Association between frailty and clinical outcomes in patients undergoing craniotomy-systematic review and meta-analysis of observational studies.

BACKGROUND: Frailty in patients undergoing craniotomy may affect perioperative outcomes. There have been a number of studies published in this field; however, evidence is yet to be summarized in a quantitative review format. We conducted a systematic review and meta-analysis to examine the effects of frailty on perioperative outcomes in patients undergoing craniotomy surgery. METHODS: Our eligibility criteria included adult patients undergoing open cranial surgery. We searched MEDLINE via Ovid SP, EMBASE via Ovid SP, Cochrane Library, and grey literature. We included retrospective and prospective observational studies. Our primary outcome was a composite of complications as per the Clavien-Dindo classification system. We utilized a random-effects model of meta-analysis. We conducted three preplanned subgroup analyses: patients undergoing cranial surgery for tumor surgery only, patients undergoing non-tumor surgery, and patients older than 65 undergoing cranial surgery. We explored sources of heterogeneity through a sensitivity analysis and post hoc analysis. RESULTS: In this review of 63,159 patients, the pooled prevalence of frailty was 46%. The odds ratio of any Clavien-Dindo grade 1-4 complication developing in frail patients compared to non-frail patients was 2.01 [1.90-2.14], with no identifiable heterogeneity and a moderate level of evidence. As per GradePro evidence grading methods, there was low-quality evidence for patients being discharged to a location other than home, length of stay, and increased mortality in frail patients. CONCLUSION: Increased frailty was associated with increased odds of any Clavien-Dindo 1-4 complication. Frailty measurements may be used as an integral component of risk-assessment strategies to improve the quality and value of neurosurgical care for patients undergoing craniotomy surgery. ETHICS AND DISSEMINATION: Formal ethical approval is not needed, as primary data were not collected. SYSTEMATIC REVIEW REGISTRATION: PROSPERO identification number: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=405240.

Re-evaluating our language when reducing risk of SARS-CoV-2 transmission to healthcare workers: Time to rethink the term, "aerosol-generating procedures".

The term, "aerosol-generating procedures" (AGPs), was proposed during the prior SARS-CoV-1 epidemic in order to maximise healthcare worker and patient protection. The concept of AGPs has since expanded to include routine therapeutic processes such as various modes of oxygen delivery and non-invasive ventilation modalities. Evidence gained during the SARS-CoV-2 pandemic has brought into question the concept of AGPs with regard to intubation, airway management, non-invasive ventilation and high flow nasal oxygen delivery. Although encounters where these procedures occur may still be associated with increased risk of infectious transmission, this is a function of the clinical context and not because the procedure itself is aerosol-generating.

Perioperative Multimodal Analgesia for Adults Undergoing Surgery of the Spine-A Systematic Review and Meta-Analysis of Three or More Modalities.

BACKGROUND: Multimodal analgesia is a strategy that can be used to improve pain management in the perioperative period for patients undergoing surgery of the spine. However, no review evidence is available on the quantitative models of multimodal analgesia within this clinical setting. We conducted a systematic review and meta-analysis to examine the effects of maximal (≥3 analgesic agents) multimodal analgesic medication for patients undergoing surgery of the spine. METHODS: We included randomized controlled trials that had evaluated the use of ≥3 multimodal analgesia components (maximal multimodal analgesia) in patients undergoing spinal surgery. We excluded patients who had received neuraxial or regional analgesia. The control group consisted of placebo, standard care (any therapeutic modality including ≤2 analgesic components). The primary outcomes were the postoperative pain scores at rest evaluated at 24 and 48 hours. We searched MEDLINE via OvidSP, EMBASE via OvidSP, and the Cochrane Library (Cochrane Database of Systematic Reviews and CENTRAL). We used the Cochrane standard methods. RESULTS: We identified consistently improved analgesic endpoints across all predetermined primary and secondary outcomes. A total of 11 eligible studies had evaluated the primary outcome of pain at rest at 24 hours. The patients who had received maximal multimodal analgesia were identified to have had lower pain scores with an average mean difference of -1.03 (P < 0.00001). The length of hospital stay was shorter for the patients who had received multimodal analgesia (mean difference, -0.55; P < 0.00001). CONCLUSIONS: Perioperative maximal multimodal analgesia consistently improved the visual analog scale scores for an adult population in the immediate postoperative period, with a moderate quality of evidence. We found a significant decrease in the hospital length of stay for patients who had received maximal multimodal analgesia with a high level of evidence and no statistical heterogeneity.

