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Comparison of Laryngeal Mask Airway Supreme and Laryngeal Mask Airway Proseal with respect to oropharyngeal leak pressure during laparoscopic cholecystectomy: a randomised controlled trial.

Context A comparison of the efficacy and safety of the Laryngeal Mask Airway (LMA) Supreme (LMAS) versus the LMA Proseal (LMAP) in elective laparoscopic cholecystectomy. Objectives To compare the LMAS with LMAP in terms of ventilatory efficacy, airway leak pressure (airway protection), ease-of-use and complications. Design Prospective, single-blind, randomised, controlled study. Setting The Hospital del Sureste and Hospital Ramon y Cajal, Madrid, between May 2009 and March 2011. The Hospital del Sureste is a secondary hospital and Hospital Ramon y Cajal is a tertiary hospital. Patients Patients undergoing elective laparoscopic cholecystectomy were studied following informed consent. Inclusion criteria were American Society of Anesthesiologists physical status I to III and age 18 or more. Exclusion criteria were BMI more than 40 kg m−2, symptomatic hiatus hernia or severe gastro-oesophageal reflux. Interventions Anaesthesiologists experienced in the use of LMAP and LMAS participated in the trial. One hundred twenty-two patients were randomly allocated to LMAS or LMAP. Main outcome measures Our primary outcome measure was the oropharyngeal leak pressure (OLP). Secondary outcomes were the time and number of attempts for insertion, ease of insertion of the drain tube, adequacy of ventilation and the incidence of complication. Patients were interviewed postoperatively to evaluate the presence of sore throat, dysphagia or dysphonia. Results Two patients were excluded when surgery changed from laparoscopic to open. A total of 120 patients were finally included in the analysis. The mean OLP in the LMAP group was significantly higher than that in the LMAS group (30.7 ± 6.2 versus 26.8 ± 4.1 cmH2O;P < 0.01). This was consistent with a higher maximum tidal volume achieved with the LMAP compared to the LMAS (511 ± 68 versus 475 ± 55 ml; P = 0.04). The success rate of the first attempt insertion was higher for the LMAS group than the LMAP group (96.7 and 71.2%, respectively; P < 0.01). The time taken for insertion, ease of insertion of the drain tube, complications and postoperative pharyngolaryngeal adverse events were similar in both groups. Conclusion The LMAP has a higher OLP and achieves a higher maximum tidal volume compared to the LMAS, in patients undergoing elective laparoscopic cholecystectomy. The success of the first attempt insertion was higher for the LMAS.

The Laryngeal Mask Airway Supreme for positive pressure ventilation during laparoscopic cholecystectomy

STUDY OBJECTIVE To evaluate the Laryngeal Mask Airway Supreme (SLMA) in patients undergoing laparoscopic cholecystectomy. DESIGN Prospective observational study. SETTING University-affiliated hospital. PATIENTS 100 ASA physical status 1, 2, and 3 adult patients undergoing laparoscopic cholecystectomy with general anesthesia. INTERVENTIONS The SLMA was inserted in all study patients. Patients were placed in the reverse Trendelenburg position. MEASUREMENTS Ease of insertion of the device and the drain tube, oropharyngeal leak pressure, frequency of postoperative sore throat, and other adverse events were recorded. The surgeon scored stomach size on an ordinal scale of 0-10 at insertion of the laparoscope and before decompression of the pneumoperitoneum. MAIN RESULTS Insertion of the SLMA was successful in all patients (91 pts on the first attempt, 9 pts on the second attempt). Gastric tube insertion was successful in all patients (easy in 97 pts, difficult in 3 pts). Initial mechanical ventilation was adequate in all cases. Mean oropharyngeal leak pressure at the 60 cm H(2)O cuff pressure level was 28.8 cm H(2)O (±5.2; range 18-40 cm H(2)O). Mean airway pressure before pneumoperitoneum was 17.5 cm H(2)O (±3.3; cm; range 11-26 cm H(2)O) and 22.9 cm H(2)O (±4 cm; range 16-32 cm H(2)O) after pneumoperitoneum. Median (range) stomach size on insertion of the laparoscope and change in stomach size during surgery did not interfere with the procedure in any patient. Twelve patients (12%) complained of a mild sore throat postoperatively. No other complications were reported. CONCLUSIONS The SLMA is easy to insert and it is an effective ventilatory device for laparoscopic cholecystectomy.

Bronchial compression due to stent placement in pulmonary artery in a child with congenital heart disease

Congenital heart disease, such as transposition of the great vessels (TGV), requires surgical procedures which can lead to important complications. We report on a case of bronchial obstruction following placement of a pulmonary artery stent in a 4‐year‐old boy who had undergone a Rastelli procedure to correct TGV, ventricular septal defect and pulmonary stenosis. There are many complications that can arise as a consequence of intravascular stents in heart surgery, as well as many causes of bronchial compression. However we have not found any report which describes bronchial compression as a direct consequence of endovascular stent.

