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Jia Y, Zhang Y, Wang Z, Pan W, Fu H, Du W. Influence of endotracheal tube and laryngeal mask airway for general anesthesia on perioperative adverse events in patients undergoing laparoscopic hysterectomy: A propensity score-matched analysis. JOURNAL OF RESEARCH IN MEDICAL SCIENCES : THE OFFICIAL JOURNAL OF ISFAHAN UNIVERSITY OF MEDICAL SCIENCES 2024; 28:88. [PMID: 38510782 PMCID: PMC10953732 DOI: 10.4103/jrms.jrms_384_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Revised: 04/17/2023] [Accepted: 10/05/2023] [Indexed: 03/22/2024]
Abstract
Background To compare perioperative adverse events between general anesthesia with endotracheal tube (ETT) and general anesthesia with laryngeal mask airway (LMA) in patients undergoing laparoscopic hysterectomy. Materials and Methods This was a large sample retrospective, propensity score-matched (PSM) study. We collected the data of 6739 female patients who underwent laparoscopic hysterectomy between January 2016 and June 2021 in our hospital, China. Patients were divided into two groups (ETT group and LMA group) according to different airway management modes. Data on all perioperative adverse events were collected. PSM analysis was performed to control confounding factors and differences in baseline values between the two groups. Finally, 4150 female patients were recruited after PSM. Results The total number of patients taking intraoperative vasoactive drugs during surgery was higher in the ETT group than in the LMA group (P = 0.04). The LMA group had a higher incidence of vomiting (51 [2.46%]) and somnolence (165 [7.95]) in the postanesthesia care unit (PACU) than the ETT group (71 [3.42%] and 102 [4.92%], respectively) (P = 0.02 and P < 0.001). Hypothermia was significantly higher in the LMA group (183 [10.36%]) than in the ETT group (173 [8.34%]) in the PACU (P = 0.03). The number of patients with sore throat was significantly higher in the ETT group (434 [20.02%]) than in the LMA group (299 [14.41%]) in the ward (P < 0.001). Other variables such as hypoxemia, moderate to severe pain, abdominal distension, diarrhea, sleep disorders, wound bleeding, and skin itch were not significantly different between the two groups (P > 0.05). Conclusion The ETT group had more incidences of vomiting, sore throat, and cough complications and needed more drug treatment than the LMA group. LMA is a better airway management mode and LMA general anesthesia can be safely used in patients undergoing laparoscopic nonemergency hysterectomy.
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Affiliation(s)
- Yanan Jia
- Department of Anesthesiology, Rehabilitation Medicine Center, Zhejiang Provincial People’s Hospital, Affiliated People’s Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Yu Zhang
- Department of Anesthesiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Zihan Wang
- Department of Anesthesiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Wei Pan
- Department of Anesthesiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Haifeng Fu
- Department of Anesthesiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
| | - Wenwen Du
- Department of Anesthesiology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China
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2
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Deng W, Nestor CC, Leung KMM, Chew J, Wang H, Wang S, Irwin MG. Aerosol generation with the use of positive pressure ventilation via supraglottic airway devices: an observational study. Anaesthesia 2023. [PMID: 37381615 DOI: 10.1111/anae.16078] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/08/2023] [Indexed: 06/30/2023]
Abstract
The amount of aerosol generation associated with the use of positive pressure ventilation via a supraglottic airway device has not been quantified. We conducted a two-group, two-centre, prospective cohort study in which we recruited 21 low-risk adult patients scheduled for elective surgery under general anaesthesia with second-generation supraglottic airway devices. An optical particle sizer and an isokinetic sampling probe were used to record particle concentrations per second at different size distributions (0.3-10 μm) during use as well as baseline levels during two common activities (conversation and coughing). There was a median (IQR [range]) peak increase of 2.8 (1.5-4.5 [1-28.1]) and 4.1 (2.0-7.1 [1-18.2]) times background concentrations during SAD insertion and removal. Most of the particles generated during supraglottic airway insertion (85.0%) and removal (85.3%) were < 3 μm diameter. Median (IQR [range]) aerosol concentration generated by insertion (1.1 (0.6-5.1 [0.2-22.3]) particles.cm-3 ) and removal (2.1 (0.5-3.0 [0.1-18.9]) particles.cm-3 ) of SADs were significantly lower than those produced during continuous talking (44.5 (28.3-70.5 [2.0-134.5]) particles.cm-3 ) and coughing (141.0 (98.3-202.8 [4.0-296.5]) particles.cm-3 ) (p < 0.001). The aerosol levels produced were similar with the two devices. The proportion of easily inhaled and small particles (<1 μm) produced during insertion (57.5%) and removal (57.5%) was much lower than during talking (99.1%) and coughing (99.6%). These results suggest that the use of supraglottic airway devices in low-risk patients, even with positive pressure ventilation, generates fewer aerosols than speaking and coughing in awake patients.
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Affiliation(s)
- W Deng
- Department of Mechanical Engineering, City University of Hong Kong, Hong Kong Special Administrative Region, China
| | - C C Nestor
- Department of Anaesthesiology, University of Hong Kong, Queen Mary Hospital, Hong Kong Special Administrative Region, China
| | - K M M Leung
- Department of Anaesthesiology, University of Hong Kong, Queen Mary Hospital, Hong Kong Special Administrative Region, China
| | - J Chew
- Department of Anaesthesiology, University of Hong Kong, Queen Mary Hospital, Hong Kong Special Administrative Region, China
| | - H Wang
- Department of Mechanical Engineering, City University of Hong Kong, Hong Kong Special Administrative Region, China
| | - S Wang
- Department of Mechanical Engineering, City University of Hong Kong, Hong Kong Special Administrative Region, China
| | - M G Irwin
- Department of Anaesthesiology, University of Hong Kong, Queen Mary Hospital, Hong Kong Special Administrative Region, China
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Muacevic A, Adler JR, Das I, Basumatary J, Mahanta P. To Compare the Intravenous Bolus Dose of Propofol With an Equipotent Dose of Intravenous Thiopentone for the Facilitation of Laryngeal Mask Airway Insertion. Cureus 2022; 14:e31917. [PMID: 36579208 PMCID: PMC9792267 DOI: 10.7759/cureus.31917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/26/2022] [Indexed: 11/28/2022] Open
Abstract
Objectives Insertion of laryngeal mask airway has been facilitated by using a variety of induction agents and their combinations with minimal side effects. The current prospective study is a randomized, double-blind study conducted using induction agents, namely, propofol and its equipotent dose of thiopentone, for laryngeal mask airway insertion, and to compare their side effects in patients undergoing minor surgeries requiring general anaesthesia. Methods This prospective study was carried out at the Anaesthesiology and Critical Care Department of Gauhati Medical College and Hospital (GMCH), Assam, India. The randomized, double-blinded study comprised 80 patients aged 18 to 60 years undergoing minor surgeries (≤45 minutes) under general anaesthesia fitting into the American Society of Anesthesiologists (ASA) physical status I and II and Mallampati score (MPS) 1 and 2. The participants were randomly divided into two groups in a 1:1 ratio. Group A (n = 40) received propofol (2.5 mg/kg), while group B (n = 40) received thiopentone (5 mg/kg) injections for induction of anaesthesia. Pre-medication with midazolam (0.04 mg/kg) injection and fentanyl (1.5 mcg/kg) injection was provided to patients in both groups. Post-laryngeal mask airway insertion, parameters like conditions for insertion, time taken for laryngeal mask airway insertion, overall response, and haemodynamic parameters were recorded. The data analysis was executed using equivalence tests considering a two-sided p < 0.05 as significant. Results Group A had a higher and statistically significant ease of insertion (p = 0.029). The mean insertion time was notably different between the two groups (p < 0.001). The difference in the overall response to insertion showed no statistical significance in the two groups. Statistically, a significant difference was found in falls in heart rate and various blood pressure levels between the groups (p < 0.001). Conclusion Propofol at a rate of 2.5 mg/kg was found to be superior to thiopentone at a rate of 5 mg/kg as far as suppression of upper airway reflexes in laryngeal mask airway insertion.