Perioperative Intravenous Lidocaine Infusion for Postoperative Analgesia in Patients Undergoing Surgery of the Spine: Systematic Review and Meta-Analysis.

OBJECTIVE: We conducted a systematic review and meta-analysis to examine the impact of perioperative intravenous lidocaine infusion on pain management scores, opioid consumption, adverse events, and hospital length of stay in patients undergoing spinal surgery. METHODS: We included randomized controlled trials evaluating the use of perioperative intravenous lidocaine in adult and pediatric patients undergoing spinal surgery. Primary outcomes were postoperative pain scores at rest and at 2, 4-6, 24, and 48 hours and adverse events attributable to lidocaine administration. We searched electronic databases from their inception to the present. We used Cochrane's standard methods. We used a random-effects model to synthetize data. We conducted three subgroup analyses: patients undergoing major surgery vs patients undergoing minor surgery, patients with chronic pain conditions vs patients without, and adult vs pediatric patients. RESULTS: A total of eight studies were included that compared patients having intravenous lidocaine (n = 349) with controls (n = 343). Intravenous lidocaine administration was associated with significantly reduced visual analog pain scores at 2 hours (mean difference [MD] = -1.13), 4-6 hours (MD = -0.79), and 24 hours (MD = -0.50) postoperatively. In the adults, efficacy of treatment was extended to 48 hours (MD = -0.72). Perioperative intravenous lidocaine administration was associated with reduced perioperative opioid consumption at 24 and 48 hours, as well as decreased hospital length of stay. CONCLUSION: Perioperative intravenous lidocaine infusion consistently improves analgesic measures in adult and pediatric populations in the first 24 hours, with an effective decrease in opioid consumption noted to 48 hours. These results are most generalizable in the adult population in the first 4-6 to 24 postoperative hours.

Pathway for enhanced recovery after spinal surgery-a systematic review of evidence for use of individual components.

BACKGROUND: Enhanced recovery in spinal surgery (ERSS) has shown promising improvements in clinical and economical outcomes. We have proposed an ERSS pathway based on available evidence. We aimed to delineate the clinical efficacy of individual pathway components in ERSS through a systematic narrative review. METHODS: We included systematic reviews and meta-analysis, randomized controlled trials, non-randomized controlled studies, and observational studies in adults and pediatric patients evaluating any one of the 22 pre-defined components. Our primary outcomes included all-cause mortality, morbidity outcomes (e.g., pulmonary, cardiac, renal, surgical complications), patient-reported outcomes and experiences (e.g., pain, quality of care experience), and health services outcomes (e.g., length of stay and costs). Following databases (1990 onwards) were searched: MEDLINE, EMBASE, and Cochrane Library (Cochrane Database of Systematic Reviews and CENTRAL). Two authors screened the citations, full-text articles, and extracted data. A narrative synthesis was provided. We constructed Evidence Profile (EP) tables for each component of the pathway, where appropriate information was available. Due to clinical and methodological heterogeneity, we did not conduct a meta-analyses. GRADE system was used to classify confidence in cumulative evidence for each component of the pathway. RESULTS: We identified 5423 relevant studies excluding duplicates as relating to the 22 pre-defined components of enhanced recovery in spinal surgery. We included 664 studies in the systematic review. We identified specific evidence within the context of spinal surgery for 14/22 proposed components. Evidence was summarized in EP tables where suitable. We performed thematic synthesis without EP for 6/22 elements. We identified appropriate societal guidelines for the remainder of the components. CONCLUSIONS: We identified the following components with high quality of evidence as per GRADE system: pre-emptive analgesia, peri-operative blood conservation (antifibrinolytic use), surgical site preparation and antibiotic prophylaxis. There was moderate level of evidence for implementation of prehabilitation, minimally invasive surgery, multimodal perioperative analgesia, intravenous lignocaine and ketamine use as well as early mobilization. This review allows for the first formalized evidence-based unified protocol in the field of ERSS. Further studies validating the multimodal ERSS framework are essential to guide the future evolution of care in patients undergoing spinal surgery.

Use of powered air-purifying respirator(PAPR) as part of protective equipment against SARS-CoV-2-a narrative review and critical appraisal of evidence.

