Failed intubation in obstetrics

Abstract

Maternal deaths may be associated with difficult or failed intubation during the course of a general anaesthetic. The combination of a simple protocol, familiar equipment, practice on simulators and trained assistance may decrease the likelihood of a failed intubation causing a catastrophe. The author has used a simple protocol that involves suitable preassessment of the patient, before preparing and positioning the patient in order to minimize the risk of failure. The patient is preoxygenated and adequately paralysed before a bougie is used to pass the tracheal tube using a perfect technique. If this first and best attempt at intubation is unsuccessful, the priorities are to oxygenate the patient (using a four-hand ventilation technique if necessary) and call for senior help. If a second laryngoscopic attempt is required the left molar approach to laryngoscopy may be successful. If the intubation is unsuccessful the patient should be awoken and an alternative technique of anaesthesia used (awake intubation or spinal). However, if the surgery has to continue (cardiac arrest, exsanguinating patient) a classic laryngeal mask airway (LMA) may provide a suitable airway conduit using a non-irritational inhalation agent (e.g. sevoflurane). If the patient cannot be oxygenated by any other means (face mask and Guedel airway or LMA) then a surgical airway using a quicktrach and manujet should be performed. All of the above techniques can and should be practised (some on patients, some on simulators) using scenario-based teaching. The trainees can be assessed by their trainers as part of competency-based training.