The effect of deep versus awake removal of the laryngeal mask airway on the incidence of emergence delirium in paediatric tonsillectomy: A randomised controlled trial.

Emergence delirium, characterised by inconsolable crying, perceptual disturbances and thrashing, occurs in young children during the recovery phase from general anaesthesia. Our aim was to determine whether timing of laryngeal mask airway removal (deeply anaesthetised versus awake) influenced the incidence of emergence delirium in children after tonsillectomy. A single-centre, randomised controlled trial was conducted at Albury Wodonga Health, a regional hospital in Australia. Included patients were two to seven years old, American Society of Anesthesiologists physical status classification 1-2, undergoing elective tonsillectomy (with or without adenoidectomy or grommet insertion) under general anaesthesia. Patients were randomised to have their laryngeal mask removed whilst deeply anaesthetised (in the operating theatre) or after awakening (in the post-anaesthesia care unit (PACU)). Pediatric Anesthesia Emergence Delirium score was determined at 5 and 20 min after eye opening, and frequency of complications (cough, vomiting, excessive salivation, oxygen desaturation and laryngospasm) in the PACU were recorded. Sixty-two patients were randomised to deep laryngeal mask removal and 62 to awake. In the awake versus deep groups, 33 (53%) versus 40 (65%) participants had emergence delirium at 5 min (odds ratio (OR) 0.63, 95% confidence interval (CI) 0.30 to 1.29, P = 0.20). At 20 min, 18 (29%) vs. 19 (31%) participants had emergence delirium (OR 0.93, 95% CI 0.43 to 2.00, P = 0.88). A greater incidence of most PACU complications was observed in the awake versus deep group; cough (24% vs. 8%), vomiting (8% vs. 0%), excessive salivation (23% vs. 8%) and oxygen desaturation (16% vs. 0%). We found no significant difference between the two techniques in terms of preventing emergence delirium. However, other PACU complications were more frequent with awake removal.

Ramped versus sniffing position for Ambu® AuraGainTM insertion in patients with obesity: a randomized controlled study.

BACKGROUND: The ramped position facilitates mask ventilation and endotracheal intubation in patients with obesity. This study aimed to determine whether the ramped position improves supraglottic airway (SGA) insertion in patients with obesity. METHODS: In this prospective, randomized, single-center trial, 48 obese patients undergoing elective surgery were randomized into either ramped or sniffing position groups. The Ambu® AuraGainTM (Ambu A/S), a second-generation SGA, was used. The primary outcome was the time required for the AuraGain insertion. Secondary outcomes included ease and number of insertion attempts, oropharyngeal leak pressure (OLP), and complications. The number needed to treat (NNT) was calculated to ensure ease of insertion. RESULTS: The time required for the AuraGain insertion was significantly shorter in the ramped group than in the sniffing group (13.0 [11.0, 16.0] vs. 24.0 [21.0, 28.0], P < 0.001). The insertion was easier in the ramped group than in the sniffing group (23/24 vs. 13/24, NNT = 2.4 [95% CI, 1.6, 5.0], P = 0.003). The first-attempt success rate was higher in the ramped group than in the sniffing group, although the difference was not statistically significant (22/24 vs. 18/24, P = 0.319). The OLP and postoperative complication rates were not significantly different between the groups. CONCLUSIONS: The ramped position reduced the time required for the AuraGain insertion in obese patients while providing comparable airway sealing without increasing adverse events. Therefore, a ramped position may be a more suitable option for SGA insertion in this population.

Comparison of incidence of sore throat with laryngeal mask airway Protector and laryngeal mask airway ProSeal: A randomised clinical trial.

