title: All India Difficult Airway Association 2016 guidelines for the management of unanticipated difficult tracheal intubation in obstetrics.
abstract: 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 H2O 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 SpO2should 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.
authors.affiliation: Department of Anaesthesiology, Kasturba Medical College, Manipal, Karnataka, India.
authors.forename: Venkateswaran
authors.initials: V
authors.lastname: Ramkumar
authors.affiliation: Department of Anaesthesiology, Kasturba Medical College, Manipal, Karnataka, India.
authors.forename: Ekambaram
authors.initials: E
authors.lastname: Dinesh
authors.affiliation: Department of Anaesthesiology and Critical Care, K S Hegde Medical Academy, Nitte University, Mangalore, Karnataka, India.
authors.forename: Sumalatha Radhakrishna
authors.initials: SR
authors.lastname: Shetty
authors.affiliation: Kailash Cancer Hospital and Research Centre, Muni Seva Ashram, Vadodara, Gujarat, India; Department of Anaesthesiology and Critical Care, Vadodara Institute of Neurological Sciences, Vadodara, Gujarat, India.
authors.forename: Amit
authors.initials: A
authors.lastname: Shah
authors.affiliation: Department of Anaesthesiology and Critical Care, JIPMER, Puducherry, India.
authors.forename: Pankaj
authors.initials: P
authors.lastname: Kundra
authors.affiliation: Department of Anaesthesiology, North Bengal Medical College, Darjeeling, West Bengal, India.
authors.forename: Sabyasachi
authors.initials: S
authors.lastname: Das
authors.affiliation: Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Mumbai, Maharashtra, India.
authors.forename: Sheila Nainan
authors.initials: SN
authors.lastname: Myatra
authors.affiliation: Department of Anaesthesiology and Critical Care, J N Medical College and Hospital, AMU, Aligarh, Uttar Pradesh, India.
authors.forename: Syed Moied
authors.initials: SM
authors.lastname: Ahmed
authors.affiliation: Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Mumbai, Maharashtra, India.
authors.forename: Jigeeshu Vasishtha
authors.initials: JV
authors.lastname: Divatia
authors.affiliation: Kailash Cancer Hospital and Research Centre, Muni Seva Ashram, Vadodara, Gujarat, India; Department of Anaesthesiology and Critical Care, Vadodara Institute of Neurological Sciences, Vadodara, Gujarat, India.
authors.forename: Apeksh
authors.initials: A
authors.lastname: Patwa
authors.affiliation: Department of Onco-Anaesthesiology and Palliative Medicine, Dr BRAIRCH, All India Institute of Medical Sciences, New Delhi, India.
authors.forename: Rakesh
authors.initials: R
authors.lastname: Garg
authors.affiliation: Department of Anaesthesiology and Critical Care, K S Hegde Medical Academy, Nitte University, Mangalore, Karnataka, India.
authors.forename: Ubaradka S
authors.initials: US
authors.lastname: Raveendra
authors.affiliation: Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Hospital, Mumbai, Maharashtra, India.
authors.forename: Jeson Rajan
authors.initials: JR
authors.lastname: Doctor
authors.affiliation: Former Professor, Department of Anaesthesiology, All India Institute of Medical Sciences, New Delhi, India.
authors.forename: Dilip K
authors.initials: DK
authors.lastname: Pawar
authors.affiliation: Department of Paediatric Anaesthesia, Kanchi Kamakoti CHILDS Trust Hospital, Chennai, Tamil Nadu, India.
authors.forename: Singaravelu
authors.initials: S
authors.lastname: Ramesh
keywords: Cricoid pressure; difficult airway; face mask ventilation; failed intubation; high-flow nasal cannula; intubation; modified rapid sequence induction; obstetrics; parturient; perimortem caesarean delivery; preoxygenation