31/10/2014 Obstetric Difficult Airway Guidelines | Difficult Airway Society http://www.das.uk.com/content/draft_obstetric_intubation_guidelines 1/9 Difficult Airway Society Search form Search... Home Publications Guidelines Newsletter Projects Education & Research Meetings Airway Leads Courses Members area Membership details Forums Login Navigate to... Home / Obstetric Difficult Airway Guidelines Status message You have been logged out due to inactivity. Obstetric Anaesthetists’ Association and the Difficult Airway Society Obstetric Difficult Airway Guidelines Members consultation process We are carrying out a public consultation with OAA and DAS members,as well as other interested groups, on proposed obstetric difficult airway guidelines. These will be the first obstetric-specific national guidelines to be published with full background information. During the writing of these guidelines, we have followed these principles: Simplicity in decision-making. Complex algorithms cannot be followed when severely stressed. The basic flow of the DAS unanticipated difficult airway guidelines is followed leading, after failed tracheal intubation (FTI), to supraglottic airway device (SAD) insertion and then front-of-neck access for Can’t Intubate, Can’t Oxygenate (CICO). Safety. The obstetric population usually have a normal airway, with the exception of the tissue swelling found in pre-eclampsia. Life threatening problems are often associated with multiple traumatic attempts at airway instrumentation. We advise as a routine, a maximum of two attempts at intubation, and two
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Obstetric Difficult Airway Guidelines _ Difficult Airway Society 2015
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31/10/2014 Obstetric Difficult Airway Guidelines | Difficult Airway Society
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Obstetric Difficult Airway Guidelines
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You have been logged out due to inactivity.Obstetric Anaesthetists’ Association and the Difficult Airway Society
Obstetric Difficult Airway GuidelinesMembers consultation process
We are carrying out a public consultation with OAA and DAS members,as well as other interested groups, onproposed obstetric difficult airway guidelines. These will be the first obstetric-specific national guidelines to bepublished with full background information.
During the writing of these guidelines, we have followed these principles:
Simplicity in decision-making. Complex algorithms cannot be followed when severely stressed. Thebasic flow of the DAS unanticipated difficult airway guidelines is followed leading, after failed trachealintubation (FTI), to supraglottic airway device (SAD) insertion and then front-of-neck access for Can’tIntubate, Can’t Oxygenate (CICO).
Safety. The obstetric population usually have a normal airway, with the exception of the tissue swellingfound in pre-eclampsia. Life threatening problems are often associated with multiple traumatic attemptsat airway instrumentation. We advise as a routine, a maximum of two attempts at intubation, and two
Practice patterns. Literature review has shown that general anaesthesia is now usually continued afterFTI. This may be because it is essential to continue, or it is considered safe to continue. The indicationsto wake the woman up – when it is not safe and not essential to continue - are clarified.
Familiarity.Anaesthetists in the UK are now very familiar with anaesthesia using SAD, but not withfacemask anaesthesia. Insertion of SAD should be considered early after FTI. We advise the provisionand use of particular equipment items, but acknowledge that there must be variations based onavailability and familiarity.
Human factors. These are emphasised along with technical skills. Pre-planning for the eventuality ofFTI, integration with the WHO sign-in, and communication with other staff during a crisis are all covered.
There are four algorithms and two tables
The specific algorithms cover the provision of safe rapid-sequence induction of general anaesthesia and theunanticipated difficult tracheal intubation, FTI and the Can’t Intubate, Can’t Oxygenate situation. A compositeoverview encapsulates these three. Table 1 gives criteria to be used in the decision to wake or proceedfollowing failed tracheal intubation at caesarean section and Table 2 summarises how to wake or proceedafter failed intubation.
Algorithm 1: Safe Obstetric General Anaesthesia
Features:
Maximizing potential for good airway outcome by attention to detail in optimalgeneral anaesthetictechnique.
31/10/2014 Obstetric Difficult Airway Guidelines | Difficult Airway Society
Pre-induction planning with team in case of failed intubation
Mask ventilation to be considered from immediately after induction
Early reduction/removal of cricoid pressure in case of problems
Two intubation attempts only are advised in normal circumstances
Abandon intubation attempts early before loss of control and/or causing trauma
Aspects for discussion:
Suggestion of a third intubation attempt only by an experienced colleague
Algorithm 2: Obstetric Failed Intubation
Features:
Ease of mask ventilation may already have been assessed – see Algorithm 1
SAD is higher in the flow diagram. Therefore, after declaring failed intubation, oxygenation can beachieved with either facemask ventilation or immediate insertion of a SAD.
Laryngoscope to aid placement of SAD can be consideredif appropriate andparticularly if insertedbefore the induction agent and muscle relaxant wear off.
Aspects for discussion:
Because of familiarity and security, the LMA (preferred second generation SAD) likely to be consideredacceptable to maintain airway if surgery proceeds; mask will be used in this situation only if SAD fails
31/10/2014 Obstetric Difficult Airway Guidelines | Difficult Airway Society
Prior to induction of anaesthesia, the anaesthetist should consider with the obstetric team whether theanaesthetic will be continued or the woman woken in the event of failed tracheal intubation, dependingon the clinical necessity and the safety of proceeding.
There are a number of factors that influence the decision to wake or proceed and these are related tothe woman, the staff and the clinical situation.
Most of these are present preoperatively, and therefore can contribute to advance planning. Twofactors emerge after the failure to intubate: the method/device used to maintain ventilation and thequality/pathophysiology of the airway. Factors including difficult airway maintenance with a mask orSAD, airway trauma, airway oedema or stridor indicate a potentially unstable situation that maydeteriorate during surgery if anaesthesia is continued.
Note that in any individual patient, some factors will suggest proceeding and others suggest waking up.The anaesthetist will use their clinical judgment to make the final decision.
Aspects for discussion
The table indicates consideration to wake up or proceed ; and the colour grading from high (red) tolower (green) risk situations.
Comments on the clarity of the different categories
Table 2: Management after failed tracheal intubation
31/10/2014 Obstetric Difficult Airway Guidelines | Difficult Airway Society