Difficult Airway Society: Difficult Intubation

 

List:

·         Preparation

·         Plan A

·         Plan B

·         Plan C

·         Plan D

·         Afterward

 

Preparation: DAMP

Drip

·      IV working

Drugs

·      Hypnotic

·      Reflex suppressant

·      Paralytic

·      Pressor

·      Reversal

Airway equipment

·      Usual things

·      Suction working

·      Manual bag-mask available

Airway plan

·      ABCD

·      Consider saying out loud

·      Consider rehearsal

Machine

·      Anaesthetic machine checked

·      Gases actually running

Monitoring

·      NIBP cycling, sats reading, ECG reading

·      Gases: O2, CO2, anaes

·      NMT

Positioning

·      Pillows & blankets?

·      Table controls?

·      Oxford ramp?

Personnel

·      Nurse ready?

·      Second anaesthetist needed?

Pre-oxygenation

·      100% 5 minutes

·      Face mask fits?

·      HFNP?

N.B. this is my checklist, it is not part of DAS guidelines

 

Plan A: face mask -> ETT

Tips

·      Remove cricoid pressure

·      ELM

·      Bougie or stylet

·      Video laryngoscope

·      Paralysis

Number of attempts

·      3+1 (seems like too many!)

If success here

·      Go ahead

If fail here

·      Declare failed ETT

·      Call for help

 

Plan B: LMA

Tips

·      2nd generation

·      Change device

·      Change size

Number of attempts

·      3

If success here

·      Stop and think:

o   Proceed with LMA?

o   Intubate via LMA?

o   Wake up?

o   Hole?

If fail here

·      Declare failed ETT and LMA

 

Plan C: face mask

Tips

·      Two hands

·      Guedel

·      Paralyse

Number of attempts

·      1

If success here

·      Wake up

If fail here

·      Declare CICO

·      Keep reading

 

Plan D: hole

Equipment

·      Scalpel

·      Bougie

·      ETT size 6

Method

·      Identify cricothyroid membrane

·      Stab

·      Rotate 90°

·      Insert bougie

·      Railroad ETT

·      Ventilate

·      Secure

If impalpable

·      10cm vertical incision

·      Dissect

·      Identify cricothyroid membrane

·      Proceed as above

 

Afterwards:

Observation

·      PACU vs ICU/HDU

Disclosure

·      Explain to patient

Documentation

·      Write in hospital notes

Notification

·      Give difficult airway form to patient

·      Send information to local database

 

Difficult Airway Society: Extubation

 

List:

·         Plan

·         Prepare

·         Perform

 

1.Plan

Risk factors for failure

·           Previous airway difficulty

·           Airway trauma/bleeding/swelling)

·           Restricted access

·           Obesity/OSA

·           Full stomach

 

2.Prepare

Physiological prerequisites

·           CVS ok (minimal supports)

·           Resp ok (minimal support, FiO2 <0.4, RR and VT adequate)

·           Neuro ok (anticipate obeying command)

·           Neuromuscular ok (TOF >0.9)

·           Acid-base ok

·           Temperature ok

Logistical pre-requisites

·           Monitoring there

·           Equipment there

·           Personnel there

 

3.Perform

If low risk

·           Awake extubation

o  Pre-oxygenate

o  Suction

o  Bite block

o  Sitting up

o  Wait until obeying command

o  Apply positive pressure

o  Deflate cuff

o  Remove ETT

o  Apply face mask with 100% oxygen and CPAP

o  Observe

·           Deep extubation

o  Experience essential

o  Observe until emergence

If high risk

·           Remifentanil infusion:

o  Awake

o  Breathing upon command

·           LMA exchange:

o  Railroad over ETT

o  Test ventilate LMA

o  Remove ETT

·           Airway exchange catheter:

o  Pass through ETT

o  Remove ETT

If very high risk

·           Postpone extubation

o  i.e. send to ICU

·           Tracheostomy

 

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