A 45-year-old patient has been admitted to your ICU with community acquired pneumonia.
During a drug infusion they develop wide-spread urticaria, severe wheeze and marked swelling of the face and tongue.
All signs and symptoms are rapidly worsening despite 0.5 mg IM adrenaline and 100mg IV hydrocortisone. Assume the specific management of anaphylaxis is correct and ongoing.
Outline your plan for intubation in this patient.
(10 marks)
Syllabus topic/section: 2.1.5b Airway Management and 2.1.10 Anaphylaxis
Discussion:
While there's no single approach to ICU airway management, this case, as presented, needed urgent RSI with a plan for deterioration. Many candidates answered this question well with a structured approach to emergency airway management in ICU.
Good answers included the need for a team approach to urgent RSI with videolaryngoscope, simultaneous set up for FONA and included appropriate monitoring, positioning and appropriate drugs. Above standard answers also included the limitations of supra-glottic devices, and the concurrent issues with vasodilatation and bronchospasm from the anaphylaxis.
Answers that did not score well tended to make unsafe statements about awake fibreoptic intubation or airway topicalisation, made generic statements about a difficult intubation approach or lacked any detail to the technique they had chosen.
The rubric is provided to aid in the candidate's future study
Rubric
|
Below standard |
At standard |
Above standard |
|
|
Outline your intubation plan for this patient. (10 Marks) |
Answer represents unsafe practice Answer given is a generic intubation and not directed to the scenario listed Major omissions / lack of detail in the answer Does not recognise the need to prepare for a difficult intubation eg include the relevant personnel that would be required Detail around management of the anaphylaxis does not attract marks as the candidate has been told this is correct and ongoing 0 - 4.5 marks |
Overall reflects safe and competent practice Consider the following for the standard: This tends to reflect the contents of an intubation checklist: For example: -Urgent need for intubation -Anticipated difficult airway with high possibility of FONA and includes a range of equipment that would be needed (small ETT, video laryngoscope, bougie, FONA kit) -Role allocation including the need for anaesthetics or experienced clinician to manage airway Level of detail provided should be appropriate to ensure a safe intubation in this patient 5 - 7 marks |
At standard PLUS Includes more detail with rationale for interventions clearly stated Consider the following for an above standard answer: Includes appropriate drug doses / rescue pressors / fluid management Demonstrates knowledge of specific airway algorithms Notes additional challenges of vasoplegia / high airway pressures in anaphylaxis 7.5 - 10 marks |
"Outline your plan" is a clearly management-oriented question, and so elaborate discussions of the assessment of airway difficulty will not have scored much marks. Still, "A" seems like a good place to start:
Preparation of the staff
Preparation of the equipment
Preparation of the patient
Frerk, C., et al. "Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults." British journal of anaesthesia 115.6 (2015): 827-848.
Heidegger, T. "The 2015 Difficult Airway Society guidelines: what about the anticipated difficult airway." Anaesthesia 71 (2016): 592
Apfelbaum, Jeffrey L., et al. "Practice Guidelines for Management of the Difficult Airway An Updated Report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway." The Journal of the American Society of Anesthesiologists 118.2 (2013): 251-270.