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Difficult Airway – Learn From Closed Malpractice Claims

November 7, 2019

Written by Clay Smith

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Learn from mistakes. These are closed anesthesia malpractice claims in patients with difficult airways. Read on to avoid the same errors.

Why does this matter?
In an era of difficult airway algorithms and better devices, how are we doing with respect to outcomes? It’s not pretty…

Learn from failure
This was an analysis of closed anesthesia malpractice claims. They compared 93 cases from the period of 1993 to 1999 to 102 cases from 2000 to 2012. The later patient group had higher ASA status and more emergent airways. Difficult airways took place outside the OR more often in the later group as well: areas such as PACU, ICU, ward, or ED. Most events took place at induction in both groups. A larger percentage of patients in the latter group died or had brain damage than in the earlier group, OR 5.5 (95%CI 1.07 – 28.4). However, airway injury was more common in the earlier group. In the 2000-2012 group, 76% had predictors of a difficult airway; half had 2 or more. The majority of these claims were “can’t intubate, can’t oxygenate” scenarios. Placement of a surgical airway was delayed in 40% of these cases. In 73% of cases, airway management was deemed inappropriate. However, in 23%, there was no failure in judgment that led to the failed airway.

The big three errors leading to failure were:

  1. Lack of a plan for a “can’t intubate, can’t oxygenate” situation – Elective cases were actually worse than emergent cases, likely due to a false sense of security.

  2. Failure to use a supraglottic airway to oxygenate after failed intubation attempt – A SGA can act as a bridge to oxygenate after intubation failure.

  3. Delay in placing a surgical airway – Often, the difficult airway cart was unavailable. Also, anesthesiologists didn’t often do this themselves. It was usually the surgeon who did it.

Management of Difficult Tracheal Intubation: A Closed Claims Analysis. Anesthesiology. 2019 Oct;131(4):818-829. doi: 10.1097/ALN.0000000000002815.

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