LARYNGEAL MASK AIRWAY IN THE PRONE POSITION

Dr. Paul ZilbermanIsrael 2013

paulzi60@yahoo.comCluj Napoca

Romania 2013

DEFINITION“Prone” means naturally inclined to something, apt, liable. It has been recorded in English since 1382. The meaning “face down” was first recorded in 1578 but it was also referred to as “lying down” or

“going

prone”

…non-anesthetized but still prone…

PHYSIOLOGICAL CHANGES IN THE PRONE POSITION

1. Cardiovascular - decreased cardiac index - IVC obstruction2. Changes in respiratory physiology - FRC - NOT CHANGED – inspiratory flow rates - static compliances3. Distribution of pulmonary blood flow4. Distribution of ventilation

COMPLICATIONS ASSOCIATED WITH THE PRONE POSITION

1. Injury to the CNS – arterial occlusion - venous occlusion - air entrainment - cervical spine injury - undiagnosed space-occupying lesions2. Injury to the peripheral nervous system3. Pressure injuries – direct - indirect

Anaesthesia in the prone positionH. Edgcombe1, K. Carter1 and S. Yarrow2*1Royal Berkshire NHS Foundation Trust, London Road, Reading RG1 5AN, UK. 2John Radcliffe Hospital,Oxford, UK*Corresponding author: Nuffield Department of Anaesthesia, John Radcliffe Hospital, Oxford OX3 9DU, UK.Email: drsyarrow@tiscali.co.uk

British Journal of Anaesthesia 100 (2): 165–83 (2008)doi:10.1093/bja/aem380

SOURCES OF POTENTIAL INJURY TO THE BRACHYAL PLEXUS AND ITS PERIPHERAL COMPONENTS WHEN THE PATIENT IS

PRONE

A. Neck rotation, stretching roots of the plexus. B. Compression of the plexus and vessels between the clavicle and first rib. C. Injury to the axillary neurovascular bundle from the head

of the humerus. D. Compression of the ulnar nerve before, beyond, and within the cubital tunnel. E. Area of vulnerability of the radial nerve to lateral compression proximal to the

elbow. (Reproduced from Martin JT, Warner MA [Eds]: Positioning in Anesthesia and Surgery, 3rd edition. Philadelphia, WB Saunders, 1997, p 185, with permission.) and permission from Prof.

Barash.

CLASSICAL AIRWAY MANAGEMENT 1. Patient supine 2. Monitors applied 3. Preoxygenation 4. Induction (i.v., mask) 5. Airway device insertion (ETT, LMA) with check and fixation 6. NG (y/n?) 7. Short disconnection of the monitors and ventilation 8. Turning the patient prone 9. Reconnect all the wires, tubes etc., check ventilation10. Check the correct position of the head, hands, other parts of the body as requested by surgery

PROBLEMS1. Workman force2. Synchronization3. Neck spine injury4. Loss of airway5. Loss of lines (i.v., AL. CL)6. Other mishaps: urinary catheter dislocation, inadvertent traction of any of the tubes, wires… and you can add whatever your experience and memory can bring…

Some of the problems can be avoided if…

ADVANTAGES OF SELF-POSITIONING1. For the OR team – only two persons needed - no “Hercules” - no problems with all the “techs”2. For the patient – places him/herself comfortable - no intubation - no risks of cervical spine damage - provides visual appreciation on how he/she will be during surgery

PRECAUTIONS1. A stretcher must be put alongside the OR table (in case something goes wrong and the patient needs to be turned supine)2. Other OR team members should be available in case of need.3. Special attention to the eyes as they need to be closed while the patient is already prone (debatable in short surgeries).

INDUCTION1. Preoxygenation2. I.V. meds until the patient is asleep. NO MUSCLE RELAXANTS!3. Check manual ventilation possible. IF NOT: STOP AND REASSESS. DON’T DO ANYTHING “JUST FOR THE RECORD”. At times we just need to go the classical way.4. Insert the LMA 5. Check for possible manual ventilation but…6. Try to keep the patient on spontaneous breathing

Complete access to the face

Only one hand is needed

MAINTAINANCE1. I.V., volatiles, at your discretion2. Observe spontaneous breathing and assist accordingly.

SIMILAR PRECAUTIONS

There are insufficient data demonstrating that the insertion of the LMA (Supreme) in prone position is safe. Data from tens of thousands of cases would be required before answering such a question. We recommend that insertion of the LMAS in the prone position is only performed in patients who can be easily be rotated back into the supine position in the event of failed insertion. A.M.Lopez, R.Valero and J.Brimacombe Original article: “Insertion of the LMA Supreme in the prone position” Anaesthesia, 2010, 65, 154-157

SIMILAR PRECAUTIONS (cont.)

Other measures to increase safety are full pre-oxygenation, tilting the head of the table to the side to improve access to the mouth, fixation with strongly adhesive tape and avoidance of neck compression, as this causes airway obstruction. [] This technique should only be used by clinicians with considerable experience with the LMA(S) and prone anesthesia.

OTHER PRECAUTIONSAVOID IMPROVISATIONS

Reproduced with permission from “A Practical Guide to the Prone Position for Surgery

Dr. Patrick Ross, Consultant Anaesthetist, Pennine Acute NHS TrustDr. Glyn Smurthwaite, Consultant Anaesthetist, Salford Royal NHS Foundation

Trust

OTHER PRECAUTIONSUSE YOUR EQUIPMENT CORRECTLY

Reproduced with permission from “A Practical Guide to the Prone Position for Surgery

Dr. Patrick Ross, Consultant Anaesthetist, Pennine Acute NHS TrustDr. Glyn Smurthwaite, Consultant Anaesthetist, Salford Royal NHS

Foundation Trust

The armrest is slightly lower than the table.

The same armrest from a slightly different angle.

Correct arm position, no tension in theshoulder, elbow and wrist articulations

Noting above 90 degrees

One assistant is holding the mouth open

While the anesthetist is inserting the LMA

The LMA is in. The rest is as usual as it can be…

MAAYANEY HAYESHUA MEDICAL CENTERBNEY BRAK

ISRAEL

DIFFERENT REACTIONS…

Are you nuts?Astonishment

Distrust Enthusiasm

CONCLUSIONS

The anesthetist is trained to anticipate and plan for the worst case scenario in all situations (wishful thinking, my note!). Where the patient is to be positioned prone this includes the risk of airway loss and for this reason the favored airway has classically been a tracheal tube, usually reinforced, secured to minimize the risk of accidental extubation. […]Use of the LMA as a primary adjunct is controversial, but it has been used effectively.“Anaesthesia in the prone position” - cited

AND IN THE ENDThe use of the LMA as a primary airway device in the prone position is still the subject of sometimes violent academic debate.However, this technique exists. AND IT SAVED LIVES!It is wise to know it as you may need it once in your career. If you are not even aware this technique exists a patient’s life could be lost. And your career too!REMEMEBER: WHAT THE BRAIN DOESN’T KNOW, THE EYE DOESN’T SEE!

MANY THANKS TO…1. My colleagues in “MAAYANEY HAYESHUA MEDICAL CENTER”.2. Dr. Archie Brain, without his invention this work wouldn’t have been possible.

3. Yes, of course…to you all for your patience!THANK YOU, MULTUMESC,תודה רבה