Anesthesia Alert: The Perfectly Organized Airway Cart

When a difficult airway strikes, there's no time to waste hunting down needed tools and supplies. Without a well-stocked airway cart, even the most advanced airway management skills will go for naught.

Your difficult airway management cart should be large enough to hold everything in your kit, but easy to move and clean. It should have a working shelf with at least 5 sealable drawers, a sealable cabinet for bronchoscope storage and a place for oxygen tank storage. Some carts have a video monitor and individually sealed bins along the side that tip out for frequently used items.

Clearly label each drawer to indicate the contents. The ASA's Difficult Airway Algorithm and a list of the cart's contents should be laminated and tethered to the cart. The cart should be checked daily and sealed to indicate the equipment is in proper functioning order and has been restocked.

If you haven't taken inventory of your difficult airway kits in a while, here's an example of what an organized cart should look like:

Restricted contents
Restrict the contents of the cart to items not normally available in every OR, anesthesia cart, drug box or medication dispensing system, with few exceptions. Restricting the contents allows for quick and easy use of the devices in an emergency situation. Ideally, the devices should be arranged following a logical methodology for managing the difficult airway based on the ASA's Difficult Airway Algorithm. However, depending on the specific design of the cart, you may need to alter this somewhat.

Generally, the top drawers should be dedicated to devices that facilitate intubation in a patient who can be mask-ventilated. Dedicate the middle drawers to items for ventilating a patient who cannot be masked. Devote the bottom drawer to the surgical airway devices.

There are 6 main categories of advanced airway management devices:

• flexible fiber-optics,
• videolaryngoscopy,
• rigid fiberscopes,
• supra- or extraglottic devices including intubating supraglottic devices,
• stylets and lighted and optical stylets,
• surgical airway devices, such as a cricothyrotomy or a tracheostomy kit, and a transtracheal jet ventilator (if a needle cricothryotomy technique is employed).

Assuming that a bougie and a variety of blade types and sizes are available in every OR, I recommend at minimum the following essentials in your cart (variations may occur depending on the expertise of your anesthesia providers):

• intubating fiber-optic bronchoscope (preferably with a camera for viewing on a monitor versus one with an eyepiece) and light source,
• video laryngoscope,
• supra- or extraglottic devices and supraglottic intubating devices,
• tube exchange catheter, and
• a cricothyrotomy or tracheostomy kit.

Make sure that the variety and sizes of the equipment and supplies that you stock reflect your patient population. You should also have several ancillary devices such as a stethoscope, a manual resuscitator bag, oral and nasal airways and an intubating airway such as an Ovassapian or Burman airway.

The cart should also be loaded with a variety of sizes of endotracheal tubes, 10cc syringes, intubating stylets, equipment for topicalization of the airway (atomizers, lidocaine, tongue depressors, cotton gauze), suction tubing, endotracheal suction catheters, a bronchoscope multiport swivel adap-ter, defog, lubricant, and a device for CO2 detection to confirm endotracheal placement of the tube.

Other cart considerations
The number of carts you'll need depends on your patient volume and the number of ORs open at the busiest time of the day. There is no specific recommended ratio of difficult airway carts to ORs, so you'll need to discuss this with your anesthesia providers to determine exactly how many you should have. Also consider the areas outside of the OR where anesthesia is provided. Wherever anesthesia is provided, you should have an airway cart, or one nearby that can be easily accessed.

The difficult airway cart should be easily visible and parked in a central location in the operating suite. Nothing should be in the way that might hinder rapid access to the cart. All anesthesia and nursing personnel should be aware of its location and know what's inside. If any items on the cart require electricity to maintain a charge (some video laryngoscopes require charging), make sure that there's an outlet nearby.

A well-stocked difficult airway cart is essential in every operating suite. Although the initial financial investment is substantial, costing about $35,000, equipment such as video laryngoscopes and bronchoscopes could last for 10 years or more. Plus, saving a life from a lost airway far outweighs the initial cost of the equipment necessary to manage the inevitable difficult or failed airways that you will have in your facility.