SCCM Resource Library-Complications Happen: How Do You Manage Them?

Video Transcription

Welcome, everyone. My name is Dr. Melissa Plugas-Moldowski, acute care nurse practitioner at Cooper Health for both hospital medicine and critical care.  Today I'll be presenting to you our conference session entitled, Complications Happen, How Do You Manage Them?  Our presenters are going to be Scott Sherry, physician assistant at Oregon Health and Science  University, and Dr. Brian Jefferson, acute care nurse practitioner at Atrium Health Cabarrus.  They're going to be presenting information about complications in the critical care setting and how to best manage them and or prevent them. Thank you and welcome today.  Thank you and welcome to Society of Critical Care Medicine's 50th annual conference. My name is Scott Sherry, and today I will be presenting to you how to avoid procedure-related  complications in the intensive care unit. I want to thank my co-speakers and the moderator for this amazing session, and I welcome additional  audience participation and dialogue in the appropriate manner. Again, thank you very much for your time, and I look forward to further discussion.  Today I want to talk to you about how to avoid complicated procedures in the ICU, and I have no current relevant disclosures.  Our objective today is to illustrate how checklists and critical incident analysis can prevent complications primarily related to the procedures.  So avoiding complications, the unfortunate part of any procedures and those of us who perform procedures in intensive care units or emergency settings is that complications  will occur at some point in your career. The goal of any procedure is to being prepared and to mitigate the complications when they  do occur and immediately respond to them appropriate interventions to prevent any further harm to the patient.  As such with each procedure, there will be varying levels of complication and the degree of harm caused during different parts of these procedures, and it's important as you perform  multiple procedures in the intensive care unit and at the bedside that you're aware of what may potentially happen in specific cases.  Avoiding complications, there are a lot of different anagrams, facts, rules of thumb that you can harp on in your experience.  I like to look at and remember a variety of things that my colleagues have taught me over  the years, and one of them is the most important is proper planning prevents poor performance.  Now there's six keys there, but I won't put the sixth one there because it is not an appropriate word for this audience.  But it is important to be prepared, and as you're doing procedures, you should be aware of how to prepare for them, how to predict what may happen next.  That way you can see if there is something that is not quite going right, you know that you're not in a good position and you may need to back up, call for help, or to reevaluate  what you're doing at that particular time. So being prepared is definitely one of the top criteria. Little mistakes can compound into bigger problems.  This is where if you are making little mistakes down the path and you notice these things or even not aware of them, they can set you up for failure at the wrong time, not being  adequately prepared, not having the right resources available around you, such as you're performing a central line, not having additional support ready and willing to assist you if  you are intubating a patient in the ICU. If you're placing news of gastric tubes and your patient becomes combative, not having  a backup plan or other people readily available to help restrain the patient while you're putting in a nasogastric tube. Another important aspect is to slow down.  And this is always very hard in the middle of either an urgent procedure or just trying to get something done in the workflow of a busy emergency environment.  But sometimes as you're doing this, you need to take a pause and just realize that it is very important for you to pay close attention, slow down, and be acutely aware of your next  steps and what needs to be done. In fact, I'm right now slowing down as well, knowing that as I'm nervous about this  presentation, I realize, too, by this point that I need just to take a big deep breath, know that I'm doing well, and pay attention to my feelings and how things are going in  order to get through this presentation for you.  And it is also all about paying attention, paying attention to the patient, paying attention  to the nursing staff in the room, paying attention to family members that may be around watching the procedures in some of our patient-centric ICUs.  It may be the fact that, you know, paying attention to the monitor, paying attention to the ventilator as well.  And as you're looking around the room and reading the room, you can gather information and you can be ready to help put the patient in the best, safest position to perform the  procedure that's indicated. There are always going to be lapses in concentration, attention, distraction will occur, and fatigue  can occur, especially at this age with the COVID era that we're in, with many of our ICU providers overwhelmed, emotionally and physically exhausted.  These things can occur, and it's important that paying attention is even more critical. As one of my personal mentors, Dr. Richard J. Mullins, said, it is always better to stay  out of trouble than to get out of trouble. One of the things that we look at as an aspect to keep us out of trouble is the use of checklists.  Now, there's a lot of different opinions on this, but I'll give you the good and the bad and give you some of the background of where they came from.  In 1935, before World War II, Boeing was introducing a new bomber plane. This airplane was a wonderful plane to fly, but unfortunately on one of its first few  flights, it had a horrible crash. Several of the pilots and crew members were killed, several were able to walk away.  One of the things that they learned from this crash is that this new plane that was being developed was very complex.  