Laryngeal Mask Airway Supreme Research Articles

Gastric Tube Insertion Performance of Second-Generation Supraglottic Airway Devices: A Prospective Manikin Study With Literature Review.

Second-generation supraglottic airway devices (SGAs) are pivotal in airway management, with the ability to accommodate gastric tube (GT) insertion. However, research on GT insertion with SGAs under controlled conditions is limited. This study aimed to evaluate the GT insertion performance of SGAs using a manikin. This prospective study included 32 anesthesiologists in our department, each with more than two years of clinical experience. These anesthesiologists randomly inserted four second-generation SGAs, including i-gel (Intersurgical Ltd., Berkshire, UK), Ambu AuraGain (Ambu, Copenhagen, Denmark), LMA ProSeal (Teleflex Medical, Wayne, PA), and LMA Supreme(Teleflex Medical), all of size 4, into a manikin, followed by GT insertion using Salem Sump™ tubes (Cardinal Health, Dublin, OH) (12 Fr for i-geland 14 Fr for others) until the GT was 55 cm deep at the port entrance. The primary outcome was the difference in GT insertion time, with participants' evaluations. The usual use of second-generation SGAs, including GT insertion, was also surveyed. The differences in GT insertion time among the four SGAs were analyzed using the Friedman test, followed by the Bonferroni method for post-hoc analysis. P < 0.05 was considered significant. The median GT insertion times were 17.2 seconds for i-gel, 9.9 seconds for AuraGain, 18.8 seconds for ProSeal, and 8.9 seconds for Supreme. These times showed significant differences (p < 0.001). Post-hoc analysis revealed that both Supreme and AuraGain had significantly shorter insertion times than i-gel and ProSeal, respectively (p < 0.001). Of the participants, 59% (19/32) evaluated Supreme as the easiest SGA for GT insertion, which is consistent with the observed insertion times. i-gel was the most frequently used SGA, chosen by 72% (23/32) of participants. Additionally, 72% (23/32) of anesthesiologists inserted GTs less than half as often following second-generation SGA placement. Significant differences in GT insertion performance were found among the four second-generation SGAs. According to a survey of participants, second-generation SGAs were often used without GT insertion. Although the differences between products may not be clinically significant, selecting an SGA with easy GT insertion may improve the efficiency and reliability of gastric contentdrainage and enhance the safety of airway management when using SGAs.

An unidentifiably severed LMA supreme: An unanticipated critical incident.

An unidentifiably severed LMA supreme: An unanticipated critical incident.

Comparative study of the clinical performance of two supraglottic airway devices, Laryngeal Mask Airway Supreme and BASKA Balum Mask in adult patients for general anaesthesia

BackgroundThe oropharyngeal leak pressure (OLP) of supraglottic airway devices (SGADs) is an important determinant of their efficacy to provide positive pressure ventilation, whereas the provision to prevent aspiration determines its safety. This study aims to compare the clinical performance of Laryngeal Mask Airway (LMA) Supreme versus BASKA Balum Mask. MethodsSeventy adult patients (18–65 years) posted for elective surgeries general anaesthesia were prospectively randomised into group B (BASKA Mask) and Group S (LMA Supreme). The primary outcome was to measure the OLP at 5 and 30 min after device insertion and secondarily, to compare the ease and time of insertion, number of attempts, leak fraction, anatomical position of the devices, and adverse respiratory event if any. ResultsThe OLP of BASKA Mask was significantly higher than LMA Supreme (31.37 ± 1.73 cmH2O versus 23.6 ± 1.73 cmH2O at 5 min and 35.94 ± 3.84 cmH2O versus 23.71 ± 1.69 cmH2O at 30 min). The time taken to insert BASKA Mask was also less (11.49 ± 2.38 s) than LMA Supreme (14.66 ± 2.79 s). Peak airway pressures were also notably less in group B than group S at both 5 and 30 min after device placement (13.43 ± 1.44 vs 18.66 ± 1.43 cmH2O and 14.91 ± 1.46 vs 21.37 ± 1.88 cmH2O). The leak fraction ranged between 1.5 and 4.3% in both groups. All other parameters studied were also comparable. ConclusionsBASKA Mask had a higher OLP, lower peak pressure, shorter time to insertion than LMA Supreme. The leak fraction, ease of insertion, number of attempts, and anatomical position of the devices were comparable in both groups.