Laryngeal Mask, Laryngeal Tube, and Frova Introducer in Simulated Difficult Airway

BACKGROUND The use of supraglottic devices is rising in the prehospital management of difficult airway; moreover, we think that patients with multiple trauma or cervical instability can take advantage of these devices without opening or retiring the cervical collar. OBJECTIVE To compare speed and ease of use between Laryngeal Tube S (LTS) and the Ambu AuraOnce laryngeal mask (LMA).Our second objective was to evaluate changing these devices to an endotracheal tube (ETT) using a Frova introducer. METHODS We studied the use of LTS and LMA in an experimental model, represented by a manikin with a rigid cervical collar and a limited mouth opening. This study was carried out in Complutense University of Madrid with 145 2(nd)-year students for the degree in Dentistry who have knowledge of the airway but lack experience in intubation. Number of attempts and time for the devices insertion were measured, as well as time for the exchange maneuver using the Frova introducer. RESULTS Insertion of all devices was possible on the first attempt; time for insertion was LTS 12.2 ± 1.28 s and LMA 6.87 ± 0.97 s. Once these devices were inserted, a Frova introducer is used to perform an exchange by an endotracheal tube; all devices could be exchanged on the first attempt, and exchange time was LTS 26.9 ± 1.2 s and LMA 16.79 ± 1.32 s. Results for both time for insertion and exchange of the LMA were significantly lower than those for the LTS (p < 0.001). CONCLUSION The method used can be considered quick and easy, even for personnel inexperienced in intubation. This exchange maneuver has not been described previously, so we can consider it as a new application of the Frova introducer.

The Laryngeal Mask Airway Supreme™: safety and efficacy during gynaecological laparoscopic surgery

Abstract Background: Laryngeal Mask Airway Supreme™ (LMA Supreme™) is a new single-use polyvinyl chloride supraglottic device that offers gastric access. To date, studies that have tested the LMA Supreme™) for use in laparoscopic surgery have been reported. We present the largest evaluative study that describes the use of this mask for anaesthesia in gynaecological laparoscopic surgery. Method: Hospital ethics board approval was obtained, and 140 fasted patients undergoing elective gynaecological laparoscopy were prospectively studied. We evaluated the ease of insertion of the device and the drain tube, the oropharyngeal leak pressure (OLP), incidence of postoperative sore throat, and other adverse events. Results: Insertion of the LMA Supreme™ was successful in all patients (first attempt, n = 123; second attempt, n = 16; and third attempt, n = 1). Gastric tube insertion was successful in all patients (easy, n = 135; difficult, n = 5). Initial mechanical ventilation was adequate in almost all cases. Mean OLP at the level of 60 cmH2O cuff pressure was 28.2 ± 5.1 cmH2O. Mean peak airway pressure before pneumoperitoneum was 17± 3.5 cmH2O, and 22.1 ± 4 cmH2O, after pneumoperitoneum. Fourteen patients (10%) complained of a mild sore throat postoperatively. Coughing occurred in 10 patients (7.1%), and blood was noted after removal of the LMA Supreme™ in five cases (3.5%). No other complications were reported. Conclusion: We conclude that LMA Supreme™ is an easy to insert, and effective ventilatory device, for gynaecological laparoscopic surgery. It provides a functional airway seal with minimum adverse events.

Role of laryngeal mask airway in laparoscopic cholecystectomy

Laparoscopic cholecystectomy is one of the most commonly performed surgical procedures and the laryngeal mask airway (LMA) is the most common supraglottic airway device used by the anesthesiologists to manage airway during general anesthesia. Use of LMA has some advantages when compared to endotracheal intubation, such as quick and ease of placement, a lesser requirement for neuromuscular blockade and a lower incidence of postoperative morbididy. However, the use of the LMA in laparoscopy is controversial, based on a concern about increased risk of regurgitation and pulmonary aspiration. The ability of these devices to provide optimal ventilation during laparoscopic procedures has been also questioned. The most important parameter to secure an adequate ventilation and oxygenation for the LMA under pneumoperitoneum condition is its seal pressure of airway. A good sealing pressure, not only state correct patient ventilation, but it reduces the potential risk of aspiration due to the better seal of airway. In addition, the LMAs incorporating a gastric access, permitting a safe anesthesia based on these commented points. We did a literature search to clarify if the use of LMA in preference to intubation provides inadequate ventilation or increase the risk of aspiration in patients undergoing laparoscopic cholecystectomy. We found evidence stating that LMA with drain channel achieves adequate ventilation for these procedures. Limited evidence was found to consider these devices completely safe against aspiration. However, we observed that the incidence of regurgitation and aspiration associated with the use of the LMA in laparoscopic surgery is very low.