BACKGROUND: The last 2 decades have seen an increasing frequency of zoonotic origin viral diseases leaping from animal to human hosts including Severe Acute Respiratory Syndrome Coronaviruses (SARS-CoV-2). Respiratory component of the infectious disease program against SARS-CoV-2 incorporates use of protective airborne respiratory equipment. METHODS: In this narrative review, we explore the features of Powered Air Purifying Respirators (PAPR) as well as logistical and evidence-based advantages and disadvantages. RESULTS: Simulation study findings support increased heat tolerance and wearer comfort with a PAPR, versus decreased communication ability, mobility, and dexterity. Although PAPRs have been recommended for high-risk procedures on suspected or confirmed COVID-19 patients, this recommendation remains controversial due to lack of evidence. Guidelines for appropriate use of PAPR during the current pandemic are sparse. International regulatory bodies do not mandate the use of PAPR for high-risk aerosol generating procedures in patients with SARS-CoV-2. Current reports of the choice of protective respiratory technology during the SARS-CoV-2 pandemic are disparate. Patterns of use appear to be related to geographical locations. DISCUSSION: Field observational studies do not indicate a difference in healthcare worker infection utilizing PAPR devices versus other compliant respiratory equipment in healthcare workers performing AGPs in patients with SARS-CoV-2. Whether a higher PAPR filtration factor translates to decreased infection rates of HCWs remains to be elucidated. Utilization of PAPR with high filtration efficiency may represent an example of "precautionary principle" wherein action taken to reduce risk is guided by logistical advantages of PAPR system.

Perioperative intravenous lignocaine infusion for postoperative pain control in patients undergoing surgery of the spine: protocol for a systematic review and meta-analysis.

INTRODUCTION: Intravenous lignocaine is an amide local anaesthetic known for its analgesic, antihyperalgesic and anti-inflammatory properties. Administration of intravenous lignocaine has been shown to enhance perioperative recovery parameters. This is the protocol for a systematic review which intends to summarise the evidence base for perioperative intravenous lignocaine administration in patients undergoing spinal surgery. METHODS AND ANALYSIS: Our primary outcomes include: postoperative pain scores at rest and movement at predefined early, intermediate and late time points and adverse events. Other outcomes of interest include perioperative opioid consumption, composite morbidity, surgical complications and hospital length of stay. We will include randomised controlled trials, which compared intravenous lignocaine infusion vs standard treatment for perioperative analgesia. We will search electronic databases from inception to present; MEDLINE, EMBASE and Cochrane Library (Cochrane Database of Systematic Reviews and CENTRAL). Two team members will independently screen all citations, full-text articles and abstract data. The individual study risk of bias will be appraised using the Cochrane risk of bias tool. We will obtain a risk ratio or mean difference (MD) from the intervention and control group event rates based on the nature of data. We will correct for the variable measurement tools by using the standardised MD (SMD). We will use a random-effects model to synthesise data. We will conduct five subgroup analysis: major versus minor surgery, emergency versus elective surgery, patients with chronic pain conditions versus patients without, duration of lignocaine infusion and adult versus paediatric. Confidence in cumulative evidence for will be classified according to the Grading of Recommendations, Assessment, Development and Evaluation system. We will construct summary of findings tables supported detailed evidence profile tables for predefined outcomes. ETHICS AND DISSEMINATION: Formal ethical approval is not required as primary data will not be collected. The results will be disseminated through a peer-reviewed publication. PROSPERO REGISTRATION NUMBER: CRD420201963314.

Use of powered air-purifying respirator (PAPR) by healthcare workers for preventing highly infectious viral diseases-a systematic review of evidence.

