Airway Anesthesia Research Articles

Comparison of ultrasound and anatomical landmark-guided technique for superior laryngeal nerve block to aid awake fibre-optic intubation: A prospective randomised clinical study.

Background and Aims:Ultrasonography has emerged as a novel, portable, non-invasive tool encouraging airway assessment and procedural interventions. This study assesses the feasibility of ultrasound for block of internal branch of superior laryngeal nerve (ibSLN) block during upper airway anaesthesia to aid awake fibre-optic intubation.Methods:Forty American Society of Anesthesiologists’ physical status I–II patients, aged 18–60 years, deemed to have a difficult airway (modified Mallampati class III–IV or inter-incisor distance <2.5 cm) and planned for awake fibre-optic intubation were randomised to either landmark group (L, n = 20) or ultrasound group (U, n = 20). All patients received nebulised 4% lignocaine (3 mL) and transtracheal injection 3 mL 2% lignocaine. Group L received landmark-guided bilateral ibSLN block with 1 mL 2% lignocaine. Group U received bilateral ibSLN block with 1 mL 2% lignocaine using a high-frequency ultrasound transducer to define the SLN space. The primary objective was assessment of quality of airway anaesthesia. Secondary objectives were time for intubation, haemodynamic parameters and patient perception of discomfort during procedure.Results:The quality of anaesthesia was significantly better in Group U than in Group L (P < 0.001). The mean time for intubation was shorter in Group U (71.05 ± 9.57 s) compared to Group L (109.05 ± 30.09 s, P < 0.001). Heart rate, mean arterial pressure and patient perception of discomfort were significantly increased in Group L.Conclusion:Ultrasound for ibSLN block as a part of preparation for awake fibre-optic intubation improves quality of airway anaesthesia and patient tolerance.

Study of the laryngeal mask airway for airway management in childrenwith acute severe tracheobronchial foreign body

Objective:To explore the application of laryngeal mask airway in the management of respiratory tract after acute and severe tracheal foreign body removal in children, and to provide a safe and effective treatment for clinical treatment.Method:Seventy cases of children with acute severe tracheal or bronchial foreign body requiring mechanical ventilation transition were randomized to receive, one group was using laryngeal mask airway for airway management after the foreign body was extracted and the bronchoscope was pulled out. Another group was using tracheal intubation. Both groups were received the same general anesthesia induction and maintenance. The blood pressure before induction, before and after insertion of LMA (TT), before and after extubation of LMA(TT) were monitored and recorded. Heart rate, tidal volume,respiratory rate,pulse oxygen saturation, and end-tidal carbon dioxide partial pressure were recorded at the same time in both groups. Airway complications during the recovering between two groups were compared.Result:HR, BP have no significant difference in LMA group before and after implantation LMA (P> 0.05). HR and BP were increased significantly after intubation (P< 0.05) in TT group; Airway pressure, SpO₂ and PET CO₂ exhibited no significant difference between two groups P> 0.05); LMA group has less airway complications than TT group during the recovering.Conclusion:Application of LMA for anesthetic airway management after tracheobronchial foreign body was extracted in children made both less effect on respiratory and circulatory system the regular using tracheal intubation and less damage to the respiratory tract. In addition,the recovery time in LMA group is much shorter than that of TT group.

