Chapter 60

A 39-year-old woman is scheduled for a laparoscopic cholecystectomy under general anesthesia. She is 5 ft 4 in (161 cm), 220 lb (100 kg), with a BMI 38.6 kg·m−2. She denies reflux. On physical examination, she has a Mallampati Class II airway, has 4 cm mouth opening, and a good neck extension. On the 3-3-2 examination she is just less than 3 on mouth, just less than 3 from mandibular to hyoid, and 2 on hyoid to thyroid notch. She has no past surgical history except for a cesarean section under epidural. The patient is placed on standard monitors. Following denitrogenation and induction of anesthesia with 200 mg of propofol, it is determined that she can easily be ventilated by a bag-mask. Rocuronium (40 mg) is administered for muscle relaxation. Direct laryngoscopy is attempted with #3 Macintosh blade. Only a large epiglottis is seen without any change following the application of laryngeal pressure. A #3 Miller blade is then used to lift the epiglottis. But, still no vocal cords are seen. An Eschmann Tracheal Introducer (bougie) is attempted, but passes repeatedly into the esophagus. Bag-mask-ventilation (BMV) remains adequate. Help and the difficult airway cart are summoned. A #3 Intubating Laryngeal Mask Airway (ILMA) is placed, resulting in adequate ventilation. An attempt at blind intubation through the ILMA is unsuccessful. So, 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.

As indicated in earlier chapters (most notably Chapter 1), a difficult or failed airway is not the same as a difficult or failed intubation. This distinction is critically important to be able to accurately describe and document an adverse event as important as airway management difficulty and/or failure.

An episode of airway management difficulty and/or failure is an enduring threat to the safety of the patient and a hazard to the airway practitioner (even if only emotionally and medicolegally). From the medicolegal point of view, the medical record is exceedingly important. Thus, it is important that the practitioner documents well.

Although a substantial percentage of difficult airways can be predicted after a routine, yet careful airway examination, unanticipated difficult and failed airways continue to occur. One to three percent of patients undergoing general anesthesia are unanticipated difficult airway/intubations with conventional laryngoscopy.1,2

The importance of documentation rests in the prevention of a future disaster. The importance of an accurate verbal, and preferably, a written description of the specific problems encountered is essential so that when these patients return to the health care system, future practitioners do not approach them with trepidation based on vague verbal histories elicited from the patient, nor an inability on the part of the practitioner to access precise documentation of the prior adverse ...

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