BACKGROUND: Healthcare workers (HCWs) are at particular risk during pandemics and epidemics of highly virulent diseases with significant morbidity and case fatality rate. These diseases include severe acute respiratory syndrome coronaviruses, SARS-CoV-1 and SARS-CoV-2, Middle Eastern Respiratory Syndrome (MERS), and Ebola. With the current (SARS-CoV-2) global pandemic, it is critical to delineate appropriate contextual respiratory protection for HCWs. The aim of this systematic review was to evaluate the effect of powered air-purifying respirators (PAPRs) as part of respiratory protection versus another device (egN95/FFP2) on HCW infection rates and contamination. METHODS: Our primary outcomes included HCW infection rates with SARS-CoV-2, SARS-CoV-1, Ebola, or MERS when utilizing PAPR. We included randomized controlled trials, non-randomized controlled trials, and observational studies. We searched the following databases: MEDLINE, EMBASE, and Cochrane Library (Cochrane Database of Systematic Reviews and CENTRAL). Two reviewers independently screened all citations, full-text articles, and abstracted data. Due to clinical and methodological heterogeneity, we did not conduct a meta-analysis. Where applicable, we constructed evidence profile (EP) tables for each individual outcome. Confidence in cumulative evidence for each outcome was classified according to the GRADE system. RESULTS: We identified 689 studies during literature searches. We included 10 full-text studies. A narrative synthesis was provided. Two on-field studies reported no difference in the rates of healthcare workers performing airway procedures during the care of critical patients with SARS-CoV-2. A single simulation trial reported a lower level of cross-contamination of participants using PAPR compared to alternative respiratory protection. There is moderate quality evidence that PAPR use is associated with greater heat tolerance but lower scores for mobility and communication ability. We identified a trend towards greater self-reported wearer comfort with PAPR technology in low-quality observational simulation studies. CONCLUSION: Field observational studies do not indicate a difference in healthcare worker infection utilizing PAPR devices versus other compliant respiratory equipment. Greater heat tolerance accompanied by lower scores of mobility and audibility in PAPR was identified. Further pragmatic studies are needed in order to delineate actual effectiveness and provider satisfaction with PAPR technology. SYSTEMATIC REVIEW REGISTRATION: The protocol for this review was prospectively registered with the International Register of Systematic Reviews identification number CRD42020184724 .

Proposed pathway for patients undergoing enhanced recovery after spinal surgery: protocol for a systematic review.

BACKGROUND: The best evidence-enhanced recovery care pathway is yet to be defined for patients undergoing spinal surgery. Minimally invasive surgery, multimodal analgesia, early mobilization, and early postoperative nutrition have been considered as critical components of enhanced recovery in spinal surgery (ERSS). The objective of this study will be to synthesize the evidence underpinning individual components of a proposed multidisciplinary enhanced recovery pathway for patients undergoing spinal surgery. METHODS: This is the study protocol for a systematic review of complex interventions. Our team identified 22 individual care components of a proposed pathway based on clinical practice guidelines and published reviews. We will include systematic reviews and meta-analysis, randomized controlled trials, non-randomized controlled trials, and observational studies in adults or pediatric patients evaluating any one of the pre-determined care components. Our primary outcomes will be all-cause mortality, morbidity outcomes (e.g., pulmonary, cardiac, renal, surgical complications), patient-reported outcomes and experiences (e.g., pain, quality of care experience), and health services outcomes (e.g., length of stay and costs). We will search the following databases (1990 onwards) MEDLINE, EMBASE, and Cochrane Library (Cochrane Database of Systematic Reviews and CENTRAL). Two reviewers will independently screen all citations, full-text articles, and abstract data. Potential conflicts will be resolved through discussion. The risk of bias for individual studies will be appraised using appropriate tools. A narrative synthesis will be provided with the information presented in the text and tables to summarize and explain the characteristics and findings of the included studies. Due to clinical and methodological heterogeneity, we do not anticipate to conduct meta-analyses. Confidence in cumulative evidence for each component of care will be classified according to the GRADE system. DISCUSSION: This systematic review will identify, evaluate, and integrate the evidence underpinning individual components of a pathway for patients undergoing spinal surgery. The formation of an evidence-based pathway will allow for the standardization of clinical care delivery within the context of enhanced recovery in spinal surgery. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42019135289.

Airway Compromise due to Retropharyngeal Emphysema-A Rare Complication of an Extravasated Peripherally Inserted Central Venous Catheter.

A 48-year-old woman was scheduled for flexible bronchoscopy, video-assisted thoracoscopic surgery and mediastinal washout. She had developed voice changes, difficulty swallowing, shortness of breath with a fever and increased respiratory rate in intensive care unit 12 days after a double liver and kidney transplantation. Computerised tomography of neck and chest demonstrated extensive retropharyngeal and subcutaneous emphysema, laryngeal distortion and pneumo-mediastinum; however, the causative factors were not immediately obvious. Intraoperatively, an un-anticipated diagnosis of extravasated peripherally inserted central venous cannula (PICC) was made. Total parenteral nutrition had extravasated into the mediastinum and thorax. Subsequent inflammation and infection resulted in air pocket formation. The retropharyngeal air pockets were caused by mediastinal emphysema tracking through the tissue planes to the anterior and posterior larynx. Awareness of the tip position and accompanying clinical and radiological enquiry, must be performed prior to use of PICC lines in critically ill patients.

Subcutaneous sumatriptan for the treatment of postcraniotomy pain (SUPS trial): protocol for a randomised double-blinded placebo controlled trial.

