Failed tracheal intubation in obstetric anaesthesia: 2 yr national case–control study in the UK

Abstract

We received 57 completed reports (100% response). The incidence using a unit-based estimation approach was one in 224 (95% confidence interval 179-281). Univariate analyses showed the index cases to be significantly older, heavier, with higher BMI, with Mallampati score recorded and score >1. Multivariate analyses showed that age, BMI, and a recorded Mallampati score were significant independent predictors of failed tracheal intubation. The classical laryngeal mask airway was the most commonly used rescue airway (39/57 cases). There was one emergency surgical airway but no deaths or hypoxic brain injuries. Gastric aspiration occurred in four (8%) index cases. Index cases were more likely to have maternal morbidities (P=0.026) and many babies in both groups were admitted to the neonatal intensive care unit: 21 (37%) vs 29 (27%) (NS). Three babies died--all in the control group.

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

“…The majority of obstetric difficult and failed intubations occur during emergencies and out of hours [22,23]. Concerns for rapid delivery of the fetus often lead to time pressure, which may result in poor preparation, planning, communication and performance of technical tasks.…”

“…There are a number of common factors that are associated with difficulty in performing all of these airway management tasks (Appendix 1). The assessment should be documented clearly [22,32]. Oral piercings should be removed before any form of anaesthesia as they may cause trauma and bleeding during intubation as well as carrying the added risk of aspiration if pieces detach [33].…”

“…In addition to lateral uterine displacement as indicated, the head-up position should be considered. A [20][21][22][23][24][25][26][27][28][29][30] o head-up position increases functional residual capacity in pregnant women [53] and safe apnoea time in nonpregnant obese and non-obese patients [54][55][56][57]. It also decreases difficulty with insertion of the laryngoscope caused by large breasts, improves the view at laryngoscopy [58] and may reduce gastro-oesophageal reflux [59].…”

“…The majority of failed intubations in obstetrics occur out of hours and in the hands of trainee anaesthetists [12,22,23], and there is hence a need to maximise training opportunities. The Royal College of Anaesthetists recommends that all general anaesthetics for elective caesarean section in training institutions should be used for teaching [169].…”

Sources of Inspiration: A Neurophysiologic Framework for Understanding Anesthetic Effects on Ventilatory Control

“…Increasing obesity rates in the decades since the Closed Claims Study have only augmented the risks. A 2012 study from the UK revealed that, among pregnant women undergoing cesarean section, there was a 7 % increase in the incidence of failed intubation for each 1 kg m -2 increase in BMI above normal [4]. The risk of ventilatory depression extends into the postoperative period.…”