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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 the need for nasal decongestant spray—given her long-standing sinusitis. Despite a slight restriction in neck movement, there was nothing to predict a problem with airway management. Specifically, there was minimal restriction in neck flexion, extension, or rotation. Mouth opening and thyromental distance were normal, and the Mallampati score was grade II.

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 mg of propofol was given but repeated attempts (including two different sizes of LMA) were also unsuccessful. After 2 minutes, the patient’s oxygen saturation had decreased to 75% and she looked cyanosed. By 5 minutes, her oxygen saturation deteriorated to below 40%. Administration of 100% oxygen using a face mask and oral airway failed to raise the oxygen saturation, and the heart rate decreased to the 40s.

The anesthesia practitioner then administered atropine and succinylcholine. He attempted tracheal intubation and was joined by a second anesthesia practitioner (who had additional airway training). Laryngoscopy provided a Cormack and Lehane grade IV view with no identifiable airway anatomy visible. Other staff entered the room, including the surgeon. Between attempts at laryngoscopy, patient ventilation was extremely difficult; despite use of a two-handed, two-person bag-mask-ventilation 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.”

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

Blind attempts were made to insert a tracheal tube through the intubating laryngeal mask (as the device is intended to work) and then use a flexible bronchoscope. The surgeon failed to pass the bronchoscope 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 anesthesia practitioners transferred her to the recovery room and told staff that they expected the patient to wake up. Both anesthesia practitioners carried on to their next cases.

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

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