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Notes: This study was designed to evaluate the routine use of a gum elastic bougie for tracheal intubation. The median time to intubation with the gum elastic bougie while simulating an ‘epiglottis only’ view was only 10 s longer than the time taken during conventional intubation with an optimum view. Three of the patients required a gum elastic bougie-assisted intubation after attempts at conventional visual intubation had failed. There was no significant difference in the incidence of postoperative sore throat and hoarseness between the two groups. We recommend that anaesthetists should use the gum elastic bougie whenever a good view of the glottis is not immediately obtained.

Notes: Cerebral palsy is the result of an injury to the developing brain during the antenatal, perinatal or postnatal period. Clinical manifestations relate to the area affected. Some of the conditions associated with cerebral palsy require surgical intervention. Problems during the peri-operative period may include hypothermia, nausea and vomiting and muscle spasm. Peri-operative seizure control, respiratory function and gastro-oesophageal reflux also require consideration. Intellectual disability is common and, in those affected, may range from mild to severe. These children should be handled with sensitivity as communication disorders and sensory deficits may mask mild or normal intellect. They should be accompanied by their carers at induction and in the recovery room as they usually know how best to communicate with them. Postoperative pain management and the prevention of muscle spasm is important and some of the drugs used in the management of spasm such as baclofen and botulinum toxin are discussed. Epidural analgesia is particularly valuable when major orthopaedic procedures are performed.

Notes: A multicentre trial of the use of the intubating laryngeal mask was carried out at seven centres in the United Kingdom using the same agreed protocol. Lung ventilation followed by blind tracheal intubation through the intubating laryngeal mask was attempted on 500 ASA grade 1 and 2 patients. It was possible to insert the intubating laryngeal mask in all 500 cases. Ventilation via the intubating laryngeal mask was described as satisfactory in 475 (95%) cases, difficult in 20 (4%) cases and unsatisfactory in 5 (1%) cases. Blind tracheal intubation through the intubating laryngeal mask was possible in 481 (96.2%) cases within three attempts. Intubation was successful at the first attempt in 399 (79.8%) cases, at the second attempt in 62 (12.4%) cases and at the third attempt in 20 (4%) cases. The tracheas of 19 (3.8%) patients were not successfully intubated within the three attempts. Ventilation via the intubating laryngeal mask was described as unsatisfactory during two of these cases but oxygenation remained satisfactory in spite of this. Seventeen of the 19 failures occurred during the individual operator's first 20 attempts. The intubating laryngeal mask provides a successful method for blind tracheal intubation in a large proportion of cases and appears to be superior to the standard laryngeal mask airway for this purpose. The intubating laryngeal mask may be of use when tracheal intubation has failed using conventional methods.

Notes: We have evaluated the Airway Management Device (AMD™) in 105 anaesthetised patients. We were successful in establishing a clear airway on the first attempt on 69 occasions and unable to establish a patent airway at all in 10 patients. Airway obstruction requiring removal of the device occurred during maintenance of anaesthesia in a further two cases and during emergence in three. Loss of the airway during anaesthesia occurred in eight of 95 patients and could be reversed by manipulation of the airway in six cases. Overall, a mean of 0.56 manipulations per patient were required to establish an airway and a further 0.42 per patient were required during maintenance of anaesthesia. In the 95 patients in whom an airway was established, assisted ventilation was satisfactory in 93, with a leak pressure above 20 cmH2O in 65. Intracuff pressure was measured in 12 cases and was above 100 cmH2O in eight. Minor complications occurred in 12 patients. Blood was visible on removal of the device in six cases.

