All India Difficult Airway Association 2016 guidelines for the management of unanticipated difficult tracheal intubation in obstetrics

Venkateswaran Ramkumar; Ekambaram Dinesh; Sumalatha Radhakrishna Shetty; Amit Shah; Pankaj Kundra; Sabyasachi Das; Sheila Nainan Myatra; Syed Moied Ahmed; Jigeeshu Vasishtha Divatia; Apeksh Patwa; Rakesh Garg; Ubaradka S Raveendra; Jeson Rajan Doctor; Dilip K Pawar; Singaravelu Ramesh

doi:10.4103/0019-5049.195482

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GUIDELINES 2 (AIDAA)

Year : 2016 | Volume : 60 | Issue : 12 | Page : 899-905

All India Difficult Airway Association 2016 guidelines for the management of unanticipated difficult tracheal intubation in obstetrics

Venkateswaran Ramkumar¹, Ekambaram Dinesh¹, Sumalatha Radhakrishna Shetty², Amit Shah³, Pankaj Kundra⁴, Sabyasachi Das⁵, Sheila Nainan Myatra⁶, Syed Moied Ahmed⁷, Jigeeshu Vasishtha Divatia⁶, Apeksh Patwa³, Rakesh Garg⁸, Ubaradka S Raveendra², Jeson Rajan Doctor⁶, Dilip K Pawar⁹, Singaravelu Ramesh¹⁰
¹ Department of Anaesthesiology, Kasturba Medical College, Manipal, Karnataka, India
² Department of Anaesthesiology and Critical Care, K S Hegde Medical Academy, Nitte University, Mangalore, Karnataka, India
³ Kailash Cancer Hospital and Research Centre, Muni Seva Ashram; Department of Anaesthesiology and Critical Care, Vadodara Institute of Neurological Sciences, Vadodara, Gujarat, India
⁴ Department of Anaesthesiology and Critical Care, JIPMER, Puducherry, India
⁵ Department of Anaesthesiology, North Bengal Medical College, Darjeeling, West Bengal, India
⁶ Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Mumbai, Maharashtra, India
⁷ Department of Anaesthesiology and Critical Care, J N Medical College and Hospital, AMU, Aligarh, Uttar Pradesh, India
⁸ Department of Onco Anaesthesiology and Palliative Medicine, Dr BRAIRCH, All India Institute of Medical Sciences, New Delhi, India
⁹ Former Professor, Department of Anaesthesiology, All India Institute of Medical Sciences, New Delhi, India
¹⁰ Department of Paediatric Anaesthesia, Kanchi Kamakoti CHILDS Trust Hospital, Chennai, Tamil Nadu, India

Correspondence Address:
Ekambaram Dinesh
Department of Anaesthesiology, Kasturba Medical College, Manipal 576 104, Karnataka
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/0019-5049.195482

The various physiological changes in pregnancy make the parturient vulnerable for early and rapid desaturation. Severe hypoxaemia during intubation can potentially compromise two lives (mother and foetus). Thus tracheal intubation in the pregnant patient poses unique challenges, and necessitates meticulous planning, ready availability of equipment and expertise to ensure maternal and foetal safety. The All India Difficult Airway Association (AIDAA) proposes a stepwise plan for the safe management of the airway in obstetric patients. These guidelines have been developed based on available evidence; wherever robust evidence was lacking, recommendations were arrived at by consensus opinion of airway experts, incorporating the responses to a questionnaire sent to members of the AIDAA and the Indian Society of Anaesthesiologists (ISA). Modified rapid sequence induction using gentle intermittent positive pressure ventilation with pressure limited to ≤20 cm H ₂ O is acceptable. Partial or complete release of cricoid pressure is recommended when face mask ventilation, placement of supraglottic airway device (SAD) or tracheal intubation prove difficult. One should call for early expert assistance. Maternal SpO ₂ should be maintained ≥95%. Apnoeic oxygenation with nasal insufflation of 15 L/min oxygen during apnoea should be performed in all patients. If tracheal intubation fails, a second- generation SAD should be inserted. The decision to continue anaesthesia and surgery via the SAD, or perform fibreoptic-guided intubation via the SAD or wake up the patient depends on the urgency of surgery, foeto-maternal status and availability of resources and expertise. Emergency cricothyroidotomy must be performed if complete ventilation failure occurs.

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