Failed intubation in obstetrics: OAA/DAS algorithm and wake-versus-proceed

Meet the patient

A 32-year-old at term needs a category-1 caesarean for prolonged fetal bradycardia. After rapid sequence induction you cannot intubate on two video-laryngoscopy attempts. SpO2 is 88 percent and falling. The obstetrician is scrubbed and waiting.[1]

This is the single most classic obstetric anaesthesia crisis on the ANZCA Final (and the FRCA, EDAIC, and ABA equivalents), and the examiner is not testing whether you can recite that pregnancy makes the airway hard. They are testing whether you can declare failure early, limit trauma, rescue oxygenation, and make an explicit wake-versus-proceed decision with the team while the clock runs on fetal and maternal wellbeing.[1]

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1. [1]Mushambi MC, Kinsella SM, Popat M, et al. Obstetric Anaesthetists' Association and Difficult Airway Society guidelines for the management of difficult and failed tracheal intubation in obstetrics Anaesthesia, 2015.PMID 26449292
2. [2]Frerk C, Mitchell VS, McNarry AF, et al. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults Br J Anaesth, 2015.PMID 26556848
3. [3]WOMAN Trial Collaborators Effect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial Lancet, 2017.PMID 28456509
4. [4]Flick RP, Wilder RT, Pieper SF, et al. Risk factors for laryngospasm in children during general anesthesia Paediatr Anaesth, 2008.PMID 18315633
5. [5]Mihara T, Uchimoto K, Morita S, Goto T The efficacy of lidocaine to prevent laryngospasm in children: a systematic review and meta-analysis Anaesthesia, 2014.PMID 24992191