Saudi Journal of Anaesthesia

LETTERS TO EDITOR
Year
: 2022  |  Volume : 16  |  Issue : 4  |  Page : 520--521

Airway security and safety: Is it a priority in the prone position during upper endoscopic procedures under general anesthesia?


Ashraf Mohamed EL-Molla 
 Department of Anesthesiology, Misr University for Science and Technology, Cairo, Egypt

Correspondence Address:
Ashraf Mohamed EL-Molla
Department of Anesthesiology, Misr University for Science and Technology, Cairo
Egypt




How to cite this article:
EL-Molla AM. Airway security and safety: Is it a priority in the prone position during upper endoscopic procedures under general anesthesia?.Saudi J Anaesth 2022;16:520-521


How to cite this URL:
EL-Molla AM. Airway security and safety: Is it a priority in the prone position during upper endoscopic procedures under general anesthesia?. Saudi J Anaesth [serial online] 2022 [cited 2022 Dec 9 ];16:520-521
Available from: https://www.saudija.org/text.asp?2022/16/4/520/355525


Full Text



Dear Editor,

I read with interest the original article “Non-intubated general anesthesia in the prone position for advanced biliopancreatic therapeutic endoscopy: A single tertiary referral center experience”.[1] There is a need to scrutinize and analyze this study critically and interpret it appropriately. The authors stated clearly that there is the absence of a secure airway associated with limited possibility to support ventilation due to shared airways and added that the main issue remains the difficult control of the airway. They also reported that ventilatory monitoring by capnography was judged not reliable. Finally, they concluded that general anesthesia may be regarded as a safe procedure.[1] Anesthesia is a medical specialty with a reputation for the highest possible standard of safety.[2] First, do no harm![3] for our profession, this means that our most important concern must be patient safety. However, I want to highlight the following considerations: first, One of the primary concerns of induction of anesthesia in a prone position is the potential for loss of airway during induction, restriction to the proper use of supraglottic airway devices and airway maneuvers, reduced ability to manage hemodynamic instability, and the hypotension associated with induction of anesthesia in prone position due to reduction of the venous return related to compression of the inferior vena cava and decreased left ventricular compliance.[4] Second, ventilatory monitoring of end tidal carbon dioxide is essential monitoring,[5] but it was reported as not reliable[1] during the procedures which have a real mean time of 57 min. Third, interpreting the absence of failure as an indication of the absence of risk and presence of safety, although the preoperative evaluation was done by experienced anesthesiologists and the procedures were performed by skilled anesthesiologists, adverse event as desaturation happened in 35% of cases. One patient had to be turned supine for airway management, however rotation of the patient to supine requires time and support of personnel that may not be necessary immediately available, and it may interrupt the procedure during a critical stage.[6] This event (emergency supine position) happened at a ratio of 1:153, which needs to be taken critically as this ratio happened in the anesthetic course provided by skilled and dedicated anesthesiologists. Gourda[7] reported that up to 72% of adverse events (cardiac arrest) in endoscopic setting was related to airway management problems. In summary, the major advantages of this technique were saving time and patient self-positioning to avoid nerve injury may not be accepted as a trade-off for hazarders of anesthesia induction in a prone position, airway safety management, emergency need for a supine position as airway rescue maneuver and proper monitoring of ventilation through endotracheal intubation.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Melis V, Aldo C, Dioscoridi L, Arlati S, Molinari P, Cintolo M, et al. Nonintubated general anesthesia in prone position for advanced biliopancreatic therapeutic endoscopy: A single tertiary referral center experience. Saudi J Anaesth 2022;16:150-5.
2Mellin-Olsen J, Staender S, Whitaker DK, Smith AF. The Helsinki declaration on patient safety in anaesthesiology. Eur J Anaesthesiol 2010;27:592-7.
3Smith CM. Origin and uses of primum non nocere—above all, do not harm! J Clin Pharmacol 2005;45:371-7.
4Ellard L, Wong DT. Should we induce general anesthesia in the prone position? Curr Opin Anaesthesiol 2014;27:635-42.
5Checketts MR, Alladi R, Ferguson K, Gemmell L, Handy JM, Klein AA, et al. Recommendations for standards of monitoring during anaesthesia and recovery 2015: Association of Anaesthetists of Great Britain and Ireland. Anaesthesia 2016;71:85-93.
6Abrishami A, Zilberman P, Chung F. Brief review: Airway rescue with insertion of laryngeal mask airway devices with patients in the prone position. Can J Anaesth 2010;57:1014-20.
7Goudra B, Nuzat A, Singh PM, Gouda GB, Carlin A, Manjunath AK. Cardiac arrests in patients undergoing gastrointestinal endoscopy: A retrospective analysis of 73,029 procedures. Saudi J Gastroenterol 2015; 21:400-11.