Dept Of Anesthesiology & Critical Care, University Of Pennsylvania School Of Medicine

“Can’t ventilate/can’t intubate”, needle cricothyrotomy and jet ventilation

Dr. Wei expands on his conference comments concerning needle cricothyrotomy and jet ventilation after needle cricothyrotomy -- The cannot ventilate/intubate emergency situation is responsible for a previously irreducible 1-28% of all deaths associated with anesthesia (Benumof and Scheller, Anesthesiology, 1989, 71:769-778). Needle cricothyrotomy followed by transtracheal jet ventilation (TTJV) or surgical cricothyrotomy are the recommended final life saving treatments in the “cannot ventilate/intubate” emergency by both the American Society of Anesthesiologists (ASA) and the Difficult Airway Society (Benumof et al., Anesthesiology 2003; 98: 1269-77, Henderson JJ et al., Anaesthesia 2004; 59: 675-94). Needle cricothyrotomy followed by TTJV is often an effective, quick, simple and inexpensive solution to the “cannot ventilate/intubate” problem, and should be available in every anesthetizing location (Benumof and Scheller, Anesthesiology, 1989, 71:769-778, attached). A commercial transtracheal jet catheter is recommended for needle cricothyrotomy as it will be less easily kinked compared to the regular #14 or #16 intravenous angiocatheter. A jet ventilator with high pressure oxygen source is recommended to perform effective TTJV after needle cricothyrotomy although the high flow but low pressure (15 liter/min) oxygen source from the anesthesia machine may provide partial oxygenation but not adequate ventilation. A needle cricothyrotomy connected to a conventional breathing circuit or Ambu bag may not be effective for adequate oxygenation and ventilation because of high resistance secondary to the small internal diameter (ID) of the needle (~ 2 mm) (Scrase and Woollard, Anaesthesia 2006, 61: 962-974). Complications of needle cricothyrotomy and TTJV include barotrauma (subcutaneous emphysema, pneumothorax and mediastinal emphysema), esophageal puncture, or bleeding (hematoma and hemoptysis). The barotrauma incidence during HFJV can be up to 10%. Strategies to prevent barotrauma during TTJV include following: 1) Obtain experience with TTJV by using it in elective cases or on a manikin before using it in the “cannot ventilate/intubate emergency” situation.  Similarly get experience in placing a needle cricothyrotomy using manikins. 2) Make sure there is adequate exit for the volume of air being injected into the lung by observing chest movement and listening to breath sounds.  In the situation of complete upper airway obstruction a second needle cricothyrotomy may be inserted as an expiration path. 3) Use low frequency (15-20 /min) and low driving pressure (starting at around 20 psi and increase gradually if needed). 4) A definite airway such as surgical airway should be established as soon as possible after successful needle cricothyrotomy.

 

Huafeng Wei, M.D., Ph.D. is Assistant Professor of Anesthesiology and Critical Care, University of Pennsylvania

Pre operative briefings reduce unexpected delays and decrease the frequency of communication breakdowns that lead to delays

Nundy et al examined the impact of a pre operative briefing on operating room delays and found that a pre operative briefing reduced unexpected delays by 31%.  The authors developed a pre operative briefing tool that included the names and roles of the team members, the time out process, confirmation of antibiotics, a review of the critical steps in the procedure, and a review of the potential problems for the case.  The review was done by the nurse, anesthesiologist and surgeon and took place just prior to the skin incision.  Data was collected for two months prior to the introduction of the briefing protocol and this was compared to data collected for three months after the process was introduced (pre intervention and post intervention).  The briefing process took about 2 minutes.  Data on delays were collected using an OR briefing assessment tool completed by participants at the end of each operation.  To the question “there was an unexpected delay related to the case”, during the pre intervention period 36% of the respondents agreed, while post intervention 25% of the respondents agreed; a reduction of 30%.  To the question “communication breakdowns that lead to delays in starting a surgical procedure are common” pre intervention 80% agreed, while post intervention this was reduced to 65%.  When examining the responses of surgeons reporting unexpected delays, the percentage decreased from 38% to 7% in the pre compared to the post intervention period.  The authors suggested that a pre operative OR briefing process may improve OR efficiency by decreasing delays.  They cited other work suggesting that a standardized communication process such as an OR briefing may also improve patient safety and outcome.  Ref: Nundy S. et al: Impact of preoperative briefings on operating rooms delays.  A preliminary report.  Arch Surg 2008;143:1068 -1072.

 

David S. Smith M.D., Ph.D.