Dispositivos supraglóticos con acceso gástrico en colecistectomía laparoscópica / Supraglottic Devices with Gastric Access in Laparoscopic Cholecystectomy

Introducción: El abordaje de la vía aérea del paciente bajo cirugía laparoscópica representa múltiples retos para el anestesiólogo. Objetivo: Evaluar la efectividad y seguridad de tres dispositivos supraglóticos con acceso gástrico en el abordaje de la vía aérea de pacientes bajo colecistectomía laparoscópica. Métodos: Se realizó un estudio cuasiexperimental, prospectivo, longitudinal en el Hospital Universitario "General Calixto García", entre el 2017 y 2019. Se constituyeron tres grupos de 40 pacientes, según dispositivo: máscara laríngea proseal, máscara laríngea supreme y máscara I-gel. Se estudió: tiempo de inserción, número de intentos para colocación, facilidad de inserción de la sonda nasogástrica, presión y suficiencia de sellado orofaríngeo, presión pico con neumoperitoneo y complicaciones. Las variables cualitativas se analizaron con frecuencias absolutas y relativas, y las cuantitativas con medias y desviación estándar. Para la asociación entre variables cualitativas, se utilizó la prueba de chi-cuadrado, y el análisis de varianza para la asociación entre cuantitativas y cualitativas. Se consideró significativo valor de p < 0,05. Resultados: La máscara laríngea supreme se insertó con éxito al primer intento en la mayoría de los pacientes (p = 0,004). La I-gel registró el menor tiempo de inserción (10,05 ± 1,75 seg) y la Supreme mayor facilidad para la sonda nasogástrica (p < 0,001). La mayor presión de sellado fue con la máscara laríngea proseal (30,87 ± 2,60 cmH2O). Las complicaciones fueron pocas y similares con cada uno. Conclusiones: La utilización de dispositivos supraglóticos con acceso gástrico demostró seguridad y efectividad en pacientes intervenidos por colecistectomía laparoscópica(AU)

Introduction: Airway management in the patient undergoing laparoscopic surgery presents multiple challenges for the anesthesiologist. Objective: To assess the effectiveness and safety of three supraglottic devices with gastric access in the airway management in patients undergoing laparoscopic cholecystectomy. Methods: A quasiexperimental, prospective and longitudinal study was carried out, between 2017 and 2019, at General Calixto García University Hospital. Three groups of forty patients were made up, according to the usage of each device: ProSeal laryngeal mask, Supreme laryngeal mask, and I-gel mask. The following variables were studied: insertion time, number of placement attempts, ease of insertion of nasogastric tube, pressure and sufficiency of oropharyngeal sealing, peak pressure with pneumoperitoneum, and complications. Qualitative variables were analyzed with absolute and relative frequencies; and quantitative variables, with means and standard deviation. For the association between qualitative variables, the chi-square test was used, while variance analysis was used for the association between quantitative and qualitative variables. A value of P< 0.05 was considered significant. Results: The Supreme laryngeal mask was successfully inserted on the first attempt in most patients (P=0.004). The I-gel mask had the shortest insertion time (10.05±1.75 seconds), while the Supreme was the easiest for the nasogastric tube (P< 0.001). The highest sealing pressure was obtained with the ProSeal laryngeal mask (30.87±2.60 cmH2O). The complications were few and similar with each device. Conclusions: The use of supraglottic devices with gastric access showed safety and effectiveness in patients who underwent laparoscopic cholecystectomy(AU)

Effectiveness of different supralottic airways during resuscitation manoeuvres. A systematic review. / Efectividad de la ventilación de los diversos dispositivos extraglóticos durante las maniobras de reanimación. Revisión sistemática.

INTRODUCTION: Supraglottic airways, which are easily inserted and minimize interruptions in cardiopulmonary resuscitation manoeuvres, are now widely used in pre- and in-hospital emergencies. However, most studies in these devices do not specify whether they ensure good ventilation during CPR. This systematic review aims to determine whether there is evidence that supraglotic airways enable effective ventilation during resuscitation. METHODS: The MEDLINE and COCHRANE databases were searched for studies published in English up to 30 November 2018. Eligible studies were all those that objectively evaluated tidal volume during resuscitation maneuvers in patients over 18 years of age using various supraglottic airways. RESULTS: A total of 3734 articles were identified, of which 252 were duplicates. Only 1 objectively evaluated ventilation during resuscitation maneuvers and presented data relevant to this review. The study included 470 patients, 51 of which underwent spirometry. Only 4.48% of patients survived to hospital discharge; however, the correlation with ventilation effectiveness was not assessed. CONCLUSION: There is no scientific evidence that supraglottic airways provide effective ventilation during resuscitation maneuvers. Evaluation by spirometry, chest impedance and ultrasound may help to determine the ventilatory efficacy of supraglottic airways during CPR, and clarify whether this factor contributes to the difficulties experienced in reversing cardiorespiratory arrest.

