A 55 year old man was admitted on the day of surgery for radical prostatectomy

LMA Case Report
Presented by: William H. Rosenblatt, MD Associate Professor of Anesthesiology and Surgery USE OF THE LARYNGEAL MASK AIRWAY

Reported is a case of a radical prostatectomy under
general anesthesia with a Laryngeal Mask Airway The laryngeal mask airway was introduced in the (LMA). The patient had a previous history of severe United States in the early 1990's as a substitute for bronchospasm. The advantages of the LMA in this the face mask in cases where spontaneous ventilation was maintained. Soon afterwards, it was realized that this device also could function in situations in Introduction
which endotracheal intubation had become the stan- A 55 year old man, 5’8” and 180 pounds, was admitted dard mode of ventilatory management.2 A number of on the day of surgery for radical prostatectomy. The case reports and clinical trials have shown that a wide patient had a significant history of asthma, with sev- variety of surgical procedures are safely managed eral hospital admissions. One admission included with the LMA. These include situations requiring intubation in the intensive care unit less than one positive pressure ventilation, intraoral and intranasal month prior to the date of surgery. The patient was surgery, intraabdominal and pelvic surgery, and offered regional anesthesia (epidural) for the sched- bronchoscopy.2, 3, 4 Concerns regarding regurgitation and aspiration limited the initial acceptance of the LMA, but in low risk patients there have been few Surgical Procedure
problems reported.5, 6 Patients in the lithotomy posi-tion have been noted to have increased passive regur- After pretreatment with an albuterol inhaler (2 puffs gitation with the LMA, but this has not been accom- self-administered by the patient) and glycopyrolate, panied by an increase in aspiration. The overall rate the patient was induced with 2mg/kg of propofol, 2 of aspiration with the LMA in low risk patients is µg/kg of fentanyl, and 0.7mg/kg of vecuronium. An equal to that in tracheally intubated patients.7 Even oral gastric tube was placed and a size 5 LMA-Classic low aspiration risk abdominal surgery patients, un- inserted using the method described by Brain.1 The dergoing open laparotomy, abdominal laparoscopy anesthetic was maintained with isoflurane, intrave- and pelvic laparoscopy, have been safely managed in nous fentanyl, and vecuronium. The patient was placed in a supine, extended position in order to maximize surgical access to the pelvis. This position Asthma, or bronchospasm, is a disease of hyperreflex- placed the head and torso in a moderately downward ivity of the bronchial smooth muscle. Intrinsic and position. Peak inspiratory pressure never exceeded 25 extrinsic forms exist. In the intrinsic bronchospasm cm of water pressure. The procedure continued under patient, no clear stimulus to bronchoconstriction ex- controlled ventilation for 4 hours. After resection of ists. With extrinsic asthma the patient can have the prostate and urethral anastamosis, the patient bronchospasm triggered by environmental pollutants, was returned to a supine position. After the abdomi- allergic reaction, cold, foreign bodies, and drying of nal musculature was repaired, neuromuscular block- the mucosa. It can be treated by removing the offend- age was reversed, and the patient was allowed to ing stimulus and by giving the patient β2 agonists and breathe spontaneously. At the completion of the pro- steroids. The LMA presents a unique opportunity for cedure, the inhaled anesthetic agent was discontinued the clinician to effectively control the airway without and the patient was allowed to emerge. When the having to introduce a foreign body in to the trachea. patient obeyed commands to open the mouth, the oral Thus, it is an ideal airway tool in the asthmatic pa- cavity was gently suctioned and the LMA was re- tient who is not at risk for reflux and aspiration. Pa- moved, fully inflated. The LMA was coated with tients managed with the LMA have less evidence of thickened saliva on the pharyngeal aspect but was reversible bronchoconstriction than those managed with a tracheal tube.11 Because the halogenated in- Agro F., Brimacombe J., Verghese C., Carassiti M., haled anesthetics are potent bronchodilators, the pa- Cataldo R. Laryngeal mask airway and incidence of tient at risk for