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CASE PRESENTATION

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A lady in her thirties presented for endoscopic sinus surgery and septoplasty. Preoperative assessment found only a congenitally fused neck vertebra and use of nasal decongestant spray for long-standing sinusitis. Despite a slight restriction in neck movement, there was nothing to suggest a problem with airway management. For example, there was minimal restriction in neck flexion extension and rotation. Mouth opening and thyromental distance were normal, and the Mallampati was Grade II.

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An experienced and diligent anesthesia practitioner planned to avoid tracheal intubation by inserting a laryngeal mask airway (LMA). However, following induction with a remifentanil infusion (0.3 mcg·kg−1 min−1) and propofol (200 mg), the LMA could not be inserted. Fifty additional milligrams of propofol were given but repeated attempts (including two different sizes of LMA) were also unsuccessful. By 2 minutes the patient's oxygen saturation had decreased to 75% and she looked cyanosed. By 5 minutes her oxygen saturation deteriorated to 40%. Administration of 100% oxygen using a face mask and oral airway failed to raise the oxygen saturation, and the heart rate decreased to 40 seconds.

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The anesthesiologist then administered atropine and succinylcholine. He attempted tracheal intubation and was joined by a second anesthesia practitioner (who had additional airway training). Laryngoscopy provided only a Cormack and Lehane Grade 3 view (meaning tracheal intubation is likely to be very difficult, if not impossible). Other staff entered the room, including the surgeon. Between attempts at laryngoscopy, patient ventilation was extremely difficult, despite use of a four-handed technique. At no point did anyone announce that this was a “failed airway,” a “can’t intubate, can’t oxygenate” situation, or an “airway emergency.”

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Both anesthesiologists made further unsuccessful laryngoscopic intubation attempts. The second anesthesia practitioner attempted tracheal intubation using a flexible bronchoscope but without success, and other staff collected additional equipment including a tracheotomy set. Next the surgeon attempted intubation by direct laryngoscopy with an Eschmann tracheal introducer; he was also unsuccessful. By 20 minutes, an intubating laryngeal mask was inserted which allowed partial ventilation. The patient's blood pressure and heart rate increased as did the oxygen saturation but not above 90%.

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Blind attempts were made to insert a tracheal tube through the intubating laryngeal mask (as the device is intended to work) and then using a flexible bronchoscope. The surgeon failed to pass the scope through the end of the LMA (a recognized problem with this device). After more than 30 minutes, it was decided to abandon the procedure and let the patient wake up. The LMA was removed and an oral airway inserted. Oxygen saturation gradually improved to 95%. The anesthesiologist transferred her to the recovery room and told staff that he expected the patient to wake. Both anesthesia practitioners carried on to their next cases.

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While the patient did breathe on her own, her level of consciousness did not improve and her vital signs ...

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