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CASE PRESENTATION

As an anesthesia practitioner, you are part of a short-term volunteer surgical program in a low-income country (LIC). The team includes a plastic reconstructive surgeon and two nurses. Your mandate is to collaborate with local health care providers to deliver surgical treatment to people who otherwise could not access the procedures. Some surgical infrastructure exists at the local hospital; however, there is a significant shortage of both personnel and equipment needed to provide safe anesthetic care. But importantly, there is capacity for basic ongoing postoperative care by local health providers after the departure of the surgical team.

Just a few days after arrival, an otherwise healthy 22-year-old woman presents with facial burns following a domestic cooking accident. The World Health Organization (WHO) describes burns worldwide as a “serious public health problem” with an estimated 265,000 deaths annually. Over 96% of fire fatalities occur in low- and middle-income countries (LMICs) with millions more suffering permanent disfigurement. This young patient 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 60.1).

FIGURE 60.1

Twenty-two-year-old woman with burn contractures.

On examination, the patient has some perioral scarring, 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.

INTRODUCTION

In high-income countries (HICs), 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. In this regard, airway management may be particularly challenging in obstetrical anesthesia (see Chapters 1 and 52). Although the principles of airway management are similar worldwide, the anesthesia practitioner in the LIC can expect to face challenges, both unrelated and related, to airway anatomy (Table 60.1). A variety of difficult conditions can 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.

TABLE 60.1Expected Developing Country Conditions with the Potential for Difficult Airway Management

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