Any time that a patient is facing a surgical procedure under general anesthesia there are serious potential risks. Anesthesiologist physicians and certified registered nurse anesthetists (CRNAs) providing anesthesia care need to give careful advance thought and preparation to manage these risks.
While many patients think of anesthesia care beginning when an anesthetic medication is being administered, one of most important parts of the care actually begins earlier.
The American Society for Anesthesiologists (ASA) requires anesthesiologist physicians to conduct a pre-anesthesia assessment of patients for anesthesia care begins. In settings where an anesthesiologist isn’t involved in medically directing or supervising a CRNA, the pre-anesthesia assessment becomes a responsibility of the nurse anesthetist.
The basic idea of the pre-anesthesia assessment is for the anesthesia provider to make a judgment call on whether it’s safe to proceed with surgery under general anesthesia (or other type of anesthesia that’s contemplated).
One of the major considerations is evaluation of the patient’s airway risk. By “airway,” anesthesiologists and CRNAs refer to the windpipe or trachea. During general anesthesia, there are risks that the airway may collapse. In some patients, for example, the palate may relax and block the airway and respiration. When this happens, it presents a medical emergency for the anesthesiologist or CRNA to recognize the problem and re-establish the airway and ventilation.
When assessing airway risk, anesthesia providers look at a variety of factors, including a history of obstructive sleep apnea (whether formally diagnosed or clinically suspected), body habitus or obesity, and a thick neck. Additionally, any time there’s a history of the patient having had a so-called difficult airway under previous anesthesia care, it’s important fact for the anesthesia provider to discover and manage.
For patients who have a heightened airway risk, the standard of care requires the anesthesia provider create an airway plan, including establishment and maintenance of the airway during anesthesia care, as well as handling timely and proper extubation (removal of the breathing tube) at the end of surgical and anesthesia care.
Interestingly, the Practice Guidelines for Management of the Difficult Airway, published by the ASA in 2013, acknowledge that there isn’t a consensus definition in the medical literature of what constitutes a difficult airway. Thus, the guidelines define a difficult airway as a clinical situation where a well-trained anesthesiologist experiences difficulty with facemask ventilation of the upper airway, difficulty with endotracheal intubation, or both.
Let’s start with the second one, endotracheal intubation. This involves placing a flexible plastic breathing tube through the patient’s mouth and pharynx into the trachea, or airway. Intubation ensures that any obstruction it’s blocking the airway is removed, allowing restoration and free flow of oxygen.
Most anesthesiologists consider endotracheal intubation the gold standard for managing and airway in the event the patient stopped breathing or is in an arrest situation. In some situations, though, even a well-trained anesthesiologist or CRNA can’t achieve successful intubation on the first attempt in an emergency situation. When this happens, experts consider the next best solution to be implementation of facemask ventilation, pending additional intubation attempts.
Facemask ventilation is exactly what it sounds like. It involves properly placing a correct-sized facemask around the patient’s nose and mouth, achieving an air-tight seal, and beginning supplemental oxygenation support.
Generally, emergency equipment and supplies are available in a hospital or facility providing general anesthesia services. In the case of a patient with a potentially difficult airway, though, part of the pre-anesthesia evaluation planning is ensuring that the correct equipment is immediately available in the event of an airway emergency. This includes emergency intubation supplies, including endotracheal tubes and fiber-optic equipment, and proper-sized facemasks.
We are currently working on a case involving a major academic hospital in Houston’s Texas Medical Center where a patient’s post-anesthesia care was bungled because of a total lack of planning for his difficult airway. In this case, the cardiac procedure that the patient needed went well, and the patient was discharged from the operating room and post-anesthesia care unit (PACU) to a regular intensive care unit (ICU) bed.
Shortly after he arrived in the ICU, some resident physicians still in their clinical training decided to prematurely extubate the patient by removing his breathing tube. The patient’s family members were in the room at the time and observed him struggling to breathe.
As nurses, respiratory therapists, and doctors tried to respond to this critical situation, they realize that the proper equipment and supplies weren’t available. In other words, there hadn’t been an airway plan for a high-risk patient whose medical records reflected that he was a difficult airway risk.
The patient’s family watched on in horror as they observed providers trying to use an ill-fitting facemask and oxygen hosing that was the wrong size. Other emergency equipment was missing or unavailable. All in all, it took nearly 45 minutes to re-intubate the patient and establish his airway.
There is no surprise, under the circumstances, that he was left with a permanent brain injury caused by a lack of oxygenation, hypoxic-ischemic encephalopathy. This would have been entirely avoided if the patient’s medical, nursing, and respiratory therapy team had created and followed a difficult airway plan.
If you’ve been seriously injured because of poor anesthesia or airway care in Texas, then contact a top-rated experienced Houston, Texas medical malpractice lawyer for help in evaluating your potential case.