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YENİAY D, ÇEKİÇ B. Comparison of the ProSeal laryngeal mask airway and endotracheal tube in septorhinoplasty surgery. CUKUROVA MEDICAL JOURNAL 2021. [DOI: 10.17826/cumj.978120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
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Kim YU, Cho BH, Cho HR. Comparison of Intracuff Pressure and Postoperative Sore Throat Following Use of Laryngeal Mask Airway Protector With or Without Nitrous Oxide Anesthesia. J Perianesth Nurs 2021; 36:247-252. [PMID: 33648860 DOI: 10.1016/j.jopan.2020.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Revised: 10/12/2020] [Accepted: 10/17/2020] [Indexed: 11/17/2022]
Abstract
PURPOSE In general anesthesia, the laryngeal mask airway (LMA) is a frequently used effective option. The effect of nitrous oxide on intracuff pressure of the LMA and postoperative sore throat is well known; however, there are no studies related to the second-generation LMA Protector. The purpose of this study was to determine the differences in intracuff pressure and postoperative sore throat, depending on the use of nitrous oxide during general anesthesia using the LMA Protector. DESIGN This randomized double-blind prospective study was conducted among 88 patients aged 20 to 70 years. METHODS The cuff pressure started with a baseline of 40 cm H2O and was measured using a digital cuff pressure manometer for 30 minutes. Postoperative sore throat, dysphonia, dysphagia, and numeric rating scale scores were also recorded. FINDINGS Over time, the intracuff pressure of the nitrous oxide group increased significantly compared with that of the air group. Furthermore, postoperative sore throat and pharyngolaryngeal complications were not significantly different between the two groups. CONCLUSIONS Intracuff pressure of the LMA Protector increased during anesthesia using nitrous oxide. When the anesthesia time was less than 2 hours, however, there was no difference in postoperative sore throat.
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Affiliation(s)
- Young Uk Kim
- Department of Anesthesiology and Pain Medicine, Catholic Kwandong University, College of Medicine, International ST. Mary`s Hospital, Incheon, Republic of Korea
| | - Byong Hyon Cho
- Department of Anesthesiology and Pain Medine, Myongji Hospital, Hanyang University College of Medicine, Goyang, Republic of Korea
| | - Hyung Rae Cho
- Department of Anesthesiology and Pain Medine, Myongji Hospital, Hanyang University College of Medicine, Goyang, Republic of Korea.
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Kim D, Park S, Kim JM, Choi GS, Kim GS. Second generation laryngeal mask airway during laparoscopic living liver donor hepatectomy: a randomized controlled trial. Sci Rep 2021; 11:3532. [PMID: 33574495 PMCID: PMC7878811 DOI: 10.1038/s41598-021-83173-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 01/18/2021] [Indexed: 11/20/2022] Open
Abstract
The second-generation laryngeal mask airway (LMA) provides a higher sealing pressure than classical LMA and can insert the gastric drainage tube. We investigated the difference in respiratory variables according to the use of second-generation LMA and endotracheal tube (ETT) in laparoscopic living liver donor hepatectomy (LLDH). In this single-blind randomized controlled trial, intraoperative arterial carbon dioxide partial pressure at 2 h after the airway devices insertion (PaCO2_2h) was compared as a primary outcome. Participants were randomly assigned to the following groups: Group LMA (n = 45, used Protector LMA), or Group ETT (n = 43, used cuffed ETT). Intraoperative hemodynamic and respiratory variables including mean blood pressure (MBP), heart rate (HR), and peak inspiratory pressure (PIP) were compared. Postoperative sore throat, hoarseness, postoperative nausea and vomiting (PONV), and pulmonary aspiration were recorded. The PaCO2_2h were equally effective between two groups (mean difference: 0.99 mmHg, P = 0.003; 90% confidence limits: − 0.22, 2.19). The intraoperative change in MBP, HR, and PIP were differed over time between two groups (P < 0.001, P = 0.015, and P = 0.039, respectively). There were no differences of the incidence of postoperative complications at 24 h following LLDH (sore throat and hoarseness: P > 0.99, PONV: P > 0.99, and P = 0.65, respectively). No case showed pulmonary aspiration in both groups. Compared with endotracheal tube, second-generation LMA is equally efficient during LLDH. The second-generation LMA can be considered as the effective airway devices for securing airway in patients undergoing prolonged laparoscopic surgery.
Trial Registration This study was registered at the Clinical Trial Registry of Korea (https://cris.nih.go.kr. CRiS No. KCT0003711).
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Affiliation(s)
- Doyeon Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
| | - Sukhee Park
- Department of Anesthesiology and Pain Medicine, International St. Mary's Hospital, Catholic Kwandong University School of Medicine, Incheon, Republic of Korea
| | - Jong Man Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Gyu Seong Choi
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Gaab Soo Kim
- Department of Anesthesiology and Pain Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea.
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Hunter JM, Aziz MF. Supraglottic airway versus tracheal intubation and the risk of postoperative pulmonary complications. Br J Anaesth 2021; 126:571-574. [PMID: 33419528 DOI: 10.1016/j.bja.2020.12.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Revised: 12/06/2020] [Accepted: 12/09/2020] [Indexed: 12/12/2022] Open
Affiliation(s)
- Jennifer M Hunter
- Department of Ageing and Chronic Disease, University of Liverpool, Liverpool, UK.
| | - Michael F Aziz
- Department of Anesthesiology & Perioperative Medicine, Oregon Health & Science University, Portland, OR, USA
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Wang X, Huang K, Yan H, Lan F, Yao D, Li Y, Xue J, Wang T. The median effective dose (ED50) of cis-Atracurium for laryngeal mask airway insertion during general Anaesthesia for patients undergoing urinary surgery. BMC Anesthesiol 2020; 20:68. [PMID: 32192431 PMCID: PMC7081559 DOI: 10.1186/s12871-020-00982-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Accepted: 03/09/2020] [Indexed: 12/18/2022] Open
Abstract
Background In clinical practice, the laryngeal mask airway is an easy-to-use supraglottic airway device. However, the cis-atracurium dosage for laryngeal mask insertion has not been standardised. We aimed to determine the optimal dose of cis-atracurium using a sequential method for successful laryngeal mask insertion. Methods The cohort study protocol is registered at clinicaltrial.gov (NCT-03668262). Twenty-three patients undergoing elective urinary surgery were sequentially administered cis-atracurium doses as follows: 150, 100, 70, 50, 30, and 20 μg·kg− 1. The main outcome involved the determination of the response to laryngeal mask airway insertion: ≥16 points and < 16 points indicated “satisfactory” and “unsatisfactory” responses, respectively. The median effective dose was estimated using the mean of the seven crossovers from “satisfactory” and “unsatisfactory” responses. The primary outcome involved the determination of the median effective dose (ED50) of cis-atracurium for laryngeal mask airway insertion. Results The median effective dose of cis-atracurium was 26.5 μg·kg− 1 (95% CI 23.6–29.8) using the sequential method. Heart rate was decreased in the 50 μg·kg− 1 group compared to that in the 30 μg·kg− 1 group at timepoints T7, T8, and T10 (P = 0.0482, P = 0.0460, and P = 0.0236, respectively), but no difference was observed in the 20 μg·kg− 1 group. Systolic blood pressure was decreased in the 50 μg·kg− 1 group compared to that in the 20 μg·kg− 1 group at timepoints T2, T3, and T4 (P = 0.0159, P = 0.0233, and P = 0.0428, respectively). The train-of-four value was significantly lower in the 50 μg·kg− 1 group than in the 30 μg·kg− 1 group at timepoint T3 (P = 0.0326). Conclusions The ED50 of cis-atracurium was 26.5 μg·kg− 1 for laryngeal mask airway insertion. Trial registration Clinicaltrial.gov Registry, NCT03668262, Registered on 11 September 2018.
