Laryngeal mask airway classic as a rescue device ...

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suggested the use of. Tomoaki and Yoshihisa's ASA PS 7 grade classification ... ASA PS score to indicate the affected organ systems. .... as easy. Grover et al.
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Letters to Editor

Laryngeal mask airway classic as a rescue device after accidental extubation in a neonate in prone position Sir, We report a case of accidental extubation in a neonate who underwent surgery in prone position, and subsequent airway management with an Laryngeal mask airway (LMA) classic, in the same position. A 6-day-old male child, weighing 2.65 kg was posted for surgical repair of meningomyelocele. After induction of anaesthesia, and adequate muscle relaxation, the trachea was intubated with an uncuffed tube of 3-mm internal diameter. The tube was connected to the paediatric circuit and positive pressure ventilation instituted. After checking for proper placement and adequate ventilation, the tracheal tube was secured with a fixation tape. The child was turned prone for the surgery, with the head turned towards his left side. About 20 minutes after the surgery had commenced, inadequate ventilation of lungs was noticed, as evidenced by the feel of the bag, and disappearance of the end-tidal CO2 graph. The tracheal tube had slipped out and the tip was found to be in the oral cavity, which probably occurred due to wetting of fixation tape by saliva, and subsequent tube displacement. The tube was removed, and a size 1 LMA Classic was inserted with the cuff partially deflated, in the first attempt. After inflating the cuff, the airway tube was connected to the breathing circuit and positive pressure ventilation reinstituted. The ventilation was adequate, as evidenced by equal bilateral air entry and the capnograph trace on the monitor. The O2 saturation was 100% during the sequence of events. The surgery was completed in another 15 minutes, during which the haemodynamic and respiratory parameters were normal. The child was turned supine, and neuromuscular blockade was reversed when he was conscious. The LMA was removed, following which, gentle oral suction was done. The postoperative period was uneventful. Another way of managing this complication would have been turning the child supine, and reintubating the trachea. But turning the patient supine and managing the patient would mean a little longer 542

time without a definite airway and ventilation in an anaesthetized, paralyzed neonate. In addition, the risk of spinal cord injury and compromising the surgical field sterility in this case during such manipulation made us consider securing airway in the prone position. Moreover, we had a size 1 LMA Classic ready on the anaesthesia cart and the authors are experienced in the use of various supraglottic airway devices in the prone position in adult patients.[1] Several authors have reported management of accidental extubation in prone position with LMA Classic.[2,3] To the best of our knowledge, this is the first report of such an instance in a neonate.

Susheela Taxak, Ajith Gopinath Department of Anesthesiology and Critical Care, Pt. B. D. Sharma PGIMS, Rohtak, Haryana, India Address for correspondence: Dr. Ajith Gopinath, Department of Anesthesiology and Critical Care, Pt. B.D. Sharma PGIMS, Rohtak, Haryana, India. E-mail: [email protected]

REFERENCES 1. 2. 3.

Taxak S, Gopinath A. Insertion of the i-gel airway in prone position. Minerva Anestesiol 2010;76:381. Dingeman RS, Goumnerova LC, Goobie SM. The use of a laryngeal mask airway for emergent airway management in a prone child. Anesth Analg 2005;100:670-1. Raphael J, Rosenthal-Ganon T, Gozal Y. Emergency airway management with a laryngeal mask airway in a patient placed in the prone position. J Clin Anesth 2004;16:560-1. Access this article online Quick response code Website: www.ijaweb.org

DOI: 10.4103/0019-5049.89902

Anaesthesia risk stratification: Time to think beyond American Society of Anesthesiologists Physical Status Classification Sir, I read a review article “American Society of Anesthesiologists Physical Status Classification” Indian Journal of Anaesthesia | Vol. 55| Issue 5 | Sep-Oct 2011

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Letters to Editor

by Mohamed Daabiss[1] in Ind J Anaesth 2011; 55(2): 111‑5 with great interest. American Society of Anesthesiologists Physical Status (ASA PS) Classification has many limitations, namely: Inability to distinguish disorders of different systems; inability to delineate or cumulate risk based upon multiple system involvement; to consider surgical invasiveness, or identify specific anaesthetic risk. Dr. Mohamed Daabiss suggested the use of Tomoaki and Yoshihisa’s ASA PS 7 grade classification which takes into consideration operative and anaesthetic factors to a certain extent.[2] However, this also seems to be quite subjective, and fails to identify single or multiple systems involvement, extent of surgical invasiveness or specificity of anaesthetic factor. [1]

