Failed tracheal intubation in obstetrics why do we need a guideline?

Transcription

1 Failed tracheal intubation in obstetrics why do we need a guideline? Chris Elton Leicester Royal Infirmary OAA Cases & Clinical Challenges in Obstetric Anaesthesia Churchhouse Westminster 2/3/16

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3 Declarations I m not Hillary Swales (sorry!) No conflicts All information and pictures are in the public domain Opinions are my own

4 Hannah Greener

5 Hannah Greener Died January , Newcastle Chloroform, toenail removal Mr Meggison (a surgeon) I seated her in a chair, and put a teaspoon of chloroform into a tablecloth, and held it to her nose. When the semicircular incision was made, she gave a struggle or jerk Her mouth was open, and her lips and face blanched. I called for water when I saw her face blanched, and I dashed some of it in her face.i then gave her some brandy, a little of which she swallowed with difficulty I then laid her on the floor and attempted to bleed her in the arm and jugular vein, but only obtained about a spoonful. She was dead, I believe

6 Hannah Greener-Coroners Inquest Hannah Greener died of congestion of the lung produced by [the direct effects of] chloroform. James Young Simpson It was the brandy and water..used to restore from the state of anaesthesia John Snow the fatal result should be attributed to the action of the chloroform on the nervous centers having extended so far as to put a stop to respiration.

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10 Frances Cappuccini Caesarean Section 0828 Significant Bleeding HDU care 1115 EUA finished at patient extubated Died 4 hours later cardiac arrest Two anaesthetists One Staff Grade One Consultant

11 Frances Cappuccini During recovery breathing irregular Bag and mask ventilation Reference to trust guidelines If in doubt take it out and ventilate with bag and mask and or LMA Locum consultant in other theatre on his own Help requested from ICU We are trying not to intubate LMA inserted Intubated initially oesophageal Subsequently died hyperkalaemia

12 Why do we need a guideline? -to defend practice Guideline was produced that supported bag and mask Expert witness did not address the duration of mask ventilation

13 Failed Intubation Guidelines

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17 Rucklidge M. International Journal of Obstetric Anesthesia 2013; 22: S37.

18 In this case I would Question A. Wake patient up B. Continue Anaesthesia with the Laryngeal Mask, breathing spontaneously C. Continue Anaesthesia with the Laryngeal Mask, with NMB and IPPV D. Use NMB and have have a further attempt at intubation eg via LMA, Video Laryngoscope, Fibreoptic etc.

19 M. W. M. Rucklidge S. M. Yentis Anaesthetist,, 52% responded that they would maintain anaesthesia following failed intubation 47% chose to abandon surgery and wake the mother ;

20 Why do we need a guideline? Rucklidge M. International Journal of Obstetric Anesthesia 2013; 22: S37.

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23 Storz C-MAC

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34 Why do we need a guideline?- to make sense of what s out there

35 Why do we need a (new) guideline Things have changed LMA s Other SAD s Devices with gastric drainage Devices that facilitate intubation via SAD Video laryngoscopes Oral antacids Oral intake protocols Fast onset NMB s Sugammadex Obesity WE DON T DO WHAT WE SAY WE WOULD DO!

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38 Why do we need a guideline -its still very common 2.6 (CI ) per General anaesthetics 2.3 (CI ) per GA for Caesarean Section) 2.3 (CI ) deaths per GA s ie 1 death for every 90 failed intubations

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40 Why do we need a (new) guideline -because old guideline not followed 73.3% (CI ) anaesthesia continued This percentage increased with each year Increasing trend for continuing with general anaesthesia with time

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45 Supra Glottic Airway Devices (SADS) Initial reports bag and mask Increasing use of LMA s May provide conduit for intubation Occasionally associated with laryngospasm Rare cases of aspiration Increasing use of second generation SAD

46 Front of Neck Procedure Can t intubate/can t oxygenate 5-28/100 Front of neck procedure 1:60 failed intubations 13 (+2) cases of front of neck access 6 cases maternal death 8 primary tracheostomy +2 after failed cricothyroidotomy Paralyse (?) Move from needle to surgical cricothyroidotomy

47 Conclusion Guidelines can inform our practice Guidelines can protect us from litigation But most importantly if based on evidence they can increase safety and improve outcomes for mother and baby Guidelines must reflect the changing practice of anaesthesia

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51 Maintenance-changing practice Face mask ventilation only after failed LMA Sponataneous ventilation IPPV without NMB IPPV with IPPV Trend for Halothane to Isoflurane to Sevoflurane

52 Maintenance (after wake up) Spinal Anaesthesia Epidural CSE Local infiltration

53 Extubation Pulmonary aspiration more common at extubation or in recovery Post extubation Pulmonary Oedema (NPPO)