Code D Delta: a Rescue Team for Emergency Tracheal Intubation Outside Operating Room in Siriraj Hospital

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Tarinee Buasuk
Aphichat Suphathamwit


Emergency airway management outside the operating room (OR) is particularly challenging. It is a high-risk procedure as compared to the OR setting. Inappropiate airway management leads to complications including pulmonary aspiration, dental trauma, esophageal intubatioin, prolonged recovery, unplanned ICU admission, brain damage and death. The emergency difficult airway management team of Siriraj Hospital under the name of Code D-delta activation, to response to all adult emergency difficult airways in outside OR situations is conducted to improve emergency airway management. Code D-delta team was implemented by the corporation of anesthesiologists and otolaryngologists since 2018. We have had an average 100 cases per year with the success rate of 85% at scene. The multidisciplinary team continuely improves the Code D-delta’s workflow, team member and airway tools management. Airway assessment, planning, and decision making of the team are related to the patients’outcomes. This article is aimed to hightlight the Siriraj’s rescue team for management of the emergency tracheal intubation outside the operating room.

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Review articles


Mort TC. Complications of emergency tracheal intubation: immediate airway-related consequences: part II. J Intensive Care Med. 2007;22:208-15.

Peterson GN, Domino KB, Caplan RA, Posner KL, Lee LA, Cheney FW. Management of the difficult airway: a closed claims analysis. Anesthesiology. 2005;103:33-9.

Mort TC. Complications of emergency tracheal intubation: hemodynamic alterations–part I. J Intensive Care Med. 2007;22:157-65.

Guidelines 2000 for cardiopulmonary resuscitation and emergency cardiovascular care. Part 6: advanced cardiovascular life support: section 3: adjuncts for oxygenation, ventilation and airway control. The American Heart Association in collaboration with the International Liaison Committee on Resuscitation. Circulation. 2000;102(8 Suppl):I95-104.

Cook TM, MacDougall-Davis SR. Complications and failure of airway management. Br J Anaesth. 2012;109(Suppl1):i68-85.

Basaranoglu G, Columb M, Lyons G. Failure to predict difficult tracheal intubation for emergency caesarean section. Eur J Anaesthesiol. 2010;27:947-9.

Warner KJ, Sharar SR, Copass MK, Bulger EM. Prehospital management of the difficult airway: a prospective cohort study. J Emerg Med. 2009;36:257-65.

Asai T. Airway management inside and outside operating rooms-circumstances are quite different. Br J Anaesth. 2018;120:207-9.

Benedetto WJ, Hess DR, Gettings E, et al. Urgent tracheal intubation in general hospital units: an observational study. J Clin Anesth. 2007;19:20-4.

Martin LD, Mhyre JM, Shanks AM, Tremper KK, Kheterpal S. 3,423 emergency tracheal intubations at a university hospital: airway outcomes and complications. Anesthesiology. 2011;114:42-8.

Jaber S, Amraoui J, Lefrant JY, et al. Clinical practice and risk factors for immediate complications of endotracheal intubation in the intensive care unit: a prospective, multiple-center study. Crit Care Med. 2006;34:2355-61.

Mark LJ, Herzer KR, Cover R, et al. Difficult airway response team: a novel quality improvement program for managing hospital-wide airway emergencies. Anesth Analg. 2015;121:127-39.

Chow YM, Tan Z, Soh CR, et al. A prospective audit of airway code activations and adverse events in two tertiary hospitals. Ann Acad Med Singap. 2020;49:876-84.

Yu TS, Sun CK, Chang YJ, Chen IW, Lin CM, Hung KC. Characteristics and outcomes of patients requiring airway rescue by the difficult airway response team in the emergency department and wards: a retrospective study. Ci Ji Yi Xue Za Zhi. 2019;32:53-7.

Long L, Vanderhoff B, Smyke N, Shaffer LE, Solomon J, Steuer JD. Management of difficult airways using a hospital-wide “Alpha Team” approach. Am J Med Qual. 2010;25:297-304.

Jeong H, Choi JW, Kim DK, Lee SH, Lee SY. Implementation and outcomes of a difficult airway code team composed of anesthesiologists in a Korean tertiary hospital: a retrospective analysis of a prospective registry. J Korean Med Sci. 2022;37:e21.

Arulkumaran N, Lowe J, Ions R, Mendoza M, Bennett V, Dunser MW. Videolaryngoscopy versus direct laryngoscopy for emergency orotracheal intubation outside the operating room: a systematic review and meta-analysis. Br J Anaesth. 2018;120:712-24.