A 44-year-old man with obstructive sleep apnea was seen by an ENT surgeon.
He was scheduled for a septoplasty and turbinate resection.
At the start of the operation, the anesthesiologist noted easy mask ventilation with an oral airway.
Intubation was attempted with a Miller 2, which was unsuccessful.
A second attempt was made with a Mac 4, which was also unsuccessful.
Vocal cords were not visible on either attempt with direct laryngoscopy.
The patient received mask ventilations, and a third attempt was made.
Video laryngoscopy was attempted with a Glidescope 4 blade.
A grade 2 view was obtained, but the ET tube could not be passed.
Backup was requested.
3 anesthesiologists, 2 CRNAs, and the ENT surgeon were present.
The most experienced anesthesiologist attempted a Glidescope intubation again.
The cords were visualized with a Grade II view, but the ET tube could not be passed due to the large amount of swollen pharyngeal tissue.
An attempt at fiberoptic intubation also was unsuccessful.
The group made a collective decision to cancel the surgery and mask ventilate the patient until he woke up.
For the next 2 hours, they ventilated the patient through a mask.
Unfortunately he was very agitated at several points, became hypoxic, and had an episode of bradycardia.
They decided a surgical airway was required, and the ENT surgeon performed a tracheotomy.
The patient suffered a pharyngeal laceration.
He developed a retropharyngeal abscess over the next few days.
He required a long inpatient stay, multiple operations, and has persistent pain with swallowing.
The patient was surprised and frustrated by these complications.
A lawsuit was filed against the anesthesiologists.
This lawsuit was removed from public view before it resolved.
I suspect it was removed because a confidential settlement was reached.
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MedMalReviewer Analysis:
This was a challenging airway situation, and the patient could have easily died if not for the expert care provided by the anesthesiologists. I can only imagine their frustration at having worked diligently to save his life, only to be slapped with a lawsuit.
The importance of mask ventilations cannot be overstated. Trainees often want to jump straight to advanced airway techniques, but perfecting mask skills is often what can save a life.
It took 2 hours from the time that they finished the intubation attempts until he received a surgical airway. I commend these physicians for their prolonged attention to detail and ability to make a decisive decision when the time came.
It’s been said that the hardest part of doing a surgical airway is making the decision to cut. The cases that have immediate and obvious need for a surgical airway are often easier to manage cognitively. The airway disasters that progress over the course of several hours (rather than seconds or minutes) can paradoxically be more challenging because they lead to decision-making inertia.This case is an excellent reminder to mentally rehearse your approach to improving your view of the cords, passing an ET tube once the cords are visible, and deciding to do a surgical airway. You may be faced with a similar situation without the benefit of a controlled environment, well-prepared equipment, and multiple specialists to assist you.
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