A 42-year-old obese man is undergoing renal dialysis in a hospital dialysis unit when he suddenly suffers a cardiac arrest. He is a diabetic with a history of cerebrovascular disease, peripheral vascular disease, and angina. He is a nonsmoker. He had no premonitory symptoms.

You are called to manage his airway. When you arrive on the scene, you see a cyanotic male looking older than his stated age, reclining at 45 degrees in a dialysis chair. He is still connected to a dialysis machine via a vascular shunt in his left arm. The head of the chair, which is not on wheels, is against the wall. A dialysis technician is straddling the patient performing cardiopulmonary resuscitation and a nurse is delivering ineffective bag-mask-ventilation (BMV) from the right side of the patient. You are informed that he receives dialysis three times a week. His dry weight is 188 kg (414 lb).

The crash cart has arrived, containing both oral and nasal airways, endotracheal tubes, a laryngoscope handle, and #3 and #4 Macintosh blades. There is an intubating stylet as well. This is the third time this year you have been called to this unit. Unfortunately, the equipment you prefer to use for airway management is never available in the dialysis unit, despite continuous reminders that you prefer a Miller blade.

What Is Meant by the Term “Ectopic” Airway Management?

Anesthesia practitioners, emergency physicians, intensivists, hospitalists, and other health care providers with airway management expertise often become involved in emergency and urgent airway management outside of their usual operating milieu. This is referred to as “ectopic” airway management.

What Are the Common Examples of Ectopic Venues?

There are several areas of a hospital where it should be anticipated that emergency airway management will be required occasionally, or even perhaps regularly. These include but are not exclusive to:

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  Post-anesthetic care unit (PACU)

  
  
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  Diagnostic imaging locations where emergency and intensive care unit (ICU) patients are taken; particularly CT, MRI, ultrasound, and angiography units

  
  
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  Units where procedural sedation is undertaken:

  
  
  
  
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    Endoscopy

    
    
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    Invasive cardiology

    
    
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    Interventional imaging

    
    
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    Pediatric clinics, such as dentistry, ophthalmology, EEG, ENT, and others

    
    
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    Lithotripsy

    
    
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    Cardiac stress testing facilities

    
    
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    Medical and surgical inpatient units

    
    
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    Obstetrical delivery suites

  
  

Outpatient clinics, medical offices, and non-patient care areas (e.g., cafeterias, residences, waiting rooms, administrative offices, and the areas immediately external to the health care facility) are occasionally the site of an airway emergency.

What Are the Unique Challenges of Ectopic Airway Management?

Managing a difficult airway is always anxiety provoking and somewhat dysphoric. Most ectopic airway management is difficult for a variety of reasons: some are related to the patient’s airway anatomy; others to the patient’s condition; and some are unique to the situation. The result is performance anxiety that may lead to less than optimal performance. Consider the following unique challenges inherent in managing the ectopic airway:

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  Medicolegal risk

  
  
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  Consistency and availability of airway kits/carts and medications

  
  
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  Unfamiliar environment

  
  
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  Unknown patient medical conditions

  
  
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  Assistants unfamiliar with airway management

  
  
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  Emotionally charged environment; stressed response

  
  
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  Post-intubation management

What Are the Medicolegal Risks Associated with Ectopic Airway Management?

Ectopic airway management is associated with an element of medicolegal risk in the event of a poor outcome. Peterson et al. published an update of the Management of the Difficult Airway: A Closed Claims Analysis in 2005. Out of 179 claims for difficult airway management, 86 (48%) were from events occurring from 1985 to 1992 and 93 (52%) were from events occurring from 1993 to 1999. The majority of claims for difficult airway management (156 out of 179 or 87%) involved perioperative care and 23 claims (13%) involved ectopic locations. Out of these 23 cases of airway management misadventures outside the operating room environment, 25% involved endotracheal tube change, and nearly half were not related to surgical procedures. Reintubation on the ward or ICU some time after a surgical procedure was related to neck swelling with respiratory distress. The procedures included cervical fusion (n = 3), total thyroidectomy (n = 1), intraoral/pharyngeal procedures (n = 2), and fluid extravasation from a central catheter (n = 1).¹

The typical scenario coming to litigation has the following features:

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  The patient is unknown to the airway practitioner.

  
  
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  It is an emergency situation:

  
  
  
  
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    Which is emotionally charged and chaotic

    
    
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    In which events preceding the airway emergency are unclear

    
    
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    In which the amount of information about the patient is limited

    
    
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    In which action is needed immediately

    
    
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    With a difficult airway (e.g., post-thyroidectomy in PACU; patient in a halo jacket)

    
    
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    In which evaluation of the airway for difficulty is inadequate

    
    
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    In which paralytic agents are inappropriately given

    
    
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    In which the management strategy is poorly thought out and executed, leading to a failed airway

  
  

The fact that the airway practitioner is thrust into an emotionally charged and unfamiliar environment provides little if any legal protection or indemnification. Furthermore, the defense of lack of familiarity or lack of desired equipment may be discredited. This is particularly so if it can be established that emergency airway management is expected to occur from time to time in that unit and that the individual charged with airway management in such situations (i.e., you) knew or ought to have known that they might be summoned to do so.

Part of the solution to this problem is in the realm of prevention by establishing policies and procedures with respect to the availability of airway management equipment and its maintenance in areas where it is predictable that emergency or urgent airway intervention will occasionally be required. This requires that the disciplines involved take ownership of this issue and communicate with each other, and among themselves, about the specifics of such policies that will ensure safe, and hopefully litigation free, ectopic airway management.