Prospective audit on the use of the LMA-Supreme for airway management of adult patients undergoing elective orthopaedic surgery in prone position.

BACKGROUND: The LMA-Supreme (SLMA) is a single-use, latex-free, supraglottic airway device with a drain tube which allows immediate assessment of correct positioning of the device at insertion and throughout the procedure and provides access to gastric contents. The anatomically shaped airway tube facilitates easy insertion in anaesthetized patients in the supine, lateral, and prone positions. We present a prospective audit in 205 consecutive adult patients presenting for elective spine surgery in the prone position. Patients positioned themselves in the prone position, on a Montreal or Wilson mattress to optimize patient comfort in this position. Anaesthesia was then induced, and an appropriate-sized SLMA was inserted. METHODS: Prospective, descriptive audit of SLMA insertion in 205 consecutive adult patients, anaesthetized in the prone position for elective orthopaedic surgery with spontaneous (n=6) or positive pressure ventilation (PPV) (n=199). RESULTS: First-pass success was achieved in 184 insertions. Forty-two SLMA insertions were performed by anaesthesia trainees with first-pass success achieved in 38 insertions. All problems encountered during insertion were minor, and no patient had to be turned to the supine position for an airway problem. Problems during insertion were independent of patients' BMI. There were no failures of SLMA insertion or of maintenance of PPV during surgery. CONCLUSIONS: The results suggest that the SLMA is a useful device for airway management in patients anaesthetized in the prone position and for subsequent airway management with PPV, with or without neuromuscular block.

LMA-Supreme--a new single-use LMA with gastric access: a report on its clinical efficacy.

BACKGROUND: LMA-Supreme (SLMA) is a new, single-use, latex-free, laryngeal mask airway with gastric access. The anatomically shaped airway tube permits easy insertion without placing fingers in the patient's mouth. The cuff is designed to provide higher seal pressures than the LMA-Classic or Unique. METHODS: A prospective, randomized, cross-over study of LMA-Proseal (PLMA) and SLMA in 36 fasted, adult, female patients with general anaesthesia, neuromuscular block (NMB) and positive pressure ventilation (PPV) is presented. RESULTS: First attempt insertion in 35/36 patients in each group (two attempts in one PLMA and three in one SLMA patient) with successful PPV in all. Median insertion time (15 s) and glottic seal pressure (28 cm H(2)O) were similar in both groups. Median volume of air for cuff inflation to 60 cm H(2)O was 22.4 ml (PLMA) and 21.9 ml (SLMA). Median age and BMI: 50 yr (range 25-74), 51 yr (23-72) and 29 kg m(-2) (range 21-46), 30 kg m(-2) (20-42) in PLMA and SLMA groups, respectively. Mallampati score mean arterial pressures after induction, and 1 min after induction and insertion of the first device were similar. A lubricated gastric tube (16Fr) was passed at the first attempt in both devices: median gastric content 15 ml (5-75), 17.5 (5-124) and a median pH of 3 (1-6), 1.5 (1-6) in the PLMA and SLMA groups, respectively. Fibreoptic laryngoscopic scores of 1-2 were recorded in 29/36 in both groups. CONCLUSIONS: Insertion success, glottic seal pressure and gastric access were similar in SLMA and PLMA.

Inflammatory pseudotumour of the maxillary sinus presenting as a sino-nasal malignancy.

Inflammatory pseudotumours are a rare group of benign neoplasms of unknown aetiology. They are uncommon in head and neck sites, particularly the paranasal sinuses. Surgical excision, radiotherapy and steroids have all been used as treatment modalities. A report is made of a 27-year-old female who presented with a rapid-onset proptosis that clinically and radiologically mimicked an aggressive sino-nasal malignancy. Histology eventually confirmed an inflammatory pseudotumour of the maxillary sinus. The patient was treated successfully with a combination of surgery and steroid therapy.

The Glidescope system: a clinical assessment of performance.

The Glidescope is a new videolaryngoscope. It has a digital camera incorporated in the blade which displays a view of the vocal cords on a monitor. This allows the placement of a tracheal tube to be visualised. We describe its performance in 50 patients who required orotracheal intubation for elective surgery. Two investigators performed 25 intubations each. Intubation with the Glidescope was successful in 47 of the 50 cases. The three failures occurred early in the series and were attributed to the initial learning curve. The success rate after the first eight patients in each series was 100%. The median (IQR [range]) time to intubation was 40 (30-55 [15-105]) s. The Glidescope provided a grade I view of the glottis in 44 cases and a grade II view in six cases. The view of the larynx was improved in almost half (23) of the cases. The Glidescope improved the view by one grade in 22 and by two grades in one patient. We conclude that the Glidescope is an effective device for tracheal intubation and provides an improved view of the larynx. Further clinical studies are necessary to evaluate its role in airways that are difficult to manage.

