A study of airway management using the ProSeal LMA laryngeal mask airway compared with the tracheal tube on postoperative analgesia requirements following gynaecological laparoscopic surgery

Identifying the Risk Factors for Postoperative Sore Throat After Endotracheal Intubation for Oral and Maxillofacial Surgery

Objective

To identify risk factors for postoperative sore throat (POST) after general anesthesia in oral and maxillOfacial surgery.

Material and Methods

This study is a retrospective cohort design study. We enrolled patients with oral and maxillofacial surgery who underwent endotracheal intubation under general anesthesia in the Stomatology Hospital, Zhejiang University School Of Medicine between April 2020 and April 2021. They were divided into the POST group and the without POST group. The distribution Of various characteristics in the two groups was firstly analyzed. Then, logistic regression analysis was performed to explore the independent predictors for POST occurrence. Following this, logistic regression and random forest models were constructed and their performance was evaluated to predict POST occurrence.

Results

A total of 891 participants were enrolled in the study. Female gender and cough during extubation were significantly associated with increased POST occurrence in multivariate analysis (all P <0.05). Stratified logistic regression analysis results showed that the female gender was an independent predictor for POST occurrence in the 4≤age≤14 and 14<age≤60 groups after adjusting all the covariates, while cough during extubation independently predicted POST in the age>60 group after adjusting American Society of Anesthesiologists status and throat and lung disease (all P <0.05). The logistic regression model had a similar effect to the random forest model in predicting POST occurrence. Interestingly, the female gender had a higher important weight compared to the cough during extubation.

Conclusion

This research reveals female gender and cough during extubation as potential risk factors for POST occurrence, which may provide guidance for the effective prevention of POST in oral and maxillofacial surgery.

AutoFlow® versus volume-controlled ventilation for laparoscopic gynecological surgery using LMA® ProSeal™: a randomized controlled trial

Background

During laparoscopic gynecological surgery, increased peak airway pressure (PAWP) can cause airway leak upon ventilation with the LMA® ProSeal™. We hypothesized that compared with the use of volume-controlled ventilation (VCV), the use of the AutoFlow® mode would decrease PAWP and airway leak during laparoscopic gynecological surgery with LMA ProSeal.

Methods

This single-center, randomized, controlled trial allocated 80 adult women undergoing elective laparoscopic gynecological surgery to one of two groups, namely, the AutoFlow group or the VCV group. Ventilation settings for both groups were 8 ml/kg of tidal volume and 5 cmH₂O of positive end-expiratory pressure, and respiratory rate was adjusted to maintain end-tidal carbon dioxide at 35–40 mmHg. Airway leak, PAWP, and other ventilatory parameters and vital signs were recorded at four timepoints (1, 1 min after insertion of the gastric tube; 2, 2 min after intravenous administration of rocuronium 0.6–0.8 mg/kg; 3, 1 min after initiation of pneumoperitoneum; and 4, 1 min after changing to the Trendelenburg position). The primary outcome was PAWP during pneumoperitoneum and in the Trendelenburg position, whereas the secondary outcomes included PAWP at other timepoints and airway leak development. We used the Mann–Whitney U test for PAWP and Fisher’s exact test for comparing airway leak among the groups.

Results

Data from 40 patients in the AutoFlow group and 39 in the VCV group were used for analysis. PAWP at pneumoperitoneum pressure and in the Trendelenburg position was significantly lower in the AutoFlow group than in the VCV group [median (interquartile range), 16 (15–18) cmH₂O vs. 18 (17–19) cmH₂O; P < 0.001]. Similarly, patients in the AutoFlow group showed lower PAWP at the other three timepoints measured. Airway leak occurred in four patients in the AutoFlow group and in two patients in the VCV group; however, this incidence was not significantly different (P = 0.68).

Conclusions

Even though AutoFlow ventilation decreased PAWP, it did not reduce the incidence of airway leak compared with VCV during laparoscopic gynecological surgery with the LMA ProSeal.

Trial registration

UMIN Clinical Trials Registry, identifier UMIN000023173.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12871-021-01406-6.

Can Positive-Pressure Ventilation be Administered with Laryngeal Mask to Pediatric Patients Undergoing Laparoscopic Inguinal Hernia Operation?

Objectives:

We aimed to investigate the effects of intubation and laryngeal mask airway (LMA) use by evaluating the results of blood gas tests, end-tidal CO₂ measurements, and airway changes during laparoscopic inguinal hernia repair in children.