Abstract PR529

Background & Objectives: Airway management remains one of the most important responsibilities of an anaesthesiologist. The purpose of this study was to compare preoperative anaesthetic airway evaluation methods of Modified Mallampati Test (MMT) and Upper Lip Bite Test (ULBT) to predict difficult intubation with the direct laryngoscopy views obtained during tracheal intubations. Materials & Methods: 200 patients (of either sex aged between 18 years and 55 years) undergoing elective surgical procedures under general anaesthesia with endotracheal intubation were evaluated for both tests before surgery. An experienced anesthesiologist, unaware of preoperative airway evaluation, performed the laryngoscopy and grading (as per Cormack and Lehane’s classification). Sensitivity, specificity, accuracy, positive and negative predictive values of upper lip bite test and Modified Mallampati test were calculated. Results: On comparing both the tests, we found that, MMT is more sensitive (75.00%) than ULBT (25.00%), both tests had high specificity (MMT 91.30%; ULBT 95.11%). Positive predictive value was 42.86% for MMT while it was 30.77% for ULBT. Similarly negative predictive value was 97.67% and 93.58% for MMT and ULBT respectively. Accuracy of MMT was 90.00% for MMT while it was 89.5% for ULBT. Conclusion: Both the tests are poor predictors of difficult intubation (low positive predictive values) when used as single preoperative bedside screening tests. MMT is a better test at predicting difficult endotracheal intubation when compared to ULBT. Both the tests are better predictors of easy intubations rather than difficult intubations (high negative predictive value).

How does early compare with late removal of the laryngeal mask airway for general anesthesia?

How does early compare with late removal of the laryngeal mask airway for general anesthesia?

Laryngeal Mask Airway Anaesthesia in Hypotonic Cases with Expected Difficult Intubation.

Laryngeal Mask Airway Anaesthesia in Hypotonic Cases with Expected Difficult Intubation.

Awake nasotracheal fiberoptic intubation and self-positioning followed by anesthesia induction in prone patients: A pilot observational study.

Anesthesia followed by placement in the prone position takes time and may result in complications. This study aimed to evaluate the feasibility of awake nasotracheal fiberoptic intubation and self-positioning followed by anesthesia induction in prone-positioned patients under general anesthesia.Sixty-two patients (ASA physical status I–II) scheduled for awake nasotracheal fiberoptic intubation and prone self-positioning before surgery under general anesthesia were selected. Patient preparation began with detailed preoperative counseling regarding the procedure. Premedication with sedative and antisialagogue was followed by airway anesthesia with topical lidocaine; then, awake nasotracheal fiberoptic intubation was carried out. The patients then positioned themselves comfortably before induction of general anesthesia. The changes in systolic blood pressure (SBP), diastolic blood pressure (DBP), heart rate (HR), incidence of coughing or gagging, and rate pressure product (RPP) were assessed. Statistical analysis was performed with repeated-measures one-way analysis of variance.Fifty-eight of the 62 patients completed prone self-positioning smoothly. Compared with values before intubation, SBP, DBP, HR, and RPP were slightly increased after intubation, although the difference was not statistically significant (P > 0.05). One patient had moderate coughing and 1 patient had gagging during prone self-positioning, which were tolerable.These findings indicated that awake nasotracheal fiberoptic intubation and self-positioning followed by induction of anesthesia is safe and feasible alternative to routine prone positioning after induction of general anesthesia.