Background and Aims: Postoperative sore throat (POST) can be as high as 42% in supraglottic devices. LMA® Protector™ is a novel second-generation laryngeal mask airway (LMA) with Cuff Pilot™ technology that allows continuous cuff pressure monitoring. Elevated cuff pressure is a risk factor for POST in supraglottic devices, so we conducted this study to determine whether continuous cuff pressure monitoring can alleviate POST. Methods: This randomised double-blinded clinical trial compared the incidence of sore throat between LMA® Protector™ and LMA® ProSeal™ and was conducted in 118 patients scheduled for elective short surgical procedures. They were randomised to either LMA® Protector™ (Group PT) or LMA® ProSeal™ (Group P). The airway was secured with either of the two devices. The primary outcome was the incidence of sore throat at 1, 6, and 24 hours postoperatively and compared using the Chi-square test along with other parameters like first attempt success rate and blood staining of the device. The time taken for insertion and oropharyngeal seal pressure were compared using an independent t-test. Results: The incidence of POST was low with Group PT (12%) compared to Group P (28.8%) (P = 0.005). The mean oropharyngeal seal pressure was significantly higher in Group PT than in Group P [33.72 (3.07) versus 27.72 (3.88) cm of H2O], P < 0.005. The first attempt success rate was 81.2% and 100% in LMA® Protector™ versus LMA® ProSeal™. Conclusion: LMA® Protector™ had a reduced incidence of POST compared to LMA ProSeal. However, a longer insertion time and difficult placement may be a concern.

Clinical Performance of I-gel® and BlockBuster™ Laryngeal Mask Airway in Adult Patients during General Anesthesia: A Randomized Comparison.

Background: Supraglottic devices have revolutionized the current practice of airway management. We compared the clinical performance of a recently introduced BlockBuster™ Laryngeal mask airway with i-gel® in adult patients under general anesthesia. Methods: Following Institutional ethical clearance, the present study was conducted on 62 patients belonging to American Society of Anesthesiologists physical status 1 and 2 of either sex in the age group of 20-60 years under general anesthesia. Patients were randomly assigned to i-gel® (I) and BlockBuster™ (B) groups (31 per group). Time for successful insertion, insertion success rate, ease of insertion, oropharyngeal leak pressures (OLPs), and complications were assessed. Results: Mean insertion time of device was less in Group I (13.52 ± 2.58 s) than that of Group B (14.10 ± 2.04 s), which was neither clinically nor statistically significant (P = 0.330). OLP in Group B (24.52 ± 2.77 cm of H2O) was found to be significantly higher compared to Group I (20.81 ± 2.56 cm of H2O) with P < 0.001. Overall insertion and first attempt success was similar (i-gel® 31/31 [100%] and 29/31 [93.5%] and BlockBuster™ 31/31 [100%] and 29/31 [93.5%], respectively). Ease of insertion (P = 0.684) and complications (P = 0.782) of both the devices were comparable. Conclusions: Both the devices are useful and effective for airway management in adult under general anesthesia. Having a high OLP and comparable insertion time, risk of aspiration may be further reduced with the use of BlockBuster™ in comparison to i-gel®.

Emergence characteristics comparing endotracheal tube to reinforced laryngeal mask airway during endoscopic sinus surgery - A randomised controlled study.

Background and Aims: During endoscopic sinus surgery, anaesthetic conditions significantly impact the intraoperative surgical field and bleeding during emergence. While the endotracheal tube (ETT) has been traditionally used in sinus surgery, a reinforced laryngeal mask airway (RLMA) that produces less upper airway stimulation may result in smoother emergence. Methods: A randomised controlled trial of 72 patients undergoing elective sinus surgery was conducted, with the allocation of airway technique to either ETT with a throat pack or RLMA. The primary outcome measure was emergence time, measured by time to opening eyes on commands at the cessation of anaesthesia, and the secondary outcomes were time to removal of airway device, remifentanil use, procedure times, mean arterial pressure (MAP) and the RLMA grade of blood contamination. The continuous variables were analysed using Student's t-tests and discrete variables, count tables were analysed using Fisher's exact tests. Results: There was no significant difference in the emergence time between the ETT and RLMA groups (P = 0.83). Remifentanil use was significantly higher in the ETT group than in the RLMA group (P = 0.022). The ETT group showed a significantly increased total anaesthetic time (P = 0.01). MAP was not significant during preinduction, maintenance or post-RMLA removal. The highest grade of contamination was grade 2 in RLMA. RLMA had lower rates of postoperative adverse events. Conclusions: RLMA comparable to ETT in terms of emergence time. The RMLA group had lower remifentanil use, anaesthesia duration and fewer postoperative adverse events such as cough and throat pain.

