Ventilación mecánica no invasiva nasal en la sedación de un paciente con esclerosis lateral amiotrófica durante una gastrostomía endoscópica percutánea / No disponible

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[Evaluation of a protocol for predicting difficult airway in routine practice: interobserver agreement]. / Evaluación de un protocolo de predicción de vía aérea difícil en la práctica habitual: estudio de concordancia.

OBJECTIVES: To evaluate a protocol for routine assessment of potential risk factors for difficult airway intubation in an anesthesia department, by measuring interobserver agreement and the behavior of the factors in a predictive model. MATERIAL AND METHODS: A cross-sectional study group of 320 consecutive patients undergoing major surgery requiring orotracheal intubation was assessed for possible difficult airway. We calculated interrater agreement for recording of the Mallampati score, thyromental distance less than 6 cm, thick neck, kyphosis, small mouth, macroglossia, and dental prosthesis during the preanesthesia examination (by an anesthetist) and on the day of the operation (by an anesthetist and a resident). We constructed a model to predict difficult intubation (requiring 3 or more attempts). RESULTS: The kappa indices of agreement between the anesthetists at the preoperative examination and in the operating room or the resident were all less than 0.6. Factors like thyromental distance, small mouth, and kyphosis had kappa indices less than 0.21. The kappa index between the resident and the anesthetist in the operating room was over 0.55. The only factor that had a different level of agreement was the presence or not of a dental prosthesis. None of the studied individual factors, nor these factors in association with the Mallampati score, achieved significance in a bivariate regression model to predict difficult intubation. CONCLUSIONS: There is poor interobserver agreement on factors for predicting difficult airway in comparisons between preoperative and operating room assessment by an anesthetist or a resident. The individual predictive factors and their association with the Mallampati score did not prove useful for predicting difficult intubation.

[Supreme laryngeal mask airway vs the I-gel supraglottic airway in patients under general anesthesia and mechanical ventilation with no neuromuscular block: a randomized clinical trial]. / Estudio comparativo entre las mascarillas laríngeas Supreme e I-gel en pacientes con anestesia general sin bloqueo neuromuscular, con ventilación mecánica.

OBJECTIVE: The Supreme Laryngeal Mask Airway (SLMA) and the I-gel Supraglottic Airway (IGSA) are recently introduced devices incorporating a gastric channel. This study assessed the ease of insertion of the devices and their efficacy in mechanical ventilation. MATERIAL AND METHODS: Eighty-five patients undergoing major outpatient surgery under general anesthesia were randomized to 2 groups for intubation using the SLMA or the IGSA. After induction of general anesthesia, the assigned mask was inserted and positioning was checked with a fiberoptic scope. Ease of insertion was evaluated. Seal pressure was measured and the following ventilatory parameters were recorded 10, 30, and 60 minutes after the start of surgery: peak pressure, mean pressure, compliance, and the ratio of tidal volume to respiratory frequency. Conditions at the moment of inserting the nasogastric tube were also noted. RESULTS: First-attempt placement of the airway was possible in 95.2% of patients using the SLMA and in 86% using the IGSA (P = .147). The mean times required for placement were 27.1 seconds for the SLMA and 32.5 seconds for the IGSA (P = .195). The nasogastric tube was inserted on the first attempt in 97.6% of patients with an SLMA and in 85.7% of patients with an IGSA. The mean times required for tube insertion were 9.5 seconds through the SLMA and 22.1 seconds through the IGSA (P < .001). Seal pressure and compliance were similar in the 2 groups at the start of surgery and at 10, 30, and 60 minutes. The incidences of complications during surgery and at 90 minutes were likewise similar (P = .945 and P = .698, respectively). CONCLUSIONS: The SLMA and the IGSA are easy to put into position on the first attempt. It is easier to insert the nasogastric tube through the gastric channel of the SLMA. Both devices provide an effective seal and the incidences of complications were similar for both in the patients we studied.

Estudio comparativo entre las mascarillas laríngeas Supreme® e I-gel® en pacientes con anestesia general sin bloqueo neuromuscular, con ventilación mecánica / Supreme Laryngeal Mask Airway vs the I-gel Supraglottic Airway in patients under general anesthesia and mechanical ventilation with no neuromuscular block: a randomized clinical trial

