Failed intubation

Between 1978 and 1983, the tracheas of eight patients could not be intubated in the maternity unit of St James' University Hospital, Leeds. The incidence of failed intubation on our labour ward is approximately one for every 300 general anaesthetics given. The results of postoperative investigation in the patients are reported.     

Failed intubation in obstetrics

Failed intubation in obstetrics is rare. However, if the situation is not managed appropriately the consequences for the mother and newborn may be catastrophic. The skill of managing the airway seems to be decreasing, primarily because the skills are not being practised in general or obstetric anaesthesia. Solutions for this decrease in skills may include improved training and the use of manikins, both for role play and for practising skills. The priority of management is to provide oxygen to the mother and to call for assistance. Oxygen can be provided using basic airway, intubation, and, if necessary, surgical airway skills. Such skills need to be practised on manikins and non-obstetric patients. The decreasing incidence of general anaesthetics means that planning and preparation should be meticulous before and during caesarean section. Ideally, the first intubation attempt should be the best. If a failed intubation occurs, initially techniques such as the use of a bougie, McCoy blade or the left molar approach may be considered, provided hypoxia is avoided. If intubation is unsuccessful the mother should be woken and a regional technique or awake fibreoptic intubation from a suitably experienced practitioner should be considered. A simple protocol shown in this article can be used as a training tool to assess skills, decision-making and teamwork in the event of a failed intubation. Extubation after a difficult intubation should be done with care, and the patient warned of the difficulty in case of further anaesthetics.     

Failed intubation in obstetrics

Failed intubation in obstetrics remains a topical issue, a rare but potentially devastating complication of obstetric general anaesthesia. The 2015 guidelines produced following several years of collaborative work between the Difficult Airway Society (DAS) and Obstetric Anaesthetist's Association (OAA) remain the definitive text. While deaths from failed intubation have declined significantly over 30 years, the incidence of failed intubation remains fairly constant at 1:300, with latest studies showing a rate of 1:224. This reflects the significant decline in the use of general anaesthesia for caesarean section over the last three decades; however it also highlights a decreased exposure for trainees to tracheal intubation in the obstetric population.     

Failed intubation in obstetrics

Failed intubation in obstetric practice is rare, however it can have a devastating impact on the mother and fetus if not managed appropriately.Over the last 20 years there have been significant changes in anaesthetic management and training; in addition The European Working Time Directive has led to a reduction in junior doctors' hours. As a result, trainees now have less exposure to airway management, specifically endotracheal intubation.Acquiring skills in obstetric general anaesthesia is increasingly difficult as the majority of women will be suitable for regional anaesthesia.Training must be targeted at the differences between the airway in the non-pregnant and pregnant woman, and it is essential that all training opportunities in obstetric general anaesthesia should be taken. Use of simulation and animal models is an effective way of improving teamwork and confidence to deal with emergency situations such as failed intubation.     

Failed intubation in a parturient with spina bifida

We describe a case of unexpected difficult intubation and ventilation during induction of general anaesthesia for caesarean section. This case was particularly challenging as the parturient suffered with particularly severe cord tethering following surgery for spina bifida as a child. The observed change in anticipated intubation difficulty during pregnancy, and the use of the laryngeal mask airway as a life-saving device in obstetrics are described. Consideration of the difficulties of anaesthetising the patient with spina bifida for caesarean section in general, and the issues relevant in deciding whether to continue with surgery or to wake the patient up in particular are discussed. Suggestions are made for the management of this emergency situation in those not skilled in fibreoptic intubation.     

Failed tracheal intubation during obstetric general anaesthesia: a literature review

We reviewed the literature on obstetric failed tracheal intubation from 1970 onwards. The incidence remained unchanged over the period at 2.6 (95% CI 2.0 to 3.2) per 1000 anaesthetics (1 in 390) for obstetric general anaesthesia and 2.3 (95% CI 1.7 to 2.9) per 1000 general anaesthetics (1 in 443) for caesarean section. Maternal mortality from failed intubation was 2.3 (95% CI 0.3 to 8.2) per 100 000 general anaesthetics for caesarean section (one death per 90 failed intubations). Maternal deaths occurred from aspiration or hypoxaemia secondary to airway obstruction or oesophageal intubation. There were 3.4 (95% CI 0.7 to 9.9) front-of-neck airway access procedures (surgical airway) per 100 000 general anaesthetics for caesarean section (one procedure per 60 failed intubations), usually carried out as a late rescue attempt with poor maternal outcomes. Before the late 1990s, most cases were awakened after failed intubation; since the late 1990s, general anaesthesia has been continued in the majority of cases. When general anaesthesia was continued, a laryngeal mask was usually used but with a trend towards use of a second-generation supraglottic airway device. A prospective study of obstetric general anaesthesia found that transient maternal hypoxaemia occurred in over two-thirds of cases of failed intubation, usually without sequelae. Pulmonary aspiration occurred in 8% but the rate of maternal intensive care unit admission after failed intubation was the same as that after uneventful general anaesthesia. Poor neonatal outcomes were often associated with preoperative fetal compromise, although failed intubation and lowest maternal oxygen saturation were independent predictors of neonatal intensive care unit admission.     

Failed intubation and emergency percutaneous tracheostomy

Failed intubation associated with difficulty with ventilation is rare. Cricothyrotomy may provide a means of oxygenating the patient, but in practice it may be difficult to perform and does not establish a definitive airway. We report two patients in whom percutaneous tracheostomy was used as an emergency procedure. In both cases placement was extremely rapid and salvaged the situation, leaving a definitive airway.