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Look before you intubate

01 May 2011

Mrs Q, a 61-year-old advertising executive, was referred to her plastic surgeon Mr A with a suspicious mole on her cheek near the left eye. Mr A diagnosed a melanoma and proposed a procedure involving wide local excision and primary reconstruction of the lower eyelid, likely to take several hours.

Dr T, a consultant anaesthetist, came to meet Mrs Q on the ward before the operation and performed an anaesthetic assessment. Mrs Q was slightly overweight and was taking omeprazole for reflux, but was otherwise very healthy. Dr T did not examine Mrs Q, but wrote on the anaesthetic chart that she was “in remarkably good shape for her age”.

Dr T induced anaesthesia with propofol and fentanyl, and gave atracurium as a muscle relaxant. He proceeded to attempt to intubate Mrs Q, but found that she had limited neck mobility and a full dentition, with very poor mouth opening.

He made several attempts to intubate her, using a McCoy-bladed laryngoscope and a bougie, but was unsuccessful, though facemask ventilation was manageable. Dr T decided to use a flexible laryngeal mask airway (LMA) to maintain the airway. This was easy to insert and provided a good seal suitable for mechanical ventilation. Dr T told Mr A about his unsuccessful intubation and use of the flexible LMA, but there was no further discussion.

Anaesthesia was maintained with oxygen, airand sevoflurane. The first five hours of the surgery were uneventful, but towards the end the ventilation became more difficult, with higher airway pressures needed.

Dr T wanted to reposition the LMA, but access to the face was difficult because of the surgical field. Dr T switched to manual ventilation, but struggled to maintain adequate oxygenation during the remainder of the operation. There was very little documentation from this period. Dr T later commented: “I couldn’t both write and ventilate.”

In recovery, Mrs Q was hypoxic and tachypnoeic despite high flow oxygen. Coarse crepitations could be heard in both lungs and a chest X-ray was performed, which was suggestive of aspiration. Dr T summoned the intensive care consultant Dr B, and together they managed to intubate Mrs Q using a fibreoptic scope, although with some difficulty.

Mrs Q had a turbulent course in intensive care. She developed extensive pneumonitis and sepsis, complicated by acute renal failure requiring haemofiltration. She had a prolonged stay and a tracheostomy was performed to facilitate weaning from mechanical ventilation. She was eventually discharged but was found to have a demonstrable degree of cognitive impairment consistent with global hypoxic brain injury.

Mrs Q brought a claim against Dr T and Mr A. The experts were critical of Dr T’s failure to examine Mrs Q’s airway prior to the surgery, which was considered an indefensible omission. The case was settled for a high sum.

Learning points

  • No matter how well a patient appears, there is no excuse for a failure to conduct a full assessment prior to a procedure.
  • Assessment of the airway is one of the cornerstones of anaesthetic assessment. It should be performed in every patient requiring anaesthesia.
  • The LMA is a fundamental piece of anaesthetic equipment, whose strengths and weaknesses should be understood in detail by every anaesthetist. In this case, the presence of reflux, the anticipated length of the operation and the restricted access to the face made the LMA an unreliable choice for airway maintenance.
  • Communication with surgical colleagues, and a full understanding of the operation being carried out, is important to ensure an appropriate decision about which airway technique to employ.
  • Good record-keeping is an essential part of anaesthetic practice. If notes cannot be made at the time of a critical incident they should be completed immediately afterwards, as they will form part of a legal defence.
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