The unexpected difficult paediatric airway: Are you prepared?

Transcription

1 The unexpected difficult paediatric airway: Are you prepared? Stephanie Bew Leeds Children s Hospital APA Linkman Meeting November 9 th 2015

2 What will this lecture cover? How often will I have to deal with an UDPA? What situations? What equipment do I need? Are there protocols/algorithms I should know? What training do I need?

3 How often do we see an unexpected difficult paediatric airway?

4 Unexpected Paediatric Difficult Intubation Age % 0.056% 0.087% Paediatric Anaesthesia :

5 We do not know the incidence of either difficult airway management or difficult intubation in the general paediatric population 2 deaths related to difficult intubation 4 other cases involved difficult or impossible intubation 1 unexpected difficult intubation due to congenital subglottic stenosis

6 Most paediatric difficult airways are predictable UDPA is less likely to be on your elective list Emergency calls to deal with a child with a normal airway presenting with acute obstruction Emergency call to secure the airway in a child with difficult anatomy who is in respiratory distress Emergency call to delivery suite/nnu

7

8 More likely to have to deal with an UDPA in an out of theatre environment Ward ED PICU NNU

9 Difficult Airway Equipment

10 Equipment Having the equipment Knowing how to use it Knowing where it is Theatre ED Ward NNU Portable bag

11

12 What equipment do we have? Equipment audit YPAN 2014 Airdale, Bradford, Huddersfield, Harrogate, Mid Yorks, Sheffield, Scarborough, Leeds, York Results for 9 Yorkshire Trusts All had an airway lead

13 Routine Equipment Laryngoscope blades 3 hospitals and Embrace reusable Tracheal tubes Portex and Mallinckrodt 7 used microcuff sometimes (Also Embrace) LMA 9 disposable (Ambu, intersurgical Solus) 5 resuable 4 used i-gel

14 Difficult airway Equipment Separate trolley 8 Choice of blades and bougies Glidescope 3 Airtraq 6 Cmac 1 King vision 1 Fibreoptic scope 6 9

15 Transtracheal Needle/cannula 6 Quick Trach 4 Jet ventilator 9

16 Difficult airway Equipment Bougie used in past year Indirect laryngoscope used in 4 trusts and Embrace No transtracheal airways

17 What to keep and where? Oropharyngeal airways Nasopharyngeal airways ETT s Laryngoscope blades Supraglottic device Bougie Stylet Magills Airway exchange catheter McCoy Videolaryngoscope Fibreoptic scope Transtracheal cannula Jet ventilator Ventrain Surgical airway kit

18 Should we standardise equipment? All areas in your Trust? With your adult equipment? With local trusts? Nationally?

19 Mersey Paediatric Airway Trolley Contents List For use in conjunction with the APA/DAS guidelines on unanticipated difficult tracheal intubation and cannot intubate and cannot ventilate Items in black are essential Items in red are optional Equipment List On top of the trolley Breathing circuit Suggested Item Jackson Rees modification of Ayres T piece if < 20 Kg Bain circuit if >20 kg Draw 1 Step A Mask Ventilation Facemasks size 0-5 Ambu Ultraseal facemasks size 0 5 HME filters Oropharyngeal Airways size Intersurgical CLEAR THERM MICRO: 3 8 kg Intersurgical CLEAR THERM MINI: 8 30 kg IntersurgicalCLEAR THERM 3: >30 kg Intersurgical oropharyngeal airways size Draw 2 - Step A - Direct Laryngoscopy Laryngoscope Blades Miller 00 Cardiff 00 Cardiff 1 Macintosh 2 Macintosh 3 Timesco Miller 00 + thin laryngoscope handle (for use in the smallest of premature neonates) Proact Cardiff 00 + thin handle for term neonates (Note Proact blade is not compatible with Timesco handle) Proact Cardiff 1, for use in infants Timesco Macintosh 2 + handle, for use in small children Timesco Macintosh 3 blade, for use in larger children Endotracheal Tubes Uncuffed ET Tubes I.D. 2.0 mm -7.0 mm Portex tracheal tube Oral/ Nasal Siliconised: I.D. 2.0 mm 7.0 mm Cuffed ET Tubes I.D mm Kimberley-Clarke Microcuff endotracheal tubes: I.D. 3.0 mm 7.0 mm

20 Draw 3 Step A- If there is a poor view with Direct Laryngoscopy McCoy laryngoscopes Penlon McCoy laryngoscopes size 1 4 Airtraq And/or Infant: size 0: ETT mm, Paediatric: size 1: ETT mm, Small: size 2: ETT 6 7.5mm, Regular: size 3: ETT C-MAC And/or C-MAC video laryngoscope with Miller size 0 and 1 blades + Macintosh 3 and 4 blades Draw 4 - Step B- Supraglottic Airway Device (SAD) Insertion LMA size 1, 1½, 2, 2½, 3, 4 Ambu AuraOnce Laryngeal masks size 1 4 (advantage = great ease of insertion) LMA for Fibreoptic intubation P3 Medical LMA (The stem has less of an acute angle compared to the Ambu AuraOnce Laryngeal mask; Guidewires for FOI COOK TSF easier when using a fibrescope via the LMA) Draw 5 Step C- Cricothyroidotomy Narrow bore cricothyroidotomy VBM Jet ventilation catheter size 16G, 14G and 13G Wide bore cricothyroidotomy Quicktrach Infant 1.5 mm ID, Child 2 mm ID and, Adult 4mm ID VBM manujet or Enk oxygen flow modulator, COOK medical Seldinger/ Surgical Scalpel + Handle Universal Melker Cricothyroidotomy Set

21 Hospital protocols and difficult airway algorithms Getting equipment to the patient or the patient to equipment (anaesthetic machine) Getting the right help - anaesthetic phone ODP Drugs

22 4

23

24

25

26

27

28

29

30

31 Training gaining and maintaining technical skills Courses Manikin practice Clinical attachments (certificate of honorary practice) Share difficult airways Practice in routine lists

32 Non technical skills High anxiety high stress situation Parents Nursing staff Other clincians Huge sigh of relief at the arrival of the anaesthetist

33 Multi tasking at speed under pressure Requirement to rapidly assess the situation Formulate and execute a plan whilst managing the airway Leadership but you are not able to stand back Delegation, situational awareness, clear instructions, closed loop communications

34 Decision making in critical situations Anaesthesia 2015; 70: Clinical crisis which may be unstable, complex and time-critical Grey rather than black and white situations External and internal factors

35 Can we improve decision making? Debriefing Why was this decision made? Reflection/insight Understand the complexity of decision making Understand your own frame of reference

36 Cognitive aids The effect of a displayed cognitive aid on non-technical skills in a simulated can t intubate, can t oxygenate crisis Anaesthesia 2014; 69:

37 Are you prepared? Have the right equipment Know how to get it where you need it Know how to get the help you need Keep your knowledge up to date Keep technical skills up to date Use simulation, debriefing and reflection to develop non technical skills