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Anesth Analg 2004;98:1467-1470
© 2004 International Anesthesia Research Society
doi: 10.1213/01.ANE.0000108134.39854.D8

OBSTETRIC ANESTHESIA

Failed Obstetric Tracheal Intubation and Postoperative Respiratory Support with the ProSealTM Laryngeal Mask Airway

Christian Keller, MD*, Joseph Brimacombe, MBChB FRCA, MD{dagger}, Philipp Lirk, MD*, and Fritz Pühringer, MD*

*Department of Anaesthesia and Intensive Care Medicine, Leopold-Franzens University, Innsbruck, Austria and {dagger}James Cook University, Department of Anaesthesia and Intensive Care, Cairns Base Hospital, Cairns, Australia

Address correspondence to Prof. J. Brimacombe, Department of Anaesthesia and Intensive Care, Cairns Base Hospital, The Esplanade, Cairns 4870, Australia. Address email to jbrimaco{at}bigpond.net.au


   Abstract
Top
 Abstract
Introduction
 Case Report
 Discussion
 References
 
The ProSealTM laryngeal mask airway (ProSealTM LMA) provides a better seal and probably better airway protection than the classic laryngeal mask airway (classic LMA). We report the use of the ProSealTM LMA in a 26-yr-old female with HELLP syndrome for failed obstetric intubation and postoperative respiratory support. Both laryngoscope-guided tracheal intubation and face mask ventilation failed, but a size 4 ProSealTM LMA was easily inserted and high tidal volumes obtained. A gastric tube was inserted through the ProSealTM LMA drain tube and 300 mL of clear fluid was removed from the stomach. There were no hemodynamic changes during ProSealTM LMA insertion. Postoperatively, the patient was transferred to the intensive care unit, where she was ventilated via the ProSealTM LMA for 8 h until the platelet count had increased and she was hemodynamically stable. Weaning and ProSealTM LMA removal were uneventful. There is anecdotal evidence supporting the use of the LMA devices for failed obstetric intubation (19 cases) and for postoperative respiratory support (8 cases). In principle, the ProSealTM LMA may offer some advantages over the classic LMA in both these situations.

IMPLICATIONS: We report the successful use of the ProSealTM laryngeal mask airway for failed obstetric intubation and postoperative respiratory support in a patient with HELLP syndrome.


   Introduction
Top
 Abstract
 Introduction
Case Report
 Discussion
 References
 
The use of the laryngeal mask airway (LMA) for the difficult obstetric airway (1–18) and postoperative respiratory support (19–25) has been widely reported; however, the LMA is not ideal for either of these tasks because high airway pressure ventilation may be required and patients are frequently at risk of aspiration. The ProSealTM LMA is a new laryngeal mask device that provides a better seal (26–28) and probably better protection against aspiration (29). We report the use of the ProSealTM LMA for airway rescue and postoperative respiratory support for a period of 8 h in a patient with HELLP syndrome. We also review the literature regarding use of LMA devices in these situations.


   Case Report
Top
 Abstract
 Introduction
 Case Report
Discussion
 References
 
A 26-yr-old female (height 165 cm, weight 100 kg) with intrauterine growth retardation and HELLP syndrome presented at 30 wk gestation for an urgent cesarean delivery because of fetal bradycardia. She had been admitted to the hospital 3 days previously with a diagnosis of severe preeclampsia and had subsequently developed impaired liver function and a rapidly decreasing platelet count (133,000/mm3 to 80,000/mm3 in 2 h). On examination she had face, tongue, and lip edema and was a Mallampati Class IV airway. Despite a complete explanation of the possible risks, she insisted on general anesthesia. Sodium citrate was administered. She was administered oxygen for 5 min and a rapid sequence induction was performed with thiopental 500 mg (dose required to achieve loss of consciousness), succinylcholine 120 mg, and cricoid pressure (CP). A surgeon was available to perform a tracheostomy, if required. Anesthesia was administered by two experienced anesthesiologists with considerable experience of laryngoscope-guided tracheal intubation, face mask ventilation, and use of the LMA. The airway management plan was to allow two brief, optimal attempts at laryngoscope-guided tracheal intubation (the first attempt with CP and the second without CP) and to use the ProSealTM LMA (without CP) for airway rescue if face mask ventilation failed (without CP). Subsequently, laryngoscope-guided tracheal intubation failed (as the glottis could not be seen) and two-man face mask ventilation with a Guedel airway failed (as a clear airway could not be obtained), but a size 4 ProSealTM LMA was easily inserted at the first attempt and the cuff inflated with 20 mL air. Tidal volumes in excess of 1000 mL were immediately obtained with peak airway pressures of 25 cm H2O. The minimal SpO2 was 93%. Her arterial blood pressure was stable during laryngoscopy and ProSealTM LMA insertion. Anesthesia was subsequently maintained with O2 and end-tidal isoflurane 0.8%. A gastric tube was inserted via the drain tube and 300 mL of clear fluid was removed from the stomach. An 1800-g male with low Apgar scores (3 at 1 min, 5 at 5 min) was delivered 5 min after ProSeal LMA insertion and transferred to the neonatal intensive care unit for respiratory support. After surgery was complete, a decision was made to ventilate the patient until the platelet count had increased (in case further surgery was required for bleeding) and she was hemodynamically stable (to reduce the risk of acute hypertension during emergence). No attempt was made to exchange the ProSealTM LMA for a tracheal tube, as ventilation was adequate and the airway probably protected. Also, there was a risk that further attempts at intubation, even fiberoptically, would fail or cause airway trauma. The patient was transferred to the intensive care unit, where she was sedated with propofol and underwent pressure-controlled ventilation via the ProSealTM LMA for 8 h. Weaning and ProSealTM LMA removal took 30 min and were uneventful. There was no evidence of aspiration, as determined by normal lung function, a clear chest radiograph, and a lack of bile-stained fluid in the bowl of the ProSealTM LMA. Both the neonate and mother made a full recovery and there were no other sequelae.