Airway management and pulmonary aspiration during surgical interventions in pregnant women in the 2nd/3rd trimester and immediate postpartum - a retrospective study in a tertiary care university hospital.

BACKGROUND: Pregnancy is associated with an increased risk of pulmonary aspiration during general anaesthesia, but the incidence of this complication is not well defined. METHODS: We performed a retrospective database review in a tertiary care university hospital to determine the incidence of pulmonary aspiration in pregnant patients undergoing endotracheal intubation, with and without Rapid Sequence Induction (RSI), as well as face-mask ventilation and supraglottic airway devices. We included Patients in the 2nd or 3rd trimester of pregnancy and immediate postpartum undergoing surgical procedures. The primary endpoint was the occurrence of pulmonary aspiration. RESULTS: Data from 2,390 patients undergoing general anaesthesia for cerclage of cervix uteri, manual removal of retained placenta, repair of obstetric laceration, or postpartum bleeding were retrospectively evaluated. A supraglottic airway device or face-mask ventilation was used in 1,425/2,390 (60%) of patients, while 638/2,390 (27%) were intubated. RSI was used in 522/638 (82%) of patients undergoing tracheal intubation, or 522/2,390 (22%) of the entire cohort. In-depth review of the charts, including 54 patients who had been initially classified as "possible pulmonary aspiration" by anaesthetists, revealed that this adverse event did not occur in the cohort. CONCLUSIONS: In conclusion, in this obstetric surgery patient population at risk for pulmonary aspiration, supraglottic airway devices were used in approximately 60% of cases. Yet, no aspiration event was detected with either a supraglottic airway or endotracheal intubation.

Comparison of i-gel® and LMA® Supreme™ for Facilitating Fiberoptic Endotracheal Intubation: A Prospective Randomized Trial.

Supraglottic airway (SGA) is an alternative to endotracheal intubation, however endotracheal intubation is often essential. One method to convert from an SGA to an endotracheal tube (ETT) is utilizing the SGA as a conduit for fiberoptic-guided advancement of an Aintree catheter (airway exchange catheter), and exchange of the SGA for an ETT. In this prospective randomized study, we compared two SGA devices in facilitating this exchange. Subjects were randomized to receive either the i-gel® or LMA® Supreme™ SGA. The SGA was placed and an Aintree intubation catheter was inserted through the SGA over a fiberoptic bronchoscope. Next, the SGA was removed, leaving the Aintree within the trachea, and an ETT was placed over the Aintree catheter and advanced into the trachea. The i-gel group exhibited shorter time to successful intubation (median, 191 vs. 434 seconds; P = .002). The i-gel group also had fewer study subjects requiring more than one attempt for successful Aintree placement (33% vs. 75%, P = .02). The i-gel group showed superior laryngeal view score (LVS) (6 vs. 4; P = .003). The i-gel SGA achieved a faster time to successful intubation, higher rate of first attempt Aintree placement, and superior LVS.

Comparative evaluation of blind supraglottic airway device insertion versus videolaryngoscope-guided technique in adults undergoing laparoscopic cholecystectomy.

OBJECTIVES: A videolaryngoscope may decrease the high incidence of aberrant positioning of supraglottic airway devices (SAD) inserted with blind techniques. We aimed to compare Igel insertion characteristics between blind and videolaryngoscope-assisted techniques. METHODS: In this study 70 adult patients scheduled for elective laparoscopic cholecystectomy under general anesthesia were randomly divided into blind (Group B, n = 35) and videolaryngoscope-guided (Group V, n = 35) Igel insertion. Oropharyngeal leak pressure (OLP), fiber-optic view score, time for device insertion, first attempt success, ease of insertion, ventilation score, maneuvers, and adverse events were assessed. RESULTS: OLP was significantly higher in group V at 1 and 10 minutes (24.80 ± 1.91 vs 21.71 ± 2.37; p < 0.001 and 32.60 ± 2.32 vs 30.68 ± 2.93; p = 0.006). The mean fiberoptic scoring (3.63 ± 0.49 vs 3.38 ± 0.49; p = 0.043), a fibreoptic score of grade 4 (24 vs 13; p = 0.012) and time-to-device insertion (25.6 ± 3.5 vs 21.7 ± 4.1; p < 0.001) was considerably higher in group V. First-attempt success (p = 0.630), ease of insertion of SAD (p = 0.540) and nasogastric tube (p = 1), ventilation score (p = 1), number of maneuvers required (p = 1), number of attempts (p = 0.592) and postoperative complications (p = 0.800) were comparable in the two groups. CONCLUSION: The videolaryngoscope-guided technique provided superior airway sealing and reduced malposition of Igel without an increase in adverse events compared to the blind technique. However, this was at the cost of increased time of device insertion. CLINICAL TRIAL REGISTRATION: www.ctri.nic.in identifier is CTRI/2022/10/046269.