Uso de Totaltrack®, nuevo dispositivo para vía aérea en México / Use of Totaltrack®, new device for airway in Mexico

Resumen: Introducción: Las complicaciones relacionadas con el manejo de la vía aérea representan de 1 a 18%. Totaltrack® es un aparato video-máscara laríngea con un orificio que permite intubar y ventilar al paciente con visión indirecta a través de una cámara, además de un puerto para introducir una sonda de aspiración esófago-gástrica. Material y métodos: Se evaluó el dispositivo en 57 pacientes, ASA I-III de 18 a 65 años de edad sometidos a anestesia general balanceada, con y sin predictores de vía aérea difícil, sin bloqueo neuromuscular. Se realizó la medición del índice predictor de intubación difícil antes de cada procedimiento. Durante la laringoscopía directa por extubación incidental se realizó la valoración Cormack-Lehane. Una vez obtenidos los resultados se realizó el análisis del uso de Totaltrack® en las presiones de sellado de la máscara laríngea y el éxito de la intubación traqueal a través del dispositivo. Resultados: Del total de pacientes analizados, la inserción y ventilación fueron exitosas en todos los casos, la fuga estática y las presiones máximas de inflado del componente de la máscara laríngea fueron a 30 cm de aire, respectivamente. La intubación traqueal a través del dispositivo tuvo éxito en el total de los pacientes, con un tiempo medio de intubación de 4.5 ± 0.58 segundos. No se observó insuflación gástrica. La variabilidad hemodinámica no fue clínicamente significativa. No se reportaron efectos secundarios significativos, el Cormack-Lehane de los dos pacientes extubados incidentalmente fue de III en ambos casos. Conclusiones: Sí se encontró útil el uso de Totaltrack® en todos los casos. El uso de Totaltrack® permite una visualización óptima de la vía aérea, la intubación no se complica y se puede realizar con secuencia rápida, independientemente del índice predictor de intubación difícil y el Cormack-Lehane.

Abstract. Introduction: Complications related to airway management represent from 1 to 18%. Totaltrack® is a laryngeal video-mask device with, that allows intubate and ventilate patients with indirect vision through a camera, also have a port to introduce an esophagogastric aspiration probe. Material and methods: The device was evaluated in 57 ASA I-III patients from 18 to 65 years of age undergoing balanced general anesthesia, with and without predictors of difficult airway, without neuromuscular block, it has been made the difficult intubation predictor index before each procedure. During the direct laryngoscopy due to incidental extubation, the Cormack-Lehane assessment was performed. Once the results were obtained, an analysis was made of the use of Totaltrack® in the sealing pressures of the laryngeal mask and the success of tracheal intubation through the device. Results: Of the total number of patients analyzed. The insertion and ventilation were successful in all cases, the static leak and the maximum inflation pressures of the laryngeal mask component were 30 cm of air respectively. The tracheal intubation through the device was successful in all cases, with a mean intubation time of 4.5 ± 0.58 seconds. Gastric insufflation was not observed. The hemodynamic variability was not clinically significant. No significant side effects were reported, the Cormack-Lehane of the two patients incidentally extubated was III in both cases. Conclusions: Yes, the use of Totaltrack® was found useful in all cases. The use of Totaltrack® allows an optimal visualization of the airway, the intubation is not complicated and can be performed with rapid sequence, independently of the difficult intubation predictor index and the Cormack Lehane.

Efectividad de la máscara laríngea Ambu® Aura40TM para anestesia general en cirugía ortopédica pediátrica / Effectiveness of Ambu® Aura40TM laryngeal mask for general anesthetic in pediatric orthopedic surgery

RESUMEN Introducción: las máscaras laríngeas son dispositivos supraglóticos utilizadas ampliamente en anestesia para el abordaje y mantenimiento de la vía respiratoria. Una de ellas, la Ambu® Aura 40TM, tiene un diseño que le permite ajustarse al entorno de la hipofaringe con su lumen dirigido a la apertura laríngea. Ha demostrado ser adecuada para procedimientos quirúrgicos donde no es necesaria la intubación endotraqueal. Objetivo: determinar la efectividad dicha máscara laríngea para anestesia general en cirugía ortopédica pediátrica. Materiales y métodos: se realizó un estudio descriptivo, prospectivo, transversal, en 135 pacientes intervenidos quirúrgicamente de forma electiva en el Hospital Pediátrico Eliseo Noel Caamaño, de Matanzas, en el periodo enero de 2015- junio 2017. Se tuvo en cuenta el número de intentos y el tiempo para insertar la máscara laríngea, la necesidad de reemplazarla por un tubo endotraqueal y las complicaciones relacionadas con su uso. Resultados: la ML Ambu® Aura 40TM fue efectiva en la mayoría de los pacientes ya que permitió realizar la cirugía sin necesidad de sustituirla por el tubo endotraqueal y la aparición de complicaciones relacionada con su uso fue baja. Conclusiones: la ML Ambu® Aura 40TM fue efectiva ya que en la mayoría de los pacientes fue insertada correctamente en el primer intento y un tiempo inferior a los 20 segundos. Solo una minoría necesitó que fuera reemplazada por el tubo endotraqueal, y la aparición de complicaciones relacionada con su uso fue baja (AU).

ABSTRACT Introduction: laryngeal mask are supra glottal devices widely used in anesthetics for approaching and maintaining the airway. One of them, the Ambu® Aura 40TM, has a design allowing to adjust to the surroundings of hypo-pharynx with its lumen directed to the pharyngeal opening. It has demonstrated to be adequate for surgical procedures when there is no need of endotracheal intubation. Objective: to determine the effectiveness of that laryngeal mask for general anesthetic in pediatric orthopedic surgery. Materials and methods: a cross-sectional, prospective, descriptive study was carried out in 135 patients who underwent elective surgical intervention in the Pediatric Hospital ?Eliseo Noel Caamaño?, of Matanzas, in the period January 2015- June 2017. The number of attempts and the time needed to insert laryngeal mask, the necessity of changing it for an endotracheal tube, and complications related to its usage were taking into account. Results: Ambu® Aura 40TM laryngeal mask was effective in most patients, due to it allowed to perform the surgery without need of changing it for an endotracheal tube, and the low appearance of complications related to its use. Conclusions: Ambu® Aura 40TM laryngeal mask was effective because it was inserted correctly at the first attempt, in a time less than 20 seconds. Only a minority needed to replace it by endotracheal tube, and the appearance of complications related to its use were low (AU).