A Germany-wide survey on anaesthesia in thoracic surgery

This study's objective was to evaluate current thoracic anaesthesia practice in Germany and to quantify potential differences depending on the hospital's level of care. A four-part online survey containing 28questions was mailed to all anaesthesiology department chairs (n= 777) registered with the German Society of Anaesthesiology and Intensive Care Medicine. The general response rate was 31.5 % (n= 245). High monthly volumes (>50operations/month) of intrathoracic procedures, performed by specialized thoracic surgeons are mostly limited to hospitals of maximum care, university hospitals, and specialized thoracic clinics. In hospitals with a lower level of care, intrathoracic operations occur less frequently (1-5/month) and are commonly performed by general (69.3 %) rather than thoracic surgeons (15.4 %). Video-assisted thoracic surgeries are the most invasive intrathoracic procedures for most hospitals with a low level of care (61.5 %). Extended resections and pneumonectomies occur mainly in hospitals of maximum care and university hospitals. Thoracic anaesthesia is primarily performed by consultants or senior physicians (59.9 %). The double lumen tube (91.4 %) is the preferred method to enable one-lung ventilation (bronchial blockers: 2.7 %; missing answer: 5.9 %). A bronchoscopic confirmation of the correct placement of a double lumen tube is considered mandatory by 87.7 % of the respondents. Bronchial blockers are available in 64.7 % of all thoracic anaesthesia departments. While CPAP-valves for the deflated lung are commonly used (74.9 %), jet-ventilators are rarely accessible, especially in hospitals with a lower level of care (15.4 %). Although general algorithms for a difficult airway are widely available (87.7 %), specific recommendations for a difficult airway in thoracic anaesthesia are uncommon (4.8 %). Laryngeal mask airways (90.9 %) and videolaryngoscopy (88.8 %) are the primary adjuncts in store for a difficult airway. While hospitals with a lower level of care admitted patients routinely (92.3 %) to an intensive care unit after thoracic surgery, larger clinics used the postanaesthesia recovery room (12.5 %) and intermediate care units (14.6 %) more frequently for further surveillance. Thoracic epidural catheters (85.6 %) are predominantly chosen for peri- and postoperative analgesia, in contrast to paravertebral blockade (single shot: 8.6 %; catheter: 8.0 %) (multiple answers possible). Ultrasound is generally accessible (84.5 %) and mostly employed for the placement of central venous (81.3 %) and arterial (43.9 %) lines as well as a diagnostic tool for pulmonary pathology (62.0 %). The study reveals considerable differences in the anaesthetic practice in thoracic surgery. These focus mostly on the postoperative surveillance, the availability of bronchial blockers, and the use of regional anaesthetic techniques. Furthermore, it is evident that specific algorithms are needed for the difficult airway in thoracic anaesthesia. A recommendation for the high-tech work environment of thoracic anaesthesia could enhance the structural quality and optimize patient outcomes. Independent of a hospital's level of care, uniform requirements could help establish national quality standards in thoracic anaesthesia.

Application of laryngeal mask airway anesthesia combined with sacral canal block in pediatric surgery

Objective To observe differences between the application of laryngeal mask anesthesia combined with sacral canal block and single intratracheal anesthesia in African pediatric surgery and provide references for child anaesthesia. Methods Sixty 4-6 year-old children for lower abdominal or lower limb surgerywere randomly divided into two groups(n=30): laryngeal mask airway anaesthesia combined with sacral canal block group(group A) and single intratracheal anaesthesia group(group B). MAP, HR and SpO2 were recorded before induction of anaesthesia(T0), before and after intubation of laryngeal mask airway or tracheal tube (T1, T2) and after removal of laryngeal mask airway or tracheal tube(T3). The waking-up time, VAS pain scores and adverse reaction were recorded after surgery. Results There were no significant differences in MAP, HR and SpO2 between the two groups at T0 and T1 (P>0.05). The MAP and HR [(68±10) mmHg(1 mmHg=0.133 kPa), (108±17) bpm] values in group A were significantly lower than the MAP and HR [(91±8) mmHg, (139±18) bpm] values in group B at T2(P<0.05). The MAP and HR [(67±9) mmHg, (121±16) bpm] values in the group A were also significantly lower than the MAP and HR [(85 ± 9) mmHg, (141 ± 17) bpm] values in the group B at T3(P<0.05). The postoperative VAS values (1.5±0.5) in groups A were significantly lower than values (6.5±1.5) in the group B (P<0.05). The waking-up time [(5.8±2.4) min] in group A was significantly shorter than the time [(12.2±2.8) min] in group B (P<0.05). There are only 4 cases of postoperative agitation in group A which was significantly lower than that in group B (P<0.05). The frequencies of postoperative cry and cough in group A were significantly lower than that in group B. Conclusions The general anesthesia via laryngeal mask airway combined with sacral canal block in children during the induction and the waking-up time guaranteed more stable hemodynamics and significantly reduce postoperative pain, the waking-up time significantly shorten, significantly reduce the incidence of postoperative mania ,so it is an more ideal anesthesia methed in lower abdominal or lower limb surgery. Key words: Laryngeal mask airway; Anesthesia, general; Sacral canal block; African child

Topical Nasal Anesthesia in Flexible Bronchoscopy--A Cross-Over Comparison between Two Devices.