Methods:

This study was designed to be a prospective randomized study enrolling 150 ASA-I patients, aged 1–8 years; who were scheduled for laparoscopic inguinal hernia repair. Group 1 (n=75) received general anesthesia with fentanyl, propofol, and rocuronium and they were orotracheally intubated. Group 2 (n=75) received general anesthesia with fentanyl and propofol and were inserted an LMA. Demographical data were recorded. Arterial blood gas test results at baseline, in the 10^th min after the insufflation, and in the 10^th min after the end of the insufflation were noted. The end-tidal CO₂, HR, SPO₂, inspiratory pressure, plateau pressure, tidal volume (TV), and respiratory frequencies were recorded. The duration of anesthesia, operation, and insufflations was noted. Emergent complications were recorded.

Results:

The duration of both anesthesia and recovery was longer in Group 1 compared to Group 2. Hemodynamical parameters, end-tidal CO₂ values, TVs, airway pressures, and respiratory frequencies were not statistically significantly different between the groups. There were no statistically meaningful differences in the levels of pH, PCO₂, and PO₂ between the groups.

Conclusion:

Compared to orotracheal intubation during laparoscopic inguinal surgery; LMA did not cause any statistically significant differences in the blood gas test results or airway pressures and recovery was faster with LMA. Therefore, LMA can be used in pediatric laparoscopic surgery as a safe tool for maintaining the airway.

A Randomized Crossover Comparison of Airway Sealing with the Laryngeal Mask Airway Ambu AuraFlex at Three Intracuff Pressures in Pediatric Laparoscopic Surgery

OBJECTIVE

An adequate intracuff pressure is important to ensure sufficient sealing function when using supraglottic airway devices to protect the airway from secretions and achieve adequate positive pressure ventilation. The aim of this study is to analyze a feasible and effective alternative Ambu AuraFlex intracuff pressure in child's laparoscopic surgery.

STUDY DESIGN

Seventy-two children were included in this study. After insertion of the laryngeal mask airway AuraFlex, oropharyngeal leak pressure (OLP) was measured at intracuff pressures of 10, 30, and 60-cmH₂O according to one of six sequences produced on the basis of 3 × 6 Williams crossover design. During the intraoperative period, AuraFlex was maintained using the last intracuff pressure of the allocated sequence. Oropharyngeal leak pressure, peak airway pressure, the fiberoptic view, mucosal change, and complications were assessed at three intracuff pressures.

RESULTS

The OLP at the intracuff pressure of 10 cmH₂O was significantly lower than that of 30 cmH₂O (2^# 18.1 ± 1.5 vs. 19.5 ± 1.4 cmH₂O, p = 0.001; 2.5^# 17.7 ± 1.2 vs. 20.2 ± 1.4, p = 0.001) and 60 cmH₂O (2^# 18.1 ± 1.5 vs. 20.0 ± 1.3 cmH₂O, p = 0.002; 2.5^# 17.7 ± 1.2 vs. 20.8 ± 1.1, p = 0.003). Compared with the peak airway pressure in pre-and postpneumoperitoneum, the OLP was significantly higher. Subgroup analysis showed no differences in mucosal change and complications.

CONCLUSION

Intracuff pressures of 30 may be sufficient for the Ambu AuraFlex in child's laparoscopic surgery, and there may be no added benefit of an intracuff pressure of 60 cmH₂O, as oropharyngeal leak pressures were similar.

Do Small Incisions Need Only Minimal Anesthesia?-Anesthetic Management in Laparoscopic and Robotic Surgery

Laparoscopic techniques have established themselves as a major part of modern surgery. Their implementation in every surgical discipline has played a vital part in the reduction of perioperative morbidity and mortality. Precise robotic surgery, as an evolution of this, is shaping the present and future operating theatre that an anesthetist is facing. While incisions get smaller and the impact on the organism seems to dwindle, challenges for anesthetists do not lessen and could even become more demanding than in open procedures. This review focuses on the pathophysiological effects of contemporary laparoscopic and robotic procedures and summarizes anesthetic challenges and strategies for perioperative management.

