A Difficult Airway Problem Katie Cranfield & Rupert Gauntlett OAA Cases and Challenges 2 nd March 2016
Outline Case presentation What have we learnt? How has it changed our practice in Newcastle?
Royal Victoria Infirmary, Newcastle
0220h Category 1 Caesarean section
Obstetric history 38 years old, BMI 33 3 previous vaginal births 40 +2 weeks gestation Induction of labour after SROM (>24 hrs) Syntocinon infusion Prolonged fetal bradycardia (7 mins) Recent VE 3cm dilated
Anaesthetic history Previous GA aged 18 no problems No allergies Last solids 2307h, sips of fluid until 0210h Airway Slumped in bed Short neck Reasonable mouth opening, MP 2, normal dentition Small chin Large breasts
0226h Arrive in theatre Syntocinon off, patient distressed FH confirmed at 60 70 beats/min Confirm decision for GA section HELP pillow on bed ready
0227h Pre oxygenation Left lateral tilt Drugs and airway kit prepared
0230h Induction of anaesthesia Alfentanil 1mg Thiopentone 500mg Suxamethonium 100mg
Shortly after Good fasciculations observed Difficult to insert laryngoscope blade Grade 3 view (MAC 3 blade, short handle) Failed attempt to pass bougie Repositioned Still unable to pass bougie (+/ cricoid) Sevofluorane switched on
0232h Declared failed intubation 2222 airway emergency call SaO 2 92% Difficult to ventilate, possible CICV LMA attempted (size 3 then 4) unsuccessful Two hands on mask and oropharyngeal airway Further emergency calls: consultant obstetric anaesthetist and consultant obstetrician
Maintain oxygenation and wake Saturations falling: 79% Prepare for cricothyroidotomy ITU ST3 arrived Attempted intubation whilst preparing for cricothyroidotomy Grade 3 view, unable to pass ETT or bougie
Extra Pairs of Hands ST5, ST6 and second ODP arrived Unable to ventilate effectively, saturations still falling Emergency call to ITU consultant Surgical cricothyroidotomy attempted
Cricothyroidotomy Scalpel, bougie + size 6 ETT Easy to feel cricothyroid membrane A lot of bleeding on incision Bougie inserted, unable to insert ETT But then
A Wonderful Noise! Some respiratory effort Stridor ++ Two hands on facemask with oropharyngeal airway, able to support respiration Cricothyroidotomy site covered and cricoid pressure resumed Oxygen saturations began to rise Await further help
Meanwhile Consultant obstetrician arrives 0246h Further measures for fetal resuscitation USS confirms fetal HR 69 72 beats/min ENT/Max fax contacted
0253h ITU + obstetric anaesthetic consultants arrive simultaneously Patient moving arms + beginning to moan Sevofluorane switched back on 5mg IV midazolam Abdomen prepped at 0256h
0259h Knife to skin 0301h delivery 0302h placenta delivered Pause in surgery to facilitate airway protection
Intubation Repeat dose of muscle relaxant Attempt at intubation: ITU consultant using video laryngoscope Poor mouth opening, struggled to insert blade Good view at second attempt but unable to pass tube (with stylet/introducer) through cords so abandoned and re oxygenated Third attempt, bougie passed, tube passed
Outcomes Baby 3895g female APGAR scores 3 and 6 Intubated and cooled Initial cord gas Arterial ph 6.7, BE 18.7 Mother Surgery completed Transferred to critical care Nasendoscopy + bronchoscopy minimal trauma Direct laryngoscopy prior to extubation, grade 3 view Extubated uneventfully
Outcomes Me Sent out of theatre with a cup of tea to write notes Sent home 4 epidurals + tear repair pending Further debrief the next night Parents Spoke with parents on delivery suite Debrief with consultant Follow up in obstetric anaesthetic clinic Critical incident form + airway alert form completed
6 Weeks Later Mother Wound healed well Mild dysphagia No recollection of events Baby MRI and EEG normal Home on day 7 Father Happy with all care and support received
My Learning Points Cricothyroidotomies bleed! I would reach for surgical kit again Optimal positioning for surgical airway is not the same as for intubation Airway emergency call Simulation training works
Issues identified by case review Pre delivery fetal resuscitation Choice of emergency anaesthetic technique Anaesthetist/obstetrician communication Conduct of emergency general anaesthesia in obstetrics Equipment issues (appropriate LMA design and size) Immediate availability of video laryngoscope Emergency surgical support (ENT/max fac) Neonatal team staffing issues Emergency calls to nearest available anaesthetic consultant Care of the birth partner in serious emergencies Awareness of failed intubation procedures in the wider team Adequacy of debriefing/support for those involved
Which GA recipe If intubation is achieved at the first attempt? If there are difficulties with intubation/airway management?
Advantages of propofol Our most familiar induction agent Trainee experience Problems and complications Distinctive appearance
GC Lichtenberg I cannot say whether things will get better if we change; what I can say is they must change if they are to get better.
Over 64,000 GA caesareans in the USA (2014) without thiopentone
Sugammadex game changer?
First 20 GAs under new regimen 18 opiate as part of the induction regimen 19 sev-oxygenation - gentle mask ventilation 19 rocuronium 13 sugammadex (1 at emergency reversal dose) On-going audit of neonatal resuscitation
Conclusion Hope for the best but prepare for the worst Prepare to defend increase sugammadex use and build the case to broaden its formulary indication