As an anesthesia practitioner, you have been deployed with your national disaster response team to a low-income country (LIC) that has just experienced an earthquake. Some surgical infrastructure did exist in the region prior to the earthquake, limited by too few anesthesia and surgical practitioners, too few safety monitors, and unpredictable access to essential medicines, including oxygen.
You are on the initial team as the only anesthetist, with a general surgeon, an orthopedic surgeon, seven nurses, and two technicians. There is no biomedical technician on the team. The team will be in country at least 2 weeks, and the mandate is to operate on any urgent or emergency surgical conditions. There will be capacity for basic ongoing postoperative care by local surgeons after the departure of the surgical team.
Just a few days after arrival, an otherwise healthy 22-year-old women presents with recent facial burns following a domestic cooking accident. She can no longer close her eyes effectively because of worsening contractures, corneal ulcers are developing, and she is becoming blind. The surgeon states that she can perform some small split skin grafts that will save her sight (Figure 59–1).
Twenty-two-year-old woman with burn contractures.
On examination the patient has limited mouth opening and a full set of healthy teeth. Her Mallampati score is III and she has a normal thyromental distance and normal neck extension. There is some scarring over her anterior neck but you can easily palpate airway structures.
In the high-income countries (HIC), about 1:50 general anesthesia cases will present difficult tracheal intubation, 1:75 will result in a failed intubation, and a failure to intubate and to ventilate will occur in 1:1000 to 1:12,000 anesthetics. Obstetrical anesthesia is particularly challenging in this regard, as the airway (AW) may be complicated by soft-tissue edema related to toxemia or prolonged labor (see section “How Common Are the Difficult and Failed Airway?” in Chapter 1). Although the principles of AW management are similar worldwide, the anesthesia practitioner in the LIC can expect to face challenges both unrelated and related, to difficult AW anatomy (Table 59–1). A variety of difficult conditions will be encountered, often in later stages of evolution, and often presenting greater challenges. Diseases and conditions less familiar to the average practitioner can also be expected. Pediatric and obstetrical patients make up a higher proportion of anesthetic practice in an LIC.
Expected Developing Country Conditions with the Potential for Difficult Airway Management