Laryngeal tubes and laryngeal mask devices for supraglottic airway management in out-of-hospital emergency care: a systematic review. / Comparación entre los diferentes dispositivos supraglóticos para el manejo de la vía aérea en la asistencia extrahospitalaria: revisión sistemática.

ABSTRACT: Various supraglottic devices are currently available for airway management and are used widely in emergency situations because they are easy to position. We undertook a systematic review of the literature comparing laryngeal tubes and various laryngeal mask airway devices (LMAs) to determine which ones can be used most efficiently in emergencies. Nine databases were searched, as follows: Cochrane Library Plus, MEDLINE, CINAHL (Cumulative Index to Nursing and Allied Health Literature), Dialnet, Global Health, Nursing & Allied Health Database, CUIDEN, the Web of Science, and ScienceDirect. We collected studies published between 2014 and 2019 in Spanish, English, French, and Portuguese that compared laryngeal tubes to LMAs of different types for supraglottic airway management. Eighteen studies were selected for analysis after critical reading. Significant differences were not seen between tubes and LMAs with respect to most variables, but in certain contexts the oropharyngeal seal and speed of insertion were superior with laryngeal tubes; however, when fiberoptic bronchoscopes were then inserted the view of the glottis was poor. The different contexts in which these devices are used and the scarcity of studies comparing laryngeal tubes to LMAs does not allow us to identify clear differences among them with respect to efficiency. However, tubes seem to offer poorer visibility of the glottis according to evaluation with fiberoptic scopes, a factor to bear in mind if tracheal intubation, which is considered the gold standard, might become necessary.

RESUMEN: En la actualidad, el uso de los dispositivos supraglóticos (DSG) para el manejo de la vía aérea está ampliamente extendido en urgencias y emergencias por su fácil manejo. El objetivo de la presente revisión es comparar los dispositivos supraglóticos para el manejo de la vía aérea, tubo laríngeo (TL) y máscara laríngea (ML), en sus diferentes versiones, para determinar cuál de ellos reúne las mejores condiciones para un uso eficiente en la atención a urgencias y emergencias. Se realiza una revisión sistemática de la literatura a través de la consulta en 9 bases de datos bibliográficas: Biblioteca Cochrane Plus, Medline, CINAHL, Dialnet, Global Health, Nursing & Allied Health Database, CUIDEN, Web of Science y ScienceDirect. Fueron seleccionados registros que estaban comprendidos entre los años 2014 y 2019, en español, inglés, francés y portugués, donde se realizara una comparación entre los DSG, TL y ML, en sus diferentes versiones. Se identificaron un total de 18 estudios válidos tras la lectura crítica. En la mayoría de aspectos evaluados, no se apreciaron diferencias significativas entre ambos dispositivos. Destancaba una presión de sellado orofaríngeo y velocidad de inserción superior en determinados contextos en la utilización del TL, y existía además una visión menor de la glotis mediante la utilización del broncoscopio. Los diferentes contextos en que se puede presentar la utilización de los DSG y la escasez de registros que comparan el TL con las ML en sus diferentes versiones no permite una clara diferenciación en cuanto a eficacia. No obstante, sí parece evidenciarse una visión menor de la glotis en la utilización del TL tras ser valorado con el fibroscopio, factor a tener en cuenta si se tiene presente que en la atención secundaria la intubación selectiva mediante la intubación traqueal, considerada el "patrón oro", puede llegar a ser una necesidad.

Anesthetic considerations for awake craniotomy: case report / Considerações anestésicas para craniotomia em paciente acordado: relato de caso

Abstract Background and objectives: The conscious patient cooperation during neurological procedures has become necessary for the delimitation of areas to be managed by a neurosurgeon, with better results in the treatment of tumor lesions, vascular or epileptic foci, and lesser sequelae. The need for perioperative awareness (responsiveness to commands) challenges anesthesiologists to further ensure patient safety during the procedure. Several techniques have been described for this purpose. Case report: In this case, interaction with the patient during brain tumor resection enabled a broad approach of the tumor lesion, limited by deficits in speech and naming observed during surgical manipulation, avoiding major consequences. The chosen technique was deepening of general anesthesia during surgical times of most painful stimulus with intraoperative awakening of the patient. Conclusions: Patient selection, an exhaustive explanation of the procedure to him, and the selection of drugs are crucial for a successful procedure. Laryngeal mask is useful in times requiring greater depth and anesthetic ventilation control, primarily in situations where endotracheal intubation may be hindered by the position. The continuous infusion of remifentanil and adjuncts in the awake period associated adequate analgesia and full consciousness.

