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A3177
October 24, 2016
10/24/2016 3:15:00 PM - 10/24/2016 5:15:00 PM
Room Hall F Foyer-Area E
Analysis of the Emergency Intubation Outside of the Operating Room: A Single Institution Pilot Study
Michael W. Block, M.D., Kara G. Segna, M.D., Uzung Yoon, M.D., Anthony Pantoja, A.A., Elizabeth Wolo, M.D., Marc C. Torjman, Ph.D.
Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, United States
Disclosures:  M.W. Block: None. K.G. Segna: None. U. Yoon: None. A. Pantoja: None. E. Wolo: None. M.C. Torjman: None.
Introduction: In an ever evolving medical environment where improving upon patient safety is a major goal, we created an easily identifiable emergency intubation form for patient charts. This document serves as a critical reference for future intubations, medical legal reviews, and quality improvement studies. This form has already proved helpful to non-anesthesia providers on the emergency response team when trying to identify potential airway problems. Emergent intubations can be considered a tenuous situation, and those performed outside of the operating room (OR) are associated with a disproportionate number and severity of airway events (1). The ASA defines a difficult intubation as one in which a trained anesthesiologist experiences difficulty with ventilation, intubation, or both (2), and for the purpose of this study, we defined it as an intubation requiring greater than 2 attempts. Our current study reviews a series of emergent non-operating room airway intubations, in a teaching institution in which the junior resident is the primary provider for emergency airway services. We sought to identify the actual incidence of difficult intubation in our facility and identify specific patient and provider differences that could contribute to the increased risk of airway difficulty. We hypothesized that emergent intubations performed by junior residents or those occurring overnight would result in an increase in airway attempts. We further hypothesized that using cricoid pressure would result in an increase in airway attempts. Lastly, we hypothesized and that the routine use of paralytics would result in a decrease in airway attempts.

Methods: This study reviewed 408 intubations outside of the operating room from August 2015 to February 2016.

Results: The overall rate of successful first attempt intubations was 89.2%. 2% of all intubations met the criteria for “difficult airway”. There was one failed intubation resulting in a surgical airway. Analysis of comparing CA1 to CA2 residents showed no significant difference in difficulty of intubation (p=0.785). Night time intubations (6pm - 6am) accounted for 44% of all out of OR intubations and analysis showed no difference in intubation difficulty (p=0.774). Cricoid pressure was used 50% of the time and, when compared to not using cricoid pressure, there was no difference with difficulty of intubations (p=0.513) (3). Overall 91% of intubations at our institution utilized muscle relaxant. The rate of difficult intubation with rocuronium, succinylcholine, and no paralytic were 1.8%, 0%, and 2.8%, respectively.

Conclusions: Emergency intubations are historically more difficult for many reasons. Our pilot study evaluated several contributing factors which preliminarily showed no significant effect on intubation difficulty. Our overall rate of difficult intubation of 2% was less than what is published in the literature (4). We found no difference in number of attempts between CA1 and CA2 residents. We attribute this to the degree of training residents receive before assuming the responsibility of directing emergency airways. Residents have a minimum 8 months of OR experience, receive multiple lectures, and participate in an emergency airway simulation. At our institution it is standard practice to bring two anesthesia trained providers to each emergency intubation. The use of cricoid pressure is controversial and we found no effect on difficulty of intubation, however this study was not designed to evaluate aspiration events. The use of paralytics is controversial as it can lead to unanticipated surgical airways. At our institution, we found paralytics were used in 91% of intubations, which is much higher than published rates of 5% to 70% (4). Our use of paralytics was associated with a high first attempt success rate and virtually no unanticipated surgical airways.

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