Obstetric difficult airway guidelines – decision‐making in critical situations

Medicine is a risky business and anaesthetists are familiar with having to make difficult decisions when complex clinical emergencies arise. There are perhaps few more challenging anaesthetic situations than failed tracheal intubation and when this arises in the obstetric setting, the burden on the anaesthetist and the consequences of his/her actions may be considerable [2, 3]. The marked decline in general anaesthesia for caesarean section in many parts of the world in recent decades has reduced the likelihood of anaesthetists’ encountering such a situation, but increased the pressure on them when they do: not only is caesarean section under general anaesthesia a relatively rare event for many anaesthetists, it tends to be reserved for women requiring the most urgent delivery [4, 5]. Conditions at these times are often adverse, the time pressure extreme and the ‘stakes’ may reasonably be described as high. Algorithms to guide anaesthetists who encounter this emergency have been described [6, 7], but despite publication of a universal difficult airway guideline for non-obstetric, non-paediatric patients in 2004 [8], it is only now that national obstetric-specific difficult airway guidelines have been developed in the UK. These guidelines, jointly developed by the Obstetric Anaesthetists’ Association (OAA) and Difficult Airway Society, are published in this edition of Anaesthesia [9], and we commend the authors for their careful and thorough work. We are certain that these guidelines will be a major tool for improving safety in obstetric anaesthesia. It is no surprise that obstetricspecific difficult airway guidelines have been long in the making, given the myriad of settings in which the airway crisis may occur and the limited available evidence base [10]. These new guidelines aim to provide a consistent framework for providing safe obstetric general anaesthesia and the management of unanticipated difficult tracheal intubation, failed tracheal intubation and the dreaded ‘can’t intubate, can’t oxygenate’ (CICO). Discussion of management after failed intubation covers the different actions to be taken should the anaesthetist decide to wake the patient or proceed with general anaesthesia. The difficulty in making this decision is acknowledged by including criteria that aim to aid selection of the most appropriate option in the light of the differing circumstances of each particular case. The guidelines’ authors emphasise the value of greater simplicity in decision-making and the importance and influence of human factors, something lacking from many previous guidelines but increasingly recognised as crucially important, especially in a clinical crisis that may be unstable, complex and time-critical [11–13]. One aspect of this is how decisions are made, and despite the most prescriptive clinical guidelines, decision-making – or more specifically, making ‘correct’ decisions – is likely to pay a big part in influencing outcome. Here, we focus on some of the factors involved in this process, basing our discussion around points raised (and comments made by respondents) in a survey we conducted in 2012 [1] in which we presented UK OAA members with a hypothetical case, summarised in Box 1, and asked how they would proceed (and why), using an inductive approach to data analysis [14].