A randomized comparative study to estimate the safety and effectiveness between laryngeal mask airway supreme and I-gel in patients undergoing elective surgeries

Background: Supreme laryngeal mask airway (SLMA) and i-gel airway devices are second generation supraglottic airway devices (SAD) and are good alternatives to intubation during elective surgeries. Aims and Objectives: This study was conducted with the objective of comparing the two SAD with respect to ease of insertion, number of attempts of insertion, insertion time, ease of gastric tube insertion, accompanying hemodynamic changes, incidence of adverse effects like regurgitation, lip and dental trauma, post-operative sore throat, dysphagia, and hoarseness. Materials and Methods: This study was conducted at M.G.M. Medical College and M.Y. hospital, Indore. Eighty patients belonging to ASA class 1 or 2, with Mallampati grading 1 or 2, between age group of 18–60 years and with BMI &lt;30 kg/m2 were selected for the study. After induction of anesthesia, one of the SAD’s (SLMA or i-gel) was inserted following randomization, and accordingly, the patients were divided into two groups of 40 each. Insertion parameters, hemodynamic, and respiratory parameters were noted. Patients were also observed for any possible complication at 1 h and 24 h postoperatively. Results: The Two groups showed no statistically significant difference in terms of demographic characteristics, insertion parameters, hemodynamic, or respiratory parameters (P&gt;0.05). Postoperatively, no significant complications were observed in terms of dental injury, laryngospasm. Ease of gastric tube insertion was found to be more in SLMA group than i-gel and the difference was statistically significant (P=0.0057). Incidence of sore throat after 1 h was found to be more in SLMA group than i-gel group (P=0.048). Conclusion: There was no significant difference between SLMA and i-gel in terms of insertion characteristics and hemodynamic changes. Ease of gastric tube insertion was found to be significantly more in SLMA group than i-gel. Incidence of post-operative sore throat at 1 h was more with SLMA as compared to i-gel.

Evaluation of thyromental distance versus tongue width versus weight-based method for size determination of laryngeal mask airway in adults

Background: Supraglottic airway devices (SGD) are indispensable for airway management. The successful placement of the laryngeal mask airway (LMA) supreme largely depends on the right size selection. Aims and Objectives: The study was undertaken to compare three LMA supreme insertion methods in short elective surgeries under general anesthesia. Materials and Methods: Atotal of 90 American Society of Anesthesiologists I and II patients (either gender, 18–55 years, Mallampati grade I and II) undergoing short surgeries were randomized into three equal groups (n=30 in each). Insertion of LMA was done after an adequate depth of anesthesia for jaw relaxation (Young’s criteria). The efficacy of controlled ventilation through LMA by each method, success rate, ease of insertion, insertion time, additional induction dose (propofol) required during insertion, hemodynamic stability (baseline vitals and 10 min after insertion), and adverse events after LMA removal were evaluated between groups. Results: Better ventilation (tidal volume at 10 cmH2O) was observed in the thyromental group (448±35) than in tongue width (440±46) and weight-based (409±33) groups. Minimum additional propofol requirement during insertion was in thyromental distance group. Thyromental distance group had the most easy LMA insertions (70%) with minimum insertion time (10±4) and minimum additional propofol requirement during insertion (P&lt;0.05) than other groups. Overall hemodynamic stability and incidence of adverse events were comparable. Conclusion: Thyromental distance may be an alternative attractive choice for size determination of LMA supreme in female adults with normal airway anatomy in comparison to tongue width and conventional body weight-based methods.

Comparative evaluation of the clinical performance of supraglottic airways- Supreme laryngeal mask airway, I gel and baska mask

There are no studies comparing Supreme laryngeal mask airway (LMA), I gel and Baska mask in Indian population. A comparison of the clinical performance of Supreme LMA, I gel and Baska mask was undertaken in this randomized controlled study.The present research was undertaken in 75 patients aged 18 to 60 years who underwent elective surgery for less than 3-hour duration under general anaesthesia. The patients were randomly divided into three groups; Supreme LMA, I gel, and Baska mask. The oropharyngeal leak pressure (OLP) after 30 minutes to loss of spontaneous respiration was the primary objective, whereas the secondary objectives were attempts required for insertion of LMA, ease of gastric tube insertion, time required for gastric tube insertion and post-operative morbidity. The mean OLP of Baska mask group was (28.2 cm HO) as compared to Supreme LMA (25.3 cm HO) and I-gel (24.1 cm HO) groups (p-value = 0.0001). The mean gastric tube insertion time of Baska mask group was (20.7 s) as compared to Supreme LMA (6.7 s) and I-gel (9.6 s) groups (p-value = 0.0001). The three groups were comparable with regards to the number of attempts required, ease of gastric tube insertion and post-operative morbidity.A higher OLP was observed in Baska mass group as compared to Supreme LMA and I-gel. The three devices were similar in terms of attempts required for insertion, ease of gastric tube insertion and post-operative morbidity.