It had a lot of new controls and a lot of processes that need to be gone through. During the course of the takeoff, one simple rudder gear was not locked down, and that  caused the plane to swerve out of control and to crash, again, killing several crew members. Now, this was a wonderful plane to fly, and the pilots really loved flying this.  It had a very great distance, it had really good fuel load, and they wanted to keep this as part of the Boeing's arsenal of developmental planes.  So the pilots upon themselves developed basically a checklist, steps to go through in order to have safe takeoff, landing, and things to do during the flight.  The checklist that you see on the right side is a checklist from 1944. This plane was the B-17 bomber prototype, and it was one of the most durable planes  used and one of the most prolific bombers of that era. The picture on the left of the screen is the actual wreckage of that flight that led to the development of the checklist.  The checklist itself is just basically a very simple checkbox and move on to be able to make sure that all the aspects of the flight were taken care of.  Fast forward into 2021, these are the modern planes to fly, and it is quite not unlike our modern intensive care units with multiple drips, monitoring devices, and so forth.  The picture on the photo on the left is a surgeon performing an exploratory laboratory at the bedside with multiple ICU machines at the ready, and as you see, she is paying  close attention to the patient and not to all the other machines. The photo on the left, we have one of our ICU physicians utilizing one of our new modern virtual ICUs.  The procedure checklist in the ICU really gained its ground in about 2006 with Dr. Provanos's groundbreaking article about central line infection reduction.  And basically, quite simply, using five simple steps and a checklist, as well as empowering  the nurses to stop a procedure, we were able to reduce central line infections from almost 11% to near zero.  Similarly, the WHO surgical checklist was also credited with harm reduction for patients  in the operating room, and many of our surgical procedures are also using surgical checklists and timeout procedures very similar to this.  Recent studies show that there was a 36% relative reduction in mortality in a British Journal of Surgery in 2019, again, reiterating that checklists are important. Why do they work?  They serve as a cognitive aid. We all have lapses in our memory, recall, and also our ego. They do help out to make sure it's a smooth process.  It aids in lapses of concentration, distraction, and fatigue, and allows somebody to double-check our work.  We're allowed to aid in correcting our mistakes when we lack the attention. Also, those of us who may lack experience, knowledge, or sufficient training can use  these as dedicated resources of education and laying a foundation of proper patient care. But also, these checklists also liberate you to concentrate on other things.  As you're following these rigorously, you can worry about other aspects as you're going through the steps efficiently.  It does save time, effort, and improves your efficiency to have these things set up ahead of time and to be able to use them in an appropriate manner.  There are a lot of different types, static-parallel, static-sequential, static-sequential with verification and confirmation, and dynamic.  As you see in the list, there are different examples of those checklists. There are also different types of high-risk or normal low-risk.  High-risk can definitely help in emergencies, help plan for contingencies, and assures proper communications in operations in high-risk environments.  Definitely something that we should be using in emergent procedures in a critically ill patient. There are limitations of the checklist.  There's obviously resistance for us to use these, as some physicians and providers feel that it insults their intelligence and doubt our effectiveness.  Not following the checklist definitely equals using and following the checklist decreases our efficiency.  Also, if we're devising poorly designed and excessive use of these checklists, we get overwhelmed and we get fatigued. The bottom line, keep it simple.  We have to keep these checklists updated, validate their use, and keep it state-of-the-art. And also, it's important for us to know when to deviate from the checklist and to make  sure that we are, when patients need different interventions. These aren't protocols. These are just guidelines. A couple of other quick comments.  One of the things that have really improved our safety and efficiency within the ICU is changing our culture of safety and establishing crew resource management principles, creating  a climate where authority may be respectfully challenged. Improved communication and dialogue between our different staff members is of utmost importance.  We need to listen to what they're saying. We need to be aware when they are concerned. And that is one thing that we need to continually improve upon.  Another concept that's an important aspect to incorporate into preventing our ICU procedures is implementing a sterile concept rule.  It was initially developed in the aviation industry. And in this industry, they have aspects of their takeoff or landing or certain aspects  of their flight where there's just to be no interruptions in the cockpit because the pilot and the co-pilot are paying 100% attention to flying the plane.  And similarly, in our intensive care unit, there may be periods of time that the critical care staff and proceduralists must pay 100% attention to the patient.  We need to learn how to communicate that to our team members and to be able to call that out. Another aspect of our care of our patients is really doing post hoc analysis of errors  and near misses. And these are critical incident analysis. These are those situations where we could have harmed the patient worse, and how can  we really make our system more effective? Internal morbidity, mortality is an opportunity. We have patient safety reporting systems to be able to log these incidences.  Non-reporting remains an issue because there is still the burden of blame within our culture,  and we need to figure out how to report more incidences without providers feeling guilty and ashamed for them to occur.  