*A Legal case of an intubation going wrong*
A 61-year-old female was referred to her plastic surgeon with a suspicious mole on her cheek near the left eye. She was diagnosed with a melanoma and proposed a procedure involving wide local excision and primary reconstruction of the lower eyelid, which was likely to take several hours. Difficult Intubation A consultant anesthetist met the patient on the ward before the operation and performed an anesthetic assessment. The patient was slightly overweight and was taking omeprazole for reflux, but was otherwise very healthy. The anesthetist did not examine the patient, but wrote on the chart that she was “in remarkably decent shape for her age”. He induced anesthesia with propofol and fentanyl and gave atracurium as a muscle relaxant. He proceeded to attempt to intubate the patient but found that she had limited neck mobility and a full dentition, with very poor mouth opening. The anesthetists made several attempts to intubate her, using a McCoy-bladed laryngoscope and a bougie, but was unsuccessful, though facemask ventilation was manageable. He then decided to use a flexible laryngeal mask airway (LMA) to maintain the airway. This was easy to insert and provided a good seal suitable for mechanical ventilation. He told the patient about his unsuccessful intubation and use of the flexible LMA, but there was no further discussion. Intubation went wrong Anesthesia was maintained with oxygen, air, and sevoflurane. The first five hours of the surgery were uneventful, but towards the end, the ventilation became more difficult, with higher airway pressures needed. The anesthetist wanted to reposition the LMA, but access to the face was difficult because of the surgical field. He then switched to manual ventilation but struggled to maintain adequate oxygenation during the remainder of the operation. There was very little documentation from this period and later commented: “I couldn’t both write and ventilate.” In recovery, the patient was hypoxic and tachypnoeic despite high flow oxygen. Coarse crepitations could be heard in both lungs and a chest X-ray was performed, which was suggestive of aspiration. The anesthetist summoned the intensive care consultant, and together they managed to intubate the patient using a fibreoptic scope, although with some difficulty. Difficult recovery The patient had a turbulent course in intensive care. She developed extensive pneumonitis and sepsis, complicated by acute renal failure requiring hemofiltration. She had a prolonged stay and a tracheostomy was performed to facilitate weaning from mechanical ventilation. She was eventually discharged but was found to have a demonstrable degree of cognitive impairment consistent with global hypoxic brain injury. Legal claim The patient brought a claim against the anesthetists and the plastic surgeon. The experts were critical of the anesthetists’ failure to examine the patients’ airway prior to the surgery, which was considered an indefensible omission. The case was settled for a high sum. Learning points No matter how well a patient appears, there is no excuse for a failure to conduct a full assessment prior to a procedure. Assessment of the airway is one of the cornerstones of anesthetic assessment and should be performed in every patient requiring anesthesia. Communication with surgical colleagues and a full understanding of the operation being carried out is important to ensure an appropriate decision about which airway technique to employ. Good record-keeping is an essential part of anesthetic practice. If notes cannot be made at the time of a critical incident they should be completed immediately afterward, as they will form part of a legal defense.

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