Boris Yanovski

A Randomized Controlled Trial Comparing the ProSeal™ Laryngeal Mask Airway with the Laryngeal Tube Suction in Mechanically Ventilated Patients

Background:The ProSeal™ Laryngeal Mask Airway (PLMA) (Laryngeal Mask Company, Henley-on-Thames, United Kingdom) is a new laryngeal mask with a modified cuff designed to improve its seal and a drain tube for gastric tube placement. Similarly, the Laryngeal Tube Suction (LTS) (VBM Medizintechnik Gmbh, Sulz a.N, Germany) is a new laryngeal tube that also has an additional channel for gastric tube placement. This study compared the placement and functions of these two devices. Methods:One hundred fifty patients undergoing general anesthesia for elective surgery were randomly allocated to the PLMA (n = 75) or LTS (n = 75). Oxygenation and ventilation, ease of insertion, fiberoptic view, oropharyngeal leak pressure, ventilatory data, ease of gastric tube insertion, and postoperative airway morbidity were determined. Results:After successful insertion of the devices in 96% of patients with the PLMA and in 94.4% with the LTS it was possible to maintain oxygenation, ventilation, and respiratory mechanics during the entire duration of surgery. Successful first and second attempt insertion rates were 57 patients (76%) and 15 patients (20%), respectively, for the PLMA and 60 patients (80%) and 11 patients (14.6%), respectively, for the LTS. Airway placement was unsuccessful with the PLMA in three patients and with the LTS in four patients. Time to achieve an effective airway was 36 ± 24 s with the PLMA versus 34 ± 25 s with the LTS. Gastric tube insertion was possible in 97.3% of patients with the PLMA and in 96% with the LTS. Conclusions:With respect to both physiologic and clinical function, the PLMA and LTS are similar and either device can be used to establish a safe and effective airway in mechanically ventilated anesthetized adult patients.

The Combitube in elective surgery: a report of 200 cases.

BackgroundThe Combitube has proved to be a valuable device for securing the airway in cases of difficult intubation. This study investigated the effectiveness of the Combitube in elective surgery during both mechanical and spontaneous ventilation. MethodsTwo hundred patients classified as American Society of Anesthesiologists physical status I and II, with normal airways, scheduled for elective surgery were randomly allocated into two groups: nonparalyzed, spontaneously breathing (n = 100); or paralyzed, mechanically ventilated (n = 100). After induction of general anesthesia and insertion of the Combitube, oxygen saturation, end-tidal carbon dioxide and isoflurane concentration, systolic and diastolic blood pressure and heart rate, as well as breath-by-breath spirometry data were obtained every 5 min. ResultsIn 97% of patients, it was possible to maintain oxygenation, ventilation, and respiratory mechanics, as well as hemodynamic stability during either mechanical or spontaneous ventilation for the entire duration of surgery. The duration of surgery was between 15 and 155 min. ConclusionsThe results of this study suggest that the Combitube is an effective and safe airway device for continued management of the airway in 97% of elective surgery cases.

A COMPARISON BETWEEN THE PLA COBRA AND THE LARYNGEAL MASK AIRWAY UNIQUE DURING SPONTANEOUS VENTILATION: A RANDOMIZED PROSPECTIVE STUDY

The Laryngeal Mask (LMA) Unique and the Cobra Perilaryngeal Airway (PLA) are single-use supraglottic devices. There are no published studies comparing these devices during spontaneous ventilation. We compared the LMA Unique and the Cobra PLA with respect to 1) ventilatory variables during spontaneous ventilation, 2) time to achieve an effective airway, 3) airway intervention requirements, 4) cuff seal pressures, 5) fiberoptic score, and 6) perioperative adverse events. Eighty adult ASA physical status I–II patients undergoing general anesthesia for minor routine surgery were randomly allocated to LMA Unique or PLA Cobra for airway management. No statistically significant differences were found between the devices with respect to inspiratory tidal volume, expiratory tidal volume, end-tidal CO2 concentration, respiratory rate, number and type of airway interventions required with placement, the fiberoptic score, and the incidence of perioperative adverse events. The oropharyngeal leak (seal) pressure was higher for the CobraPLA (27 ± 7 versus 21 ± 4 cm H2O; P < 0.001). The oxygen saturation was higher (98.1% ± 1% versus 97.3% ± 2%; P = 0.02) in the LMA group. Time of insertion was shorter for LMA (23.7 ± 2 s versus 26.6 ± 7 s; P = 0.02) and insertion difficulty was less for LMA (P = 0.03). As these differences were not judged to be clinically important, both devices appear to be effective in establishing an adequate airway in patients who are spontaneously breathing under general anesthesia.