Achieving Successful Extubation and Cost-Effective Recovery Following Anesthetic Airway Management in Supracarinal Tracheal Reconstruction Surgeries: A Retrospective Analysis.

Introduction From an anesthesiologist's perspective, perioperative concerns related to supracarinal tracheal reconstruction surgery include having uninterrupted smooth ventilation without any laryngeal edema, glottic dysfunction, and airway leak. Surgical concerns comprise various kinds of anastomotic dissections, fistulas to innominate arteries, and the esophagus. The most serious complication following tracheal surgery is anastomotic separation, which might manifest modestly as stridor, respiratory distress, and extremis. To avoid dire repercussions, prompt management and securing the airway are necessary.Against this background,we wanted tohighlight the importance of early extubation and discharge of supracarinal tracheal reconstruction patients from hospitals without any postoperative complications and with the least expenses possible, since mostof these patients have already undergone postintubation tracheal stenosis and prolonged intensive care unit stay, and have experienced significant financialburden incurring from preceding events. Methodology Medical records of allpatients admitted for tracheal reconstruction during the period from March 2019 toApril 2022(four years)were reviewed to collect patient demographic details, surgical descriptions, anesthesia data, records of pre-anesthetic evaluations, and postoperative details up until the hospital discharge. Results The most common reason for tracheal stenosis among our patients was post-intubation tracheal stenosis (PITS), which was seen in 8/13 patients (61.53%);4/13patients (30.76%)had stridorat rest and underwent emergency tracheostomy preoperatively immediately following admission to the hospital.The stenosis was situated at a median distance of 3 cm [interquartilerange (IQR): 0.5-7] from the true vocal cords or 7 cm (IQR: 3-9) from the carina. The median length of tracheal resection was 2 cm(IQR: 1-4).Weobserved that the mode ofinductionfor airway management was tracheostomytubein four patients (with 90% tracheal stenosis), placement of laryngeal mask airway (LMA) with spontaneous ventilationin four patients (with 75% tracheal stenosis), andsmall-size (#5-7.5sizes) endotracheal tube (ETT) placement in five patients (with less than 75% tracheal stenosis).The postoperative complicationnoted was bleeding from the operative site in 1/13 patients (7.6%); a 0% mortality rate was noted during the hospital stay and up until six months post-discharge. We noted that the median duration of postoperative hospitalizationwas five days (IQR: 2-15), and the total cost incurred by each patientwas less thanINR 85,000 (USD 1,000). Conclusion Our analysis revealed that all our patients were extubated in the operative room andshifted to the ward. In the "open airway phase",standard distal tracheal intubation and cross-field ventilation techniques, and tracheal suturing were facilitated by the apnoea-ventilation-apnoea technique. Both the techniques along with the emergency tracheostomies done in severe tracheal obstruction preoperatively and intraoperative anesthesia management with the insertion of LMA Supreme,maintained with spontaneous breathing techniques, offered potential advantages in the management ofsupracarinal tracheal reconstruction surgeries. The multidisciplinary teamwork along with close communication and good rapport with the surgical team was found to be the key factor in the fast-track extubation and recovery of these patients.

Supreme laryngeal mask airway for cesarean section under general anesthesia: a 10-year retrospective cohort study.

Previous research showed the use of supraglottic airways in obstetric anesthesia. The relevant evidence of laryngeal mask airway (LMA) on maternal and neonatal outcomes is still limited. We aimed to assess the maternal and neonatal outcomes when the LMA Supreme was used for cesarean section under general anesthesia. We included all patients who underwent general anesthesia for cesarean section between January 2010 and December 2019. Propensity score matching was used to reduce potential bias from non-random selection of airway intervention. The primary outcome was adverse maternal and neonatal outcomes defined as maternal regurgitation, aspiration, hypoxemia, and low neonatal Apgar scores. Secondary outcomes included patient admission to the intensive care unit, neonate required tracheal intubation, external cardiac massage, and admission to the neonatal intensive care unit. A total of 723 patients were included in the analysis; of whom, 221 received Supreme laryngeal mask airway (LMA group) and 502 were intubated with an endotracheal tube (ETT group). After propensity score matching, 189 patients remained in each group. No episode of regurgitation and aspiration occurred in both groups. There was no difference in the rates of Apgar score below 7 at 1 min (14.3% LMA group vs. 15.3% ETT group, OR 0.931, 95% CI 0.574 to 1.510, P = 0.772) and 5 min (3.7% vs. 4.2%, OR 0.875, 95% CI 0.324 to 2.365, P = 0.792). No difference was observed in the secondary outcomes between the two groups. The LMA Supreme was not associated with higher adverse maternal and neonatal outcomes when compared to an endotracheal tube for cesarean section under general anesthesia. It might be considered an alternative to tracheal intubation in obstetric practice.

