Rare case of intraoperative LMA detachment.

Abstract

Dear Editor, A 35-year-old female weighing 80 kgs was posted for abdominal liposuction. Patient was accepted under ASA (American Society of Anesthesiology) I and Mallampati score 1. After preoxygenation the patient was premedicated with intravenous midazolam 1 mg, ondansetron 4 mg, and fentanyl 100 mcg. Induction was done with intravenous propofol 120 mg and atracurium 30 mg. Bag mask ventilation was confirmed and classic LMA (Laryngeal Mask Airway) size 4 was placed in the prone position and patient was put on elective ventilation. Proper minute ventilation was achieved with peak airway pressure of 16 cm of water. After 45 min, posterior liposuction was completed and patient was placed in supine position for anterior abdominal liposuction but it was observed that the airway pressure started showing low volume of 4–5 mm of H2O and saturation was starting to fall. ETCO2 was not showing any reading and capnograph was not present. Monitors and ventilator settings were rechecked for any disconnection but everything was in place. There was no chest rise and saturation was starting to fall. LMA was pulled out immediately but only the shaft (airtube) came out and cuff remained inside. Laryngoscopy had to be performed and the cuff was removed with the help of Magill’s forceps. After ruling out any injuries to the airway, bag mask ventilation was done and a fresh LMA number 4 was placed again to complete the remaining procedure. Circuit was connected to the LMA and ventilation was started. All the parameters were normal thereafter. The procedure was completed properly without any difficulty. Patient was normal at the time of discharge. The LMA mask was carefully examined and detachment was confirmed as shown in Figures 1 and 2.Figure 1: Laryngeal mask airway detachmentFigure 2: Laryngeal mask airway detachmentThe cause of such a detachment could not be pinpointed but repetitive use and sterilization of the device may have been responsible for this malfunction. According to some researchers, the reusable LMA can be used for more than 40 times.[1] According to hospital records the LMA that we used during the procedure was sterilized by ethylene oxide and used for over 24 times before. Though this number lies within the recommended safety limit of 40 times, it raises a question on the accepted norm of reusability of LMA.[1] In spite of using correct techniques for cleaning and sterilizing the device, the probability of its deterioration over time with each use cannot be ruled out. It has been suggested that the cuff of the device should be deflated and dehydrated as much as possible before sterilization.[2] In conclusion, a thorough external examination of the LMA device preoperatively is obligatory along with following strict sterilization techniques including complete deflation and dehydration of the cuff before sterilization to avoid such incidences in future. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.