bronchospasm is most likely to gastro-oesophageal reflux in paralysed patients under- wheeze when they are discontinued and the patient going ventilation for elective orthopaedic surgery. Brit- begins to emerge. In the patient managed with the ish Journal of Anaesthesia 1998;81(4):537-539 LMA, there is no foreign body in the sensitive bron- McCrory C.R., McShane A.J. Gastroesophageal reflux cho-respiratory tree and the patient can be fully during spontaneous respiration with the laryngeal emerged prior to removal of the device. In the event mask airway. Can J Anaesth 1999;46(3):268-270 that uncontrollable bronchospasm does occur intraop- eratively (e.g. from vagal stimuli such as traction on Brimacombe J.R., Berry A. The incidence of aspiration the peritoneum), intubation can be performed through associated with the laryngeal mask airway: A meta- analysis of published literature. J Clin Anesth When an LMA is used as the primary airway man- Skinner H.J., Ho B.Y., Mahajan R.P. Gastro- agement technique, a naso- or oral gastric tube can be oesophageal reflux with the laryngeal mask during used as indicated by the surgery. It may be placed day-case gynaecological laparoscopy. Br J Anaesth before the insertion of the LMA, or behind the LMA after it has been inserted. Modest deflation of the mask may facilitate gastric tube insertion.13 Bapat P.P., Verghese C. Laryngeal mask airway and the incidence of regurgitation during gynecological laparoscopies. Anesth Analg 1997;85(1):139-143 In the current case, the LMA provided a practical and 10) Tobias J.D., Holcomb G.W.III., Rasmussen G.E., Lowe safe alternative to endotracheal intubation. It affords S., Morgan W.M. III. General anesthesia using the la- a special advantage to the patient with bronchospastic ryngeal mask airway during brief, laparoscopic inspec- disease by allowing airway control without manipula- tion of the peritoneum in children. J Laparoendosc tion of the sensitive larynx or trachea. Positive pres- sure ventilation, gastric tube placement and non- 11) Kim E.S., Bishop M.J. Endotracheal intubation, but supine positioning are all possible with LMA use.14 not laryngeal mask airway insertion, produces re- versible bronchoconstriction. Anesthesiology Though it is recommended that the clinician become experienced with basic LMA use before applying it to unconventional cases, it is apparent that the scope of 12) Benumof J.L. Laryngeal mask airway and the ASA its applicability is far greater than previously appre- difficult airway algorithm. Anesthesiology 1996;84:686- References
13) Graziotti J. Intermittent positive pressure ventilation through a laryngeal mask airway - is a nasogastric Brain A.I.J., Denman W.T., Goudsouzian N.G. LMA- tube useful? Anaesthesia 1992;47:1088-1089 Classic and LMA-Flexible Instruction Manual. 1999 14) Brimacombe J.R., Brain A.I.J., Berry A.M. The La- ryngeal Mask Airway - A Review and Practical Guide Rosenblatt W.H., Ovassapian A., Eige S. Use of the (Chapter 12-Advanced Uses: Techniques). 1997;144- laryngeal mask airway in the United States: A Ran- domized Survey of ASA Members. Anesthesiology Verghese C. Survey of laryngeal mask airway usage in 11,910 patients: safety and efficacy for conventional and nonconventional usage. Anesth Analg 1996;82(1): 4) Keller C., Sparr H.J., Luger T.J., Brimacombe J. Pa- tient outcomes with positive pressure versus sponta- neous ventilation in non-paralysed adults with the la- ryngeal mask. Can J Anaesth 1998;45(6):564-567 LMA North America, Inc., 9360 Towne Centre Dr., San Diego, CA 92121 ■ (800) 788-7999 ■ Fax (858) 622-4130 ■ Website: www.LMANA.com Consult the instructions for information on indications, contraindications, warnings, and precautions, or information on which LMAs are best suited for different clinical applications. LMA and LMA-Classic are trademarks of The Laryngeal Mask Company Ltd. 1999 LMA North America, Inc. All rights reserved. LMA-GEN-138

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Ira L. Flax, M.D., MACG • ernst r. dorsch, M.D., FACG robert a. herman, M.D., FACG • p. martin mauk, M.D., FACG COLE T. THOMSON, M.D., PH.D., PLLC • KATHERINE NGUYEN, M.D. Hashim M. Khandwalla, M.D. • PAT WALZEL, PA-C General Information for Your Procedure Restrictions the day of the procedure: 1. A responsible adult must take you home. Driving yourself, taking the bus,

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