Fiberoptic-Guided and Blind Tracheal Intubation Through iLTS-D, Ambu® Auragain™, and I-Gel® Supraglottic Airway Devices: A Randomized Crossover Manikin Trial.

BACKGROUND: The use of supraglottic airway devices (SADs) is becoming more widespread. However, there is little evidence to show which device is best in an emergent clinical scenario. OBJECTIVE: We compared both fiberoptic-guided and blind tracheal intubation through the Intubating Laryngeal Tube Suction-Disposal (iLTS-D), the AuraGain™, and the i-gel® in an airway manikin. METHODS: Thirty residents were included in a randomized trial to perform both fiberoptic-guided and blind tracheal intubation using the iLTS-D, the AuraGain, and the i-gel. The main endpoint was the total time taken to achieve successful fiberoptic intubation through the SAD. Additional endpoints included total time for blind intubation, SAD insertion time, tracheal tube insertion time, intubation success rate, fiberoptic view, and maneuvers performed to achieve tracheal intubation. RESULTS: All participants performed fiberoptic intubation using all three SADs on the first attempt. The total time to fiberoptic tracheal intubation using the i-gel, AuraGain, and iLTS-D was 42 s, 56 s, and 56 s, respectively. The blind tracheal intubation success rate was 80% with the iLTS-D, 43% with the i-gel, and 0% with the AuraGain. The total time for blind tracheal intubation through the i-gel and the iLTS-D was 29 s and 40 s, respectively. Laryngeal view grades were significantly poorer with the iLTS-D compared to the other devices. The iLTS-D required significantly more maneuvers to achieve successful tracheal intubation. CONCLUSIONS: In an airway manikin, the iLTS-D, AuraGain, and i-gel appear to be reliable devices for airway rescue and fiberoptic-guided tracheal intubation. The iLTS-D is recommended for blind tracheal intubation.

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 CO(2) 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.

Optimising the dose of oral midazolam sedation for dental procedures in children: a prospective, randomised, and controlled study.

BACKGROUND: Midazolam sedation poses a significant dilemma in paediatric dentistry, which is to find out the optimal dosing with minimal undesirable adverse events. In this study, we aimed to compare the effect of three doses of oral midazolam (0.5, 0.75, and 1 mg/kg) on the sedative state and cooperative behaviour of children during dental treatment. We further compared completion rates, parent satisfaction, and all adverse events. DESIGN: Ninety children aged 3-10 years were randomised to three equal groups. Groups A, B, and C received 0.5, 0.75, and 1 mg/kg of oral midazolam, respectively. Levels of sedation, cooperative behaviour, procedures completion rates, parent satisfaction, and adverse events were prospectively recorded. RESULTS: Sedation scores in B and C were higher (P < 0.001) than in A. Cooperation scores (CS) in B and C were higher (P < 0.001) than in A. Significant increase in completion rates was observed between A and C (P = 0.025). Parent satisfaction was greater in B and C (P < 0.001) compared to A. Adverse events were higher in C (P < 0.05) than in A or B. CONCLUSION: Amount of 0.75 mg/kg oral midazolam appears to be the optimal oral dose in terms of effectiveness, acceptability, and safety for dental treatments in paediatric patients, when administered by an experienced, paediatric anaesthetist.

The esophageal-tracheal combitube resistance and ventilatory pressures.