INTRODUCTION: Postcraniotomy pain protocols use opioids, which are considered suboptimal analgesia following this procedure. Multimodal analgesia components are sparse. Our null hypothesis states that sumatriptan is not different to placebo in addition to usual intravenous opioids, for the treatment of acute postcraniotomy pain. METHODS AND ANALYSIS: This is a prospective single-centre randomised double-blinded placebo-controlled phase III clinical trial comparing subcutaneous sumatriptan injection in the recovery area with placebo for the treatment of postcraniotomy pain. Eligible adult patients (18 years and older) undergoing craniotomy will be identified preoperatively. Both patient groups will receive a subcutaneous injection at a point where recovery-nursing staff would initiate the usual intravenous opioid analgesia as per standardised pain management protocol. In both groups, further pain management will be followed by the usual intravenous opioid administration. Primary outcome will consist of the difference in pain experienced by the two groups of patients in recovery area 60 min after the study drug administration. Postcraniotomy pain will be measured at regular intervals using the Visual Analogue Scale (VAS) in recovery area. The minimal clinically important difference of 10 mm on the VAS between the two groups will be considered as statistically significant. We will include selected clinical and patient-reported outcomes as secondary endpoints. Univariate regression will be conducted on each one of the clinically plausible potential confounders. We will enrol a total 136 patients, with the study duration of 2 years. This trial will commence recruitment on the 1 July 2019. ETHICS AND DISSEMINATION: This trial protocol has achieved approval by the Austin Health Research Committee, HREC/17/Austin/596. This trial was prospectively registered with Australian New Zealand Clinical Trials Registry on the 10/05/2018 with a unique trial identifier U1111-1209-9072 and registration Number ACTRN12618000793213P. Findings of this study will be disseminated in peer-reviewed academic journals. TRIAL REGISTRATION NUMBER: U1111-1209-9072, ACTRN12618000793213P.

Anaesthesia for a biopsy of corpus callosum in patient with a recent intra-operative anaphylaxis to an unknown anaesthetic allergen: a case report.

BACKGROUND: Anaphylaxis in general anaesthesia occurs with a frequency of 1:5000-1:20000. This clinical summary reports on the use of an effective risk management strategy employing second line anaesthesia agents and alternative endotracheal intubation tools in a patient with a recent history of an intra-operative anaphylaxis to an unknown anaesthetic agent. CASE PRESENTATION: A 71-year-old male presented for a repeat biopsy of corpus callosum 4 days following the cancellation of the procedure for a presumed anaphylactic reaction to an unknown anaesthetic agent. During the repeat care episode, the decision was made to proceed based on the urgent need for tissue diagnosis to facilitate further treatment and lack of feasibility for more definitive identification of the causative agent(s). A consideration was made of the optimum ways to manage and mitigate risk in this setting. The airway was managed using flexible endoscopic intubation in a spontaneously ventilating awake patient. Continuous remifentanil infusion was maintained throughout the case. Anaesthesia was maintained with sevoflurane at less than one MAC, with an uneventful completion of the biopsy of corpus callosum. All of the anaesthetic agents used during the prior care episode, with the exception of remifentanil, were avoided. CONCLUSION: In cases of an anaphylaxis to an unknown anaesthetic allergen, anaesthetic strategy consists of careful risk mitigation and deployment of second agent approaches. Awake flexible endoscopic intubation and remifentanil infusion are viable alternatives to standard induction techniques.

Acute Abdominal Compartment Syndrome following Extraperitoneal Bladder Perforation.

Extraperitoneal bladder perforation is a known complication of a commonly performed rigid cystoscopy. If unrecognized, this complication can lead to continuous intra-abdominal fluid leakage with consequent organ function impairment and symptoms. This is the first case report in literature of a transurethral bladder perforation causing an acute abdominal compartment syndrome, which was subsequently managed conservatively with supportive management only. Case Presentation. We describe a clinical course of a 73-year-old Caucasian female whose initial acute presentation involved urinary symptoms. Surgery and general anaesthesia during rigid cystoscopy were complicated by an initially unrecognized extraperitoneal bladder perforation, resulting in fluid extravasation. This extravasation resulted in transurethral bladder resection syndrome with acute intra-abdominal free fluid accumulation. This complication caused acute abdominal compartment syndrome resulting in respiratory end-organ compromise and immediate postextubation respiratory failure. Patient required an emergency reintubation. During the management, diagnosis was considered through the use of the point of care abdominal ultrasound. Postoperatively, patient was managed conservatively in intensive care. Postoperative course included an approximate nine liters of urinary diuresis and supportive ventilation for four days. Conclusion. There is equipoise in the clinical management of abdominal compartment syndrome with regard to supportive medical management alone or invasive surgical treatment.