I came across one such score SHAPE™ (Silverman‑Holt Aggregate Preoperative Evaluation),[3] which overcomes all above mentioned limitations. It is easy to use as Acronym “ASPIRIN”: A ‑ ASA physical status, S ‑Surgical risk/invasiveness, P ‑ Physical factors predominantly affecting mask ventilation, I ‑Intubation predictors, R ‑ Risk Indicators that reflect potential anaesthesia‑related concerns. They have further formed SHAPE™ Individual Systems [SIS™]) score in which 1 to 5 severity score is assigned for each major organ system, based on information learned from the patient history and physical examination. A code (e.g., first few letters of the given system) is superscripted to the traditional ASA PS score to indicate the affected organ systems. The presence of multiorgan system disease would be represented by each of the appropriate system identifications. Thus, a patient who has exertional angina and insulin‑dependent diabetes would be an ASA 3CARD,ENDO. A five‑tiered classification scheme is used for ranking of surgical risk and invasiveness. Each score has a name, description and examples. This covers almost all surgeries. Applications as stated by them are many. Namely: Clinical, institutional, administrative and investigative. They have hard‑coded the system into automated information management systems and have applied for patent in United States of America.[4] Though one may think that it is alright to use the complex system in computer based automated records, this may not be possible for individual anaesthesiologist working in peripheral hospitals. I have made a simple solution to that in the form of a single page user friendly chart where one has to just write a number or encircle a number [Figure 1]. Indian Journal of Anaesthesia | Vol. 55| Issue 5 | Sep-Oct 2011

SHAPE™ (Silverman-Holt Aggregate Preoperative Evaluation)

A ASA PS CNS PSYCH ENDO CARD VASC RS LPS GI KUB GENDER NMS EENT HEME FLUID & SPECIFIC ELECTROLYTES

S 1

2

Surgical Risk / Invasiveness 3

P Physical factors affecting Mask ventilation Predictor Score Age Score 15–55 yrs 0 56–80 yrs 0.5 >80 yrs 1.0 History & Physical Score None 0 Habitual snoring 0.5 Possible sleep apnoea 2 Probable/definite sleep apnoea 3 Body Mass Index Score 0 £ 30 31–45 1 46–60 2 > 60 4 Internal/external airway pathology Score Present, unlikely to be significant 0.5 Possible, moderate deformity 2 Obstruction/Impending 5 obstruction Miscellaneous factors Score Large beard or edentulous 0.5 Moderately distorted facial 2 anatomy Significantly distorted facial 5 anatomy 5 Persistent aspiration risk (eg, term pregnancy, Zencker’s diverticulum, obstruction)

Final SHAPETM Risk

4

I Intubation predictors* Predictor Score Mallampati class I or II 0 III 1 IV but improves with 3 vocalizing IV with no improvement with 4 vocalizing Ability to prognath No overbite, good extension 0 No overbite, poor extension 1 Overbite, easily reversed 0.5 Overbite, barely able to reverse 2 Overbite, unable to reverse 4 Can’t understand request to 0.5 prognath Mouth opening > 4 cm 0 3–4 cm 1 2–3 cm 4 < 2 cm 5 Moderate TMJ Ankylosis +0.5 Severe TMJ +2 Neck mobility (degrees*) & Size > 600, normal size 0 0 > 60 , short neck 0.5 300–600, normal neck 0.5 300–600, short neck 2 0 0 10 –30 , normal neck 3 100–300, short neck 4 6 cm 0 4–6 cm 0.5 3–4 cm 1 2–3 cm 2 < 2 cm 4 *Intubation history Moderate difficulty 3 Pronounced difficulty 4 Impossible 5

5

RIN Code Conditions/issues A Aspiration risk despite pretreatment B Bleeding risk C Communication problem Dx Diagnosis or prior anaesthetic problem indicative of anaesthesiaspecific risks E Emergency I ICD in place L Latex allergy M Management issues O Morbid obesity P Pregnancy T Tracheostomy W Withdrawal risk

Figure 1: SHAPETM Score

This can be printed on back side of the informed consent paper, which can perhaps help in medico legal issues as well. Example: Male/60 years/height 160 cm/weight 50 kg with poorly controlled diabetes with Ketoacidosis presented for below knee amputation. Echocardiography showed wall motion abnormalities. Ejection Fraction (EF) was 25%–50%. He is edentulous. SHAPE™   4ENDO>CARD, 3, 1, 2, A, E I think it is worth an evaluation.

