg
Ventilation Masque Facial
= Appel à l’aide dans tous les cas + Chariot + Maintien anesthésie
ALGORITHME DE L’INTUBATION
ALGORITHME DE L’OXYGENATION
efficace inefficace
Laryngoscopie 2 essais – optimisation exposition -
long mandrin béquillé
SFAR 2006
Ventilation MLI-FASTRACH
inefficace efficace
Vidéolaryngoscopes
CT
CT
90 % ID réglée avec mandrin
98 % patients intubés
100 % patients oxygénés
