Third Laryngoscopy at SpO2 79%: When to Stop

No. Abort the attempt now.

The rule is simple: an intubation attempt stops when the patient's oxygenation is deteriorating, not when the operator has run out of ideas. A falling SpO2 in the 70s with a rising CO2 and no plan B already deployed is a stop signal. Continued attempts convert a difficult airway into a hypoxic arrest.

What you do in the next 30 seconds:

1. Say it out loud - stop, we are desaturating, mask now.
2. Remove the blade, suction the blood, and apply a two-person mask technique with an oral airway, and a nasal airway if the mouth seal is acceptable, at 100% O2 with the head ramped and the chin lifted.
3. Re-oxygenate to SpO2 of at least 94-95% before any further plan is carried out.
4. Decide the next step now, not after another failure: a second-generation supraglottic airway is the rescue for a cannot-intubate/cannot-oxygenate trajectory.

Evidence to bring to the debrief: three attempts including a video laryngoscope, a bloody field, and a predicted difficult mask ventilation in a 124 kg patient is a recognized point to stop and call for help. The blood means the anatomy is now worse than it was at attempt 1.

Set up before anything goes back in the mouth:

• Second-generation supraglottic airway, size 5 (i-gel sizing is 90 kg and above; a size 4 is rated 50-90 kg and would be undersized here).
• Video laryngoscope with a hyperangulated blade and a second operator confirmed as the next attempt.
• Bougie and a tube loaded with a stylet, plus a smaller tube (6.5) ready.
• Working suction with a rigid tip, and the blood cleared from the pharynx.
• Emergency front-of-neck kit open on the table, not still in the drawer.
• Vasopressor drawn up - the blood pressure after 6 minutes of propofol and a hypoxic episode will be poor.

Dose math:

• Sugammadex 16 mg/kg x 124 kg = 1,984 mg, so draw four 500 mg vials (2,000 mg) for a full rescue reversal of the 1.2 mg/kg rocuronium.
• If you instead need push-dose phenylephrine, label it clearly: 100 mcg/mL in a 10 mL syringe, 1 mL increments.

Write the weight (124 kg) on the whiteboard and state the calculated doses aloud so the next person does not have to do math during a crisis.

Next: rescue, escalate, and declare.

1. Reposition the supraglottic airway (depth, jaw thrust, head position) once, briefly - a single corrective move, not a series of them.
2. Call the surgeon to the bedside and say the words: cannot intubate, cannot oxygenate.
3. Prepare for emergency front-of-neck airway - scalpel-bougie-tube - with the most experienced operator present. In this patient the neck is short and thick, so the landmarks need to be identified by palpation now, before the SpO2 drops further.
4. Keep 100% O2 flowing and support whatever ventilation you can while the kit is opened.

Documentation afterward:

• The number and type of attempts with times, and the best view at each.
• Every device used and why each was abandoned.
• The SpO2 nadir and the times of desaturation and recovery.
• The doses and times of induction agents and muscle relaxant, and any reversal given.
• The rescue sequence and who performed each step.
• A factual summary, followed by a formal airway alert communicated to the patient and entered in the record for future anesthetics.

Finish with a team debrief within 24 hours while the sequence is still fresh.