Professional Documents
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Prone Position
Dennis Thiel, MD, John Houten, MD, and Matthew Wecksell, MD
While undergoing emergency C6-C7 corpectomy and anterior and posterior fusion, our prone
patient in whom airway management had been difficult experienced unplanned tracheal extubation. Herein, we describe emergency airway management including reintubation and provide
suggestions for airway management in the prone-positioned patient.(A&A Case Reports
2014;2:202)
CASE PRESENTATION
20 cases-anesthesia-analgesia.org
mask, likely secondary to his long beard and airway anatomy. We then proceeded to direct laryngoscopy (DL) with
inline stabilization. We were unable to visualize any part of
his vocal cords (CormackLehane grade 1V) and placed an
LMA Supreme, which allowed ventilation of the lungs until
a GlideScope (Verathon, Bothell, WA) was brought into the
room. However, and unlike some other supraglottic airway
devices, the LMA Supreme does not allow for intubation
through its barrel, and tracheal intubation was then achieved
by passing the large cuffed NIM ETT under indirect visualization using the GlideScope. The patients hemoglobin oxygen saturation (Spo2) remained 100% throughout this period.
Tincture of benzoin was then applied to the patients face and
beard, after which we taped the ETT in place.
The surgeon proceeded with the planned anterior C6-C7
corpectomy and fusion. He then decided to continue the
case with a posterior fusion of C5-T2 as well, requiring a
midcase prone repositioning. At this time, the ETT was
resecured with extra tape to the patients face and forehead.
Using Mayfield pinning (Integra, Plainsboro, NJ), the head
was secured to the table, with the slack from the anesthesia
circuit secured upward onto the table.
At completion of placement of the pedicle screws and just
before attachment to the fusion plate, the surgeon requested
radiographic examination of the spine to confirm screw
placement. As the toroidal O-Arm machine (Medtronic,
Minneapolis, MN) was positioned around the patients head,
it came into contact with the ETT. Soon after, the ventilator
bellows were noted not to be refilling after each breath. The
ETT was visually checked, and, because there was no change
in the capnogram at this time, the ETT was deemed to still
be in place. However, because the pilot balloon was felt to
be underinflated, several milliliters air was added, after
which it was noted that the bellows were now completely
collapsed, with the apnea alarm sounding 30 seconds later.
Additional anesthesia staff was called into the room.
LMA placement was attempted with the patient still
prone to no avail, and it was decided to turn the patient
supine despite only the partial fusion and the open surgical field. The wound was covered with Ioban (3M, St.
Paul, MN), a stretcher was obtained, and the patient
placed supine.
The attending anesthesiologist attempted mask ventilation while the resident prepared an LMA and called for the
GlideScope to be returned to the OR, because it had been
removed for use in another location. As was the case on
initial tracheal intubation, ventilation was extremely difficult and minimally effective. An LMA was placed, allowing
January 15, 2014 Volume 2 Number 2
DISCUSSION
While the traditional manner of airway management afthaner unintended tracheal extubation of the prone-positioned
patient involves returning the patient to the supine position, this introduces some delay in a high acuity situation.
The literature suggests that a return to the supine position
may not be necessary as a first-line response due to the efficacy of LMA placement while the patient remains prone.29
Given the familiarity, availability, and ease of use of
LMAs, many anesthesiologists are electing to use them in
patients positioned prone. A review by Abrishami et al.2
of studies and case reports describing emergency LMA
use in prone patients yielded a summary of 526 cases. The
LMA was successfully inserted 87.5% of the time with first
attempt improving to 100% success by the second attempt.
However, in only 83% of cases was proper ventilation possible with the LMA. Additional case reports support this
experience in neonatal, pediatric, and adult patients.35
The placement of LMAs in prone patients is not restricted
to emergencies. Ng et al.6 reported a series of 73 patients
in whom insertion of the LMA occurred after induction.
Additionally as part of a retrospective audit, Brimacombe
et al.7 reported the use of ProSeal LMAs in 245 patients. All
attempts were successful, though 8 of 254 required a gum
elastic bougie to aid in LMA placement during a second effort.
