Airway Management Failure after Delayed Extubation in a Patient with Oral Malignant Melanoma Who Underwent Partial Mandibulectomy and Reconstruction with a Free Flap

Maxillofacial surgery may cause severe complications in perioperative airway management. We report a case of failed airway management in a patient who underwent segmental mandibulectomy, radical neck dissection, and reconstruction with a free flap. The patient was extubated approximately 36 hours after surgery. Approximately 7 hours after extubation, the patient complained of dyspnoea, and respiratory failure followed. Bag-mask ventilation, direct laryngoscopy, video laryngoscopy, and supraglottic airway access were ineffective. The surgical airway was secured with an emergency tracheostomy while performing cardiopulmonary resuscitation. However, the patient experienced permanent hypoxic brain damage. The airway of patients with oral cancer may be compromised postoperatively due to surgical trauma and bulky flap reconstruction. Patients should be closely monitored during the postoperative period to prevent airway failure. Early diagnosis and airway management before airway failure occurs are important. Medical staff should be aware of airway management algorithms, be trained to perform difficult airway management, and have the required equipment readily available.

Oxygenation laryngoscope vs. nasal standard and nasal high flow oxygenation in a technical simulation of apnoeic oxygenation

Background Failed airway management is the major contributor for anaesthesia-related morbidity and mortality. Cannot-intubate-cannot-ventilate scenarios are the most critical emergency in airway management, and belong to the worst imaginable scenarios in an anaesthetist’s life. In such situations, apnoeic oxygenation might be useful to avoid hypoxaemia. Anaesthesia guidelines recommend careful preoxygenation and application of high flow oxygen in difficult intubation scenarios to prevent episodes of deoxygenation. In this study, we evaluated the decrease in oxygen concentration in a model when using different strategies of oxygenation: using a special oxygenation laryngoscope, nasal oxygen, nasal high flow oxygen, and control. Methods In this experimental study we compared no oxygen application as a control, standard pure oxygen application of 10 l·min− 1 via nasal cannula, high flow 90% oxygen application at 20 l·min− 1 using a special nasal high flow device, and pure oxygen application via our oxygenation laryngoscope at 10 l·min− 1. We preoxygenated a simulation lung to 97% oxygen concentration and connected this to the trachea of a manikin model simulating apnoeic oxygenation. Decrease in oxygen concentration in the simulation lung was measured continuously for 20 min. Results Oxygen concentration in the simulation lung dropped from 97 ± 1% at baseline to 40 ± 1% in the no oxygen group, to 80 ± 1% in the standard nasal oxygen group, and to 73 ± 2% in the high flow nasal oxygenation group. However, it remained at 96 ± 0% in the oxygenation laryngoscope group (p < 0.001 between all groups). Conclusions In this technical simulation, oxygenation via oxygenation laryngoscope was more effective than standard oxygen insufflation via nasal cannula, which was more effective than nasal high flow insufflation of 90% oxygen.

¿ Caminamos hacia el manejo del videolaringoscopio como primera opción en una vía aérea difícil?

Determinar los factores predictivos de una vía aérea difícil constituye un reto para el médico anestesiólogo. La mayoría de guías actuales, sitúan los videolaringoscopios como elementos de rescate de una vía aérea fallida, tras una laringoscopia tradicional óptima. Establecer un algoritmo que en base a unas características físicas, permita determinar qué pacientes se beneficiarán del uso del videolaringoscopio como primera opción, puede suponer una ventaja y una disminución en los problemas relacionados con la vía aérea. Por otra parte, establecer cuáles de estos factores predicen con más fuerza una dificultad con el videolaringoscopio, nos ayudará a realizar mejores planes de abordaje y una óptima toma de decisiones sobre una vía aérea difícil. Este algoritmo ha sido capaz de conseguir la intubación traqueal de todos los pacientes en los que se ha previsto una laringoscopia difícil. ABSTRACT Moving towards videolaryngoscopy handling as first option in difficult airway management? Determining the predictors of a difficult airway is a challenge for the anesthesiologist. Most current guides place videolaryngoscopes as recue elements of a failed airway, after an optimal traditional laryngoscopy. Establishing an algorithm which, based on physical charcteristics, allows to determine which patients will benefit from the use of videolaryngoscopy as a first option, may lead to a potential advantage and a net decrease in airway related problems. On the other hand, establishing which of those factors predict in a more reliable way a difficulty with the videolaryngoscopy, will contribute to make better plans of approach as well as an optimal decision making on a difficult airway. This algorithm has been able to achieve tracheal intubation of all patients for which a difficult laryngoscopy is expected.

P053: Adverse events and errors in trauma resuscitation: a systematic review

Introduction: Trauma resuscitations are plagued with high stress and require time sensitive and intensive interventions. It is a landscape that is a perfect hot bed for clinical errors and adverse events for patients. We sought to describe the adverse events and errors that occur during trauma resuscitation and any associated outcomes. Methods: Medline was searched for a combination of key terms involving trauma resuscitation, adverse events and errors from January 2000 to May 2019. Studies that described adverse events or errors in initial adult trauma resuscitations were included. Two reviewers analyzed papers for inclusion and exclusion criteria with a third reviewer for any discrepancies. Descriptions of errors, adverse events and associated outcomes were collated and presented. Results: A total of 3,462 papers were identified by our search strategy. 18 papers met our inclusion and exclusion criteria and were selected for full review. Adverse events and errors reported in trauma resuscitation included missed injuries, aspiration, failed airway, and deviation from protocol. Rates of adverse events and errors were reported where applicable. Mortality outcomes or length of stay were not directly correlated to adverse events or errors experienced in the trauma resuscitation. Conclusion: Our study highlights the predominance of adverse events and errors experienced during initial trauma resuscitation. We described a multitude of adverse events and errors and their rates but further study is needed to determine outcome differences for patients and possibility for quality improvement.

Clinical leadership in reducing risk: Managing patient airways

Niagara Health, a multi-site hospital organization, has developed a multimodal, comprehensive strategy to manage patients with a Difficult Airway (DA) in a non-operative setting. The Difficult Airway Pathway (DAP) is an evidence-based strategy aimed to train staff to reduce critical events. The DAP initiative aligns with the LEADS framework for change management and includes an annual review of reported critical incidents and an Enterprise Risk Management (ERM) Assessment Summary, with the goal to “create a regional systematic approach to support personnel, equipment and education.” The guiding vision is: “Right people, Right equipment, Right timing: No failed airway.” Preliminary evaluation suggests the strategy reduces morbidity and mortality of difficulty airway incidents outside the operating room.