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Affiliation(s)
- Xiaohua Wang
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China. .,Institute of Geriatrics, Beijing, 100053, China. .,National Clinical Research Center for Geriatric Disorders, Beijing, 100053, China.
| | - Ke Huang
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China.,Institute of Geriatrics, Beijing, 100053, China.,National Clinical Research Center for Geriatric Disorders, Beijing, 100053, China
| | - Hao Yan
- Department of Urinary surgery, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China
| | - Fei Lan
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China.,Institute of Geriatrics, Beijing, 100053, China.,National Clinical Research Center for Geriatric Disorders, Beijing, 100053, China
| | - Dongxu Yao
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China.,Institute of Geriatrics, Beijing, 100053, China.,National Clinical Research Center for Geriatric Disorders, Beijing, 100053, China
| | - Yanhong Li
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China.,Institute of Geriatrics, Beijing, 100053, China.,National Clinical Research Center for Geriatric Disorders, Beijing, 100053, China
| | - Jixiu Xue
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China.,Institute of Geriatrics, Beijing, 100053, China.,National Clinical Research Center for Geriatric Disorders, Beijing, 100053, China
| | - Tianlong Wang
- Department of Anesthesiology, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China. .,Institute of Geriatrics, Beijing, 100053, China. .,National Clinical Research Center for Geriatric Disorders, Beijing, 100053, China.
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Kang SH, Park M. Comparison of early postoperative recovery between laryngeal mask airway and endotracheal tube in laparoscopic cholecystectomy: A randomized trial. Medicine (Baltimore) 2019; 98:e16022. [PMID: 31232934 PMCID: PMC6636935 DOI: 10.1097/md.0000000000016022] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Laryngeal mask airway (LMA) insertion provokes fewer stress responses than endotracheal intubation. This study aimed to evaluate the LMA Protector for assessing improvements in intraoperative hemodynamic stability and to reduce postoperative discomfort compared with endotracheal intubation in laparoscopic cholecystectomy. METHODS Fifty-six patients who underwent laparoscopic cholecystectomy while under sevoflurane-based general anesthesia were randomly allocated to airway management using LMA (LMA group) or endotracheal tube (ETT group). Heart rate, blood pressure, and peak airway pressure were recorded before and after carboperitoneum. Postoperative pain and analgesic requirements were assessed, in addition to nausea, hoarseness, dysphonia, and sore throat during the first 1 hour postoperatively and until postoperative day 1. RESULTS All patients underwent successful LMA or ETT placement within 2 attempts. There was no difference in highest mean (SD) peak airway pressure during carboperitoneum between the LMA and ETT groups (17.7 [2.8] mm Hg vs 19.1 [3.8] mm Hg, P = .159, respectively). The incidence of high systolic blood pressure and bradycardia was higher in the LMA group. The highest pain scores 1 hour postoperatively and on postoperative day 1 were lower in the LMA group than in the ETT group (3.9 [2.0] vs 5.4 [2.3], P = .017 and 5.6 [1.9] vs 6.7 [1.7], P = .042, respectively); requirements for analgesics were similar in the 2 groups. The incidence of nausea was lower in the LMA group than in the ETT group until postoperative day 1 (4/28 [14%] vs 12/28 [43%], P = .031, respectively). CONCLUSION The LMA Protector was an effective ventilator device associated with fewer intraoperative hemodynamic stress responses and improved the quality of early recovery after laparoscopic cholecystectomy.
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Calevo MG, Veronese N, Cavallin F, Paola C, Micaglio M, Trevisanuto D. Supraglottic airway devices for surfactant treatment: systematic review and meta-analysis. J Perinatol 2019; 39:173-183. [PMID: 30518796 DOI: 10.1038/s41372-018-0281-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Revised: 09/26/2018] [Accepted: 10/24/2018] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To compare surfactant administration via supraglottic airway device (SAD) vs. nasal CPAP alone or INSURE. STUDY DESIGN A systematic search of PubMed, EMBASE, SCOPUS, Cochrane Central Register of Controlled Trials and Clinicaltrials.gov was performed. Articles meeting inclusion criteria (RCT, surfactant administration via SAD, laryngeal mask, I-gel) were assessed RESULTS: Five RCTs were eligible. Surfactant administration via SAD reduced the need for intubation/mechanical ventilation (RR 0.57, 95%CI 0.38-0.85) and short-term oxygen requirements (MD -8.00, 95%CI -11.09 to -4.91) compared to nCPAP alone. Surfactant administration via SAD reduced the need for intubation/mechanical ventilation (RR 0.43, 95%CI 0.31-0.61), but increased short-term oxygen requirements (MD 3.10, 95%CI 0.51-5.69) compared to INSURE approach. CONCLUSIONS In preterm infants with RDS, surfactant administration via SAD reduces the need for intubation/mechanical ventilation. Overall, available literature includes few, small, poor-quality studies. Surfactant administration via SAD should be limited to clinical trials.
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Affiliation(s)
- Maria Grazia Calevo
- Epidemiology, Biostatistics and Committees Unit, Istituto Giannina Gaslini, Genoa, Italy
| | - Nicola Veronese
- National Research Council, Neuroscience Institute, Aging Branch, Padua, Italy
| | | | | | - Massimo Micaglio
- Department of Anesthesia and Intensive Care, Careggi University Hospital, Florence, Italy
| | - Daniele Trevisanuto
- Department of Woman's and Child's Health, University of Padova, Padova, Italy.
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Griffiths JD, Nguyen M, Lau H, Grant S, Williams DL. A Prospective Randomised Comparison of the LMA ProSeal™ versus Endotracheal tube on the Severity of Postoperative Pain following Gynaecological Laparoscopy. Anaesth Intensive Care 2019; 41:46-50. [DOI: 10.1177/0310057x1304100109] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- J. D. Griffiths
- Department of Anaesthesia, Royal Women's Hospital, Melbourne, Victoria, Australia
| | - M. Nguyen
- Department of Anaesthesia, Royal Women's Hospital, Melbourne, Victoria, Australia
| | - H. Lau
- Department of Anaesthesia, Royal Women's Hospital, Melbourne, Victoria, Australia
- Medical Student, University of Melbourne
| | - S. Grant
- Department of Anaesthesia, Royal Women's Hospital, Melbourne, Victoria, Australia
| | - D. L. Williams
- Department of Anaesthesia, Royal Women's Hospital, Melbourne, Victoria, Australia
- Department of Anaesthesia and Pain Management, Royal Melbourne Hospital
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Hegde HV, Bandi J, Mudakanagoudar MS, Honnannavar KA. Evaluation of performance of Streamlined Liner of the Pharynx Airway™, Laryngeal Mask Airway-ProSeal and endotracheal tube in prone position: A prospective, randomised study. Indian J Anaesth 2018; 62:173-181. [PMID: 29643550 PMCID: PMC5881318 DOI: 10.4103/ija.ija_691_17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background and Aims: Airway used in prone position should be efficacious and safe. The Streamlined Liner of the Pharynx Airway (SLIPA™) and Laryngeal Mask Airway-ProSeal (PLMA) provide better airway seal and protection against aspiration. We planned to evaluate the performance of SLIPA™, PLMA and endotracheal tube (ETT) in prone position. Methods: 114 adult patients undergoing elective surgery in prone position under general anaesthesia were randomised into Group-T (ETT), Group-S (SLIPA™) and Group-P (PLMA). Airways were inserted in supine position and patients turned prone subsequently. Airway characteristics, ventilatory parameters and complications were noted. One-way analysis of variance, Mann–Whitney U-test and Chi-square or Fisher's exact test were used. Results: Tidal volumes, peak airway pressure and compliance were comparable at all times. Leak pressure was significantly higher (P < 0.001) in Group-T (mean leak pressure = 40 cmH2O) when compared to Group-S and Group-P at all the times of recording, and there was no significant difference between Group-S and Group-P. The number of patients requiring airway/neck manipulation in prone position was significantly higher (P < 0.001) in Group-S (19 [55.9%]) when the three groups were compared (none in Group-T) and in comparison with Group-P (5 [14.7%], P < 0.001). On airway removal, the incidence of complications and airway reaction was significantly higher in Group-T. Group-S had a significantly higher incidence of dysphagia at 2 h postoperatively. Conclusion: ETT was most efficacious. SLIPA™ and PLMA were efficacious, safe and less stimulating to the airway during removal. More patients required SLIPA™ airway/neck manipulation.
