Tuesday, 13 September 2016

Obstetric Anaesthetists’ Association/Difficult Airway Society difficult and failed tracheal intubation guidelines – the way forward for the obstetric airway. BJA Oct 2015.

Last year a joint working group from Obstetric Anaesthetists’ Association (OAA) and the Difficult Airway Society (DAS) published the first obstetric-specific difficult airway guideline in UK. This editorial discusses the major points in difficult obstetric airway management. I have also included the OAA/DAS guideline for your review.
Summary of important points:

  • ‘Worst case’ is category 1 Caesarean section.
  • Use airway assessment to predict global airway management difficulty, not just laryngoscopy and intubation problems.
  • Before induction, make provisional plan should intubation fail – either awaken or proceed with surgery – communicate this with the team.
  • Head up position and apnoeic oxygenation can prolong safe apnoea time.
  • Gentle mask ventilation with cricoid pressure after administering induction agents is recommended.
  • Cricoid pressure should be reduced or released if there is a poor view at laryngoscopy.
  • Supraglottic airway device or facemask ventilation are valid first options after failed tracheal intubation. A second-generation supraglottic airway device is recommended.
  • After failed intubation, the immediate situation will determine the decision to awakening or proceed with surgery.
  • Unless it is safe or essential to proceed, the patient should be awakened.
  • Safety – strong indications for waking the patient after failed intubation include one or more of: obstructed airway, inadequate capnogram, hypoxaemia secondary to hypoventilation; a relative indication is if the patient has eaten recently.
  • Essential to proceed – strong indications to proceed are maternal compromise or fetal indications with an identified sentinel event (review current status), difficulty with providing alternatives (regional anaesthesia, awake securement of the airway).
  • Awakening – during failed intubation at category 1 Caesarean section for fetal indications without an identified sentinel event, there is a high chance that fetal condition will remain the same or even improve.
  • Proceed with surgery – if there is adequate airway/ventilation, further intubation attempts are discouraged unless a new factor presents that significantly increases the chance of success, or there is an indication for prolonged airway control.
  • Can’t intubate can’t oxygenate – if this occurs, ensure muscle paralysis before performing front-of-neck access procedure.
  • After failed intubation at Caesarean section, there is increased risk of neonatal admission to the neonatal intensive care unit; the neonatologist should be informed about the problem.

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