Inconsistent size nomenclature in extraglottic airway devices.

BACKGROUND: Extraglottic airway devices (EADs) are frequently used airway devices, yet often they seal poorly, resulting in a functionally unacceptable leak. Optimal size selection of the EAD is therefore critical to the safe and effective use of an EAD. This review is designed to delineate the sizing recommendations of EADs and indicate the differences in order to make the optimal choice for device effectiveness and patient safety. METHODS: We searched manufacturing' guidelines regarding size recommendations of EADs. Alternative size selection suggestions were obtained through an extensive literature search. RESULTS: Most manufacturers offer different types and a wide range of (up to 8 different) sizes of EADs. Size ranges offered by manufacturers are most often based on weight, although some manufacturers offer alternative EADs based on a variety of patient variables (age, gender, height). Even 'one-size-fits-all' adult EADs have been introduced into clinical practice. Special formulae and methods are suggested to aid the clinician to find the optimal EAD size, especially for children. CONCLUSION: Selecting the appropriate size of an EAD is critical to optimal use, although applying the correct size of an EAD has been subject of controversy, as recommendations on sizing differ substantially and are far from a coherent and universal sizing system. Successful use of an EAD depends in part on appropriate size selection, in addition to clinical judgment, as well as patient anatomy and physiology. Standardization in the use of EAD sizes and a consensus about a consistent size systematic of EADs would benefit to promote a safer clinical practice in airway management.

Anticipation of the difficult airway: preoperative airway assessment, an educational and quality improvement tool.

BACKGROUND: Assessment of the potentially difficult airway (DA) is a critical aspect of resident education. We investigated the impact of a new assessment form on airway prediction and management by anaesthesia residents. We hypothesized that residents would demonstrate improvement in evaluation of DAs over the study duration. METHODS: After IRB approval, anaesthesia residents were randomized into two groups: control (existing form) and experimental (new form). Data were collected prospectively from August 2008 to May 2010 on all non-obstetric adult patients undergoing non-emergent surgery. RESULTS: Eight thousand three hundred and sixty-four independent preoperative assessments were collected and 8075 were analysed. The experimental group had the higher completion rate than the control group (94.3% vs 84.3%, P=0.001). DA prediction was higher for the control group (71.2%) compared with the experimental group (69.1%; P=0.032). A significant improvement in prediction rates was found over time for the experimental group (likelihood estimate=0.00068, P=0.031). CONCLUSIONS: The use of a comprehensive airway assessment did not improve resident ability to predict a DA in an academic, tertiary-based hospital, anaesthesiology residency training programme.

Submental intubation: a literature review.

A literature review was performed to analyse the evidence supporting submental intubation and to aid in the development of a new airway algorithm in craniofacial surgery patients. A systematic search of Pub Med, OVID, the Cochrane Database and Google Scholar between January 1984 and April 2011 was performed. Measured variables included the outcome, complications, publishing specialty journal and method of intubation including technique modifications, indications for the procedure, devices utilized and the total procedure time to complete the submental intubation. Of the 842 patient cases from 41 articles represented in the review, the success rate was 100%. Minor complications were reported in 60 patients and included superficial skin infections (N=23), damage to the tube apparatus (N=10), fistula formation (N=10), right mainstem bronchus tube dislodgement/obstruction (N=5), hypertrophic scarring (N=3), accidental extubation in paediatric patients (N=2), excessive bronchial flexion (N=2), lingual nerve paresthesia (N=1), venous bleeding (N=2), mucocele (N=1), and dislodgement of the throat pack sticker in the submental wound (N=1). The average reported time to complete a submental intubation was 9.9 min. Submental intubation is a safe, effective and time efficient method for securing an airway when increased surgical exposure or restoration of occlusion is a priority.

Xenon exposure in the neonatal rat brain: effects on genes that regulate apoptosis.

