Supraglottic Airway Devices: Present State and Outlook for 2050.

Correct placement of supraglottic airway devices (SGDs) is crucial for patient safety and of prime concern of anesthesiologists who want to provide effective and efficient airway management to their patients undergoing surgery or procedures requiring anesthesia care. In the majority of cases, blind insertion of SGDs results in less-than-optimal anatomical and functional positioning of the airway devices. Malpositioning can cause clinical malfunction and result in interference with gas exchange, loss-of-airway, gastric inflation, and aspiration of gastric contents. A close match is needed between the shape and profile of SGDs and the laryngeal inlet. An adequate first seal (with the respiratory tract) and a good fit at the second seal of the distal cuff and the gastrointestinal tract are most desirable. Vision-guided insertion techniques are ideal and should be the way forward. This article recommends the use of third-generation vision-incorporated-video SGDs, which allow for direct visualization of the insertion process, corrective maneuvers, and, when necessary, insertion of a nasogastric tube (NGT) and/or endotracheal tube (ETT) intubation. A videoscope embedded within the SGD allows a visual check of the glottis opening and position of the epiglottis. This design affords the benefit of confirming and/or correcting a SGD's position in the midline and rotation in the sagittal plane. The first clinically available video laryngeal mask airways (VLMAs) and multiple prototypes are being tested and used in anesthesia. Existing VLMAs are still not perfect, and further improvements are recommended. Additional modifications in multicamera technology, to obtain a panoramic view of the SGD sitting correctly in the hypopharynx and to prove that correct sizes have been used, are in the process of production. Ultimately, any device inserted orally-SGD, ETT, NGT, temperature probe, transesophageal scope, neural integrity monitor (NIM) tubes-could benefit from correct vision-guided positioning. VLMAs also allow for automatic recording, which can be documented in clinical records of patients, and could be valuable during teaching and research, with potential value in case of legal defence (with an airway incident). If difficulties occur with the airway, documentation in the patient's file may help future anesthesiologists to better understand the real-time problems. Both manufacturers and designers of SGDs may learn from optimally positioned SGDs to improve the design of these airway devices.

Features of new vision-incorporated third-generation video laryngeal mask airways.

Numerous studies have shown that blindly inserted supraglottic airway devices (SADs) are sub-optimally placed in 50 to 80% of all cases. Placement under direct vision has been recommended. We describe the very first two new SADs of the third generation that incorporate a videoscope with flexible tip. Both devices are made up of two interlocking components-the SAD and a videoscope. The 3rd generation, direct vision SADs allow vision-guided insertion, corrective manoeuvres, if needed, and correct placement in the hypopharynx and possess additional features which permit insertion of a gastric tube and endotracheal intubation should the need arise. This article describes the two new devices' physical characteristics, features, rationale for use, advantages and limitations in comparison to existing devices. Each of the two new devices-the Video Laryngeal Mask (VLMTM, UE Medical®) and the SafeLM® Video Laryngeal Mask System (SafeLMTM VLMS, Magill Medical Technology®) consist of two parts: (a) a disposable 2nd generation SAD with a silicone cuff and an anatomically curved tube; and (b) a reusable patient-isolated videoscope and monitoring screen, with the flexible scope located into a specially-designed, blind-end channel terminating in the bowl of the SAD, preventing the videoscope from contacting patient body fluids in the SAD bowl. Third generation placement-under-direct-vision supraglottic airway devices possess several theoretical safety and ease of use advantages which now need to be validated in clinical use.

Effects of Ketamine and Lidocaine Infusion on Acute Pain after Elective Open Abdominal Surgery, a Randomized, Double-Blinded Study.

