Can't Ventilate, Can't Intubate: What Now?

Summary CV-CI happens, and it is not reliably predictable. The first response to the occurrence can be denial but should, in fact, be prompt recognition. An orderly management plan first depends on strategy, which is beyond the anesthesiologist's control but not their understanding. It then shifts to tactics, which are essentially what is available, and thought of, that really works for this particular anesthesiologist or their responding colleagues. Resource management is essential and must be thought out well in advance. Call for assistance early and often. Reject offers for help at your, and the patient's, peril. Within reason, obtain the necessary devices to deal with the airway because expertise with all devices is probably unobtainable and certainly unaffordable. No matter how the administrator squeals, this is money well spent. Practice, and practice again every few months, with patients or with mannequins. Never employ relaxants for an uncertain airway without mulling over holding your own breath for 8 minutes. Remember situational awareness, and include the clock, and the nonairway portions of the patient, in your scan. Once the difficult airway has been secured, decompress the stomach, yourself, and everyone else in the room. Be in no hurry to unsecure this airway despite societal pressures to join mother and baby. The decision to return to the natural airway is arrived at democratically, with votes assigned as follows: no demonstrated airway expertise, no vote. Gently educate everyone else that dyspnea and hypoxia are such malevolent intruders that they can drain the joy out of any occasion, even one as special and unique as this. In rough terms, “sedate and relate”, the former for the patient and the latter for those who cannot comprehend their wife/mother/daughter immobile with a breathing tube and no voice. Candidly, in their eyes, there is not much to separate this picture from that of an organ doner. Admittedly controversial, 39 consider corticosteroids as an ally against airway edema. Evaluate natural airway patency with the test proposed by Potgieter and Hammond, 40 and if in doubt, extubate over a tube introducer/insufflation catheter. After the dust settles, return to the record and verify that it displays correctly what actually happened and when, along with what worked or did not. The true just reward for bad record keeping is for the same person to face the same challenge with no recollection of what happened before. Visit the patient after the event inquire as to their well-being, and thoroughly explain what transpired. Do not appear apologetic, unless you are of the opinion that you really should be, and remember that a sore throat is not just cause. In all probability, if the patient is still able to comprehend your words, it is directly due to your skill and preparation. Nearly anybody can manage the guaranteed perfect airway, but most of these anybodies will be nowhere to be found after the first class IV view. That is where the expert steps up. An expert is defined as someone who clearly knows how bad things can get, has no intention of allowing, and has the capability of preventing, the situation from getting there.