Eventually, the root cause analysis may be occurred, and this may occur when there is a significant deviation from a policy where there is a significant adverse event creating  death or injury. These root cause analysis, a goal is to mitigate further events, as well as to develop action plans. These two, unfortunately, have limitations.  They're usually multidisciplinary teams. It takes months to go through this process. Sometimes it is very difficult to get to the root cause because of system failures, competing  interests, as well as challenges to the process itself. Sometimes we also focus on only single events.  There's an estimate in a recent article that said that RCAs are only implemented in the findings in about 45% to 70% of the time, and in some cases, the incidences still occur.  In conclusion, I want to just remind you that I think that preventing errors is a team event. We must do our part, and checklists do work.  They're reminders of what we do, and they have an effect and impact when it's also combined  with a culture change, and as well as attitude change towards them, and an effort to remove the barriers to their use.  We also need to be more robust in our systems that monitor, track, and respond to complications and near misses, and also have an opportunity to improve safety.  And in conclusion, that checklist is one of my favorite because that's from my wife who  was a checklist-baking bread, who in our current pandemic has taken that up as a personal hobby, and I am very proud of her and her bread-making abilities.  Again, thank you very much for your time. I appreciate all that you do out there for critically ill and injured patients, and I  hope you find this to be of benefit and use in the future care of our patients. Good morning. My name is Brian Jefferson, and I will be speaking on the incidence of complications  related to ICU procedures. I have no financial conflicts of interest as it relates to this topic. ICU procedures are integral for both diagnostic and therapeutic indications.  Several procedures are performed in the ICU, including advanced airway management, central line insertion, tube thoracostomy, and others.  An added factor that places patients at additional risk for procedural complications is the severity of illness and associated comorbidities that may impact procedural success.  Thus, it is of paramount importance that each operator understand the indications of each  procedure, the procedural steps, the anticipated risk, and possible complications of each procedure, and take steps to mitigate those risks.  Given the time constraints today, I will be discussing airway management and central line placement in terms of the incidence and prevalence of complications.  Without a doubt, intubation is a common but risky procedure carried out in the ICU. Intubations outside of the OR are often performed in urgent or emergent circumstances.  Thus, challenges exist that place the patient at a higher risk for complications.  Such challenges include hemodynamic instability anywhere from 10 to 25% of cases, hypoxia and up to 25% of cases, presumed full stomach and others.  In addition, comorbidities and or severity of disease often results in limited physiologic reserve. Several studies have demonstrated an incidence  of difficult intubation at 8 to 12%, whereas incidence of difficult intubation in the operating room is approximately 5.8%. Thus the goal is to improve first attempt success  thereby decreasing the rate of complications.  Patients undergoing endotracheal intubation are at risk for significant complications, particularly as these complications are already experiencing physiologic,  I'm sorry, as these patients are already experiencing physiologic decompensation, leading to the need to secure the airway.  In fact, many critically ill patients who require intubation are already experiencing acute respiratory failure and or shock. As such, physiologic reserves are already limited.  Furthermore, the presence of shock places the patient at risk for further deterioration with intubation, including cardiac arrest and death.  In the critically ill patient, post-intubation hypotension can occur for many reasons, including sedative medications used at induction.  Studies have shown that the incidence of severe hypotension, which is defined as a systolic blood pressure less than 80, can be in the range of 20 to 22%.  In fact, Heffner and colleagues demonstrated that post-intubation hypotension is an independent predictor for in-hospital mortality. Even in risk adjusted models,  patients are three times as likely to experience hypotension in the setting of an intubation complication. Again, medications can be implicated as an etiology of hypotension  in that certain medications can cause either a direct hemodynamic effect through a decrease in vascular tone or myocardial suppression, or it can be an indirect hemodynamic effect  through suppression of the adrenal axis.  Simpson and colleagues in their evaluation of post-intubation complications looked at the role of induction agents. They report frequent use of propofol at their institution.  And as you can see here, the highest risk for hypotension in their study was with midazolam and propofol. Not surprisingly, the lowest risk  for development of hypotension in those patients were in those patients who received etomidate.  Green and colleagues also looked at medications for RSI. And interestingly, the only medication that demonstrated statistical significance was ketamine with a p-value of 0.04.  However, ketamine only was used in about 6% of those patients in the study. Interestingly, propofol was not associated with hypotension  and was used in approximately in 36% of patients.  As you can see here, there were more patients who demonstrated no evidence of post-intubation hypotension than those who did.  As far as it pertains to neuromuscular blocker agents, there were no agents that demonstrated significance for post-intubation hypotension.  Much like patients with post-intubation hypotension, patients with hypoxemic respiratory failure  are also at risk for developing worsening hypoxia and or cardiac arrest with the intubation procedure. As previously stated, physiologic reserves  are often already limited by the time intubation is required.  