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An unwanted event when using Proseal LMA

An unwanted event when using Proseal LMA. Jerry Wong. Case (certain info withheld). Pre-operative assessment. Non-smoker, non-drinker Exercise tolerance more than 5 flights of stairs Good past health, no history of reflux symptoms Fasting time 12 hours before operation.

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An unwanted event when using Proseal LMA

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  1. An unwanted event when using Proseal LMA Jerry Wong

  2. Case (certain info withheld)

  3. Pre-operative assessment • Non-smoker, non-drinker • Exercise tolerance more than 5 flights of stairs • Good past health, no history of reflux symptoms • Fasting time 12 hours before operation

  4. Pre-operative assessment • Airway: MP 1, no loose teeth, normal mouth opening and neck movement • Chest: clear • CVS: unremarkable • No investigations performed

  5. Intra-operative management • GA • Standard monitoring: SpO2, CO2, real time O2 / agent analyser, spirometer, ECG, NIBP • Pre-oxygenation for 3 minutes • Fentanyl 75mcg • Propofol 150mg

  6. Intra-operative management • No bag-mask ventilation • Waited for 15 seconds until heart rate slowed down and jaw was relaxed • Proseal laryngeal mask airway size 4.0 inserted with introducer at first attempt • 20mL air injected to cuff • Satisfactory position with bilateral chest expansion and end-tidal CO2 • Put on pressure support mode: pressure 10cmH2O, rate 10/minute

  7. Intra-operative management • Upon taping the LMA, large amount of clear colourless fluid came out from the drain port of LMA

  8. Intra-operative management • Head down • Suction of oral cavity with Yankuer suction • Ryle’s tube 14F inserted via drain port easily, large amount clear colourless fluid drained

  9. Intra-operative management • Decided to intubate • Propofol 30mg • Suxamethonium 100mg • Direct laryngoscopy showed grade 1 larynx • Size 8.0 ETT inserted, position confirmed • Atracurium 30mg

  10. Intra-operative management • Suction catheter inserted via ETT • Yielded nothing • SpO2 98% – 100% all along • Airway pressure <18cmH2O all along • Chest air entry symmetrical, no crepitations nor wheeze • Naso-gastric Ryle’s tube inserted • Yielded small amount of clear fluid

  11. Post-operative progress • Uneventful operation for 1.5 hours • Extubated • Naso-gastric tube removed • CXR taken at recovery room showed clear lung fields • Discharged 2 days afterwards

  12. What is the potential risk of aspiration when using supra-glottic airway?

  13. Laryngeal mask airway • Background of laryngeal mask airway • Common types of laryngeal mask airway • Risk of aspiration • New devices • Management of regurgitation and aspiration

  14. History • Designed by British anaesthetist Dr. Archie Brain • Designed after careful study of plaster casts of cadaver airways • First introduced in practice in 1988

  15. Indications • Alternative to the facemask for achieving and maintaining control of the airway in fasted patients • To secure an immediate airway for failed intubation • To establish airway for ventilation in patients with absent glossopharyngeal and laryngeal reflexes in CPR LMA Classic Instruction Manual 2009

  16. Contra-indications • No protection from regurgitation and aspiration • Symptomatic hiatus hernia • Morbid obesity • Pregnancy past 14 weeks • Multiple or massive injury • Acute abdominal or thoracic injury • Conditions associated with delayed gastric emptying • Use of opiate medication prior to fasting LMA Classic Instruction Manual 2009

  17. Contra-indications • Patients with fixed decreased pulmonary compliance • Infra-glottic problems LMA Classic Instruction Manual 2009

  18. Common types of LMA Eva HE et al. The Laryngeal Mask Airway: A Review and Update

  19. Risk of aspiration Peak airway inspiratory pressure 20 cmH2O

  20. Risk of aspiration Joseph B et al. Aspiration of Gastric Contents During Use of a ProSeal™Laryngeal Mask Airway Secondary to UnidentifiedFoldover Malposition

  21. Proseal LMA • Larger and deeper mask bowl with no bars • Drainage tube • Integral silicone bite block • Anterior pocket for sitting introducer or finger Eva HE et al. The Laryngeal Mask Airway: A Review and Update

  22. Risk of aspiration for Proseal LMA • 103 adults under general anaesthesia • Size 4.0 Proseal LMA for female, size 5.0 Proseal LMA for male • Intra-cuff pressure 60cmH2O • Filling hypopharynx with methylene blue dyed saline • Observation for presence of dye in bowl of mask • No leakage of saline to bowl of mask in 100 subjects (98%)

  23. Risk of aspiration for Proseal LMA • Observational study • 2114 adult patients aged from 18 to 93 • Proseal LMA size 3.0 to 5.0 • Mean airway leak pressure 28cmH2O • Gastric tube inserted in 781 (36.9%) patients • Regurgitation in 12 patients (5%): 5 after induction, 5 during maintenance, 2 during emergence

  24. Risk of aspiration for Proseal LMA

  25. Risk of aspiration for Proseal LMA • Observational study • 1000 size 3.0 to 5.0 Proseal LMA use in adult • Mean peak airway pressure 15 cmH2O • Minor regurgitation without aspiration in 3 cases

  26. Technique of insertion

  27. Technique of insertion • 75 adult subjects, randomized trial • Midazolam 15-30mcg/kg + Fentanyl 1-1.5mcg/kg + Propofol 3-4mg/kg • Introducer group versus bougie group • Passage of FOB >35cm and visualization of gastric mucosa

  28. Technique of insertion

  29. Supreme LMA • High seal cuff, intrinsic bite block, gastric access • Drainage tube at midline • Fixed curve and guiding handle • Single use http://www.lmaco.com/supreme.php

  30. Risk of aspiration for Supreme LMA • Observational study • 100 patients • Induction with Fentanyl 1-2mcg/kg and Propofol TCI 4 – 7 mcg/mL • No muscle relaxant • Intra-cuff pressure 60cmH2O • Mean airway leak pressure 24 cmH2O • Minor regurgitation in 1 patient

  31. i-gel Supra-glottic airway i-gel information sheet

  32. i-gel Supra-glottic airway • Made of soft gel-like material • Non-inflatable cuff • Gastric channel • Integral bite-block

  33. i-gel Supra-glottic airway http://www.i-gel.com/lib/docs/brochures/igelposter.pdf

  34. i-gel Supra-glottic airway http://www.i-gel.com/lib/docs/brochures/igelposter.pdf

  35. Risk of aspiration for i-gel W. Schmidbauer et al. Oesophageal seal of the novel supralaryngeal airway deviceI-GelTM in comparison with the laryngeal mask airways ClassicTM and ProSealTM using a cadaver model

  36. What to do if regurgitation occurs? • If no desaturation, no need to remove the device • Adequate depth of anaesthesia • If positioned correctly, fluid can come out of drain tube without laryngeal contamination LMA Proseal Instruction Manual 2008

  37. What to do if aspiration occurs? • Head down • Adequate depth of anaesthesia • Momentarily disconnection from circuit • Consider reposition of device • Suction through airway tube • Gastric tube through drain tube • Intubation if necessary • Antibiotics • Chest physiotherapy • Tracheal suction LMA Proseal Instruction Manual 2008

  38. Conclusion • Regurgitation and aspiration is not a common event when using Proseal laryngeal mask airway • Selection of patients • Technique of insertion, role of drain tube • Important to consider contraindications before using laryngeal mask airway

  39. The End Thank you

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