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INCREASED DOLLAR COSTS ASSOCIATED WITH DIFFICULT INTUBATION

THE ANESTHESIA CONSULTANT Leave a comment
THE ANESTHESIA CONSULTANT
THE ANESTHESIA CONSULTANT
Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
emailrjnov@yahoo.com
THE ANESTHESIA CONSULTANT
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The safe management of a difficult airway is the most important single skill for an anesthesiologist. Every critically ill patient is managed by the priority of A – B – C, or Airway – Breathing – Circulation. Just as the initial most important factors in real estate are location, location, location, the three initial important factors in a critically ill patient are airway, airway, airway. I’ve written previously on the American Society of Anesthesiologists 2022 modifications to their Difficult Airway Algorithm, on the importance of expert airway management, and on advice for avoiding lost airway lawsuits, but I haven’t discussed the economic consequences of each difficult airway patient.

A 2021 publication, “Factors and Economic Outcomes Associated with Documented Difficult Intubation in the United States,”  by Moucharite et al, studied the economic cost of a difficult intubation in hospitalized patients. Using data from the Premier Healthcare Database, the study looked at adult patients with inpatient surgical admissions during 2016, 2017, and 2018. Patients in the difficult intubation group had average inpatient costs $14,468 higher than patients without difficult intubations. Patients in the difficult intubation group had average ICU (intensive care unit) costs $4,029 higher than patients without difficult intubations. For difficult intubation patients the mean hospital length of stay was 3.8 days longer and ICU length of stay was 2.0 days longer. All data were significant to a p value of < 0.0001.

In California where I practice, these numbers would be significantly higher. The mean cost of a single hospital day in California is $4181, and the mean cost of an ICU day is significantly higher.

The Moucharite study was a large retrospective review of 2,233,751 cases from hospitals in all parts of the United States. With 609 cases in the difficult intubation group and 2,233,142 cases in the non-difficult intubation group, the incidence of difficult intubation was only 0.027%. Difficult intubation patients were more likely be male, black, less than 65 years old, and have urgent or emergent admissions, obesity, cancer, congestive heart failure, COPD, renal disease, and had been treated in a teaching hospital or a hospital of 500 beds or more.

Moucharite wrote, “Difficult intubation has been associated with a variety of complications including oxygen desaturation, hypertension, dental damage, admission to the intensive care unit, and complications at extubation, as well as arrhythmias, bronchospasm, airway trauma, CICV (can’t intubate, can’t ventilate), and sequela of hypoxia (cardiac arrest, brain damage, and death). This was consistent with a 2011 study of difficult airways from the British Journal of Anesthesia which stated, “Obesity markedly increases risk of airway complications. Pulmonary aspiration remains the leading cause of airway-related anesthetic deaths. . . . Unrecognized esophageal intubation is not of only historical interest and is entirely avoidable. . . . prediction scores are rather poor, so many failures are unanticipated . . . the first-pass success rate of intubation in the operating room ranges from only 63% to 85% . . . and up to 93% of difficult intubations are unanticipated.”

The Moucharite study has limitations. It’s a retrospective study of economic Big Data, and there is no direct evidence for a cause-and-effect relationship between a difficult intubation and a more costly hospitalization. The study does not include data from electronic medical records, so we have no knowledge on all the comorbidities and complications of the difficult intubation patients. The study included only hospitalized patients, even though seventy percent of surgical procedures in the United States take place in ambulatory surgery centers and offices outside of hospitals. The reported incidence of difficult intubation  is estimated to be 1.5–8.5% of the general population, but in  the Moucharite study only 0.027% of patients were found to have difficult intubation. This discrepancy implies some patients in the Moucharite study were difficult intubations but may have been assigned to the non-difficult intubation cohort.

Note that all three authors of the Moucharite study are employees of Medtronic, a medical device company which manufactures the McGrath videolaryngoscope.

