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Emergency airway management with a laryngeal mask airway in a patient placed in the prone position
Case Reports Emergency Airway Management with a Laryngeal Mask Airway in a Patient Placed in the Prone Position Jacob Raphael, MD,* Tatyana Rosenthal-Ganon, MD,† Yaacov Gozal, MD‡ Department of Anesthesiology and Critical Care Medicine, Hadassh University Hospital, Jerusalem, Israel
Accidental extubation of a patient while placed in the prone position is a life-threatening, anesthesia-related complication. We describe a case of accidental extubation of the trachea during spine surgery in a patient placed in the prone position. We successfully managed this emergent problem by inserting a Laryngeal Mask Airway while maintaining the patient in the same position. © 2004 by Elsevier Inc. Keywords: Airway management; Laryngeal Mask Airway, patient positioning: prone.
Introduction
*Resident in Anesthesiology and Critical Care Medicine †Staff Anesthesiologist ‡Senior Lecturer in Anesthesiology; Director, Operating Rooms and PACU Address correspondence to Dr. Gozal at the Department of Anesthesiology and Critical Care Medicine, Hadassah University Hospital, P.O. Box 12000, Jerusalem 91120, Israel. E-mail: [email protected] Received for publication July 10, 2003; revised manuscript accepted for publication March 3, 2004. Journal of Clinical Anesthesia 16:560 –561, 2004 © 2004 Elsevier Inc. All rights reserved. 360 Park Avenue, South, New York, NY 10010
Prone positioning of the patient is often required for major reconstructive spinal surgery. Accidental extubation of a patient’s trachea while placed in this position is a life-threatening, anesthesia-related complication. In the event of extubation, it is necessary to turn the patient supine for emergency airway management. However, during placement of spinal instrumentation, turning a patient may compromise the stability of the spine and result in paraplegia. We describe a case of emergency Laryngeal Mask Airway (LMA; LMA North America, Inc., San Diego, CA) insertion after accidental extubation while the patient was in the prone position.
Case Reports A 12-year-old, 35-kg female was scheduled for anterior and posterior spine fusion due to severe congenital scoliosis. Her past medical history was unremarkable except for her spine pathology. Anesthesia was induced with midazolam, propofol, and fentanyl intravenously (IV). Vecuronium bromide was administered to facilitate tracheal intubation. Anesthesia was maintained with isoflurane and 67% nitrous oxide in oxygen supplemented by intermittent boluses of fentanyl. The patient underwent an uneventful anterior spine fusion and then was turned prone for posterior spine fusion. During spinal instrumentation in the prone position, the surgical team decided to perform a wake-up test to evaluate the neurologic integrity of the lower limbs. Evoked potential analysis 0952-8180/04/$–see front matter doi:10.1016/j.jclinane.2004.03.004
Emergency LMA use in prone position: Raphael et al.
was considered but the equipment was not available during this surgery. Oxygen concentration was increased to 100% and anesthesia was discontinued. The patient awoke while still in the prone position, at which time her sensory-motor neurologic status was grossly evaluated by the surgeons. Although special emphasis was given to the endotracheal tube, accidental extubation occurred. The patient was breathing spontaneously but not efficiently, and her oxygen saturation (SpO2) rapidly decreased to 85%. Mask ventilation was attempted, but SpO2 continued to deteriorate. At this point, the option of turning the patient supine was raised, but the risk of causing permanent neurological damage when moving the patient while her spine was unstable was considered very high. A #3 LMA was inserted without difficult with the patient in the same prone position. The patient was mechanically ventilated with a tidal volume of 6 mL/kg, maintaining peak inspiratory pressure of less than 20 cm H2O, and respiratory rate was adjusted to maintain normocarbia. Oxygen saturation increased rapidly to 100% with an inspired oxygen concentration (FIO2) of 1.0. The operation was completed within 1 hour while the patient was mechanically ventilated through the LMA and was still prone. At the end of surgery, the patient was turned supine, and she underwent extubation in the operating room. Neurologic examination was normal and her subsequent convalescence was uneventful.