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Affiliation(s)
- Harihar Vishwanath Hegde
- Department of Anaesthesiology, SDM College of Medical Sciences and Hospital, Dharwad, Karnataka, India
| | - Joshiraj Bandi
- Department of Anaesthesiology, SDM College of Medical Sciences and Hospital, Dharwad, Karnataka, India
| | | | - Kiran A Honnannavar
- Department of Anaesthesiology, SDM College of Medical Sciences and Hospital, Dharwad, Karnataka, India
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Patil PC, Chikkapillappa MA, Pujara VS, Anandswamy TC, Parate LH, Bevinaguddaiah Y. ProSeal Laryngeal Mask Airway Placement: A Comparison of Blind versus Direct Laryngoscopic Insertion Techniques. Anesth Essays Res 2017; 11:380-384. [PMID: 28663626 PMCID: PMC5490140 DOI: 10.4103/0259-1162.206274] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background and Objectives: The laryngeal mask airway (LMA) ProSeal is most commonly used supraglottic airway device; it is routinely inserted by blind technique. Although blind insertion technique is most widely used, there are many techniques which are available such as priming the drain tube with a guiding instrument such as a suction catheter, a gum elastic bougie, a Flexi-Slip Stylet, direct laryngoscopy, and even a fiber-optic bronchoscope (FOB). The present study was undertaken to compare and assess the placement of LMA ProSeal using blind versus direct laryngoscopy techniques using FOB. Materials and Methods: A prospective randomized comparative study of 110 patients divided into two groups of 55 each as Group I (blind insertion) and Group II (direct laryngoscopic insertion) after satisfying the inclusion criteria. The anatomical position was assessed by flexible FOB and evaluated based on fiber-optic scoring system. Results: In the present study, demographic characteristics, vital parameters, Mallampati score, and Wilson's score were comparable in both the groups (P > 0.05). The fiber-optic score (FOS) 1 in Group II was 78.18% compared to 60% in Group I, but the difference was statistically not significant (P > 0.05). Furthermore, the mean FOS in Group II was slightly high (3.84 ± 0.87) compared to Group II (1.62 ± 0.87), but the difference was statistically not significant (P > 0.05). Further hemodynamic parameters (P > 0.05) and complications (P > 0.05) were comparable in both the groups. Conclusion: The LMA placement scoring was similar in both blind and direct laryngoscopic techniques. Blind insertion technique is a simpler, easier, and has stood the test of time.
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Affiliation(s)
| | | | | | | | - Leena Harshad Parate
- Department of Anaesthesia, M. S. Ramaiah Medical College, Bengaluru, Karnataka, India
| | - Yatish Bevinaguddaiah
- Department of Anaesthesia, M. S. Ramaiah Medical College, Bengaluru, Karnataka, India
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Gill RK, Tarat A, Pathak D, Dutta S. Comparative Study of Two Laryngeal Mask Airways: Proseal Laryngeal Mask Airway and Supreme Laryngeal Mask Airway in Anesthetized Paralyzed Adults Undergoing Elective Surgery. Anesth Essays Res 2017; 11:23-27. [PMID: 28298751 PMCID: PMC5341671 DOI: 10.4103/0259-1162.177184] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Context: Supraglottic airway devices can act as an alternative to endotracheal intubation in both normal and difficult airway. LMA Proseal (P-LMA) and LMA Supreme (S-LMA) alongwith acting as effective ventilating device, provide port for gastric drainage. Aim: The objective of this study was to compare the two devices for effective ventilation and complications. Setting and Design: A prospective, randomized, single-blinded study was conducted in a tertiary care teaching hospital. Methods: 100 patients of ASA grade I–II undergoing elective surgery under general anaesthesia were included after ethical committee clearance and written consent. Patients were randomly allocated size 4 P-LMA (Group P) or S-LMA (Group S) (50 patients in each group). Insertion attempt, insertion time, oropharyngeal leak pressure (OLP) and complications were compared. Results: There was no difference demographically. The first insertion attempts were successful in 92% with P-LMA and 96% with S-LMA. Insertion time was faster in S-LMA. The mean OLP was 24.04 cmH2O in Group P and 20.05 cmH2O in Group S. Complications were cough, mild blood staining. Conclusion: Both can act as an effective ventilatory devices. But where LMA Proseal provides a more effective glottic seal by having a greater OLP, single use LMA Supreme provides acceptable glottic seal with easier and faster insertion, therefore, it can be accepted as better alternative to LMA Proseal.
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Affiliation(s)
- Ravneet Kaur Gill
- Department of Anaesthesiology and Critical Care, Silchar Medical College, Silchar, Assam, India
| | - Abhijit Tarat
- Department of Anaesthesiology and Critical Care, Silchar Medical College, Silchar, Assam, India
| | - Debagopal Pathak
- Department of Anaesthesiology and Critical Care, Silchar Medical College, Silchar, Assam, India
| | - Suneeta Dutta
- Department of Anaesthesiology and Critical Care, Silchar Medical College, Silchar, Assam, India
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van Esch BF, Stegeman I, Smit AL. Comparison of laryngeal mask airway vs tracheal intubation: a systematic review on airway complications. J Clin Anesth 2016; 36:142-150. [PMID: 28183554 DOI: 10.1016/j.jclinane.2016.10.004] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Revised: 09/28/2016] [Accepted: 10/28/2016] [Indexed: 10/20/2022]
Abstract
To determine whether the laryngeal mask airway (LMA) has advantages over the tracheal tube (TT) in terms of incidence of cough, sore throat, laryngospasm, dysphagia, dysphonia, and blood staining. This is a systematic literature review performed at the Universtity Medical Center of Utrecht. The online databases PubMed, Embase, and the Cochrane Library were searched for relevant randomized controlled trials. Two independent reviewers selected relevant articles after title, abstract, and full text screening. Articles were assessed on risk of bias in accordance with the Cochrane risk of bias tool. Study results of the LMA and the TT were related to the method of selection of the device size and the method for cuff inflation. Of the 1718 unique articles, we included 19 studies which used the LMA Classic, the LMA Proseal, the Flexible Reinforced LMA, and the LMA Supreme compared with TT. After methodological inspection, data could not be pooled due to heterogeneity among the selected studies. Overall, no clear advantage of the LMA over the TT was found but the LMA Supreme was related to the lowest incidence of airway complications. In this review, no clear difference in incidence of postoperative airway complications could be demonstrated between LMA and TT. The LMA Supreme may reduce the incidence of airway complication in comparison to the TT but high quality randomized trials are recommended to further objectify if use of the LMA decreases the risk on postoperative airway complications.
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Affiliation(s)
| | - Inge Stegeman
- Department of Otorhinolaryngology, University Medical Center Utrecht, The Netherlands and Brain Center Rudolf Magnus, University Medical Center Utrecht, The Netherlands.
| | - Adriana L Smit
- Department of Otorhinolaryngology, University Medical Center Utrecht, The Netherlands and Brain Center Rudolf Magnus, University Medical Center Utrecht, The Netherlands.