Timing of general anesthesia for pediatric patients recovering from COVID-19: a prospective cohort study.

OBJECTIVE: To explore the timing of general anesthesia for pediatric patients who have recovered from novel coronavirus infection and summarize anesthesia-related complications. METHODS: We summarized the perioperative management of children under 14 years of age who underwent general anesthesia in our hospital according to national epidemic prevention and control requirements. We compared the incidence of postoperative pulmonary complications within 2 weeks (Group A), 3-4 weeks (Group B), and 5-6 weeks (Group C) after COVID-19 recovery. RESULTS: There were differences among the three groups in terms of decreased blood oxygen saturation (< 94%), secretions, and coughing during the PACU period. The risk of low blood oxygen saturation during PACU decreased as the time of COVID-19 recovery extended in the three groups. Compared to Group A, the risk of low blood oxygen saturation was lower in Group B. The presence of respiratory symptoms and a body temperature above 40℃ increased the risk of decreased blood oxygen saturation. The proportion of children aged 11-14 years and children with high fever experiencing decreased blood oxygen saturation during PACU was higher in Groups A and B. Among the three groups, children with respiratory symptoms and longer illness duration had a higher proportion of decreased blood oxygen saturation during PACU. CONCLUSION: Pediatric patients who have recovered from COVID-19 for more than 2 weeks have a lower risk of postoperative complications after general anesthesia. For children with respiratory system symptoms or high fever, there is a higher risk of transient blood oxygen saturation decrease during PACU. For older children, those with high fever, respiratory system symptoms, or longer illness duration, it is recommended to appropriately extend the time from COVID-19 recovery to surgery.

Comparison of lidocaine viscous gargle and topical application on laryngeal mask airway in general anesthesia: A randomized clinical trial.

OBJECTIVES: To investigate the effects and safety of lidocaine viscous gargle on postoperative sore throat (POST) in patients receiving a laryngeal mask airway (LMA) in general anesthesia. METHODS: In this randomized controlled trial, 90 patients undergoing urological surgery were allocated into 2 treatment arms (n=45): lidocaine viscous gargle before LMA insertion (Group G) and topical application of lidocaine viscous on the LMA (Group T). Outcome data were collected before placement of LMA (T0), after insertion of LMA (T1), immediately (T2), one hour (T3), and 24 hours after removal of LMA (T4). We analyzed the incidence of POST, pharynx dryness, and adverse events. RESULTS: The incidence of POST was lower in Group G than Group T at T2 (11.1% vs. 28.9%; p=0.063), T3 (11.1% vs. 24.4%; p=0.167), and T4 (2.2% vs. 4.4%; p=0.566), but there was no significant difference between groups. No patient in either group experienced severe pain or treatment-related adverse events. There was a significantly lower incidence of pharynx dryness in Group G than Group T (p<0.05) at T2, T3, and T4. CONCLUSION: Lidocaine viscous gargle showed no statistically significant difference in incidence of POST and incidence of pharynx dryness compared with topical application of lidocaine on the LMA. Both approaches were safe for patients receiving LMA.Chinese Clinical Trial Register No.: ChiCTR2200059720.

2023 American Heart Association and American Academy of Pediatrics Focused Update on Neonatal Resuscitation: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care.

