Alternate Plans

Although one can learn a lot from textbooks, anesthesia is a specialty learned through practice. For example, in the abstract, all anesthesiologists know that there should be backup or alternate plans for the airway should the primary plan fail. But putting this in action is difficult.

A patient with a fixed cervical spine, morbid obesity, full beard, and large neck presents for surgery. All of these characteristics put him at higher risk for being a difficult mask ventilation and intubation, though he had gone through anesthetics in the past without reported difficulties. In talking with my attending, we came up with a well-articulated airway plan and backup. After adequate pre-oxygenation, we induced anesthesia. He was indeed difficult to ventilate; with two hands and an oral airway, I could get minimal air exchange. But we planned for that and attempted to place a large laryngeal mask airway, intending on using that as a conduit for intubation. However, I could not get the LMA to seat well. After attempting to place it several times, I kept getting a leak. Although the vital signs were stable, I knew that I was running out of time. My attending then indicated we should switch over to our alternate plan. After the best mask ventilation we could do, we gave succinylcholine and used a video laryngoscope to intubate the patient.

A dozen anesthesiologists would come up with a dozen different plans and criticisms of what we did. Some might have started with the video laryngoscope. Others may have balked at giving succinylcholine when our ventilation was so tenuous. Yet others may have tried a different sized LMA or a second generation LMA (supreme, proseal, or fastrach). And the most conservative would have kept the patient awake until intubation. My attending and I had discussed all those approaches and arguments. But what I learned most from this experience was when to pull the trigger and say that the primary plan simply wasn't working and to switch to the alternative. And perhaps, the importance of having even a Plan C if A and B failed.