   Discussion
Top
 Abstract
 Introduction
 Case Report
 Discussion
References
 
Our case is the 19th describing LMA use in the difficult obstetric airway (Table 1). Most previous cases have involved the classic LMA (1–3,5–15,17,18), but one involved the Intubating LMA (16). Analysis of these reports reveals that the LMA was used as a ventilatory device in 44 patients, including 4 as an airway intubator and 4 as an aid to awake intubation, with success rates of 84% (37 of 44), 25% (1 of 4), and 100% (4 of 4) respectively. These reports also show that the LMA was successfully inserted with CP applied in 81% (13 of 16) of patients, and in the lateral position in 100% (6 of 6). There were no episodes of regurgitation or aspiration or hypoxic brain injury. In this case, we inserted the ProSealTM LMA without CP because the distal cuff must be perfectly positioned in the hypopharynx, which lies immediately behind the cricoid cartilage, to provide protection against regurgitation and gastric insufflation (30). The lack of success as an aid to blind intubation suggests that this technique should not be attempted with the classic LMA; however, this may be a more reasonable option with the intubating LMA, as success is more frequent (31). Han et al. (32) reported the successful use of the classic LMA as a ventilatory device in 1060 of 1067 patients for elective cesarean delivery (32).


View this table:
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[in a new window]
  		Table 1. Laryngeal Mask Airway as a Ventilatory Device and Airway Intubator in the Difficult Obstetric Airway
 
The ProSealTM LMA offers several advantages over the classic LMA for failed obstetric intubation. First, the seal is 10 cm H2O higher giving it greater ventilatory capability (28). Second, it may protect against aspiration when correctly positioned, as evidenced by cadaver (29) and laboratory (33) studies demonstrating isolation of the respiratory tract from the gastrointestinal tract. Third, a gastric tube can be easily inserted to empty the stomach of fluid and air insufflated during difficult face mask ventilation (28). Aspiration, however, has been reported with the ProSealTM LMA in association with an unidentified malposition (34). A disadvantage of the ProSealTM over the classic LMA is that the first-time insertion success rate is less (28); however, the first-time success rate approaches 100% using laryngoscope-guided, gum elastic bougie-guided insertion (35), and this may be the technique of choice for airway rescue, even though CP must be briefly released during esophageal placement of the bougie. We did not use the bougie technique, as its efficacy was not established when this case occurred. A disadvantage of the ProSealTM LMA compared with the intubating LMA is that it is less suitable as an airway intubator because of the narrow internal diameter of the airway tube. We elected to use the ProSealTM LMA rather than the intubating LMA to avoid airway trauma, as it exerts lower pressures against the pharyngeal mucosa (36).

There are only two previous reports of ProSealTM LMA use in the difficult airway. The first was for fiberoptic-guided awake insertion in a patient with a known difficult airway (37) and the second was in nine morbidly obese patients who were Cormack and Lehane grade 3–4 (38). The other nonsurgical airway option in this situation, according to the ASA Task Force Report, is the esophageal tracheal Combitube (39), but a recent study has shown that it exerts high pressures against the pharyngeal mucosa (40). The ASA algorithm recommends that tracheal intubation should only be planned after induction of anesthesia in two situations: first, if there are no anticipated difficulties, and second if the patient refuses/cannot cooperate with awake intubation (39). Interestingly, one study reported that the success rate for awake fiberoptic intubation and blind intubation with the Intubating LMA under anesthesia are similar, but patients are less satisfied with the awake technique (41).

Our case is the eighth describing LMA use for postoperative respiratory support (Table 2). Most previous cases involved the classic LMA (19–22,24,25), but one involved the Flexible LMA (23). Analysis of these reports reveals that it was used in 9 patients after lung surgery (21,22,24,25), in 2 patients after uvulopalatopharyngoplasty (23), in one patient after cardiac surgery (19), and in one patient after acute gastric surgery (20). In two patients the rationale for use was failed intubation (19,24), as in the current case, and in 11 patients its use was to avoid barotrauma or airway protective reflex activation (20–23,25). The duration of postoperative respiratory support ranged from 45 to 140 min. No problems were reported with the technique.


View this table:
[in this window]
[in a new window]
  		Table 2. Laryngeal Mask Airway for Postoperative Respiratory Support
 
In summary, we report the use of the ProSealTM LMA for failed obstetric intubation and postoperative respiratory support in a patient with HELLP syndrome. There is anecdotal evidence supporting the use of the LMA in failed obstetric intubation and for postoperative respiratory support. In principle, the ProSealTM LMA may offer some advantages over the classic LMA in both these situations.


   References
Top
 Abstract
 Introduction
 Case Report
 Discussion
 References
 

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  29. Keller C, Brimacombe J, Kleinsasser A, Loeckinger A. Does the ProSeal laryngeal mask airway prevent aspiration of regurgitated fluid? Anesth Analg 2000; 91: 1017–20.[Abstract/Free Full Text]
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Accepted for publication October 29, 2003.





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Lippincott, Williams & Wilkins Anesthesia & Analgesia® is published for the International Anesthesia Research Society® by Lippincott Williams & Wilkins with the assistance of Stanford University Libraries' HighWire Press®. Copyright 2006 by the International Anesthesia Research Society. Online ISSN: 1526-7598   Print ISSN: 0003-2999 HighWire Press