McGRATH VIDEOLARYNGOSCOPE

I expect Medtronic could cite the Moucharite study as evidence that a videolaryngoscope (such as a McGrath) is a crucial piece of equipment for avoiding expensive difficult intubation outcomes. Moucharite wrote that there is, “a need for clinicians who perform tracheal intubations to carefully consider options . . . several studies demonstrated the benefits of videolaryngoscopy [emphasis added] including a shorter time required for tracheal intubation, a higher rate of successful intubations.”

For the first look when intubating a patient, most anesthesia providers still use a traditional direct laryngoscope:

MAC 3 DIRECT LARYNGOSCOPE

 

If the direct laryngoscope does not enable a successful intubation, a reasonable second step is to switch to a videolaryngoscope such as the GlideScope, manufactured by Verathon:

GLIDESCOPE

or the C-MAC, manufactured by Karl Storz:

C-MAC

 

or the McGrath, manufactured by Medtronic:

McGRATH VIDEOLARYNGOSCOPE

 

In my experience the larger 6.4-inch screen on a GlideScope or the 5.9-inch screen on a C-MAC makes them superior videolaryngoscopes to the McGrath with its diminutive 2.5-inch screen.

Why use a direct laryngoscope in the initial intubation attempt rather than use a videolaryngoscope? A direct laryngoscope costs less than a videolaryngoscope. Most direct laryngoscopes blades are washed and reused. Videolaryngoscopes require a new disposable sleeve or blade for every case. In facilities with budget concerns, replacing all traditional laryngoscopes with videolaryngoscopes would be expensive. A McGrath costs about $2500 on eBay, and each new nonreusable blade cover costs about $10. A new GlideScope was $12,745 in 2017. A reconditioned GlideScope costs between $1000 and $10,000 on eBay, and each new nonreusable blade costs $38.

A 2022 study comparing direct laryngoscopy to videolaryngoscopy concluded that “videolaryngoscopy likely provides a safer risk profile compared to direct laryngoscopy for all adults undergoing tracheal intubation.” A recent review  stated that, “Though videolaryngoscopes have been recommended for use at first attempt of intubation by most international airway guidelines, the universal use of videolaryngoscopes is still facing hurdles because of limited training opportunities, availability and high cost.”

Should a videolaryngoscope replace a direct laryngoscope for all initial intubation attempts? I don’t think so. The majority of intubations are straightforward and are successful with a Miller 2 or a Mac 3 direct laryngoscope. Should a videolaryngoscope be available as a back-up piece of equipment for every intubation? Absolutely. The ASA Difficult Airway Algorithm includes the possible use of a videoscope, and states,
“Consider the relative merits and feasibility of basic management choices:  (consider) video-assisted laryngoscopy as an initial approach to intubation.” An anesthesia provider who initiates general anesthesia and intubation without an immediately available videolaryngoscope is in danger of not being able to follow the algorithm. The hospital I work in is stocked with either the GlideScope and the C-MAC both readily available for difficult intubations. The availability of a videolaryngoscope for either a first attempt or for backup attempts to intubate a difficult airway patient is vital.

Difficult airway cases can lead to malpractice claims. A 2009 study published in Anesthesiology showed that 2.3% of 2,211 anesthesia-related deaths in the United States from 1999-2005 were attributable to difficult intubation and failed intubation.  A 2019 study from the Anesthesia Closed Claims Project database showed that the 102 difficult intubation closed malpractice claims from 2000 to 2012 included sicker patients (n = 78 of 102), emergency procedures (n = 37 of 102), and non-perioperative locations (n = 23 of 102).  Preoperative predictors of difficult tracheal intubation were present in only 76% of the patients. Inappropriate airway management occurred in 71 patients. A “can’t intubate, can’t oxygenate” emergency occurred in 80 of the 102 claims, with a delayed surgical airway occurring in 39% of those cases. The authors wrote, “outcomes remained poor in recent malpractice claims related to difficult tracheal intubation. Inadequate airway planning and judgment errors were contributors to patient harm.”

