Unexpected Oesophageal Intubation - DAS Members EZINE January 2022

January 2022

UNEXPECTED OESOPHAGEAL INTUBATION | Learning from events | Many DAS members will be familiar with the case of Mrs Glenda Logsdail, a former NHS Radiographer, who tragically died after being anaesthetised for a ‘straight-forward’ case of acute appendicitis.

The Coroner recorded the cause of her death as “hypoxic-ischaemic encephalopathy resulting from a failure to correct a misplaced endotracheal tube.” He went on to add, “Her death was wholly avoidable and was contributed to in major part by neglect.”

The Coroner subsequently issued a Regulation 28: Report to Prevent Future Deaths, speci cally identifying the Royal College of Anaesthetists as a body who had the power to prevent such deaths in the future.

[The primary purpose of a Regulation 28 order is to prevent other deaths from similar causes or risks, so it's sent to those who are in a position to take action to reduce the risk] The Presidents of the RCoA, DAS and the Association of Anaesthetists issued a joint letter in response which recognised the importance of Human Factors, a attened hierarchy ( attened authority gradient) and in situ multidisciplinary team training in dealing with emergency situations. The letter can be viewed here.

The case is currently featured on the RCoA website, was discussed during Professor Cook’s keynote lecture at the recent DAS annual scienti c meeting, presented in detail at the joint DASSALG meeting also in November 2021, and will have had an entire session dedicated to it during the College’s Winter Symposium in December 2021.

Any discussion of the events surrounding Mrs Logsdail’s death must be sensitive and sympathetic but should recognise and build on her family’s commitment to ensure that this does not happen again.

So what do we know about unrecognised oesophageal intubation already?

In the last ve years the President of the RCoA has received seven Regulation 28 orders related to the airway and undetected oesophageal intubation has been sadly a recurring theme.

NAP41 was clear that, even during a cardiac arrest, an attenuated capnograph waveform should be seen with a tracheal tube in situ. Other causes of a at capnography trace do exist but in the event of a at capnograph trace active exclusion of oesophageal intubation should be the rst priority.

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Dif cult Airway Society E-Zine

Dif cult Airway Society E-Zine

January 2022

[image taken from the NAP4 report] Given the Coroner’s report, the ‘No Trace Wrong Place’ video is essential viewing for every anaesthetist, who must consider its implications for their practice. Much like the pre-take off safety brie ng on an aircraft, even those who have seen it before, anaesthetists and anyone who manages the airway would bene t from seeing it again.

Watch the “No Trace Wrong Place” video here.

In the case of Mrs Logsdail, the coroner speci cally highlighted the role of Human Factors, including the facts that we, as humans, are fallible and liable to make mistakes however well trained, hardworking and conscientious we are. Our physiological make up means that we tend to perform less well in high pressure situations (in short, everything that makes us behave entirely unlike a predictable machine). But what does that mean in practice?

No one involved in airway management would ever intentionally place a tracheal tube in the oesophagus. Similarly, every anaesthetist knows that an absent CO2 trace means that accidental oesophageal intubation must be excluded.

So, what goes wrong and, more importantly, how can it be prevented?

The suggestions below encompass the Human Factors and Ergonomics subjects of Design, (stopping errors from occurring in the rst place), Barriers (a way of trapping/ identifying errors and preventing harm) and Mitigations (strategies for reducing the potential impact of an error).

For a more technical analysis of these aspects please see the article by Joy and Kelly.

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Dif cult Airway Society E-Zine

January 2022

i. Use the best tools – the process of tracheal intubation is a technical skill which can be taught and learnt. The Cochrane Review in 20162 proved that videolaryngoscopy (VL) is more effective than conventional (direct) laryngoscopy at successfully placing a tracheal tube.

Therefore, using the best equipment will make this easier, freeing up headspace for nontechnical skills.

