In 2009, the Authority received 448 event reports involving complications related to anesthesia. Of these reports, 36 involved a difficult intubation. Six events were reported as an anticipated difficult airway involving patients with the following risk factors:
- Known history of difficult intubation (two patients)
- Anterior larynx (one patient)
- Small mouth (one patient)
- Kyphosis resulting in difficult positioning(one patient)
- Severe neck swelling due to bleeding (one patient)
For 23 events, difficult intubation was reported as unanticipated. In the seven remaining reports, it was indeterminable whether the difficult intubation was anticipated. Nine events involving a difficult intubation resulted in harm to the patient.
Reports of difficult intubation in which the patient was harmed include the following:
Intubation took three attempts. The larynx was anterior and made for difficult intubation. The patient had difficulty swallowing postoperatively and was found to have an esophageal perforation.
The anesthesiologist was attempting to insert the [endotracheal] tube using a GlideScope®. The patient's mouth was small, and the size of the tube prevented direct visual placement. Several attempts were made; then, copious amounts of blood were noted in the oropharynx. A laceration of the tonsil occurred.
A patient was admitted for shoulder surgery under general anesthesia. [It was a] difficult intubation. During intubation, an approximate 1 cm laceration of the soft palate occurred.
Excerpted from: Management of unanticipated difficult intubation. Pa Patient Saf Advis 2010 Dec.