Print “PDF version”
What’s New in the
Patient Safety World
October 2022
Preventing
Unrecognized Esophageal Intubation
Because preventable mortality and serious morbidity from
unrecognized esophageal intubation continue to occur worldwide, a group of
medical specialty societies came together to publish a new guideline.
Unrecognized esophageal intubation
results in profound hypoxemia, brain injury and death. Such events occur in the
hands of both inexperienced and experienced practitioners. The new guideline (Chrimes
2022) focuses on both
prevention of esophageal intubation and prompt recognition and correction when
it does occur.
“The detection of ‘sustained exhaled carbon dioxide’ using waveform capnography is the mainstay for excluding esophageal placement of an intended tracheal tube. Tube removal should be the default response when sustained exhaled carbon dioxide cannot be detected.”
The guideline also focuses on strategies to address cognitive biases and the deterioration of individual and team performance in stressful situations, to which all practitioners are vulnerable.
Key recommendations in the guideline:
· Exhaled carbon dioxide monitoring and pulse oximetry should be available and used for all episodes of airway management.
· Routine use of a videolaryngoscope is recommended whenever feasible.
· At each attempt at laryngoscopy, the airway operator is encouraged to verbalize the view obtained.
· The airway operator and assistant should each verbalize whether ‘sustained exhaled carbon dioxide’ and adequate oxygen saturation are present.
· Inability to detect sustained exhaled carbon dioxide requires esophageal intubation to be actively excluded.
· The default response to the failure to satisfy the criteria for sustained exhaled carbon dioxide should be to remove the tube and attempt ventilation using a facemask or supraglottic airway.
· If immediate tube removal is not undertaken, actively exclude esophageal intubation: repeat laryngoscopy, flexible bronchoscopy, ultrasound and use of an esophageal detector device are valid techniques.
· Clinical examination should not be used to exclude esophageal intubation.
· Tube removal should be undertaken if any of the following are true:
o Esophageal placement cannot be excluded
o Sustained exhaled carbon dioxide cannot be restored
o Oxygen saturation deteriorates at any point before restoring sustained exhaled carbon dioxide
· Actions should be taken to standardize and improve the distinctiveness of variables on monitor displays.
· Interprofessional education programs addressing the technical and team aspects of task performance should be undertaken to implement these guidelines.
References:
Chrimes N, Higgs A, Hagberg .A, et al. Preventing unrecognised oesophageal intubation: a consensus guideline from the Project for Universal Management of Airways and international airway societies*. Anaesthesia 2022; First published: 17 August 2022
https://associationofanaesthetists-publications.onlinelibrary.wiley.com/doi/10.1111/anae.15817
Print “PDF version”
http://www.patientsafetysolutions.com/
What’s New in
the Patient Safety World Archive