Resumo Justificativa e objetivos: A colaboração consciente do paciente durante procedimentos neurológicos tem se tornado necessária para delimitar áreas a serem abordadas pelo neurocirurgião, com melhores resultados no tratamento de lesões tumorais, vasculares ou focos epiléticos e minimização de sequelas. A necessidade de consciência perioperatória e responsividade a comandos desafia o anestesiologista a garantir ainda a segurança do paciente durante o procedimento. Várias técnicas têm sido descritas para esse fim. Relato de caso: No presente caso, a interação com paciente durante ressecção de tumor cerebral possibilitou abordagem ampla de lesão tumoral, limitada por déficits de fala e de identificação notados à manipulação cirúrgica, e evitou sequelas maiores. A indução de anestesia geral em tempos cirúrgicos de maior estímulo doloroso com despertar intraoperatório do paciente foi a técnica escolhida. Conclusões: A seleção do paciente, seu exaustivo esclarecimento e a seleção das drogas são de fundamental importância para o sucesso do procedimento. A máscara laríngea é instrumento útil em tempos que exigem maior profundidade anestésica e controle da ventilação, primariamente em situações em que a intubação endotraqueal pode estar dificultada pelo posicionamento. A infusão contínua de remifentanil e coadjuvantes no período desperto associou analgesia adequada e consciência plena.

[Difficult fiberoptic tracheal intubation in 1 month-old infant with Treacher Collins Syndrome]. / Intubação traqueal difícil com fibra óptica em bebê de um mês de idade com síndrome de Treacher Collins.

Neonates and small infants with craniofacial malformation may be very difficult or impossible to mask ventilate or intubate. We would like to report the fiberoptic intubation of a small infant with Treacher Collins Syndrome using the technique described by Ellis et al. CASE REPORT: An one month-old infant with Treacher Collins Syndrome was scheduled for mandibular surgery under general endotracheal anesthesia. Direct laryngoscopy for oral intubation failed to reveal the glottis. Fiberoptic intubation using nasal approach and using oral approach through a 1.5 size laryngeal mask airway were performed; however, both approach failed because the fiberscope loaded with a one 3.5mm ID uncuffed tube was stuck inside the nasal cavity or inside the laryngeal mask airway respectively. Therefore, the laryngeal mask airway was keep in place and the fiberoptic intubation technique described by Ellis et al. was planned: the tracheal tube with the 15mm adapter removed was loaded proximally over the fiberscope; the fiberscope was advanced under video-screen visualization into the trachea; the laryngeal mask airway was removed, leaving the fiberscope in place; the tracheal tube was passed completely through the laryngeal mask airway and advanced down over the fiberscope into the trachea; the fiberscope was removed and the 15mm adapter was reattached to the tracheal tube. CONCLUSION: The fiberoptic intubation method through a laryngeal mask airway described by Ellis et al. can be successfully used in small infants with Treacher Collins Syndrome.

[Anesthetic considerations for awake craniotomy: case report]. / Considerações anestésicas para craniotomia em paciente acordado: relato de caso.

BACKGROUND AND OBJECTIVES: The conscious patient cooperation during neurological procedures has become necessary for the delimitation of areas to be managed by a neurosurgeon, with better results in the treatment of tumor lesions, vascular or epileptic foci, and lesser sequelae. The need for perioperative awareness (responsiveness to commands) challenges anesthesiologists to further ensure patient safety during the procedure. Several techniques have been described for this purpose. CASE REPORT: In this case, interaction with the patient during brain tumor resection enabled a broad approach of the tumor lesion, limited by deficits in speech and naming observed during surgical manipulation, avoiding major consequences. The chosen technique was deepening of general anesthesia during surgical times of most painful stimulus with intraoperative awakening of the patient. CONCLUSIONS: Patient selection, an exhaustive explanation of the procedure to him, and the selection of drugs are crucial for a successful procedure. Laryngeal mask is useful in times requiring greater depth and anesthetic ventilation control, primarily in situations where endotracheal intubation may be hindered by the position. The continuous infusion of remifentanil and adjuncts in the awake period associated adequate analgesia and full consciousness.

Comparison of three different insertion techniques with LMA-UniqueTM in adults: results of a randomized trial / Comparação de três técnicas diferentes de inserção com a máscara laríngea LMA-UniqueTM em adultos: resultados de um estudo randômico

Abstract Background The triple airway maneuver insertion technique allowed faster insertion of the LMA. This study compared three different insertion techniques of the laryngeal mask airway-UniqueTM. Methods One hundred and eighty ASA I-II patients aged 18-65 years were included into the study. Patients were randomly allocated to the standard, rotational and triple airway maneuver (triple) group. In the standard group (n = 60), the LMA (Laryngeal Mask Airway) was inserted with digital intraoral manipulation. In the triple group (n = 60), the LMA was inserted with triple airway maneuver (mouth opening, head extension and jaw thrust). In the rotational group (n = 60), LMA was inserted back-to-front, like a Guedel airway. Successful insertion at first attempt, time for successful insertion, fiber optic assessment, airway morbidity and hemodynamic responses were assessed. Results Successful insertion at the first attempt was 88.3% for the standard, 78.3% for the rotational and 88.3% for the triple group. Overall success rate (defined as successful insertion at first and second attempt) was 93% for the standard, 90% for the rotational and 95% for the triple group. Time for successful insertion was significantly shorter in the triple group (mean [range] 8.63 [5-19]s) compared with the standard (11.78 [6-24]s) and rotational group (11.57 [5-31]s). Fiber optic assessment, airway morbidity and hemodynamic responses were similar in all groups. Conclusions Rotational and triple airway maneuver insertion techniques are acceptable alternatives. Triple airway maneuver technique shows higher overall success rates and allows shorter insertion time for LMA insertion and should therefore be kept in mind for emergent situations.