Discussion Loss of airway control in an anesthetized patient placed prone is a life-threatening complication. If this situation occurs, the accepted procedure is to turn the patient to a lateral or supine position and reintubate the trachea without delay. In this case, we were facing a dilemma because changing the position in this situation had several drawbacks, including: 1) it was time-consuming and would delay initiation of treatment; 2) turning the patient would have required at least four people, not all of whom might be present in the room when such emergency occurs; 3) at the stage of surgery when extubation occurred, turning the patient may cause severe neurologic or infectious complications. At this point, the following options were considered: 1) Reintubating the patient using a direct laryngoscopy technique. This option obviously necessitated the patient being in supine or at least lateral position. We thought that the time needed and the risks involved were too high to justify this solution. 2) Intubation in the prone position using a flexible fiberoptic bronchoscope. This solution has been adopted by Neal and colleagues in a patient who presented with a severe facial trauma but was fully awake.1 The patient was placed in the semi-prone position, supporting himself on his elbows. However, in our case, the patient was not fully conscious and certainly not cooperative. In addition, the rapid decrease in SpO2 would not have allowed enough time to perform a fiberoptic-guided intubation. 3) Other emergency intubation techniques in a supine patient may include the following possibilities:
laryngeal lighted stylet, retrograde wire technique, and tracheal intubation by feel. We thought that these techniques were too difficult and time-consuming to be useful in this particular situation. 4) The last option considered was to insert an LMA under the difficult conditions of an anesthetized patient placed prone, with a rapidly declining SpO2. The LMA is considered one of the major advances in airway management. It has been included in the algorithm for the management of the difficult airway.2 The LMA has also been used for airway management during various elective procedures in the prone position. However, the LMA was inserted while the patient was supine before being turned prone.3 The LMA has even been placed when patients were already in the prone position during elective minor surgery such as excision of a pilonidal sinus.4,5 In these reports, the patients were allowed to position themselves in the prone position required for the surgery before induction of anesthesia. The placement was considered as easy as in the supine position because gravity caused the tongue to fall forward. However, Benumof states that one of the relative contraindications for the LMA is its use in the prone position.6 Indeed, this notion is especially important in clinical situations when there is no possibility of turning the patient quickly to the lateral or supine position for emergency management of any problem. In the present case, we felt that the only reasonable solution to the problem of accidental extubation in this situation was to attempt to insert an LMA. Certainly, if this attempt had failed, there would have been no other solution but to turn the patient supine and to reintubate her trachea, even at the risk of incurring neurologic damage. One of the criticisms of our airway management could be that we did not try to insert an endotracheal tube through the LMA using a fiberoptic bronchoscope for the remaining of the case. Because there was no problem of oxygenation or ventilation, and the expected remaining duration of the case was relatively short, we decided to proceed only with the LMA. We believe this is the first reported case of use of an LMA as a means of emergency airway management during surgery in the prone position.
References 1. Neal MR, Groves J, Gell IR: Awake fibreoptic intubation in the semi-prone position following facial trauma. Anaesthesia 1996;51: 1053–4. 2. Benumof JL: Laryngeal mask airway and the ASA difficult airway algorithm. Anesthesiology 1996;84:686 –99. 3. Kee WD: Laryngeal mask airway for radiotherapy in the prone position. Anaesthesia 1992;47:446 –7. 4. McCaughey W, Bhanumurthy S: Laryngeal mask placement in the prone position. Anaesthesia 1993;48:1104 –5. 5. Ng A, Raitt DG, Smith G: Induction of anesthesia and insertion of a laryngeal mask airway in the prone position for minor surgery. Anesth Analg 2002;94:1194 –8. 6. Benumof JL: Laryngeal mask airway: Indications and contraindications. Anesthesiology 1992;77:843–6.
J. Clin. Anesth., vol. 16, November 2004
561
Accidental extubation of a patient while placed in the prone position is a life-threatening, anesthesia-related complication. We describe a case of accidental extubation of the trachea during spine surgery in a patient placed in the prone position. We successfully managed this emergent problem by inserting a Laryngeal Mask Airway while maintaining the patient in the same position. © 2004 by Elsevier Inc. Keywords: Airway management; Laryngeal Mask Airway, patient positioning: prone.
Introduction
*Resident in Anesthesiology and Critical Care Medicine †Staff Anesthesiologist ‡Senior Lecturer in Anesthesiology; Director, Operating Rooms and PACU Address correspondence to Dr. Gozal at the Department of Anesthesiology and Critical Care Medicine, Hadassah University Hospital, P.O. Box 12000, Jerusalem 91120, Israel. E-mail: [email protected] Received for publication July 10, 2003; revised manuscript accepted for publication March 3, 2004. Journal of Clinical Anesthesia 16:560 –561, 2004 © 2004 Elsevier Inc. All rights reserved. 360 Park Avenue, South, New York, NY 10010
Prone positioning of the patient is often required for major reconstructive spinal surgery. Accidental extubation of a patient’s trachea while placed in this position is a life-threatening, anesthesia-related complication. In the event of extubation, it is necessary to turn the patient supine for emergency airway management. However, during placement of spinal instrumentation, turning a patient may compromise the stability of the spine and result in paraplegia. We describe a case of emergency Laryngeal Mask Airway (LMA; LMA North America, Inc., San Diego, CA) insertion after accidental extubation while the patient was in the prone position.
Case Reports A 12-year-old, 35-kg female was scheduled for anterior and posterior spine fusion due to severe congenital scoliosis. Her past medical history was unremarkable except for her spine pathology. Anesthesia was induced with midazolam, propofol, and fentanyl intravenously (IV). Vecuronium bromide was administered to facilitate tracheal intubation. Anesthesia was maintained with isoflurane and 67% nitrous oxide in oxygen supplemented by intermittent boluses of fentanyl. The patient underwent an uneventful anterior spine fusion and then was turned prone for posterior spine fusion. During spinal instrumentation in the prone position, the surgical team decided to perform a wake-up test to evaluate the neurologic integrity of the lower limbs. Evoked potential analysis 0952-8180/04/$–see front matter doi:10.1016/j.jclinane.2004.03.004
Emergency LMA use in prone position: Raphael et al.
