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A 46-year-old man with a history of nonalcoholic steatohepatitis (NASH) cirrhosis and prior upper gastrointestinal (GI) bleeding presents to the emergency department (ED) with acute onset of hematemesis and melena. His past medical history is significant for obesity with a body mass index of 38 kg·m−2, obstructive sleep apnea (OSA) for which he declined the use of noninvasive ventilation, diabetes mellitus, and hypertension. He was noted to have ascitic fluid on his most recent liver ultrasound but has never needed large-volume paracentesis. His vital signs demonstrate a sinus tachycardia with a rate of 108 beats per minute and blood pressure of 110/68. He is afebrile and has a mildly delayed peripheral capillary refill. On exam he is an obese man, appears as stated age, in mild distress, and somewhat drowsy. He has a thick neck with palpable, but not visible, laryngeal structures. He has mild retrognathia with a decreased thyromental distance. Examination of his mouth revealed intact dentition, Mallampati IV, and inability to bring the lower incisors above the upper vermillion border.

Discussions are underway between the emergency physician and the gastroenterologist regarding the need for urgent or emergency upper endoscopy for control of a suspected brisk variceal GI hemorrhage. Tracheal intubation is thought to be indicated for either endoscopy or placement of a gastric and esophageal tamponade device. You have been consulted for assistance with airway management and perioperative considerations.

The patient notes that he was once told that his airway was difficult to manage during a prior elective upper endoscopy for variceal surveillance. He recalls that he was given a document regarding the event by the anesthesiology team afterward but does not recall the specifics. Upon perusal of the prior anesthetic records, it appears that the patient developed apnea and oxygen desaturations while undergoing deep sedation with fentanyl, midazolam, and propofol. Face-mask ventilation (FMV) was found to be difficult and two attempts to intubate the trachea via direct laryngoscopy by two different anesthesia practitioners were both unsuccessful. An extraglottic airway device (EGD) was placed as a rescue maneuver and the patient was supported via this device until return of native ventilation at which point the procedure was aborted.


How Urgent Is the Planned Procedure and in Which General Timeframe Should the Airway Be Managed?

Given the presentation of a patient with signs of early shock and altered mentation, the procedure should be considered at least urgent. Given the potential instability of patients with brisk upper GI bleeding, the situation could rapidly progress to emergency if the patient loses the ability to protect his own airway from aspiration. Observational data indicate a higher rate of complications in patients prophylactically intubated for endoscopy.1 Thus, the decision to intubate would result from the patient’s actual clinical status and not from a perceived future benefit. Given the difficulty in ...

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