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Management of unanticipated difficult intubation with intubating LMA ( LMA-Fastrach) and review of literature including comparison to classic LMA
Abstract Number: 169
Abstract Type: Case Report/Case Series
The use of the CLMA has been described for elective Cesarean sections in over 1000 healthy parturients without any detected aspiration or regurgitation1.The use of CLMA has also been described after failed intubation in the obstetric population.The intubating LMA (ILMA) facilitates rapid and blind intubation of the trachea in an urgent situation but has not been reported in the Obstetric Anesthesia literature as a useful rescue airway device. It has the benefit of rapidly and blindly securing the airway with an endotracheal tube which is particularly useful in urgent C sections in parturients who are at high risk for aspiration of gastric contents. We report 2 cases of the use of an ILMA after failed intubation. The ILMA also served as a conduit for fiber optic intubation of the trachea subsequently.
Failed intubation in parturient is more common than the general surgical population with incidences in the obstetric population being as high as 1 in 250. According to the ASA difficult airway algorithm, the LMA may be used as a rescue airway device after initial intubation attempts have failed and mask ventilation is inadequate( emergency pathway), the LMA may serve as a conduit for fiber optic intubation of the trachea.While both types of the classic and intubating LMA are useful, unique features of the ILMA or LMA-Fastrach provide better insertion and intubation characteristics compared to the classic device
A study describes The ILMA used in 257 patients with an overall success rates for blind and fiber optically guided intubations of 96.5% and 100.0%, respectively.3
In comparison , studies of the CLMA as a conduit for for endotracheal intubation report a wide range of success rates from 30 to 90%4. It is also important to consider the potential damage to laryngeal structures during blind intubation attempts if the CLMA is not positioned well.
There is anecdotal evidence supporting the use of the LMA devices for failed ventilation and intubation in obstetric patients.In principle, the ILMA may offer some advantages over the CLMA in both these situations. We report this case as there are no cases reported in the literature about the use of an ILMA for airway rescue in a parturient for urgent C section and compare and contrast some of the characteristics of the 2 devices
1. Tac-Hyung H, Brimacombe J, Eun-Ju L, Hong-Seuk Y. The laryngeal mask airway is effective (and probably safe) in selected healthy parturients for elective Cesarean section: a prospective study of 1067 cases. Can J Anesth 2001; 48: 1117-1121.
2. McClune S, Reagan M, Moore J. Laryngeal mask airway for Caeserean section. Anaesthesia 1990; 45: 227-8.
3. Ferson DZ, Rosenblatt WH, Johansen MJ, Osborn I, Ovassapian A. Use of the intubating LMA-Fastrach in 254 patients with difficult-to-manage airways. Anesthesiology. 2001 Nov;95(5): 1175-81.
4. Hawthorne L, Wilson R, Lyons G, Dresner M. Failed intubation revisited: 17 yr experience in a teaching maternal hospital