Failed intubation for retained placenta27-year-old woman, 118 kg (BMI 44), 40 minutes after vaginal birth

The patient

The examiner asks

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1. Consider

   What concerns you?

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   • A 27-year-old with BMI 44 and predicted difficult airway, bleeding from a retained placenta. Patient
   • Just delivered, she still has a pregnant airway, a full stomach and low oxygen reserve.
   • Obesity worsens all three: harder laryngoscopy, faster desaturation, more airway closure. Disease
   • 1500 mL lost with HR 124: she is unstable and still bleeding. Surgery

2. Prepare

   Spinal or general, and how do you prepare?

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   • Neuraxial would be my choice, but unstable bleeding makes general anaesthesia necessary. Patient
   • Before induction, the obstetrician and I decide: if intubation fails, we proceed, as her bleeding won't wait. Airway
   • Ramped 20–30° head-up, ear level with the sternal notch: more FRC and a better view.
   • Videolaryngoscope first, size 7.0 tube, bougie, second-generation SAD and front-of-neck kit open.
   • Two large cannulas, blood running, and the most experienced anaesthetist present. Patient

3. Plan

   Take me through the induction.

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   • Preoxygenate with a tight mask until end-tidal oxygen reaches 90%, nasal oxygen on throughout. Airway
   • Ketamine 1 mg/kg for her low pressure, then rocuronium 1.0 mg/kg.
   • Rocuronium leaves sugammadex 16 mg/kg as a route to wake her.
   • Cricoid at 10 N awake, 30 N asleep; released if it spoils the view.
   • Gentle mask ventilation under 20 cmH2O after induction to slow desaturation.
   • Uterine relaxation: nitroglycerin in 50 mcg steps up to 250, phenylephrine ready for her hypovolaemia. Surgery

4. Crisis

   Two videolaryngoscope attempts fail, grade 3 view. SpO2 93%, BP 96/58, HR 120. What do you do?

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   • Obstetric failed intubation algorithm: two attempts have failed, so I declare it and call for help. (Crisis)
   • No more laryngoscopy unless a more experienced anaesthetist takes a third look; trauma swells her airway.
   • Oxygenate: second-generation SAD, cricoid released to insert it, two insertion attempts at most.
   • Ventilating well, so we proceed as agreed: her bleeding needs the placenta out.
   • Stomach drained through the SAD, anaesthesia deepened, fastest senior obstetrician operating.
   • If we had to wake her: sugammadex 16 mg/kg, then awake intubation or a spinal once stable.

5. Crisis

   Through the SAD, SpO2 falls to 78% and you cannot ventilate; facemask fails too. BP 88/50, HR 130. What do you do?

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   • Can't intubate, can't oxygenate: I declare it and go straight to front-of-neck access. Crisis
   • Surgical cricothyroidotomy; cannula techniques often fail in obese patients.
   • Call ENT or intensive care, but I start without waiting for them.
   • If oxygenation isn't restored and she arrests, CPR and the arrest algorithm.
   • Afterwards a team debrief, airway alert letter to her and her GP, and a follow-up visit. After surgery