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Park SK, Ko G, Choi GJ, Ahn EJ, Kang H. Comparison between supraglottic airway devices and endotracheal tubes in patients undergoing laparoscopic surgery: A systematic review and meta-analysis. Medicine (Baltimore) 2016; 95:e4598. [PMID: 27537593 PMCID: PMC5370819 DOI: 10.1097/md.0000000000004598] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Comparisons between the efficacies of supraglottic airway devices (SGAs) and endotracheal tubes (ETTs) in patients undergoing laparoscopic surgeries have yielded conflicting results. Therefore, in this meta-analysis, we compared the clinical performance and incidence of complications between SGAs and ETT intubation in laparoscopic surgery. METHODS A comprehensive search was conducted using MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials, and Google Scholar to identify randomized controlled trials that compared SGAs with ETTs in laparoscopic surgery. RESULTS In total, 1433 patients from 17 studies were included in the final analysis. SGAs and ETTs showed no difference in insertion success rate on the first attempt (relative risk [RR] 1.01, 95% confidence interval [CI] 0.99-1.03), insertion time (standardized mean difference 1.57, 95% CI -3.74 to 0.61), and oropharyngeal leak pressure (OLP) (mean difference -2.54, 95% CI -7.59 to 2.50). The incidence of desaturation (RR 3.65, 95% CI 1.39-9.62), gastric insufflations (RR 0.90, 95% CI 0.48-1.71), regurgitation (RR 0.98, 95% CI 0.02-49.13), and aspiration (RR 0.99, 95% CI 0.01-78.4) also showed no intergroup differences. However, the incidence of laryngospasm (RR 3.12, 95% CI 1.29-7.52), cough at removal (RR 6.68, 95% CI 4.70-9.48), dysphagia (RR 1.47, 95% CI 1.12-1.95) or dysphonia (RR 4.41, 95% CI 1.25-15.55), sore throat (RR 1.60, 95% CI 1.33-1.93), and hoarseness (RR 1.53, 95% CI 1.29-1.81) was higher in the ETT group than in the SGA group. CONCLUSIONS The incidence of laryngospasm, cough at removal, dysphagia or dysphonia, sore throat, and hoarseness were higher in the ETT group than in the SGA group. However, the groups showed no differences in the rate of insertion success on the first attempt, insertion time, OLP, and other complications. Therefore, SGAs might be clinically more useful as effective airways in laparoscopic surgery.
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Affiliation(s)
- Sun Kyung Park
- Department of Anesthesiology and Pain Medicine, College of Medicine
| | - Geum Ko
- Medical Course, Jeju National University School of Medicine, Jeju National University, Jeju
| | - Geun Joo Choi
- Department of Anesthesiology and Pain Medicine, Chung-Ang University College of Medicine
| | - Eun Jin Ahn
- Department of Anesthesiology and Pain Medicine, Inje University Seoul Paik Hospital, Seoul, Korea
| | - Hyun Kang
- Department of Anesthesiology and Pain Medicine, Chung-Ang University College of Medicine
- Correspondence: Hyun Kang, Associate Professor, Department of Anesthesiology and Pain Medicine, Chung-Ang University College of Medicine, 84 Heukseok-ro, Dongjak-gu, Seoul 156–755, Korea (e-mail: )
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Schaer AC, Keel MJB, Dubach P, Greif R, Luyet C, Theiler L. Mucosal Erosion of the Cricoid Cartilage After the Use of an i-Gel Supraglottic Airway Device in a Patient with Diffuse Idiopathic Skeletal Hyperostosis. ACTA ACUST UNITED AC 2015; 3:45-7. [PMID: 25611221 DOI: 10.1213/xaa.0000000000000049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
After standard hip arthroplasty, an 82-year-old patient with previously undiagnosed diffuse idiopathic skeletal hyperostosis of the cervical spine experienced life-threatening side effects after use of a supraglottic airway device (i-gel). Extensive mucosal erosion and denudation of the cricoid cartilage caused postoperative supraglottic swelling and prolonged respiratory failure requiring tracheostomy. In this case report, we highlight the importance of evaluating risk factors for failure of supraglottic airway devices.
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Affiliation(s)
- Andreas C Schaer
- From the Departments of *Anesthesiology and Pain Therapy, †Orthopedic and Trauma Surgery, and ‡Otorhinolaryngology, Head and Neck Surgery, Bern University Hospital and University of Bern, Bern, Switzerland
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Hegde HV, Yaliwal VG, Annigeri RV, Sunilkumar K, Rameshkumar R, Rao PR. Efficacy of orally disintegrating film of ondansetron versus intravenous ondansetron in prophylaxis of postoperative nausea and vomiting in patients undergoing elective gynaecological laparoscopic procedures: A prospective randomised, double-blind placebo-controlled study. Indian J Anaesth 2014; 58:423-9. [PMID: 25197110 PMCID: PMC4155287 DOI: 10.4103/0019-5049.138977] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background and Aims: Ondansetron is one of the most widely used drugs for postoperative nausea and vomiting (PONV) prophylaxis. Orally disintegrating film (ODF) formulations are relatively recent innovations. We evaluated the efficacy of ODF of ondansetron for the prophylaxis of PONV. Methods: One hundred and eighty American Society of Anaesthesiologists-I or II women, in the age group 18-65 years, scheduled for elective gynaecological laparoscopic procedures were studied in a prospective randomised, double-blind, placebo-controlled trial. The patients were randomised into four groups: Placebo, intravenous (IV) ondansetron 4 mg, ODF of ondansetron 4 mg (ODF4) and 8 mg (ODF8) groups. PONV was assessed in two epochs of 0-6 and 7-24 h. Primary outcome measure was the incidence of PONV and secondary outcome measures were severity of nausea, need for rescue anti-emetic, analgesic consumption, time to oral intake, overall patient satisfaction and side effects such as headache and dizziness. PONV was compared using analysis of variance or Mann–Whitney U-test as applicable. Results: Data of 173 patients were analysed. The incidence of postoperative nausea was significantly lower (P = 0.04) only during the 0-6 h in the ODF8 group when compared with the placebo group. During the 0-6 h interval postoperatively, the ODF8 group had a significantly lower incidence of vomiting when compared with the placebo (P = 0.002) and the IV group (P = 0.044). During the 0-24 h interval postoperatively, ODF4 (P = 0.01) and ODF8 (P = 0.002) groups had a significantly lower incidence of vomiting compared to the placebo group. Conclusions: Orally disintegrating film of ondansetron is an efficacious, novel, convenient and may be a cost-effective option for the prophylaxis of PONV.
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Affiliation(s)
- Harihar V Hegde
- Department of Anaesthesiology, SDM College of Medical Sciences and Hospital, Sattur, Dharwad, Karnataka, India
| | - Vijay G Yaliwal
- Department of Anaesthesiology, SDM College of Medical Sciences and Hospital, Sattur, Dharwad, Karnataka, India
| | - Rashmi V Annigeri
- Department of Anaesthesiology, SDM College of Medical Sciences and Hospital, Sattur, Dharwad, Karnataka, India
| | - Ks Sunilkumar
- Department of Obstetrics and Gynaecology, SDM College of Medical Sciences and Hospital, Sattur, Dharwad, Karnataka, India
| | - R Rameshkumar
- Department of Obstetrics and Gynaecology, SDM College of Medical Sciences and Hospital, Sattur, Dharwad, Karnataka, India
| | - P Raghavendra Rao
- Department of Anaesthesiology, SDM College of Medical Sciences and Hospital, Sattur, Dharwad, Karnataka, India
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Endotracheal intubation versus laryngeal mask airway for esophagogastroduodenoscopy in children. J Pediatr Gastroenterol Nutr 2014; 59:54-6. [PMID: 24637966 DOI: 10.1097/mpg.0000000000000348] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVES The present study examined the safety and efficacy of a laryngeal mask airway (LMA), compared with an endotracheal tube (ETT), for children undergoing elective esophagogastroduodenoscopy (EGD). METHODS A total of 84 American Society of Anesthesiologists (ASA) patients, status I to III, were randomly assigned to receive an ETT or LMA. All participants were premedicated with midazolam 0.5 mg/kg (up to 15 mg). Airway device placement occurred after induction with 8% sevoflurane and 100% oxygen, placement of an intravenous catheter, and intravenous lidocaine 2 mg/kg up to 100 mg. The following data were collected: time from induction of anesthesia to placement of the airway device, time from end of procedure to arrival in the postoperative acute care unit (PACU), time in the PACU, time from arrival in the operating room (OR) to discharge, vomiting after the procedure, nausea requiring medicine, lowest oxygen saturation, highest concentration of sevoflurane, highest pain, amount of pain medicine, adverse events, and satisfaction of doctor performing the EGD. RESULTS Group ETT had higher time from room arrival to airway placement, mask to airway placement, room arrival time to discharge, mask placement to discharge, airway placement to discharge, and end of procedure to discharge. Group ETT had a higher proportion of patients with vomiting than group LMA. No statistical difference was noted in endoscopist satisfaction when comparing ETT and LMA. The ETT group had 3 adverse events, including laryngospasm (n=2) and asthma attack (n=1). CONCLUSIONS The LMA appears to be an acceptable and safe alternative for otherwise healthy children undergoing routine EGD. Benefits appear to be decreased incidence of vomiting and overall decreased time spent in the hospital.
