View selected GUIDELINE examples

Ipswich Hospital

North Bristol NHS Trust

Queen Charlotte's Hospital London

Sandwell & West Birmingham Hospitals NHS Trust

Southampton University Hospitals NHS Trust

Number submitted

14 

Minimum pages

 1

Maximum pages

 8

Wider scope

 Difficult and failed intubation

General points

• Most guidelines include a clear easy to follow flowchart which incorporated the DAS failed intubation principles with an obstetric slant to it. 
• Some clearly define failed intubation 
• Importance of assessing airway and positioning the patient especially in morbidly obese patients is usually emphasised. 
• Most stress the importance of calling for help early and defining who to call with bleep numbers. 
• Avoiding second dose of sux and repeated attempts at laryngoscopy highlighted 
• Easing off cricoid pressure suggested in most protocols to facilitate LM insertion/ventilation. 
• Many include the fact that failure to oxygenate kills not failure to intubate.
• Some have separate algorithms for difficult and failed intubation, others combine these aspects in one. 
• Some split difficulty with intubation into difficulty with inserting laryngoscope (& corrective manoeuvres) and poor laryngoscopic view (& manoeuvres). 
• Supine position with tilt is maintained initially; some suggest left lateral when the wake-up decision is made. 
• Emphasis to proceed with LSCS varies from ‘wake up if mother’s life not in danger without surgery’ to ‘proceed in most cases.’ 
• Some suggest proceed for maternal indications but not fetal. 
• Extra information may include: pre-operative airway assessment, equipment lists, jet ventilation instructions, phone numbers for help, follow-up and airway alerts. 
• Choice of rescue airway device –mostly LM others have suggested Proseal, ILMA or Combitube.

We liked

• ‘Best practice points’  (North Bristol NHS Trust)
• Clear format and flow chart with all the do’s and don’ts incorporated with contact numbers. 
• Reminder that LSCS may be necessary as part of maternal CPR 
• Detail equipment for rescue and cricothyroid puncture 
• Decision to continue with LSCS unitubated made on the basis of the reasons to proceed with LSCS (Sandwell and West Birmingham) although this grading may be confused with category of section.

We didn't like

• Not having a flowchart at all as part of the guidelines. A flowchart is visually appealing and easy to convey information to the reader. Many tend to read just flowchart so incorporation of all important detail on this is important.
• Having multiple flow charts for different situations-should all be amalgamated into one-as this provides a broader picture 
• Some algorithms have unclear flow sequences, suggesting spontaneously breathing GA after cricothyroidotomy 
• CICV is called 'failed ventilation drill'
• No mention/unclear about whether an option to proceed with LSCS option when no threat to mom's life but threat to baby's life. 
• Inserting Proseal LM before 'sux wears off'. May persuade the trainee to rush for it too early? Trainee's competence with Proseal needs to be assured.

We're not sure

• One algorithm proceeds straight to pLMA after failed intubation, with no ‘mask ventilation’ stage 
• All g/l suggest using spontaneous ventilation if GA is continued after failed intubation – is this essential with LMA / pLMA or is positive pressure ventilation acceptable? 
• One hospital has an algorithm for the ‘standard pathway’ (failed intubation-mask ventilation-LMA-cricothyroidotomy) and a separate one for ‘ventilation possible/ decision about awakening’; each one is clearer than those where these aspects are combined, but don’t ‘follow through’ easily 
• Mentions of nasal airways or blind nasal intubations - risk of bleeding to add to problems 
• High concentration of volatile agent has been recommended-not good for uterine tone although it is important to avoid awareness. 
• Colours – attract attention but photocopying and most in-hospital printing will lose this detail