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A 33-year-old female patient with Down syndrome (DS) and moderate intellectual disability presented with a history of vomiting and abdominal pain (Figure 40.1). A perforated diverticulitis was diagnosed in the emergency department (ED).


Patient with Down syndrome admitted to general surgery department with a perforated diverticulitis.

You first encountered the patient when she was brought to the operating room (OR) during an on-call shift. Shortly after her first bolus of crystalloid fluid, her only intravenous (IV) catheter was inadvertently pulled out. The prepared antibiotics could not yet be administered. Upon arrival, she was not cooperative and did not allow an IV catheter to be reinserted. She did not answer questions. She was lying on her side with her head flexed forward and did not extend her neck when requested nor did she permit you to do so. She appeared to have a short, thick neck. She did not open her mouth as per your request. Her sister, who accompanied her, has been her caregiver for the past 20 years. As far as her sister knew, the patient was healthy, with no known cardiac history and a good functional capacity. As a child, she had two uneventful general anesthetics for dental care. She was on no medication and had no allergies.

On examination, she was 157.5 cm (5 ft 2 in) tall and weighed 96 kg (211 lb). Her body mass index was 38.4 kg·m−2. Her vital signs have been deteriorating since her arrival. Last vital signs were: heart rate 122 beats per minute, blood pressure 88/54 mmHg, temperature 39.2°C, respiratory rate 28 breaths per minute, and peripheral capillary oxygen saturation (SpO2) 92% on room air. She was combative and repeatedly removed any supplemental oxygen delivery device. You suspected that she may have aspirated gastric contents.

The patient was thus unable to cooperate and showed features of a potential difficult airway despite limited evaluation. Moreover, she demonstrated signs of sepsis with hemodynamic instability and respiratory compromise due to sepsis and potential aspiration of gastric contents.

The general surgeon planned to attempt a laparoscopic sigmoidectomy. The patient required a general anesthetic with endotracheal intubation.


What Are the Factors That Make Airway Management Challenging in This Situation?

Considering the patient has DS, obesity, and limited airway evaluation, it is anticipated that airway management would be difficult and challenging. The airway practitioner should recognize multiple factors that may further hinder airway management of this patient and be prepared for alternative plans in the event of failure.

First, this patient’s physiology has been altered by her sepsis. This will increase cognitive load for the airway practitioner during airway management because of potential hemodynamic instability ...

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