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GENERAL ARTICLES

Emergency Tracheal Intubation: Complications Associated with Repeated Laryngoscopic Attempts

Department of Anesthesiology, Hartford Hospital, University of Connecticut School of Medicine

Address correspondence and reprint requests to Thomas C. Mort, MD, Senior Associate, Anesthesiology, Hartford Hospital, 80 Seymour Street, Hartford, CT 06102. Address e-mail to tmort{at}harthosp.org

Repeated conventional tracheal intubation attempts may contribute to patient morbidity. Critically-ill patients (n = 2833) suffering from cardiovascular, pulmonary, metabolic, neurologic, or trauma-related deterioration were entered into an emergency intubation quality improvement database. This practice analysis was evaluated for airway and hemodynamic-related complications based on a set of defined variables that were correlated to the number of attempts required to successfully intubate the trachea outside the operating room. There was a significant increase in the rate of airway-related complications as the number of laryngoscopic attempts increased (2 versus >2 attempts): hypoxemia (11.8% versus 70%), regurgitation of gastric contents (1.9% versus 22%), aspiration of gastric contents (0.8% versus 13%) bradycardia (1.6% versus 21%), and cardiac arrest (0.7% versus 11%; P < 0.001). Although predictable, this analysis provides data that confirm the number of laryngoscopic attempts is associated with the incidence of airway and hemodynamic adverse events. These data support the recommendation of the ASA Task Force on the Management of the Difficult Airway to limit laryngoscopic attempts to three in lieu of the considerable patient injury that may occur.

IMPLICATIONS: Intraoperative blood glucose control with 1 U of insulin for every 1–50 mg of blood glucose value more than 100 mg/dL added to 100 mL of 5% dextrose in a measured volume set was tested hourly. It is a simple and effective method and combines the advantages of combined glucose insulin and variable rate insulin infusion.

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