Repositioning After LMA Intubation: A Question of Safety

Since its introduction in the UK in 1983 by AIJ Brain, the use of Laryngeal Mask Airway (LMA) has become increasingly popular for its short out patient procedures for all surgical specialties. While the literature has many anecdotal observations of its use and potential complications, it is lacking in comprehensive prospective randomized studies. It is currently held that patients requiring longer procedures, those with difficult LMA tube size-fits, those with gastric reflux and, of course, those with complex medical risk factors are not appropriate candidates for this technique.

Goals/Purpose:

The goal of this presentation is to emphasize yet another potential contraindication to the use of LMA intubation.

Methods/Technique:

This technique is demonstrated in its use in a single patient.

An older, otherwise healthy male, undergoing a short, quality of life surgical procedure in which I was directly involved underlies graphically yet another potential risk factor. This patient required repositioning for surgical purposes to a complete lateral position after LMA intubation. Near catastrophe followed—rapid severe hypoxia, hypotension to zero, severe arrhythmias with atrial fibrillation, ventricular tachycardia and cardiac arrest, which proved, despite 2 cardioversions, nearly refractory to resuscitation.

Results/Complications:

The supine position best facilitates for the gas and oxygen column to pass directly through the hypopharynx toward the trachea. A rotation to a lateral position adopted after intubation as in this case may distort the airway and lead to obstruction. Repositioning raises issues of safety with the use of this device.

 Results of this case outlined above and in which I participated, not surprisingly, was terrorizing for the Anesthesia team, the Surgeon and the OR team involved, but none more in retrospect than for the patient himself. I am grateful to be here to present this, as that patient was, in fact, actually me.

Conclusion:

In conclusion, this case highlights a potential contraindication for use of an LMA and the value that communication and teamwork add to improving patient safety. The configuration and position of an LMA can be unpredictable with various intra operative positioning changes as seen in aesthetic procedures such as liposuction. The anesthesia personnel are the custodians of airway management in the OR and must confirm the ultimate choice between an LMA versus an endotracheal tube. Communcation by the surgeon to both nursing and anesthesia about these intraoperative position changes wil enable a 'team approach" to this decision, ultimately improving patient safety.

Benumof, JL. JL of Anesth 1992; 77: No 5, 843-5

Brain, AIJ, The Laryngeal Mask: A New Concept in Airway Management.

BRJ Anaesth 1983; 55: 801-5

McCaul, CL, Harney, D, Ryan, M, Moran, C, Kavanagh, BP, Boylan, JF.

Airway Management in the Lateral Position. A Randomized Controlled Trial.

Anaesth ANALG 2005; 101:1221-5