After failed intubation in a 'cannot intubate, can oxygenate' scenario during RSI, the anaesthetist has placed an LMA Supreme and ventilation is adequate. According to the DAS 2015 guidelines, the next priority step is:
- A Proceed with surgery maintaining oxygenation via the second-generation supraglottic airway
- B Immediately perform front-of-neck access (cricothyrotomy)
- C Wake the patient up and plan awake fibreoptic intubation ✓
- D Attempt blind intubation through the LMA with an ETT
Explanation
In the DAS 2015 difficult airway algorithm, once the 'can't intubate, can oxygenate' scenario is established and a second-generation SGA provides adequate oxygenation, the gold standard is to wake the patient and defer to a planned awake technique (awake fibreoptic intubation or other awake approach). Continuing with surgery through an SGA may be acceptable in specific circumstances but is not the default recommendation; it risks conversion to CICO if conditions change. Front-of-neck access is reserved for the CICO emergency pathway. Blind intubation through an LMA risks further airway trauma and is not recommended.
Reference: Morgan & Mikhail's Clinical Anesthesiology, 6th ed.
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Written and medically reviewed by the StethoPrep medical team.