31/10/2014

Obstetric Difficult Airway Guidelines | Difficult Airway Society

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Obstetric Difficult Airway Guidelines

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Obstetric Anaesthetists Association and the Difficult Airway Society
Obstetric Difficult Airway Guidelines
Members consultation process
We are carrying out a public consultation with OAA and DAS members,as well as other interested groups, on
proposed obstetric difficult airway guidelines. These will be the first obstetric-specific national guidelines to be
published with full background information.
During the writing of these guidelines, we have followed these principles:
Simplicity in decision-making. Complex algorithms cannot be followed when severely stressed. The
basic flow of the DAS unanticipated difficult airway guidelines is followed leading, after failed tracheal
intubation (FTI), to supraglottic airway device (SAD) insertion and then front-of-neck access for Cant
Intubate, Cant Oxygenate (CICO).
Safety. The obstetric population usually have a normal airway, with the exception of the tissue swelling
found in pre-eclampsia. Life threatening problems are often associated with multiple traumatic attempts
at airway instrumentation. We advise as a routine, a maximum of two attempts at intubation, and two
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insertions of a SAD.
Practice patterns. Literature review has shown that general anaesthesia is now usually continued after
FTI. This may be because it is essential to continue, or it is considered safe to continue. The indications
to wake the woman up when it is not safe and not essential to continue - are clarified.
Familiarity.Anaesthetists in the UK are now very familiar with anaesthesia using SAD, but not with
facemask anaesthesia. Insertion of SAD should be considered early after FTI. We advise the provision
and use of particular equipment items, but acknowledge that there must be variations based on
availability and familiarity.
Human factors. These are emphasised along with technical skills. Pre-planning for the eventuality of
FTI, integration with the WHO sign-in, and communication with other staff during a crisis are all covered.
There are four algorithms and two tables
The specific algorithms cover the provision of safe rapid-sequence induction of general anaesthesia and the
unanticipated difficult tracheal intubation, FTI and the Cant Intubate, Cant Oxygenate situation. A composite
overview encapsulates these three. Table 1 gives criteria to be used in the decision to wake or proceed
following failed tracheal intubation at caesarean section and Table 2 summarises how to wake or proceed
after failed intubation.
Algorithm 1: Safe Obstetric General Anaesthesia

Features:
Maximizing potential for good airway outcome by attention to detail in optimalgeneral anaesthetic
technique.
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Pre-induction planning with team in case of failed intubation

Mask ventilation to be considered from immediately after induction
Early reduction/removal of cricoid pressure in case of problems
Two intubation attempts only are advised in normal circumstances
Abandon intubation attempts early before loss of control and/or causing trauma
Aspects for discussion:
Suggestion of a third intubation attempt only by an experienced colleague
Algorithm 2: Obstetric Failed Intubation

Features:
Ease of mask ventilation may already have been assessed see Algorithm 1
SAD is higher in the flow diagram. Therefore, after declaring failed intubation, oxygenation can be
achieved with either facemask ventilation or immediate insertion of a SAD.
Laryngoscope to aid placement of SAD can be consideredif appropriate andparticularly if inserted
before the induction agent and muscle relaxant wear off.
Aspects for discussion:
Because of familiarity and security, the LMA (preferred second generation SAD) likely to be considered
acceptable to maintain airway if surgery proceeds; mask will be used in this situation only if SAD fails
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Algorithm 3: Cant Intubate, Cant Oxygenate (CICO)

Features
Management options after CICO is declared
Aspects for discussion:
Not removing the SAD
Ruling out laryngeal spasm and considering neuromuscular agents.
Obstetric General Anaesthesia and Failed Intubation Algorithm

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Features
An overall summary of algorithms 1, 2 and 3.
Useful teaching tool
Table 1: Criteria to be used in the decision to wake or proceed following failed tracheal intubation at
caesarean section

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Features:
Prior to induction of anaesthesia, the anaesthetist should consider with the obstetric team whether the
anaesthetic will be continued or the woman woken in the event of failed tracheal intubation, depending
on the clinical necessity and the safety of proceeding.
There are a number of factors that influence the decision to wake or proceed and these are related to
the woman, the staff and the clinical situation.
Most of these are present preoperatively, and therefore can contribute to advance planning. Two
factors emerge after the failure to intubate: the method/device used to maintain ventilation and the
quality/pathophysiology of the airway. Factors including difficult airway maintenance with a mask or
SAD, airway trauma, airway oedema or stridor indicate a potentially unstable situation that may
deteriorate during surgery if anaesthesia is continued.
Note that in any individual patient, some factors will suggest proceeding and others suggest waking up.
The anaesthetist will use their clinical judgment to make the final decision.
Aspects for discussion
The table indicates consideration to wake up or proceed ; and the colour grading from high (red) to
lower (green) risk situations.
Comments on the clarity of the different categories
Table 2: Management after failed tracheal intubation

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Features
This table gives guidance on how to either continue the anaesthetic and surgery or wake the woman
following failed tracheal intubation.
Recognition of unfamiliarity with spontaneous breathing / inhalational anaesthesia for abdominal
surgery
Known effects of inhalational anaesthetics on uterine muscle tone
Aspects for discussion
Position of the patient during waking up
Preparing for laryngeal spasm/ CICO
Considering the use of TIVA if proceeding
Membership of the Obstetric Anaesthetists Association and Difficult Airway Society Obstetrics Difficult and
Failed Intubation Guidelines Group:
M. C .Mushambi (Chairman), M. Popat, S.M. Kinsella, A. Winton, H. Swales, A. Quinn and K.K. Ramaswamy
Please send all your comments by 21st November2014 to mary.mushambi@uhl-tr.nhs.uk
Attachments

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Download DRAFT Algorithm - PDF version

Tags:
guidelines

Related pages
Update on DAS intubation guidelines 2015
DAS Guidelines Home
Fibreoptic guided tracheal intubation through SAD using Aintree intubation catheter
Paediatric Difficult Airway Guidelines
DAS extubation guidelines
Downloads
Intubation Guidelines - Follow up / airway alert
Intubation guidelines - Cannot Intubate, Cannot Ventilate
Intubation guidelines - Default strategy for intubation
Intubation guidelines - Rapid sequence induction

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