Multicentered Study of Model of Difficult Endotracheal Intubation by Incident Reports from University and Non-University Hospitals
Ketchada Uerpairojkit MD*, Tharnthip Pranootnarabhal MD**, Yodying Punjasawadwong MD***, Sirilux Chumnanvej MD****, Surasak Tanudsintum MD****, Wirat Wasinwong MD*****, Wiroj Pengpol MD******
Affiliation : * Department of Anesthesiology, Chulalongkorn University, Bangkok ** Department of Anesthesiology, Siriraj Hospital, Mahidol University, Bangkok *** Department of Anesthesiology, Chiang Mai University, Chiang Mai **** Department of Anesthesiology, Phramongkutklao College of Medicine, Bangkok ***** Department of Anesthesiology, Prince of Songkla University, Songkla ****** Division of Anesthesia, Ratchaburi Hospital, Ratchaburi
Objective : To compare the characteristics, causative factors, outcomes, prevention, and suggested preventive
strategies of difficult intubation between university (U) and general community (non-U) hospitals.
Material and Method: One thousand nine hundred and ninety-six reports were reviewed from Thai anesthesia
incident monitoring study (Thai AIMS) conducted in 51 hospitals nationwide between January and June
2007. Thirty-four cases of DI were reported from U hospitals and 69 cases from non-U hospitals. The described
details on each report on difficult intubation (DI) in adults undergoing general anesthesia were thoroughly
reviewed by three reviewers to give their consensus opinions on causative factors, outcomes, contributing
preventive factors, and strategies for corrections. Descriptive statistics were used for data analysis.
Results : Patient factors were the most common cause of DI (88% in U and 87% in non-U hospitals). Fifty
percent of U and 51% of non-U DI cases were consequences of human errors, which were preventable and
mostly based on knowledge (88% vs. 71%) and rules of practice (23% vs. 51%). Substitution of an intubating
anesthesiologist, reducing the size of endotracheal tubes, and stylet guided technique were the three commonly
used methods after DI. MacCoy laryngoscope, fiber optic-aided intubation, laryngeal mask airway, and Frova
introducer were commonly used as substitutes for the standard laryngoscope. Inadequate experience was the
major problem of U hospitals, which required additional training to gain more skill. The most common
problem of DI in non-U hospitals was inadequate preanesthetic evaluation. Therefore, they required practice
guidelines and experienced assistants in difficult situations.
Conclusion : Half of DI cases were preventable. DI cases in Non-U hospitals were mostly caused by inadequate
preanesthetic evaluation. This indicates the necessities of providing practice guidelines and experienced
assistants. In U hospitals, in-training practice of intubation should be performed under supervision. More
advanced substitution techniques were applicable in U hospitals.
Keywords : Difficult intubation, Adverse events, Complication, Incident report, Guidelines, Patient safety