Military Standard Testing of Commercially Available Supraglottic Airway Devices for Use in a Military Combat Setting.

Airway obstruction is the second leading cause of death on the battlefield. The harsh conditions of the military combat setting require that devices be able to withstand extreme circumstances. Military standards (MIL-STD) testing is necessary before devices are fielded. We sought to determine the ability of supraglottic airway (SGA) devices to withstand MIL-STD testing. We tested 10 SGA models according to nine MIL-STD-810H test methods. We selected these tests by polling five military and civilian emergency-medicine subject matter experts (SMEs), who weighed the relevance of each test. We performed tests on three devices for each model, with operational and visual examinations, to assign a score (1 to 10) for each device after each test. We calculated the final score of each SGA model by averaging the score of each device and multiplying that by the weight for each test, for a possible final score of 2.6 to 26.3. The scores for the SGA models were LMA Classic Airway, 25.9; AuraGain Disposable Laryngeal Mask, 25.5; i-gel Supraglottic Airway, 25.2; Solus Laryngeal Mask Airway, 24.4; LMA Fastrach Airway, 24.4; AuraStraight Disposable Laryngeal Mask, 24.1; King LTS-D Disposable Laryngeal Tube, 22.1; LMA Supreme Airway, 21.0; air-Q Disposable Intubating Laryngeal Airway, 20.1; and Baska Mask Supraglottic Airway, 18.1. The limited (one to three) samples available for testing provide adequate preliminary information but restrict the range of failures that could be discovered. Lower scoring SGA models may not be optimal for military field use. Models scoring sufficiently close to the top performers (LMA Classic, AuraGain, i-gel, Solus, LMA Fastrach, AuraStraight) may be viable for use in the military setting. The findings of our testing should help guide device procurement appropriate for different battlefield conditions.

Comparison of dexmedetomidine with fentanyl as intravenous adjuvants to propofol induction for LMA supreme insertion

Comparison of dexmedetomidine with fentanyl as intravenous adjuvants to propofol induction for LMA supreme insertion

Comparison of the supraglottic airway device BlockBusterTM and laryngeal mask airway Supreme in anaesthetised, paralyzed adult patients: a multicenter randomized controlled trial

ABSTRACT Background This multicenter prospective, randomized controlled clinical trial compared the clinical performance of supraglottic airway device (SAD) BlockBusterTM and laryngeal mask airway (LMA) Supreme for airway maintenance in anesthetized, paralyzed adult patients. Methods A total of 651 adult patients scheduled for elective surgery in 13 hospitals were randomly allocated into BlockBuster group (n = 351) or Supreme group (n = 300). The primary outcome was oropharyngeal leak pressure (OLP). Duration and ease of insertion, fiberscopic view of positioning, airway manipulations, and complications were also assessed. Results The OLP was significantly higher in BlockBuster group compared with Supreme group (29.9 ± 4.2 cmH2O vs 27.4 ± 4.3 cmH2O, p < 0.001). Success rate of insertion at the first attempt (90.2% vs 85.1%, p = 0.027), rate of optimal fiberscopic view (p = 0.002) and satisfactory positioning of SAD (p < 0.001) were significantly increased in BlockBuster group. Conclusions Both SAD BlockBusterTM and LMA Supreme are safe, effective, and easy-to-use devices for airway maintenance in anesthetized, paralyzed adult patients, but the SAD BlockBusterTM is superior to LMA Supreme in terms of OLP, success rate at the first attempt, and fiber-optic view of positioning. Trial registration The trial is registered at www.chictr.org.cn (ChiCTR-ONC-16009105).

Comparison of Outcome of Proseal Laryngeal Mask Airway and Supreme Laryngeal Mask Airway in Patients Undergoing Surgery Under General Anaesthesia

