Comparison of the use of laryngeal mask airway Supreme and laryngeal mask airway ProSeal in prone position for pilonidal sinus excision surgery
Adel A.N. Mahgoub
Department of Anesthesia and Surgical Intensive Care, Faculty of Medicine, University of Alexandria, Alexandria, Egypt
Date of Submission 09-Sep-2015
Assistant Professor of Anesthesia and Surgical Intensive Care, Faculty of Medicine, University of Alexadria, 88206
Surgeries that require the patient to be in the prone position represent a challenge to the anesthesiologist in terms of securing the airway and additional time and personnel required for induction in the supine position and shifting to the prone position. Use of the classic laryngeal mask airway (LMA) in the prone position is a subject of controversy; the ProSeal LMA may be more suitable as it forms a better seal and provides access to the stomach. LMA Supreme is a newly introduced single-use supraglottic device that shares common features of both the LMA ProSeal and the intubating LMA.
Aim of this study
The aim of the study was to compare the use of LMA ProSeal and LMA Supreme after induction of anesthesia in the prone position.
The study included 80 adult male patients for pilonidal sinus excision surgery. They were randomly divided into two equal groups: group P and group S. The ProSeal was used in group P and the Supreme was used in group S. Ease of insertion, ease of ventilation, leakage of inspiratory gases, SpO 2 , EtCO 2 , blood on the airway device after removal, and postoperative incidences of sore throat were recorded.
There was no statistical difference between the two groups in terms of age, BMI, or duration of surgery. Both devices provided good air seal and good ventilation. Blood-stained saliva and postoperative sore throat were found more with ProSeal use than with Supreme.
Allowing the patients to take the prone position themselves and then inducing general anesthesia and securing the airway either with ProSeal or with Supreme is a safe practice.
Keywords: laryngeal mask airway, pilonidal sinus excision surgery, prone position, ProSeal, Supreme
Mahgoub AA. Comparison of the use of laryngeal mask airway Supreme and laryngeal mask airway ProSeal in prone position for pilonidal sinus excision surgery. Res Opin Anesth Intensive Care 2015;2:111-5
Mahgoub AA. Comparison of the use of laryngeal mask airway Supreme and laryngeal mask airway ProSeal in prone position for pilonidal sinus excision surgery. Res Opin Anesth Intensive Care [serial online] 2015 [cited 2020 Jan 19];2:111-5. Available from: http://www.roaic.eg.net/text.asp?2015/2/4/111/178902
The prone position is used for both major operations such as vertebral surgeries and for minor ambulatory procedures such as percutaneous nephrolithotomy, posterior varicose vein avulsion, pilonidal sinus excision, posterior calf surgery, Achilles tendon repair, arthroscopy of the ankle, etc. [1],[2].
Surgeries requiring the patient to be in the prone position represent a challenge to the anesthesiologist in terms of securing the airway and additional time and personnel needed for induction in the supine position and shifting of the patient to the prone position. Routinely, patients are anesthetized in the supine position, and after tracheal intubation they are turned over to the prone position. This method is time-consuming and involves numerous personnel, necessitating a shift of manpower (nurses, operating theater assistants, anesthesiologists, and surgeons) from other tasks to properly position the patient. Therefore, in busy operating theaters, operations performed in the prone position are a potential cause of delay in surgery schedules. In addition, special care is required to avoid respiratory impairment, adequate padding must be supplied at pressure points, and protection must be applied to the eyes. All these can further delay the initiation of surgery and the operating theater workflow [3],[4].
Over the past years it has become common practice to induce anesthesia and introduce the laryngeal mask airway (LMA) after patients have positioned themselves in the prone position [5],[6]. This is done to improve the flow of work in the operating theater. Use of the classic LMA in the prone position is subject to debate. Other LMA types have been used in different studies [7]. The ProSeal LMA may be more suitable than classic LMA as it forms a better seal and provides access to the stomach. LMA Supreme is a newly introduced single-use supraglottic device that shares common features of both the LMA ProSeal and the intubating LMA [8],[9],[10].
The aim of this study was to compare the efficacy and side effects of LMA ProSeal with those of LMA Supreme after induction of anesthesia in the prone position for pilonidal sinus excision surgery.
The study was conducted on 80 male patients of ASA grade 1. Their ages ranged from 20 to 50 years. They were presented for pilonidal sinus excision that required them to be in the prone position and under general anesthesia. This study was approved by the Ethical Committee. Written informed consent was obtained from patients following detailed explanation of the study. Exclusion criteria were a BMI greater than 35, being edentulous, and having reflux esophagitis.
The patients were randomly allocated into two equal groups of 40 patients each. In the first group (group S) LMA Supreme was used and in the second group (group P) LMA ProSeal was used to secure the airway.