Patient reported experiences following laparoscopic prophylactic bilateral salpingo-oophorectomy or salpingectomy in an ambulatory care hospital

Women at risk of developing ovarian cancer because of a BRCA1 or BRCA2 pathogenic variant are candidates for prophylactic bilateral salpingo-oophorectomy (BSO). While BSO surgeries are routinely performed, to our knowledge there are no studies that have examined patient-reported experiences following laparoscopic BSO performed in an ambulatory care setting. The objective of this study was to examine whether women undergoing prophylactic laparoscopic BSO felt they were adequately informed about post-operative outcomes. A telephone interview was conducted among 46 women undergoing laparoscopic BSO to collect detailed information regarding surgical outcomes, complications, symptoms, and time to return to daily activities. The average age at surgery was 45.0 years (range 34-66) and 67% of women underwent BSO prior to age 50. The mean reported hospital stay was 7.2 h (range 4-12 h) and at time of discharge, 78% of the women felt well enough to go home. None of the women required a readmission to hospital. Forty-three percent (n = 20) of the women did not feel well informed about what to expect post-operatively. Most of the patient-reported outcomes (including pain, vaginal bleeding, and nausea/vomiting) were expected and patient-reported menopausal symptoms were more common among women who were premenopausal at surgery. In terms of returning to regular activities, premenopausal women (n = 36) resumed sexual activity on average at 43 days (range 2-365), which is later than postmenopausal women (n = 15) at 19 days (range 7-30). On average, women returned to full-time work in 16 days (range 1-56 days). Despite patients receiving pre-surgery counselling, our findings suggest that there is a need to provide supplemental, reinforcing patient materials in preparing patients for what to expect after surgery.

Comparison of LM-Supreme™ and endotracheal tube in patients undergoing gynecological laparoscopic surgery

While laryngeal mask is widely used for laparoscopic interventions in some countries, concerns exist regarding pulmonary aspiration and inadequate ventilation. We compared the LM-Supreme™ (LM-S) with the endotracheal tube (ETT) for laparoscopic gynecological interventions in terms of ventilation parameters and gastric distention. This prospective randomized and double-blind study. The patients were divided into two groups: ETT (n = 50) and LM-S group (n = 50). All patients in the LM-S and ETT groups recieved total intravenous general anaesthesia and standard ventilation protocols. Ventilation parameters (airway peak pressure, mean airway pressure, end-tidal carbon dioxide, total volume, oropharyngeal leak pressure) and perioperative laryngopharyngeal morbidity were recorded before peritoneal insufflation, during and after the peroperative period. The mean airway pressure values in the ETT group 2 min after airway device insertion were significantly higher. The gastric distension after the laparoscope entered the abdomen in the LM-S group was found to be significantly lower. In the first hour postoperative sore throat, disphonia and dysphagia were statistically significantly higher in the ETT group. In our study we concluded that LM-S provides reliable endotracheal intubation in ASA I & II patients undergoing laparoscopic gynecological surgery under positive pressure ventilation.ClinicalTrials.gov ID NCT02127632.

Comparison of early postoperative recovery between laryngeal mask airway and endotracheal tube in laparoscopic cholecystectomy: A randomized trial

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.

ProSeal Laryngeal Mask Airway Placement: A Comparison of Blind versus Direct Laryngoscopic Insertion Techniques

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.

Risk factors for postoperative throat pain after general anaesthesia with endotracheal intubation at the University of Gondar Teaching Hospital, Northwest Ethiopia, 2014

Introduction

Postoperative sore throat is listed from the top as patients’ most undesirable outcome in the postoperative period. It is believed to originate from mucosal dehydration or edema, tracheal ischemia secondary to the pressure of endotracheal tube cuffs, aggressive oropharyngeal suctioning, and mucosal erosion from friction between delicate tissues and the endotracheal tube. Even if the problem was indicated in many literatures, it has never been studied in our country. The study aimed to assess prevalence and factors associated with postoperative sore throat among patients who were operated under general anesthesia with endotracheal intubation.

Methods

Hospital based cross sectional study was conducted from February 25 - April 10, 2014 in Gondar University hospital. Patient interview and chart review were employed for data collection. Bivariate and multivariate logistic regressions were used to determine the association.

Results

A total of 240 out of 299 patients were included in this study with a response rate of 80.3%. The prevalence of postoperative sore throat within 48 hours after operation was 59.6%. Factors which had association with postoperative sore throat from the multivariate logistic regression were female sex (AOR = 3.3, 95% CI: 1.07, 10.375), repeated number of attempts to intubate (AOR = 3.291, 95% CI: 1.658, 6.531), and the use of nasogastric tube (AOR = 0.41, 95% CI: 0.174, 0.965) respectively.

Conclusion

The prevalence of postoperative sore throat was high in Gondar University Hospital. Awareness creation about the problem should be made for health professionals and postoperative sore throat management protocol need to be introduced.

Comparison of laryngeal mask airway vs tracheal intubation: a systematic review on airway complications

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.

