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Annals of Cardiac Anaesthesia Annals of Cardiac Anaesthesia Annals of Cardiac Anaesthesia
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Table of Contents
LETTER TO EDITOR  
Year : 2013  |  Volume : 16  |  Issue : 1  |  Page : 67-68
Successful conversion to tracheal intubation during cardiopulmonary bypass after emergency airway rescue with ProSeal TM laryngeal mask airway in cardiac surgery


Department of Anesthesiology and Intensive Care, University Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif, Bandar Tun Razak, Cheras, Kuala Lumpur, Malaysia

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Date of Web Publication2-Jan-2013
 

How to cite this article:
Ooi J. Successful conversion to tracheal intubation during cardiopulmonary bypass after emergency airway rescue with ProSeal TM laryngeal mask airway in cardiac surgery. Ann Card Anaesth 2013;16:67-8

How to cite this URL:
Ooi J. Successful conversion to tracheal intubation during cardiopulmonary bypass after emergency airway rescue with ProSeal TM laryngeal mask airway in cardiac surgery. Ann Card Anaesth [serial online] 2013 [cited 2019 Nov 14];16:67-8. Available from: http://www.annals.in/text.asp?2013/16/1/67/105377


The Editor,

A 64-year-old male with triple vessel disease involving 80% of the left main stem with an ejection fraction of 33% was scheduled for an elective coronary artery bypass grafting (CABG). He weighed 68 kg and was 165 cm tall (body mass index 25 kg/m 2 ). The patient also suffered from diabetes mellitus, hypertension, hypercholesterolemia, myocardial infarction five years before, and a left frontal infarct of which he fully recovered. He was also a chronic smoker. Airway assessment showed a Mallampati Class II with no other clinical features of difficult intubation. Induction was achieved with fentanyl 700 μg, etomidate 6 mg, and midazolam 4 mg. Following rocuronium 60 mg, an oropharyngeal airway was inserted and facemask ventilation commenced. The head was repositioned several times after facing difficulty in maintaining his airway and mask ventilation. At this point, the oxygen saturation (SpO 2 ) decreased to 95% and laryngoscopy was performed which revealed a Cormack-Lehane Grade 4 view; the view did not improve with external laryngeal pressure. Meanwhile the SpO 2 decreased to 89%. In a desperate attempt, a size 4 ProSeal TM laryngeal mask airway (PLMA; Intavent Orthofix, Maidenhead, UK) was inserted to secure the airway, oxygenation and ventilation. The PLMA slipped in easily and SpO 2 improved. Anesthesia was maintained with oxygen-air mixture and sevoflurane. Intermittent positive pressure ventilation with a tidal volume of 500 ml was achieved with a peak airway pressure of 20-22 cmH 2 O. A Ryle's tube was passed down through the PLMA drain tube without much difficulty. Decision was made to proceed with the surgery using the PLMA during the initial period. After establishment of cardiopulmonary bypass (CPB), the PLMA was removed and with the aid of a flexible fiberoptic bronchoscope, a size 8 tracheal tube was inserted orally. Placement was confirmed by bilateral lung inflation, which was visible through the sternotomy. The surgery continued uneventfully over the next 5 hours and postoperatively the patient was transferred to the cardiac intensive care unit (ICU). He required a brief period of inotropic support, remained ventilated for the next 36 hours and was transferred to the ward on postoperative day 3.

The use of PLMA as an emergency airway rescue especially in cases of unanticipated "cannot intubate, cannot ventilate" (CICV) is not new and its use has been incorporated in the algorithm of Difficult Airway Society Guidelines 2004. [1] Van Zundert, et al., successfully inserted a PLMA with the aid of a tracheal tube guide as an airway rescue after two failed attempts of intubation and failed mask ventilation in a hypoxic patient undergoing off-pump CABG. They proceeded with PLMA throughout the surgery, which was only removed in ICU 3 hours later with no complications. [2] In the present case, maintaining the patient's airway with the PLMA throughout the surgery and into the postoperative period was not considered ideal as we anticipated a stormy intraoperative period and a high possibility of prolonged postoperative ventilation. PLMA is, however, not a substitute for a tracheal tube and appropriate protection of the airway occurs only when correctly positioned. Even so, pulmonary aspiration has been reported with a correctly placed PLMA. [3] Cases of cranial nerve injury involving the lingual nerve, hypoglossal nerve, and recurrent laryngeal nerve have been reported after use of PLMA for surgeries of up to 180 minutes. [4] Iorio, et al., reported its prolonged use (up to 40 hours) in ICU without causing excessive pressure and mucosal damage to the hypopharynx. [5] The highlight in the management of this case is the timing of the changeover from PLMA to tracheal tube. This was performed safely during CPB without the possibility of desaturation or hemodynamic instability which could be detrimental in such cases. This technique can be recommended to a selected group of patients coming for elective on-pump CABG with anticipated difficult airway; hence awake fibreoptic intubation can be avoided. However, the major limitation would be the inability to perform transesophageal echocardiography prior to CPB.

 
   References Top

1.Henderson JJ, Popat MT, Latto IP, Pearce AC. Difficult Airway Society. Difficult Airway Society guidelines for management of the unanticipated difficult intubation. Anaesthesia 2004;59:675-94.  Back to cited text no. 1
    
2.van Zundert A, Brimacombe J. ProSeal laryngeal mask airway for cardiac surgery after airway rescue. Acta Anaesthesiol Belg 2008;59:47-9.  Back to cited text no. 2
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3.Koay CK. A case of aspiration with the Proseal LMA. Anaesth Intensive Care 2003;31:123.  Back to cited text no. 3
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4.Brimacombe J, Clarke G, Keller C. Lingual nerve injury associated with the ProSeal laryngeal mask airway: A case report and review of the literature. Br J Anaesth 2005;95:420-3.  Back to cited text no. 4
[PUBMED]    
5.Di Iorio C, Cafiero T, Varriale P, Spatola R, Mannelli R, Di Minno RM. Prolonged use of the ProSeal laryngeal mask in ICU: A case report. Eur J Anaesthesiol 2006;23:975-86.  Back to cited text no. 5
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Correspondence Address:
Joanna Ooi
Department of Anesthesiology and Intensive Care, University Kebangsaan Malaysia Medical Centre, Jalan Yaacob Latif, Bandar Tun Razak, Cheras, 56000, Kuala Lumpur
Malaysia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9784.105377

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