AIDAA Airway Alert Form

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AIDAA Airway Registry

Airway Alert Form

Patient Demographics

First Name*

Middle Name

Last Name*

Gender*

Male Female

Age*

Mobile Number*

Email Address*

Hospital Registration Number

Date of event*

Other Details

Surgical Procedure

Difficult Airway Anticipated

Risk Factors (Specify)*

Primary airway management plan

Nature of Airway Difficulty Encountered (Tick all that apply and elaborate in comments)*

Difficult mask ventilation Difficult direct laryngoscopy Difficult videolaryngoscopy Difficult tracheal intubation Difficult SGA Unanticipated airway obstruction (e.g., mass, oedema) Need for alternative airway (e.g., Supraglottic airway) Failed tracheal intubation Need for surgical airway Failed Extubation

Comments:

Airway Management Details

DL/VL with adjuncts Wake up the patient SGA insertion Awake tracheal intubation Fibrescope-guided tracheal intubation Cricothyrotomy/Tracheostomy

Comments:

Complications

Hypoxia [oxygen saturation (SpO2) <94%] Aspiration Dental/Lip injury Airway trauma Oesophageal intubation Laryngospasm/Bronchospasm Postoperative stridor Bradycardia Cardiac arrest ICU admission due to an airway event Other

Comments:

Patient Outcome

Transferred to ICU with tracheal tube Surgical airway/Tracheostomy Mortality Extubated/ wake up in the operation room

Note to Anaesthesiologists (Summary)

Anaesthesiologist Name*

Anaesthesiologist Designation*

Do you wish to display your Name & Designation in display card?

Anaesthesiologists sugession for future management

Do you wish to display your Suggestion in display card?

Do you consent to use this data for Patient Registry

Security Verification

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