Hemodynamic and Hormonal Stress Responses to Endotracheal Tube and ProSeal Laryngeal Mask Airway™ for Laparoscopic Gastric Banding

Abstract

T he increase in the number of morbidly obese patients undergoing surgery has prompted investigations into the most optimal anesthesia procedures for these individuals. Although the classic type of laryngeal mask airway is safe and efficacious in lean subjects, it has not been used often in obese patients because it provides only incomplete protection of upper airway against risk of aspiration and a limited range of positive-pressure ventilation. Stress responses from tracheal intubation can be dangerous in patients with higher cardiovascular risk, such as obese patients. The availability of the ProSeal Laryngeal Mask Airway (PLMA), which has a gastric drainage tube and higher sealing pressures to offer increased protection against aspiration, has been effective in some surgical procedures in obese patients. This double-blind, randomized study was performed to assess the benefits of PLMA over the endotracheal tube (ETT) in obese patients undergoing laparoscopic gastric banding (LGB).Reference values for catecholamines and cortisol were obtained in 15 healthy subjects. Seventy morbidly obese patients were randomized to airway management with an ETT or with PLMA. Patients were premedicated with intravenous (IV) midazolam 0.05 mg/kg ideal body weight (IBW) and 50 mg ranitidine. Standard monitoring was used. Heart rate and oxygen saturation (pulse oximetry) were measured continuously and arterial blood pressure at 5-minute intervals. Inspiratory and expiratory end-tidal gas concentrations and train-of-four ratio were monitored. Anesthesia was induced with IV fentanyl (1 Kg/kg total body weight [TBW]) and propofol 2 to 3 mg/kg TBW. Intravenous succinylcholine 1 mg/kg TBW was given to patients in the ETT group; no muscle relaxant was used for patients in the PLMA group. The ETT and PLMA devices were inserted based on the manufacturers' recommendations. Neuromuscular blockade was produced using a single IV bolus of cisatracurium 0.15 mg/kg IBW given after tracheal intubation in the ETT group; the PLMA group received the drug 0.05 mg/kg IBW before carboperitoneum. At the end of LBG, methylene blue solution was injected through the gastric tube to detect gastric leakage or endoscopic stain aspiration in the upper airway. Metoclopramide and ketorolac tromethamine were given to reduce postoperative nausea and vomiting (PONV). Atropine and neostigmine methylsulfate were given to reverse muscle relaxation. Before removal of the airway devices, lung ventilation was manually assisted with continuous positive airway pressure during inspiration. The devices and the gastric tube were removed when a trainof-four ratio of greater than 0.89 was reached, and the patient was awake and able to respond to simple commands. Patients were then followed up until the Aldrete score was 9 or greater. Fentanyl and paracetamol were given as needed for pain and ondansetron for PONV. Time of surgery was calculated from skin incision to placement of the last suture. Emergence times and time of device removal were registered from cessation of sevoflu...

A comparative study between ProSeal laryngeal mask airway and endotracheal tube for ease of insertion and haemodynamic changes in patients undergoing laparoscopic cholecystectomy under general anaesthesia

“…11 Similarly, Patel et al reported that there was rise in heart rate both during insertion and extubation in ETT group as compare to ProSeal LMA group and this change was highly significant,(P<0.01) The findings of Shroff et al, Carron et al and Kannan et al also concurred with present findings. 7,10,12,13 However, Lalwani et al and Dave et al found that heart rate was increased significantly in both ETT and PLMA group whereas in our study, HR is increased significantly in ETT group only. 14,15 This haemodynamic pressor response may be attributed to the sympathetic stimulation during laryngoscopy and intubation and this is due to sympathoadrenal response to tracheal intubation arises from stimulation of the pharyngeal wall and supraglottic region by tissue tension induced by laryngoscopy.…”

“…The reflex circulatory response is seen with an increase in the plasma catecholamine levels after laryngoscopy. 13 Among the catecholamine's, noradrenaline levels show a greater surge after laryngoscopy and intubation.…”

“…The attenuation of the pressor response is due to diminished catecholamine release and lower cortisol levels after insertion of the ProSeal LMA. 2,13,16 The PLMA forms effective seal around the glottis opening which provides adequate ventilation and oxygenation along with CO 2 insufflation and pnemoperitoneum in reverse trendelenburg position without any significant gastric distension and pulmonary aspiration. Maltby et al also reported that both of the devices have equal effectiveness in terms of adequate ventilation and oxygenation in their study groups.…”

Supraglottic Devices in Laparoscopic Surgery - A Review of Literature

“…Carron et al, were able to achieve adequate gas exchange with PCV and I:E ratio of 1:1 in obese patients undergoing gastric banding while ventilating through a PLMA [67]. No hemodynamic instability was noted in any of these studies during PCV.…”

“…Carron M et al, compared the hemodynamic and hormone stress response of PLMA and ETT in 70 morbidly obese pts (BMI > 30 kg/m 2 ) for laparoscopic banding surgery [67]. The study showed that there was significantly less hemodynamic and hormonal stress response with PLMA compared to ETT.…”