Obstetric Anaesthetists' Association and Difficult Airway Society guidelines for the management of difficult and failed tracheal intubation in obstetrics

Abstract

The 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 second-generation) 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.

Radical evolution: the 2015 Difficult Airway Society guidelines for managing unanticipated difficult or failed tracheal intubation

“…The first (2004) guideline rapidly became one of the most important in the specialty [2]. The society's pre-eminence in this field is underlined by subsequent paediatric [3], obstetric [4] and tracheal extubation guidelines [5], all of which have made important contributions to patient safety. The 2004 DAS Intubation Guidelines may have stood the test of time, but this update seems long overdue, as the new update itself acknowledges, in the light of many new and widespread techniques, notably videolaryngoscopes, and new ideas about surgical frontof-neck access.…”

A Short Update on Sugammadex with a Special Focus on Economic Assessment of its Use in North America

“…The rocuronium-sugammadex combination has been claimed to be an advantage in parturients with neurologic disease [29]. Sugammadex is now part of the UK Obstetric Anaesthetist Association's newest algorithm for management after failed tracheal intubation as rocuronium can be fully reversed by sugammadex within 3 min instead of 9 min to reach spontaneous recovery using succinylcholine [30].…”

Through a glass darkly - ultrasound imaging in obstetric anaesthesia

“…Following the publication of the Obstetric Anaesthetists' Association / Difficult Airway Society guidelines for the management of the potential difficult and failed tracheal intubation in obstetrics [18], there has been renewed discussion in this area [19,20]. These guidelines have moved the focus of attention after failed intubation away from continued intubation attempts to maintaining oxygenation including front-of-neck airway access in a 'can't intubate, can't oxygenate' situation.…”