In conclusion: Difficult intubations are a major anesthesia problem, because of: 1) the difficulty in identifying difficult intubation patients prospectively, 2) the medical comorbidities that occur with difficult airway patients, 3) the medical complications that can occur if difficult airways are mismanaged, 4) the dollar cost of increased healthcare utilization as reported in the Moucharite study, and 5) the potential medical-legal liability risk with each difficult intubation.

SuperMorbidly Obese Patient with a Difficult Airway

 

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The most popular posts for laypeople on The Anesthesia Consultant include: How Long Will It Take To Wake Up From General Anesthesia? Why Did Take Me So Long To Wake From General Anesthesia? Will I Have a Breathing Tube During Anesthesia? What Are the Common Anesthesia Medications? How Safe is Anesthesia in the 21st Century? Will I Be Nauseated After General Anesthesia? What Are the Anesthesia Risks For Children?

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include: 10 Trends for the Future of Anesthesia Should You Cancel Anesthesia for a Potassium Level of 3.6? 12 Important Things to Know as You Near the End of Your Anesthesia Training Should You Cancel Surgery For a Blood Pressure = 170/99? Advice For Passing the Anesthesia Oral Board Exams What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

READ ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM

AVOIDING AIRWAY DISASTERS IN ANESTHESIA

THE ANESTHESIA CONSULTANT 8 Comments
THE ANESTHESIA CONSULTANT
THE ANESTHESIA CONSULTANT
Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
emailrjnov@yahoo.com
THE ANESTHESIA CONSULTANT
Latest posts by THE ANESTHESIA CONSULTANT (see all)

Every anesthesia practitioner dreads airway disasters.  Anesthesiologists and nurse anesthetists are airway experts, but anesthesia professionals are often the only person in the operating room capable of keeping a patient alive if the patient’s airway is occluded or lost. Hypoxia from an airway disaster can lead to brain damage within minutes, so there is little time for human error.

A fundamental skill is the ability to assess a patient’s airway prior to anesthesia. One must assess whether the patient will pose: 1) difficult bag-mask ventilation, 2) difficult supraglottic/laryngeal mask airway placement, 3) difficult laryngoscopy, 4) difficult endotracheal intubation, or 5) difficult surgical airway.

Of critical importance is #1) above, that is, recognizing the patient who will present difficult mask ventilation. Conditions that make for difficult bag-mask ventilation are uncommon, and usually can be detected during physical examination. Despite the importance of expertise in endotracheal intubation, I teach residents and trainees that the most important airway skill is bag-mask ventilation. Every year I encounter several patients who present unanticipated difficult intubations. In each of these patients, I’m able to mask ventilate the patient to keep them oxygenated while I try various strategies and techniques to successfully place an endotracheal tube or a laryngeal mask airway.

Most anesthesia airway disasters aren’t merely difficult intubations, but scenarios that are classified as “can’t intubate, can’t ventilate.” In these “can’t intubate, can’t ventilate” situations, the anesthesiology professional has only minutes to restore oxygenation to the patient or else the risk of permanent brain damage is very real.

The American Society of Anesthesiologists Difficult Airway Algorithm is a guide for anesthesia practitioners regarding how proceed in airway management. The algorithm is detailed, complex, comprehensive, and defines the standard of care in any medical-legal battle concerning hypoxic brain damage due difficult airway clinical cases. The algorithm is so detailed, complex, and comprehensive that some would say it’s impossible to remember every step in the acute occurrence of an airway disaster.

A simplified approach has been touted.