STUDY OBJECTIVE: To measure resistance of the Combitube, a supraglottic ventilatory device used in the management of the patients with difficult airways, and its influence on delivered ventilatory pressures. DESIGN: Prospective study. SETTING: University-affiliated hospital. PATIENTS: A total of 20 patients with ASA status I or II who were scheduled for elective knee arthroscopy. INTERVENTIONS: (Part 2 of the study) After induction of general anesthesia and insertion of the Combitube, mechanical ventilation was initiated. Airway pressures were measured using fluid-filled pressure lines at the Y-piece (P(Y-piece)) of the breathing system and in the oropharynx (P(oropharynx)) at a position 2 cm beyond the second proximal anterior hole of the Combitube. These pressures were simultaneously recorded and the pressure curves were compared. MEASUREMENTS: (Part 1 of the study) Resistance of the esophageal and the tracheal lumen of the 37-F Combitube and standard endotracheal tubes (with internal diameters of 6, 7, and 8 mm) was compared ex vivo with a Datex AS/3 monitor. Ventilation conditions were kept constant at a tidal volume of 0.5 L, frequency of 10 breaths per minute, and ramp flow waveform and peak flow of 1 L/s. MAIN RESULTS: Resistance of standard endotracheal tubes was inversely proportional to their diameters (16, 11, and 7 cm H(2)O/L per second for the tubes with internal diameters of 6, 7, and 8 mm, respectively). The resistance of the Combitube's tracheal lumen was 12 cm H(2)O/L per second. There was a significant difference in peak respiratory pressures between P(Y-piece) and P(oropharynx) (40 +/- 5 and 23 +/- 5 cm H(2)O, respectively). CONCLUSIONS: The Combitube has significant airflow resistance that should be considered when patients are mechanically ventilated because the delivered oropharyngeal pressure is significantly lower than the pressure measured at the anesthesia breathing system.

Current status of the EasyTube: a review of the literature.

EasyTube is an esophageal-tracheal double lumen airway device that combines the features of an endotracheal tube with a supraglottic airway device, enabling ventilation with either tracheal or esophageal insertion. EasyTube can be inserted blindly or by using a laryngoscope. Its main indication is for airway emergencies both in pre-and in-hospital areas. In this article we review the current knowledge on the use of the EasyTube.

Treating acute anaemia in a Jehovah's Witness in Israel: an innovative approach to a medical and legal challenge.

A person's right to control his or her own body, expressed through the concept of informed consent to medical treatment, has gained worldwide acceptance. Nevertheless, this right may conflict with the state's interest in preserving life in cases where patients refuse treatment in medical emergencies. This paper examines the management of treating acute anaemia in a Jehovah's Witness in Israel who refused blood transfusion on religious grounds. The medical and legal ramifications are discussed in light of the Israeli Patients' Rights Law of 1996. This law established statutory ethics committees which may, under defined conditions of emergency or threat to life, approve treatment against the patient's will. This power, previously vested in the courts, should be used only in extreme circumstances while, in general, patients' wishes and beliefs must be respected. Sensitivity to the legal and ethical aspects involved deserves greater emphasis in medical school curricula.

The effect of combined spinal-epidural anesthesia versus general anesthesia on the recovery time of intestinal function in young infants undergoing intestinal surgery: a randomized, prospective, controlled trial.

STUDY OBJECTIVE: To assess the rate of restoration of gastrointestinal (GI) function following combined spinal-epidural (CSE) anesthesia compared with general anesthesia in young infants undergoing elective intestinal surgery. DESIGN: Prospective, randomized, controlled study. SETTING: Operating room and neonatal intensive care unit of a university hospital. SUBJECTS: 50 young infants undergoing elective intestinal surgery. INTERVENTIONS AND MEASUREMENTS: 50 young infants were randomly allocated to two groups of 25 patients each, a general anesthesia group and a CSE anesthesia group. The two groups were further divided into two subgroups according to whether the surgical procedure was performed on the small or large intestine. The main outcome of this study was to measure the recovery times of GI function by determining the time to the first postoperative stool, duration of nasogastric feeding, and onset time of full enteral nutrition. The secondary outcome was to detect adverse events postoperatively. MAIN RESULTS: Recovery of intestinal function was faster (P < 0.0001) and the frequencies of postoperative abdominal distension and pneumonia were less (P < 0.04) in infants who were anesthetized with CSE anesthesia than general anesthesia. CONCLUSIONS: Combined spinal-epidural anesthesia leads to faster restoration of GI function while reducing adverse events in infants who require elective intestinal surgery.

Prospective randomized comparison of the EasyTube and the esophageal-tracheal Combitube airway devices during general anesthesia with mechanical ventilation.

