LAUSR

The inability to secure the airway is the leading cause of anesthesiarelated injury [1]. The failure of one technique increases the risk of failure of successive techniques, which raises the number of attempts and the risk of progression to a “cannot intubate, cannot oxygenate” situation (CICO). Therefore, limiting the number of interventions and achieving a timely nontraumatic endotracheal intubation (ETI) are the main goals in airway management [2,3]. Video laryngoscope, extraglottic airway devices and fiberoptic bronchoscopy (FOB) are the principal rescue techniques to secure the airway. However, no single airway instrument is perfect in all circumstances. We present the successful use of the Totaltrack VLM (TT, Medcomflow s.a., Barcelona, Spain) as a rescue device after failed ventilation and ETI with LMA Fastrach (LMA-Fastrach; LMA Nort America, Inc., San Diego, California) in two emergent difficult airways. The patients gave written informed consent for publication of this article. The first patient was a 73-yr-old, 90 kg male with oral anticoagulation required urgent posterior nasopharyngeal tamponade under general anesthesia due to uncontrollable epixtasis. Preoperative airway assessment included a Mallampati class II, a 4.2-cm interincisive distance, a 7.5-cm thyromental distance and Upper Lip Bite Test class II. Inhalational induction with preserved spontaneous ventilation was adopted. A direct laryngoscopy (LD) showed a Cormack-Lehane grade IV glottic view and presence of blood. After failed ETI with airtraq and LMA-Fastrach plus FB, TT allowed satisfactory ventilation (confirmation with capnography within 10 s), sealing off the periglottic área from blood. An adequate glottic view (POGO 100%) facilitated the ETI in 69.4 s. The procedure was carried out without incident resolving the bleeding. The second patient was a 73-yr-old, 101 kg male (Fig. 1, panel B and C). He required emergent ETI due to acute respiratory insufficiency and chronic renal disease reagudized with anasarca. The preinduction evaluation indicated a Mallampati class III, a 5-cm thyromental distance, thick neck and a sentinel tooth. The DL showed a Cormack Lehane 4 and airway edema. The TT allowed to establish a correct oxygenation at 11.3 s and ETI with the combined use of FB (after 67 s) after failed ventilation and ETI with LMA-Fastrach. Mechanical ventilation and renal replacement therapy were initiated with satisfactory results. The risk of airway complications in emergency and intensive care unit settings is increased. When DL fails, an alternative strategy to airway management should be adopted immediately. The intubating laryngeal mask airway (ILMA) plays an indispensable role as primary and rescue device in difficult airway by providing both a patent airway