Objective: To compare the proseal laryngeal mask airway's performance to that of the supreme laryngeal mask airway in patients undergoing surgery under general anesthesia. Study design: Descriptive-Comparative Study Settings:Department of Anesthesia, Jinnah Postgraduate Medical Centre Karachi Study duration:December 2020 to June 2021 Materials &amp; Methods: It was estimated that 154 patients of both genders were considering elective surgery while under the effect of general anesthesia. They were between the ages of 18 and 60. Patients were not allowed to participate in the trial if they had trouble breathing, were known to have lung or heart problems, were at danger of aspiration, or had a fractured neck spine. Following the acquisition of informed permission, the selected cases were then randomly separated into two groups, one labelled group P and the other designated group S. Group P patients were given a proseal laryngeal mask, which is a form of airway. A supreme laryngeal mask was used by those in Group S. During the first twenty-four hours, the researcher checked on each patient to see if they were coughing or had sore throats. Results: More than 96% of patients with Proseal and 88% of patients with Supreme-LMA were able to successfully insert the device on their first try in our study. When it came to inserting patients, the S-LMA group performed better than the others (19.17 2.69 min vs. 23.16 1.73 min). When comparing the adverse effects of Proseal-LMA and Supreme-LMA, we found that 27.27 Vs 20.78 percent reported cough, 18.18 Vs 12.99 percent blood stains, and 20.78 Vs 3.90 percent painful throat respectively. Conclusion: The results of this study show that the supreme laryngeal mask airway is superior than the proseal laryngeal mask airway in patients undergoing surgery under general anesthesia. Keywords: general anesthesia, supreme laryngeal mask airway, outcome.

Hemodynamic Changes during Traditional Awake Extubation and Extubation Using LMA Supreme in Controlled Hypertensive Patients

Background: Anesthesia is quite remarkable and attenuation of pressor response is one of the most keenly researched subjects in the field of anaesthesiology, the reason being the non-availability of a ‘procedure/drug of choice’ for the same. Patients with arterial hypertension generally exhibit excessive pressor response to stress such as laryngoscopy, intubation, surgical incision and extubation, which can lead to arrhythmias, myocardial ischemia and cerebrovascular accidents. Exchange extubation with LMA Supreme can be used to overcome or blunt the excessive pressor response following extubation. Objective: To compare the hemodynamic changes during traditional awake extubation and extubation using LMA supreme in controlled hypertensive patients. Methods: The prospective study was carried out in the department of Anaesthesiology, Shaheed Tajuddin Ahmad Medical College Hospital, Gazipur, Bangladesh from January to December-2021. Fifty (50) patients were randomized by permuted blocks into two groups. After complete pre- anesthetic check-up and investigations. Controlled hypertensive patients with ASA (American Society of Anesthesiologists) grade II, between the age of 17 and 65 years, undergoing elective, non-oral surgery were included in the group. Hemodynamic stress response between traditional awake extubation of the endotracheal tube (ETT) and that following exchange extubation of ETT by using a laryngeal mask airway (LMA Supreme) in terms of Post Extubation Heart Rate (H.R), Systolic Blood Pressure (S.B.P), Diastolic Blood Pressure (D.B.P), Mean Arterial Pressure (MAP), to determine whether this method is easy to perform, the amount of experience needed to perform the exchange well and to calculate the time delay in extubation caused by adopting this method. Results: There was highly significant increase in pulse rate in Group A (ETT Group) as compare to LMA SupremeTM group, which was statistically significant till 15min. of extubation. Statistically ...........

Comparison of the Jcerity Endoscoper Airway with the LMA supreme for airway management in patients undergoing cerebral aneurysm embolization: a randomized controlled non-inferiority trial

BackgroundJcerity Endoscoper Airway is a new back-open endoscopic laryngeal mask airway device with a unique design. Our study sought to compare the implantation, ventilation quality and complications of JEA (Jcerity Endoscoper airway) versus LMA (Laryngeal Mask Airway) Supreme in the procedure of cerebral aneurysm embolization.MethodsIn this prospective, randomised clinical trial, 182 adult patients with American Society of Anesthesiologists class Ι-II scheduled for interventional embolization of cerebral aneurysms were randomly allocated into the Jcerity Endoscoper airway group and the LMA Supreme group. We compared success rate of LMA implantation, ventilation quality, airway sealing pressure, peak airway pressure, degree of blood staining, postoperative oral hemorrhage, sore throat and other complications between the groups.ResultsThere were no significant differences between the groups in terms of one-time success rate of LMA implantation, ventilation quality, airway sealing pressure or airway peak pressure. However, LMA Supreme group showed a higher degree of blood staining than the JEA group when the laryngeal mask airway was removed (P = 0.04), and there were also more oral hemorrhages and pharyngeal pain than JEA group (P = 0.03, P = 0.02). No differences were observed between groups in terms of other airway complications related to the LMA.ConclusionsThe JEA could not only achieve comparable one-time success rate of implantation and quality of ventilation as the LMA Supreme, but also have lower blood staining degree of mask and less sore throat in patients undergoing perioperative anticoagulation for cerebral aneurysm interventional embolization.Trial registrationChinese Clinical Trial Registry, ChiCTR2100044133; Registered 11/03/2021.Statement: This study adheres to CONSORT guidelines.

