New guidelines for anesthesiologists address emergency planning for difficult airway patients

An anesthesiologist shared an experience on Twitter. When first meeting the anesthesiologist, a patient commented if she was the doctor who would put him to sleep. The anesthesiologist replied, no, she was the one who would keep him alive.

Anesthesiologists are physicians with significant classroom and clinical training on how to safely sedate or anesthetize patients for procedures. Their training includes critical care and airway management.

The standard of care requires anesthesiologists to perform a pre-anesthesia assessment on patients before anesthetic medication is administered. Ultimately, it’s the anesthesiologist’s decision whether it’s safe for a patient to proceed with the initiation (induction) of anesthesia and surgery.

Certified registered nurse anesthetists (CRNAs)

It’s important to note that not all anesthesia services are performed by anesthesiologist physicians. As their name suggests, CRNAs are not physicians; however, CRNA professional organizations aggressively lobby state legislatures to grant them ability to provide practice authority. In some states, CRNAs are allowed to provide anesthesia care without any physician supervision.

Under Texas law, CRNAs must be medically supervised or medically directed by a licensed physician to prescribe and use medications only under prescriptive delegation agreements with a physician. At a minimum, medical supervision or direction requires the licensed physician, and anesthesiologist, to be immediately available during an emergency and participate in the most challenging parts of anesthetic care, including induction and emergence of anesthesia.

Many patients are surprised to learn that federal guidelines allow one anesthesiologist physician to simultaneously medically direct four CRNAs handling four different cases in four different operating rooms. In a medical supervision model, the same anesthesiologist can supervise five or more CRNAs at once.

As you can imagine, when a patient crashes and there is an emergency, there can be a frantic situation in the operating room to try to get the anesthesiologist’s attention and assistance.

As a patient, it’s up to you whether you want an anesthesiologist or CRNA to handle your care.

When scheduling a surgery procedure, consider discussing with your surgeon how anesthesia services are typically staffed, and the qualifications of the personnel involved. It’s your right to request an anesthesiologist physician. It’s also your right to have CRNA care if that’s what you choose. If you don’t ask, though, someone else’s choice will be imposed on you.

New guidelines for difficulty airway safety

One of the safety considerations that anesthesiologists should consider for every patient is whether they have a difficult airway that requires extra planning and preparation in case something goes wrong. If a patient experiences low oxygen saturation, respiratory distress, or respiratory arrest while under anesthesia, there’s only a short amount of time to secure the airway before hypoxia (inadequate oxygenation) can cause a brain injury.

Anesthesiologists are trained to look at medical history, neck thickness and anatomy, and obstructive sleep apnea, among other factors that can impact the degree of difficulty that may be encountered to secure the patient’s airway emergency.

The American Society of Anesthesiologists defines a difficult airway when someone experiences difficulty with facemask ventilation of the upper airway, difficult with tracheal intubation, or both.

The ASA recently updated its Difficult Airway Guidelines for the first time in a decade. When an anesthesiologist recognizes that patient has a difficult airway, new guidelines recommend preparations for an emergency situation, including:

• Having airway management equipment available in the room. We recently settled a case involving a major hospital in Houston’s Texas Medical Center where patient with a well-documented difficult airway was extubated (had his breathing tube removed after a procedure) without any advance preparations of assembling emergency equipment in the room.

• Having a portable storage unit containing specialized equipment immediately available. It’s important for staff to know where this equipment is located. We’ve handled cases where an operating room turned into a madhouse as nurses, techs, and staff looked for emergency equipment and supplies.

• Ensuring that a skilled individual is present or immediately available to assist with airway management, if feasible. This is an interesting new recommendation that requires assessment of an individual’s competence in airway management. Who will make that assessment? The anesthesia practice group? An anesthesiologist? The CRNA?

• Inform the patient or responsible person of the special risks and procedures pertaining to management of a difficult airway. I think this should be an important part of the informed consent discussion, which should take place in conjunction with the anesthesiologist’s pre-anesthesia assessment.

• Properly position the patient and administer supplemental oxygen before airway management and throughout the case, including extubating (removing the breathing tube). This, too, is an important new recommendation. Logically speaking, providing supplemental oxygenation before there’s a problem may increase the patient’s oxygen reserve and allow a little extra time to secure the airway in an emergency.

If you’ve been seriously injured because of poor anesthesia care from an anesthesiologist physician or certified registered nurse anesthetist (CRNA) in Texas, then contact a top-rated experienced Texas medical malpractice lawyer for a free consultation about your potential case.

Robert Painter
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Robert Painter

Robert Painter is an award-winning medical malpractice attorney at Painter Law Firm Medical Malpractice Attorneys in Houston, Texas. He is a former hospital administrator who represents patients and family members in medical negligence and wrongful death lawsuits all over Texas. Contact him for a free consultation and strategy session by calling 281-580-8800 or emailing him right now.