A frail patient with small bowel obstruction required emergency laparotomy. Previous difficult intubation was noted, and it was decided to induce anaesthesia in theatre preoxygenated. Plan for RSI: Mac-VL, bougie, cricoid. After careful positioning the patient was pre-oxygenated. First attempt at laryngoscopy was by the resident anaesthetist who found copious gastric contents obscuring the view; the airway was suctioned and the patient positioned head down. During a second attempt at laryngoscopy further copious gastric secretions were suctioned. SpO2 started to decline slowly (92%). The consultant inserted an igel to restore oxygenation with good effect. Assistance was requested from second consultant anaesthetist and ENT consultant in adjacent theatre. The trachea was intubated with Mac –VL and stylet. The ENT consultant performed immediate bronchoscopy and lavage. However, oxygenation became increasingly challenging despite recruitment manoeuvres. CXR showed a collapsed right upper lobe. The ICU consultant performed repeat bronchoscopy and lavage with some improvement in oxygenation.

Commentary.

As with our first case, all patients require a full airway strategy. Awake techniques maybe preferable and should always be considered.

The use of cricoid pressure as a component of rapid sequence intubation (RSI) is a matter for debate but when bowel obstruction is suspected, cricoid pressure is recommended.^1,2 Furthermore, the insertion of the NG tube should be considered pre-operatively.

The Difficult Airway Society is currently updating its 2015 guidelines for management of unanticipated difficult intubation in adults, including the section on rapid sequence induction (RSI). In addition to this update, SALG is developing a best practice statement specifically focussed on RSI, which will be included in the revised guidelines. This work is one of the actions identified in SALG’s response to a Prevention of Future Deaths notice issued in December 2024, following the coroner’s inquest into the death of Mrs Pamela Anne Marking.

Project for Universal Management of the Airway (PUMA)⁴ also discusses the different components of RSI.

References:

1. Coroner for Surrey Pamela Marking: Prevention of Future Deaths Report. Dec. 2024
2. Safe Anaesthesia Liaison Group, Difficult Airway Society. Joint response to Regulation 28: Report to prevent future deaths in the matter of Mrs Pamela Anne Marking, 2025
3. Difficult Airway Society. DAS guidelines for management of unanticipated difficult intubation in adults, 2015
4. Project of Universal Management of Airways. Guidelines for Rapid Sequence Intubation, 2025