In the Difficult Airway Society algorithm, after failed intubation and failed oxygenation during emergence from general anesthesia, what is the NEXT recommended action?

Explanation

## Failed Intubation + Failed Oxygenation — DAS Algorithm (Emergence Pathway) **Key Point:** The DAS (Difficult Airway Society) 2015 guidelines specify a stepwise approach even in the "can't intubate, can't oxygenate" (CICO) scenario. The **immediate next step** after failed intubation and failed oxygenation is to **insert a supraglottic airway device (SAD)** and attempt to restore oxygenation — surgical airway is reserved for when SAD also fails. **High-Yield DAS Algorithm Steps (Failed Intubation + Failed Oxygenation):** 1. **Call for help** (simultaneously) 2. **Insert a supraglottic airway device (e.g., LMA)** → attempt oxygenation 3. If SAD restores oxygenation → stabilize and plan definitive airway 4. If SAD fails to oxygenate → **Emergency surgical airway (cricothyrotomy)** **Why not immediate cricothyrotomy?** The DAS guidelines explicitly recommend attempting SAD rescue oxygenation *before* proceeding to surgical airway, because SAD is faster, less invasive, and frequently successful. Cricothyrotomy is the final rescue step when all supraglottic attempts have failed. **Clinical Pearl:** The "CICO" scenario is life-threatening, but the DAS algorithm is sequential: SAD first, then surgical airway if SAD fails. Jumping directly to cricothyrotomy without attempting SAD is not consistent with DAS 2015 guidelines [Frerk C et al., *British Journal of Anaesthesia*, 2015 — DAS Difficult Airway Guidelines]. **Mnemonic:** **CICO** = **C**an't **I**ntubate, **C**an't **O**xygenate → **SAD first → if SAD fails → Surgical Airway** ### Decision Tree: Failed Intubation + Failed Oxygenation (DAS) ``` Failed Intubation + Failed Oxygenation ↓ Call for help + Insert SAD (LMA) ↓ Oxygenation restored? YES → Stabilize, plan definitive airway NO → Emergency Surgical Airway (Cricothyrotomy) ``` **Warning:** Repeated laryngoscopy attempts in a hypoxic patient waste critical time and worsen airway trauma. Proceed directly to SAD rescue, not further intubation attempts.