In the pre anesthesia clinic thorough physical examination and routine laboratory investigations were done. The patients were advised to stay NPO (nothing per os) for 6 h preoperatively. In the operating suit the patients' vital signs were checked and an intravenous cannula was inserted. They were asked to lie comfortably in the prone position before receiving anesthesia, with pillows under their thorax and pelvis. The head was gently directed to the right side and made to rest over a horse shoe gel pad with its opening opposite the mouth to allow airway manipulation. Standard vital sign monitors were applied, including ECG, SpO 2 , and non invasive blood pressure (NIBP). Preoxygenation was done for 3 min with 100% oxygen through the face mask; 2 μg/kg fentanyl was given, followed by propofol 2 mg/kg for induction of anesthesia. The LMA airway was checked and lubricated with lidocaine gel 2% before insertion. After the induction of anesthesia, a laryngeal mask (Supreme or ProSeal) of size 3 or 4 or 5 was introduced, depending on the patient's weight and manufacturer's recommendation. Size 3 was used for patients under 50 kg, size 4 for patients between 50 and 70 kg, and size 5 for patients heavier than 70 kg. All insertions were performed by anesthetists with good experience in using these supraglottic devices. Digital guidance was adopted to insert the ProSeal, and in case of failure another trial was attempted with the use of a ProSeal special metal introducer. LMA Supreme was inserted following the manufacturer's recommendations. Lubricate the posterior surface of the mask and airway tube just before insertion. The device is held firmly at its fixation tab with the thumb and index finger. The distal tip is pressed against the inner aspect of the upper teeth or gums. It is then slid inwards using a slightly diagonal approach (direct the tip away from the mid-line). The tip is continued to slide inwards by rotating the hand in a circular motion so that the device follows the curvature behind the tongue. Resistance should be felt when the distal end of the device meets the upper esophageal sphincter. The device is now fully inserted. All LMAs were deflated before insertion and lubricated with water-soluble gel over its posterior surface. After insertion of LMA in the two groups, we used maximum cuff inflating volumes as recommended by the manufacturer (20 ml for size 3, 30 ml for size 4, and 40 ml for size 5 in ProSeal; and 30 ml for size 3 and 45 ml for size 4 or 5 Supreme). In all cases LMA cuff pressure is not allowed to exceed 60 cmH 2 O measured with a manometer (VBM Medizintechnik GmbH, Sulz, Germany). Two attempts at insertion were made before we considered the process a failure and the patient was shifted to the supine position in the nearby trolley kept for this purpose. The patient's airway was then secured with an armored flexo-metallic endotracheal tube. Face mask ventilation with sevoflurane 2% in oxygen was given for 2 min. The anesthetist assistant helped pull up the patient by the shoulders while the anesthesiologist inserted the airway, which was LMA Supreme in group S (The Laryngeal Mask Company Limited, Le Rocher, Victoria, Mahe, Seychelles) and LMA ProSeal in group P (LMA north America). The patient was then connected to the breathing circuit of the anesthesia machine and started on manual breathing followed by mechanical ventilation with sevoflurane 2% and N 2 O 50% in oxygen [Figure 1], [Figure 2], [Figure 3] and [Figure 4] for group P and [Figure 5], [Figure 6], [Figure 7] and [Figure 8] for group S). Synchronized intermittent mandatory ventilation mode was adopted with tidal volume (Vt) 5-7 ml/kg, rate 10-14, pressure support of 10 cmH 2 O, and positive expiratory airway pressure of 5 cmH 2 O. The target was to maintain SpO 2 greater than 96% and end tidal CO 2 (EtCO 2 ) between 35 and 45 mmHg. The patient emerged from anesthesia in the supine position. LMA was removed when the patient awakened with adequate spontaneous minute ventilation (more than 100 ml/kg).
Figure 1: After patient positioned himself prone and induction of anesthesia.
Figure 2: Start of insertion of laryngeal mask airway (LMA) ProSeal.
Figure 3: Laryngeal mask airway (LMA) ProSeal is fully inserted.
Figure 4: After successful insertion of laryngeal mask airway (LMA) ProSeal, it was connected to the breathing circuit.
Figure 5: After patient positioned himself and induction of anesthesia.
Figure 6: Start to open the mouth for insertion of laryngeal mask airway (LMA) Supreme.
Figure 7: Laryngeal mask airway (LMA) Supreme is fully inserted.
Figure 8: After successful insertion of laryngeal mask airway (LMA) Supreme, it was connected to the breathing circuit.
Ease of insertion, failed attempts at insertion, quality of ventilation, airway peak pressure, efficacy of seal calculated by percentage of inspiratory gas leak [(preset Vt−exhaled Vt)/preset Vt%], appearance of blood-stained mask on removal, intraoperative accidental dislodgement, and incidence of postoperative sore throat after 6 h were recorded.
