Difficult intubation: lessons learned from the courts of South Korea.

Endotracheal intubation is one of the most common practices during general anesthesia and a daily procedure for most anesthesiologists working in the operating room. Furthermore, the introduction of advanced equipment, such as video-laryngoscopy, into our routine has made intubation easier to perform, increasing the success rate at the first attempt [1]. Therefore, our caution for difficult intubation seems to be diminishing. However, difficult intubation has been a major contributor to adverse patient outcomes worldwide [2-5]. Moreover, previous analyses of anesthesia-related medical disputes using the Korean Society of Anesthesiologists database also showed that difficulties in airway management were related to more than half of the disputes [6,7]. Therefore, attention must be paid to difficult airway management. To improve difficult airway management, it is essential to analyze the complications following airway management. However, the incidence of difficult airways or its complications is very low [8]. Therefore, analyses of past closed claims related to difficult airway management have been used for management [2-5].

In the current issue of the Korean Journal of Anesthesiology, Cho et al. [9] published an article analyzing the closed judicial precedents of intubation-related complications registered between 1994 and 2020, using the Korean Supreme Court database. It reveals medical malpractices and severe complications related to endotracheal intubation in South Korea. Among the 63 cases analyzed, the most common problem was failed or delayed intubation (88.9%). Most cases (95.2%) were associated with severe injury, more than half of which resulted in deaths. These findings suggest that the occurrence of intubation-related complications causing major permanent injury can lead to legal conflict. The article also describes common types of malpractices recognized by the courts. The most common type of malpractice is not attempting the alternative airway technique. It is particularly surprising that the supraglottic airway device was used in only 5.2% of delayed or failed intubation cases. The guidelines for difficult intubation management emphasize on attempting the use of supraglottic airway devices if intubation fails, to provide a route for oxygenation, limit the number of airway interventions to minimize trauma from repetitive airway interventions, and get time to review how to proceed [10,11]. Therefore, not attempting alternative airway techniques seems to have been recognized as a malpractice, which is a reminder of the importance of training to become experts in difficult airway management guidelines.

This article deals with extreme cases of difficult intubation that ended up in courts. Evidently, the findings in this article do not comprehensively reflect the difficult intubation management in South Korea. However, such cases of rare and severe complications have attracted attention. It can be hoped that this would serve as an opportunity to check our level of difficult airway management and infrastructure for difficult airway situations.