This 2023 focused update to the neonatal resuscitation guidelines is based on 4 systematic reviews recently completed under the direction of the International Liaison Committee on Resuscitation Neonatal Life Support Task Force. Systematic reviewers and content experts from this task force performed comprehensive reviews of the scientific literature on umbilical cord management in preterm, late preterm, and term newborn infants, and the optimal devices and interfaces used for administering positive-pressure ventilation during resuscitation of newborn infants. These recommendations provide new guidance on the use of intact umbilical cord milking, device selection for administering positive-pressure ventilation, and an additional primary interface for administering positive-pressure ventilation.

Unanticipated difficult airway after prolonged use of a laryngeal mask airway.

The laryngeal mask airway (LMA) is recognized as a safe alternative to endotracheal intubation for short-term airway maintenance. In this case report we present the case of a term neonate with upper airway obstruction which was managed with a deflated LMA for 7 consecutive days. Despite previous reports of extended LMA use in neonates without complications, this patient experienced significant pharyngeal mucosal injury and edema, leading to difficulty with subsequent intubation attempts.

Safety of removal of ProSeal laryngeal mask airway in children in the supine versus lateral position in a deep plane of anesthesia: A randomized controlled trial.

Importance: When a ProSeal laryngeal mask airway (PLMA) is removed with the child in a deep plane of anesthesia, the upper airway muscle tone and protective upper airway reflexes may be obtunded. Objective: To determine whether the supine or lateral position is safer for the removal of a PLMA in deeply anesthetized children by comparing the incidence of upper airway complications. Methods: This randomized single-blind comparative trial was conducted at a tertiary care hospital between January 2020 and September 2020. Forty children of the American Society of Anesthesiologists class I/II of ages 1-12 years age undergoing surgery under general anesthesia with PLMA used as the definitive airway device were recruited. Patients were randomly allocated to lateral group or supine group for PLMA removal in a deep plane of anesthesia in the lateral or supine position. The primary outcome was the number of patients experiencing one or more upper airway complications and the secondary outcomes were incidence of individual respiratory adverse effects and of severe airway complications. Results: The incidence of airway complications was 30% in the supine group and 20% in the lateral group (P = 0.6641). Incidence of laryngospasm, immediate stridor, and excessive secretions were similar. Early stridor and oxygen desaturation were higher in the supine group (P = 0.0374, P = 0.0183 respectively). Interpretation: The overall incidence of upper airway complications was similar with the removal of a PLMA in the supine or lateral position in deeply anesthetized children. The incidence of oxygen desaturation and stridor were higher with PLMA removal in the supine as compared to the lateral position.

Alternatives to neonatal intubation.

Opportunities to learn and maintain competence in neonatal intubation have decreased. As many clinicians providing care to the newborn infant are not skilled in intubation, alternative strategies are critical. Most preterm infants breathe spontaneously, and require stabilisation rather than resuscitation at birth. Use of tactile stimulation, deferred cord clamping, and avoidance of hypoxia can help optimise breathing for these infants. Nasal devices appear a promising alternative to the face mask for early provision of respiratory support. In term and near-term infants, supraglottic airways may be the most effective initial approach to resuscitation. Use of supraglottic airways during resuscitation can be taught to a range of providers, and may reduce need for intubation. While face mask ventilation is an important skill, it is challenging to perform effectively. Identification of the best approach to training the use of these devices during neonatal resuscitation remains an important priority.

Updates in neonatal resuscitation: routine use of laryngeal masks as an alternative to face masks.

Though positive-pressure ventilation (PPV) has traditionally been performed using a face mask in neonatal resuscitation, face mask ventilation has a high failure rate in delivering PPV due to mask leaks, airway obstruction, or gastric inflation. Further, face mask ventilation is compromised during chest compressions. Endotracheal intubation in neonates requires a high skill level, with a first-attempt success rate of <50%. Laryngeal masks can transfer positive pressure more effectively even during chest compressions resulting in lower failure rate of PPV compared to face masks in neonatal resuscitation. Further, inserting a laryngeal mask is easier and more accessible than endotracheal intubation, and there are no differences in the mortality rate between the laryngeal mask and endotracheal intubation in neonatal resuscitation. Therefore, in neonatal resuscitation, laryngeal masks are recommended in infants with gestational age >34 weeks and/or birth weight >2 kg in case of unsuccessful attempts at face mask ventilation (as a primary airway device) or endotracheal intubation (as a secondary airway device, alternative airway). In other words, laryngeal masks are recommended not only when endotracheal intubation fails but also when PPV cannot be achieved. Laryngeal masks are commonly used in anesthetized pediatric patients. However, laryngeal masks are not frequently used in neonatal resuscitation due to limited experience, a preference for endotracheal tubes, or a lack of awareness. Healthcare providers must be aware of the usefulness of laryngeal masks in depressed neonates requiring PPV or endotracheal intubation, which can promptly resuscitate these infants and improve the outcomes of them, resulting in decreased morbidity and mortality.

