As an anesthesia practitioner, you were in a developing country on a short-term, 2-week mission with a team of plastic and maxillofacial surgeons. The team's mandate was to operate on patients with unrepaired cleft lips and palates. As word spread in the area of the team's successes, on the final day of the mission a 12-year-old boy was brought to the clinic. One year before, the boy had sustained significant burns to his lower face, neck, and chest. No surgical remediation had been undertaken and he now had severe burn contractures (Figure 56-1).
A 12-year-old boy with severe burn contractures.
In the developed world, about 1:50 general anesthesia cases will present with difficult tracheal intubation; 1:75 will result in a failed intubation; and a failure to intubate and to ventilate occurs in 1:1000 to 1:12,000. Obstetrical anesthesia is particularly challenging in this regard, as the airway may be complicated by edema related to toxemia or prolonged labor (see Section 1.2.1). Although the principles of airway management are similar worldwide, the anesthesia practitioner in the developing world can expect to face challenges both unrelated, and related, to difficult airway anatomy (Table 56-1). A variety of difficult conditions will be encountered, often in later stages of evolution, presenting greater challenges with higher airway acuity. Pathology less familiar to the average practitioner can also be expected. A higher proportion of anesthesia practice appears to be made up of pediatric and obstetrical patients.
Table 56-1 Expected Developing Country Conditions with the Potential for Difficult Airway Management ||Download (.pdf)
Table 56-1 Expected Developing Country Conditions with the Potential for Difficult Airway Management
|• Familiar conditions, but more advanced:|
|• Obstetrics—preeclampsia, placenta previa, placenta accreta|
|• Upper airway infections and tumors|
|• Less familiar conditions:|
|• Severe uncorrected head/neck burn contractures|
|• Uncorrected congenital defects|
|• Cancrum oris (Noma)|
|• Late presentations of obstructing tumors|
|• Temporomandibular ankylosis|
|• Higher proportion of pediatric and obstetric anesthesia practice|
56.2.1 What Are the Risks Inherent in Airway Management in Austere Environments?
Forty years of intense commitment has greatly reduced avoidable anesthesia-related mortality in wealthy countries to a rate of about 1/56,000 anesthetics (1/180,000 when anesthesia is the sole cause of mortality and morbidity), and airway misadventure is no longer the primary reason for seriously adverse outcome.1 Training in airway management has advanced, guidelines and standards have been introduced, technology has evolved immensely, and a culture of safety is in place.2,3 Sadly, such benefits have been largely restricted to the few who live in relatively privileged societies. Published mortality due to airway misadventure in less resourced areas can vary from 100 to 1000 times that in affluent societies. 4-7 Indeed, in one report, the avoidable mortality from airway-related ...