Resumo Justificativa A técnica de inserção com a manobra tripla das vias aéreas permitiu a inserção mais rápida da ML. Este estudo comparou três técnicas de inserção da máscara laríngea UniqueTM. Métodos Foram incluídos no estudo 180 pacientes ASA I-II, entre 18-65 anos. Os pacientes foram aleatoriamente designados para grupos de manobra das vias aéreas padrão, rotacional e tripla. No grupo padrão (n = 60), a máscara laríngea (ML) foi inserida com a técnica digital intraoral. No grupo tripla (n = 60), a ML foi inserida com a técnica de manobra tripla das vias aéreas (abertura bucal, extensão da cabeça e elevação da mandíbula). No grupo rotacional (n = 60), a ML foi inserida com a técnica de inserção de trás para frente, como uma cânula de Guedel. Inserção bem-sucedida na primeira tentativa, tempo de inserção bem-sucedida, avaliação por fibra óptica, morbidade das vias aéreas e respostas hemodinâmicas foram avaliados. Resultados O sucesso da inserção na primeira tentativa foi de 88,3% para o grupo padrão, 78,3% para o grupo rotacional e 88,3% para o grupo tripla. A taxa de sucesso global (definida como inserção bem-sucedida na primeira e segunda tentativas) foi de 93% para o grupo padrão, 90% para o grupo rotacional e 95% para o grupo tripla. O tempo de inserção bem-sucedida foi significativamente menor no grupo tripla (média [intervalo] 8,63 [5-19]s), em comparação com o grupo padrão (11,78 [6-24]s) e o grupo rotacional (11,57 [5-31]s). A avaliação por fibra óptica, a morbidade das vias aéreas e as respostas hemodinâmicas foram semelhantes em todos os grupos. Conclusões As técnicas de inserção rotacional e de manobra tripla das vias aéreas são opções aceitáveis. A técnica de manobra tripla das vias aéreas apresenta taxas mais altas de sucesso global e permite um tempo menor de inserção da ML e, portanto, deve ser considerada em situações de emergência.

A randomized controlled trial of the laryngeal mask airway for surfactant administration in neonates / Ensaio controlado randomizado de máscara laríngea para administração de surfactantes em neonatos

Abstract Objective: To compare the short-term efficacy of surfactant administration by laryngeal mask airway versus endotracheal tube. Methods: Preterm infants (28-35 weeks of gestational age), weighing 1 kg or more, with respiratory distress syndrome, requiring nasal continuous positive airway pressure, with increased respiratory effort and/or fraction of inspired oxygen (FiO2) ≥ 0.40 to maintain oxygen saturation 91-95%, were randomized to receive surfactant by LMA following nCPAP or by ETT following mechanical ventilation (MV). The primary outcome was a clinical response defined as FiO2 ≤ 0.30 three hours after surfactant. Secondary outcomes for LMA group were: need of surfactant retreatment during the first 24 h, MV requirement, and presence of surfactant in gastric content. Results: Forty-eight patients were randomized; 26 in the LMA group and 22 in the ETT group. Six of 26 patients (23%) in the LMA group and five of 22 patients (22.7%) in the ETT group did not meet the primary outcome (p = 0.977). Fourteen (53.8%) of the LMA patients were not intubated nor ventilated; 12 (46.1%) were ventilated: for surfactant failure (23%), for nCPAP failure (11.5%), and for late complications (11.5%). Groups were similar regarding prenatal status, birth conditions, and adverse events. No significant gastric content was found in 61.5% of the LMA patients. Oxygen and second dose surfactant requirements, arterial/alveolar ratio, and morbidities were similar among groups. Conclusions: Surfactant administration by LMA showed short-term efficacy, with similar supplementary oxygen need compared to surfactant by ETT, and lower MV requirement. Further studies with larger sample size are necessary to confirm these results.

Resumo Objetivo: Comparar a eficácia de curto prazo da administração de surfactante por máscara laríngea em comparação com o tubo endotraqueal. Métodos: Neonatos prematuros (28-35 semanas de idade gestacional), com 1 kg ou mais, com síndrome do desconforto respiratório, que necessitavam de pressão positiva nasal contínua nas vias aéreas, com aumento do esforço respiratório e/ou fração de oxigênio inspirado (FiO2) ≥ 0,40 para manter a saturação de oxigênio 91-95%, foram randomizados para receber surfactante por ML seguido por nCPAP ou por TE seguido por ventilação mecânica (VM). O resultado clínico primário foi definido como FiO2 ≤ 0,30 três horas após o surfactante. Os resultados secundários do grupo de ML foram: necessidade de segunda dose de surfactante nas primeiras 24 horas, necessidade de VM e presença de surfactante no conteúdo gástrico. Resultados: Foram randomizados 48 pacientes; 26 no grupo de ML e 22 no grupo de TE. Seis dentre os 26 pacientes (23%) do grupo de ML e cinco dentre 22 pacientes (22,7%) do grupo de TE não apresentaram o resultado primário (p = 0,977); 14 (53,8%) dos pacientes do grupo de ML não foram intubados nem ventilados; 12 (46,1%) foram submetidos a VM: por falha do surfactante (23%), por falha da nCPAP (11,5%) e por complicações tardias (11,5%). Os grupos foram semelhantes em relação às condições pré-natais e de nascimento e a ocorrência de eventos adversos. Não foi encontrado conteúdo gástrico significativo em 61,5% dos pacientes do grupo de ML. As necessidades de oxigênio e da segunda dose de surfactante, o índice arterial/alveolar e as morbidades foram semelhantes entre os grupos. Conclusões: A administração de surfactante por ML mostrou eficácia de curto prazo com necessidade complementar de oxigênio semelhante ao surfactante por TE e menor necessidade de VM. Serão necessários estudos adicionais com tamanho da amostra maior para confirmar esses resultados.