The VL screen allows a shared view of intubation, but it must be positioned in a way that helps an assistant see exactly what is happening. If using a device with an integrated screen, the operator and assistant must consider how to share the view. ii. Use the best assistance – trained practitioners to assist the anaesthetist are vital. To provide best assistance (and therefore improve team performance) we must: a. Train Together – Ahead Ahead of the 2019 grand prix season the Williams Formula 1 Team (responsible for two cars in a race) had practised pitstops over 1200 times to make the team as ef cient as possible.3 The option of rehearsing an intubation with the same team 1200 times before doing it is clearly unrealistic but training together is vital. DAS has always been at the forefront of encouraging training together – please see the details of the SMART Course from 2011 here.

[This doesn’t mean that there us anything wrong with an individual’s attendance at a (national) airway workshop – but it is vital that the learning is shared locally upon their return] b. Train locally – Develop an institutional awareness and knowledge. One of the problems in this case was that the airway pressure trace was mistaken as the capnograph trace by one doctor. Standardisation of theatre monitor layout within a hospital (perhaps nationally or even internationally), both in terms of colour and position on the screen, could help prevent this. c. Empower colleagues – Multidisciplinary team training and good brie ng can empower nonanaesthetists, and less senior colleagues, to speak up. If they are concerned that the tracheal tube may be incorrectly positioned anyone, regardless of grade, should be able to say “if there is ‘No Trace’ we should actively exclude oesophageal intubation”. In a crisis anyone can become task- xated and ‘inadvertently blind’ to other possibilities. iii. Space and Time – Since the introduction of the 2015 guidelines (which state that a right handed person should stand on a patient’s left to perform eFONA) the amount (or lack) of available space to conduct procedures in the anaesthetic room has been a recurring issue amongst delegates attending airway workshops. The cramped conditions of an anaesthetic room were highlighted by the Coroner in his report. Is it time for all emergency cases to be anaesthetised in theatre – or at least time for a rethink on where we anaesthetise our patients in the UK? Patients are routinely anaesthetised in the operating theatre in other countries and COVID-19 has made us more familiar with this style of working.

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Dif cult Airway Society E-Zine

January 2022

Time to train – multidisciplinary training requires team members to be free to attend training together – short, targeted interventions e.g. before the start of a list may make this possible.

None of these suggestions will be new to anaesthetists, but they are important considerations to integrate into the behaviour of an individual, a department and an institution – indeed for every team member involved in airway management.

There are of course topics for discussion; many Airway Leads already provide excellent local training in airway management for the multidisciplinary team. Asking the question “should provision or attendance at such events be mandatory?”, is much more complex than it

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appears as it will require the collaboration of many stakeholders to achieve. However, in light of this case, aspiring to mandatory local provision of multidisciplinary training must remain rmly on the DAS agenda.

The Dif cult Airway Society will be working together with the Royal College of Anaesthetists and the Association of Anaesthetists to ensure that the lessons of the case are effectively communicated such that future events can be avoided.

Dr Imran Ahmad

Dr Barry McGuire

DAS President

DAS Immediate Past President

Dr Alistair McNarry

Dr Abhijoy Chakladar

Dr Lewys Richmond

Airway Leads Co-ordinator

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Dif cult Airway Society E-Zine

January 2022

Image courtesy of Dr Fiona Kelly, highlighting that well designed systems are better at preventing errors than any other intervention.

References 1.

Cook T, Woodall N, Frerk C. 4th National Audit Project of The Royal College of Anaesthetists and The Dif cult Airway Society (NAP4) Major complications of airway management in the United Kingdom. Report and ndings. Cook T, Woodall N, Frerk C, editors. London;

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Lewis SR, Butler AR, Parker J, Cook TM, Smith AF. Videolaryngoscopy versus direct laryngoscopy for adult patients requiring tracheal intubation. In: Lewis SR, editor.

Cochrane Database Syst Rev [Internet] UK: John Wiley & Sons, Ltd; 2016 [cited 2017 Jun 13]. p. CD011136 Available from: http://www.ncbi.nlm.nih.gov/pubmed/27844477

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No Title [Internet]. [cited 2021 Nov 29]. Available from: https://www.formula1.com/en/ l a t e s t / a r t i c l e . g o n e - i n - 1 - 8 8 s - p u t t i n g - t o g e t h e r- t h e - p e r f e c t - f 1 - p i t stop.3lLKnEoPKdJgACsUn9IltC.html

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