Supraglottic Airway Devices Nap4

1. Supraglottic Airway DevicesNap4 • Dr Anil Patel • Royal National Throat Nose & Ear Hospital • and • University College Hospital, London

2. I have received an honorarium from the Laryngeal Mask Company & I have helped design the A.P. Advance Videolaryngoscope

3. Numerical Analysis • SAD 56% of all UK general anaesthetics • 90% cLMA or LM’s • 10% i-gel or Proseal LMA • 34 cases where SAD was primary airway • Of these 17 were aspiration • Of the Non-aspiration events • 2 deaths • 5 emergency surgical airways • 13 ICU admissions

4. Non-Aspiration Events - Deaths • loss of airway in the semi-prone position during prolonged surgery in a patient with a predicted difficult airway • poor laryngeal mask positioning, loss of airway and unrecognised oesophageal intubation during response to this event

5. Anaesthesia Events - 16 cases • generally young (10/16 < 40years) • healthy (14/16 ASA 1-2) • ‘urgent’ procedure (7/16 ‘urgent’) • Obesity (11/15 73%) • compared to 31% outside this group • None of the patients who aspirated during use of a SAD weighed >100kg

6. Outcome and quality of airway management

7. Devices Used

8. SAD - Themes • Patient selection • Limitation of use to appropriate surgery • Understand limits of chosen SAD • Inexperience, insertion and fixation • Use of second generation devices • Problems during maintenance • Problems at emergence, recovery or removal

9. Patient Selection • aspiration risk, predicted difficult airway, urgent surgery, obesity

10. Limitation of use to appropriate surgery • obese, lithotomy, head / down, very prolonged, prone

11. Inexperience

12. Inexperience and Insertion

13. Maintenance

14. Emergence, Recovery or Removal

15. SAD - Themes • Patient selection • Limitation of use to appropriate surgery • Understand limits of chosen SAD • Inexperience, insertion and fixation • Use of second generation devices • Problems during maintenance • Problems at emergence, recovery or removal

16. Recommendations • Laryngeal mask anaesthesia is a fundamental skill • Same attention to detail as intubation • patient selection • indications • contraindications • insertion • confirmation correct position • maintenance • removal and recovery

17. Recommendations • SAD use for difficult intubation, consider awake FOI or FOI through SAD • Difficult or failed SAD placement should raise the possibility of complications during maintenance / emergence / recovery • Continuing anaesthesia with a suboptimal airway after SAD insertion is not acceptable • Recovery staff competent with SAD procedures and timing of removal

18. Recommendation • If tracheal intubation is not considered to be indicated but there is some (small) increased concern about regurgitation risk a second generation SAD is a more logical choice than a first generation one. • Factors that mean use of SAD is at limits of normality (prone, airway access, size) consider second generation SAD • All hospitals have second generation SAD’s available for both routine use and rescue airway management

19. Supraglottic Airway DevicesNap4