In fact, risk-adjusted models indicate that patients in hypoxemic respiratory failure are three times as likely to develop worsening hypoxia during intubation.  McCown and colleagues studied risk factors for the development of hypoxemia during tracheal intubation.  The incidence of severe hypoxemia was 21%, which is in line with other published studies. Additionally, they found that severe hypoxia during intubation  was independently associated with lower oxygen saturation at induction, younger age, the presence of hypoxemic respiratory failure,  BMI of greater than 30, and limited operator experience. Interestingly, they found that increasing operator experience was associated with higher oxygen saturation  during the intubation attempt, with a plateau at or above 100 intubations.  Cardiac arrest during or immediately after intubation is typically a culmination of other intubation complications,  including intubation failure, shock, and severe hypoxemia. This was an interesting study from France published in the Critical Care Medicine Journal  that sought to determine the prevalence of and risk factors for cardiac arrest during intubation in the ICU, as well as other association  of intubation-related cardiac arrest with 28-day mortality.  As you can see from this diagram, 49 of approximately 1,000 patients developed intubation-related cardiac arrest,  of which approximately 74% of those patients died within 28 days. In contrast, 30% of those who did not suffer  cardiac arrest during intubation ultimately died within 28 days.  Baseline characteristics of patients who suffered cardiac arrest are low oxygen saturation,  baseline characteristics of patients who suffered cardiac arrest are demonstrated here.  Significant characteristics include age greater than 75, a higher SOFA score, hypoxemia at the time of induction, the patient's first intubation experience in the ICU,  and the presence of decompensated shock. Interestingly, no sedation or neuromuscular blocking agents played a factor in cardiac arrest in this study. As you can see here,  all 49 patients who suffered intubation-related cardiac arrest developed a severe complication.  Obviously, all suffered cardiovascular collapse,  but 53% suffered severe hypoxemia and 29% died during the intubation procedure. And likewise, more patients in the cardiac arrest cohort suffered a moderate complication  than those who did not with statistical significance. The primary complication in the moderate complication category for those who suffered cardiac arrest was cardiac arrhythmia.  So as you can see, and also as you can see, median length of stay was significantly longer for those who did not suffer cardiac arrest,  and ultimately 28-day mortality was significantly higher than the cardiac arrest cohort. As you can see from this Kaplan-Meier curve of 28-day mortality,  approximately 45% of those patients died  within the first two days, as you can see from this bottom curve.  In total, 70% of those patients died within 28 days, and intubation-related cardiac arrest was an independent risk factor for 28-day mortality with a hazard ratio of 4.3.  And this had a P-value of less than 0.0001.  As stated earlier, operator experience does correlate to the risk for complications with a plateau of experience at approximately 100 intubations.  Simpson and colleagues also looked at anesthesia residents who intubated patients in an environment outside of the operating room.  They demonstrated that experience in intubation correlated with overall success. Those with greater than 24 months of experience achieved a success rate of 95%,  whereas those with less than six months of experience, or excuse me, of less than six months of training demonstrated a success rate of 69%, even in the presence of supervision  or a supervising physician.  This is an older study by Mort from 2004 that evaluated complications according to the number of intubation attempts. And he highlights the risk  associated with multiple intubation attempts and was able to demonstrate a relatively, I'm sorry, a higher relative risk for hypoxemia, esophageal intubations, aspiration,  bradycardia, and cardiac arrest with patients who require more than two intubation attempts.  This is a graphic image of the data from the previous slide to just, again, demonstrate that when you are  at a place of requiring two or more attempts, more than two attempts, that the risk for complications goes up substantially.  Okay, now we'll turn our attention to central venous catheter placement.  Central venous catheter placement is one of the most common, or one of the most common procedures performed in the hospital setting, and some estimate that more than 5 million  central venous catheters are placed annually in the United States. That said, complication rates have been documented in the range of 15 to 20% through published studies.  Complications can be categorized according to mechanical, infectious, and thrombotic categories. Mechanical complications include things such as arterial puncture,  hematoma formation, enema thorax, and procedure failure. Infectious complications tend to be, tend to occur later after the procedure and include central line bloodstream infections  or catheter-associated bloodstream infections or localized wound infections. And then finally, thrombotic complications can include DVT, and again, tend to be a later complication.  Certain studies have defined the grade of complication with a small degree of variability  between studies to provide better insight into the incidence of severe complications.  Pariente and colleagues define the grade three or higher mechanical complications as listed on this slide. And as you read through these, you will see that the definition  will typically incorporate the need for an intervention related to that complication.  There are multiple factors that can lead to procedural complications. One such factor is catheter placement site. The principal sites that we use for central line placement include  the internal jugular, subclavian, and femoral sites. And each site has its own unique risk factors. For instance, the internal jugular and femoral sites  place patients at higher risk for arterial puncture and hematoma, whereas the risk for enema thorax is highest at the subclavian sites, the site.  