Maintaining cardiac output and systemic vascular resistance (SVR).
Foreign body, secretions, oedema, laryngospasm, soft tissue collapse (e.g., obtunded patient or obstructive sleep apnoea), vocal cord palsy.
Phenylephrine, metaraminol, or noradrenaline.
By correcting electrolytes and using anti-arrhythmics.
Perform cannula cricothyroidotomy or surgical cricothyroidotomy.
Pre-oxygenate, apply cricoid force (10N awake, 30N anaesthetised), and perform direct laryngoscopy while checking neck flexion, head extension, laryngoscopy technique, and external laryngeal manipulation.
The patient must be informed of the difficult airway and encouraged to alert all future anaesthetists.
Plan B involves using ILMA™ or LMA™, not more than 2 insertions, oxygenating and ventilating, and reverting to face mask if oxygenation fails.
Awake patients will complain of pain on injection, which should always be taken seriously. Other signs include skin blanching leading to cyanosis secondary to arterial spasm.
Postpone surgery and awaken the patient.
Kink-resistant cannula (e.g., Patil or Ravussin) and a high-pressure ventilation system (e.g., Manujet III).
Most events were complications of rapid sequence induction.
Heart rate, blood pressure, ECG, and end-tidal CO2.
A clear thought process and a structured approach to the clinical problem.
A systematic approach to elucidate the cause while maintaining the patient's airway, oxygenation, and ventilation.
Rescue techniques for 'can't intubate, can't ventilate' situation.
State that it is an anaesthetic emergency, call for senior anaesthetic assistance, remove the stimulus, apply 100% O2, apply positive pressure to the airway, deepen anaesthesia if necessary, administer suxamethonium if deepening anaesthesia fails, and consider reintubation if needed.
β-blocker, opioids, vagal response, hypoxia.
140/90 mmHg in the USA and 160/100 mmHg in the UK.
Use an introducer (bougie) to seek clicks or hold-up and/or use an alternative laryngoscope.
Severe symptoms include tonic–clonic convulsions, coma, and respiratory arrest.
The snapshot phase and the data collection phase.
State that this is an anaesthetic emergency and call for senior anaesthetic assistance. Stop injecting the drug.
Failure to use capnography in ventilated patients.
A short and rounded scalpel (e.g., no. 20 or Minitrach scalpel) and a small cuffed tracheal or tracheostomy tube (e.g., 6 or 7 mm).
Consider intubation to secure the airway.
They may not have the muscle strength to sustain adequate ventilation post-operatively.
Laryngospasm is the reflex adduction of the vocal cords and occurs most commonly during lighter planes of anaesthesia.
As intra-operative stridor or sudden difficulty in ventilating the un-intubated patient.
Complete upper airway obstruction, desaturation and hypoxaemia, and negative-pressure pulmonary oedema.
Inform the patient, complete a critical incident report form, and document the sequence of events and management in the medical notes.
Call for help and follow the Difficult Airway Society Guidelines.
The spread of intrathecal local anaesthetic above T4.
Symptoms include visual disturbances, agitation, and muscular twitching.
Cannulation in the antecubital fossa (risk of cannulating the brachial artery or aberrant ulnar artery) and the dorsum of the hand (risk of cannulating superficial branches of the radial artery).
Plan D involves using the Difficult Airway Society Guidelines Flow-chart, maintaining oxygenation with face mask and anesthesia, verifying tracheal intubation, and confirming ventilation, oxygenation, anesthesia, CVS stability, and muscle relaxation.
Paraesthesia in the upper limbs that may progress into the face.
Arterial O2 saturation < 90% or PaO2 < 8 kPa.
Initial tracheal intubation plan.
It has a long-lasting therapeutic effect.
Opiate-induced respiratory depression, presence of inhalational agents, extremes of arterial CO2 tension, loss of hypoxic drive in COPD patients, acute intracranial catastrophe.
Incomplete reversal of neuromuscular blocking agents, plasma cholinesterase deficiency, high spinal anaesthesia, spinal cord lesion, neuromuscular disease (e.g., myasthenia gravis), restriction due to pain.
Revert to face mask, oxygenate and ventilate.
Factors include the local anaesthetic itself, site of injection, speed of absorption, rate of rise in plasma concentration, and the physiological and metabolic state of the patient.
The exact nature of the difficult airway, with particular mention of the ease of bag valve mask ventilation.
Administer 100% O2, recheck measurement and ensure invasive monitoring equipment is correctly positioned, check for sudden blood loss or surgical caval compression, and ensure normal abdominal insufflation pressures.
Rescue techniques for 'can’t intubate, can’t ventilate' situation, following the Difficult Airway Society Guidelines Flow-chart 2004.