Background: Most patients suffer from moderate to severe pain after elective laparotomy. They often require opioids to alleviate their pain. Opiates invariably induce certain side effects and, occasionally, dependence. Intraoperative infusion of lidocaine and low-dose ketamine reduces postoperative pain and analgesic requirements. This study aims to evaluate the effects of simultaneous infusion of lidocaine and ketamine during open abdominal surgery on the postoperative pain severity and analgesic consumption. Methods: In this randomized, double-blinded, single-center study that was performed in Iran, 80 patients scheduled for elective open abdominal surgery under general anesthesia were enrolled in two LK and P groups. Group LK (n=40) received lidocaine-ketamine infusion, and group P (n=40) received placebo (normal saline). Both infusions were started thirty minutes after initiation of surgery and were terminated once the surgery was completed. For postoperative pain management, patient-controlled analgesia (PCA), including fentanyl and paracetamol, was administered for both groups. All patients were evaluated for pain visual analogue scale (VAS) and total adjunctive analgesic (diclofenac suppository) consumption within the first 24 hours after the surgery. The data were analyzed using SPSS. P values <0.05 were considered significant. Results: Intraoperative infusion of Lidocaine and Ketamine resulted in desirable postoperative pain control. Patients of LK group demonstrated a significant reduction in the pain score at 1, 6, 12, 18, and 24 hours after termination of surgery (p<0.001). It also resulted in a decreased requirement for postoperative analgesics, as cumulative analgesic consumption was decreased meaningfully in the patients of LK group (p<0.001). Conclusion: Intravenous infusion of lidocaine and ketamine during elective open abdominal surgery reduces pain intensity and analgesic requirements in the first 24 hours postoperatively, without major additional side effects.

The case for a 3rd generation supraglottic airway device facilitating direct vision placement.

Although 1st and 2nd generation supraglottic airway devices (SADs) have many desirable features, they are nevertheless inserted in a similar 'blind' way as their 1st generation predecessors. Clinicians mostly still rely entirely on subjective indirect assessments to estimate correct placement which supposedly ensures a tight seal. Malpositioning and potential airway compromise occurs in more than half of placements. Vision-guided insertion can improve placement. In this article we propose the development of a 3rd generation supraglottic airway device, equipped with cameras and fiberoptic illumination, to visualise insertion of the device, enable immediate manoeuvres to optimise SAD position, verify whether correct 1st and 2nd seals are achieved and check whether size selected is appropriate. We do not provide technical details of such a '3rd generation' device, but rather present a theoretical analysis of its desirable properties, which are essential to overcome the remaining limitations of current 1st and 2nd generation devices. We also recommend that this further milestone improvement, i.e. ability to place the SAD accurately under direct vision, be eligible for the moniker '3rd generation'. Blind insertion of SADs should become the exception and we anticipate, as in other domains such as central venous cannulation and nerve block insertions, vision-guided placement becoming the gold standard.

A novel method of intubation and orogastric tube insertion using a C-MAC-D-blade videolaryngoscope-bougie technique.

INTRODUCTION: Expertise in airway management is a fundamental aspect of anesthesia practice. Fortunately 'can't intubate, can't ventilate' scenarios are extremely rare. In particular, patients with tumors on the right side of the oropharynx and larynx can be very problematic to intubate. METHODS: We present an alternative intubation technique, whereby a C-MAC D-blade videolaryngoscope is loaded with a Frova catheter in the narrow, curving channel within the blade's infero-posterior aspect on the left side of the blade. This technique can be a successful alternative in patients with difficult airways. RESULTS: The proposed technique was successfully demonstrated in a case whereby a 47-year old male with premetrics of a difficult airway, presented with a large mass in the right supraglottis and hypopharynx with through-and-through thyroid cartilage infiltration, obstructing completely the view of the glottis with direct laryngoscopy. The referral hospital considered the patient unintubatable and sent the patient to our academic center for treatment. Endotracheal intubation with the new technique was successful at the first attempt. CONCLUSIONS: The C-MAC D-Blade videolaryngoscope-bougie technique provides an alternative method to intubate patients with difficult airways, even in exceptional situations such as in patients with a large right-sided oropharynx-larynx tumor.

Prevention and treatment of noncognitive complications.

Patients aged 65 and older are the fastest growing segment in the population of many countries. Based on evolving demographics showing increasing life expectancies, it is expected that there will be a concurrent rise in the demand for a large variety of surgical and anesthesia services. Surgery offers definitive management of many age-related diseases and provides symptom-relieving (morbidity) and life-extending (mortality) benefits. However, elderly adult surgical patients, especially the frail ones, often require a different level of care than younger patients during the perioperative period. As many have chronic illnesses and acquired deconditioning and functional decline, older patients are prone to develop untoward outcomes such as postoperative complications and loss of independence. This manuscript focuses on the holistic quality person-centered care, supported by a wide stakeholder team of health-care workers, ensuring fidelity to comprehensive geriatric assessment and optimization services where possible, offering a systematic approach to early health risk assessment and risk modification in the perioperative period, with the ultimate goal of reducing postoperative complications and health-care costs. The "comprehensive geriatric assessment and optimization" cost-effective approach builds on robust evidence with older people more likely to be alive, a shorter length of hospital stay due to fewer postoperative medical complications, and improved rates of return to usual residence. Prehabilitation programs are delivered focusing on primary (through counseling) and secondary prevention (through screening) with an aim to improve fitness for surgery, by evaluating functional capacity, nutritional and psychological health, prompting interventions, targeting physical exercise, lifestyle and nutritional advice, and psychological support.