Supraglottic airway devices versus endotracheal intubation for laparoscopic surgeries: An updated systematic review and meta-analysis of randomised controlled trials.

Background and Aims: Laparoscopic surgeries are among the most frequent procedures done worldwide. There is a gradual shift in the method of airway securement from endotracheal intubation to supraglottic airway devices (SAD). The objective of the current work was to perform a systematic review and meta-analysis of published RCTs on airway complications in laparoscopic surgery performed with a SAD or endotracheal intubation (ETT). Methods: The research was registered in PROSPERO, and a literature search was conducted in Google Scholar and PubMed until August 2022. Out of 78 studies, 31 studies were screened and 21 were included for analysis. RevMan 5.4 was used to analyse data on sore throat, hoarseness, nausea, vomiting, stridor and cough. Results: Twenty-one randomised controlled trials, enrolling a total of 2213 adult patients, were included in the quantitative analysis. A significant incidence of sore throat and hoarseness was seen at post-operative period in ETT group with risk ratio (RR) 0.44, P < 0.00001 [0.30, 0.65], i2 = 72% and RR 0.38, P < 0.001 [0.21, 0.69], i2 = 72%, respectively. However, incidence of nausea, vomiting and stridor was not significant with RR 0.83, P = 0.26 [0.60, 1.15], i2 = 52% for nausea and RR 0.55, P = 0.03 [ 0.33, 0.93], i2 = 14% for vomiting. Incidence of cough was more in ETT group with RR 0.11, P < 0.00001 [ 0.06, 0.20], i2 = 42%, as compared to SAD group. Conclusion: There was a substantial variation between SADs and ETTs with respect to the incidence of hoarseness, sore throat, nausea and cough. The existing literature is reinforced by the evidence uncovered in this updated systematic review.

Comparison of insertion characteristics of LMA ProSeal and Ambu AuraGain in adult patients under controlled ventilation: A randomised study.

Background and Aims: Supraglottic devices are preformed or flexible, and the insertion characteristics of the two types may be different. This study aims to compare the insertion characteristics of Ambu AuraGain (AAG), preformed) and LMA ProSeal (PLMA), flexible, requires an introducer tool for placement. Methods: Forty American Society of Anesthesiologists (ASA) physical status I/II patients of either sex between 18 and 60 years with no anticipated airway difficulty were randomly allocated to either group AAG or PLMA (n = 20 each). Pregnant females, known case of chronic respiratory disorders and gastroesophageal reflux were excluded. After induction of anaesthesia and muscle relaxation, appropriately sized AAG or PLMA was inserted. Time for successful insertion (primary outcome), ease of device insertion and gastric drain insertion, first attempt success rate (secondary outcomes) were recorded. Statistical analysis was done using SPSS version 20.0. Quantitative parameters were compared using Student's t-test, and qualitative parameters were compared using Chi-square test. A P value of <0.05 was considered significant. Results: Time taken for successful insertion of PLMA was 22.94 ± 6.12 s and for AAG was 24.32 ± 4.96 s, (P = 0.458). Device insertion was significantly easy in PLMA group (P < 0.002). First attempt success rate was achieved in 17 (94.4%) cases in PLMA group compared to 15 (78.9%) cases in AAG group (P = 0.168). Ease of drain tube insertion was comparable among the groups (P = 0.298). The haemodynamic variables were also comparable. Conclusion: PLMA is easier to insert as compared to AAG, but the insertion time and first attempt success rate are similar. The preformed curvature in AAG does not provide any added advantage over the non-preformed PLMA.