And the infectious risk tends to be highest for the femoral site, followed by internal jugular and then subclavian. The evolution of ultrasound over the last several years  in multiple facets of critical care have allowed for better physical assessment as well as enhanced safety during procedures. Ultrasound has been studied  in all central venous catheter sites and has consistently demonstrated to increase safety and facilitate central line placement.  And then finally, training and education do have an impact on procedural success, decreasing the overall incidence of complications. Over the last several years,  the evolution of simulation training has allowed for safe practice of central venous catheter placement prior to performing the procedure on live patients.  Informal education in addition to simulation training have had a clear impact on complications and overall safety during this procedure.  Bleeding and hematoma formation can occur with arterial punctures or other vessel injury, particularly with multiple attempts at central line placement.  The incidence across published studies is approximately 0.7 to 0.9%. B.R. Condor and colleagues demonstrated that in a retrospective study that the primary risk factors for bleeding  include pre-existing coagulopathy, multiple attempts, I'm sorry, and multiple attempts, both with an odds ratio of 1.8. And then finally, arterial puncture  with an odds ratio of 2.7.  Arterial cannulation or arterial puncture  particularly with, can occur particularly with internal jugular ephemeral approaches given the proximity of that vein at the respective locations to the artery  and with respect to technique. Documented incidence of arterial cannulation can range from 0.7 to 1%. And the incidence of decreased, I'm sorry,  the incidence of arterial puncture or cannulation has decreased over time with increasing use of ultrasound for central line placement.  Camerlotto and colleagues in a retrospective study found that thrombocytopenia is associated with an increased risk of complications  related to arterial puncture with an odds ratio of 4.9. And this is consistent with other studies with similar findings and findings of coagulopathy  as an independent risk factor for bleeding.  Pneumothorax is certainly a complication we have to be alert to, especially for central lines that are placed both in the internal jugular and subclavian sites.  In fact, the incidence across published studies  is in the range of 0.2 to 11%. The 11% number in my review came from Odendal and colleagues in their retrospective review of trauma patients  and complications of central venous catheter placements. They reported a possible confounder in that not all patients had a chest x-ray prior to central line placement.  Thus, it's unclear whether any of those patients had a preexisting pneumothorax prior to central line placement and evaluating risk factors for pneumothorax,  Bjorkander and colleagues identified the subclavian approach, arterial puncture, and chronological order of the present central line catheter insertion  as significant risk factors for pneumothorax with an odds ratio of 3.8, 4.5, and 1.5 respectively.  As it relates to DVT and central line associated bloodstream infections,  these tend to be late complications that can occur as a result of central line placement or possibly care afterwards. Pariente and colleagues found  that the site with the highest rate of symptomatic DVT was femoral with incidence of 1.4% followed by internal jugular at 0.9% and subclavian at 0.5%.  And certainly there's been a lot of literature on central line associated bloodstream infections.  Pariente and colleagues studied this as part of their study on overall risk factors  for central line complications. In their study, they found that the femoral site was associated with four points, I'm sorry, they studied infections were more prevalent  in the femoral site with 4.6 per 1,000 catheter days followed by the jugular site with 3.6 per 1,000 days and then subclavian at 1.5 per 1,000 days.  Statistical significance was achieved with the subclavian versus jugular evaluation and also with subclavian versus femoral sites, but not significant  when comparing femoral and jugular sites.  As it pertains to operator experience, similar to intubations, operator experience does play a role in procedural success. Lennon and colleagues compared the number of complications  by experience level with categories being those with less than 25 intubations, those with 25 to 50 intubations and those with greater than 50 intubations.  I know this is a bit of a busy slide, but what you'll see here, especially outlined in red, is that they found that overall success rate  amongst their proceduralists was in approximately 80%.  Interestingly, the primary complications of statistical significance related to inexperience were the number of failed attempts and the need for a second proceduralist.  As a side note, there were no reported arterial dilations, pneumothorax, hemothoraces or cardiac tamponade in the study.  In addition, Lennon and colleagues evaluated the incidence of complications by catheter insertion site, primarily comparing the IJ and seplagin sites.  There were significantly fewer complications with the IJ sites. And the statistical significant complications, I'm sorry, the statistically significant complications  include inability to pass a guidewire, the need for a second site to insert the central line and arterial puncture.  And as you can see, Lennon and colleagues found in a logistic regression model that operator experience and seplagin veins site were the, as a procedural site,  were the primary predictors for procedural complications.  So in conclusion, it's important to realize that every procedure carried out in the ICU will have some degree of risk for complications. As proceduralists or operators,  it's important to understand the potential complications and those risk factors that place the patient at highest risk for those complications  then implement strategies to mitigate those risks to assure procedural success. Thank you.