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Arun O, Oc B, Duman A, Yildirim S, Simsek M, Farsak B, Oc M. Endovenous Laser Ablation under General Anesthesia for Day Surgery: Feasibility and Outcomes of the 300 Patients. Ann Thorac Cardiovasc Surg 2014; 20:55-60. [DOI: 10.5761/atcs.oa.13-00222] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Barreira SR, Souza CM, Fabrizia F, Azevedo ABG, Lelis TG, Lutke C. Prospective, randomized clinical trial of laryngeal mask airway Supreme(®) used in patients undergoing general anesthesia. Braz J Anesthesiol 2013; 63:456-60. [PMID: 24565342 DOI: 10.1016/j.bjane.2012.08.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2012] [Accepted: 08/20/2012] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Supraglottic airway devices are increasingly used as an option to tracheal intubation for elective procedures of varying complexity. The aim of this study was to prospectively evaluate the clinical use of the laryngeal mask airway Supreme(®) (LMAS) in patients undergoing elective breast surgery and compare it with endotracheal tube (ETT). METHODS Sixty patients undergoing breast procedures under general anesthesia were randomly divided into two groups according to the device used (LMAS or ETT). Time of insertion, number of insertion attempts, hemodynamic response to insertion, presence of blood on the device used; and incidence of sore throat, dysphagia, nausea and vomiting were assessed postoperatively. RESULTS There was no difference between groups regarding time of insertion, number of attempts for successful insertion, and presence of blood on the device. Heart rate and blood pressure after insertion were higher in ETT group. Incidence of sore throat and dysphagia was also higher in ETT group after two hours in the postoperative period. There was no difference regarding incidence and severity of complications evaluated after six hours postoperatively. CONCLUSIONS The use of the LMAS technique to access airway during general anesthesia for elective breast surgery is as safe and effective as tracheal intubation, with the advantage of promoting smaller hemodynamic response during its management and lower incidence of sore throat and dysphagia in the first hours after surgery.
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Affiliation(s)
- Sara R Barreira
- Department of Anesthesiology, Pain, and Intensive Care, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Camila Machado Souza
- Department of Anesthesiology, Pain, and Intensive Care, Universidade Federal de São Paulo, São Paulo, SP, Brazil.
| | - Fernanda Fabrizia
- Department of Anesthesiology, Pain, and Intensive Care, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Ana Bárbara G Azevedo
- Department of Anesthesiology, Pain, and Intensive Care, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Talitha G Lelis
- Department of Anesthesiology, Pain, and Intensive Care, Universidade Federal de São Paulo, São Paulo, SP, Brazil
| | - Claudia Lutke
- Department of Anesthesiology, Pain, and Intensive Care, Universidade Federal de São Paulo, São Paulo, SP, Brazil
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Barreira SR, Souza CM, Fabrizia F, Azevedo ABG, Lelis TG, Lutke C. Estudo clínico prospectivo aleatório sobre o uso da máscara laríngea Supreme® em pacientes submetidos a anestesia geral. Braz J Anesthesiol 2013. [DOI: 10.1016/j.bjan.2012.08.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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Nicholson A, Cook TM, Smith AF, Lewis SR, Reed SS. Supraglottic airway devices versus tracheal intubation for airway management during general anaesthesia in obese patients. Cochrane Database Syst Rev 2013; 2013:CD010105. [PMID: 24014230 PMCID: PMC11180383 DOI: 10.1002/14651858.cd010105.pub2] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND The number of obese patients requiring general anaesthesia is likely to increase in coming years, and obese patients pose considerable challenges to the anaesthetic team. Tracheal intubation may be more difficult and risk of aspiration of gastric contents into the lungs is increased in obese patients. Supraglottic airway devices (SADs) offer an alternative airway to traditional tracheal intubation with potential benefits, including ease of fit and less airway disturbance. Although SADs are now widely used, clinical concerns remain that their use for airway management in obese patients may increase the risk of serious complications. OBJECTIVES We wished to examine whether supraglottic airway devices can be used as a safe and effective alternative to tracheal intubation in securing the airway during general anaesthesia in obese patients (with a body mass index (BMI) > 30 kg/m(2)). SEARCH METHODS We searched for eligible trials in the following databases: Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 8, 2012), MEDLINE via Ovid (from 1985 to 9 September 2012) and EMBASE via Ovid (from 1985 to 9 September 2012). The Cochrane highly sensitive filter for randomized controlled trials was applied in MEDLINE and EMBASE. We also searched trial registers such as www.clinicaltrials.gov and the Current Controlled Clinical Trials Website (http://www.controlled-trials.com/) for ongoing trials. The start date of these searches was limited to 1985, shortly before the first SAD was introduced, in 1988. We undertook forward and backward citation tracing for key review articles and eligible articles identified through the electronic resources. SELECTION CRITERIA We considered all randomized controlled trials of participants aged 16 years and older with a BMI > 30 kg/m(2) undergoing general anaesthesia. We compared the use of any model of SAD with the use of tracheal tubes (TTs) of any design. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by The Cochrane Collaboration. Two review authors independently assessed trial quality and extracted data, including information on adverse events. We contacted study authors for additional information. If sufficient data were available, results were presented as pooled risk ratios (RRs) with 95% confidence intervals (CIs) based on random-effects models (inverse variance method). We employed the Chi(2) test and calculated the I(2) statistic to investigate study heterogeneity. MAIN RESULTS We identified two eligible studies, both comparing the use of one model of SAD, the ProSeal laryngeal mask airway (PLMA) with a TT, with a total study population of 232. One study population underwent laparoscopic surgery. The included studies were generally of high quality, but there was an unavoidable high risk of bias in the main airway variables, such as change of device or laryngospasm, as the intubator could not be blinded. Many outcomes included data from one study only.A total of 5/118 (4.2%) participants randomly assigned to PLMA across both studies were changed to TT insertion because of failed or unsatisfactory placement of the device. Postoperative episodes of hypoxaemia (oxygen saturation < 92% whilst breathing air) were less common in the PLMA groups (RR 0.27, 95% CI 0.10 to 0.72). We found a significant postoperative difference in mean oxygen saturation, with saturation 2.54% higher in the PLMA group (95% CI 1.09% to 4.00%). This analysis showed high levels of heterogeneity between results (I(2) = 71%). The leak fraction was significantly higher in the PLMA group, with the largest difference seen during abdominal insufflation-a 6.4% increase in the PLMA group (95% CI 3.07% to 9.73%).No cases of pulmonary aspiration of gastric contents, mortality or serious respiratory complications were reported in either study. We are therefore unable to present effect estimates for these outcomes.In all, 2/118 participants with a PLMA suffered laryngospam or bronchospasm compared with 4/114 participants with a TT. The pooled estimate shows a non-significant reduction in laryngospasm in the PLMA group (RR 0.48, 95% CI 0.09 to 2.59).Postoperative coughing was less common in the PLMA group (RR 0.10, 95% CI 0.03 to 0.31), and there was no significant difference in the risk of sore throat or dysphonia (RR 0.25, 95% CI 0.03 to 2.13). On average, PLMA placement took 5.9 seconds longer than TT placement (95% CI 3 seconds to 8.8 seconds). There was no significant difference in the proportion of successful first placements of a device, with 33/35 (94.2%) first-time successes in the PLMA group and 32/35 (91.4%) in the TT group. AUTHORS' CONCLUSIONS We have inadequate information to draw conclusions about safety, and we can only comment on one design of SAD (the PLMA) in obese patients. We conclude that during routine and laparoscopic surgery, PLMAs may take a few seconds longer to insert, but this is unlikely to be a matter of clinical importance. A failure rate of 3% to 5% can be anticipated in obese patients. However, once fitted, PLMAs provide at least as good oxygenation, with the caveat that the leak fraction may increase, although in the included studies, this did not affect ventilation. We found significant improvement in oxygenation during and after surgery, indicating better pulmonary performance of the PLMA, and reduced postoperative coughing, suggesting better recovery for patients.