Local versus general anaesthesia for adults undergoing pars plana vitrectomy surgery.

BACKGROUND: Vitrectomy surgery is one of the commonest ophthalmic procedures performed across the world. It may be performed using general or local anaesthesia encompassing regional or topical anaesthesia depending on a number of factors, including patient suitability, and patient, surgeon or anaesthetist preference. There have so far been no evidence-based recommendations on the best form of anaesthesia for this intervention. There is no clear collated evidence base as to the best type of anaesthesia to reduce harm, and provide best surgical conditions and optimal outcome for patients. OBJECTIVES: To compare local with general anaesthesia for adults undergoing pars plana vitrectomy. SEARCH METHODS: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library and the reference lists of updated studies on the 25th of July 2016; MEDLINE via Ovid SP (1972 to July 2016) and Embase via Ovid SP (1972 to July 2016). In addition we searched the metaRegister of Controlled Trials (mRCT), ClinicalTrials.gov and the WHO International Clinical Trials Registry Platform (ICTRP) in July 2016. We searched the proceedings of the Annual Meeting of the Association for Research in Vision and Ophthalmology (ARVO) up to July 2016 for information about other relevant studies.We also searched appropriate databases for ongoing reviews. We did not apply any language restriction. We assessed the search as up-to-date on the 25th of July 2016. SELECTION CRITERIA: We planned to include all published randomized controlled trials (RCTs) involving comparison of different modalities of local anaesthesia with general anaesthesia for pars plana vitrectomy. We considered the following different modalities of local anaesthesia: sub-Tenon's anaesthesia, retrobulbar anaesthesia, topical anaesthesia, peribulbar anaesthesia. We planned to include cluster-randomized controlled trials. We excluded quasi-RCT trials. DATA COLLECTION AND ANALYSIS: Two review authors conducted independent searches and assessed identified studies for inclusion according to the prespecified selection criteria. Two review authors assessed trial quality and planned to extract the data. MAIN RESULTS: We found no eligible studies that met our inclusion criteria and were therefore unable to perform a meta-analysis or conduct a methodological quality assessment. AUTHORS' CONCLUSIONS: This systematic review failed to locate relevant clinical evidence to support or refute a pars plana vitrectomy performed with various modalities of local anaesthesia versus general anaesthesia. Good-quality clinical trials are needed to define the role of local versus general anaesthesia for pars plana vitrectomy.

Lower cuff pressures improve the seal of pediatric laryngeal mask airways.

BACKGROUND: Hyperinflation of laryngeal mask airway (LMA) cuffs may be harmful because of the exertion of high pressures on pharyngeal and laryngeal structures. Although cuff manometers may be used to monitor cuff pressure, their use is not routine in many institutions and clinical endpoints are used instead. Furthermore, it is common clinical practice to add air to the cuff in the presence of an air leak to obtain a better seal. METHODS: In a prospective audit, the authors assessed air leakage around pediatric sized LMAs (n = 200) following inflation guided by common clinical endpoints (slight outward movement of the LMA) and then following adjustment of the cuff pressure to the recommended pressure range (<60 cmH(2)O) according to institutional guidelines with the use of a calibrated cuff manometer, directly after induction of anesthesia. Following induction, all children were gently ventilated with pressure control ventilation with 10 cmH(2)O and a positive end-expiratory pressure of 5 cmH(2)O. RESULTS: Following inflation of the cuff guided by clinical endpoints, the median initial cuff pressure (LMA size 1-3) was 92 (size 3) to >120 cmH(2)O (size 1) and the median leakage around the cuff ranged from 0.66 to 1.07 ml x kg(-1). Following cuff pressure adjustment according to the recommended pressure range (<60 cmH(2)O), the leakage decreased significantly to 0.51-0.79 ml x kg(-1) (P = 0.002 for size 1, P < 0.001 for size 1.5-3). CONCLUSION: The use of clinical endpoints to inflate LMA cuffs is not only associated with significant hyperinflation in the majority of patients but also with an increased leakage around the LMA cuff when compared with adjusted LMA cuff pressures. Therefore, cuff manometers should routinely be used not only to avoid unnecessary hyperinflation but also to improve cuff sealing of LMA in children.