BACKGROUND: In the developing rodent brain, exposure to volatile anesthetics causes widespread neuronal apoptosis in several regions of the brain. Increasing evidence points to a possible neuroprotective role for the anesthetic gas xenon, following neuronal injury. To address this gap in understanding, we explored the transcriptional consequences of xenon in the brains of postnatal day 7 (P7) rats exposed to xenon compared to those of air-breathing animals, with particular emphasis on the mRNA transcript levels of Akt and c-Jun N-terminal kinase kinase 1 (JNKK1), which are important for cell survival and the activation of extrinsic neuroapoptotic pathways, respectively. METHODS: P7 Sprague/Dawley rats were exposed to air (75% nitrogen, 25% oxygen) or xenon (75% xenon, 25% oxygen) for 120 min (N=6/group). Forebrains were harvested for reverse transcription polymerase chain reaction, which enabled quantification of Akt and JNKK1 mRNA transcripts. Suppression subtractive hybridization was used to explore the "genetic signature" of xenon exposure. RESULTS: Compared to control air-breathing animals, xenon-breathing rats exhibited a 0.7-fold decrease in Akt mRNA expression (P<0.01) and a 1.6-fold increase in JNKK1 mRNA levels (P<0.05). CONCLUSION: The concomitant decrease in the Akt mRNA expression level and increase in the JNKK1 mRNA transcript level provide evidence that xenon has a neuroapoptotic effect in the developing rodent forebrain. Given these results, further study into the paradoxical neuroprotective and neuroapoptotic effects of xenon is warranted.

A randomized clinical comparison of the Intersurgical i-gel and LMA Unique in non-obese adults during general surgery.

BACKGROUND: The i-gel is a cuffless, single-use supralaryngeal airway device designed to provide a more effective seal than the laryngeal mask airway (LMA). Although the superiority of the i-gel compared to the LMA Classic was determined in a previous study, no studies have been performed that compare it to the disposable LMA Unique. The aim of this study was to compare the Intersurgical i-gelTM against the LMA UniqueTM (uLMA) in terms of ease of placement, time of insertion, and adequacy of placement through a randomized, controlled clinical trial. METHODS: Following Institutional Review Board (IRB) approval and written informed consent, 50 adult patients were recruited for this study. All enrolled patients were ASA 1-2, Mallampati I-II, and scheduled to receive general anesthesia. Patients were randomized to have either the i-gel or the uLMA placed for airway management. After standardized induction techniques, the airway was secured with the assigned device. All patients were interviewed postoperatively for sore throat, hoarseness, and dysphagia. Standard vital signs, end-tidal CO2, tidal volumes, and peak pressures were recorded. Insertion time, leak pressures, and anatomic placement as assessed fiberoptically for the i-gel were recorded. Ease of placement and complications were also recorded. RESULTS: The insertion time was significantly less with the i-gel (21.04±12.6 s vs. 30.04±14.1 s, P=0.02). An inadequate seal was noted in three patients with the i-gel, and it was exchanged for the uLMA in all three cases. There were no significant differences in the ease of insertion, leak pressures, or fiberoptic view. Most of the fiberoptic views, as assessed through the drain tube, demonstrated esophageal mucosa (22/25). Patients receiving the i-gel were significantly more likely to require a second attempt at insertion by the anesthesiologist (OR 8.11, CI 1.1-58.6, P=0.03). Finally, patients receiving the size 5 i-gel were significantly more likely to complain of immediate postoperative symptoms, such as sore throat and dysphagia (OR 29.32, CI 1.4-613.1, P=0.03). CONCLUSION: Although the i-gel had a faster insertion time in comparison to the uLMA, there was a greater need for repeat insertions. The weight criteria established by the manufacturer may need to be readjusted to recommend a larger size device in some patients less than 90 kg because all of the repeat insertions were in patients weighing more than 80 kg. In all other aspects of its use, the i-gel performed similarly to the uLMA.

Perioperative management of proximal hip fractures in the elderly: the surgeon and the anesthesiologist.

The comprehensive management of proximal hip fractures in elderly patients requires dedicated and responsive teamwork. Elderly patients often present with several comorbidities and the immediate treatment of a fracture has to optimize both medical therapy and analgesic control in order to reduce surgical and anesthetic complications and to preserve as much cognitive functioning as possible. The elderly are uniquely exposed to complications related to bed rest, delirium and postoperative cognitive dysfunction (POCD), which appear to be independent factors of morbidity. Anesthetic management that includes good perioperative pain management can influence the patient's inflammatory response and possibly decrease the incidence of POCD. The best choice of surgical treatment depends on the type of fracture as well as the patient's age and medical condition. However, the type of anesthesia management, which includes neuraxial blocks, peripheral nerve blocks and/or general anesthesia, has to be tailored towards generated the best outcome. We present a review from a surgical and anesthetic perspective on the most common perioperative issues in proximal fracture repair.