Correspondence
consultant support. Surely we have learned, from the Con®dential
Management of failed intubation in a septic
parturient
EditorÐI was dismayed to read the case report from Hinchliffe
and Norris1 `Management of failed intubation in a septic
parturient', which actually presents an example of how to not
manage a dif®cult obstetric case! In the ®rst instance, trainees
were left to, or decided to, take on a high-risk case without
937
Enquiries into Maternal Deaths,2 that most deaths in obstetrics
associated with anaesthesia involve less experienced anaesthetists
providing emergency anaesthesia for Caesarean section. When a
consultant arrived, however, the management decision was
puzzling. In a patient in whom it had been decided that
laryngoscopy and intubation were either extremely dif®cult or
even impossible, it was elected to proceed to epidural anaesthesia.
What would have been done in the event of an accidental total
spinal anaesthetic? In this particular case, the decision to proceed
to epidural anaesthesia was taken despite the fact that the patient
was only just managing to maintain adequate arterial oxygen
saturation breathing oxygen 100%, and was confused and
haemodynamically unstable!
This patient should have undergone awake ®breoptic intubation
from the start. Anything less borders on negligence. Muddled
thinking, as illustrated in this case report, is exactly what leads to
disasters.
M. O'Leary
NSW, Australia
EditorÐI read with interest the case report by Hinchcliffe and
Norris.1 I have serious concerns about the way this patient was
managed. The patient, a young, obese (105 kg) nurse, was very
unwell on admission and the fetus was in considerable distress. A
decision to proceed to Caesarean section was made. Assessment
of the patient found her to have a Mallampati score of 3 and a
`cricothyroid membrane that was dif®cult to identify'. No reason
is given for the dif®culty in identi®cation. I assume she had a short
fat neck, in keeping with her weight. These factors, in
combination with her obesity, indicate there is a substantial risk
for her being a dif®cult intubation, in a population where the risk
is only 1 in 300. Nevertheless, the decision to proceed with
general anaesthesia was taken, without discussing the case with
the consultant obstetric anaesthetist. Surely such a complex case
with numerous risk factors demands consultant input at an early
stage? Moreover, after induction of anaesthesia, she was given an
inadequate dose of succinylcholine (100 mg); a dose of 150 or
200 mg would have been appropriate. I wonder whether
incomplete muscle relaxation contributed to the poor view at
laryngoscopy? Having anaesthetized and paralysed the patient,
why was no attempt made to pass a gum elastic bougie on
visualization of the epiglottis? Surely one attempt was warranted.
The other major concern I have is, had you been unable to
ventilate the patient after induction, the option for formation of
an emergency surgical airway was severely limited because of
poor landmarks. I suggest that the decision to proceed with
general anaesthesia in someone with serious potential airway
problems was inappropriate. The appropriate course of action
would have been to perform a regional technique (epidural), or
an awake ®breoptic intubation at the outset. Although systemic
infection is a relative contraindication to regional techniques,
Chestnut3 found only one case of epidural infection in 500 000
obstetric epidurals, with an assumed incidence of 1%
bacteraemia. If we assume this episode of epidural infection
occurred in one of those patients who was bacteraemic, this
indicates a risk of 1 in 5000 for developing epidural infection
in such patients compared with a risk of less than 1 in 300 for
a serious airway problem on induction of general anaesthesia
in the obstetric population. Of the 531 patients in the study by
Goodman and colleagues,4 none developed epidural or spinal
infection despite having a regional technique in the presence
of chorioamnionitis. Although there is a theoretical risk for
seeding infection in the epidural/spinal spaces in those who are
bacteraemic, hard evidence appears to be lacking in patients
 Correspondence

having `single shot' regional techniques. The risk bene®t ratio 1 Hinchliffe D, Norris A. Management of failed intubation in a septic
in this case appears to favour a regional technique. parturient. Br J Anaesth 2002; 89: 328±30
The reasons given for not performing an awake ®breoptic 2 Report on Con®dential Enquiries into Maternal Deaths in the United
intubation are, at best, dubious. We must remember that what we Kingdom 1985±1987. London: HMSO, 1990
should do is take the safest option, in the patient's best interest. It 3 Chestnut DH. Spinal anaesthesia in the febrile patient. Anesthesiology
is worth drawing attention to a recent editorial in The Royal 1992; 76: 667±9
College of Anaesthetists Bulletin,5 which claims that there have 4 Goodman EJ, Dehorta E, Taguiam JM. Safety of spinal and epidural
been three deaths attributable to failed intubation by trainee anaesthesia in parturients with chorioamnionitis. Reg Anesth 1996; 21:
anaesthetists in pregnant patients, since the last triennial report 436±41
into maternal deaths (1997±1999)6 was published. It is better to 5 The Royal College of Anaesthesists. Bulletin 14; July 2002: 662±3
take a little longer over a procedure and in¯ict some discomfort if 6 Why Mothers Die. Report on Con®dential Enquiries into maternal
this is the safest option, rather than rush into something potentially deaths in the United Kingdom 1997±1999. London: RCOG Press,
disastrous. 2001
7 Yentis SM. Predicting dif®cult intubation±worthwhile exercise or
M. F. Dunsire pointless ritual? Anaesthesia 2002; 57: 105±9
London, UK 8 American Society of Anesthesiologists. Practice Guidelines for
management of the dif®cult airway: A report by the American
Society of Anesthesiologists Task Force on Management of the
EditorÐThank you for the opportunity to reply. Dr O'Leary Dif®cult Airway. Anesthesiology 1993; 78: 597±602
appears to misunderstand the role of case reports of this type, 9 Popat MT, Srivastava M, Russell R. Awake ®breoptic intubation skills
which is partly for interest, and partly to illustrate some wider in obstetric patients: a survey of anaesthetists in the Oxford region.
lesson. The lesson in our case is that regional anaesthesia may IJOA 2000; 9: 78±82
remain the obstetric anaesthetist's best option, even when
systemic infection is present (albeit after antibiotic treatment).
Dr Dunsire makes a similar point. Our description of events does
not pretend to be an essay on how to manage such cases.
The suggestion that the case was mismanaged because of lack
of experience on the part of the senior trainees involved is
misplaced. The specialist registrars both possessed the FRCA, in
addition to several years experience of obstetric anaesthesia. Only
in the UK and Eire would such doctors still be part of a training
scheme, and this is re¯ected in the nature of their clinical
responsibilities. The decision to request additional assistance from
a colleague with particular experience or skills re¯ects sound
clinical practice not lack of competence.
In contrast to Dr O'Leary's remarks, the management of this
case enshrines many of the principles contained in maternal
mortality and CEPOD reports;2 6 a formal assessment of the
airway was made, assistance was requested, preparations for
dif®cult intubation were made, a failed intubation drill was
adopted promptly without repeated attempts, and intensive care
was involved early.
Both correspondents suggest that awake ®breoptic intubation
should have been performed from the outset. Indeed, Dr O'Leary
says not to do so verges on negligence. We disagree. We
acknowledged in our report that awake intubation might have
been the best option, but there is no consensus on when this is
indicated on the basis of predictive factors, and the problems with
this approach have been summarized by Yentis.7 Even when
awake intubation appears to be indicated, a cooperative patient is
still required. Is a woman with a fever in advanced labour with
fetal distress likely to be cooperative? The ASA dif®cult airway
guidelines8 suggest regional anaesthesia (as in our case) or
®breoptic intubation under anaesthesia as options in this context.
Even if the indications for awake intubation were clear, which
they are not, it is futile to argue, as a current standard of practice,
that all potentially dif®cult cases undergo awake intubation, when
the reality (at least in the UK) is that most anaesthetists lack the
necessary skills, training and equipment, especially for a case like
this.9 Dif®cult cases require knowledgeable, skilled doctors to
exercise their clinical judgement, not the re¯ex application of a
single `solution'.

A. M. Norris
D. Hinchliffe
Nottingham, UK

938