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CASE PRESENTATION

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A 42-year-old obese man is undergoing renal dialysis in a hospital dialysis unit when he suddenly suffers a cardiac arrest. He is a diabetic with a history of cerebrovascular disease, peripheral vascular disease, and angina. He is a nonsmoker. He had no premonitory symptoms.

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You are called to manage his airway. When you arrive on the scene, you see a cyanotic male looking older than his stated age, reclining at 45 degrees in a dialysis chair. He is still connected to a dialysis machine via a vascular shunt in his left arm. The head of the chair, which is not on wheels, is against the wall. A dialysis technician is straddling the patient performing cardiopulmonary resuscitation and a nurse is delivering ineffective bag-mask-ventilation (BMV) from the right side of the patient. You are informed that he receives dialysis three times a week. His dry weight is 188 kg (414 lb).

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The crash cart has arrived, containing both oral and nasal airways, endotracheal tubes, a laryngoscope handle, and #3 and #4 Macintosh blades. There is an intubating stylet as well. This is the third time this year you have been called to this unit. Unfortunately, the equipment you prefer to use for airway management is never available in the dialysis unit, despite continuous reminders that you prefer a Miller blade.

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INTRODUCTION

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What Is Meant by the Term “Ectopic” Airway Management?

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Anesthesia practitioners, emergency physicians, intensivists, hospitalists, and other health care providers with airway management expertise often become involved in emergency and urgent airway management outside of their usual operating milieu. This is referred to as “ectopic” airway management.

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What Are the Common Examples of Ectopic Venues?

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There are several areas of a hospital where it should be anticipated that emergency airway management will be required occasionally, or even perhaps regularly. These include but are not exclusive to:

  • Post-anesthetic care unit (PACU)

  • Diagnostic imaging locations where emergency and intensive care unit (ICU) patients are taken; particularly CT, MRI, ultrasound, and angiography units

  • Units where procedural sedation is undertaken:

    • Endoscopy

    • Invasive cardiology

    • Interventional imaging

    • Pediatric clinics, such as dentistry, ophthalmology, EEG, ENT, and others

    • Lithotripsy

    • Cardiac stress testing facilities

    • Medical and surgical inpatient units

    • Obstetrical delivery suites

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Outpatient clinics, medical offices, and non-patient care areas (e.g., cafeterias, residences, waiting rooms, administrative offices, and the areas immediately external to the health care facility) are occasionally the site of an airway emergency.

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AIRWAY MANAGEMENT CHALLENGES

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What Are the Unique Challenges of Ectopic Airway Management?

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Managing a difficult airway is always anxiety provoking and somewhat dysphoric. Most ectopic airway management is difficult for a variety of reasons: some are related to the patient's airway anatomy; others to the patient's condition; and some are unique to the situation. The result ...

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