Case 1

A patient was admitted to the emergency department with complete airway obstruction due to possible regurgitation and aspiration of solid material. On arrival of the anaesthetic team, the SpO2 <30 with a good trace, with pO2 4.45. Prior to intubation There was no discussion about airway management, no equipment check, videolaryngoscopy was unavailable, end tidal capnography not ready and no drugs were drawn up. The first two unsuccessful attempts to intubate were undertaken without sedation or paralysis. The patient appeared to be gagging and became hypertensive. A third, successful attempt was undertaken by the anaesthetic team using rapid sequence induction with rocuronium and propofol.  At this point patient had had SpO2 <60% for a prolonged period.  Following intubation, it was >5 minutes before end-tidal CO2 was obtained. As this was not working properly, a new monitor had to be sourced.

Case 2

There was a delay undertaking emergency intubation in the neonatal high dependency unit. The first laryngoscope blade handed to the anaesthetist was the wrong size. When a larger blade was requested, the new blade was the same size as the previous one, and the light did not work. There was a further delay extracting the blades from the plastic packaging that needed to be cut open with scissors that were not immediately available.

Case 3

A patient required a time critical transfer to a tertiary neuro centre from ED. When connecting up the patient, the CO₂ module on the transfer module was found to be missing from the transfer trolley. On inspection the module was broken and needed repair. This caused delay to this time critical transfer.

Commentary

Remote site anaesthesia and transfer of patients are high risk points in a patient’s journey. The Royal College of Anaesthetists make recommendations around the upkeep and checking of equipment in any area anaesthetists may be asked to provide care.¹ It is important that those involved in the provision of care are trained and have sufficient, frequent and recent experience. Guidelines for the management of airway emergencies should be immediately available in all areas where airway management is carried out.²

1. Royal College of Anaesthetists. Chapter 7: Guidelines for the provision of anaesthesia services in the non-theatre environment, 2025. Section 2.2
2. Higgs, A et al. Guidelines for the management of tracheal intubation in critically ill adults. BJA. 2018. 120(2): 323-352