IntroductionTopical airway anesthesia is known to improve tolerance and patient satisfaction during flexible bronchoscopy (FB). Lidocaine is commonly used, delivered as an atomized spray. The current study assesses safety and patient satisfaction for nasal anesthesia of a new atomization device during outpatient bronchoscopy in lung transplant recipients.MethodsUsing a prospective, non-blinded, cross-over design, patients enrolled between 01-10-2014 and 24-11-2014 received 2% lidocaine using the standard reusable nasal atomizer (CRNA). Those enrolled between 25-11-2014 and 30-01-2015, received a disposable intranasal mucosal atomization device (DIMAD). After each procedure, the treating physician, their assistant and the patient independently rated side-effects and satisfaction, basing their responses on visual analogue scales (VAS). At their next scheduled bronchoscopy during the study period, patients then received the alternative atomizer. Written consent was obtained prior to the first bronchoscopy, and the study approved by the institutional ethics committee.ResultsOf the 252 patients enrolled between 01-10-2014 and 30-01-2015, 80 (32%) received both atomizers. Physicians reported better efficacy (p = 0.001) and fewer side effects (p< = 0.001) for DIMAD in patients exposed to both procedures. Among patients with one visit, physicians and their assistants reported improved efficacy (p = 0.018, p = 0.002) and fewer side effects (p< = 0.001, p = 0.029) for the disposable atomizer, whereas patients reported no difference in efficacy or side effects (p = 0.72 and p = 0.20). No severe adverse events were noted. The cost of the reusable device was 4.08€ per procedure, compared to 3.70€ for the disposable device.DiscussionTopical nasal anesthesia via a disposable intranasal mucosal atomization device (DIMAD) offers comparable safety and patient comfort, compared to conventional reusable nasal atomizers (CRNA) in lung transplant recipients. Procedural costs were reduced by 0.34€ per procedure.Trial Registrationclinicaltrials.gov NCT02237651

UPPER AIRWAY BLOCKS FOR AWAKE DIFFICULT AIRWAY MANAGEMENT

Airway anesthesia is pivotal for successful awake intubation provided either topically or by blocks. Airway blocks are considered technically more difficult to perform and carry a higher risk of complications. However, in experienced hands, they can be useful as they provide excellent intubating conditions. For complete upper airway anesthesia, bilateral glossopharyngeal and superior laryngeal nerve blocks with translaryngeal injection are required. Superior laryngeal nerve block and translaryngeal injection can be performed easily, safely and with a high success rate in patients with normal anatomy. In those with difficult landmarks, ultrasound can be of assistance. For the superior laryngeal nerve block, other targets than the nerve itself must be established to make the technique consistently successful, easy to teach, learn and perform. The same applies to the translaryngeal injection, where the use of ultrasound is necessary for correct midline identification. Intraoral glossopharyngeal nerve block is also safe and easy to perform, but associated with long lasting discomfort. Bilateral extraoral peristyloid approach should be discouraged since inadvertent blocks of the closely adjacent vagus nerve cannot be prevented in this location. A safe and easy method of blocking the distal portions of the glossopharyngeal nerve for awake intubation is therefore required.

A good laryngeal view does not guarantee perfectly successful tracheal intubation.