Intercostal muscle paralysis leading to reduced tidal volumes, block above C3 involving the diaphragm causing respiratory embarrassment, and total spinal involving the brainstem resulting in apnoea.
GTN is a short-acting vasodilator (veins > arteries) with tolerance developing within 24 hours.
Confirm ventilation, oxygenation, anesthesia, CVS stability, and muscle relaxation.
Call for senior anaesthetic assistance.
Check chest movements and auscultate the chest.
A fluid challenge, e.g., 10 mL/kg of crystalloid or colloid, assessing response and repeating as necessary.
A vascular surgeon.
Early use of cardiac output monitoring devices to guide further therapy.
Awaken the patient and confirm, then perform fibreoptic tracheal intubation through ILMA or LMA.
Drugs, spinal and epidural anaesthesia, local mediators, hypercapnia, pyrexia, sepsis, anaphylaxis.
NAP4 is the world's largest prospective audit on major airway complications, conducted by the Royal College of Anaesthetists and DAS.
Severe ischaemia may lead to digital necrosis.
Consider using an LMA (Laryngeal Mask Airway) with a maximum of 2 attempts at insertion.
Call for senior anaesthetic assistance, adopt an ABC approach, administer 100% O2, monitor breathing and consider intubation and ventilation, support circulation with fluids and vasopressors, treat bradycardia, support ventilation and circulation until block regresses, document the event, complete a critical incident report, and inform the patient.
Assume it is due to hypoxaemia until proved otherwise.
It provides both analgesia and vasodilatation.
Inadequate alveolar minute ventilation, obstructed airway, endobronchial/oesophageal intubation, increased alveolar-arterial gradient, pre-existing lung disease, pneumothorax, pulmonary oedema, aspiration, atelectasis, pulmonary embolism, and low cardiac output.
Revert to face mask, oxygenate and ventilate.
Bradycardia, arrhythmias, reduced circulating volume or venous return, impaired myocardial contractility, increased afterload.
Appropriate post-operative care in the critical care unit.
Reduce cricoid force, use an introducer (bougie) to seek clicks or hold-up, and/or use an alternative laryngoscope.
Inadequate depth of anaesthesia, inadequate analgesia, inadequate ventilation causing hypercapnia or hypoxia, overdosing of vasopressor drugs, malignant hyperpyrexia.
Revert to face mask, oxygenate and ventilate, and reverse non-depolarising relaxant using a 1 or 2 person mask technique with oral ± nasal airway.
56%
Continue anaesthesia with LMA™ or ProSeal LMA™.
Consider using a long flexometallic, nasal RAE, or microlaryngeal tube.
Increase FiO2 and check the oxygen analyser to verify the increase.
Addition of PEEP, ensure adequate tidal volume (6–10 mL/kg), pulmonary toilet (suction endobronchial tube), restore circulating blood volume, bronchoscopy, maintain cardiac output and Hb levels (Hb > 10 g/dL), transfer patient to supine position if applicable, terminate surgery as soon as safely possible, optimise ventilation, arrange check CXR, arrange transfer to ICU, document sequence of events and complete critical incident form.
Check anaesthetic machine, use O2 analyser and alarms, ensure adequate ventilation, maintain tidal volumes in normal range, monitor and adjust FiO2, and use caution with spontaneous ventilation in lung disease.
Maintenance of oxygenation, ventilation, postponement of surgery, and awakening.
Ephedrine, dobutamine, dopexamine, or milrinone.
By checking the patient's train-of-four with a nerve stimulator looking for fade, which would indicate a residual block.
Ensure documentation of the event and completion of a critical incident form.
Plan A: Initial tracheal intubation plan includes direct laryngoscopy, checking neck flexion and head extension, laryngoscope technique and vector, external laryngeal manipulation, and using an introducer (bougie) if the view is poor.
Consider reducing cricoid force and use a 1 or 2 person mask technique with an oral ± nasal airway.
Identify the cause and intervene accordingly, such as increasing the depth of anaesthesia, providing supplemental analgesia, or administering antihypertensive medications.
Visually if possible, using a capnograph, or an oesophageal detector.
Poor airway assessment and planning strategies contributed to poor airway outcomes.
Insert the cannula through the cricothyroid membrane.
Inflate the cuff and ventilate with a low-pressure source, then verify tube position and pulmonary ventilation.
Low cardiac output, anaemia, intracardiac shunting (e.g., congenital heart disease), histotoxic hypoxia.
Changes in BP or HR, altered mental state, and late signs like myocardial ischaemia, arrhythmias, bradycardia, hypotension, and cardiac arrest.
Direct stimulation (e.g., blood, mucus, laryngoscope, or endotracheal tube) or indirect stimulation (e.g., pain, cervical or anal stimulation).
Uncoordinated 'see-saw' breathing movements or inability to sustain a head lift for more than 5 seconds.