Recovery time in target controlled infusion versus manual infusion of propofol in total intravenous anaesthesia for endoscopic retrograde cholangio-pancreatography procedure using laryngeal mask airway-gastro: A randomised comparative study.

Background and Aims: This study aimed to compare manual infusion versus target-controlled infusion (TCI) in total intravenous anaesthesia (TIVA) utilising laryngeal mask airway (LMA)-gastro during endoscopic retrograde cholangio-pancreatography (ERCP) procedures. Methods: This was a single-blind randomised trial. Patients were randomly allocated into two groups. TCI group included 27 patients, where TCI of propofol was implemented with the Schnider pharmacokinetic model driven by a computer-controlled syringe pump. The TIVA group included 27 patients with a loading dose of 2 mg/kg of propofol, followed by manual infusion of 15 mg/kg/h for the first 15 min, 13 mg/kg/h for the next 15 min, then 11 mg/kg/h for 30 min and 10 mg/kg/h for 60 min and finally maintained at 9 mg/kg/h. The primary objective was to compare recovery time following cessation of propofol infusion in both groups. The difference in the total dose of propofol, time to achieve anaesthesia induction, first attempt success rate, ease of LMA-gastro insertion, ease of insertion, success rate of endoscope device and post-anaesthesia care unit (PACU) discharge time were the secondary objectives. T-test and Chi-square test were used for statistical analysis. Results: The time required for the recovery was significantly less in the TCI group than in the TIVA group (mean ± standard deviation; 11.60 ± 2.27 versus 15.4 ± 3.25 minutes, P < 0.001). The duration of ERCP, ease of LMA and endoscope insertion were comparable between the groups. There was no post-operative recall of intra-operative events in the groups. Conclusion: TCI offers earlier recovery than TIVA in patients undergoing ERCP procedures using LMA-gastro.

A randomized controlled trial comparing three supraglottic airway devices used as a conduit to facilitate tracheal intubation with flexible bronchoscopy.

PURPOSE: Once difficult ventilation and intubation are declared, guidelines suggest the use of a supraglottic airway (SGA) as a rescue device to ventilate and, if oxygenation is restored, subsequently as an intubation conduit. Nevertheless, few trials have formally studied recent SGA devices in patients. Our objective was to compare the efficacy of three second-generation SGA devices as conduits for bronchoscopy-guided endotracheal intubation. METHODS: In this prospective, single-blinded three-arm randomized controlled trial, patients with an American Society of Anesthesiologists Physical Status of I-III undergoing general anesthesia were randomized to bronchoscopy-guided endotracheal intubation using AuraGain™, Air-Q® Blocker, or i-gel® devices. We excluded patients with contraindications to an SGA or drugs and who were pregnant or had a neck, spine, or respiratory anomaly. The primary outcome was intubation time, measured from SGA circuit disconnection to CO2 measurement. Secondary outcomes included ease, time, and success of SGA insertion; success of intubation on first attempt; overall intubation success; number of attempts to intubate; ease of intubation; and ease of SGA removals. RESULTS: One hundred and fifty patients were enrolled from March 2017 to January 2018. Median intubation times were similar across the three groups (Air-Q Blocker, 44 sec; AuraGain, 45 sec; i-gel, 36 sec; P = 0.08). The i-gel was faster to insert (i-gel: 10 sec; Air-Q Blocker, 16 sec; AuraGain, 16 sec; P < 0.001) and easier to insert (Air-Q Blocker vs i-gel, P = 0.001; AuraGain vs i-gel, P = 0.002). Success of SGA insertion, success of intubation, and number of attempts were similar. The Air-Q Blocker was easier to remove than the i-gel (P < 0.001). CONCLUSION: All three second-generation SGA devices performed similarly regarding intubation. Despite minor benefits of the i-gel, clinicians should select their SGA based on clinical experience. STUDY REGISTRATION: ClinicalTrials.gov (NCT02975466); registered on 29 November 2016.

