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Crisis management in anaesthesia: difficult intubation in obese patients
Crisis management in anaesthesia: difficult intubation in obese patients -- Posted by I Jah Rastafari on 06-07-05 09:50
BACKGROUND: Anaesthetists may experience difficulty with intubation
unexpectedly which may be associated with difficulty in ventilating the
patient. If not well managed, there may be serious consequences for the
patient. A simple structured approach to this problem was developed to
assist the anaesthetist in this difficult situation.
OBJECTIVES: To examine the role of a specific sub-algorithm for the
management of difficult intubation.
METHODS: The potential performance of a structured approach developed
by review of the literature and analysis of each of the relevant
incidents among the first 4000 reported to the Australian Incident
Monitoring Study (AIMS) was compared with the actual management as
reported by the anaesthetists involved.
RESULTS: There were 147 reports of difficult intubation capable of
analysis among the first 4000 incidents reported to AIMS. The
difficulty was unexpected in 52% of cases; major physiological changes
occurred in 37% of these cases. Saturation fell below 90% in 22% of
cases, oesophageal intubation was reported in 19%, and an emergency
transtracheal airway was required in 4% of cases. Obesity and limited
neck mobility and mouth opening were the most common anatomical
contributing factors.
CONCLUSION: The data confirm previously reported failures to predict
difficult intubation with existing preoperative clinical tests and
suggest an ongoing need to teach a pre-learned strategy to deal with
difficult intubation and any associated problem with ventilation. An
easy-to-follow structured approach to these problems is outlined. It is
recommended that skilled assistance be obtained (preferably another
anaesthetist) when difficulty is expected or the patient's
cardiorespiratory reserve is low. Patients should be assessed
postoperatively to exclude any sequelae and to inform them of the
difficulties encountered. These should be clearly documented and
appropriate steps taken to warn future anaesthetists.
Qual Saf Health Care. 2005 Jun;14(3):Crisis management during
anaesthesia: difficult intubation. Paix AD, Williamson JA, Runciman
WB.Australian Patient Safety Foundation, GPO Box 400, Adelaide, South
Australia 5001, Australia. research@apsf.net.au.
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