was considered but the equipment was not available during this surgery. Oxygen concentration was increased to 100% and anesthesia was discontinued. The patient awoke while still in the prone position, at which time her sensory-motor neurologic status was grossly evaluated by the surgeons. Although special emphasis was given to the endotracheal tube, accidental extubation occurred. The patient was breathing spontaneously but not efficiently, and her oxygen saturation (SpO2) rapidly decreased to 85%. Mask ventilation was attempted, but SpO2 continued to deteriorate. At this point, the option of turning the patient supine was raised, but the risk of causing permanent neurological damage when moving the patient while her spine was unstable was considered very high. A #3 LMA was inserted without difficult with the patient in the same prone position. The patient was mechanically ventilated with a tidal volume of 6 mL/kg, maintaining peak inspiratory pressure of less than 20 cm H2O, and respiratory rate was adjusted to maintain normocarbia. Oxygen saturation increased rapidly to 100% with an inspired oxygen concentration (FIO2) of 1.0. The operation was completed within 1 hour while the patient was mechanically ventilated through the LMA and was still prone. At the end of surgery, the patient was turned supine, and she underwent extubation in the operating room. Neurologic examination was normal and her subsequent convalescence was uneventful.
Discussion Loss of airway control in an anesthetized patient placed prone is a life-threatening complication. If this situation occurs, the accepted procedure is to turn the patient to a lateral or supine position and reintubate the trachea without delay. In this case, we were facing a dilemma because changing the position in this situation had several drawbacks, including: 1) it was time-consuming and would delay initiation of treatment; 2) turning the patient would have required at least four people, not all of whom might be present in the room when such emergency occurs; 3) at the stage of surgery when extubation occurred, turning the patient may cause severe neurologic or infectious complications. At this point, the following options were considered: 1) Reintubating the patient using a direct laryngoscopy technique. This option obviously necessitated the patient being in supine or at least lateral position. We thought that the time needed and the risks involved were too high to justify this solution. 2) Intubation in the prone position using a flexible fiberoptic bronchoscope. This solution has been adopted by Neal and colleagues in a patient who presented with a severe facial trauma but was fully awake.1 The patient was placed in the semi-prone position, supporting himself on his elbows. However, in our case, the patient was not fully conscious and certainly not cooperative. In addition, the rapid decrease in SpO2 would not have allowed enough time to perform a fiberoptic-guided intubation. 3) Other emergency intubation techniques in a supine patient may include the following possibilities:
laryngeal lighted stylet, retrograde wire technique, and tracheal intubation by feel. We thought that these techniques were too difficult and time-consuming to be useful in this particular situation. 4) The last option considered was to insert an LMA under the difficult conditions of an anesthetized patient placed prone, with a rapidly declining SpO2. The LMA is considered one of the major advances in airway management. It has been included in the algorithm for the management of the difficult airway.2 The LMA has also been used for airway management during various elective procedures in the prone position. However, the LMA was inserted while the patient was supine before being turned prone.3 The LMA has even been placed when patients were already in the prone position during elective minor surgery such as excision of a pilonidal sinus.4,5 In these reports, the patients were allowed to position themselves in the prone position required for the surgery before induction of anesthesia. The placement was considered as easy as in the supine position because gravity caused the tongue to fall forward. However, Benumof states that one of the relative contraindications for the LMA is its use in the prone position.6 Indeed, this notion is especially important in clinical situations when there is no possibility of turning the patient quickly to the lateral or supine position for emergency management of any problem. In the present case, we felt that the only reasonable solution to the problem of accidental extubation in this situation was to attempt to insert an LMA. Certainly, if this attempt had failed, there would have been no other solution but to turn the patient supine and to reintubate her trachea, even at the risk of incurring neurologic damage. One of the criticisms of our airway management could be that we did not try to insert an endotracheal tube through the LMA using a fiberoptic bronchoscope for the remaining of the case. Because there was no problem of oxygenation or ventilation, and the expected remaining duration of the case was relatively short, we decided to proceed only with the LMA. We believe this is the first reported case of use of an LMA as a means of emergency airway management during surgery in the prone position.
References 1. Neal MR, Groves J, Gell IR: Awake fibreoptic intubation in the semi-prone position following facial trauma. Anaesthesia 1996;51: 1053–4. 2. Benumof JL: Laryngeal mask airway and the ASA difficult airway algorithm. Anesthesiology 1996;84:686 –99. 3. Kee WD: Laryngeal mask airway for radiotherapy in the prone position. Anaesthesia 1992;47:446 –7. 4. McCaughey W, Bhanumurthy S: Laryngeal mask placement in the prone position. Anaesthesia 1993;48:1104 –5. 5. Ng A, Raitt DG, Smith G: Induction of anesthesia and insertion of a laryngeal mask airway in the prone position for minor surgery. Anesth Analg 2002;94:1194 –8. 6. Benumof JL: Laryngeal mask airway: Indications and contraindications. Anesthesiology 1992;77:843–6.
J. Clin. Anesth., vol. 16, November 2004
561