|LETTER TO EDITOR
|Year : 2015 | Volume
| Issue : 4 | Page : 253-254
Emergency tracheal intubation through intubating laryngeal mask airway in patients with stereotactic frame in situ
Lakshmi N Kurnutala1, Sudhakar Kinthala2, D Padmaja3
1 Department of Anesthesiology, University of Mississippi Medical Center, Jackson, MS, USA
2 Department of Anesthesiology, New York Methodist Hospital, Brooklyn, New York, USA
3 Department of Anesthesiology, Nizam's Institute of Medical sciences, Hyderabad, Telangana, India
|Date of Web Publication||13-Apr-2015|
Dr. Lakshmi N Kurnutala
Department of Anesthesiology, University of Mississippi Medical Center, Jackson 39216, MS
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Kurnutala LN, Kinthala S, Padmaja D. Emergency tracheal intubation through intubating laryngeal mask airway in patients with stereotactic frame in situ. Indian J Anaesth 2015;59:253-4
|How to cite this URL:|
Kurnutala LN, Kinthala S, Padmaja D. Emergency tracheal intubation through intubating laryngeal mask airway in patients with stereotactic frame in situ. Indian J Anaesth [serial online] 2015 [cited 2021 May 13];59:253-4. Available from: https://www.ijaweb.org/text.asp?2015/59/4/253/155007
Stereotactic radiosurgery is a major advance in the treatment of intracranial lesions. Stereotactic surgery is performed with patients fully awake or with minimal sedation. However, the stereotactic frame used for neurosurgical procedures interferes with access to the airway and limits neck mobility. The presence of frame poses significant difficulty for airway interventions such as conventional mask ventilation, laryngoscopy, and tracheal intubation. Fibreoptic bronchoscopy and laryngeal mask airway (LMA) are suitable for emergency airway access, but an intubating laryngeal mask airway (ILMA) might be suitable for emergency airway management in those patients who need endotracheal intubation. 
We report management of two patients who underwent stereotactic guided biopsies of a thalamic lesion and brainstem lesion, respectively, and who developed respiratory depression and sudden deterioration in consciousness under monitored anaesthesia care. Immediate intubation was accomplished with a size #4 ILMA inserted from a position anterior to the patient without disturbing the stereotactic frame in both patients. The endotracheal tube easily placed through the ILMA in the first patient while the stereotactic frame needed to be released in the second. In both patients, the airway was secured to prevent aspiration and for the possibility of prolonged postoperative ventilation related to intraoperative events.
The applications of stereotactic surgery are increasing. Except for the paediatric patient population, general anaesthesia is not usually required for the stereotactic procedures. Sedation is provided to improve patient comfort and to decrease extreme blood pressure swings during frame placement. The intraoperative anaesthetic complications during stereotactic surgery include depressed consciousness, impaired respiration, and airway obstruction requiring emergency airway management.
Tracheal intubation can be challenging with the placement of a stereotactic frame for many reasons. These patients have intracranial disease and might be particularly sensitive to hypoxia or severe hypercapnia as a complication of airway obstruction in the presence of the stereotactic device, stabilising the neck and head to ensure a patent airway might be difficult.
Fibreoptic bronchoscopy has been recommended for tracheal intubation in these patients, but considerable intubation experience is required to perform fibreoptic in an emergency. Flexible fibreoptic bronchoscopes are expensive and might not be readily available. Therefore, it is prudent to have alternative management techniques. Intubation techniques using a light wand or gum elastic bougie might allow easy passage of the tube without direct visualisation of the glottis, but not without complications.  A supraglottic airway device for airway management and an Allen wrench for removal of the crossbar must be immediately available if intubation proves unsuccessful.
Placement of the ILMA and subsequent intubation are blind techniques, and placement is not affected by heavy secretions or blood, which might impair fibreoptic techniques. Moreover, the ILMA allows for ventilation and oxygenation during tracheal intubation attempts. It can be used in patients with a difficult airway,  and can facilitate blind tracheal intubation when fibreoptic intubation is unsuccessful.  Fukutome et al.,  found that tracheal intubation through the ILMA was successful in 93% of patients with a difficult airway. The advantage of the ILMA in stereotactic surgery is that ventilation and intubation might be accomplished without disturbing the frame. Failure to intubate through the ILMA can be overcome by fibreoptic-guided intubation, failing which release of the stereotactic frame might be required.
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