Difficult tracheal intubation is the most common factor related to serious airway complications during anesthesia [1]. Difficult tracheal intubation is defined as insertion of the endotracheal tube using direct laryngoscopy that requires more than two attempts lasting more than 10 min each or that requires an alternative technique [2]. The difficult airway involves interactions among patient factors, the clinical setting, and the practitioner's skills [3]. Many alternative tools and techniques have been developed to facilitate intubation in cases of difficult direct laryngoscopy. Among these, videolaryngoscopy (VL) improves glottis visualization using either an optical or video system, which allows communication between the operator and assistants and facilitates teaching; this method is gaining popularity [4]. Recently, VL has begun to be considered as a first-line tool for airway management, rather than as a rescue tool for difficult intubation [3,5,6]. However, VL does not achieve a 100% intubation success rate, and complications have been associated with the procedure [5,7,8]. With VL, the success of intubation lies not in the view obtained, but in the ease of inserting the endotracheal tube. Instead of the Cormack-Lehane scoring system, Swann et al. [9] proposed the Fremantle score, calculated using a three-part scoring system based on the laryngeal view (full, partial, or no view), ease of endotracheal intubation (easy, modified, or unachievable), and device used. The Korean Society of Anesthesiologists should consider the use of this new scoring system and various tools for cases of difficult intubation. In this issue of the Korean Journal of Anesthesiology, Shim et al. [10] compared GlideScope® and McGrath® laryngoscopes in simulated cases of difficult intubation. They used a four-grade videoscopic view. However, they did not precisely describe the grade. In addition, a tube exchanger and vascular forceps were used instead of a rigid stylet, which can be associated with complications [8]. Although a difficult airway was simulated with an extrication collar, actual patients with difficult airways were excluded. In the simulation, the first-attempt success rates were 82.8% (GlideScope® group) and 83.8% (McGrath® group). Failed intubation with the GlideScope® was also reported in this issue of the Korean Journal of Anesthesiology [11]. There was resistance to passage of the endotracheal tube into the larynx with a conventional laryngoscope. The GlideScope® then revealed that a septum divided the subglottic area into two sections. A laryngeal mask did not provide adequate ventilation due to laryngeal edema caused by multiple intubation attempts, and the surgery was postponed. In this case, the patient failed to recall any previous difficulties with anesthesia. The preanesthetic history, chest radiography, and spirometry failed to reveal the patient's tracheal stenosis under the vocal cords. The difficulty grade of direct laryngoscopy was not described; passing the endotracheal tube was impossible due to the unusual trachea. A full view of the larynx was obtained using direct laryngoscopy and the GlideScope®. Considering these two articles, we need to keep in mind that neither the use of VL nor achievement of a laryngeal view guarantees intubation success. Accurately predicting a difficult airway remains as a cornerstone of airway management. Furthermore, considering the recognized associations between a difficult airway and patient characteristics, the patient's medical history may help to predict a difficult airway [3,12]. To avoid airway complications, anesthesiologists should be proficient in the use of a wide range of anesthetic airway techniques and alternative intubation tools and should know how to manage a failed airway, including when and how they will wake the patient in cases of difficulty [1]. In addition, for follow-up care, the anesthesiologist should inform the patient of the airway difficulty that was encountered. A written report that describes the difficult airway, including the apparent reasons for difficulty, how the intubation was finally accomplished, and the implications for future care, is recommended [3]. In conclusion, anesthesiologists should determine a strategy for a difficult intubation. They should assemble a team that can assist one another and make prompt decisions, use the most familiar and skilled tool, and record the findings in detail.

Early versus late removal of the laryngeal mask airway (LMA) for general anaesthesia.