STUDY OBJECTIVE: To evaluate the ease of use of two airway devices, the EasyTube (EzT) versus the esophageal-tracheal Combitube (ETC). DESIGN: Prospective, randomized controlled trial. SETTING: University hospital. SUBJECTS: 80 adult, ASA physical status 1 and 2 patients scheduled for elective surgery. INTERVENTIONS: Patients' tracheas were intubated with the EzT or the ETC in randomized fashion. MEASUREMENTS: Difficulty of insertion, time to achieve an effective airway, insertion success rate, maneuvers to achieve an effective airway, oropharyngeal leak pressure, intracuff pressure, ventilatory parameters, success rate of gastric tube insertion, and frequency of adverse effects were compared. MAIN RESULTS: Insertion was easier in the EzT than in ETC; insertion of the EzT was rated easy in 36 7 cases and moderately difficult in 4 cases versus 26 and 14 cases, respectively, for the ETC (P = 0.014). Less time was required to achieve an effective airway with the EzT than the ETC: 19.4 ± 5.3 sec versus 30.6 ± 4.1 seconds, respectively (P < 0.001). Oropharyngeal leak pressure was higher with the EzT than the ETC (34.3 ± 5.95 vs 31.6 ± 2.42 cm H(2)O; P = 0.011). Peak airway pressures for the EZT and the ETC were 22.2 ± 0.99 cm H(2)0 and 33.7 ± 1.82 cm H(2)O, respectively (P < 0.001). Gastric tube insertion was successful with both devices; however, the EzT allowed insertion of gastric tubes of wider diameter. No severe perioperative adverse events were recorded for either device. CONCLUSION: The EzT has distinct advantages over the ETC in airway management, including shorter time to achieve an effective airway and easier insertion.

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. METHODS: Spinal anesthesia was performed in 28 neonates and infants with isobaric bupivacaine 0.5%, 1 mg.kg(-1) followed by placement of a caudal epidural catheter to thoracic spinal segments. The catheter tip position was confirmed radiographically. Respiratory and hemodynamic data were collected before and after the CSE-A and throughout the operation, as a measure of anesthetic effectiveness. Complications related to the anesthesia technique were collected as a measure of the anesthetic technique safety. RESULTS: Satisfactory surgical anesthesia was achieved in 24 neonates and infants, four patients were converted to general anesthesia. Respiratory and hemodynamic variables did not change significantly during surgery, compared with baseline values: oxygen saturation (P = 0.07), systolic and diastolic blood pressures (P = 0.143, P = 0.198 respectively), heart rate (P = 0.080) and respiratory rate (P = 0.127). However, twenty infants were fussy during the surgical procedures and were calmed with intravenous midazolam; our patients required oxygen supplementation and transient manual ventilation intraoperatively. CONCLUSIONS: Combined spinal-epidural anesthesia could be considered as an effective anesthetic technique for elective major upper abdominal surgery in awake or sedated neonates and infants, and could be used cautiously by a pediatric anesthesiologist as an alternate to general anesthesia in high-risk neonates and infants undergoing upper gastrointestinal surgery.

Bee stings of children: when to perform endotracheal intubation?

Hymenoptera stings account for more deaths in United States that any other envenomation. Oropharyngeal stings, although rare, may produce life-threatening airway obstruction by way of localized swelling. We present 4 cases of bee stings in children that necessitated tracheal intubation and mechanical ventilation. Two children had breathing difficulties at admission; the other 2 presented with minimal symptoms but were preventively intubated and mechanically ventilated. Orofacial bee sting victims should be given parenteral treatment with epinephrine, steroids, antihistamines, and inhalational bronchodilators even when they initially present with minimal symptoms, with general anaphylaxis management in large envenomations, as well as immediate endotracheal intubation and mechanical ventilation for at least 24 hours in patients with signs of airway compromise.

The Esophageal-Tracheal Combitube.

The ETC is an easily inserted, double-lumen/double-balloon supraglottic airway device. The major indication of the ETC is as a back-up device for airway management. It is an excellent option for rescue ventilation in both in- and out-of-the-hospital environments and in situations of difficult ventilation and intubation. It is useful especially in patients with massive airway bleeding or limited access to the airway and in patients in whom neck movement is contraindicated. Continued airway management with an ETC that has been placed is a reasonable option in many cases. Having thus secured the airway, it may not be necessary to abort the anesthetic or to continue with further airway management efforts. In order to avoid serious trauma to the esophagus or airway, redesigning the ETC using a softer material for the tube is advisable.

