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Correspondence |
Lahey Clinic, Burlington, USA, E-mail: michael.stix{at}lahey.org
Dr. Cook or others may have a different reinsertion rate than we experienced, and these differences may be due to a number of variables: pharmacological paralysis or not, use of the insertion tool or fingertip, presence of assistants providing mouth-opening and jaw thrust or no such assistance, level of experience and familiarity with the ProSeal, technique for deflation and preparation of the cuff, size selection for the mask, patient age and anatomy. What Dr. Cook does not explain is how he diagnosed his 17% of patients with unsuccessful insertion attempts, or how he established diagnosis of glottic insertion in 1.8% of reinsertions. We fear most ProSeal laryngeal mask air-way (PLMA) users simply insert the device, hook up the anesthetic circuit, and hope for the best.
The drain tube permits rapid and reliable diagnosis of malposition without use of any ventilatory trial. Such ventilatory trials cannot diagnose the foldover malposition.1,2 When glottic insertion occurs the ventilation is simply ineffective. In both circumstances, these ventilatory trials occur while there is inadequate separation of the gastrointestinal and respiratory tracts and thus endanger the patient. Our first goal using the ProSeal is to ensure that the tip of the mask is inserted into the esophageal inlet. This takes only ten to 15 sec and soap solution on the drain tube port to create a membrane. If we find that the mask is malpositioned, we reinsert it. If the position appears satisfactory, we then proceed to test ventilation.
Once the user has excluded malposition of the PLMA, the anesthesia circuit may be connected with confidence to assess how well the PLMA will function as an airway.3 The user can then make an informed decision about the appropriate use of the device for the intended surgical procedure. The drain tube of the PLMA is much more than a portal to empty the stomach or a conduit for a bougie.
References
1 Brimacombe J, Keller C, Berry A. Gastric insufflation with the ProSeal laryngeal mask. Anesth Analg 2001; 92: 1614–5.
2 Brimacombe J, Keller C. Aspiration of gastric contents during use of a ProSeal laryngeal mask airway secondary to unidentified foldover malposition. Anesth Analg 2003; 97: 1192–4.
3 Stix MS, O’Connor CJ Jr. Maximum minute ventilation test for the ProSeal laryngeal mask airway. Anesth Analg 2002; 95: 1782–7.
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