Comparison of the third-generation streamlined liner of the pharynx airway (SLIPA-3G) with the laryngeal mask airway supreme for laparoscopic cholecystectomy: a randomized prospective study

BackgroundThe third-generation streamlined liner of the pharynx airway (SLIPA-3G) is a new-generation supraglottic airway device (SAD) that is non-cuffed and disposable, with a sealing pressure that varies dynamically with the airway pressure. This study compared the SLIPA-3G with the laryngeal mask airway supreme (LMAS) in patients undergoing laparoscopic cholecystectomy.MethodsTwo hundred and twenty patients scheduled for laparoscopic cholecystectomy were randomly allocated to either the SLIPA-3G group or the LMAS group. Data were collected on the patients’ hemodynamic parameters at different time points, ease of insertion, fiberoptic view, oropharyngeal leak pressure (OLP) at different time points and SAD-related complications.ResultsThe mean OLP immediately after device placement in the LMAS group was significantly higher than that of the SLIPA-3G group (31.34 ± 6.99 cmH2O vs.28.94 ± 6.01 cmH2O, P = 0.008, 95% CI 0.62–4.17). The OLPs of the two groups were not significantly different after the induction of a pneumoperitoneum until the end of surgery. The OLP increased gradually through the course of the operation in the SLIPA-3G group (P value = 0.035) but not in the LMAS group (P value = 0.945). There was no significant difference between the two groups in hemodynamic parameters, insertion time and success rate, fiberoptic view and complication rate.ConclusionsThe SLIPA-3G and LMAS were associated with comparable OLPs, hemodynamic parameters, ease of insertion, fiberoptic views and complication rates when used during laparoscopic cholecystectomy. The SLIPA-3G can be used as an effective alternative to the LMAS in patients undergoing laparoscopic surgeries.

Airway hitches and management in Maroteaux-Lamy syndrome.

Dear Editor, Maroteaux-Lamy Syndrome (mucopolysaccharidosis type VI [MPS VI]) is caused by deficiency of N-acetylgalactosamine-4-sulfatase resulting in accumulation of dermatan sulfate which evokes the varied spectra of clinical symptoms.[1] Dysmorphic facial features with multi-systemic involvement pose a formidable challenge to anesthetists. We present a case of an 8-year-old female child with progressive bilateral flexion deformity of fingers, mouth breathing and snoring. She was posted for cervical (C1-C2) fixation surgery. Child had coarse facial features, macrocephaly (head circumference: 60 cm), macroglossia, short neck (thyromental distance: 4.5 cm, sternomental distance: 7 cm) and restricted neck mobility [Figure 1a]. Our plan A was C-MAC videolaryngoscopic (C-MAC®VL)-guided intubation with backup plans of fiber-optic bronchoscope (FOB)-guided intubation, retrograde intubation, and front of neck access as plans B, C, and D respectively. Consent of the mother was obtained. ASA standard monitors were attached. Continuous high flow nasal cannula (HFNC) oxygen therapy was started [Figure 1b]. Fentanyl 2mcg/kg (IV) was given and inhalational induction with sevoflurane was started. There was difficulty in mask ventilation even after oral airway insertion. So, immediate insertion of supreme laryngeal mask airway (LMA) size-2 enabled adequate ventilation [Figure 2a]. Injection rocuronium 1 mg/kg (IV) was administered. LMA was removed and endotracheal intubation was performed using C-MAC®VL at second attempt using bougie. Apneic oxygenation with HFNC and manual in-line stabilization was ensured until endotracheal intubation was achieved. When the patient was turned from prone to supine position after surgery, we noticed edema of the lips and tongue [Figure 2b]. Videolaryngoscopy revealed edema of posterior commissure which resolved with intravenous steroids and then extubated 24 hours later in ICU.Figure 1: (a) shows facial and airway profile in this child with MPS. (b) shows continuous HFNC therapyFigure 2: (a) Supreme LMA inserted to facilitate ventilation before endotracheal intubation. (b) Edematous tongue and lips noted when patient turned supine after surgeryMaroteaux–Lamy syndrome is a type of mucopolysaccharidosis characterized by learning difficulties, mental retardation, coarse facial features, frontal bossing, depressed nasal bridge, macroglossia, adeno-tonsillar hypertrophy, narrowed airway, short, stiff neck and temporomandibular joints leading to difficult airway.[2,3] Multi-systemic involvement includes obstructive or, restrictive lung disease, valvular heart disease and cardiomyopathy. Instability of the atlantoaxial joint requires special care during intubation to prevent further compression of the cervical spinal cord.[4] Difficulty in maintaining adequate ventilation may be due to obstructive and restrictive lung disease. Intraoperative hemodynamic instability may occur due to underlying cardiac disease. Prone position can further aggravate existing airway narrowing as it can lead to airway edema which may pose difficulty during extubation. In our case, we chose inhalational induction over intravenous induction as it was anticipated difficult airway. We could overcome the difficulty of mask ventilation by expeditious insertion of LMA. C-MAC®VL-guided intubation was chosen over the fiber-optic technique as it provides fixed wide view of the glottis that aids in quick recognition of airway landmarks.[5] FOB-guided intubation would be difficult as the patient had poor comprehension and, airway collapse leads to difficulty in maneuvering and advancement. HFNC oxygen therapy prevented desaturation. Thus, from this case, we infer that in a child with mucopolysaccharidosis, inhalational induction, ventilation with LMA followed by intubation with C-Mac videolaryngoscope would be a logical method of airway management. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