Gastric regurgitation in patients undergoing gynecological laparoscopy with a laryngeal mask airway: a prospective observational study

OBJECTIVE

The use of pneumoperitonium and the placement of patients in Trendelenburg position are commonly cited reasons for the potential development of intraoperative regurgitation of gastric contents and the need for an endotracheal tube in laparoscopic surgery. The main objective of the current investigation was to evaluate the presence of regurgitation of gastric contents in the oropharynx of patients having laparoscopic gynecological surgery with a laryngeal mask airway (LMA).

DESIGN

Prospective, observational clinical investigation.

INTERVENTIONS

Not applicable.

MEASUREMENTS

Healthy subjects having a laparoscopic gynecological surgery under general anesthesia with a ProSeal LMA were included in the study. An insufflation pressure of 15 mm Hg was established as the maximum intra-abdominal pressure for the pneumoperitonium, and patients were placed in Trendelenburg position at a 15° angle. The pH of secretions extracted from subjects' hypopharynx was measured at multiple time points during the surgical procedure. A pH of oropharynx secretions ≤4.1 indicated the regurgitation of gastric contents.

MAIN RESULTS

Eighty subjects were recruited and completed the study. The median (range) of pH measurements at any time (T3-T9) was 6.5 (5.5-7.0). The median (range) for the lowest pH for each subject was 6.0 (5.5-7.0). The lowest detected pH in the hypopharynx was not correlated (Spearman ρ) with total surgical time (P = .9), total pneumopertitonium time (P = .17), or total Trendelenburg position time (P = .47).

CONCLUSIONS

Our current results suggest that the use of an LMA in healthy patients undergoing laparoscopic gynecological surgery may be safe. Future studies to confirm or refute our findings are warranted.

Comparison between supraglottic airway devices and endotracheal tubes in patients undergoing laparoscopic surgery: A systematic review and meta-analysis

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.

Anaesthesia for laparoscopic surgery

Laparoscopic surgery has become increasingly common with reduced postoperative pain and faster recovery. Clinicians managing patients undergoing abdominal laparoscopic surgery should appreciate the physiological changes which mainly arise from patient positioning and the effects of pneumoperitoneum.

Effect of pneumoperitoneum and Trendelenberg position on oropharyngeal sealing pressure of I-gel™ and ProSeal LMA™ in laparoscopic gynecological surgery: A randomized controlled trial

Background:

A sustained and effective oropharyngeal sealing with supraglottic airway (SGA) is required to maintain the ventilation during laparoscopic gynecological surgery in the Trendelenburg position. This study was conducted with I-gel™ and ProSeal LMA™, two prototype SGA devices with a gastric access.

Materials and Methods:

We enrolled 60 American Society of Anesthesiologists physical status I and II patients and randomized to either I-gel or ProSeal LMA (PLMA) group. After induction of anesthesia using a standardized protocol, one of the SGA devices was inserted. The primary objective of this study was to compare the oropharyngeal leak (sealing) pressure of I-gel™ and ProSeal LMA™ after pneumoperitoneum and Trendelenberg position. The secondary objectives were to compare ease of insertion, cuff position as assessed by the fiberoptic view of the glottis, adequacy of ventilation and incidence of complication.

Results:

The baseline (before pneumoperitoneum) oropharyngeal leak pressure of I-gel was less than the PLMA (mean (standard deviation [SD]) 24 (4) vs. 29 (4) cmH₂O, respectively; P < 0.001). After pneumoperitoneum, the leak airway pressure in I-gel group was significantly less than that of PLMA group (mean [SD] 27 (3) vs. 34.0 (4) cmH₂O, respectively; P < 0.001). Peak airway pressure was increased after pneumoperitoneum compared to baseline in both the groups. However, end-tidal carbon dioxide was maintained within normal limits. The insertion parameters, fiberoptic view of the glottis, fiberoptic view of the drain tube, and complications were comparable between the groups.

Conclusion:

Both I-gel and PLMA are effective for ventilation in gynecological laparoscopic surgeries. However, PLMA provides better sealing as compared to I-gel.