[Comparison of three different insertion techniques with LMA-Unique™ in adults: results of a randomized trial]. / Comparação de três técnicas diferentes de inserção com a máscara laríngea LMA­Unique™ em adultos: resultados de um estudo randômico.

BACKGROUND: The triple airway maneuver insertion technique allowed faster insertion of the LMA. This study compared three different insertion techniques of the laryngeal mask airway-Unique™. METHODS: One hundred and eighty ASA I-II patients aged 18-65 years were included into the study. Patients were randomly allocated to the standard, rotational and triple airway maneuver (triple) group. In the standard group (n=60), the LMA (Laryngeal Mask Airway) was inserted with digital intraoral manipulation. In the triple group (n=60), the LMA was inserted with triple airway maneuver (mouth opening, head extension and jaw thrust). In the rotational group (n=60), LMA was inserted back-to-front, like a Guedel airway. Successful insertion at first attempt, time for successful insertion, fiber optic assessment, airway morbidity and hemodynamic responses were assessed. RESULTS: Successful insertion at the first attempt was 88.3% for the standard, 78.3% for the rotational and 88.3% for the triple group. Overall success rate (defined as successful insertion at first and second attempt) was 93% for the standard, 90% for the rotational and 95% for the triple group. Time for successful insertion was significantly shorter in the triple group (mean [range] 8.63 [5-19]s) compared with the standard (11.78 [6-24]s) and rotational group (11.57 [5-31]s). Fiber optic assessment, airway morbidity and hemodynamic responses were similar in all groups. CONCLUSIONS: Rotational and triple airway maneuver insertion techniques are acceptable alternatives. Triple airway maneuver technique shows higher overall success rates and allows shorter insertion time for LMA insertion and should therefore be kept in mind for emergent situations.

Simple method for determining the size of the ProSeal laryngeal mask airway in children: a prospective observational study / Método simples para determinar o tamanho da máscara laríngea ProSeal em crianças: um estudo observacional, prospectivo

Abstract Background and objectives: The size of the ProSeal laryngeal mask airway in children is determined by the patient's weight. However, in some instances, an alternative method may be required. This study aimed to compare sizing by the auricle with conventional ProSeal laryngeal mask airway sizing by weight in children. Methods: After approval by the institutional ethics board and written informed consent from parents, 197 children with American Society of Anesthesiologists physical status I-II who were scheduled for a routine genitourinary operation were included in the study. The correct ProSeal laryngeal mask airway size was determined according to the size of the auricle in children. The results were compared with the standard weight-based method recommended by the manufacturer's guidelines. The patients were classified into different groups depending on the ProSeal laryngeal mask airway sizes as determined by both methods. Agreement between both techniques was evaluated with κ coefficient statistics. Results: Insertion and adequate ventilation were achieved in 185 patients at the first attempt, and 12 patients required a second attempt. Three patients had to be intubated. Agreement between the two methods of size selection of the ProSeal laryngeal mask airway was moderate using κ statistics. Conclusions: Choosing the size of the ProSeal laryngeal mask airway in children according to the auricle of the child is valid and practical. In particular, this is an alternative method in situations where the patient's weight is unknown, such as in emergency situations.

Resumo Justificativa e objetivos: O tamanho da máscara laríngea ProSeal (MLPS) em crianças é determinado com base no peso do paciente. No entanto, em alguns casos, pode ser necessário um método opcional. Este estudo teve como objetivo comparar o tamanho da MLPS convencional pela orelha e pelo peso em crianças. Métodos: Após aprovação do Comitê de Ética institucional e receber o consentimento informado assinado pelos pais, 197 crianças com estado físico ASA I-II (de acordo com a classificação da Sociedade Americana de Anestesiologistas), programadas para uma operação geniturinária de rotina, foram incluídas no estudo. O tamanho correto da MLPS foi determinado de acordo com o tamanho da orelha em crianças. Os resultados foram comparados com os do método padrão, baseado no peso, recomendado pelas diretrizes do fabricante. Os pacientes foram classificados em diferentes grupos, a depender dos tamanhos das MLPS, conforme determinado por ambos os métodos. A concordância entre as duas técnicas foi avaliada com as estatísticas do coeficiente kappa (k). Resultados: Inserção e ventilação adequada foram obtidas em 185 pacientes na primeira tentativa e 12 pacientes precisaram de uma segunda tentativa. Três pacientes precisaram ser intubados. A concordância entre os dois métodos de seleção do tamanho da MLPS foi moderada com a estatística κ. Conclusões: A escolha do tamanho da MLPS em crianças de acordo com a orelha da criança é válida e prática. Em particular, é um método opcional em situações nas quais o peso do paciente é desconhecido, como em situações de emergência.

A randomized controlled trial of the laryngeal mask airway for surfactant administration in neonates.

