Clinical Case of the Month: A 44-year-old man is scheduled for a knee arthroscopy. He takes Prilosec for Gastro Esophageal Reflux Disease (GERD). He is six feet tall, weighs 70 kg, and refuses regional anesthesia. Regarding airway management for general anesthesia, you may choose a Laryngeal Mask Airway (LMA) or an endotracheal tube. What do you do?

Discussion: The symptoms of esophageal reflux and heartburn are exceedingly common in our society. For years the histamine-2 blockers such as cimetidine and ranitidine were among the top money-making prescription drugs in America, before they became the over-the-counter bestsellers they are today. Open any weekly magazine such as Newsweek or Sports Illustrated and you may find full page ads for Nexium and Protonix today. People hurt, and they want these pills.

This is relevant in an anesthesia practice because a large percentage of patients will answer “yes” to the question of heartburn or GERD in a pre-operative questionnaire. Thus GERD goes on their chart as a diagnosis. How important is this? Are they an ASA I or and ASA II based on GERD? Do they need endotracheal intubation for general anesthesia to prevent the dreaded complication of pulmonary aspiration of gastric contents?

A leading textbook says “Because of the limited ability of the LMA to seal off the laryngeal inlet, the elective use of the device is contraindicated in any of the conditions associated with an increased risk for aspiration. In patients without these predisposing risks, the risk for pharyngeal regurgitation appears to be low.” (Miller: Miller’s Anesthesia, 6th edition, 2005, pp 1626-7). “GERD has been increasingly appreciated as a risk factor for perioperative aspiration. These patients are presumed to chronically aspirate greater quantities of gastric contents during sleep than normal patients do. . . . Patients with GERD should receive preoperative non-particulate antacids (Bicitra) and gastropropulsive medications such as metoclopramide preoperatively, and cricoid pressure should be applied during induction of anesthesia.” (Miller: Miller’s Anesthesia, 6th edition, 2005, p1860).

I submitted the Clinical Case above to the twenty attending anesthesiologists in private practice in Palo Alto who are members of the Palo Alto Medical Clinic or the Associated Anesthesiologists Medical Group. What follows is a consensus of what the majority do, every day, in operating rooms in the heart of Silicon Valley:

If the patient had GERD which was well-treated on medication, and had no symptoms at present, my colleagues said they would use an LMA for airway management, rather than intubate the patient’s trachea. If the patient had active symptoms of GE reflux that were not under control, then they would use an endotracheal tube following cricoid pressure.

Why the disconnect between what we do and the textbook? Are we negligent? Is the textbook (gasp) wrong?

One could be dogmatic and say this: If a patient has GERD, then intubate the trachea with a rapid sequence intubation each time, or you run the risk of aspiration pneumonitis. And if you do not use an endotracheal tube, and the patient aspirates, you will be practicing below the standard of care, be sued, and lose millions in a devastating malpractice settlement. Defensive medicine is common, right? So why not intubate them all?

A common theme in this column is the standard of care in medical practice, defined as “within a specialty field, the standard of care is that of the reasonably competent specialist, not that of the most experienced or the least qualified specialist . . . a physician who performs in accordance with the commonly accepted practice of other physicians in similar circumstances will not be held to have been negligent.” (Tsushima WT, Effective Medical Testifying, 1998, p 119.)

In a court of law, to prove that an anesthesiologist is negligent, an attorney would have to obtain an expert witness to testify that what the anesthesiologist did was below the standard of care, and therefore negligent. Would it be possible to find a medical expert witness to state that the standard of care is to intubate the trachea on all patients with GERD when they have general anesthesia? As one of my partners often states, “for a fee, if the plaintiff attorney searches hard enough, he can find a medical expert witness to say just about anything is below the standard of care.” Furthermore, such an expert witness could validate his or her argument by quoting the references from Miller’s textbook above.

The ProSeal LMA has a larger cuff, and a drain tube inside the cuff, which allows the insertion of a gastric tube to drain the stomach. There is a case report in which an anesthetized patient with a ProSeal regurgitated 25 ml of brown fluid into the drain tube. The conclusion was that the ProSeal protected the airway by allowing the regurgitated fluid to pass up the drainage tube without leaking into the glottis. (Evans NR, Can J Anaesth. 2002 Apr;49(4);413-6). The ProSeal may have a role in this patient population, but to date it has a trivial market share of the LMA usage in Palo Alto private practices.

No one would use an LMA to do an anesthetic on a patient who had a full stomach. But on an otherwise healthy NPO patient with treated GERD and no current symptoms, there are anesthetists — well trained graduates of the Stanford anesthesia residency program — who use an LMA.

What will you do? When you finish your training, you will decide what you are comfortable with in your practice. You will pay your own malpractice insurance, and have to live with the consequences of your complications. The good news is that the prevalence of clinically important aspiration in otherwise healthy NPO patients is negligible. I believe that is why most of my colleagues use the LMA in this case.