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Paediatric Emergency Intubation Checklist

A Service Improvement Project

Dr Ollie de Brett (ST6) Dr Ray Ackwerh (Consultant UCLH)

Emergency airway management of critically ill children is a stressful undertaking for even the seasoned anaesthetist. They are often carried out in remote or new environments, with inexperienced team members and unfamiliar equipment. The 4th National Audit Project revealed that out of theatre intubations were especially fraught and had significant morbidity and mortality associated with them(1). The APRICOT study revealed 5.3% serious adverse events in children under the age of 15 undergoing general anaesthesia (2). University College Hospital, London is a busy teaching hospital carrying out over 2000 paediatric general anaesthetics per year. We are the local Accident and Emergency department to Great Ormond Street and see a number of sick and syndromic children presenting through the Emergency Department.

Introduction

To create a Paediatric Emergency Intubation Checklist specific to our trust. To improve patient safety. Aid junior and non-paediatric anaesthetists in emergency intubation of critically ill child.

Aims

The introduction of our Paediatric Emergency Intubation Checklist has been well received by anaesthetics, paediatrics, emergency and theatre departments. It is an invaluable aid to planning and carrying out anaesthesia of the critically ill child. Implementation has had entirely positive feedback and we believe it has improved paediatric emergency care within our trust, improved the confidence of the team caring for the critically ill child as well. Ultimately, paediatric patient safety has been improved.

Conclusion

References 1. Cook, T.M., Woodall, N., Harper, J. & Benger, J. Major complications of airway management in the UK; results of the Fourth National Audit Project of the Royal College of Anaesthetists. British Journal of Anaesthesia 2011; 106: 632–642 2. Habre W et al. APRICOT Group of the European Society of Anaesthesiology Clinical Trial Network. Incidence of severe critical events in paediatric anaesthesia (APRICOT): a prospective multicentre observational study in 261 hospitals in Europe. Lancet Respir Med. 2017 May;5(5):412-425.

Olivier de Brett ST6 Anaesthetics University College Hospital, London o.debrett@nhs.net

Contact

Having identified the need for a paediatric emergency intubation checklist, we reviewed the literature and based the lay out on the pro forma in NAP4. The single sheet checklist was split into four sections: Prepare the TEAM, Prepare the PATIENT, Prepare the EQUIPMENT and Prepare for DIFFICULTY. Prepare the TEAM ensures the most appropriate staff are available and includes introduction of members and delegation of roles such as 1st intubator and cricoid pressure. Prepare the PATIENT ensures the most appropriate location for intubation is chosen, optimisation of cardiovascular and respiratory parameters has been achieved, adequate intra-venous or intra-osseous access is gained and induction drugs drawn to patient weight. Prepare the EQUIPMENT identifies whether the necessary equipment is available such as capnography and that all necessary patient weight specific equipment is available in the location intubation will be carried out. Since the Coronavirus outbreak we have updated this section with a PPE reminder. Prepare for DIFFICULTY ensures difficulties are anticipated, Plan A to D are created and verbalised to the team and weight specific emergency drugs are available. Using the checklist helps the team maintain situational awareness, ensures adequate resuscitation has taken place and that any missing equipment, drugs or personnel can be gathered prior to induction. The checklist is used as a time out, and is read out point-by-point by a member of the team. This gives opportunity for all members to have input into the case, createing an empowered and cohesive team environment. Our checklist has been used in real life emergency situations and we have introduced it into multi-disciplinary simulation training both in situ and within the simulation suite to increase trainee familiarity and confidence in using it. The introduction of this checklist has been crucial in increasing confidence levels of trainees, non-paediatric anaesthetists and the entire paediatric emergency team.

Discussion