Migraine headache: a rare complication after cervicothoracic block

post-injury complex regional pain syndrome (CRPS) type II involving her left hand came to the Pain Clinic. The rest of her medical history was unremarkable. A left cervicothoracic sympathetic block according to the classic method, using 8 ml of 0.375% ropivacaine, was performed without incident. The patient developed a left side Horner’s syndrome and other signs of sympathetic blockade in her left arm. Thirty minutes following the block, she developed sudden blurry vision added to speech disturbances and 30 min later she reported an intensive and progressive left frontal headache accompanied by nausea and phonophobia. The patient did not have a history of migraine headache or any other chronic headache condition. She received sumatriptan succinate, with good response. Twenty-four hours later she came to the ER reporting the same intense left hemicranial headache with aura. During the following 3 months her episodic left headaches occurred once every couple of weeks. The neurologist reported a normal neurologic examination and diagnosed the headache as a limited migraine headache with aura and her episodic headache resolved completely. We only found one other report describing this phenomenon in a patient, with a previous history of meningitis [1]. But how did the cervicothoracic block trigger the headache in a patient without neurological or vascular disorders? Extracranial blood flow is increased by 50% during migraine headache, compared to normal subjects, and there is some evidence that this contributes to pain in some migraine sufferers [2]. This increase may result from alterations in sympathetic tone. Cervicothoracic block increases intracranial blood flow [3], and probably the sympathetic blockade produced by the technique may precipitate the migraine headache [4]. Other possible explanations include coincidence and factitious or psychogenic causes. Finally, we cannot conclude on the pathogenesis of migraine, but vascular and neurologic mechanisms are involved in this complex disorder.

Randomized double-blind comparison of remifentanil and alfentanil in patients undergoing laparoscopic cholecystectomy using total intravenous anesthesia

Background and Aims: To compare the use of remifentanil and alfentanil to suppress intraoperative adrenergic response of pain and the influence of these drugs on the recovery profile in patients undergoing laparoscopic cholecystectomy using a total intravenous anesthesia (TIVA) technique. Material and Methods: One hundred patients undergoing elective laparoscopic cholecystectomy were randomized to be managed with either remifentanil (group R) or alfentanil (group A). During general anesthesia, we evaluated adrenergic responses to intubation to first surgical incision and over the surgical procedure. We also recorded time to first spontaneous breathing, time to successful ventilation, time to respond to verbal orders, and time to extubation. Results: The R group reported a significantly lower number of responses to intubation and responses to first surgical incision (14% vs. 30%; P = 0.013 and 8% vs. 18%; P = 0,037, respectively). The event of one or more responses during the surgical procedure was also lower in the R group (56% vs. 70%; P = 0.017). Hypertensive response to surgical stimuli during the procedure was lower in the R group as well as a lower frequency of tachycardia episodes in this group (34% vs. 56%; P = 0.033 and 28% vs. 44%; P = 0.041, respectively). No differences were found between groups relating to the percentage of hypotensive episodes and no episodes of bradycardia were appreciated. Both groups were similar relating to recovery times: time to the first spontaneous breathing, time to successful ventilation, time to respond to verbal orders, and time to extubation. Conclusion: Remifentanil showed a more stable hemodynamic response during the surgery compared with the use of alfentanil in anesthetized patients undergoing laparoscopic cholecystectomy using TIVA. Both opioids, alfentanil and remifentanil, have a similar recovery profile, and they do not delay time to awakening.

Effects of pneumoperitoneum on severe hypernatremia in an adult patient who underwent laparoscopic surgery of hydatid cysts

We describe the first case of severe hypernatremia associated to laparoscopic surgery for hydatid cyst in an adult patient after the use of hypertonic saline solution with complete resolution. Severe hypernatremia is an unusual fact at the immediate postoperative period but may have fatal consequences for the patient and need immediate action. The patient reached a serum sodium concentration of 179 mmol/L without adverse effects after 6 days of treatment. Laparoscopy could play a crucial role in Na+ absorption due to high intraabdominal pressure caused by the pneumoperitoneum and its limitations to avoid peritoneal absorption of hypertonic saline solution. The relation between this surgical technique and the severe complication is discussed. More experience is needed in terms of safety for the patient.

Proposing a Novel Concept to Evaluate Safety of Supraglottic Devices Regarding Seal Pressure during Laparoscopic Surgery

C l i n M e d International Library Citation: Belena JM, Nunez M, Vidal A (2015) Proposing a Novel Concept to Evaluate Safety of Supraglottic Devices Regarding Seal Pressure during Laparoscopic Surgery. Int J Anesthetic Anesthesiol 2:019 Received: January 20, 2015: Accepted: January 21, 2015: Published: January 23, 2015 Copyright: