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CASE PRESENTATION

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An obese 39-year-old female is scheduled for a laparoscopic cholecystectomy under general anesthesia. She takes no meds and has no allergies. She is 5′4″ (161 cm), 220 lb (100 kg), with a BMI 38.6 kg·m−2. She denies reflux. On physical exam, she has a Mallampati Class II airway, has 4 cm mouth opening, and a good neck extension. Her hyomental distance is also less than 5 cm and her hypothyroid distance is about 3 cm. She has no past surgical history except for a cesarean section under epidural. Upon arrival at the operating room, standard monitors are placed on the patient. Following denitrogenation and induction of anesthesia with 200 mg of propofol, rocuronium (40 mg) is administered for muscle relaxation. Direct laryngoscopy is attempted with #3 Macintosh blade. Only a large epiglottis is seen with no improvement in the view following the application of laryngeal pressure. A #3 Miller blade is then used to lift the epiglottis, but vocal cords are still not visible. An Eschmann Tracheal Introducer (“bougie”) repeatedly goes into the esophagus. Bag-mask-ventilation (BMV) remains adequate. Help and the difficult airway cart are summoned. A #3 Intubating Laryngeal Mask Airway (LMA-Fastrach) is placed, resulting in adequate ventilation. An attempt at blind intubation through the Intubating Laryngeal Mask Airway (ILMA) is unsuccessful. In a further attempt, a 7.0-mm ID endotracheal tube (ETT) is loaded onto the FAST (Foley fiberoptic airway stylet, Clarus Medical LLC, Minneapolis, MN) and placed through the ILMA. The ILMA is manipulated till vocal cords are visualized and the ETT is placed into trachea without difficulty. Correct ETT placement is confirmed by means of end-tidal CO2 and auscultation. The surgical procedure proceeds uneventfully. At the conclusion of the cholecystectomy, tracheal extubation is achieved with no difficulties when the patient is awake and alert. Appropriate monitoring and disposition of the patient are provided.

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WHY SHOULD WE DOCUMENT BOTH THE OCCURRENCE AND THE MANAGEMENT OF A DIFFICULT OR FAILED AIRWAY?

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As indicated in earlier chapters (most notably Chapter 1), a difficult or failed airway is not the same as a difficult or failed intubation, or a failed attempt at using an extraglottic device (EGD) or BMV. It is critically important to be able to accurately describe, document, and communicate an adverse event related to airway management difficulty and/or failure.

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Failure to manage successfully an airway problem may certainly threaten patient safety and may also threaten the welfare of any airway practitioner. Attempts to improve outcomes in the management of a difficult/failed airway would require a system which records and reports this information to a widely disparate group of practitioners. The challenge is to create a system that conveys this information to this disparate group of practitioners dispersed in location and time. Practitioners are both legally and professionally vulnerable if they either fail to record or communicate critical information or fail to access and be aware ...

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