EditorWe read with interest the recent editorial by Asai1 who highlighted those patients thought to be at increased risk from aspiration with use of the laryngeal mask airway (LMA), and the case reports of Keller and colleagues2 highlighting three cases of aspiration associated with use of the LMA.
We would like to report the case of an 81-yr-old gentleman who presented for biopsy of an enlarged supraclavicular lymph node. He had previously undergone a left hemicolectomy for bowel carcinoma, and a total thyroidectomy for follicular carcinoma. There was no history of oesophageal reflux or hiatus hernia. He had been admitted 10 days previously with nausea and vomiting, and a change in bowel habit. At this time left supraclavicular and bilateral axillary lymphadenopathy was noted. He had been managed for bowel obstruction and, for 48 h, his symptoms had resolved, with no nausea, and his stoma was functioning normally. The previous day he had eaten normally with no ill effects, and had fasted overnight.
In view of the resolution of the gastrointestinal symptoms the decision was made to use a size 4 classic LMA. Anaesthesia was induced with fentanyl 50 µg and propofol 200 mg. The LMA was inserted easily and gentle ventilation was commenced initially until the patient made respiratory effort. However, it was felt that the position was suboptimal and the LMA was removed and resited on two occasions. On the second removal some green staining of the secretions on the tip on the laryngeal mask was noted. The decision was made to proceed to endotracheal intubation. Neuromuscular block was achieved with vecuronium. Ventilation with a face mask with oxygen 100% was easy with low inflation pressures and at no point was there an obstructed airway, cough, or hiccough. During the time to paralysis the patient vomited a large volume of yellowish fluid around the face mask. He was immediately turned to the left lateral position with head down tilt of the table applied whilst ventilation with oxygen 100% was continued. After suctioning of the oropharynx the trachea was intubated, after which a suction catheter was repeatedly passed and a minimal amount of yellow fluid was recovered from the lungs. During this episode the arterial oxygen saturation briefly fell to 65% but recovered quickly to 95%. A nasogastric tube was passed and a further 500 ml of non-particulate fluid was aspirated from the stomach.
The decision was made to continue with the surgery, on the basis that minimal fluid had been recovered from the trachea, there was no bronchospasm or residual impairment of oxygenation, and that a histological diagnosis could potentially lead to curative treatment. The patient remained stable for the rest of the procedure, with of 0.5. At the end of the procedure neuromuscular blockade was antagonized. The trachea was extubated once the patient was fully alert. However, immediate reintubation was required owing to respiratory insufficiency. Over the next hour there was a rapid deterioration in respiratory and circulatory function requiring full ventilatory and inotropic support. The patient was transferred to the intensive care unit where he died within 6 h.
Histological examination of the enlarged supraclavicular lymph node revealed moderately differentiated metastatic adenocarcinoma with extracapsular spread. Post-mortem examination revealed a tumour in the small bowel mesentery with adherent loops of small bowel, which on histological examination was found to be lymphoma. The stomach, duodenum and jejunum were dilated. The lungs showed signs consistent with adult respiratory distress syndrome.
This case reinforces the importance of systematic preoperative assessment as previously advocated,1 bearing in mind the possibility of systemic involvement from disease processes. Despite the resolution of gastrointestinal symptoms, our patient was still at risk of aspiration.
1 Portsmouth, UK
2 Southampton, UK
References
1 Asai T. Who is at increased risk of pulmonary aspiration? Br J Anaesth 2004; 93: 497500
2 Keller C, Brimacombe J, Bittersohl J, Lirk P, von Goedecke A. Aspiration and the laryngeal mask airway: three cases and a review of the literature. Br J Anaesth 2004; 93: 57982
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