Video Summary

In this video transcript, Dr. Melissa Plugas-Moldowski introduces a conference session on managing complications in the critical care setting. Presenters Scott Sherry and Dr. Brian Jefferson discuss how to prevent complications in procedures performed in intensive care units (ICUs), such as intubation and central line placement. Sherry emphasizes the importance of preparation, attention, and slowing down during procedures to avoid mistakes that can lead to complications. He also discusses the use of checklists as a cognitive aid to prevent errors and improve efficiency. Jefferson focuses on the complications and risk factors associated with intubation and central line placement. He highlights the significance of operator experience, training, and the use of ultrasound in reducing complications. Both presenters stress the need for a culture of safety, effective communication, and analysis of errors to improve patient care and prevent complications in ICUs.

Asset Subtitle

Procedures, Quality and Patient Safety, 2021

Asset Caption

The Society of Critical Care Medicine's Critical Care Congress features internationally renowned faculty and content sessions highlighting the most up-to-date, evidence-based developments in critical care medicine. This is a presentation from the 2021 Critical Care Congress held virtually from January 31-February 12, 2021.

Learning Objectives

Describe epidemiology and outcomes associated with procedure-related complications
Demonstrate management strategies for common complications of ICU procedures
Illustrate how checklists and critical incident analyses can prevent complications

How to Avoid Procedure-Related Complications in the ICU
Scott P. Sherry

Complications Happen, But How Many Exactly?
Brian Jefferson

Meta Tag

Content Type Presentation

Knowledge Area Procedures

Knowledge Area Quality and Patient Safety

Knowledge Level Intermediate

Knowledge Level Advanced

Membership Level Select

Tag Surgery

Tag Airway Management

Tag Mortality

Year 2021

Keywords

critical care setting

intensive care units

complications

procedures

checklists

ultrasound

patient care

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