An Evaluation of the Laryngeal Tube ® During General Anesthesia Using Mechanical Ventilation

The Laryngeal Tube® is a new supraglottic ventilatory device for airway management. It has been developed to secure a patent airway during either spontaneous or mechanical ventilation. In this study, we sought to determine the effectiveness of the Laryngeal Tube for primary airway management during routine surgery with mechanical ventilation. One-hundred-seventy-five subjects classified as ASA physical status I and II, scheduled for elective surgery, were included in the study. After the induction of general anesthesia and insertion of a Size 4 Laryngeal Tube, measurements of oxygen saturation, end-tidal CO2 and isoflurane concentration, and breath-by-breath spirometry data were obtained every 5 min throughout surgery. The lungs were ventilated with volume-controlled mechanical ventilation. The number of attempts taken to insert the Laryngeal Tube and the insertion time were recorded. In 96.6% of patients, it was possible to maintain oxygenation, ventilation, and respiratory mechanics by using mechanical ventilation throughout the surgical procedure. The results of this study suggest that the Laryngeal Tube is an effective and safe airway device for airway management in mechanically ventilated patients during elective surgery. IMPLICATIONS: In 96.6% of patients intubated with the Laryngeal Tube®, it was possible to maintain oxygenation, ventilation, and respiratory mechanics during mechanical ventilation.

Combined spinal-epidural anesthesia in major abdominal surgery in high-risk neonates and infants.

Background:  Combined spinal‐epidural anesthesia (CSE‐A) is reportedly safe and effective for the pediatric population in infraumbilical surgery. Our main purpose was to describe our experience of this technique in neonates and infants undergoing elective major upper abdominal surgery.

Catastrophic complication of an interscalene catheter for continuous peripheral nerve block analgesia

We report a catastrophic postoperative complication of a prolonged interscalene block performed under general anaesthesia. The course of the anaesthetic was uneventful and the patient remained stable during his stay in the recovery area with the operative extremity paralysed and insensate. No further local anaesthetic was administered until later that day when the patient received 10 ml bupivacaine 0.25% through the catheter. Upon completion of the top‐up dose, no change in the patient’s status was noticed. The patient was next assessed 6.5 h later when he was found dead in his bed. A postmortem CT scan revealed the catheter to be sited intrathecally, presumably the result of dural sleeve penetration.

Effect of ilioinguinal nerve block on the catecholamine plasma levels in orchidopexy: comparison with caudal epidural block.

Summary Background: Both caudal epidural and ilioinguinal/iliohypogastric nerve blocks have been used to provide effective intra‐ and postoperative analgesia. Stress response hormone levels can be used as an objective method to assess the analgesic efficacy of the anaesthetic techniques used in infraumbilical surgery in children. In this study, we compared catecholamine blood levels in children undergoing these two different supplementary analgesic/anaesthetic techniques.

