Failed intubation

A 21-year-old woman has acute appendicitis and requires general anaesthesia for an

appendicectomy. Thorough pre-oxygenation is undertaken and a rapid sequence

induction of anaesthesia is performed using 5 mg/kg of thiopentone and 1.5 mg/kg

of suxamethonium while a trained assistant applies 30N of cricoid pressure. After

three attempts at tracheal intubation it has not been possible to intubate the trachea.

According to the Difficult Airway Society guidelines, which one of the following

options is the most appropriate action to be taken NEXT?

a) Have one last (fourth) attempt at intubation

b) Check and optimise the patient’s head and neck position

c) Request that the assistant perform backwards–upwards–rightwards pressure

d) Recognise that this is a failed intubation and move to ‘Plan B’

e) Ventilate via a facemask

Answer: e

Explanation

It is essential to be familiar with the Difficult Airway Society guidelines on management

of failed intubation. There are separate, slightly dissimilar, guidelines for intubation

of the trachea in the presence of high or low risk of aspiration of stomach

contents. Clearly there are certain sensible behaviours and their precise order can be

debated so this question is based on the suggested order of the Difficult Airway

Society. As the guidelines stand it is suggested that during a rapid sequence induction,

no more than three attempts at tracheal intubation should be made in order to prevent

delay in acknowledging failure and moving on toward a solution. Where there is low

risk of aspiration, it is suggested that no more than four attempts should be made. The

patient’s head and neck position should be optimised before pre-oxygenation is commenced

and re-checked after the first failed attempt. However, after three failed

attempts, options such as re-positioning, using a different laryngoscope blade, external

laryngeal manipulation or use of an introducer should be abandoned in favour of

moving on through the algorithm. The objective (Plan C) should be to maintain oxygenation

while awakening the patient – this may be with a facemask although a

supraglottic device may become necessary. There is no ‘Plan B’ (secondary tracheal

intubation plan) here, as attempts to intubate the trachea have been abandoned. Plan B

applies where there is a low risk of aspiration of stomach contents.

Reference

Difficult Airway Society. Rapid sequence induction – Guidelines. Online at www.das.

uk.com/guidelines/rsi.html (Accessed 30 October 2009)