The Comparison Between Supreme Laryngeal Mask Airway and Endotracheal Tube With Respect to Adequacy of Ventilation in Patients Undergoing Laparoscopic Cholecystectomy Under General Anesthesia-A Prospective, Randomized, Double-Blind Study, and Comparative Study.

Laparoscopic cholecystectomy is a commonly performed surgical procedure. Most anesthesiologists advocate tracheal intubation. Laparoscopic cholecystectomy is becoming a day care surgery, hence many anaesthesiologists have started using laryngeal masks to decrease airway manipulation seen with conventional laryngoscopy and endotracheal intubation and avoid hemodynamic pressor responses and postoperative sore throat. The Supreme laryngeal mask airway (LMA) is an innovative, sterile, single use, supraglottic airway management device which provides access to and functional separation of the respiratory and digestive tracts. In this study, there are two objectives-(1) primary objective: to assess the adequacy of ventilation when using LMA-Supreme^(TM) (LMA-S) and endotracheal tube (ETT), and (2) secondary objective: the first is to give the time for achieving effective airway and number of attempts for securing airway. The second is to assess haemodynamic parameters (heart rate and blood pressure). The last is to show the incidence of gastric distension, regurgitation and postoperative sore throat. A total of 132 American Society of Anesthesiologists (ASA) I-II patients were randomly assigned to LMA-S and ETT for intraoperative ventilation. After induction of general anaesthesia, the device was inserted, correct placement was checked, and parameters were recorded. SPSS version 20.0 software (IBM Corp., Armonk, NY, USA) was used for statistical analysis. A P-value less than 0.05 is statistically significant. Ventilatory parameters such as inspiratory and expiratory leak volumes, and peak airway pressure values were comparable between the groups throughout the entire time interval. The number of attempts for successful insertion were comparable, but the mean time required for achieving effective airway was significantly longer in ETT than LMA-S (25.2 ± 8.3 sec vs. 18.6 ± 5.1 sec, respectively [P ＜ 0.05]). There was no situation in which the patient from the LMA-S group had to be intubated. The haemodynamic responses to insertion, pneumoperitoneum inflation and deflation, and removal of the device were greater for the ETT than the LMA-S. There were no complications like gastric distension or regurgitation in either groups. The postoperative sore throat at 2 hours and 24 hours was significantly lower in group LMA-S than group ETT. Positive pressure ventilation with a correctly placed LMA-S allows adequate pulmonary ventilation, without the untoward hemodynamic and postoperative adverse effects of endotracheal intubation, in laparoscopic cholecystectomy surgery.

The Comparison Between Supreme Laryngeal Mask Airway and Endotracheal Tube With Respect to Adequacy of Ventilation in Patients Undergoing Laparoscopic Cholecystectomy Under General Anesthesia-A Prospective, Randomized, Double-Blind Study, and Comparative Study.

Laparoscopic cholecystectomy is a commonly performed surgical procedure. Most anesthesiologists advocate tracheal intubation. Laparoscopic cholecystectomy is becoming a day care surgery, hence many anaesthesiologists have started using laryngeal masks to decrease airway manipulation seen with conventional laryngoscopy and endotracheal intubation and avoid hemodynamic pressor responses and postoperative sore throat. The Supreme laryngeal mask airway (LMA) is an innovative, sterile, single use, supraglottic airway management device which provides access to and functional separation of the respiratory and digestive tracts. In this study, there are two objectives-(1) primary objective: to assess the adequacy of ventilation when using LMA-Supreme^(TM) (LMA-S) and endotracheal tube (ETT), and (2) secondary objective: the first is to give the time for achieving effective airway and number of attempts for securing airway. The second is to assess haemodynamic parameters (heart rate and blood pressure). The last is to show the incidence of gastric distension, regurgitation and postoperative sore throat.A total of 132 American Society of Anesthesiologists (ASA) I-II patients were randomly assigned to LMA-S and ETT for intraoperative ventilation. After induction of general anaesthesia, the device was inserted, correct placement was checked, and parameters were recorded. SPSS version 20.0 software (IBM Corp., Armonk, NY, USA) was used for statistical analysis. A P-value less than 0.05 is statistically significant.Ventilatory parameters such as inspiratory and expiratory leak volumes, and peak airway pressure values were comparable between the groups throughout the entire time interval. The number of attempts for successful insertion were comparable, but the mean time required for achieving effective airway was significantly longer in ETT than LMA-S (25.2 ± 8.3 sec vs. 18.6 ± 5.1 sec, respectively [P ＜ 0.05]). There was no situation in which the patient from the LMA-S group had to be intubated. The haemodynamic responses to insertion, pneumoperitoneum inflation and deflation, and removal of the device were greater for the ETT than the LMA-S. There were no complications like gastric distension or regurgitation in either groups. The postoperative sore throat at 2 hours and 24 hours was significantly lower in group LMA-S than group ETT.Positive pressure ventilation with a correctly placed LMA-S allows adequate pulmonary ventilation, without the untoward hemodynamic and postoperative adverse effects of endotracheal intubation, in laparoscopic cholecystectomy surgery.