The effectiveness and safety of spinal anaesthesia in the pyloromyotomy procedure.

BACKGROUND: Hypertrophic pyloric stenosis is a relatively common disorder of the gastrointestinal tract in infancy, causing projectile vomiting and metabolic abnormalities. Surgical management in the form of pyloromyotomy under general anaesthesia has been reported as safe for relieving the obstructed bowel. A number of studies have demonstrated the advantages of spinal anaesthesia over general anaesthesia in high risk infants undergoing minor infraumbilical surgery. The purpose of this study was to evaluate spinal anaesthesia as an alternative option to general anaesthesia in infants undergoing pyloromyotomy. METHODS: Twenty-five infants undergoing pyloromyotomy under spinal anaesthesia were studied. Haemodynamic and respiratory parameters were noted before performing the spinal block, 5 min after the spinal block, and every 10 min after performing the spinal block; for a total period of 30 min. The spinal block was performed using spinal isobaric bupivacaine 0.5%, 0.8 mg.kg-1. Blood pressure, heart rate, respiratory rate and oxygen saturation values were recorded. RESULTS: The sensory levels achieved ranged between T3-T5 thoracic segments within 6-8 min and were sufficient to perform surgery in 23 cases. There were no statistically significant differences in the oxygen saturation, systolic blood pressure and respiratory rate compared with before the spinal block and after 5, 10, 20 and 30 min. CONCLUSIONS: This study proposes that spinal anaesthesia is an alternative option to general anaesthesia in infants undergoing pyloromyotomy, and should be considered in infants undergoing pyloromyotomy.

A new supraglottic airway, the Elisha Airway Device: a preliminary study.

We describe the Elisha Airway Device (EAD), a new reusable supraglottic ventilatory device. Its uniqueness consists of its ability to combine three functions in a single device: ventilation, blind and/or fiberoptic-aided intubation without interruption of ventilation, and gastric tube insertion. This study was performed in 70 ASA status I-II, Mallampati class I-II patients undergoing elective knee arthroscopy and receiving general anesthesia with mechanical ventilation. Anesthesia was induced with fentanyl and propofol and was maintained with isoflurane in N20/oxygen. Neuromuscular blockade was achieved with vecuronium. Blind insertion of the device was successful in 96% of patients, with a mean insertion time of 20 +/- 4 s. In these patients it was possible to maintain oxygenation and ventilation throughout the surgical procedure. Gastric tube insertion was successful in all cases. Endotracheal intubation via the EAD was attempted in 20 patients. Blind intubation was possible during the first and second attempts in 15 and 2 patients, respectively. Fiberoptic intubation was then successful in two of the remaining three patients. The EAD is a new alternative in the evolution of supraglottic ventilatory devices; however, further clinical studies are necessary to evaluate its efficacy.

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.

An evaluation of the Laryngeal Tube during general anesthesia using mechanical ventilation.

UNLABELLED: 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 CO(2) 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.

Postdural puncture headache: an imaging-guided management protocol.

IMPLICATIONS: We propose an imaging-based algorithm for the management of headache caused by the inadvertent puncture of dura that occurs sporadically during epidural analgesia. Its implementation can identify those postdural puncture headache cases that cannot benefit from epidural blood patches, and their unnecessary application can consequently be avoided.

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

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. METHODS: Thirty male paediatric patients undergoing orchidopexy, ASA I, received inhalation general anaesthesia, and were randomly allocated to one of two groups: a caudal group (n = 15) and an ilioinguinal/iliohypogastric nerve block group (n = 15). Plasma epinephrine and norepinephrine concentrations were measured at the induction time, at the end of surgery, and in the postanaesthesia care unit. Postoperative pain score was also assessed in the postanaesthesia care unit. RESULTS: In both groups, there was a substantial decrease in the catecholamine blood levels; however, there were significantly higher levels of epinephrine in the ilioinguinal group at the end of surgery (P = 0.008) and in the recovery room (P = 0.02) and a significant higher level of norpinephrine in the recovery room (P = 0.008). CONCLUSIONS: The result of this study revealed that caudal epidural block was more effective than ilioinguinal block in suppressing the stress response as reflected in epinephrine and norepinephrine blood levels in orchidopexy patients.