The laryngeal mask airway (LMA) is a safe and effective modality to maintain the airway for general anaesthesia during surgical procedures. The LMA is removed at the end of surgery and anaesthesia, when the patient maintains an adequate respiratory rate and depth. This removal of the LMA can be done either when the patient is deep under anaesthesia (early removal) or only after the patient has regained consciousness (late removal). It is not clear which of these techniques is superior. The objective of this review was to compare the safety of LMA removal in the deep plane of anaesthesia (early removal) versus removal in the awake state (late removal) for participants undergoing general anaesthesia. We searched the Cochrane Central Register of Controlled Trials (CENTRAL; 2014, Issue 8); MEDLINE (1966 to August 2014); EMBASE (1980 to August 2014); LILACS (1982 to August 2014); CINAHL (WebSPIRS; 1984 to August 2014); and ISI Web of Science (1984 to August 2014). We searched for ongoing trials through various trial registration websites. In addition, we searched conference proceedings and reference lists of relevant articles. We included randomized controlled trials (RCTs) on adults and children undergoing elective general anaesthesia using the LMA, that compared early removal of the LMA (defined as removal of the LMA in the deep plane of anaesthesia) versus late removal of the LMA (defined as removal of the LMA after the patient is awake). Two authors independently assessed trial quality and extracted data. We contacted study authors for additional information. We used a random-effects model to generate forest plots from the data. We identified a total of 9188 citations and included 15 RCTs conducted on 2242 participants in this review. All trials used the LMA Classic in American Society of Anesthesiologists (ASA) physical status I or II for patients undergoing elective general anaesthesia. Children were enrolled in 11 trials and adults in five trials. None of the trials were of high methodological quality. Eight of the 15 studies had adequate generation of random sequence, whereas only one trial had adequate concealment of random sequence. Three trials had blinded the outcome assessor. Thus, the majority of the studies appeared to have a high risk of bias in the study design.Using the GRADE approach, we found low quality evidence that the risk of laryngospasm was similar with early removal of the LMA (3.3%) versus late removal (2.7%): risk ratio (RR) 1.23, 95% confidence interval (CI) 0.74 to 2.03; 11 trials, 1615 participants. The quality of evidence was very low that the risk of coughing was less after early removal (13.9%) than late removal (19.4%): RR 0.52, 95% CI 0.29 to 0.94; 11 trials, 1430 participants. The quality of evidence for the risk of desaturation was also very low; there was no difference between early removal (7.9%) and late removal (10.1%): RR 0.68, 95% CI 0.4 to 1.16; 13 trials, 2037 participants. We found low quality evidence that the risk of airway obstruction was higher with early removal (15.6%) compared to late removal of the LMA (4.6%): RR 2.69, 95% CI 1.32 to 5.5; eight trials, 1313 participants. This systematic review suggests that current best evidence comparing early versus late removal of the LMA in participants undergoing general anaesthesia does not demonstrate superiority of either intervention. However, the quality of evidence available is either low or very low. There is a paucity of well designed RCTs and a need for large scale RCTs to demonstrate whether early removal or late removal of the LMA is better after general anaesthesia.

Efficacy of Ambu AuraOnce laryngeal mask airway in Chinese patients undergoing general anesthesia

Objective To evaluate the efficacy of Ambu AuraOnce laryngeal mask airway (LMA) in Chinese patients undergoing general anesthesia. Methods Fifty-six female patients, aged 20-64 yr, weighing 45-75 kg, of American Society of Anesthesiology physical statusⅠor Ⅱ (MallampatiⅠ-Ⅲ), scheduled for elective breast surgery under general anesthesia, were equally and randomly divided into either Ambu AuraOnce LMA group (group A) or LMA Supreme group (group S) using a random number table. After induction of anesthesia, Ambu AuraOnce LMA was inserted in group A, and LMA Supreme was placed in group S. After successful placement of LMA, correct position was confirmed by fiberoptic laryngoscopy. Intermittent positive pressure ventilation was performed during surgery to maintain pulse oxygen saturation > 95% and partial pressure of end-tidal CO2 at 30-45 mmHg. The success rate, insertion time, extubation time, airway sealing pressure, peak airway pressure and occurrence of air leakage of LMA were recorded. After removal of the LMA, the blood stains on the LMA were checked, and the occurrence of hypoxemia, regurgitation, nausea, vomiting and bucking was recorded. The occurrence of sore throat, hoarseness and dysphagia was also recorded within 24 h after surgery. Results There were no significant differences in terms of insertion time, overall success rate, success rate at first attempt, removal of LMA time, airway sealing pressure, and incidence of air leakage of LMA, hypoxemia, blood stains on the LMA, sore throat, hoarseness and dysphagia between the two groups. The rate for correct position of LMA confirmed by fiberoptic laryngoscopy was significantly higher in group A than in group S. Conclusion Ambu AuraOnce LMA can safely and effectively be applied for airway management in Chinese patients undergoing general anesthesia. Key words: Laryngeal masks; Respiration, artificial; Anesthesia, general

Brochoscopy Intervention using Laryngeal Mask Airway in Infant for Severe Airway Stenosis

