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Failed Intubation during an Emergency Cesarean: Use of i-gel Second-Generation Supraglottic Airway Rescue Device
Abstract Number: S2C-7
Abstract Type: Case Report/Case Series
Failed intubation incidence in obstetrics, with general anesthesia (GA) for Cesarean Delivery (CD) is 1 in 390 cases and has remained unchanged for the last 40 years.(1,5) The new American Society of Anesthesiologists and Difficult Airway Society (DAS) difficult airway (DA) guidelines have incorporated supraglottic airways (SGA) and videolaryngoscopes (VL) into their respective guidelines.(2,3) DAS guidelines recommend second-generation SGA because they are designed to provide better airway seal; positive pressure ventilation; conduit for intubation and minimize aspiration risk. We present a case of i-gel® (Intersurgical®) use with subsequent fiberoptic intubation (FOB) following failed intubation in an emergency CD.
A 33 year-old G2P0 parturient was admitted at 33 weeks gestation for preeclampsia with severe features including BP of 180/110s, thrombocytopenia, and BMI of 49 with predictors of DA. MgSO4 and antihypertensive nicardipine infusions were initiated. Initial platelet count was 90K with normal coagulation panel and TEG.
Given possible DA, a combined-spinal epidural was attempted in early labor using ultrasound. Loss of resistance was at 7 cm; spinal was attempted twice without return of CSF. The epidural catheter threaded easily and the patient reported a 0/10 pain score with bilateral T10 analgesia.
Nine hours later an urgent CD was called for fetal intolerance to labor. Lidocaine 2% was administered in incremental doses through the epidural catheter with no sensory or motor block. After discussion of risk/benefits with patient and husband, both strongly opted for GA.
With the difficult airway cart in the operating room the patient was positioned on a ramp. Pre-oxygenation included both facemask plus apneic O2 by 10L/min nasal cannula. Rapid sequence induction was performed with two unsuccessful attempts at VL. She began to desaturate, failed intubation was declared, and a #4 i-gel® was immediately inserted resulting in easy ventilation and improvement of O2 saturation. After delivery, a FOB was used with easy placement of 6.0 ETT through the i-gel®. O2 saturation remained stable. The surgery was uneventful, she was extubated awake and transported to the intermediate care unit.
Emergency airway management in obstetrics is challenging. Restoration of ventilation and oxygenation is priority and the decision to intubate through the SGA is dependent on the maternal clinical condition. There are prospective longitudinal studies with second-generation LMA ProSeal® and LMA Supreme® in obstetrics.(4,5) However, these devices are not suitable conduits for intubation. This case illustrates the i-gel® as a useful rescue airway device for ventilation and as a conduit for FOB intubation, which resulted in favorable outcome for both mother and baby.
1. Int J of Obstet Anesth, 2015;24:356-374
2. Anesthesiology, 2013;118:1-20
3. Br J Anaesth, 2015;115:827-48
4. Br J Anaesth, 2015;115:812-814
5. Anaesthesia, 2015;70:1286-1306