Anila D Malde Department of Anaesthesiology, Lokmanya Tilak Municipal Medical College and Lokmanya Tilak Municipal General Hospital, Sion, Mumbai, Maharashtra, India Address for correspondence: Dr. Anila D Malde, Block No. 3, Nagjibhai Mansion, Manubhai P. Vaidya Marg, Ghatkopar (East), Mumbai ‑ 400 077, Maharashtra, India. E‑mail: [email protected]

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Letters to Editor

REFERENCES 1.

Daabiss M. American Society of Anesthesiologists Physical Status Classification. Indian J Anaesth 2011;55:111‑5. 2. Tomoaki H, Yoshihisa K. Modified ASA physical status (7grades) may be more practical in recent use for preoperative risk assessment. Internet J Anesthesiol 2007;15. [Last accessed on 2011 Jun 05]. 3. Holt NF, Silverman DG. Modeling perioperative risk: Can numbers speak louder than words? Anesthesiol Clin 2006;24:427‑59. 4. Silverman. Patent Application Publication. United States, Pub No: US 2007/0214013 A1 Pub. Date. Sept. 13, 2007. http:// www.freshpatents.com/Method-and-system-for-assessingquantifying-coding‑‑‑x26‑‑communicating-a-patient-s-healthand-perioperative-risk-dt20070913ptan20070214013.php. Access this article online Quick response code Website: www.ijaweb.org

DOI: 10.4103/0019-5049.89903

Mallampati class ‘zero’ ‑ yet another cause? Sir, I present a 40‑year‑old female patient with severe kyphoscoliosis involving cervical, thoracic and lumbar spine, bilateral staghorn renal calculi and renal failure scheduled for percutaneous nephrolithotripsy. The patient has given consent to report this. On examination, she had Mallampati class zero airway and a visible epiglottis on mouth opening. In view of cervical spine involvement, a lateral radiographic view of the neck was done to rule out any airway difficulty (Figure 1). It showed that the epiglottis was at C2 level with distortion of airway. On induction of anaesthesia, there was no difficulty in mask ventilation. Initial attempt at intubation by the trainee resident resulted in oesophageal intubation as he went past the glottic opening and experienced difficulty in glottic visualization. After the reason for difficulty was recognized, subsequent attempt at intubation by attending anesthesiologist taking appropriate measures was successful and was graded as easy. Grover et al.[1] reported a similar encounter of difficult laryngoscopy in a class zero airway due to a large obstructive epiglottis. Grade 1 position of the larynx can cause difficulty in intubation despite 544

Figure 1: X‑Ray neck lateral view showing the epiglottis at C2 level with distortion of airway

normal epiglottis if the laryngoscopist does not use an appropriate technique. In a prospective study by Ezri et al.,[2] all patients with Mallampati class zero were women and had laryngoscopic grade 1. The difference in neck fat deposition between the sexes was suggested as an explanation for the perceived easier class of airway in women. Difficulty in not only intubation but also mask ventilation due to large floppy epiglottis in class zero patient was reported by Fang and Norris.[3] The possible cause for Mallampati class zero in my patient was distortion of airway. Severe kyphoscoliosis may have caused alteration in the alignment of the pharyngeal and laryngeal axes. This may have contributed to elevation of laryngeal inlet resulting in class zero view. This case highlights the other causes for mallampati class 0 airway, in addition to earlier reports of large redundant epiglottis and female gender. It is important to recognize the possibility of difficult laryngoscopy despite an easily visible epiglottis. The increased force during laryngoscopy in the event of difficulty in visualizing the glottis has potential for causing neurological injury, especially in patients with cervical spine abnormality.

G Indira Department of Anaesthesiology, Narayana Medical College, Nellore, Andhra Pradesh, India Address for correspondence: Dr. Gurajala Indira, Plot No. 8, Lalithanagar, Jamai Osmania, Hyderabad, Andhra Pradesh, India. E‑mail: [email protected]

REFERENCES 1.

Ezri T, Warters RD, Szmuk P, Saad‑Eddin H, Geva D, Katz J, Indian Journal of Anaesthesia | Vol. 55| Issue 5 | Sep-Oct 2011