Deviation in the Standard of Anesthetic Care During Intubation Resulting in Aspiration

Evaluate breaches in the standard of care when evaluating the Deviation in the Standard of Anesthetic Care During Intubation Resulting in Aspiration

Answer the following questions to find out if the standard of care was followed for your case.

  • Did the patient require elective or emergency intubation?
    Emergency intubation
    Elective intubation for surgery
    Why is this important?
    Indications for emergency airway management are in 3 main groups; (1) airway obstruction, (2) inability to maintain/protect an open intact airway, and, (3) respiratory failure. Intubation is electively performed during major surgical procedures involving general anesthesia.
    (2012) 30 EMDCNA 2 401-420

  • Was a Rapid Sequence Intubation (RSI) initiated? Why is this important?
    Answer this question
    
To minimize and prevent an acid aspiration syndrome, in hospitalized patients at risk for acid aspiration, intravenous administration of antacids may be required.

    (1999) 17 EANESC 1 63-81 



  • Was the endotracheal tube used for intubation the correct type and size? Why is this important?
    Answer this question
    
Placement of a cuffed endotracheal tube is currently the best method for isolating the airway from the gastrointestinal tract, but cannot serve as an absolute preventive measure.

    (2004) 18 EBPRCA 4 719-737 



  • Was the integrity of the balloon and cuff assessed prior to intubation? Why is this important?
    Answer this question
    
Check the integrity of the balloon and cuff is on tracheal tube before intubation is mandatory.

    (1996) 14 EMDCNA 1 233-244 



  • Were the patient's dentures removed before intubation? Why is this important?
    Answer this question
    
It is paramount to identify any anatomical abnormality that may be unfavorable for ventilation and intubation.

    (2012) 30 EMDCNA 2 401-420 



  • Were measures taken to rule out any spinal cord/head injury before head positioning? Why is this important?
    Answer this question
    
In the adult, a pillow or pad is usually placed under the occiput to elevate the patient's head. This positioning will align the oral, pharyngeal and laryngeal structures.

    (2005) 19 EBPRCA 4 595-609 



  • Was a rigid intubation fiberscope used? Why is this important?
    Answer this question
    
Rigid intubation fibroscopes improve the view of larynx, especially in patients with difficult airway.

    (2005) 19 EBPRCA 4 595-609 



  • Was pre-oxygenation provided to the patient prior to intubation? Why is this important?
    Answer this question
    
Pre-oxygenation prevents hypoxia during the period of apnea before tracheal intubation and is of particular value if intubation is difficult.

    (2012) 13 EAICMD 9 401-406 



  • Was the Sellick’s maneuver performed during intubation? Why is this important?
    Answer this question
    
The Sellick maneuver is used routinely and successfully to protect patients from sequelae associated with esophageal aspiration during endotracheal intubation and gastric insufflation from positive pressure ventilation.

    (1999) 25 JLEMNU 4 283-284 



  • Which of the following was performed during intubation?(Choose all that apply) Why is this important?
    Answer this question
    
The following basic physiologic monitors must be in place before induction of anesthesia and tracheal intubation in the emergency department:
    • Electrocardiography for rhythm and rate
    • Noninvasive blood pressure
    • Pulse oximetry for the assessment of blood oxygenation
    • End-tidal carbon dioxide analysis to confirm tracheal intubation and monitor pulmonary ventilation
    • Temperature monitoring as clinically indicated


    (1999) 46 EPDCNA 6 1249-1284 



  • Was an end-tidal/CO2 detection device (Capnography) used during intubation? Why is this important?
    Answer this question
    
Capnography provides continuous, dynamic assessment of the ventilatory status of patients. Clinical applications with regard to ventilation and airway management are verification of endotracheal tube placement and continuous monitoring of tube position.

    (2008) 26 EMDCNA 4 881-897 



  • What method to confirm endotracheal tube placement was used?(Choose all that apply) Why is this important?
    Answer this question
    
Rapid confirmation of correct tube placement is important because tube malposition is associated with serious adverse outcomes.

    (2013) 84 ERESUS 6 731-737 



  • Were any avulsed teeth removed after intubation? Why is this important?
    Answer this question
    
The main injury associated with use of laryngoscopes is damage to the teeth.

    (2005) 19 EBPRCA 4 641-659 



  • Were endotracheal tube cuff pressures maintained? Why is this important?
    Answer this question
    
Leakage around the endotracheal tube cuff enables pooled secretions and bacteria to enter the trachea, leading to ventilator associated pneumonia. This may be prevented by maintaining appropriate cuff pressures and by the continuous aspiration of subglottic secretions (CASS).

    (2001) 85 EMEDCN 6 1545-1563 



  • Was a post intubation chest radiograph obtained? Why is this important?
    Answer this question
    
The current gold standard test for confirming tube position is a chest radiograph.

    (2013) 84 ERESUS 6 731-737 



  • Which of the following symptoms did the patient exhibit?(Choose all that apply) Why is this important?
    Answer this question
    
Aspiration often initially presents with bronchospasm, cyanosis and tachycardia. Within minutes of pulmonary aspiration there is exudation of fluid that neutralizes the aspirate. The second phase involves development of acute lung injury (ALI) which may lead to frank respiratory distress syndrome.

    (2004) 18 EBPRCA 4 719-737 



  • Were radiological investigations ordered to rule out aspiration? Why is this important?
    Answer this question
    
Radiographic changes may be visible within a few hours.

    (2004) 18 EBPRCA 4 719-737 



  • Which of the following treatment measures were initiated? (Choose all that apply) Why is this important?
    Answer this question
    
Suggested initial management of aspiration during anesthesia involves positioning the patient and clearing the airway of debris with suctioning. The patient must receive aggressive suctioning of the tracheobronchial tree before using 100% O2. A bronchoscopy may be useful to check for residual debris and remove larger aspirated particles. When deciding whether to treat patients who have aspirated with antibiotics, it is crucial to make the differential diagnosis of pneumonitis from pneumonia. All efforts need to be made to avoid use of empirical antibiotics, and treatment must not be initiated until there is a clear diagnosis of pneumonia.

    (2004) 18 EBPRCA 4 719-737 



  • Was the intubation recorded and documented by the clinician? Why is this important?
    Answer this question
    
A detailed documentation of events in the patient’s medical record is mandatory.

    (2001) 16 JPANEN 3 195-197