OBJETIVO: La mascarilla laríngea Supreme(R) y la mascarillaI-gel(R) son dos dispositivos supraglóticos de recienteaparición que incorporan un canal de acceso gástrico.En este estudio valoramos la facilidad de inserción deldispositivo, así como la eficacia de ambos en ventilaciónmecánica controlada. MATERIAL Y MÉTODOS: Estudio prospectivo de 85pacientes intervenidos en cirugía mayor ambulatoriacon anestesia general. Se asignaron aleatoriamente a dosgrupos, grupo LMA-S pacientes a los que se coloca mascarillalaríngea Supreme(R) y grupo I-gel(R) pacientes a losque se colocó la mascarilla laríngea I-gel(R). Tras la inducciónde anestesia general se colocó la mascarilla asignaday se comprobó la posición con un fibrobroncoscopio.Se valoró la facilidad de inserción. Se midió la presión desellado y los siguientes parámetros ventilatorios: presiónpico (Pp), presión media (Pm), complianza, volumencorriente y frecuencia respiratoria (VT/FR) al inicio, y alos 10, 30 y 60 minutos de iniciada la intervención. Secomprobó asimismo las condiciones del paso de una sondanasogástrica.RESULTADOS: La LMA-S se colocó al primer intento en el95,2% de los pacientes, frente a 86% de los casos con I-gel(R) (p = 0,147). El tiempo medio de colocación fue de 27,1segundos con la mascarilla laríngea Supreme(R) frente a 32,5 segundos en el caso de la I-gel(R) (p = 0,195). La colocaciónal primer intento de la sonda nasogástrica en el grupoLMA-S fue del 97,6% frente al 85,7% de I-gel(R). El tiempomedio de colocación de la sonda nasogástrica para el grupoLMA-S fue de 9,5 segundos y de 22,1 segundos para elgrupo I-gel(R) (p < 0,001). No se evidenciaron diferenciasentre ambas mascarillas para las variables presión de selladoy complianza al inicio, y a los 10, 30 y 60 minutos, nitampoco entre los efectos secundarios intraoperatorios(p = 0,945) y dichos efectos a los 90 minutos (p = 0,698) (AU)

OBJECTIVE: The Supreme Laryngeal Mask Airway(SLMA) and the I-gel Supraglottic Airway (IGSA) arerecently introduced devices incorporating a gastricchannel. This study assessed the ease of insertion of thedevices and their efficacy in mechanical ventilation.MATERIAL AND METHODS: Eighty-five patients undergoingmajor outpatient surgery under general anesthesiawere randomized to 2 groups for intubation usingthe SLMA or the IGSA. After induction of generalanesthesia, the assigned mask was inserted and positioningwas checked with a fiberoptic scope. Ease of insertionwas evaluated. Seal pressure was measured and thefollowing ventilatory parameters were recorded 10, 30,and 60 minutes after the start of surgery: peak pressure,mean pressure, compliance, and the ratio of tidalvolume to respiratory frequency. Conditions at themoment of inserting the nasogastric tube were alsonoted.RESULTS: First-attempt placement of the airway waspossible in 95.2% of patients using the SLMA and in 86%using the IGSA (P=.147). The mean times required forplacement were 27.1 seconds for the SLMA and 32.5seconds for the IGSA (P=.195). The nasogastric tube wasinserted on the first attempt in 97.6% of patients with anSLMA and in 85.7% of patients with an IGSA. The meantimes required for tube insertion were 9.5 secondsthrough the SLMA and 22.1 seconds through the IGSA(P<.001). Seal pressure and compliance were similar inthe 2 groups at the start of surgery and at 10, 30, and 60 minutes. The incidences of complications during surgeryand at 90 minutes were likewise similar (P=.945 and P=.698, respectively).CONCLUSIONS: The SLMA and the IGSA are easy to putinto position on the first attempt. It is easier to insert thenasogastric tube through the gastric channel of theSLMA. Both devices provide an effective seal and theincidences of complications were similar for both in thepatients we studied (AU)

[Air seepage from endotracheal tube cuffs during anesthetic procedures. How to solve this problem without changing tubes? An experimental model using human tracheas]. / Pérdida de aire en los manguitos de los tubos endotraqueales durante el procedimiento anestésico. Cómo solucionar este problema sin cambiar el tubo? Modelo experimental con tráqueas humanas.

OBJECTIVES: To demonstrate by an experimental model that a continuous medicinal airflow system giving a pressure of 30 cmH2O effectively stops leakage from endotracheal tubes. MATERIAL AND METHODS: Ten tracheas with their main bronchi were removed from cadavers with no pulmonary disease. The tracheas were placed vertically and tubes previously perforated with increasing caliber needles were inserted and connected to a continuous flow system. The flow of medicinal air generated in the cuff was monitored with a flow meter and pressure was measured with a manometer. When a pressure of 30 cmH2O was reached, the trachea was filled with saline. We then observed the moment at which, when pressure fell, the saline began to leak from the bronchi. The levels observed were expressed as arithmetic means and standard deviations. RESULTS: No leakage was observed when the flow produced pressures above 10 cmH2O for 25 G caliber holes, above 15 cmH2O for 24 G holes, or above 20 cmH2O for 25 G, 21 G, 20 G, 18 G or 16 G holes. For 14 G holes, a flow producing pressures over 25 cmH2O were needed. Pressure up to 80 cmH2O was required to stop leakage from a scalpel cut. CONCLUSIONS: We found that adjusting flow and pressure is a valid way to stop leakage from small holes. The method does not control leakage from large holes or cuts.