My name is Andy Higgs.
I am the new DAS Treasurer and I also chair a group jointly representing DAS, the Intensive Care Society, Faculty of ICM and the Royal College of Anaesthetists.
We are pretty early on in the process of producing a guideline addressing airway management in the critically ill patient - ie not just in the ICU but wherever a patient is deemed to require airway management as a consequence of critical illness.
This is intended to be the DAS response to the NAP4 ICU / AED findings.
We are keen to hear from DAS members who would like to suggest specific issues that they think the guideline should address.
At this stage, we want to keep our call for suggestions as broad as possible.
As time passes, we will refine our requests depending on the views of those who reply.
Please feel free to suggest anything; obviously we already have certain aspects in mind, but please suggest any topic you feel is important and I can promise that I will bring your thoughts to the attention of the guideline committee. None are too obvious or obscure to consider - we NEED to hear from you!
This is your chance to influence, at a very early stage, the direction and content of the next stage for DAS Guidelines.
Just post your thoughts and suggets here on the website.
Thanks, in advance, for your input.
Andy.
Airway management in the Critically Ill
#1
by andyhiggs on Tue, 2015-05-05 21:57
Hi Andy,
I am Rhendra, anesthetist from Malysia just join the DAS as member, I usually take care of the patients in the ICU, for me the problem that mostly seen is after extubation of the ICU patients, whereby some of them might not tolerate well after extubation. For some cases there might be a degree of subglottic stenosis which might not detected and maybe due to trauma during intubation, this will rise to the issue cannot intubate, cannot ventilate. Can we follow the algorithm like the DAS algorithm for CICV in OT?
Thanks
Hi Andy,
At present ,I have a patientin the ICU with CAP on NIV. He is likely to deteriorate and need intubation, unless he turns around soon. My trainee asks me if he needs to do endobronchial intubation and OLV? Since this pneumonectomy was a year ago, I'd say Tracheal intubation , ventilate with low Vt.(3-4 mls/kg) and low pressures. Can you say how long after is the bronchial stump healed enough to not be "at risk" of rupture? I have no idea. Look forward to hearing your or other's views on it.Thanks.
Let me first say that I am not a surgeon but a cardiothoracic anesthesiologist and intensivist so keep that in mind. I very often switch double lumen ETTs' out for single lumens after double lung transplants. Obviously, these stumps are at risk from mechanical and barotrauma. Also, I have seen many bronchial stumps dehisce within 2 weeks or so. The etiology of these cases were always predicable poor healing: Glucocorticoid usage, diabetes, malnutrition, immunosuppressive agents, etc. I will obtain the usual laryngoscopic glottic view, place the ETT just barely past the cords, then place a bronchoscope through the tube to position the tube. I do this because it is almost NEVER the wrong choice, I can also assess the stump myself, and the patient may need to be bronched anyway. However, I will not perform an awake or 'asleep' fiberoptic intubation unless 1) There is another indication to do this or 2) I (or the surgeon) is very concerned about the stump and I desire to maintain spontaneous respirations right after intubation to reduce any pressure on the stump. In your patient, unless there were documented problems with the stump, I would intubate as underlined above. Hope this helps
This is a stumbling attempt of mine to address some of the accepted variations in 'traditional' RSI that may be used in the critically ill, outside of OT. Thinking particuarly prehospital, rural-austere, ED.
No doubt variation between eg UK and Oz. but any moves towards acceptable consensus on mRSI has to be a good thing.
P,ease dont flame me too badly....
http://www.criticalcarehorizons.com/airway-management-of-the-critically-...
Hi Andy,
I'm an ED intensivist in Manchester - we have been doing some work on making airway management safer locally and I thought I would just highlight some of the issues that have arisen as a result, which we are trying to work on. It would be really helpful for a national body like DAS to try and take a stance on some of these thorny issues:
1 - Checklists - still variation in type and uptake between ICU / AED - although NAP4 recommends and intiutively I find them very useful there is limited direct applicable clinical evidence - will DAS be taking a stance on a particular type or method?
2 - Prefilled drug syringes - we have significant dealys to intubation, hazards in the ED from cracked vials and drug errors resulting from our current 'grab bags' - we are working on pharmacy dispensed mRSI boxes at present. There is potential for increased safety and guidance with these (such as smaller syringes of vasodilating agents to trigger a thought process about induction dosing)
3 - SOPs for induction in trauma patients or those with haemodynamic compromise - I know this is a very contentious area and would be interested to see what DAS make of it
4 - Kit dumps / placemats for ICU/ED nursing staff to prepare equipment for airway intervention - a good ODP can of course obviate the need for this but in their absence (most often on ICU) visual reminders can be helpful to nursing staff in a difficult situation.
5 - Apnoeic oxygenation with nasal cannulae - still debate and discussion within the literature and clinical practice - will you be taking a view?
6 - Cricoid pressure - variable practice within the region - I would question the evidence supporting use, certainly in ICU patients with an aspirated and open NG tube. The unfasted ED patient is a slightly seperate issue, but worthy of discussion I suspect.
7 - positioning - there is little guidance to be found about optimal positioning in critical care airway algorithms, but I find that can sometimes be half the battle. Will you be covering this? I would be particularly interested to see mention of 'earlobe level with sternal notch', face up and ramped positioning for the obese patient as sometime I see quite senior trainees making life very hard for themselves with a sick patient poorly positioned.
Hope those suggestions are useful and look forward to seeing the work evolve.
Cheers,
Dan
Hi Andy,
NAP4 provided excellent insight into the goings-on of difficult airway management in the anaesthetic room, ICU and emergency department. However, these are not the only settings in which difficult airway presentations can be found.
Ambulance clinicians including paramedics and technicians (or their equivalents), anaesthetists, EM consultants and others are all presented with airways to manage in the prehospital setting on an at least somewhat regular basis. Critical care paramedics can expect to attend hundreds of out-of-hospital cardiac arrests in merely a few years, where they may be the only individual capable of performing advanced airway techniques. All of these airways are best considered "difficult" for a number of reasons, including that patient positioning is unavoidably suboptimal at best, patients have not fasted and are at very high risk of regurgitation, there is often no access to anaesthetic and paralytic drugs, and many others.
DAS guidelines are rarely mentioned in paramedic practice. I am only aware of one ambulance trust that uses scalpel-bougie-tube on a regular basis, and this is reserved for its critical care paramedics (I have not researched this - there may well be other trusts using the technique!) Air ambulance trusts use physicians wherever possible, and I believe London's Advanced Trauma Team is never without a doctor or two. However, some trusts often have no choice but to use a crew of two paramedics, who have a more limited scope of practice than their physician colleagues.
I believe it would be a very positive step for DAS to advertise itself to ambulance trusts and paramedic training programmes. Critical airway guidelines designed to be used by paramedics and other ambulance personnel as well as physicians and other anaesthetic/surgical staff would be an excellent platform for this.
I am excited to see what this project produces!
Ben