OBJECTIVE: To compare the short-term efficacy of surfactant administration by laryngeal mask airway versus endotracheal tube. METHODS: Preterm infants (28-35 weeks of gestational age), weighing 1kg or more, with respiratory distress syndrome, requiring nasal continuous positive airway pressure, with increased respiratory effort and/or fraction of inspired oxygen (FiO2)≥0.40 to maintain oxygen saturation 91-95%, were randomized to receive surfactant by LMA following nCPAP or by ETT following mechanical ventilation (MV). The primary outcome was a clinical response defined as FiO2≤0.30 three hours after surfactant. Secondary outcomes for LMA group were: need of surfactant retreatment during the first 24h, MV requirement, and presence of surfactant in gastric content. RESULTS: Forty-eight patients were randomized; 26 in the LMA group and 22 in the ETT group. Six of 26 patients (23%) in the LMA group and five of 22 patients (22.7%) in the ETT group did not meet the primary outcome (p=0.977). Fourteen (53.8%) of the LMA patients were not intubated nor ventilated; 12 (46.1%) were ventilated: for surfactant failure (23%), for nCPAP failure (11.5%), and for late complications (11.5%). Groups were similar regarding prenatal status, birth conditions, and adverse events. No significant gastric content was found in 61.5% of the LMA patients. Oxygen and second dose surfactant requirements, arterial/alveolar ratio, and morbidities were similar among groups. CONCLUSIONS: Surfactant administration by LMA showed short-term efficacy, with similar supplementary oxygen need compared to surfactant by ETT, and lower MV requirement. Further studies with larger sample size are necessary to confirm these results.

[Simple method for determining the size of the ProSeal laryngeal mask airway in children: a prospective observational study]. / Método simples para determinar o tamanho da máscara laríngea ProSeal em crianças: um estudo observacional, prospectivo.

BACKGROUND AND OBJECTIVES: The size of the ProSeal laryngeal mask airway in children is determined by the patient's weight. However, in some instances, an alternative method may be required. This study aimed to compare sizing by the auricle with conventional ProSeal laryngeal mask airway sizing by weight in children. METHODS: After approval by the institutional ethics board and written informed consent from parents, 197 children with American Society of Anesthesiologists physical status I-II who were scheduled for a routine genitourinary operation were included in the study. The correct ProSeal laryngeal mask airway size was determined according to the size of the auricle in children. The results were compared with the standard weight-based method recommended by the manufacturer's guidelines. The patients were classified into different groups depending on the ProSeal laryngeal mask airway sizes as determined by both methods. Agreement between both techniques was evaluated with κ coefficient statistics. RESULTS: Insertion and adequate ventilation were achieved in 185 patients at the first attempt, and 12 patients required a second attempt. Three patients had to be intubated. Agreement between the two methods of size selection of the ProSeal laryngeal mask airway was moderate using κ statistics. CONCLUSIONS: Choosing the size of the ProSeal laryngeal mask airway in children according to the auricle of the child is valid and practical. In particular, this is an alternative method in situations where the patient's weight is unknown, such as in emergency situations.

Simple method for determining the size of the ProSeal laryngeal mask airway in children: a prospective observational study.

BACKGROUND AND OBJECTIVES: The size of the ProSeal laryngeal mask airway in children is determined by the patient's weight. However, in some instances, an alternative method may be required. This study aimed to compare sizing by the auricle with conventional ProSeal laryngeal mask airway sizing by weight in children. METHODS: After approval by the institutional ethics board and written informed consent from parents, 197 children with American Society of Anesthesiologists physical status I-II who were scheduled for a routine genitourinary operation were included in the study. The correct ProSeal laryngeal mask airway size was determined according to the size of the auricle in children. The results were compared with the standard weight-based method recommended by the manufacturer's guidelines. The patients were classified into different groups depending on the ProSeal laryngeal mask airway sizes as determined by both methods. Agreement between both techniques was evaluated with κ coefficient statistics. RESULTS: Insertion and adequate ventilation were achieved in 185 patients at the first attempt, and 12 patients required a second attempt. Three patients had to be intubated. Agreement between the two methods of size selection of the ProSeal laryngeal mask airway was moderate using κ statistics. CONCLUSIONS: Choosing the size of the ProSeal laryngeal mask airway in children according to the auricle of the child is valid and practical. In particular, this is an alternative method in situations where the patient's weight is unknown, such as in emergency situations.

Vía aérea crítica pediátrica / Critical pediatric airway

The airway often provides predictable or in some instances unexpected situations depending the different scenarios like the emergency, the operating room or critical patient units. The challenge is to ensure proper management of the airway in these different situations of varying complexity. Therefore, planning based on what anesthetists call difficult airway will allow us to anticipate different ventilation and airway situations. This will then allow us conduct a judicious collaborative management of these situations with an emphasis on planning the different devices to be used as well as considering at any time the aid of the processes of intubation and mechanical ventilation connection in pediatric critical patients.

La vía aérea representa una situación que a menudo ofrece desafíos previsibles o en algunas situaciones inesperados, en diferentes escenarios tanto en la urgencia, pabellón como en unidades de paciente crítico. El desafío es lograr un adecuado manejo de la vía aérea en diferentes situaciones de menor a mayor complejidad, por lo cual, una planificación basada en lo que los anestesistas llaman vía aérea difícil nos permitirá prever diferentes situaciones de ventilación y vía aérea complicada que nos permitirán realizar un manejo juicioso, en equipo, dando énfasis en la planificación de los diferentes dispositivos a usar, como también a considerar la ayuda en cualquier momento del proceso de intubación y conexión a ventilación mecánica en pacientes críticos.

