|Year : 2020 | Volume
| Issue : 1 | Page : 39-40
Ambu® Auragain™, an alternative supraglottic airway device for airway management in prone position
Deepak Dwivedi1, Vidhu Bhatnagar2, Saurabh Sud1, Bhavna Hooda1
1 Department of Anaesthesia and Critical Care, Armed Forces Medical College, Command Hospital (SC), Pune, Maharashtra, India
2 Department of Anaesthesia and Critical Care, Institute of Naval Medicine, INHS, ASVINI, Mumbai, Maharashtra, India
|Date of Submission||17-Nov-2019|
|Date of Acceptance||03-Apr-2020|
|Date of Web Publication||30-May-2020|
Dr. Deepak Dwivedi
Department of Anaesthesia and Critical Care, Command Hospital (Southern Command) Armed Forces Medical College, Pune - 411 040, Maharashtra
Source of Support: None, Conflict of Interest: None
A 24-year-old male, operated at the age of 4 years for congenital meningomyelocoele, later developed kyphoscoliosis and flaccid paraplegia. He presented to us for debridement of a bedsore in the left gluteal region. Such cases can pose a challenge for anaesthesia both because of the higher chances of pulmonary complications due to pulmonary hypertension and severe restrictive lung pathology and increased sensitivity to muscle relaxants. This case highlights the successful airway management in the prone position with Ambu® AuraGain™, a second-generation laryngeal mask airway, which completely obviated the requirement of intubation and neuromuscular relaxation for a procedure of short duration without increasing the morbidity.
Keywords: Airway management, Ambu® AuraGain™, flaccid paraplegia, prone position, supraglottic airway device
|How to cite this article:|
Dwivedi D, Bhatnagar V, Sud S, Hooda B. Ambu® Auragain™, an alternative supraglottic airway device for airway management in prone position. Airway 2020;3:39-40
|How to cite this URL:|
Dwivedi D, Bhatnagar V, Sud S, Hooda B. Ambu® Auragain™, an alternative supraglottic airway device for airway management in prone position. Airway [serial online] 2020 [cited 2020 Jul 12];3:39-40. Available from: http://www.arwy.org/text.asp?2020/3/1/39/285430
| Introduction|| |
Various surgeries can be performed in the prone position using supraglottic airway devices (SADs) as the definitive airway. Gupta et al. have compared three variants of SADs in prone position as a rescue device during accidental extubation and found all of them effective as rescue devices. We describe an operated case of congenital meningomyelocoele with total flaccid paralysis and kyphoscoliosis who presented for debridement of left gluteal ulcer 20 years following the first surgery.
| Case Report|| |
A 24-year-old male, weighing 42 kg, was brought by his parents with bed sore on the left gluteal region. He was an operated case of meningomyelocoele at the age of 4 years. Post-surgery, he developed acute flaccid paralysis and loss of bladder and bowel control. As a result of his bedridden state, he developed severe kyphoscoliosis [Figure 1]. On investigation, there was leucocytosis, Cobb angle was 40° on chest X-ray and echocardiography revealed pulmonary hypertension with severe restrictive pattern on pulmonary function test. Other investigations were within normal limits. Written informed consent was obtained, and nil per oral orders were instituted.
|Figure 1: Chest X-ray (anteroposterior view) showing kyphoscoliosis with crowding of ribs on the right side|
Click here to view
On arrival in the operation theatre, standard monitoring was established, and peripheral intravenous access was secured. The patient positioned himself prone with assistance over gel pads, and adequate padding was provided over pressure points. General anaesthesia was achieved using intravenous glycopyrrolate 0.2 mg, fentanyl 50 μg and propofol 80 mg. Following induction, the neck was extended using pressure over the forehead which facilitated mouth opening. A size 3.0 Ambu® AuraGain™ (Ambu A/S, Ballerup, Denmark) was inserted at the first attempt, and the cuff was inflated to achieve adequate laryngeal seal. Anaesthesia was maintained using sevoflurane in air–oxygen mixture with the patient breathing spontaneously. Ventilation was assisted during periods of hypoventilation. Vital parameters were maintained within normal limits throughout the surgery. Bispectral index value between 65 and 70 was targeted to maintain sedation. Surgery lasted for 45 min. The intraoperative period was uneventful, and the patient was shifted following surgery to the postoperative surgical ward.
| Discussion|| |
Numerous studies exist supporting the role of SADs in the prone position. Gable et al. used the laryngeal mask airway (LMA) successfully in prone position while maintaining spontaneous ventilation in a paediatric patient for release of hamstrings. Complications are uncommon which include laryngospasm, bronchospasm and the need for assisted ventilation should hypoxaemia and/or hypoventilation occur. Kundra described downfolding of the tip of LMA as a concern during prone positioning and recommended a preformed LMA, which was being used in our case also. To avoid muscle relaxant in view of upregulation of the acetylcholine receptors owing to the long-standing flaccid paralysis, the patient was managed with sedation and spontaneous ventilation, although assisted ventilation was provided during periods of hypoventilation.
In comparison to other preformed SADs, Ambu® AuraGain™ requires less volume of air to attain intracuff pressures of 60 cm H2O, facilitates easier gastric access with large bore tube and results in significantly less sore throat. It scores better than the ProSeal LMA for providing lower mucosal pressure and higher oropharyngeal leak pressure.
From our experience, we suggest that Ambu® AuraGain™ could be an effective SAD for use in the prone position where one can completely obviate the requirement of endotracheal intubation in such subsets of patients.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given consent for his clinical information to be reported in the journal. The patient understands that his name and initials will not be published and due efforts will be made to conceal his identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Gable A, Whitaker EE, Tobias JD. Use of the laryngeal mask airway in the prone position. Pediatr Anesth Crit Care J 2015;3:118-23.
Gupta B, Gupta S, Hijam B, Shende P, Rewari V. Comparison of three supraglottic airway devices for airway rescue in prone position. A manikin-based study. J Emerg Trauma Shock 2015;8:188-92.
] [Full text]
Kundra P. Securing of supraglottic airway devices during position change and in prone position. Indian J Anaesth 2018;62:159-61.
] [Full text]
Shariffuddin II, Teoh WH, Tang E, Hashim N, Loh PS. Ambu®
AuraGain™ versus LMA supreme™ Second Seal™: A randomised controlled trial comparing oropharyngeal leak pressures and gastric drain functionality in spontaneously breathing patients. Anaesth Intensive Care 2017;45:244-50.
Singh K, Gurha P. Comparative evaluation of Ambu Auragain™ with ProSeal™ laryngeal mask airway in patients undergoing laparoscopic cholecystectomy. Indian J Anaesth 2017;61:469-74.
] [Full text]