Notes: We were interested in recent correspondence relating to reflux of gastric contents into the drain tube of the Pro-Seal laryngeal mask airway (Dalgleish & Dolgner. Anaesthesia 2001; 56: 1010). As part of a trial comparing performance of the Pro-Seal with the classic laryngeal mask airway we inserted a gastric tube into the drain tube of 30 Pro-Seal laryngeal mask airways in elective surgery patients. All patients were starved for 6 h for solids and 3 h for fluids. In all cases, fibre-optic examination of the drain tube and the oesophagus below was undertaken before passage of the gastric tube. On no occasion was gastric content seen in the drain tube or in the upper oesophagus. Gastric fluid was aspirated in 29 of 30 cases with a median volume of 22 ml and a range of 0–85 ml. In none of the cases was there any suggestion of clinical regurgitation or aspiration.In a recent case in our intensive care unit, a Pro-Seal was being used to allow endoscopic guidance during a percutaneous tracheostomy. The patient had been nasogastrically fed and the stomach was aspirated before the procedure. During dilation of the trachea, some nasogastric feed was vented a considerable distance out of the drain tube. Since the endoscope was at the glottic opening during this episode of regurgitation, it was possible to confirm, under direct vision, that there was no laryngeal or tracheal soiling.Large studies and meta-analysis has suggested that the incidence of aspiration of gastric contents when using a classic laryngeal mask airway is approximately 0.05–0.009% [1, 2]. A recent editorial on mechanical ventilation via the laryngeal mask airway rather speculatively suggested that aspiration of gastric contents might occur in up to 360 patients per year in the UK [3] and implied that such practice could not be considered entirely safe. The choice of whether to use a laryngeal mask airway when artificially ventilating a patient varies considerably in UK practice [4].If elective cases may have significant volumes of gastric fluid, and there is some doubt as to whether ventilation via the classic laryngeal mask airway is safe, then the Pro-Seal is likely to be a valuable addition to the airway armamentarium. Laryngeal seal pressure is increased by approximately 50% [5] and the drain tube allows easy and reliable access to the stomach [5]. In addition, the drain tube might be expected to vent gas leaking into the oesophagus reducing gastric dilation, although this is untested. Should regurgitation occur, the drain tube may allow venting of regurgitated material and its appearance in the drain tube may act as an early warning.However, these potential advantages have not been rigorously examined and it is therefore too early to be sure of the role of the Pro-Seal in anaesthetic practice. What evidence is there that the Pro-Seal allows a greater margin of safety in the event of regurgitation? At present there is little; we are aware of three cases in which regurgitated matter has appeared in the drain tube without laryngeal or tracheal soiling (A. Brain, Personal communication). Drs Dalgleish and Dolgner's report brings the total to four, but is the first to be published. In addition, a study in cadavers [6] supports the contention. A study, at present only presented at a meeting, of the use of the Pro-Seal for laparoscopic cholecystectomy showed no more gastric distension than with a tracheal tube (Maltby JR, Beriault MT, Watson NC, Liepert DJ, Fick GH. Laparoscopic cholecystectomy: LMA-Proseal vs. tracheal intubation. Poster presentation. Canadian Anaesthesiologist's Congress 2001, Halifax, Canada).If we wait for a controlled study between the two devices to give us the answer, it will be a long wait. If the incidence of aspiration during anaesthesia while ventilating through the classic laryngeal mask is 1 in 11 000 cases, as has recently been suggested [3] and this␣number can be halved by using the Pro-Seal, this would reduce the number of such cases in the UK by 180 per year. Conducting a trial to detect such a reduction, however, would require approximately 1.3 million patients in each group.

Notes: Arterial oxygen tension and mean arterial blood pressure were measured during total hip replacement with either cemented n = 10) or uncemented components (n = 10). All surgery was performed under general anaesthesia. Compared with baseline values, mean arterial oxygen tension decreased by 16% (p 〈 0.05) and mean arterial pressure increased by 23% (p 〈 0.05) and 20% (p 〈 0.05) after insertion of cemented acetabular and femoral components, respectively. In the uncemented group, arterial oxygen tension and mean arterial pressure remained unchanged after insertion of both components. This implies that for some patients, particularly those with cardiovascular or respiratory disease, the risk of significant immediate complications may be lower with the insertion of uncemented, rather than cemented, components.