Anesthesia and perioperative pain relief in the frail elderly patient.

Demand for anesthesia and analgesia for the frail elderly is continuously increasing as the likelihood of encountering very elderly, very vulnerable, and very compromised patients has, ever so subtly, increased over the last three decades. The anesthesiologist has, increasingly, been obliged to offer professional services to frail patients. Fortunately, there has been a dramatic improvement in medications, methods of drug delivery, critical monitoring, and anesthesia techniques. Specific methodologies peculiar to the frail are now taught and practiced across all anesthesia subspecialties. However, administering anesthesia for the frail elderly is vastly different to giving an anesthetic to the older patient. Frail patients are increasingly cared for in specialized units-geriatric intensive therapy units, post-acute care services, palliative, hospices, and supportive care and aged care facilities. Several medications (e.g., morphine-sparing analgesics) more suited to the frail have become universally available in most centers worldwide so that best-practice, evidence-based anesthesia combinations of drugs and techniques are now increasingly employed. Every anesthetic and pain management techniques in the frail elderly patient are going to be discussed in this review.

Recombinant activated factor VII in obstetric hemorrhage: experiences from the Australian and New Zealand Haemostasis Registry.

OBJECTIVE: Through the Australian and New Zealand Haemostasis Registry, we report on the Australian and New Zealand experience with recombinant activated factor VII (rFVIIa) in obstetric patients. METHODS: The role of rFVIIa for off-label indications, including trauma, cardiac surgery, and severe postpartum hemorrhage, remains controversial. The Haemostasis Registry established by Monash University in Melbourne, Australia monitors off-label use of rFVIIa across Australia and New Zealand. The purpose of this study was to summarize Registry data for all obstetric hemorrhage patients treated with rFVIIa at participating hospitals between January 2002 and July 2008. The primary outcome measures were reduction or cessation of bleeding (positive therapeutic response), mortality, and hysterectomy rate. RESULTS: During the study period, the Registry received data for 2128 patients. This included 110 cases of administration of rFVIIa in obstetric patients from 38 hospitals, comprising 5% of the total Registry population, 105 of whom were treated for acute hemorrhage. Women received median (interquartile range) individual doses of 92 microg/kg (73-100) of rFVIIa (median total dose 92 microg/kg [58-108]), and 78% of patients received a single dose. The positive response rate to rFVIIa was 76% with 64% responding to the first dose. Ninety-one percent of women were alive at 28 days. Forty-three women (41%) underwent hysterectomy before receiving rFVIIa and, of those remaining, 13 (21%) required hysterectomy after rFVIIa therapy. Two thromboembolic events (1 pulmonary embolism and 1 deep venous thrombosis) and 1 case of hypoxic-ischemic encephalopathy resulting from severe anoxia were reported. CONCLUSIONS: The reported effect of rFVIIa in many, but not all, obstetric cases was positive. There was no mortality as a result of thromboembolic complications. Randomized, controlled trials are required to confirm its safety and efficacy and to assess the possibility that use at an earlier stage in treatment of severe postpartum hemorrhage may avoid the need to resort to postpartum hysterectomy for control of bleeding, thus preserving fertility.

Guidelines for the management of hypertensive disorders of pregnancy 2008.

This is the Executive Summary of updated guidelines developed by the Society of Obstetric Medicine of Australia and New Zealand for the management of hypertensive diseases of pregnancy. They address a number of challenging areas including the definition of severe hypertension, the use of automated blood pressure monitors, the definition of non-proteinuric pre-eclampsia and measuring proteinuria. Controversial management issues are addressed such as the treatment of severe hypertension and other significant manifestations of pre-eclampsia, the role of expectant management in pre-eclampsia remote from term, thromboprophylaxis, appropriate fluid therapy, the role of prophylactic magnesium sulfate and anaesthetic issues for women with pre-eclampsia. The guidelines stress the need for experienced team management for women with pre-eclampsia and mandatory hospital protocols for treatment of hypertension and eclampsia. New areas addressed in the guidelines include recommended protocols for maternal and fetal investigation of women with hypertension, preconception management for women at risk of pre-eclampsia, auditing outcomes in women with hypertensive diseases of pregnancy and long-term screening for women with previous pre-eclampsia.

