Master algorithm – obstetric general anaesthesia and failed


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Master algorithm – obstetric general anaesthesia and failed tracheal intubation

Algorithm 1
Safe obstetric general anaesthesia

Pre-induction planning and preparation Team discussion

Rapid sequence induction Consider facemask ventilation (Pmax 20 cmH2O)

Algorithm 2 Obstetric failed tracheal intubation
Algorithm 3 Can’t intubate, can’t oxygenate

Laryngoscopy (maximum 2 intubation attempts; 3rd intubation attempt only by experienced colleague)
Fail
Declare failed intubation Call for help Maintain oxygenation Supraglottic airway device (maximum 2 attempts) or facemask
Fail
Declare CICO Give 100% oxygen Exclude laryngospasm – ensure neuromuscular blockade Front-of-neck access

Success

Verify successful tracheal intubation and proceed
Plan extubation

Success

Is it essential / safe to proceed with surgery
immediately?*

No

Yes

Wake§

Proceed with surgery§

*See Table 1, §See Table 2 © Obstetric Anaesthetists’ Association / Difficult Airway Society (2015)

Algorithm 1– safe obstetric general anaesthesia

Pre-theatre preparation
Airway assessment Fasting status Antacid prophylaxis Intrauterine fetal resuscitation if appropriate

Plan with team
WHO safety checklist / general anaesthetic checklist Identify senior help, alert if appropriate Plan equipment for difficult / failed intubation Plan for / discuss: wake up or proceed with surgery (Table 1)

Rapid sequence induction
Check airway equipment, suction, intravenous access Optimise position – head up / ramping + left uterine displacement Pre-oxygenate to FETO2 ≥ 0.9 / consider nasal oxygenation Cricoid pressure (10 N increasing to 30 N maximum) Deliver appropriate induction / neuromuscular blocker doses Consider facemask ventilation (Pmax 20 cmH2O)

1st intubation attempt If poor view of larynx optimise attempt by:
• reducing / removing cricoid pressure • external laryngeal manipulation • repositioning head / neck • using bougie / stylet

Fail

Ventilate with facemask

Communicate with assistant

2nd intubation attempt Consider:
• alternative laryngoscope • removing cricoid pressure 3rd Intubation attempt only by experienced colleague
Fail
Follow Algorithm 2 – obstetric failed tracheal intubation

Success

Verify successful tracheal intubation Proceed with anaesthesia and surgery Plan extubation

© Obstetric Anaesthetists’ Association / Difficult Airway Society (2015)

Algorithm 2 – obstetric failed tracheal intubation
Declare failed intubation Theatre team to call for help Priority is to maintain oxygenation

Supraglottic airway device
(2nd generation preferable) Remove cricoid pressure during insertion (maximum 2 attempts)

Facemask +/- oropharyngeal airway
Consider: • 2-person facemask technique • Reducing / removing cricoid pressure

Is adequate oxygenation possible?

No

Yes

Follow Algorithm 3
Can’t intubate, can’t oxygenate

Is it essential / safe to proceed with surgery immediately?*

No

Yes

Wake§

Proceed with surgery§

*See Table 1, §See Table 2 © Obstetric Anaesthetists’ Association / Difficult Airway Society (2015)

Algorithm 3 – can’t intubate, can’t oxygenate
Declare emergency to theatre team Call additional specialist help (ENT surgeon, intensivist)
Give 100% oxygen Exclude laryngospasm – ensure neuromuscular blockade
Perform front-of-neck procedure

Is oxygenation restored?

No

Yes

Maternal advanced life support Perimortem caesarean section

Is it essential / safe to proceed with surgery immediately?*

No

Yes

Wake§

Proceed with surgery§

*See Table 1, §See Table 2 © Obstetric Anaesthetists’ Association / Difficult Airway Society (2015)

Factors to consider
Maternal condition
Fetal condition Anaesthetist

Table 1 – proceed with surgery?

WAKE
• No compromise
• No compromise • Novice

• Mild acute compromise
• Compromise corrected with intrauterine resuscitation, pH < 7.2 but > 7.15
• Junior trainee

• Haemorrhage responsive to resuscitation
• Continuing fetal heart rate abnormality despite intrauterine resuscitation, pH < 7.15
• Senior trainee

PROCEED
• Hypovolaemia requiring corrective surgery
• Critical cardiac or respiratory compromise, cardiac arrest
• Sustained bradycardia • Fetal haemorrhage • Suspected uterine rupture
• Consultant / specialist

Before induction

Obesity

• Supermorbid

• Morbid

• Obese

• Normal

Surgical factors Aspiration risk

• Complex surgery or major haemorrhage anticipated
• Recent food

Alternative anaesthesia • regional • securing airway awake

• No anticipated difficulty

• Multiple uterine scars • Some surgical difficulties
expected
• No recent food • In labour • Opioids given • Antacids not given
• Predicted difficulty

• Single uterine scar
• No recent food • In labour • Opioids not given • Antacids given • Relatively contraindicated

• No risk factors
• Fasted • Not in labour • Antacids given
• Absolutely contraindicated or has failed
• Surgery started

Airway device / ventilation
Airway hazards

• Difficult facemask ventilation
• Front-of-neck
• Laryngeal oedema • Stridor

• Adequate facemask ventilation
• Bleeding • Trauma

• First generation supraglottic airway device
• Secretions

• Second generation supraglottic airway device
• None evident

Criteria to be used in the decision to wake or proceed following failed tracheal intubation. In any individual patient, some factors may suggest waking and others proceeding. The final decision will depend on the anaesthetist’s clinical judgement.
© Obstetric Anaesthetists’ Association / Difficult Airway Society (2015)

After failed intubation

Table 2 – management after failed tracheal intubation

Wake

Proceed with surgery

• Maintain oxygenation • Maintain cricoid pressure if not impeding ventilation • Either maintain head-up position or turn left lateral
recumbent • If rocuronium used, reverse with sugammadex • Assess neuromuscular blockade and manage awareness
if paralysis is prolonged • Anticipate laryngospasm / can’t intubate, can’t oxygenate
After waking
• Review urgency of surgery with obstetric team • Intrauterine fetal resuscitation as appropriate • For repeat anaesthesia, manage with two anaesthetists • Anaesthetic options:
‰‰ Regional anaesthesia preferably inserted in lateral position
‰‰ Secure airway awake before repeat general anaesthesia

• Maintain anaesthesia • Maintain ventilation - consider merits of:
‰‰ controlled or spontaneous ventilation ‰‰ paralysis with rocuronium if sugammadex available
• Anticipate laryngospasm / can’t intubate, can’t oxygenate
• Minimise aspiration risk: ‰‰ maintain cricoid pressure until delivery (if not impeding ventilation) ‰‰ after delivery maintain vigilance and reapply cricoid pressure if signs of regurgitation ‰‰ empty stomach with gastric drain tube if using second-generation supraglottic airway device ‰‰ minimise fundal pressure ‰‰ administer H2 receptor blocker i.v. if not already given
• Senior obstetrician to operate • Inform neonatal team about failed intubation • Consider total intravenous anaesthesia

© Obstetric Anaesthetists’ Association / Difficult Airway Society (2015)

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Master algorithm – obstetric general anaesthesia and failed