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Clinical Case for Discussion: A 44-year-old man is scheduled for a knee arthroscopy. He takes Prilosec for Gastro Esophageal Reflux Disease (GERD). He is six feet tall, weighs 70 kg, and refuses regional anesthesia. Regarding airway management for general anesthesia, you may choose a Laryngeal Mask Airway (LMA) or an endotracheal tube. What do you do?
Discussion: The symptoms of esophageal reflux and heartburn are exceedingly common in our society. For years the histamine-2 blockers such as cimetidine and ranitidine were among the top money-making prescription drugs in America, before they became the over-the-counter bestsellers they are today. Open any weekly magazine such as Newsweek or Sports Illustrated and you may find full page ads for Nexium and Protonix today. People hurt, and they want these pills.
This is relevant in an anesthesia practice because a large percentage of patients will answer “yes” to the question of heartburn or GERD in a pre-operative questionnaire. Thus GERD goes on their chart as a diagnosis. How important is this? Are they an ASA I or an ASA II, based on GERD? Do they need endotracheal intubation for general anesthesia to prevent the dreaded complication of pulmonary aspiration of gastric contents?
Miller’s Anesthesia, a leading textbook, says,”The incidence of aspiration of gastric contents is infrequent in fasted elective surgical patients. Despite improvements in several surrogate measures, insufficient evidence exists of clinical benefit (i.e., a reduction in morbidity or mortality from aspiration) to recommend the routine use of antacids, metoclopramide, H 2 -receptor antagonists, or proton pump inhibitors before elective ambulatory surgery. Patients who are receiving these medications chronically should take them before surgery. Patients who regularly suffer from significant acid reflux in the fasted state will also benefit from the head-up tilt position during induction of anesthesia.” (Smith I. Ambulatory(Outpatient)Anesthesia, Miller’s Anesthesia.10e,Chapter 89.2015; 2612-2645)
The same textbook says, “Many ambulatory surgical patients can be managed with an LMA, which results in a significantly less frequent incidence of sore throat, hoarseness, coughing, and laryngospasm compared to inserting a tracheal tube. The LMA can occasionally cause pressure trauma to a variety of cranial nerves, in particular the recurrent laryngeal nerve, whereas hoarseness and vocal cord injuries are common after the use of endotracheal intubation during short-term anesthesia. The LMA is relatively easy to insert with patients in the prone position, 230 making it a simple way of managing procedures such as pilonidal sinus repair or surgery to the short saphenous vein.”
In 2010 I submitted the Clinical Case above to the twenty-plus attending anesthesiologists in private practice in Palo Alto who are members of the Palo Alto Medical Foundation/Sutter or the Associated Anesthesiologists Medical Group. What follows is a consensus of what the majority do, every day, in operating rooms in the heart of Silicon Valley:
If the patient had GERD which was well-treated on medication, and had no symptoms at present, my colleagues said they would use an LMA for airway management, rather than intubate the patient’s trachea. If the patient had active symptoms of GE reflux that were not under control or had gastric paresis, then they would use an endotracheal tube following cricoid pressure.
One could be dogmatic and say this: If a patient has GERD, then intubate the trachea with a rapid sequence intubation each time, or you run the risk of aspiration pneumonitis. However, no data exist to support this practice. There is no prospective, randomized trial that documents an endotracheal tube is more safe than an LMA in an NPO GERD patient for routine outpatient minor surgery.
The ProSeal LMA has a larger cuff, and a drain tube inside the cuff, which allows the insertion of a gastric tube to drain the stomach. There is a case report in which an anesthetized patient with a ProSeal regurgitated 25 ml of brown fluid into the drain tube. The conclusion was that the ProSeal protected the airway by allowing the regurgitated fluid to pass up the drainage tube without leaking into the glottis. (Evans NR, Can J Anaesth. 2002 Apr;49(4);413-6). The ProSeal may have a role in the GERD patient population, but to date there is little data to compare it to a classic LMA in this setting.
No physician anesthesiologist would use an LMA in a patient who was not NPO. No one would use an LMA in a patient for emergency surgery, or for a patient with a bowel obstruction. No one, or very few, would use an LMA in a patient who was morbidly obese, or a patient who was having a laparoscopy.
But for a routine outpatient surgery on an NPO patient with controlled GERD, most anesthesia professionals feel safe using an LMA rather than an endotracheal tube. There are anesthesiologists — well trained graduates of the Stanford anesthesia residency program — who use an LMA in this situation. The good news is that the prevalence of clinically important aspiration in otherwise healthy NPO patients is negligible. I believe that is why most of my colleagues choose the LMA in this case.
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Published in September 2017: The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.
KIRKUS REVIEW
In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.
Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.
Nuanced characterization and crafty details help this debut soar.
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How does one approach a situation where, a patient has a significant recent h/o GERD aspirations likely leading to lung damage, and they are to undergo a relatively minor IR procedure such as PEG tube placement? In this situation, would it be the accepted standard to always intubate with either LMA or ET tube? When would you feel comfortable doing conscious sedation in the scenario?
Thank you,
Lucas
I’d recommend a rapid-sequence intubation with an endotracheal tube to control the airway. You don’t want to join the list of those who brought on “significant recent history of GERD aspirations.” Conscious sedation is OK if indeed, the patient is conscious throughout. If the patient loses consciousness, and loses airway protective reflexes, you are at significant risk for aspiration in this patient.