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Affiliation(s)
- Amanda Nicholson
- University of LiverpoolLiverpool Reviews and Implementation GroupSecond FloorWhelan Building, The Quadrangle, Brownlow HillLiverpoolUKL69 3GB
| | - Tim M Cook
- Royal United HospitalDepartment of AnaesthesiaCombe ParkBathUKBA1 3NG
| | - Andrew F Smith
- Royal Lancaster InfirmaryDepartment of AnaestheticsAshton RoadLancasterLancashireUKLA1 4RP
| | - Sharon R Lewis
- Royal Lancaster InfirmaryPatient Safety ResearchPointer Court 1, Ashton RoadLancasterUKLA1 1RP
| | - Stephanie S Reed
- Royal Lancaster InfirmaryDepartment of AnaestheticsAshton RoadLancasterLancashireUKLA1 4RP
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Nicholson A, Cook TM, Smith AF, Lewis SR, Reed SS. Supraglottic airway devices versus tracheal intubation for airway management during general anaesthesia in obese patients. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2013. [PMID: 24014230 DOI: 10.1002/14651858.cd010105] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND The number of obese patients requiring general anaesthesia is likely to increase in coming years, and obese patients pose considerable challenges to the anaesthetic team. Tracheal intubation may be more difficult and risk of aspiration of gastric contents into the lungs is increased in obese patients. Supraglottic airway devices (SADs) offer an alternative airway to traditional tracheal intubation with potential benefits, including ease of fit and less airway disturbance. Although SADs are now widely used, clinical concerns remain that their use for airway management in obese patients may increase the risk of serious complications. OBJECTIVES We wished to examine whether supraglottic airway devices can be used as a safe and effective alternative to tracheal intubation in securing the airway during general anaesthesia in obese patients (with a body mass index (BMI) > 30 kg/m(2)). SEARCH METHODS We searched for eligible trials in the following databases: Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 8, 2012), MEDLINE via Ovid (from 1985 to 9 September 2012) and EMBASE via Ovid (from 1985 to 9 September 2012). The Cochrane highly sensitive filter for randomized controlled trials was applied in MEDLINE and EMBASE. We also searched trial registers such as www.clinicaltrials.gov and the Current Controlled Clinical Trials Website (http://www.controlled-trials.com/) for ongoing trials. The start date of these searches was limited to 1985, shortly before the first SAD was introduced, in 1988. We undertook forward and backward citation tracing for key review articles and eligible articles identified through the electronic resources. SELECTION CRITERIA We considered all randomized controlled trials of participants aged 16 years and older with a BMI > 30 kg/m(2) undergoing general anaesthesia. We compared the use of any model of SAD with the use of tracheal tubes (TTs) of any design. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by The Cochrane Collaboration. Two review authors independently assessed trial quality and extracted data, including information on adverse events. We contacted study authors for additional information. If sufficient data were available, results were presented as pooled risk ratios (RRs) with 95% confidence intervals (CIs) based on random-effects models (inverse variance method). We employed the Chi(2) test and calculated the I(2) statistic to investigate study heterogeneity. MAIN RESULTS We identified two eligible studies, both comparing the use of one model of SAD, the ProSeal laryngeal mask airway (PLMA) with a TT, with a total study population of 232. One study population underwent laparoscopic surgery. The included studies were generally of high quality, but there was an unavoidable high risk of bias in the main airway variables, such as change of device or laryngospasm, as the intubator could not be blinded. Many outcomes included data from one study only.A total of 5/118 (4.2%) participants randomly assigned to PLMA across both studies were changed to TT insertion because of failed or unsatisfactory placement of the device. Postoperative episodes of hypoxaemia (oxygen saturation < 92% whilst breathing air) were less common in the PLMA groups (RR 0.27, 95% CI 0.10 to 0.72). We found a significant postoperative difference in mean oxygen saturation, with saturation 2.54% higher in the PLMA group (95% CI 1.09% to 4.00%). This analysis showed high levels of heterogeneity between results (I(2) = 71%). The leak fraction was significantly higher in the PLMA group, with the largest difference seen during abdominal insufflation-a 6.4% increase in the PLMA group (95% CI 3.07% to 9.73%).No cases of pulmonary aspiration of gastric contents, mortality or serious respiratory complications were reported in either study. We are therefore unable to present effect estimates for these outcomes.In all, 2/118 participants with a PLMA suffered laryngospam or bronchospasm compared with 4/114 participants with a TT. The pooled estimate shows a non-significant reduction in laryngospasm in the PLMA group (RR 0.48, 95% CI 0.09 to 2.59).Postoperative coughing was less common in the PLMA group (RR 0.10, 95% CI 0.03 to 0.31), and there was no significant difference in the risk of sore throat or dysphonia (RR 0.25, 95% CI 0.03 to 2.13). On average, PLMA placement took 5.9 seconds longer than TT placement (95% CI 3 seconds to 8.8 seconds). There was no significant difference in the proportion of successful first placements of a device, with 33/35 (94.2%) first-time successes in the PLMA group and 32/35 (91.4%) in the TT group. AUTHORS' CONCLUSIONS We have inadequate information to draw conclusions about safety, and we can only comment on one design of SAD (the PLMA) in obese patients. We conclude that during routine and laparoscopic surgery, PLMAs may take a few seconds longer to insert, but this is unlikely to be a matter of clinical importance. A failure rate of 3% to 5% can be anticipated in obese patients. However, once fitted, PLMAs provide at least as good oxygenation, with the caveat that the leak fraction may increase, although in the included studies, this did not affect ventilation. We found significant improvement in oxygenation during and after surgery, indicating better pulmonary performance of the PLMA, and reduced postoperative coughing, suggesting better recovery for patients.
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Affiliation(s)
- Amanda Nicholson
- Faculty of Health and Medicine, Furness Building, Lancaster University, Lancaster, UK, LA1 4YG
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Abstract
Gynecological laparoscopy is a commonly performed procedure. Providing anesthesia for this can present a challenge, particularly in the day surgery population. Poor analgesia, nausea, and vomiting can cause distress to the patient and increased cost for the health system, because of overnight admission. In this review we discuss anesthetic and analgesic techniques for day-case gynecological laparoscopy. The principles include multimodal analgesia, the use of the oral route wherever possible, and the contribution of the surgeon.
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Affiliation(s)
- Ben Gibbison
- Department of Anesthesia, St. Michael's Hospital, Southwell St. Bristol, UK
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Lalwani J, Dubey KP, Sahu BS, Shah PJ. ProSeal laryngeal mask airway: An alternative to endotracheal intubation in paediatric patients for short duration surgical procedures. Indian J Anaesth 2010; 54:541-5. [PMID: 21224972 PMCID: PMC3016575 DOI: 10.4103/0019-5049.72644] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
The laryngeal mask airway (LMA) is a supraglottic airway management device. The LMA is preferred for airway management in paediatric patients for short duration surgical procedures. The recently introduced ProSeal (PLMA), a modification of Classic LMA, has a gastric drainage tube placed lateral to main airway tube which allows the regurgitated gastric contents to bypass the glottis and prevents the pulmonary aspiration. This study was done to compare the efficacy of ProSeal LMA with an endotracheal tube in paediatric patients with respect to number of attempts for placement of devices, haemodynamic responses and perioperative respiratory complications. Sixty children, ASA I and II, weighing 10-20 kg between 2 and 8 years of age group of either sex undergoing elective ophthalmological and lower abdominal surgeries of 30-60 min duration, randomly divided into two groups of 30 patients each were studied. The number of attempts for endotracheal intubation was less than the placement of PLMA. Haemodynamic responses were significantly higher (P<0.05) after endotracheal intubation as compared to the placement of PLMA. There were no significant differences in mean SpO(2) (%) and EtCO(2) levels recorded at different time intervals between the two groups. The incidence of post-operative respiratory complications cough and bronchospasm was higher after extubation than after removal of PLMA. The incidence of soft tissue trauma was noted to be higher for PLMA after its removal. There were no incidences of aspiration and hoarseness/sore throat in either group. It is concluded that ProSeal LMA can be safely considered as a suitable and effective alternative to endotracheal intubation in paediatric patients for short duration surgical procedures.
