LARYNGEAL MASK AIRWAY IN THE PRONE POSITION Dr

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LARYNGEAL MASK AIRWAY IN THE PRONE POSITION Dr. Paul Zilberman Israel 2013 paulzi 60@yahoo.

LARYNGEAL MASK AIRWAY IN THE PRONE POSITION Dr. Paul Zilberman Israel 2013 paulzi [email protected] com Cluj Napoca Romania 2013

DEFINITION “Prone” means naturally inclined to something, apt, liable. It has been recorded in

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…

…non-anesthetized but still prone…

PHYSIOLOGICAL CHANGES IN THE PRONE POSITION 1. Cardiovascular - decreased cardiac index - IVC

PHYSIOLOGICAL CHANGES IN THE PRONE POSITION 1. Cardiovascular - decreased cardiac index - IVC obstruction 2. Changes in respiratory physiology - FRC - NOT CHANGED – inspiratory flow rates - static compliances 3. Distribution of pulmonary blood flow 4. Distribution of ventilation

COMPLICATIONS ASSOCIATED WITH THE PRONE POSITION 1. Injury to the CNS – arterial occlusion

COMPLICATIONS ASSOCIATED WITH THE PRONE POSITION 1. Injury to the CNS – arterial occlusion - venous occlusion - air entrainment - cervical spine injury - undiagnosed space-occupying lesions 2. Injury to the peripheral nervous system 3. Pressure injuries – direct - indirect

British Journal of Anaesthesia 100 (2): 165– 83 (2008) doi: 10. 1093/bja/aem 380 Anaesthesia

British Journal of Anaesthesia 100 (2): 165– 83 (2008) doi: 10. 1093/bja/aem 380 Anaesthesia in the prone position H. Edgcombe 1, K. Carter 1 and S. Yarrow 2* 1 Royal Berkshire NHS Foundation Trust, London Road, Reading RG 1 5 AN, UK. 2 John Radcliffe Hospital, Oxford, UK *Corresponding author: Nuffield Department of Anaesthesia, John Radcliffe Hospital, Oxford OX 3 9 DU, UK. Email: [email protected] co. uk

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

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, 3 rd 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.

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 ventilation 10. Check the correct position of the head, hands, other parts of the body as requested by surgery

PROBLEMS 1. Workman force 2. Synchronization 3. Neck spine injury 4. Loss of airway

PROBLEMS 1. Workman force 2. Synchronization 3. Neck spine injury 4. Loss of airway 5. 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…

Some of the problems can be avoided if…

ADVANTAGES OF SELF-POSITIONING 1. For the OR team – only two persons needed -

ADVANTAGES OF SELF-POSITIONING 1. 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

PRECAUTIONS 1. A stretcher must be put alongside the OR table (in case something

PRECAUTIONS 1. 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).

INDUCTION 1. Preoxygenation 2. I. V. meds until the patient is asleep. NO MUSCLE

INDUCTION 1. Preoxygenation 2. 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

Complete access to the face

Only one hand is needed

Only one hand is needed

MAINTAINANCE 1. I. V. , volatiles, at your discretion 2. Observe spontaneous breathing and

MAINTAINANCE 1. I. V. , volatiles, at your discretion 2. Observe spontaneous breathing and assist accordingly.

SIMILAR PRECAUTIONS There are insufficient data demonstrating that the insertion of the LMA (Supreme)

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 prone position” Anaesthesia, 2010, 65, 154 -157 the

SIMILAR PRECAUTIONS (cont. ) Other measures to increase safety are full preoxygenation, tilting the

SIMILAR PRECAUTIONS (cont. ) Other measures to increase safety are full preoxygenation, 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 PRECAUTIONS AVOID IMPROVISATIONS Reproduced with permission from “A Practical Guide to the Prone

OTHER PRECAUTIONS AVOID IMPROVISATIONS Reproduced with permission from “A Practical Guide to the Prone Position for Surgery Dr. Patrick Ross, Consultant Anaesthetist, Pennine Acute NHS Trust Dr. Glyn Smurthwaite, Consultant Anaesthetist, Salford Royal NHS Foundation Trust

OTHER PRECAUTIONS USE YOUR EQUIPMENT CORRECTLY Reproduced with permission from “A Practical Guide to

OTHER PRECAUTIONS USE YOUR EQUIPMENT CORRECTLY Reproduced with permission from “A Practical Guide to the Prone Position for Surgery Dr. Patrick Ross, Consultant Anaesthetist, Pennine Acute NHS Trust Dr. Glyn Smurthwaite, Consultant Anaesthetist, Salford Royal NHS Foundation Trust

The armrest is slightly lower than the table.

The armrest is slightly lower than the table.

The same armrest from a slightly different angle.

The same armrest from a slightly different angle.

Correct arm position, no tension in the shoulder, elbow and wrist articulations

Correct arm position, no tension in the shoulder, elbow and wrist articulations

Noting above 90 degrees

Noting above 90 degrees

One assistant is holding the mouth open While the anesthetist is inserting the LMA

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…

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

MAAYANEY HAYESHUA MEDICAL CENTER BNEY BRAK ISRAEL

MAAYANEY HAYESHUA MEDICAL CENTER BNEY BRAK ISRAEL

DIFFERENT REACTIONS… Are you nuts? Distrust Astonishment Enthusiasm

DIFFERENT REACTIONS… Are you nuts? Distrust Astonishment Enthusiasm

CONCLUSIONS The anesthetist is trained to anticipate and plan for the worst case scenario

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 END The use of the LMA as a primary airway device

AND IN THE END The 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

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