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Department of Anesthesia and Pain Management, Mount Sinai Hospital, Toronto, Canada, e.goldszmidt@utoronto.ca
To the Editor:
I must comment on the recent case report by Keller et al. (1) describing the use of a ProSealTM laryngeal mask in a case of failed obstetric intubation and postoperative ventilation.
My main concern with this case is their decision to proceed with a rapid sequence induction in the face of an anticipated difficult intubation. Standard practice would dictate that such a patient should have a regional anesthetic or an awake intubation (2). Although she insisted on general anesthesia, an awake intubation was definitely indicated. Exposing this patient to a prolonged and failed intubation was a potentially dangerous choice. The authors reported the removal of 300 mL of gastric contents, thereby demonstrating that conditions were present that could have led to regurgitation and aspiration. Deaths in obstetric anesthesia have declined significantly. This has been attributed to the increased use of regional anesthesia and perhaps to better airway management practices. This case report suggests a step backwards.
Postoperatively, the authors decided to prolong the ventilation until the thrombocytopenia recovered. I should point out that the nadir of thrombocytopenia might occur beyond 24 hours postpartum (3). It is also unusual to have severe hemorrhage with a platelet count over 40,000/µL (4).
References
Department of Anaesthesia and Intensive Care, Cairns Base Hospital, Cairns, Australia, jbrimaco@bigpond.net.au Department of Anaesthesia and Intensive Care Medicine, Leopold-Franzens University, Innsbruck, Austria
In Response:
We thank Dr. Goldszmidt for his interest in our case report describing the use of the ProSeal laryngeal mask airway (PLMA) for airway rescue and postoperative ventilation in an obstetric patient with a known difficult airway and HELLP syndrome. We will respond to each of his points in turn.
First, Dr. Goldszmidt is concerned that we conducted a rapid sequence induction in a patient with a known difficult airway, thereby contravening the American Society of Anesthesiologists recommendation to conduct awake tracheal intubation in this situation (1). However, this recommendation does not apply to the patient who "refuses or cannot cooperate" (1). Our patient, who had no cerebral impairment, refused awake intubation and refused regional anesthesia, we therefore had to proceed with general anesthesia or ignore the patient’s rights to self-determination. There was no time for a psychological evaluation of the patient’s decision. Regional anesthesia would also have been risky due to the rapidly falling platelet count, which would have been below 50,000/mm3 by the time surgery commenced, as it fell from 133,000 to 80,000/mm3 in 2 h, and surgery was performed 2 h after the last count. In our institute, we follow the "rule of 50" and avoid regional anesthesia if the PT is below 50 s, the PTT above 50, or the platelet count below 50,000/mm3.
Second, Dr Goldszmidt indicates that the discovery of 300 mL of residual fluid in the stomach further emphasizes the folly of our approach. We were well aware that this patient was at risk of aspiration and we took measures to prevent this occurring, including the application of cricoid pressure and the use of the PLMA rather than the classic LMA for airway rescue. Perhaps we could have used the esophageal tracheal Combitube to protect the airway, but this exerts high pressures against the pharyngeal mucosa (2) and has a high incidence of airway trauma (3).
Third, Dr Goldszmidt implies that the use of the PLMA is a retrograde step towards reducing the obstetric anesthesia mortality rate. We consider that the use of the PLMA in failed obstetric intubation is an important step forward because (i) high airway pressure ventilation is feasible, (ii) the airway can be protected, and (iii) very high first attempt success rates are possible using an esophageal guide, such as a gum elastic bougie, which may already be in the esophagus following failed tracheal placement (4).
Fourth, while agreeing that the lowest platelet count can occur after 24 h in patients with HELLP syndrome and that bleeding is unlikely with a platelet count above 40,000/mm3, in our patient the nadir occurred shortly after the procedure and was as low as 20,000/mm3.
Finally, once committed to general anesthesia, we devised a plan to minimize the risk of failed airway management by (i) having a surgeon available to perform a surgical airway, (ii) having two highly experienced anesthesiologists make their best attempts at face mask ventilation and laryngoscope-guided tracheal intubation, and (iii) by using an airway rescue technique with a known high success rate in the failed ventilation, failed intubation scenario (5).
References
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