1. Supraglottic Airway Devices Nap4
Dr Anil Patel
Royal National Throat Nose & Ear Hospital
and
University College Hospital, London

2. I have received an honorarium from the Laryngeal Mask Company & I have helped design the A.P. Advance Videolaryngoscope

3. Numerical Analysis SAD 56% of all UK general anaesthetics
90% cLMA or LM’s
10% i-gel or Proseal LMA
34 cases where SAD was primary airway
Of these 17 were aspiration
Of the Non-aspiration events
2 deaths
5 emergency surgical airways
13 ICU admissions

4. Non-Aspiration Events - Deaths
loss of airway in the semi-prone position during prolonged surgery in a patient with a predicted difficult airway
poor laryngeal mask positioning, loss of airway and unrecognised oesophageal intubation during response to this event

5. Anaesthesia Events - 16 cases
generally young (10/16 < 40years)
healthy (14/16 ASA 1-2)
‘urgent’ procedure (7/ ‘urgent’)
Obesity (11/ %)
compared to 31% outside this group
None of the patients who aspirated during use of a SAD weighed >100kg

6. Outcome and quality of airway management

7. Devices Used

8. SAD - Themes Patient selection
Limitation of use to appropriate surgery
Understand limits of chosen SAD
Inexperience, insertion and fixation
Use of second generation devices
Problems during maintenance
Problems at emergence, recovery or removal

9. Patient Selection
aspiration risk, predicted difficult airway, urgent surgery, obesity

10. Limitation of use to appropriate surgery
obese, lithotomy, head / down, very prolonged, prone

11. Inexperience

12. Inexperience and Insertion

13. Maintenance

14. Emergence, Recovery or Removal

15. SAD - Themes Patient selection
Limitation of use to appropriate surgery
Understand limits of chosen SAD
Inexperience, insertion and fixation
Use of second generation devices
Problems during maintenance
Problems at emergence, recovery or removal

16. Recommendations Laryngeal mask anaesthesia is a fundamental skill
Same attention to detail as intubation
patient selection
indications
contraindications
insertion
confirmation correct position
maintenance
removal and recovery

17. Recommendations
SAD use for difficult intubation, consider awake FOI or FOI through SAD
Difficult or failed SAD placement should raise the possibility of complications during maintenance / emergence / recovery
Continuing anaesthesia with a suboptimal airway after SAD insertion is not acceptable
Recovery staff competent with SAD procedures and timing of removal

18. Recommendation
If tracheal intubation is not considered to be indicated but there is some (small) increased concern about regurgitation risk a second generation SAD is a more logical choice than a first generation one.
Factors that mean use of SAD is at limits of normality (prone, airway access, size) consider second generation SAD
All hospitals have second generation SAD’s available for both routine use and rescue airway management

19. Supraglottic Airway Devices Nap4