title: Emergency Surgical Airways Following Activation of a Difficult Airway Management Team in Hospitalized Critically Ill Patients: A Case Series.
abstract: BACKGROUND
  An emergency surgical airway (ESA) is widely recommended for securing the airway in critically ill patients who cannot be intubated or ventilated. Little is known of the frequency, clinical circumstances, management methods, and outcomes of hospitalized critically ill patients in whom ESA is performed outside the emergency department or operating room environments.
  
  
  METHODS
  We retrospectively reviewed all adult patients undergoing ESA in our intensive care units (ICUs) and other hospital units from 2008 to 2012 following activation of our difficult airway management team (DAMT).
  
  
  RESULTS
  Of 207 DAMT activations for native airway events, 22 (10.6%) events culminated in an ESA, with 59% of these events occurring in ICUs with the remainder outside the ICU in the context of rapid response team activations. Of patients undergoing ESA, 77% were male, 63% were obese, and 41% had a history of a difficult airway (DA). Failed planned or unplanned extubations preceded 61% of all ESA events in the ICUs, while bleeding from the upper or lower respiratory tract led to ESA in 44% of events occurring outside the ICU. Emergency surgical airway was the primary method of airway control in 3 (14%) patients, with the remainder of ESAs performed following failed attempts to intubate. Complications occurred in 68% of all ESAs and included bleeding (50%), multiple cannulation attempts (36%), and cardiopulmonary arrest (27%). Overall hospital mortality for patients undergoing ESA was 59%, with 38% of deaths occurring at the time of the airway event.
  
  
  CONCLUSIONS
  An ESA is required in approximately 10% of DA events in critically ill patients and is associated with high morbidity and mortality. Efforts directed at early identification of patients with a difficult or challenging airway combined with a multidisciplinary team approach to management may reduce the overall frequency of ESA and associated complications.
authors.affiliation: 1 Department of Critical Care Medicine, The University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
authors.forename: Joseph M
authors.initials: JM
authors.lastname: Darby
authors.affiliation: 2 Department of Anesthesiology, The University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
authors.forename: Gregory
authors.initials: G
authors.lastname: Halenda
authors.affiliation: 3 Department of Otolaryngology, The University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
authors.forename: Courtney
authors.initials: C
authors.lastname: Chou
authors.affiliation: 2 Department of Anesthesiology, The University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
authors.forename: Joseph J
authors.initials: JJ
authors.lastname: Quinlan
authors.affiliation: 4 Department of Surgery, The University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
authors.forename: Louis H
authors.initials: LH
authors.lastname: Alarcon
authors.affiliation: 4 Department of Surgery, The University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
authors.forename: Richard L
authors.initials: RL
authors.lastname: Simmons
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D058109:Airway Management / Q000009:adverse effects* / Q000379:methods* / Q000401:mortality / Q000592:standards; D003422:Critical Care / Q000379:methods* / Q000592:standards; D004636:Emergency Service, Hospital; D005260:Female; D006323:Heart Arrest / Q000209:etiology; D006470:Hemorrhage / Q000209:etiology; D006801:Humans; D007362:Intensive Care Units; D008297:Male; D008875:Middle Aged; D010348:Patient Care Team; D063868:Patient Outcome Assessment; D058996:Quality Improvement; D012140:Respiratory Tract Diseases / Q000209:etiology; D012189:Retrospective Studies
keywords: cricothyrotomy; critically ill; difficult airway; difficult airway team; emergency surgical airway