Anaesthesia's dirty laundry – let's all learn from it

NAP4 is here! Is that good? Yes. Why? Because it’s the long awaited 4th National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society in the United Kingdom – a multi-phase national survey that was designed to answer the questions;

  • What types of airway device are used during anaesthesia and how often?
  • How often do major complications, leading to serious harm, occur in association with airway management in anaesthesia, in the intensive care units and in the emergency departments of the UK?
  • What is the nature of these events and what can we learn from them, in order to reduce their frequency and consequences?

The Audit identified 33 deaths and 46 cases of death or brain damage as a result of airway complications during anaesthesia, in ICU and the emergency department over a one year period in the four countries of the United Kingdom.

Some major findings include:

  • Poor planning contributed to poor airway outcomes – often a failure to plan for failure.
  • The project identified numerous cases where awake fibreoptic intubation (afoi) was indicated but was not used. A lack of suitable equipment was prevalent on ICU.
  • Problems arose when difficult intubation was managed by multiple repeat attempts at intubation.
  • Events were reported where supraglottic airway devices (SAD) were used inappropriately. Patients who were markedly obese, often managed by junior trainees, were prominent in the group of patients who sustained non-aspiration events. Numerous cases of aspiration occurred during use of a first generation SAD in patients who had multiple risk factors for aspiration and in several in whom the aspiration risk was so high that rapid sequence induction, should have been used.
  • The proportion of obese patients in case reports submitted to NAP4 was twice that in the general population
  • When rescue techniques were necessary in obese patient they failed more often than in the non-obese.

Here’s my favourite bit so far – in keeping with what the literature has already told us about this technique:

There was a high failure rate of emergency cannula cricothyroidotomy, approximately 60%. There were numerous mechanisms of failure and the root cause was not determined; equipment, training, insertion technique and ventilation technique all led to failure. In contrast a surgical technique for emergency surgical airway was almost universally successful. The technique of cannula cricothyroidotomy needs to be taught and performed to the highest standards to maximise the chances of success, but the possibility that it is intrinsically inferior to a surgical technique should also be considered. Anaesthetists should be trained to perform a surgical airway.

  • failure to correctly interpret a capnograph trace led to several oesophageal intubations going unrecognised in anaesthesia. A flat capnograph trace indicates lack of ventilation of the lungs: the tube is either not in the trachea or the airway is completely obstructed. Active efforts should be taken to positively exclude these diagnoses. This applies equally in cardiac arrest as CPR leads to an attenuated but visible expired carbon dioxide trace.
  • at least one in four major airway events reported to NAP4 was from ICU or the emergency department. The outcome of these events was more likely to lead to permanent harm or death than events in anaesthesia. Analysis of the cases identified gaps in care that included: poor identification of at-risk patients, poor or incomplete planning, inadequate provision of skilled staff and equipment to manage these events successfully, delayed recognition of events and failed rescue due to lack of or failure of interpretation of capnography. The project findings suggest avoidable deaths due to airway complications occur in ICU and the emergency department.


  • failure to use capnography in ventilated patients likely contributed to more than 70% of ICU related deaths. Increasing use of capnography on ICU is the single change with the greatest potential to prevent deaths such as those reported to NAP4.
  • Displaced tracheostomy, and to a lesser extent displaced tracheal tubes, were the greatest cause of major morbidity and mortality in ICU. Obese patients were at particular risk of such events and adverse outcome from them. All patients on ICU should have an emergency re-intubation plan.


  • Most events in the emergency department were complications of rapid sequence induction. This was also an area of concern in ICU. RSI outside the operating theatre requires the same level of equipment and support as is needed during anaesthesia. This includes capnography and access for equipment needed to manage routine and difficult airway problems.

These are just snippets – there is much more in the report, and I’m still going through it.
The Executive Summary and all other Sections of NAP4 can be downloaded here from the Royal College of Anaesthetists

11 thoughts on “Anaesthesia's dirty laundry – let's all learn from it”

  1. Great summary Cliff.
    I suspect that most docs in the ED would consider needle cric their go to in the failed intubation scenario, due to familiarity with Seldinger and needle access procedures. I think practicing with a knife, and making this your first choice is prob the way to go.
    There may be some bias, in that maybe docs are more likely to go with a needle in a patient that looks like they have a difficult neck for surgical cric.

  2. In my prehospital area we are only to do “needle” crics with prefabricated kits, however, we are allowed to use a scalpel to “assist” in needle passage. This was relaxed due to our area’s inability to utilize the prefabricated kits without a scalpel! My service is working on adding pure surgical crics as the technique of choice, and reading this audit only seals that for me.
    If trained anesthetists couldn’t not perform needle crics…how is a lesser trained Paramedic going to fare?

