PerOral Endoscopic Myotomy Failed intubation | Final Exam Viva

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You are the duty anaesthetist at a busy tertiary hospital. Your provisional fellow calls you for
urgent assistance with an airway emergency.

They have performed a rapid sequence induction and attempted to intubate a 22-year-old man
for a Per-Oral Endoscopic Myotomy (POEM) procedure for type 2 achalasia in the main
theatres.

Intubation was attempted with a videolaryngoscope and hyperangulated blade. The percentage
of glottic opening visible was 10% and they were unable to pass the endotracheal tube or a
gum elastic bougie. They were then unable to bag-mask ventilate the patient but successfully
placed a second generation supraglottic airway. Ventilation has been restored, and green
tinged fluid has been noted in the gastric port.

Current observations are:

HR 95 bpm
BP 97/56 mmHg
SpO2 90% on FiO2 1.0
ETCO2 41 mmHg (5.47 kPa)
TV 400 mL with a small air leak

Weight 169 kg
Height 199 cm
BMI 42 kg/m2

Past Medical History

Type 2 achalasia
Class III obesity
Attention deficit hyperactivity disorder
Mild developmental delay
Severe anxiety

Medication

Lisdexamfetamine 70 mg once daily
Melatonin 4 mg nocte
Diazepam 10 mg was given orally preoperatively

Allergies
Nil known

What are your priorities in managing this situation?

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