Responsive Contingency Planning: A novel system for anticipated difficulty in airway management in dental abscess

Abstract

Background. This study is of a novel system for management of anticipated difficult airway (Responsive Contingency Planning). It is based on the notion that almost all problems in airway management have already been experienced, so they can be anticipated and prepared for using 'worst case' planning. Methods. Anaesthetic colleagues were introduced to the new system. Thirty-two patients with dental abscess were recruited for anaesthetic airway management based around the new scheme. Data collection involved a preoperative assessment of problems specific to dental abscess, fascia-spaces involved, details of the contingency planning process, laryngoscopy grade, and comments regarding the efficacy of the new system. Results. No problems were encountered that had not been anticipated during planning and colleagues' comments about using the system were generally favourable. Examples are highlighted to suggest how the planning may have avoided certain complications (e.g. abscess rupture) and helped in dealing with others when they occurred. If trismus (≤2 cm inter-incisor distance) occurred with superficial infection alone, it always improved (to >2 cm) after induction of anaesthesia. In contrast, difficult laryngoscopy (grade 3 or 4) occurred in 6/15 cases of floor of mouth infection. Conclusions. The system fulfilled expectations for its use at this stage of development. It can be easily updated for refinements, alternative techniques, and tailoring to any difficult airway scenario. Computerization should make it easier to use and flag-up inconsistencies. Floor of mouth infections in the presence of trismus are easily underestimated and require careful assessment. © The Board of Management and Trustees of the British Journal of Anaesthesia 2007. All rights reserved.