Electron Microscopy of Dural and Arachnoid Disruptions After Subarachnoid Block.

BACKGROUND: It has been customary to attribute postdural puncture headache (PDPH) incidence and severity to size and nature of the dural hole produced during major neuraxial blockade or diagnostic dural puncture. Needle orientation in relation to the direction of dural fibers was thought to be of importance because of the propensity for horizontal bevel placement to cause cutting rather than splitting of the dural fibers. METHODS: In vitro punctures of stringently quality-controlled human dural sac specimens were obtained with 27-gauge (27G) Whitacre needle (n = 33), with 29G Quincke used parallel to the spinal axis (n = 30), and with 29G Quincke in perpendicular approach (n = 40). The samples were studied with a scanning electron microscope, and the perimeter, appearance, and area (%) of the lesion were calculated. RESULTS: When using small 27G to 29G needles, neither needle tip characteristics nor needle orientation had a substantial bearing on the damage to dural fibers in the dural lesion. Of ultimate importance was the characteristic and size of the hole in the arachnoid. Arachnoid layer lesions produced by different types of spinal needles were not markedly different. CONCLUSIONS: Accepted theories of the etiology of PDPH need to be revised. This article marks the first time that arachnoid layer damage has been quantified. Dural fibers tend to have sufficient "memory" to close back the hole created by a spinal needle, whereas arachnoid has diminished capacity to do so. The pathogenesis of PDPH and its resolution algorithm are a far more complex process that involves many more "stages" of development than hitherto imagined.

Cervical decompression and unexpected soft tissue oedema: case report.

ABSTRACT: Acute upper airway obstruction (UAO) is a life threatening complication that is well recognized after carotid endarterectomy, thyroidectomy and pharyngeal area intervention. It is not widely acknowledged that airway obstruction can occur after cervical spinal fusion surgery which was first described in 1955. There are a number of common postoperative problems which may become apparent in the short to medium term. These include: sore throat, dysphagia, hoarseness, dysphonia, recurrent laryngeal nerve palsy and soft tissue swelling.

Guidelines for the use of recombinant activated factor VII in massive obstetric haemorrhage.

Recombinant activated factor VII (rFVIIa) is emerging as a novel therapy for the treatment of life or fertility-threatening post-partum haemorrhage (PPH) unresponsive to standard therapy that in some cases may prevent the need for peripartum hysterectomy. The level of evidence to date for use of rFVIIa in PPH is limited to case reports and case series with one nonrandomised study. No high-quality randomised controlled trials have been published at this stage, precluding a quality systematic review. Guidelines have been published for the use of rFVIIa in non-obstetric haemorrhage, though to date none are available for PPH. A multidisciplinary group of Australian and New Zealand clinicians from the fields of obstetrics, anaesthesia and haematology, who have both clinical experience in and/or knowledge of rFVIIa was convened by the manufacturer. This group produced an opinion and guideline based on their experience and the published international literature on the use of rFVIIa. This is intended to be used as a guideline and algorithm for the use of rFVIIa, though any use should be tailored to local practice and resources.

Pregnancy, delivery and the intensive care unit: need, outcome and management.

PURPOSE OF REVIEW: Increasing numbers of sick pregnant and peripartum women are cared for in the intensive care unit. This review looks at the current mortality, the disease severity of admitted patients and the current need for intensive care unit and high dependency unit beds to cater for these women. It also looks at some recent advances in the treatment of some specific disease entities encountered in the intensive care unit in pregnant women and parturients which have been covered in the 2001-2002 literature. RECENT FINDINGS: There has been a substantial fall in intensive care unit mortality in the last decade and there is a definite place for these women in intensive care unit. They represent a subgroup of severely ill patients with a need for intensive treatment and monitoring and who are worth the investment in time and money because they often recover from their acute illness to return to full productivity. SUMMARY: The high dependency unit and intensive care unit and their role in the service to the pregnant woman and parturient are the main focus of this review which looks at the last 2 years' literature to determine the critical care services' worth and efficacy. In almost all countries, even in the smaller regional hospitals, the intensive care units and high dependency units have reduced maternal mortality and morbidity. The neonatal high dependency units have done much the same for the newborn but the neonatal literature is not reviewed for the purposes of this symposium.