Administer 4 mg/kg of suxamethonium intramuscularly.
Without vasoconstrictor: 3 mg/kg; With adrenaline: 7 mg/kg.
Intra-arterial injection is the inadvertent injection of a drug into an artery, which can cause severe complications such as vasospasm and arterial thrombosis. It requires prompt and effective management.
A 'difficult airway alert' form should be completed and given to the patient, with a copy sent to the GP.
Consequences include cardiotoxicity, cardiovascular collapse, and malignant arrhythmias such as conduction blocks, ventricular tachyarrhythmias, and asystole.
Face mask oxygenation and ventilation with maximum head extension and jaw thrust.
Sodium nitroprusside is an arteriolar vasodilator that is light-sensitive and can lead to cyanide accumulation with prolonged use.
Convert immediately to a surgical cricothyroidotomy.
Serious complications can occur; these techniques should only be used in life-threatening situations.
Pulse oximetry and cyanosis occurring at SaO2 < 85% or PaO2 < 6.7 kPa.
Guanethedine block.
Pre-existing upper respiratory tract infection, smoking, children (especially if asthmatic, recent chest infection, or exposed to passive smoking), inadequate depth of anaesthesia, soiling of the vocal cords, and upper airway surgery.
The Association of Anaesthetists of Great Britain and Ireland (AAGBI).
Magnesium sulphate.
Early symptoms include light-headedness, tinnitus, circumoral tingling, and tongue numbness.
Difficult intravenous access, unconscious or anaesthetised patients, and positioning intravenous and intra-arterial access ports close to each other.
Hypotension due to vasodilatation and bradycardia due to inhibition of cardio-accelerator fibres (T1–T4).
Hydralazine is a directly acting vasodilator (arteries > veins) used if β-blockers are contraindicated.
Visual verification if possible, capnograph, and oesophageal detector. If in doubt, remove the tube.
Displaced tracheostomies and, to a lesser extent, tracheal tubes.
Call for help and follow the Difficult Airway Society guidelines.
Acidosis and hypothermia.
Stellate ganglion block, interscalene block, or axillary block.
Secondary tracheal intubation plan.
MAP = Cardiac Output × Systemic Vascular Resistance (SVR) or MAP = (Heart Rate × Stroke Volume) × SVR
Ensure that the patient is not aware during the period of inadequate reversal.
Hypovolaemia, cardiac tamponade, aorto-caval compression, tension pneumothorax.
Pre-existing uncontrolled hypertension, disease states exacerbated by surgery (e.g., thyroid storm, Cushing’s reflex).
Dosage, volume, and baricity of the local anaesthetic; patient position; patient characteristics (e.g., height, intra-abdominal pressure); injection technique (e.g., speed of injection, barbotage).
Not more than 3 attempts, while maintaining oxygenation with face mask, cricoid pressure, and anaesthesia.
Loss of consciousness.
Aim to dilute the drug, dilate the artery, prevent thrombosis, and provide analgesia. Leave the cannula in situ, flush with 0.9% NaCl or heparinised saline, administer papaverine 40–80 mg if available, administer 1000 IU heparin, and provide 10 mL of 1% lignocaine for analgesia and vasodilation.
Call for help.
Check the position, assess signal waveform and amplitude, and consider changing the site.
The patient may require a period of post-operative ventilation during which deranged physiology can be corrected.
Low FiO2, inadequate alveolar minute ventilation, V/Q mismatch, anatomical shunt, anaemia, low cardiac output, histotoxic hypoxia, and excess metabolic O2 demand.
When indicated based on the patient's condition.
For 10–14 days.
Advancements include ultrasound-guided nerve blockade and the introduction of less cardiotoxic local anaesthetics such as levobupivacaine and ropivacaine.
Because it may have consequences on end-organ function.
Postpone surgery and awaken the patient.
Intrathecal local anaesthetic-induced depression of the cervical spinal cord and/or brainstem.
Call for senior anaesthetic assistance.
Esmolol (ultra-short-acting, given by infusion) and labetalol (α and β effects, given as slow boluses titrated to effect).
'If in doubt, take it out' and consider postponing surgery and awakening the patient if possible.
Motor loss in the upper limbs.
Pulse oximeter malfunction, hypothermia, poor peripheral circulation, artefacts (diathermy, motion, ambient lighting), dyes (e.g., methylene blue).
Hand ventilate the patient.
Pneumothorax, bronchospasm, lobar collapse, mucous plugging, aspiration, massive atelectasis, pulmonary embolism, aspiration of foreign body, acute pulmonary oedema.
Remifentanil is a synthetic opioid that decreases mean arterial pressure and heart rate, but its use can be limited by profound bradycardia.
Identify the cricothyroid membrane.
Establish the cause and treat as appropriate, considering both pulmonary and extra-pulmonary causes.