Role of laryngeal mask airway in laparoscopic cholecystectomy

Laparoscopic cholecystectomy is one of the most commonly performed surgical procedures and the laryngeal mask airway (LMA) is the most common supraglottic airway device used by the anesthesiologists to manage airway during general anesthesia. Use of LMA has some advantages when compared to endotracheal intubation, such as quick and ease of placement, a lesser requirement for neuromuscular blockade and a lower incidence of postoperative morbididy. However, the use of the LMA in laparoscopy is controversial, based on a concern about increased risk of regurgitation and pulmonary aspiration. The ability of these devices to provide optimal ventilation during laparoscopic procedures has been also questioned. The most important parameter to secure an adequate ventilation and oxygenation for the LMA under pneumoperitoneum condition is its seal pressure of airway. A good sealing pressure, not only state correct patient ventilation, but it reduces the potential risk of aspiration due to the better seal of airway. In addition, the LMAs incorporating a gastric access, permitting a safe anesthesia based on these commented points. We did a literature search to clarify if the use of LMA in preference to intubation provides inadequate ventilation or increase the risk of aspiration in patients undergoing laparoscopic cholecystectomy. We found evidence stating that LMA with drain channel achieves adequate ventilation for these procedures. Limited evidence was found to consider these devices completely safe against aspiration. However, we observed that the incidence of regurgitation and aspiration associated with the use of the LMA in laparoscopic surgery is very low.

Comparison of three methods for the confirmation of laryngeal mask airway placement in female patients undergoing gynecologic surgery

The laryngeal mask airway (LMA) is a supraglottic device that is commonly used to provide lung ventilation during general anesthesia. LMA placement needs to be confirmed to provide adequate lung ventilation. To investigate the feasibility of using ultrasound examination, compared with clinical tests and fiberoptic laryngoscopy, to confirm LMA placement, we performed a clinical study of 64 female patients classified as American Society of Anesthesiologists Physical Status I or II who were scheduled for gynecologic surgery with LMA insertion for airway management. After insertion, placement of the LMA was confirmed by clinical tests, ultrasound examination and fiberoptic laryngoscopy. Of the 64 women, placement was confirmed as acceptable in 89.1% by clinical tests, in 59.4% by fiberoptic laryngoscope assessment and in 67.2% by ultrasound examination. With respect to patients with oropharyngeal leaks classified as high, there were no differences in confirmation of acceptable placement between clinical tests and ultrasound examinations (p = 0.092), but the number of patients determined to have acceptable placement by ultrasound examination was greater than that determined by fiberoptic laryngoscopy (p = 0.034). Thus, ultrasound examination is a superior technique for confirming the seal on the LMA.

Efficacy and safety of intraperitoneal dexmedetomidine with bupivacaine in laparoscopic colorectal cancer surgery, a randomized trial

OBJECTIVE

Our objective is to investigate the efficacy and safety of intraperitoneal dexmedetomidine (Dex) combined with bupivacaine in patients undergoing laparoscopic colorectal cancer surgery.

DESIGN

Randomized double-blind study.

SETTING

Academic medical center.

PATIENTS AND METHODS

Forty-five patients scheduled for laparoscopic colorectal cancer surgery were randomly assigned for intraperitoneal administration of 50 mL saline (control group; GI, n = 15), 50 mL bupivacaine 0.25% (125 mg; GII, n = 15), or 50 mL bupivacaine 0.25% (125 mg) +1 μg/kg Dex (GIII, n = 15). Patients were assessed during the first 24 hours postoperatively for hemodynamics, visual analogue scale (VAS), time to first request of analgesia, total analgesic consumption, shoulder pain, and side effects.

RESULTS

A significant reduction was observed in VAS in GIII at base line, 2, 4, and 24 hours postoperatively in comparison to GI and GII (P < 0.05). The time to first analgesic requirement was significantly prolonged in GIII (P < 0.05). The mean total consumption of rescue analgesia was significantly reduced in GIII.

CONCLUSION

We conclude that intraperitoneal administration of Dex 1 μg/kg combined with bupivacaine improves the quality and the duration of postoperative analgesia and provides an analgesic sparing effect compared to bupivacaine alone without significant adverse effects in patients undergoing laparoscopic colorectal cancer surgery.

Supraglottic airway devices versus tracheal intubation for airway management during general anaesthesia in obese patients

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.

Supraglottic airway devices versus tracheal intubation for airway management during general anaesthesia in obese patients

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.

A comparison of two different ketamine and diazepam combinations with an alphaxalone and medetomidine combination for induction of anaesthesia in sheep

AIMS

To investigate the perceived adverse effects of a particular batch of ketamine during induction of anaesthesia in sheep and to assess if any adverse effects would make intubation more difficult for the veterinary students.

