Department of Anaesthesia, Royal United Hospital, Combe Park, Bath BA1 2NG, UK*Corresponding author
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Accepted for publication: May 12, 2002
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Abstract |
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Br J Anaesth 2002; 89: 7867
Keywords: complications, difficult intubation; complications, RubensteinTaybi syndrome; equipment, masks anaesthesia; gastrointestinal tract, gastroesophageal reflux
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Introduction |
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Case report |
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Examination showed a woman of short stature (120 cm, 45 kg). She had a pronounced kyphoscoliosis. Her head was held flexed and extension of the neck was reduced, apparently by increased muscle tone. She had a small mandible, pronounced incisors, a high arched palate, and a high anterior larynx. The Mallampati airway grading as modified by Samsoon and Young was 3.6 7 We predicted difficult intubation. Examination of the cardiovascular system was normal. A normal full blood count, electrolyte profile, and ECG were obtained. Chest x-ray showed the kyphoscoliosis with small lung fields and a normal cardiac outline.
We planned to ventilate the patient via a ProSeal laryngeal mask airway (PLMA), (Laryngeal Mask Company, Henley on Thames, UK). We made sure that two experienced anaesthetists, and equipment necessary to manage a difficult airway, including fibreoptic bronchoscope, were immediately available.
The patient received a H2 antagonist (nizatidine 150 mg), and a sedative (temazepam 20 mg), as premedication. Local anaesthetic cream (ametop) was applied to both hands. After non-invasive monitoring and a peripheral venous cannula had been placed, anaesthesia was induced with propofol 100 mg and fentanyl 50 µg. Adequate ventilation with a bag and mask was confirmed before a non-depolarizing neuromuscular blocking agent (atracurium 25 mg) was administered. We carried out laryngoscopy to ascertain the potential difficulty of future intubation, and the cords were partially seen (Cormack and Lehane Grade II view8). A size 4 PLMA was inserted and intermittent positive pressure ventilation was established. A size 14 orogastric tube was passed via the drainage tube of the PLMA and was aspirated. No fluid was obtained.
Anaesthesia was maintained with isoflurane 1% in 50% oxygen and nitrogen. Ventilation via the PLMA was readily achieved with inflation pressures less than 20 cm of water and with no evidence of gas leakage. The orogastric tube was left in place to vent the stomach throughout the case. The patient had uneventful bilateral phaecoemulsification with intra-ocular lens implants. Neuromuscular block was antagonized at the end of surgery and the PLMA was removed with the orogastric tube after spontaneous breathing had returned. The patient made an uncomplicated recovery from anesthesia and was discharged from hospital later the same day.
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Discussion |
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We considered difficult intubation as the biggest risk for this individual. However, the procedure planned was ophthalmic surgery for which the laryngeal mask airway is preferable from a surgical, anaesthetic, and patient perspective.9 The patient we describe had no significant history of gastro-oesophageal reflux but we considered some protection from aspiration of stomach contents advisable. The PLMA offers a compromise between the two options. It is specifically designed for intermittent positive pressure ventilation unlike the standard or reinforced LMA. The design aims to separate the respiratory and gastrointestinal tracts. The drain tube is designed to vent stomach contents and may, therefore, reduce the risk of regurgitation of stomach contents.10 An orogastric tube may also be reliably passed via this lumen into the stomach.11 In addition, the PLMA achieves a seal against the larynx that is approximately 50% higher than the classic LMA,11 12 reducing the likelihood of failed or inadequate ventilation. Whilst this patient could have been safely anaesthetized in several ways, by using the PLMA we were able to reliably ventilate the patient, confirm that the stomach was empty, and still provide an LMA-based anaesthetic, which is desirable for such ophthalmic cases.
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References |
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2 Stirt JA. Anaesthetic problems in RubensteinTaybi syndrome. Anaesth Analg 1981; 60: 5346[ISI][Medline]
3 Critchley LA, Gin T, Stuart JC. Anaesthesia in an infant with RubensteinTaybi syndrome. Anaesthesia 1995; 50: 378[ISI][Medline]
4 Stevens CA, Bhakta MG. Cardiac abnormalities in the Rubenstein-Taybi syndrome. Am J Med Genet 1995; 59: 3468[ISI][Medline]
5 Stirt JA. Succinylcholine in RubensteinTaybi syndrome. Anesthesiology 1982; 57; 429
6 Mallampati SR, Gatt SP, Gugino LD, et al. A clinical sign to predict difficult tracheal intubation. Can Anaesth Soc J 1985; 32: 42934[ISI][Medline]
7 Samsoon GLT, Young JRB. Difficult tracheal intubation: a retrospective study. Anaesthesia 1987; 42: 48790[ISI][Medline]
8 Cormack RS, Lehane J. Difficult intubation in obstetrics. Anaesthesia 1984; 39: 110511[ISI][Medline]
9 Akhtar TM, McMurray P, Kerr WJ, Kenny GN. A comparison of laryngeal mask airway with tracheal tube for intra-ocular ophthalmic surgery. Anaesthesia 1992; 47: 66871[ISI][Medline]
10 Keller C, Brimacombe J, Kleinsasser A, Loeckinger A. Does the ProSeal laryngeal mask airway prevent aspiration of regurgitated fluid. Anaesth Analg 2000; 91: 101720
11 Cook TM, Nolan JP, Vergese C, et al. Randomized crossover comparison of the ProSeal with the classic laryngeal mask airway in unparalysed anaesthetized patients. Br J Anaesth 2002; 88: 52733
12 Keller C, Brimacombe J. Mucosal pressure and oropharyngeal leak pressure with the ProSeal vs laryngeal mask airway in anaesthetized paralysed patients. Br J Anaesth 2000; 85: 2626