Obstetric Anaesthetists’ Association and Difficult Airway Society Guidelines for the Management of Difficult and Failed Tracheal Intubation in Obstetrics

Abstract

SummaryThe Obstetric Anaesthetists' Association and Difficult Airway Society have developed the first national obstetric guidelines for the safe management of difficult and failed tracheal intubation during general anaesthesia. They comprise four algorithms and two tables. A master algorithm provides an overview. Algorithm 1 gives a framework on how to optimise a safe general anaesthetic technique in the obstetric patient, and emphasises: planning and multidisciplinary communication; how to prevent the rapid oxygen desaturation seen in pregnant women by advocating nasal oxygenation and mask ventilation immediately after induction; limiting intubation attempts to two; and consideration of early release of cricoid pressure if difficulties are encountered. Algorithm 2 summarises the management after declaring failed tracheal intubation with clear decision points, and encourages early insertion of a (preferably secondgeneration) supraglottic airway device if appropriate. Algorithm 3 covers the management of the 'can't intubate, can't oxygenate' situation and emergency front-of-neck airway access, including the necessity for timely perimortem caesarean section if maternal oxygenation cannot be achieved. Table 1 gives a structure for assessing the individual factors relevant in the decision to awaken or proceed should intubation fail, which include: urgency related to maternal or fetal factors; seniority of the anaesthetist; obesity of the patient; surgical complexity; aspiration risk; potential difficulty with provision of alternative anaesthesia; and post-induction airway device and airway patency. This decision should be considered by the team in advance of performing a general anaesthetic to make a provisional plan should failed intubation occur. The table is also intended to be used as a teaching tool to facilitate discussion and learning regarding the complex nature of decision-making when faced with a failed intubation. Table 2 gives practical considerations of how to awaken or proceed with surgery. The background paper covers recommendations on drugs, new equipment, teaching and training.

Difficult Airway Society guidelines for awake tracheal intubation (ATI) in adults

“…Although there are many guidelines on unanticipated difficult airway management , there are few that specifically focus on the anticipated difficult airway. The ASA, Canadian Airway Focus Group, French Society for Anesthesia and Intensive Care and German Society for Anesthesiology and Intensive Care describe clinical decision making in the anticipated difficult airway .…”

Care of Women with Obesity in Pregnancy

“…Obesity in pregnancy is associated with an increased risk of difficulties with airway management, including difficult bag mask ventilation and failed intubation, a higher risk of desaturation when difficulty is encountered and postoperative atelectasis. Guidelines from the Difficult Airway Society and Obstetric Anaesthetists’ Association highlight the importance of thoughtful formation of both primary and secondary airway plans . Obesity is also associated with a significantly higher gastric volume in labouring parturients .…”

Visual aids for pediatric airway management

“…A modification of the universal algorithm striving to cover all possible airway problems in one page may be represented by the set of visual aids developed by the Difficult Airway Society (DAS). The DAS guidelines, along with a set of specific algorithms, may be found on the Society's Web site (http://www.das.uk.com) and in a series of publications . They are also accompanied by an extensive background text and an intelligent discussion of difficult airway management.…”

“…A pragmatic set of visual aids for various situations are provided: first a Difficult Intubation Overview, in which the basic principles are presented, with the left column presenting the tentative airway management plans A‐D, the central column with various airway options, and a right column with possible outcomes and the ever‐important reminder to STOP AND THINK (supplemental digital content, Figure S2). This general scheme is subsequently modified for specific situations, with algorithms for the unexpected difficult intubation, difficult mask ventilation, a subset of four algorithms for obstetric airway management, and an algorithm for intubation of critically ill adults included in the most recently published ICU difficult airway guideline . And last but not least, difficult airway guidelines modified for pediatrics, available at the DAS and the APAGBI Web sites (http://www.apagbi.org.uk/guidelines).…”