METHODS

Thirty adult sheep (mean bodyweight 74.5 (SD 9.4) kg) were randomly assigned to one of six groups of five sheep. Sheep in Groups A and B received I/V 0.5 mg/kg diazepam and 10 mg/kg ketamine (Ketamine Injection; Parnell Laboratories NZ Ltd, of the suspect batch); those in Groups C and D received I/V 0.5 mg/kg diazepam and 10 mg/kg ketamine (Ketalar; Hospira NZ Ltd.), and those in Groups E and F received I/V 2 μg/kg medetomidine and 2 mg/kg alphaxalone. In Groups A, C and E, intubation was by an experienced anaesthetist, and in Groups B, D and F intubation was by a veterinary student. Time from injection to successful intubation, the ease of intubation, saturation of haemoglobin with oxygen (SpO₂) and partial pressure of oxygen in arterial blood (PaO₂) were measured before the sheep were connected to an anaesthetic machine and allowed to breath oxygen. Times to extubation, holding its head up and standing, maximum and minimum heart rates, respiratory rates, maximal end tidal CO₂, and the quality of recovery were then recorded.

RESULTS

There were no measurable differences in outcomes between sheep in Groups A and B compared with C and D. Time to intubation was slightly shorter for the experienced anaesthetist than the student, but the difference was not significant. The sheep in Groups E and F took less time to recover than those in Groups A-D (p<0.05), but there were no significant differences between the groups in either the ease of induction or quality of recovery. Most sheep in Groups E and F showed minor excitatory effects, mainly at induction, which did not interfere with induction. Respiratory rates were lower in Groups E and F than Groups A-D (p<0.01), but SpO₂ was higher in Groups E and F than A and B (p<0.05).

CONCLUSIONS

The clinical impression that the batch of Parnell ketamine produced unexpected effects was shown to be incorrect. All the combinations produced anaesthesia that allowed intubation by the veterinary student.

CLINICAL RELEVANCE

All the drug combinations produced satisfactory anaesthesia in sheep, but the alphaxaloneand medetomidine combination resulted in faster recovery.

Postoperative analgesia for gynecological laparoscopy

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.

Reinforced laryngeal mask airway compared with endotracheal tube for adenotonsillectomies

BACKGROUND

The endotracheal tube (ETT) has traditionally been considered the best airway device during adenotonsillectomy because a well protected and secured airway is provided. This has been challenged by the introduction of the reinforced laryngeal mask airway (RLMA). It does not kink, is less traumatic during insertion and better tolerated during emergence. The purpose of this study was to compare the use of the RLMA with ETT with regards to postoperative pain, nausea, vomiting and perioperative efficacy in a series of children due for adenotonsillectomy.

METHODS

One hundred and thirty-four children, aged 3-16 years and scheduled for ambulatory adenotonsillectomies, were randomly assigned to two groups where the airways were secured with either the ETT (n = 62) or the RLMA (n = 69). We registered the incidence of peroperative and postoperative anaesthesiological complications and time consume, in addition to postoperative pain, nausea and overall satisfaction.

RESULTS

The Group RLMA scored significantly lower for maximal pain during the first 4 h postoperatively (P = 0.015). There were no significant differences in pain scores at 24 h or rescue pain medication postoperatively. The Group RLMA spent mean 4.2 min less in the operating room after surgery (P = 0.001). There were no significant differences in postoperative nausea. In those patients finally treated with ETT, including five conversions from RLMA, significantly more patients (10 vs. 2) had airway irritations (P < 0.02).

CONCLUSION

The RLMA, when feasible, is a well tolerated and effective alternative to the ETT for use during adenotonsillectomies in children, with beneficial effects on airway irritations, operating room efficiency and early postoperative pain.

Supraglottic airway devices in the ambulatory setting

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.

Laryngeal mask airways have a lower risk of airway complications compared with endotracheal intubation: a systematic review

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.

Airway management in the outpatient setting: new devices and techniques

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.

[Special features of laparoscopic operations from an anesthesiologic viewpoint: a review]

The value of laparoscopic procedures has increased over the last decade. Many patients undergoing laparoscopic surgery also have coexisting diseases. The hemodynamic effects of intraperitoneal carbon dioxide insufflation depend on the extent of intraperitoneal pressure, severity of preexisting cardiopulmonary diseases, volume state of the patient and alterations of acid-base balance due to a capnoperitoneum. In addition to endocrinologic reactions, patient positioning also affects hemodynamic parameters. In high risk patients extended cardiopulmonary monitoring with an arterial line and repeated blood gas analysis is recommended intraoperatively, in addition to assessment of end-expiratory CO(2). In this patient group the intra-abdominal pressure should be maintained in the range of 5-7 mmHg.