Unexpectedly difficult airway

Abstract

Introduction: Difficult airway is defined as ‘clinical situation where an experienced anesthesiologist has difficulty in ventilation patient’s facial mask difficulty in tracheal intubation or loth’ The assessment of the airway is one of the first and key step in anesthetit preoperative examination, and determined strategy to plan positioning of patients, equipment, technology and medicine. There are few difficult airway predictors: obesity, deformities of the jaw and neck, macroglossia, interincisor small space, prominent chest, large breasts, small tireomental distance. The most commonly used Mallampati, wherein the class 3 and 4 predictors of difficult intubation. The most useful is a combination of tests, there is no perfect predictor for assessing airway difficulties, unexpected difficult intubation in practice occur from time to time. Objective: Case report of unanticipated difficult intubation, analysis procedures and measures taken. Materials and method: A descriptive method, the data from the anesthetic records. Case report: A 62 year old female patient, weighing 50 kg and a height of 160 cm, is preparing for the planned operation, with the diagnosis: Tumor ovarii dextri per magna. Without significant comorbidity. In assessing the airway, patient had sufficient mobility of the neck, tireomental distance, Mallampati class 2, not obese, only interincisor space limits of about 3 cm. The possibility for difficult ntubation is not anticipated. After premedication, the patient is positioned in a horizontal position. After the introduction of anesthesia, ventilation facial mask was good. After aplication short acting depolarizing muscle relaxants, access to laryngoscopy. It is observed that a large epiglottis is impossible to raise, and plicae vocalis were unavailable for visualization. Endotracheal intubation was attempted in 3 times. After the failure, the supraglottic device laryngeal mask was placed. Laryngeal mask was not positioned satisfactorily to achiev the correct ventilation. Because insufflation of air in the stomach and unsatisfactory ventilation, we made a decision to postpone the surgery for a few days. The patient wakes up, breathe spontaneously. All data, with detailed descriptions were recorded in the anesthetic card. Confronted with the unanticipated difficult intubation, anesthetic team is thoroughly prepared for delayed surgery, and changes the strategy for airway management. The patient is placed in the anti-Trendeleburg position, the head is elevated, thus the axes of the upper airway and allows a better visualization of anatomical structures. One anesthesiologist approach to direct laryngoscopy, and other performed BURP maneuver (Backward, Upward, Rightward Pressure), approaching structures of the larynx, and allows visualization of the successful intubation. Discussion and conclusion: The Guide Association for difficult airway from 2015 emphasis on careful planning and detailed knowledge of the entire team with the strategy of securing the airway. The positioning of the head and neck must be optimized from the start to make the first intubation attempt successful. Equipment for difficult intubation must be easily accessible. All the difficulties must bedetaily noted in the medical records, which is of great importance for the anesthesiologist and patient with possible following surgery.