Thyroid abscess--an acute emergency.

An abscess in a long-standing goitre is usually life threatening. A patient with a large goitre was lost to follow-up for about 10 years and presented with a large thyroid abscess causing acute respiratory obstruction. The abscess caused erosion of the tracheal wall and perforation of the esophagus. Clostridium septicum was the causative organism, which is almost always associated with cancer of the colon. This led to the detection of colonic malignancy in this patient on further investigations. We describe the complications of a thyroid abscess and discuss the pathophysiology and treatment.

Randomized crossover comparison of the proseal with the classic laryngeal mask airway in unparalysed anaesthetized patients.

BACKGROUND: The ProSeal is a wire-reinforced laryngeal mask airway with an additional drain tube that leads to the distal tip of the laryngeal cuff. The design should improve the seal with the larynx. METHODS: The ProSeal and classic laryngeal mask airways were compared in 180 patients in a randomized crossover study. Patients were anaesthetized without neuromuscular blocking drugs. RESULTS: The ProSeal took more time and more attempts to insert successfully than the classic laryngeal mask airway. Insertion was successful on the first attempt in 81% of cases with the ProSeal and 90% with the classic laryngeal mask airway. The ProSeal required more air to achieve an intracuff pressure of 60 cm H2O (6 ml more for size 4 and 12 ml more for size 5). Laryngeal seal pressure was better with the ProSeal than the classic laryngeal mask airway. Median seal pressure was 29 cm H2O with the ProSeal and 18 cm H2O with the classic laryngeal mask airway. Laryngeal seal pressure was greater than 20 cm H2O in 87% of patients with the ProSeal and 41% with the classic laryngeal mask airway. Laryngeal seal pressure was greater than 40 cm H2O in 21% of patients with the ProSeal and in none of the patients with the classic laryngeal mask. Once placed, the ProSeal remained a stable and effective airway. Gastric tube insertion through the drain tube was attempted in 147 cases and was successful in 135 (92%). CONCLUSION: The ProSeal is more difficult to insert than the classic laryngeal mask airway but allows positive pressure ventilation more reliably than the classic laryngeal mask airway.

Resolution of ST-segment elevation after streptokinase therapy in anterior versus inferior wall myocardial infarction.

BACKGROUND: Resolution of ST-segment elevation is the best bedside predictor of myocardial reperfusion. HYPOTHESIS: This study was conducted to examine the resolution of ST-segment elevation after streptokinase therapy in anterior versus inferior acute myocardial infarction (MI) and to corroborate it with echocardiographic and coronary angiographic data. METHODS: The study population consisted of 70 patients, 35 each in the anterior and inferior MI groups. The electrocardiograms (ECGs) were recorded before, on completion of, and on Days 1 and 2 post streptokinase therapy. The resolution of ST segment determined from post-streptokinase ECGs was compared between the two groups and correlated with echocardiographic and coronary angiographic data. RESULTS: On completion of and on Day 1 post streptokinase therapy, ST-segment resolution in both groups was not significantly different. On Day 2 post streptokinase therapy, resolution of the ST segment per lead was significantly lower in anterior than that in inferior MI (61 +/- 21% anterior vs. 77 +/- 21% inferior, p 0.003). The number of patients with akinesis of infarct-related ventricular wall was significantly higher (17 anterior vs. 7 inferior, p 0.02), and left ventricular ejection fraction was significantly lower in anterior MI (39 +/- 7% anterior vs. 48 +/- 8% inferior, p < 0.01). There was no significant difference in coronary angiographic data. One patient in each group demonstrated normal coronary arteries. CONCLUSIONS: The resolution of ST-segment elevation on the completion of and on Day 1 post streptokinase therapy was comparable between anterior and inferior MI. The significantly less frequent resolution of ST-segment elevation in anterior MI on Day 2 post streptokinase could be due to more akinesis, larger infarct size, and worse systolic function rather than due to failure to open the infarct-related vessel.

The LMA 'ProSeal'--a laryngeal mask with an oesophageal vent.

We describe a new laryngeal mask airway (LMA) that incorporates a second tube placed lateral to the airway tube and ending at the tip of the mask. The second tube is intended to separate the alimentary and respiratory tracts. It should permit access to or escape of fluids from the stomach and reduce the risks of gastric insufflation and pulmonary aspiration. It can also determine the correct positioning of the mask. A second posterior cuff is fitted to improve the seal. A preliminary crossover comparison with the standard mask in 30 adult female patients showed no differences in insertion, trauma or quality of airway. At 60 cm H2O intracuff pressure, the new LMA gave twice the seal pressure of the standard device (P < 0.0001) and permitted blind insertion of a gastric tube in all cases. It is concluded that the new device merits further study.