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Affiliation(s)
- Jaya Lalwani
- Pt. J.N.M. Medical College & Dr. BRAM Hospital, Raipur (C.G.), India
| | | | - Bal Swaroop Sahu
- Pt. J.N.M. Medical College & Dr. BRAM Hospital, Raipur (C.G.), India
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Russo SG, Moerer O, Nickel EA, Goetze B, Timmermann A, Quintel M. [Extraglottic airway devices in the intensive care unit]. Anaesthesist 2010; 59:555-63. [PMID: 20502847 DOI: 10.1007/s00101-010-1728-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Extraglottic airway devices (EGA) are not only used in routine anaesthesia practice, they also have a distinct value for in-hospital and out-of-hospital difficult airway management. In the environment of the intensive care unit (ICU) EGA are not used on a regular basis. However, expertise and knowledge regarding EGA coming from the operating theatre or the out-of-hospital setting may also be of value for the ICU setting. This review presents the potential indications for EGA on the ICU for the management of difficult airway situations as well as during percutaneous tracheotomy. Furthermore, the possible advantages of EGA during postoperative recovery from anaesthesia as well as termination of controlled ventilation for intensive care patients are discussed.
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Affiliation(s)
- S G Russo
- Zentrum Anaesthesiologie, Rettungs- und Intensivmedizin, Universitätsmedizin Göttingen, Robert-Koch-Str. 40, 37075 Göttingen, Deutschland.
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Carron M, Freo U, Ori C. Usefulness of spirometry in air leak evaluation during laparoscopic surgery in an obese patient with laryngeal mask airway Supreme™. Br J Anaesth 2010; 105:387-9. [DOI: 10.1093/bja/aeq223] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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30
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Abstract
Supraglottic airway devices (SGAs) offer certain advantages over endotracheal intubation, making them particularly well suited for the specific demands of outpatient anesthesia. Patients may tolerate the placement and maintenance of an SGA at a lower dose of anesthetic than that needed for an endotracheal tube; neuromuscular blocking agents are rarely necessary for airway management with an SGA; the incidence of airway morbidity is lower with SGAs than with endotracheal tubes; and SGAs may facilitate faster recovery and earlier discharge of patients. Two limitations of SGAs are incomplete protection against aspiration of gastric contents and inadequate delivery of positive pressure ventilation. Newer variants of the original laryngeal mask airway, the LMA Classic (LMA North America, Inc), as well as an array of other recently developed SGAs, aim to address these limitations. Their utility and safety in specific patient populations (eg, the morbidly obese) and during certain procedures (eg, laparoscopic surgery) remain to be determined.
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Affiliation(s)
- Katarzyna Luba
- Department of Anesthesia and Critical Care, Pritzker School of Medicine, University of Chicago Medical Center, University of Chicago, 5841 South Maryland Avenue, Chicago, IL 60637, USA.
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Yu SH, Beirne OR. Laryngeal mask airways have a lower risk of airway complications compared with endotracheal intubation: a systematic review. J Oral Maxillofac Surg 2010; 68:2359-76. [PMID: 20674126 DOI: 10.1016/j.joms.2010.04.017] [Citation(s) in RCA: 116] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2009] [Revised: 03/31/2010] [Accepted: 04/23/2010] [Indexed: 01/12/2023]
Abstract
PURPOSE The purpose of the present study was to determine whether, in patients undergoing general anesthesia, those provided with a laryngeal mask airway (LMA) have a lower risk of airway-related complications than those undergoing endotracheal intubation. MATERIALS AND METHODS A systematic review of randomized prospective controlled trials was done to compare the risk of airway complications with an LMA versus an endotracheal tube (ETT) in patients receiving general anesthesia. Two independent reviewers identified 29 randomized prospective controlled trials that met the predetermined inclusion and exclusion criteria. The data for each individual outcome measure were combined to analyze the relative risk ratios (RRs). The Cochrane RevMan software was used for statistical analysis. RESULTS When an ETT was used to protect the airway, a statistically significant greater incidence of hoarse voice (RR 2.59, 95% confidence interval [CI] 1.55 to 4.34), a greater incidence of laryngospasm during emergence (RR 3.16, 95% CI 1.38 to 7.21), a greater incidence of coughing (RR 7.12, 95% CI 4.28 to 11.84), and a greater incidence of sore throat (RR 1.67, 95% CI 1.33 to 2.11) was found compared with when an LMA was used to protect the airway. The differences in the risk of regurgitation (RR 0.84, 95% CI 0.27 to 2.59), vomiting (RR 1.56, 95% CI 0.74 to 3.26), nausea (RR 1.59, 95% CI 0.91 to 2.78), and the success of insertion on the first attempt (RR 1.08, 95% CI 0.99 to 1.18) were not statistically significant between the 2 groups. CONCLUSIONS For the patients receiving general anesthesia, the use of the LMA resulted in a statistically and clinically significant lower incidence of laryngospasm during emergence, postoperative hoarse voice, and coughing than when using an ETT. The risk of aspiration could not be determined because only 1 study reported a single case of aspiration, which was in the group using the ETT.
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Affiliation(s)
- Seung H Yu
- Department of Oral and Maxillofacial Surgery, University of Washington School of Dentistry, Seattle, WA 98195-7134, USA
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Carron M, Freo U, Ori C. Succinylcholine in morbidly obese patients: another interesting advantage. Obes Surg 2010; 21:1981-2. [PMID: 20556537 DOI: 10.1007/s11695-010-0220-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Carron M, Marchet A, Ori C. Supreme laryngeal mask airway for laparoscopic cholecystectomy in patient with severe pulmonary fibrosis. Br J Anaesth 2009; 103:778-9. [DOI: 10.1093/bja/aep288] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Bernardini A, Natalini G. Risk of pulmonary aspiration with laryngeal mask airway and tracheal tube: analysis on 65 712 procedures with positive pressure ventilation. Anaesthesia 2009; 64:1289-94. [DOI: 10.1111/j.1365-2044.2009.06140.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Zanardo V, Buzzacchero R, Giustardi A, Trevisanuto D, Micaglio M. Breastfeeding the ‘healthy’ near-term infants after laryngeal mask airway or traditional resuscitation methods. J Matern Fetal Neonatal Med 2009; 22 Suppl 3:92-5. [DOI: 10.1080/14767050903181302] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Fabregat López J, Garcia-Rojo B, Cook TM. Comments on a statistical note on the Poisson (binomial) distribution. Anaesthesia 2009; 64:571-2; author reply 572. [DOI: 10.1111/j.1365-2044.2009.05921_1.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Abstract
PURPOSE OF REVIEW There are an ever-increasing number of supraglottic airway devices available on the market, many being suitable for ambulatory surgery and the specific demands it creates. These include constraints of time, high turnover and the need for early and effective discharge. This article hopes to highlight the potential benefits of the current devices available. RECENT FINDINGS Laryngeal masks are still undoubtedly the most popular supraglottic devices available but there are an increasing number of other airways on offer. Advantages of these include higher seal pressures, ease of insertion and the ability to drain gastric fluids. SUMMARY Some of the unique advantages offered by certain devices lend themselves well to anaesthesia in ambulatory surgery. The laryngeal mask airway has a proven track record but newer airway devices are becoming more popular and may offer advantages. Further research is needed in this fast-moving field to assess these benefits, especially in specific cohorts of patients (such as the obese), who are appearing with increasing regularity on outpatient surgery lists.
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Fabregat-López J, Garcia-Rojo B, Cook TM. A case series of the use of the ProSeal laryngeal mask airway in emergency lower abdominal surgery. Anaesthesia 2008; 63:967-71. [DOI: 10.1111/j.1365-2044.2008.05539.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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40
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Thompson J, O'Neill S. Are supraglottic airways a safe alternative to tracheal intubation for laparoscopic surgery? Br J Hosp Med (Lond) 2008; 69:303. [DOI: 10.12968/hmed.2008.69.5.29371] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
| | - Sarah O'Neill
- Nuffield Department of Anaesthesia, John Radcliffe Hospital, Oxford
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