Does the addition of fentanyl to bupivacaine in caudal epidural block have an effect on the plasma level of catecholamines in children

We evaluated the effect of adding fentanyl to bupivacaine, compared with bupivacaine alone, on the stress response. The effect was evaluated by determining blood levels of epinephrine (E) and norepinephrine (NE) in pediatric patients receiving caudal epidural blocks. Sixty children, 1–8 yr of age, scheduled for elective herniorrhaphy, were randomly allocated to two groups of 30 patients each. Group A received inhaled anesthesia and caudal epidural block with bupivacaine 0.25% alone, 1.0 mL/kg. Group B received identical anesthesia; however, fentanyl 1 &mgr;g/kg was added to the bupivacaine in the caudal block. Blood samples for E and NE plasma levels were drawn at induction time (H0), at the end of surgery (H1), and in the postanesthesia care unit (H2). In both groups, there was a significant decrease in the E and NE plasma levels, when comparing H1 and H2 with H0 within the same group (P < 0.001). There were no significant differences in the E and NE plasma levels between the two groups at H0, H1, and H2 (P = 0.5, P = 0.12, P = 0.5, respectively). Pain scores (modified Children’s Hospital of Eastern Ontario Pain Score) were also similar in both groups (P = 0.19). This study suggests that adding fentanyl 1 &mgr;g/kg to bupivacaine in the caudal epidural block in children does not influence plasma levels of E and NE, nor does it improve the analgesic intensity of the caudal block. Implications This study demonstrates that adding fentanyl to bupivacaine for caudal epidural blocks has no beneficial effect on the stress response in pediatric patients undergoing inguinal herniorrhaphy, as evaluated by plasma epinephrine and norepinephrine values, compared with bupivacaine alone.

Comparison of the CobraPLATM (Cobra Perilaryngeal Airway) and the Laryngeal Mask Airway UniqueTM in children under pressure controlled ventilation

Background:  The Laryngeal Mask Airway‐Unique (LMAU) and CobraPLATM (Cobra Perilaryngeal Airway) are supraglottic airway devices. There are no published studies comparing these devices in children breathing with pressure controlled ventilation (PCV).

A feasibility study using the VivaSight Single Lumen™ to intubate the trachea through the Fastrach Laryngeal Mask Airway: A preliminary report of 50 cases

BACKGROUND:The VivaSight Single Lumen™ (SL) is new endotracheal tube with a video camera and a light source in the tip allowing continuous visual observation of the airway. In this study, we checked the feasibility of endotracheal intubation with a VivaSight-SL through the Fastrach Laryngeal Mask Airway® (FT-LMA). METHODS:We studied 50 patients with normal airways, scheduled for elective surgery during general anesthesia requiring endotracheal intubation. The FT-LMA was inserted and once adequate ventilation was achieved, the VivaSight-SL was passed through the FT-LMA into the trachea under visual control. The following criteria were used to score the laryngeal view: grade 1: full view of the arytenoids and glottis; grade 2: epiglottis, arytenoids or glottic opening are partly visible, the structure of cords is difficult to see; grade 3: dark areas indicating an open space; and grade 4: no part of the larynx can be identified. RESULTS:The FT-LMA was placed successfully in 49 patients at the first attempt. One patient was excluded from the study after 2 failed attempts to ventilate with the FT-LMA. All 49 patients were successfully intubated with the VivaSight-SL, (95% confidence interval [CI] 0.89–0.99), 47 patients at the first attempt (95% CI, 0.83–0.98) and 2 patients at the second attempt. (95% CI, 0.004–0.13). The time to achieve an effective airway with the FT-LMA was 15.4 ± 6 (mean ± SD) seconds. The time to achieve a laryngeal view with the VivaSight-SL was 28.8 ± 5 seconds. Correct position of the VivaSight-SL was confirmed with visualization of the carina. Time of successful intubation with VivaSight-SL from picking up the VivaSight-SL to observing a end-tidal CO2 curve was 45 ± 7 seconds. After introducing the VivaSight-SL through the intubating channel of the FT-LMA, a grade 1 view was obtained in 18 patients, grade 2 in 18 patients, a grade 3 in 4 patients, and grade 4 in 9 patients. CONCLUSION:The high first-attempt intubation success rate using the VivaSight-SL to intubate the trachea through a FT-LMA makes this technique an attractive and promising concept.