Airway management considerations for appendectomy

Abstract

To the Editor, Recently, Istvan et al. reported a case review of airway management for appendectomies from the Hopital Maisonneuve-Rosemont, Montreal, Quebec, Canada. Rapid sequence induction (RSI) with tracheal intubation was used for more than 80% of 250 emergency appendectomies, with transient blood pressure changes (35%) and intubation difficulty (1.2%) being the only complications. Istvan et al. concluded that it is not necessary to recommend a change in practice and implied both efficacy and safety of RSI for appendectomies. There is some debate regarding airway management for emergency appendectomies. Traditionally, authors recommend tracheal intubation and RSI because of concerns over pulmonary aspiration. In practice, there are likely wide variations in airway management, e.g., in Istvan et al.0s series, 19% of the patients did not receive RSI and two patients in their pilot phase underwent laryngeal mask airway (LMA; LMA North America, San Diego, CA, USA) anesthesia. Recently, we published a series of 102 patients who presented for emergency appendectomies in a one-year period (2007) and were managed with a ProSeal laryngeal mask airway (PLMA; LMA North America, San Diego, CA, USA). There are clear advantages to avoiding intubation where it is not necessary; the only difficulty is defining those circumstances. Although it has been assumed that the combination of abdominal surgery and urgency must predispose to passive regurgitation, as summarized by Istvan et al., the incidence appears to be low. Prior to our study, we could find no data on the incidence of regurgitation in this population. Review of the literature suggests that the pulmonary aspiration in the perioperative period is infrequent. Thus, perhaps there is a discrepancy between the risk of regurgitation during induction and the number of patients treated as at risk of aspiration. In our study, all patients were managed effectively and safely throughout surgery, and, while we acknowledge readily that such a small study cannot confirm safety, the absence of complications is notable. As a small first step, at least our results are reassuring and provide a starting point. Recent advances in supraglottic airway device (SAD) technology not only make some devices easy to use, they also increase their level of protection against aspiration. If a SAD is to be considered for such use in a higher risk patient, we would argue that it is logical to use a device that has a good airway seal, design features that reduce the risk of aspiration, and a proven track record. The PLMA is foremost among such devices. Inevitably, testing the limits of safe use of equipment is very difficult, as studies designed to explore boundaries are likely to have intrinsic risk. However, failure to consider such possibilities has its own risk. While some might consider even selective use of a PLMA for appendectomies as inappropriate, it is notable that others might equally point to the science of RSI as unproven and associated with increased risk. As ever, more high quality research is required in this difficult area.