Handling Error Traps in Difficult Airway Management in Paediatric Patients With Mandible Tumour: Lessons Learned From Two Cases

Abstract

Introduction Various factors can cause difficult airways in the paediatric population, such as congenital anomalies, obstruction, tumours, etc. Failure in managing difficult airways in children is associated with significant morbidity and mortality. We present a case series of how identifying error traps will improve patient care and safety. Case We present two similar cases of children with impending airway obstruction due to mandible tumours who were indicated for an urgent tracheostomy. In the first case, there was an airway management failure (cannot intubate, cannot oxygenate). The patient deteriorated rapidly and died in the operating theatre. Aftermath, we conducted a multidisciplinary discussion of experts and analysed this sentinel case. In the first case, there were some error traps related to preparation, performance, and proficiency. Thus, recommendations were advised. The second case occurred 14 days following the first one. This time we delivered the airway management by implementing the recommendation from previous case failures, which were: choosing the appropriate anaesthesia technique and airway device, performing adequate passive oxygenation before an intubation attempt, having a mitigation plan, and communicating it with the surgeon. Also, an airway expert should always be available to be consulted. Lastly, conducting a debriefing with the team involved after the procedure to identify the experienced problems. The team managed to perform the tracheostomy on the second child successfully. Conclusion Mortality and morbidity due to airway management failure in paediatric patients with difficult airways could be reduced by averting error traps and following the recommendation to have better preparation in airway management techniques and planning, good inter-team communication and coordination, and consult a more experienced anaesthesiologist to lead the team.