Hung et al.10 describe using a FOB to facilitate emergency intubation in the prone-positioned patient. Others
have had success as well with FOB intubations in the prone
patient.1113 However, due to the additional time and equipment needed, an LMA would likely remain the most frequently used first choice. Also, once a supraglottic airway
is successfully placed, it may be used as a conduit for a
fiberoptic intubation, provided it is a device supporting
such a maneuver. In our case, an intubating laryngeal airway, rather than an LMA Supreme, may have been a better
choice to have readily available at the start of the procedure.
Some have used a traditional DL in the prone-positioned
patient.14 Other reasonable options include video laryngoscopy. However, success in using any of these devices
depends on the experience of the anesthesiologist as well
as the availability of the equipment, and in the end, the best
treatment is prevention of circumstances leading to tracheal
extubation such as those occurring in our patient. Several
methods of securing ETTs to patients before moving to the
prone position have been proposed. These include using
extra tape and dressings, commercial ETT holders, suturing the ETT to the cheek or around a tooth, or to a nasally
routed pediatric orogastric tube.1518
Remembering to tighten all circuit/tube connections can
lesson the occurrence of disconnect, which could be confused for actual extubation. Some practitioners even prefer
to tape all the circuit/tube connections together,15 though
we do not recommend this as the tape may obscure a partial
disconnect of the taped components. We also prefer using
tape to secure the anesthesia circuit to either the OR table or
the Mayfield frame to prevent the weight of the circuit from
pulling on the ETT.
Failure of the original airway securement device or technique is a common cause of accidental extubation. Oral
secretions and other fluids from the surgical fields can
loosen the tape adhesive. Two techniques frequently used at
our institution, and in this case, can help prevent this. First,
after adequately securing the ETT with tape (usually >1
piece is required), an occlusive dressing is applied over the
tape edges. We use Tegaderm (3M, St. Paul, MN) dressings
in a variation of a technique originally described by Mikawa
et al.16 Secretions have a much harder time, penetrating the
Tegaderm to the tape itself.
In addition, before surgical preparation (if a cranial or
cervical spine procedure), we often apply towels or small
adhesive surgical drapes (1010; 3M, St. Paul, MN) on the
sides of the head to prevent excess fluid from the surgical prep, or blood from the procedure, to track down the
patients head, and directly onto our ETT. Of course, if
the ETT is secured by means other than tape, these additional precautions are not needed. Finally while there are
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21
CONCLUSION
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9. Osborn IP, Cohen J, Soper RJ, Roth LA. Laryngeal mask airway:
a novel method of airway protection during ERCP: comparison
with endotracheal tube. Gastrointest Endosc 2002;56:1228
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airway management with fiberoptic intubation in the prone
position with a fixed flexed neck. Anesth Analg 2008;107:17046
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rescue device in an anesthetized patient in the prone position.
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Massicotte EM, Fehlings MG. Intraoperative adverse events
and related postoperative complications in spine surgery:
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the semi-prone position following facial trauma. Anaesthesia
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laryngoscopy and endotracheal intubation in the prone position following traumatic thoracic spine injury. J Anesth
2008;22:1702
15. Ezike HA, Ajuzieogu VO, Amucheazi AO. A Reliable Method
of Securing The Endotracheal Tube in Patients Undergoing
Neurosurgical Procedure in the Prone Position. The Internet
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16. Mikawa K, Maekawa N, Goto R, Yaku H, Obara H. Transparent
dressing is useful for the secure function of the endotracheal
tube. Anesthesiology 1991;75:112344
17. Ota Y, Karakida K, Aoki T, Yamazaki H, Arai I, Mori Y,
Nakatogawa N, Suzuki T. A secure method of nasal endotracheal tube stabilization with suture and rubber tube. Tokai J
Exp Clin Med 2001;26:11922
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tube fixation using the infant feeding tube. Anesth Analg
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19. Carlson J, Mayrose J, Krause R, Jehle D. Extubation force:
tape versus endotracheal tube holders. Ann Emerg Med
2007;50:68691