Comparison of sevoflurane concentration for insertion of proseal laryngeal mask airway and tracheal intubation in children (correlation with BIS) / Comparação da concentração de sevoflurano para a inserção de ML proseal e intubação traqueal em crianças (correlação com BIS)

BACKGROUND: Sevoflurane is an inhalational agent of choice in paediatric anaesthesia. For management of airways in children a suitable alternative to ETT is a paediatric proseal laryngeal mask airway (benchmark second generation SAD). Various studies have shown that less sevoflurane concentration is required for LMA insertion in comparison to TI. BIS is a useful monitor of depth of anaesthesia. AIMS: To compare concentration of sevoflurane (end tidal and MAC value) required for proseal laryngeal mask airway insertion and tracheal intubation in correlation with BIS index. METHOD: The prospective randomised single blind study was done in children between 2 and 9 years of ASA I and II and they were randomly allocated to Group P (proseal laryngeal mask airway insertion) and Group TI (tracheal intubation). No sedative premedication was given. Induction was done with 8% sevoflurane and then predetermined concentration was maintained for 10 min. Airway was secured either by proseal laryngeal mask airway or endotracheal tube without using muscle relaxant. End tidal sevoflurane concentration, MAC, BIS, and other vital parameters were monitored every minute till insertion of an airway device. Insertion conditions were observed. Statistical analysis was done by ANOVA and Students t test. RESULTS: Difference between ETLMI (2.49 ± 0.44) and ETTI (2.81 ± 0.65) as well as MACLMI (1.67 ± 0.13) and MACTI (1.77 ± 0.43) was statistically very significant, while BISLMI (49.05 ± 10.76) and BISTI (41.25 ± 3.25) was significant. Insertion conditions were comparable in both the groups. CONCLUSION: We can conclude that in children airway can be secured safely with proseal laryngeal mask airway using less sevoflurane concentration in comparison to tracheal intubation and this was supported by BIS index.

JUSTIFICATIVA: Sevoflurano é um agente inalatório de escolha em anestesia pediátrica. Para o manejo de vias aéreas em crianças, uma opção adequada para o TET é uma MLP pediátrica (referência de segunda geração SAD). Vários estudos mostraram que uma menor concentração do sevoflurano é necessária para a inserção da ML em comparação com a IT. O BIS é um monitor útil da profundidade da anestesia. OBJETIVOS: Comparar a concentração de sevoflurano (valores no fim da expiração e da CAM) necessária para a inserção de MLP e intubação traqueal em correlação com o BIS. MÉTODO: Estudo prospectivo, randômico e cego conduzido com crianças entre 2-9 anos, estado físico ASA I-II, randomicamente alocados nos grupos P (inserção de MLP) e IT (intubação traqueal). Pré-medicação sedativa não foi administrada. A indução foi feita com sevoflurano a 8% e, em seguida, a concentração predeterminada foi mantida durante 10 minutos. A via aérea foi garantida por MLP ou tubo endotraqueal, sem o uso de relaxante muscular. A concentração de sevoflurano no fim da expiração, CAM, BIS e outros parâmetros vitais foram monitorados a cada minuto até a inserção do dispositivo respiratório. As condições de inserção foram observadas. A análise estatística foi feita com o teste t de Student e Anova. RESULTADOS: As diferenças entre TEIML (2,49 ± 0,44) e TEIT (2,81 ± 0,65), bem como CAMIML (1,67 ± 0,13) e CAMIT (1,77 ± 0,43), foram estatisticamente muito significativas; enquanto BISIML (49,05 ± 10,76) e BISIT (41,25 ± 3,25) foram significativos. As condições de inserção foram comparáveis em ambos os grupos. CONCLUSÃO: Podermos concluir que a MLP em comparação com a intubação traqueal pode ser segura para a via aérea de crianças com o uso de menos concentração de sevoflurano, o que foi confirmado pelo BIS.

Comparison of sevoflurane concentration for insertion of proseal laryngeal mask airway and tracheal intubation in children (correlation with BIS).

BACKGROUND: Sevoflurane is an inhalational agent of choice in paediatric anaesthesia. For management of airways in children a suitable alternative to ETT is a paediatric proseal laryngeal mask airway (benchmark second generation SAD). Various studies have shown that less sevoflurane concentration is required for LMA insertion in comparison to TI. BIS is a useful monitor of depth of anaesthesia. AIMS: To compare concentration of sevoflurane (end tidal and MAC value) required for proseal laryngeal mask airway insertion and tracheal intubation in correlation with BIS index. METHOD: The prospective randomised single blind study was done in children between 2 and 9 years of ASA I and II and they were randomly allocated to Group P (proseal laryngeal mask airway insertion) and Group TI (tracheal intubation). No sedative premedication was given. Induction was done with 8% sevoflurane and then predetermined concentration was maintained for 10 min. Airway was secured either by proseal laryngeal mask airway or endotracheal tube without using muscle relaxant. End tidal sevoflurane concentration, MAC, BIS, and other vital parameters were monitored every minute till insertion of an airway device. Insertion conditions were observed. Statistical analysis was done by ANOVA and Students t test. RESULTS: Difference between ETLMI (2.49 ± 0.44) and ETTI (2.81 ± 0.65) as well as MACLMI (1.67 ± 0.13) and MACTI (1.77 ± 0.43) was statistically very significant, while BISLMI (49.05 ± 10.76) and BISTI (41.25 ± 3.25) was significant. Insertion conditions were comparable in both the groups. CONCLUSION: We can conclude that in children airway can be secured safely with proseal laryngeal mask airway using less sevoflurane concentration in comparison to tracheal intubation and this was supported by BIS index.