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PEDIATRIC ANESTHESIA

The Use of a Laryngeal Mask Airway for Emergent Airway Management in a Prone Child

Departments of Anesthesiology, Perioperative and Pain Medicine and Neurosurgery; Children’s Hospital Boston, Harvard Medical School, Boston, Massachusetts

Address correspondence and reprint requests to R. Scott Dingeman, MD, Department of Anesthesiology, Perioperative and Pain Medicine, Children’s Hospital, 300 Longwood Ave., Boston, MA 02115. Address e-mail to scott{at}dingeman.com.

	Abstract

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A 5-yr-old girl with Arnold-Chiari Malformation, Type 1, was accidentally tracheally extubated while positioned prone in a Mayfield neurosurgical headrest during a decompressive craniectomy and cervical laminectomy. While preparations were being made to return the patient to the supine position for reintubation, we placed a laryngeal mask airway (LMA) without difficulty. The child was kept in the prone position with the LMA in place using positive-pressure ventilation for the remainder of the operation. This case report emphasizes the practical, emergent use of a LMA to secure the airway of a pediatric patient in the prone position after accidental extubation.

	Introduction

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Accidental tracheal extubation may occur in the prone position during neurosurgical procedures for any number of reasons. It presents a challenge in airway management and may require urgently turning the patient supine, which has major implications to the surgery and sterile field. In this case report, a laryngeal mask airway (LMA) was inserted emergently with the patient remaining prone after accidental displacement of a nasotracheal tube (NTT). There are no reports in the literature demonstrating the use of a LMA to manage an airway emergency in the prone pediatric patient.

	Case Report

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A 37-kg 5-yr-old female was scheduled for a decompressive craniectomy and cervical laminectomy. She presented with a history of headaches and absence seizures. A magnetic resonance image revealed an Arnold-Chiari Malformation, Type 1. On the day of surgery, the patient had a nonproductive cough and clear rhinitis. She was premedicated with PO midazolam and taken to the operating room. An inhaled induction with sevoflurane and nitrous oxide was performed. IV access was obtained and IV sodium thiopental, pancuronium, and fentanyl were given. Nasotracheal intubation with a 5.0 cuffed Mallinckrodt Lo-Pro® endotracheal tube (Mallinckrodt, Hazelwood, MO) was performed without difficulty under direct laryngoscopy. A leak was noted at 14 cm H₂O. The patient was maintaining adequate tidal volumes; therefore, to minimize subglottic pressure and subsequent potential edema the NTT cuff was not inflated.

After applying benzoin periorally, along the nasal bridge and directly on the NTT, the NTT was secured with cloth tape at 21 cm at the right nare. Tegaderms were applied over the cloth tape to prevent secretions from penetrating the tape. A soft bite block, temperature probe, and orogastric tube were placed. After placing skull pins and securing the patient in a Mayfield neurosurgical headrest, she was positioned prone. Just before closure of the dura mater, 127 min into the operation, the patient’s end-tidal CO₂ tracing disappeared suddenly. The patient was visualized under the drapes, and the NTT was noted to be only 13 cm at the nare. Although the precise mechanism of accidental extubation was unclear, we speculate that the patient’s clear rhinitis on the day of surgery, in addition to gravitational forces present on the prone patient, may have interfered with the adhesive properties of the benzoin, cloth tape, and Tegaderm used to secure the NTT. After extubation was noted, a sterile towel was placed over the patient’s open dura and the surgical drapes were removed. The NTT, orogastric tube, and esophageal temperature probe were also removed to facilitate mask ventilation. The attending and fellow anesthesiologists attempted two-person mask ventilation with the patient remaining in the prone position, but this was difficult. Preparations were simultaneously made to return the patient to the supine position for direct laryngoscopy. The Spo₂ fluctuated between 89% and 96% during mask ventilation. The fellow anesthesiologist placed a #3 LMA without difficulty while the patient remained prone. End-tidal CO₂ was noted on the capnograph, and the patient had bilateral breath sounds with assisted ventilation. The LMA was secured periorally using silk tape, and the patient was again prepared and draped for surgery. The patient’s lungs were ventilated using gentle controlled hand ventilation with mean airway pressures at 10 cm H₂O and peak inspiratory pressures of 20 cm H₂O for the remainder of surgery. The operation continued without complications. The computerized record noted that the LMA was placed and an airway re-established <6 min after the accidental extubation occurred. At the conclusion of surgery, 35 min after LMA placement, the patient was placed supine. The Mayfield headrest was removed by the neurosurgeon. The inhaled anesthetic was turned off, the patient’s muscle paralysis reversed, and her spontaneous respirations returned. Once the patient was awake, breathing regularly, and following commands, the LMA was removed in the operating room. The patient was transported to the postanesthesia care unit with oxygen via face mask. Postoperatively, the patient suffered no neurological or respiratory sequelae.

	Discussion

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Two studies in the literature involve inserting the LMA in prone patients under elective surgical conditions. Ng et al. (1) reported, in their prospective audit, successful elective placement of a LMA in the prone position in 73 adult patients presenting for minor surgery. Osborn et al. (2) also showed successful LMA placement and removal in 6 adult patients while prone during endoscopic retrograde cholangiopancreatography with their retrospective cohort study. Although we are not recommending placing a LMA electively in the prone position for neurosurgical procedures in the pediatric patient, we demonstrated in this case report that the LMA can be successfully inserted during an airway emergency while the patient remains prone. Although direct or fiberoptic laryngoscopy can be attempted with the patient prone after accidental extubation, the position of the patient is not optimal for these techniques and it may take too much time to perform. Placing the patient supine to attempt reintubation with the dura open may place the patient at significant risk for infection and neurological injury. With the patient prone, the soft tissues of the oropharynx are displaced, facilitating the placement of the LMA. The LMA in this case was a useful adjunct in securing an airway emergently in a prone child.

The authors would like to thank our anesthesiology colleagues Dr. Peter Kovatsis and Dr. Christian Seefelder for their assistance in managing this case.

	References

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1. Ng A, Raitt DG, Smith G. Induction of anesthesia and insertion of a laryngeal mask airway in the prone position for minor surgery. Anesth Analg 2002;94:1194–8.[Abstract/Free Full Text]
2. Osborn IP, Cohen J, Soper RJ, Roth LA. Laryngeal mask airway: a novel method of airway protection during ERCP: comparison with endotracheal tube. Gastrointest Endosc 2002;56:122–8.[Medline]

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a colleague Similar articles in this journal Similar articles in Web of Science Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Request Permissions Citing Articles Citing Articles via HighWire Citing Articles via Web of Science (3) Citing Articles via Google Scholar Google Scholar Articles by Dingeman, R. S. Articles by Goobie, S. M. Search for Related Content PubMed PubMed Citation Articles by Dingeman, R. S. Articles by Goobie, S. M. Related Collections Airway Pediatrics