Dr. C. Philip Larson, Professor Emeritus, Anesthesia and Neurosurgery, Stanford University, and Professor of Clinical Anesthesiology at UCLA, and previous Chairman of Anesthesiology at Stanford, was one of my teachers and mentors for both endotracheal intubation and fiberoptic intubation. In a Letter to the Editor of the Stanford Gas Pipeline in May, 2013, Dr. Larson wrote, “there is no scientific evidence that anesthesia is safer because of the ASA Difficult Airway Algorithm.  While an interesting educational document, I question the daily clinical value of this algorithm, even in its most recent form (Anesthesiology 2013; 118:251-70). The ASA Difficult Airway Algorithm was developed by committee and has all the problems that result when done that way.  It is complex, diffuse, multi-dimensional, and all-encompassing such that it is not an instrument that one can easily adopt and practice in the clinical setting.”

Dr. Larson recommends a system of Plans A-D, a system he published in Clinical Anesthesiology, editors Morgan GE, Mikhail MS, Murray MJ, Lange Medical publication, 4th edition, 2006, pp 104-5, and in Current Reviews in Clinical Anesthesiology (2009; 30:61-72), and also in the Appendix on airway management and intubation in the newest edition of Anesthesiologists Manual of Surgical Procedures by Richard Jaffe et al (Lippincott Williams and Wilkins, 5th Edition, May 2014). An outline of the system is as follows:

A.  Plan A is direct laryngoscopy an intubation using a Miller or MacIntosh blade.

B.  If Plan A is unsuccessful, Plan B includes use of video laryngoscopy with a GlideScope or similar device.

C.  If Plan B is unsuccessful, Plan C is placement of an LMA with intubation through that LMA using a fiberoptic bronchoscope.

D.  “If Plans A-C fail,” Larson wrote in his Letter to the Editor of the Stanford Gas Pipeline in May, 2013, “one needs Plan D.  The first and perhaps the most prudent option is to cancel the proposed operation, terminate the anesthetic, and wake the patient up. The operation would be rescheduled for another day, and at that time an awake fiberoptic intubation technique would be used.  Alternatively, if the operation cannot be postponed, then the surgeon should be informed that a surgical airway (i.e.: tracheostomy) must be performed before the planned operation can commence.  To date, utilization of Plan D because of failure of Plans A-C has not occurred.”

Dr. Larson wrote that the airway skills in Plan A – C should be practiced regularly on patients with normal airways. I agree with Dr. Larson that in managing difficult airways, a practitioner needs a short list of procedural skills that he or she is expert at rather that a large array of procedures that they rarely use (such as the alternative intubation techniques using light wands or blind nasal techniques, or invasive airway procedures such as retrograde wires passed through the cricothyroid membrane or transtracheal jet ventilation through a catheter). It’s wise for anesthesiologists to regularly hone their techniques of video laryngoscopy (Plan B) and fiberoptic intubation via an LMA (Plan C) on patients with normal airways, to remain expert with these skills.

Regarding Plan B, an important advance is the availability of portable, disposable video laryngoscopes such as the Airtraq, a guided video intubation device. In my career I sometimes work in solo operating room suites distant from hospitals. In these settings, the operating room is usually not be stocked with an expensive video scope such as the GlideScope, the C-MAC, or the McGrath 5. I carry an Airtraq in my briefcase, and if the need for Plan B arises I am prepared to utilize video laryngoscopy at any anesthetizing location. I suggest the practice of carrying an Airtraq to any anesthesiologist who gives general anesthetics in remote locations.

Regarding emergency surgical rescue airway management, Dr. Larson recently published a Letter to the Editor in the American Society of Anesthesiologists Newsletter, February 2014, entitled, Ditch the Needle – Teach the Knife. In this letter, Dr. Larson wrote:

“in life-threatening airway obstruction, … an emergency cricothyrotomy is much quicker, easier, safer and more effective than any needle-based technique. I can state with confidence that there is no place in emergency airway management for needle-based attempts to establish ventilation. It should be deleted from the ASA Difficult Airway Algorithm. I have participated in seven cricothyrotomies in emergency airway situations, and all of the patients left the hospital without any neurological injury or complications from the cricothyrotomy. The risk-benefit ratio is markedly in favor the knife technique…. With a knife, or scissors, one cuts quickly either vertically or horizontally below the thyroid cartilage and there is the cricothyroid membrane or tracheal rings. The knife is inserted into the trachea and turned 90 degrees, and an airway is established. At that point, a small tube of any type can be inserted next to the knife. The knife technique is much safer because there is virtually nothing that one can harm by making an incision within two inches or less in the midline of the neck, and it can be performed in less than 30 seconds. In contrast, the needle is fraught with complications, including identifying the trachea, making certain that the needle is entirely in the trachea and does not move ( to avoid subcutaneous emphysema when an oxygen source is established), establishing a pressurized oxygen delivery system (which will take more than five minutes even in the most experienced circumstances), and avoiding causing a tension pneumothorax… I know of multiple cases of acute airway obstruction where the needle technique was attempted, and in all cases the patients died. I know of no such cases when a cricothyrotomy was used as the primary treatment of acute airway obstruction.”

A final note on the awake intubation of patients with a difficult airway: In hindsight in any difficult airway case, one often wishes they had secured an endotracheal tube prior to the induction of general anesthesia. The difficult problem is deciding prior to a case which patient has such a difficult airway that the induction of general anesthesia should be delayed until after intubation. In anesthesia oral board examinations it may be wise to say you would perform an awake intubation on a difficult airway patient rather than risk the “can’t intubate, can’t ventilate” scenario the examiner is probably poised to skewer you with. In medical malpractice lawsuits, plaintiff expert witnesses in anesthesia airway disaster cases often testify that a brain-dead patient’s life would have been saved if only the anesthesiologist had performed awake intubation rather than inducing general anesthesia first and then losing the airway. The key question is: how does one decide which patient needs an awake intubation? As an anesthesia practitioner, if you performed awake intubations on one out of 50 cases because you were worried about a difficult airway, you would delay operating rooms and surgeons multiple times per year because of your caution. You will not be popular if you do this. In my clinical practice and in the practice of the excellent Stanford anesthesiologists I work with, the prevalence of awake intubation is very low. I estimate most anesthesiologists perform between zero and two awake intubations per year. The most common indications include patients with severe ankylosing spondylitis of the cervical spine, congenital airway anomalies, and severe morbid obesity. Dr. Larson wrote in his Letter to the Editor of the Stanford Gas Pipeline in May, 2013, “I do anesthesia for most of the patients with complex head and neck tumors, and I find fewer and fewer indications for awake fiberoptic intubation. As long as the lungs can be ventilated by bag-mask or LMA, which is true for almost all sedated patients, Plan C is easier, quicker and safer than awake fiberoptic intubation both for the patient and the anesthesia provider.  In experienced hands, Plan C can be completed in less than 5 minutes, and one can become proficient by practicing in normal patients. I have done hundreds of Plan C’s, many under difficult circumstances, without a single failure or complication.  Obviously, no technique will encompass every conceivable airway problem, but mastering Plans A-D and awake oral and nasal fiberoptic intubation will meet the needs of anesthesia providers in almost all circumstances.”

May you never experience the  emotional trauma of an airway disaster. Become an expert in bag-mask ventilation, always have access to a video laryngoscope or an Airtraq, and consider  Dr. Larson’s  Plan A-D system, described in detail in the Appendix on airway management and intubation in the newest edition of Anesthesiologists Manual of Surgical Procedures by Richard Jaffe et al (Lippincott Williams and Wilkins, 5th Edition, May 2014).

 

The most popular posts for laypeople on The Anesthesia Consultant include:

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

 

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Published in September 2017:  The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.

KIRKUS REVIEW

In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.

Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.

Nuanced characterization and crafty details help this debut soar.

Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:

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Learn more about Rick Novak’s fiction writing at ricknovak.com by clicking on the picture below:  

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