LARYNGEAL MASK AIRWAY IN
THE PRONE POSITION
Dr. Paul Zilberman
Israel 2013
paulzi60@yahoo.com
Cluj 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 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
- 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/aem380
Anaesthesia in the prone position
H. 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
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 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
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…
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 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 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
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) 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 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 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 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 same armrest from
a slightly different angle.
Correct arm position, no tension in the
shoulder, 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 CENTER
BNEY BRAK
ISRAEL
DIFFERENT REACTIONS…
Are you nuts?
Distrust
Astonishment
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 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 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