Fibreoptic bronchoscopy (FB) and laryngeal mask airway (LMA) have been used successfully in children since the early 1980s [11. Wood RE, Postma D (1988) Endoscopy of the airway in infants and young children. J Pediatr 112: 1-6.,22. Brain AI (1983) The laryngeal mask-a new concept in airway management. Br J Anaesth 55: 801-805.]. The paediatric fibreoptic bronchoscopy visa laryngeal mask airway (LMA) in general anesthesia was established in 1990s [33. Smyth AR, Bowhay AR, Heaf LJ, Smyth RL (1996) The laryngeal mask airway in fibreoptic bronchoscopy. Arch Dis Child 75: 344-345.,44. Wood RE (1996) Pediatric bronchoscopy. Chest Surg Clin N Am 6: 237-251.]. Although previous studies have shown some experience on FB in infant, conclusive effects on bronchoscopy intervention are unknown. We report the use of laryngeal mask airway (LMA) to guide electric bronchoscopy interventions (EBI) while maintaining an adequate depth of anesthesia and effective ventilation in small infant who was diagnosed of having severe airway stenosis from computed tomography (CT) scan.

Nebulized lidocaine and fentanyl before sevoflurane induction of anesthesia in congenital diaphragmatic hernia repair: Prospective double blind randomized study

IntroductionGastric overdistension by mask ventilation during induction of anesthesia in congenital diaphragmatic hernia (CDH) repair may worsen hypoxemia. Topical airway anesthesia may improve the intubating conditions during sevoflurane induction without muscle relaxation.The present study was designed to evaluate the effect of nebulized lidocaine and fentanyl on the intubating conditions without muscle relaxation during sevoflurane induction of anesthesia in infants undergoing CDH repair. The secondary aim was studying hemodynamic changes during induction.Patients and methodsForty patients scheduled for (CDH) repair were randomly selected and blindly categorized to the following: Nebulizer group: Nebulized solution of 4 mg kg−1 lidocaine 1% plus 2 μg kg−1 fentanyl, Control group: Nebulized solution of comparable volume/weight normal saline 0.9%. Nebulizer of either solution was applied 15 min before sevoflurane induction.ResultsHeart rate (HR) and mean arterial blood pressure (mABP) statistically significantly increased in the control group following intubation and for 2 min regarding HR and for 5 min regarding mABP in comparison with the base line and relative to the nebulizer group. There was a statistical significant improvement regarding the intubation conditions in the nebulizer group relative to the control group (p ⩽ 0.001). The same was noticed regarding the intubation time and the number of intubation attempts (p ⩽ 0.001).ConclusionsPremedication of infants undergoing CDH repair with nebulized solution containing 4 mg kg−1 lidocaine 1% plus 2 μg kg−1 fentanyl improves the intubating conditions under inhalational sevoflurane induction without muscle relaxation. The studied combination can suppress patients’ hemodynamic changes to intubation.

Flexible fibreoptic bronchoscope and the difficult airway: A case report

BACKGROUND: Management of the difficult airway will always confront the anaesthetist. This is one area of the practice that the anaesthetist is required to develop divers skills suited for each clinical situation. The ability to use the flexible fibreoptic bronchoscope (FOB) presents the anaesthetist with an addition tool to conduct endotracheal intubation when faced with a difficult airway.&#x0D; OBJECTIVE: To demonstrate the effectiveness of the flexible fibreoptic bronchoscope in the management of the difficult airway.&#x0D; CASE REPORT: A 21-year old male farmer who presented with a 2-year history of a slowly increasing left-sided jaw swelling. The swelling was painless with protrusion into the oral cavity. There was limited mouth opening but no history of trauma. Examination revealed a clinically ill-looking patient who was not in respiratory distress. Interincisor distance was less than 3cm with associated dental anarchy and a large tumour mass in the oral cavity. Cardiorespiratory findings were within normal limits. Radiology revealed translucency of the mandible with multiloculated “soap bubble” appearance. Histology showed typical characteristics of ameloblastoma of the plexiform type.The flexible FOB was checked before the patient was bought into the theatre. An intravenous access was established and a multi-parameter monitor was attached to the patient. Baseline vital signs were within normal limits. Premedication was with intravenous atropine, diazepam and fentanyl.Using a combination of inhalational and airway anaesthesia, with patient breathing spontaneously, flexible FOB was used to effect right nasotracheal intubation with a size 7.0mm cuffed endotracheal tube. The cuff was inflated and the tube secured with adhesive tape. Anaesthesia was augmented with sodium thiopentone and pancuronium bromide was given to achieve muscle relaxation. Left-hemimandibulectomy was done with disarticulation of the left temporomandibular joint. The patient was extubated fully awake after suctioning and reversal of residual relaxation. Postoperative analgesia was with intramuscular pentazocine and diclofenac. The patient was discharged home after ten days.&#x0D; CONCLUSION: The use of the flexible FOB can be very effective in the management of the difficult airway and the modern anaesthetist must strive to acquire the necessary skill needed to use it.