The unpaired Student t-test was used for comparison of continuous variables and Fisher's exact test for comparison of sex, sore throat, and bloody saliva. A P value less than 0.05 was considered significant.
There was no statistical difference between the two groups with respect to age and BMI [Table 1]. There was no statistical difference in the duration of surgery between the two groups (52.3+8.4 in group S and 50.9+9.3 in group P). P value was greater than 0.05.
Table 1: Patient's data and duration of surgery
In all patients in the S group, the Supreme was successfully inserted at the first attempt. In group P the ProSeal was successfully inserted in 35 patients in the first attempt and in 15 patients in the second attempt using its special metallic introducer. No case in the study was considered as having failed; that is, in no case in the study did we have to shift the patient to the supine position and insert the endotracheal tube. Incidence of blood-stained laryngeal mask on extubation was significantly higher in group P than in group S (12 and five cases, respectively). Postoperative sore throat was significantly higher in group P than in group S. Fifteen patients in group P and seven patients in group S complained of postoperative sore throat [Table 2].
Table 2: The incidence of complications
During intraoperative ventilation there was insignificant difference between group S and group P in terms of air leak ratio (65.8 + 10.7 and 63.7 + 11.4, respectively).
One of the important aims behind ambulatory surgery is to shorten the time the patient spends in the operating room. Ambulatory procedures, such as percutaneous nephrolithotomy, excision of pilonidal sinus, short varicose vein avulsion, excision of back lipoma, etc., require the prone position. These patients are usually anesthetized on a trolley placed beside the operating table in the supine position. After tracheal intubation many operating room personnel should be available to securely and safely shift the patient from the trolley to the prone position on the operating table and special care must be taken to avoid accidental extubation, impairment of ventilation, reduction of blood pressure, reduction of venous return, strain over joints, and pressure on the eye globe; padding of pressure points must be ensured. This approach is time-consuming and may cause delays in patient turn over during ambulatory surgery. Rapid tracking is very important, particularly in ambulatory surgery, because it facilitates more optimal use of available resources and operating rooms [11].
The use of LMA for surgery in the supine position with either spontaneous or controlled ventilation is widely accepted [12]. However, when lateral or prone positions are needed for surgical access, some authors rule out the use of the LMA for airway control [13]. Räsänen [14] recommends the use of the LMA for surgery in the lateral decubitus or the Trendelenburg position, but not in the prone position.
In our study we asked the patients to place themselves comfortably in the prone position before induction of anesthesia. This enables optimal positioning because patients know their most comfortable position; thus, the whole process is simplified, the induction time is shortened, and the operative track is quickened. Besides, anesthesia induction after prone positioning avoids the occurrence of hypotension while shifting the anesthetized patient from the supine to the prone position [15].
In our study we compared between the use of two kinds of LMA: Supreme and ProSeal. We found that efficacy of ventilation was comparable in the two groups; none of the patients developed hypoxemia (all SpO 2 readings were >96%) or hypercapnia (all EtCO 2 readings were <45 mmHg). There was no statistical difference between group S and group P in terms of percentage of inspiratory gas leak [13.3% (2.5) and 14.1% (2.2), respectively; P > 0.05]. The relatively good seal in prone position may be explained by the cephalic displacement of the larynx by the effect of gravity and the sustained counter pressure of the LMA by operating table.
Unfortunately many anesthesiologists do not use LMA when the prone position is required, perhaps because they are afraid of losing control of the airway. A few reports were published in the early 1990s [16], but no new reports have been published over the past decade, until recently. In the recently published series there were no adverse effects. Use of LMA in the prone position has been reported after accidental extubation in spine surgery [17].
In our study, blood-stained saliva over the LMA was found more frequently with ProSeal use than with Supreme (7.5 and 17.5%, respectively; P < 0.05). More patients complained of postoperative sore throat in group P than in group S (15 and 20%, respectively; P < 0.05). This may be because two trials for insertion of ProSeal were conducted; besides, LMA ProSeal has a relatively hard peak of the esophageal opening.
Weksler et al. [13] found blood-stained saliva over LMA in 15 of 25 patients (60%). This incidence is significantly higher than that reported by Dingley et al. [18], who found that 22% of patients undergoing short operative procedures with the LMA had incidences of blood staining in the LMA.
From our study we can conclude that for pilonidal sinus excision or other short day-case surgeries that require the patient to be in the prone position allowing the patient to take the prone position themselves, then inducing general anesthesia, and securing the airway either with ProSeal or with Supreme is a safe practice. This saves time and requires fewer healthcare personnel who are usually required for the positioning.
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Mahgoub AA
laryngeal mask airway
pilonidal sinus excision surgery
ProSeal