RéSUMé: OBJECTIF: Une fois qu'une ventilation et une intubation difficiles sont déclarées, les lignes directrices préconisent le recours à un dispositif supraglottique comme modalité de sauvetage pour ventiler le patient et, si l'oxygénation est rétablie, être ensuite utilisé comme conduit d'intubation. Toutefois, peu d'études ont formellement analysé l'utilisation des dispositifs supraglottiques récents chez de véritbales patients. Notre objectif était de comparer l'efficacité de trois dispositifs supraglottiques de deuxième génération utilisés comme conduits pour l'intubation endotrachéale guidée par bronchoscopie. MéTHODE: Dans cette étude prospective randomisée contrôlée à trois bras et à simple insu, les patients de statut physique I-III selon l'American Society of Anesthesiologists bénéficiant d'une anesthésie générale ont été randomisés à recevoir une intubation endotrachéale guidée par bronchoscopie via les dispositifs AuraGain™, Air-Q® Blocker ou i-gel®. Nous avons exclu les patients présentant des contre-indications à l'utilisation d'un dispositif supraglottique ou aux médicaments, ainsi que les patientes enceintes et les patients présentant une anomalie au niveau du cou, de la colonne vertébrale ou des voies aériennes. Le critère d'évaluation principal était le temps d'intubation mesuré entre le moment de déconnexion du dispositif supraglottique du circuit et le moment de mesure du CO2. Les critères d'évaluation secondaires comprenaient la facilité, le délai et la réussite de l'insertion du dispositif supraglottique; la réussite de l'intubation à la première tentative; la réussite globale de l'intubation; le nombre de tentatives d'intubation; la facilité d'intubation; et la facilité de retrait du dispositif supraglottique. RéSULTATS: Cent cinquante patients ont été recrutés de mars 2017 à janvier 2018. Les délais d'intubation médians étaient similaires dans les trois groupes (Air-Q Blocker : 44 sec; AuraGain : 45 sec; i-gel : 36 sec; P = 0,08). L'i-gel était plus rapide à insérer (i-gel : 10 sec; Air-Q Blocker : 16 sec; AuraGain : 16 sec; P < 0,001) et plus facile à insérer (Air-Q Blocker vs i-gel : P = 0,001; AuraGain vs i-gel : P = 0,002). La réussite de l'insertion du dispositif supraglottique, la réussite de l'intubation et le nombre de tentatives étaient similaires. L'Air-Q Blocker était plus facile à retirer que l'i-gel (P < 0,001). CONCLUSION: Les trois dispositifs supraglottiques de deuxième génération ont tous affiché une performance similaire en matière d'intubation. Malgré des avantages mineurs de l'i-gel, les cliniciens devraient choisir leur dispositif supraglottique en fonction de leur expérience clinique. ENREGISTREMENT DE L'éTUDE: ClinicalTrials.gov (NCT02975466); enregistrée le 29 novembre 2016.

Learning curve of fiberoptic bronchoscope-guided tracheal intubation through supraglottic airway device for pediatric airway management: a manikin study.

BACKGROUND: Although fiberoptic-guided endotracheal intubation using a supraglottic airway device (SAD) is a good alternative for the management of difficult airways, its learning curve for residents has not been evaluated in pediatric patients. We aimed to train residents using a pediatric manikin and obtain learning curves to evaluate the efficiency of the training. METHODS: We conducted a single-armed prospective study with anesthesiology residents. Plain endotracheal tube (ETT) intubation guided by a fiberoptic bronchoscope through Ambu® AuraGainTM was demonstrated in a pediatric manikin to the participants before training. The procedure was divided into four steps: SAD insertion, vocal cord identification, carina identification, and ETT insertion into the trachea. The results and elapsed procedure times of each trial were recorded. The learning curves for the participants were constructed and analyzed using the cumulative sum method. RESULTS: All the 30 participants acquired proficiency at the end of practice between eight and 25 trials. The overall success rate for the procedure was 92.8%, and above 80% for all participants. Mean ± standard deviation procedure time was 71.3 ± 50.7 s. The 4th step accounted for 86.2% and 48.0% of the total failures and procedure time, respectively. The procedure time rapidly decreased in the 2nd trial; a modest decline was observed thereafter. CONCLUSIONS: Trainees can obtain proficiency for fiberoptic-guided intubation through SAD within 25 times when using pediatric manikin. Effect of the training on performance in actual clinical situation should be studied.