(This is a very technical post - mind the terms but I want to keep this as an entry)
After a long lapse of this possibility, we had this episode recently. This was something all anaesthetist feared and the nightmare happened.
This patient had a BMI of just 30 however the airway was suspect from the beginning. His mouth opening was small, a Malampati 4 and he had a thick short neck. However, it was not we have not encountered such patients before so the case was to proceed as planned. I was there to help up my colleague and this meant we had 2 consultants standing by.
The issue about difficult airway is IF YOU LOSE THE AIRWAY. This means the inability to oxygenate the patient and that can be catastrophic. If one can continue to oxygenate, then the attempt for laryngoscopy and intubation can theoretically be as long as possible.
At the same time, patient was suspected of having an acute abdomen which means the risk as gastric content regurgitation to be high! So it was a catch 22 situation.
Traditionally RSI (rapid sequence induction) will be the gold standard to secure such airways. The arrival of sugammaddex (direct reversal of Rocuronium) has changed the airway management to a certain extent, however traditionally one would still use suxamethonium as the mainstay for safety. Especially in a centre where one might not have the full equipment for back up.
True enough, this patient had a very anterior position of the vocal cord despite a satisfactory tube on the C blade of CMAC. The view on the Long blade was 3B at least and no way of manipulating to get it a 2 or 1. It was difficult to negotiate the tube to be placed in the trachea.
As i've mentioned before, we had BIG issues trying to bag mask the patient when the saturation dropped, and by the 3rd attempt it was almost impossible to mask ventilate the patient. He desaturated badly and in my mind i was already thinking of attempting a direct invasive airway.
And the magic came.. sux effect came to and end and the patient breathed spontaneously. And this spontaneous breathing was the thing that kept him alive. His saturation picked up straight away without the muscle relaxation.
It was a sigh of relief.. ultimately safe this time around. Thank god for suxamethonium property of being a depolarizing muscle relaxant!
We woke up this patient as how the protocol would recommend us to do so. We explained to him what had happened. The next step was supposed to be awake fibreoptic intubation - unfortunately we did not have that facility. Thus we had to transfer the patient to our sister hospital so that this case can be managed accordingly.
It wasa heart stopping moment, i have not had this type of situation for quite some time. It tested our ability to think as based per protocol. It made both of us reflect on the importance of having plans B and C all ready when disaster strikes.