From Death we Learn – RCA Audit outcomes

The Royal College of Anaesthetists in the UK has released its 4th National Audit – looking into the root causes of airway disasters.  It is definitely worth a read for anyone who does a regular anaesthetic list or tackles emergency airways in the ED. Check out the Executive summary for the short version.

If you are really busy or lazy – here is the super short summary for airway tips from the audit:

  • Failure to plan for airway difficulty  =  planning to fail (or flail)
  • You should have a pre-meditated backup plan
  • Awake-Fibreoptic airway techniques should be used – the Audit found failure to use where indicated resulted in complications
  • If you can’t intubate or ventilate (code brown) then don’t keep trying the same technique – STOP and try something new
  • LMAs were used inappropriately a lot – aspiration resulted.  Especially in obese patients.  If you think aspiration is possible – do a RSI!
  • LMAs are not a good “plan” for a known difficult airway – unless you have a good plan B at your disposal
  • Obese patients were underrated – represented twice as many airway disasters tan thin peole.
  • Needle crics are not easy (60% failure) – you should know how to do a scalpel technique
  • Failure to recognise a flat capnograph trace led to failue to ID oesophageal tube or tube obstruction.
  • Emergence events accounted for 1/3 of disasters.  NPPE was 10% – see Broome Docs Case 004 for example
  • Most cases included some degree of operator error / poor judgement – consider discussing any tricky case with a colleague
  • 25 % of disasters occurred in ICU or ED – a lot of these were due to poor planning / not having the standard equipment / people available for a RSI etc
  • In non-anaestetic environments – tube dislodgement was a major cause of poor outcomes.  Keep an eye on your tube – even in the ED, especially in the ED.


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