This case involves a patient that went in for a routine surgery that required they be given general anesthesia. The procedure was not expected to last long, so the anesthesiologist administered the patient a dose of short-acting anesthesia. The doctors were subsequently unable to intubate the patient. The patient suffered from diaphragm paralysis and passed away. An anesthesiology expert was sought to opine on appropriate measures that should be taken to avoid intubation complications.
Question(s) For Expert Witness
- 1. Please elaborate on your experience with intubating patients.
- 2. When encountering a difficult intubation, at what point is it warranted to abort intubation to avoid a complication such as the one in this case?
Expert Witness Response E-153481
I have performed many cases involving difficult intubation in expected and unexpected scenarios. Based on the vignette provided, it appears the anesthesiologist was not too concerned about difficult intubation, otherwise, he would have chosen to do an awake intubation. This lack of concern may have been on the basis of a reassuring patient airway exam or previous intubation notes demonstrating easy intubation. However, the anesthesiologist chose to use a short-acting anesthetic for intubation. This may have been for several reasons, including (a) the surgery did not require muscle relaxant, and a longer acting muscle relaxant was not indicated, (b) the surgery was expected to be short, and they did not want to administer a longer acting agent that would require reversal, or (c) the anesthesiologist was concerned enough about a difficult intubation that he wished to use a short-acting agent.
I would need more information to judge whether the difficult airway algorithm was appropriately executed once this situation was clear. Typically, this proceeds to a surgical airway (cricothyroidotomy or tracheostomy) in the extreme circumstance that the airway could not be secured, ventilation with alternative devices (LMA, other supraglottic airway) failed, and the patient did not recover spontaneous respiration following administration of the induction agents. Also, it isn’t clear if the anesthesiologist used an IV induction technique or an inhalational induction technique, and whether the short-acting anesthesia was administered IV, intramuscularly, or sublingually.