  3. Hi Cliff et al
    yes I have done both , needle and surgical. Christopher, you would be happy to put a scalpel to a 4 yo’s neck with epiglottitis? Its easy to say yes but how many of us would really when push came to shove??
    We all would say that if we had to we would all be able to do a surgical airway with a blade…research from Royal Perth’s airway wet lab over 7 years would suggest that in the heat of the moment with a critically desaturated sheep, many docs including ENT surgeons have a lot of trouble with using the blade to the neck.
    The problem with all surgical airways is that training and practice in general is so infrequent and unrealistic on mannikins that people are unable to react in a meaningful manner when they encounter a CICV/CICO event.
    So the needle cric is important to not dismiss it..because it is better to attempt to do the needle cric or in fact anywhere along the trachea than not do anything in the CICV/CICO situation. At least with a needle attempt you can try multiple times in a short period of time as opposed to the open surgical airway in which you generally have 1-2 goes at the most…in fact I know of one case where the doc stopped doing the open cric because the degree of loss of blood was unexpected…an issue of practice and training not meeting reality as I mentioned
    as you know there are no perfect answers out there at the roadside..keep your options open…you don’t need fancy Manujet ventilators and wall oxygen supply or dedicated needle catheters to do an effective needle cric…one case we did on the kid with epiglottitis we used a PIV catheter and oxygen tubing held onto the catheter hub to rescue oxygenate prior to a second more controlled attempt at intubation that was successful.

  4. Minh,
    In our area we cannot perform crics on patients less than 12 years of age (basically if you fit on the Broselow tape I am unable to perform any cric). Which is in some ways unfortunate, but in others unavoidable. As you point out, we probably do not have sufficient training for CICV/CICO in peds with a cric.
    We routinely practice 14ga angiocaths with 5mL syringe connected to a 3.0mm ETT hub as a rescue cric; this is to keep our skills current even though our protocols may not be.
    Good discussion!

  5. Dear all
    I follow your analysis of NAP4 with interest. There is much good sense.
    I’m interested to see the title ‘annaesthesia’s dirty llinen’
    About 25% of airway events reported to NAP4 were from ICU and ED but than 50% of the deaths.
    The rate of death and brain damage in events reported to NAP4 were as follows
    Anaesthesia 14%
    ED 33%
    ICU 61%
    One of my collaegues has estimated that based on denominators (3 million GAs vs approx 50,000 intubated patients on ICU pa) the risk of airway death on ICU is 67x that in anaesthesia.
    Our paper in the BJA concluded that many of the deaths in ED/ICU were avoidable. Cappnography is a big issue.
    I hope NAP4 can bring together all those who ‘own the airway’ to improve care for patients whoever looks after them and in whatever location.

  6. Hi TIm
    I and my colleagues are in awe of NAP4 in terms of the positive impact these data and recommendations are bound to have on airway management in all domains.
    The title of the blog post was not meant to be inflammatory – merely relating to the idea of ‘airing ones dirty laundry in public’ meaning to make known that which normally remains private – in this case the avoidable errors and deaths. ‘Anaesthesia’ here meaning the practice of anaesthetising patients and managing their airways, not targeting one professional group. I hope the second half of the title clarifies the point of blogging about it.
    I recorded an interview with one of the NAP4 contributors – Professor Jonathan Benger, along with EMCrit podcaster Scott Weingart last week. This should be posted by Scott in the near future. Professor Benger was at pains to point out the ‘heroic’ efforts (his word), particularly on your and Nick Woodall’s parts, in seeing this project through. The international interest already generated is hopefully a sign of the scale of the impact this work will have on saving lives worldwide.
    Thanks for posting your comments, thanks for visiting the blog, and thanks especially for NAP4.
    Best wishes

  7. Thanks for the kind comments. I wasn’t worried by the title but I think it is important to look at some of the wider picture too. I hope NAP4, which has really just ‘shone the light’ on the issues, will perhaps be the stimulus that leads to some ‘real research’ looking at what can be done to make airway management more reliably good. I suspect we need to move away from ‘new kit’ analysis to analysis of processes surounding airway managment and the decision processes.
    Mandatory capnography for all airway management and elimination of problems due to ‘faliing to prepare fro failure’ would be a good start.
    Seen the podcast looks great…..a must for all to listen to I think.
    One interesting aspect is the issue of needle vs knife for cricothyroidotomy. Again I think NAP4 shines a light on it, but as a collection of anecdotes I’m not sure it gives us an answer. There were cases of canula failure due to poor kit (not using correct kit and it kinking, kit breaking, kit too short for obese necks) poor technique (missing trachea,etc) and poor ventilation (failure to use a high pressure source when using 2mm cannula). So whether the solution lies in eliminating poor kit (ie too short, use of easily kinking IVs etc), better training or abandonment is still open to debate (and high quality research).

  8. Hi Cliff Reid and Tim Cook
    thanks for the useful comments, Tim. NAP4 is an excellent piece of work on a topic that keeps cropping up as a problem in routine practice yet little good quality research has been done on it. NEAR and NAP4 are probably some of the best attempts at shedding light onto the issue.
    Tim your comments regarding cricothyroidotomy are very true. the issue is training not the equipment available. Actually human factors plays a huge role in the CICV and CICO events and I was deeply impressed to read that Martin Bromiley wrote the foreword introduction to the NAP4.
    At a recent airway conference in Australia, one of the speakers said we should create a patient monitor that alarms with a female voice telling you to perform a surgical airway once the SaO2 and capnography readings have dropped below a critical level for a critical period of time. It sounds silly but try to explain Mrs Bromiley’s case and the many that still occur since hers and the notion makes reasonable sense . Aircraft pilots have such alarms routinely called terrain warning systems.

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