When may systematic reviews and meta-analyses be considered reliable?

When may systematic reviews and meta-analyses be considered reliable?

Anesthetic Management of a Child with Simpson-Golabi-Behmel Syndrome—A Case Report

Simpson-Golabi-Behmel syndrome (SGBS) is an X-linked recessive condition associated with pre-natal and postnatal overgrowth with visceral and skeletal anomalies. Abnormal airway anatomy may complicate the perioperative management of SGBS. However, there have been few reports regarding the anesthetic management of children with SGBS. We present the preoperative evalua-tion and intraoperative management of a 1.5-year-old child with SGBS undergoing plastic surgery for cleft palate. Sevoflurane-fentanyl anesthesia without a neuromuscular blocker was planned, due to the preoperative evaluation that airway management would be complicated by the macroglossia and short neck characteristic of SGBS. Fortunately, there was no difficulty in endotracheal intubation in the present patient due to careful planning of general anesthesia and meticulous airway management. Appropriate preoperative preparation for a difficult airway by the anesthe-siologist can ameliorate the difficulties inherent to the anesthetic management of patients with SGBS.

Clinical Usefulness of Proseal Laryngeal Mask Airway for Anesthesia during Dental Procedures in Children

Although the Proseal laryngeal mask airway (PLMA) has been widely used in anesthesia, little is known about its clinical effectiveness during dental procedures. We describe the clinical feasibility of the PLMA for managing airways in the field of pediatric dentistry. . We reviewed the medical records of children who underwent airway management with the use of the PLMA from January 2011 to December 2012 at an outpatient facility at Seoul National Dental University Hospital. During the study period, the airways of 19 children were managed with the PLMA for dental procedures. During its placement, blood pressure and heart rate were stably maintained. There were no interruptions of the dental procedures. None of the children experienced oxygen desaturation or ventilation difficulty. In one patient, the PLMA was dislodged for a short time, but the problem was easily solved with repositioning. After transferring to the post-anesthetic care unit, there were no incidences of oxygen desaturation or vomiting. All of the children were discharged from the hospital without complications. The PLMA can be successfully used in airway management during dental treatment in children.

Crouzon syndrome: an anesthetic challenge

Crouzon syndrome is a rare hereditary disorder, characterized by craniosynostosis. Management of difficult airway is challenging because of craniofacial abnormalities. Presentation during adulthood is rare. We describe the case of a 37-year-old man with a known case of Crouzon syndrome who was posted for fixation of humerus fracture. The patient was unique because of the presence of kyphoscoliosis with severe restrictive lung functions, atlantoaxial dislocation, and mental retardation, having almost all features of the syndrome. Anesthesia plan A was to use laryngeal mask airway proseal as the patient had adequate mouth opening. Nasal fiberoptic bronchoscopy was contraindicated and regional nerve block was not a feasible option. Plan A was not successful because of obstructed breathing pattern. Plan B of oral fiberoptic bronchoscopy-guided intubation with good airway anesthesia and sedation was successfully managed in the next attempt.