Another case of use of the ProSealTM laryngeal mask airway in a difficult obstetric airway

S. J. Vaida1, L. A. Gaitini1, T. M. Cook2, R. Awan2 and J. P. Nolan2

1 Haifa, Israel 2 Bath, UK

Editor—We read with interest the case report by Awan and colleagues,1 describing successful use of the ProSealTM laryngeal mask airway (PLMA) after failed tracheal intubation in a parturient undergoing Caesarean section. After securing the airway with the PLMA, the authors removed it and tried again to perform tracheal intubation. We think that the PLMA can be left in place and used as a definitive airway after failed intubation in Caesarean section. We report another case where the PLMA was used as an alternative to intubation and as a definitive airway throughout elective Caesarean section after failed tracheal intubation.

A 36-yr-old parturient, gravida 2, para 1, was scheduled for elective Caesarean section, on request, after a previous emergency Caesarean section. She was 168 cm tall and weighed 89 kg. Preoperative examination of the airway revealed a Mallampati score2 of 1. After two failed attempts to perform spinal anaesthesia it was decided to perform general anaesthesia, upon the request of the patient. Rapid sequence induction (RSI) was performed after preoxygenation using thiopental 450 mg and succinylcholine 100 mg. After two failed attempts to perform tracheal intubation, using first the Miller and then the Magill laryngoscope blade, a size 4 PLMA was introduced using the digital technique. A female infant with Apgar score 10 was delivered. The patient was satisfactorily ventilated and oxygenated (SpO2 99%, E'CO2 38 mm Hg) and the PLMA was left in place throughout surgery, which lasted 25 min. No other attempts to perform tracheal intubation were made. A gastric tube (size 14) was passed though the gastric channel of the PLMA and 5 ml of gastric fluid was aspirated. Neuromuscular block was achieved using atracurium 30 mg and analgesia provided with fentanyl 0.3 mg. At the end of surgery, the PLMA was removed when the patient was awake. Leaving the PLMA in place after securing the airway and using it as the definitive airway for the duration of anaesthesia is a reasonable alternative to the classic LMA in an unrecognized difficult obstetric airway. Unlike the classic LMA, the PLMA is capable of protecting the airway in the event of passive regurgitation intraoperatively by allowing regurgitated fluid to pass up the drain tube and bypass the glottis.3

S. J. Vaida

L. A. Gaitini

Haifa, Israel

Editor—We thank Drs Vaida and Gaitini for their interest in our case report. They describe use of the PLMA during an elective case. It is therefore likely that the patient had both been starved and given routine gastric prophylaxis preoperatively. It is not clear from their letter whether ventilation of the lungs was possible when tracheal intubation failed. We reported an emergency case where the difficulty occurred both with tracheal intubation and with pulmonary ventilation (‘can’t intubate, can’t ventilate’ or CICV).1

Vaida and Gaitini state that ‘leaving the PLMA in place... seems to be a reasonable alternative to the classic LMA in an unrecognized difficult obstetric airway’. There are two issues here; first, which is the best rescue device, and second, how to proceed after the airway has been ‘rescued’? First, we entirely agree that in this circumstance the PLMA is a better choice than the cLMA. Regarding subsequent management, at present, rightly or wrongly, it is standard practice to use RSI for elective Caesarean section. While this is the case, an airway rescue device should be regarded as a device to enable oxygenation and ventilation until the patient can be woken.4 5 If this was not the case, surely it would be logical to use the cLMA or PLMA in the first place. In their case, therefore, standard practice would be to establish an airway and ventilation, then wake the patient before proceeding to fibreoptic intubation or further attempts at regional anaesthesia. A broader discussion might include the necessity for RSI in elective Caesarean section,5 6 and the role of the PLMA would be central to this discussion.

Our clinical experience and the published evidence (clinical, anecdotal, laboratory-based and design-based) lead us to believe that the PLMA does provide greater protection against pulmonary aspiration of stomach contents than other ‘rescue’ airways that might be used in the event of failed tracheal intubation. In due course, it may become recognized that the PLMA provides enough protection from pulmonary aspiration for it to become acceptable as a standard choice when tracheal intubation has failed during RSI, and for subsequent ventilation of the lungs (a ‘silver standard’ to the tracheal tube’s ‘gold’). Vaida and Gaitini appear to tacitly assume that this state of affairs is with us, but we would caution that there is not enough evidence (nor consensus view) to regard this as safe practice, at present.

T. M. Cook

R. Awan

J. P. Nolan

Bath, UK

References

1 Awan R, Nolan JP, Cook TM. Use of a ProSeal laryngeal mask airway for airway maintenance during emergency Caesarean section after failed tracheal intubation. Br J Anaesth 2004; 92: 144–6[Abstract/Free Full Text]

2 Mallampati SR, Gatt SP, Gugino LD, et al. A clinical sign to predict tracheal intubation. Can Anaesth Soc J 1985; 32: 429–34[ISI][Medline]

3 Evans NR, Llewellyn RL, Gardner SV, James MF. Aspiration prevented by the ProSeal laryngeal mask airway: a case report. Can J Anaesth 2002; 49: 413–16[Abstract/Free Full Text]

4 Benumof JL, Dagg R, Benumof R. Critical hemoglobin desaturation will occur before return to an unparalyzed state following 1 mg/kg intravenous succinylcholine. Anesthesiology 1997; 87: 979–82[CrossRef][ISI][Medline]

5 Heier T, Feiner JR, Lin J, Brown R, Caldwell JE. Hemoglobin desaturation after succinylcholine-induced apnea: a study of the recovery of spontaneous ventilation in healthy volunteers. Anesthesiology 2001; 94: 754–9[CrossRef][ISI][Medline]

6 Thwaites AJ, Rice CP, Smith I. Rapid sequence induction: a questionnaire survey of its routine conduct and continued management during a failed intubation. Anaesthesia 1999; 54: 376–81[CrossRef][ISI][Medline]





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