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A I R W A Y M A N A G E M E N T existing anatomical anomalies, or congenital or acquired conditions. You identify • uvula not visible when tongue is protrud- of basic management problems: difficul- ed with patient in sitting position; such patients in advance, and make sure • highly arched and very narrow palate; they're scheduled in a surgical setting with ty with patient cooperation or consent; • stiff, indurated mandibular space occupied by mass or non-resilient; adequate emergency backup. It's the unpredictable airways that present the real issue for outpatient facili- ADVERSE OUTCOMES Risks Associated With Difficult Airways • thyromental distance of less than 3 ordinary finger-breadths; TOOL TIME Airway Cart Essentials UNPREDICTABLE AIRWAY If intubation isn't possible without causing significant harm or risking airway obstruction, the case should be cancelled. ties. If there are no reasons • bleeding • short and/or thick neck; and to see the patient in • abscess • inability to touch chin to advance, anesthesia • infection chest, or to extend neck. providers typically perform • death pre-op assessments on the • brain injury for airway management by cult airway management (see "Airway day of surgery. The new • cardiopulmonary arrest ensuring the availability of Cart Essentials" on page 8) and think ASA guidelines provide a • unnecessary surgical difficult airway equipment (a about how to manage a difficult airway in useful, tabular chart that airway (tracheotomy) portable storage unit/difficult advance. The first time they use a supra- In these patients, prepare H Plan for problems Your anesthesia providers should be trained in the techniques and tools of diffi- ave a difficult airway cart on hand for patients with suspected airway problems, and immediately available in the event an unpredictable difficult airway arises. This cart typically takes the form of a portable storage unit that includes rigid laryngoscope blades, a rigid fiber-optic laryngoscope, a video laryngo- details what to look for • airway trauma airway kit, for example); glottic airway (SGA) or video-assisted when examining patients at • damage to the teeth informing the patients of their laryngoscope device should be during a this time: • prolonged hospital stays known or suspected airway routine case, not an emergency one. • relatively long upper inci- • additional treatment for statuses; having an assistant Conduct ongoing drills and practice with complications arising on hand to act in the event a difficult airway techniques and scenarios. • prominent overbite; from the difficult airway difficult airway arises; admin- The algorithm in the new guidelines pro- • inability to bring management istering preanesthetic pre- vides a useful flowchart with recommend- oxygenation by mask; and ed steps. The non-exhaustive summary I administering supplemental can provide here comprises 3 main steps sors; — Robert Caplan, MD mandibular incisors in front of maxillary inci- oxygen throughout the difficult airway sors; event. • less than 3cm between incisors; 1 0 scope, and tracheal tubes of assorted sizes and tube guides. Supgraglottic airways such as a laryngeal mask airway or intubating LMA should be included in the cart for non-invasive airway ventilation/intubation. The cart should also include flexible fiberoptic intubation equipment, retrograde intubation equipment, emergency invasive airway-access equipment and an exhaled CO2 (with a number of substeps). detector. First, the anesthesia provider should — Robert Caplan, MD assess the likelihood and clinical impact SUPPLEMENT TO O U T PAT I E N T S U R G E R Y M A G A Z I N E | J A N U A R Y 2013 J A N U A R Y 2013 | S U P P L E M E N T TO O U T PAT I E N T S U R G E R Y M A G A Z I N E 1 1