Double trouble - Airway equipment problem in a difficult airway!

Sir, A 11-year-old boy weighing 29 kg was posted for pelvic supporting osteotomy with limb lengthening and external fixation. He had a history of sepsis in infancy with post-sepsis sequelae and resultant limb length discrepancy. The patient also had surgery six years ago for posttraumatic bilateral temporomandibular ankylosis. Bilateral distraction osteotomy followed by release of ankylosis was performed in a two-stage procedure. On examination, he had micrognathia and retrognathia, with a mouth opening restricted to 2 cm [Figure 1]. He was otherwise healthy, and blood investigations were within normal limits.Figure 1: (a) Patient profile showing significant retrognathia (b) Limited mouth openingWe anticipated a difficult airway and planned to conduct the case under general anaesthesia using supraglottic airway device (SAD), with femoral nerve block for analgesia. Plan B, in case SAD insertion failed, was fibreoptic-guided tracheal intubation. The operating room preparation included difficult airway cart and team briefing about the airway plan. An intravenous line was secured prior to induction. The child was very anxious, so 1 mg midazolam was administered under monitoring. Following administration of glycopyrrolate 4 μg/kg and fentanyl 2 μg/kg, inhalational induction with incremental sevoflurane in 100% oxygen was performed. Once ability to mask ventilate was confirmed, we administered propofol 3 μg/kg. Laryngeal mask airway (LMA) Supreme® size 2.5 was chosen (over our standard preference of i-gel® airway) since it has a rather lean profile which we thought would easily fit into the narrow oral cavity. LMA insertion was easy, and adequate ventilation was achieved with a good seal. Muscle relaxant was avoided and patient was ventilated on pressure support mode with oxygen, air and sevoflurane using low flow anaesthesia. Midway through the procedure, the attending anaesthetist (our fellow in paediatric anaesthesia) noticed that the ventilator bellows had suddenly collapsed and the end-tidal carbon dioxide (EtCO2)value fell from 35 mmHg to 20 mmHg. He immediately took the reservoir bag in hand and started manual ventilation with 100% oxygen. The consultant anaesthetist was called for help and manual ventilation revealed a large leak in the LMA. Functional airway obstruction (laryngospasm, bronchospasm), shifting of the LMA were some of the differentials that came to mind. 1 mg/kg of propofol was administered and decision to change the LMA was taken. The orthopaedic surgeons were informed about the problem and requested to stop surgery. When the tapes securing the LMA were removed and the LMA Supreme® was taken out, we noticed a breach at proximal end at the junction of the bite block, causing the massive leak and loss of ventilation [Figure 2]. Another LMA Supreme® was inserted and the rest of the case proceeded uneventfully. Prompt detection, identification of the problem and timely intervention prevented fall in oxygen saturation. We are a close-knit team of paediatric anaesthetists, fellows and experienced technicians, and the shared understanding of the case ensured efficient crisis management.Figure 2: LMA Supreme® with arrow indicating site of breakage at the junction of shaft with the bite portionWe did a root cause analysis and also conducted a team debriefing after the case. The LMA Supreme® used was a near expiry device, and we believe it may have deteriorated during storage leading to the breakage. On performing a literature search, we found a report of breakage of LMA Supreme® similar to our case.[1] We decided to send this communication for publication to highlight the following points. A visual inspection to confirm the integrity of the airway device and the cuff (in case of cuffed SADs) should be part of the mandatory anaesthesia trolley pre-check. Excessive reuse of reusable SADs can also result in damage.[2] Team briefing is vital prior to every case; especially so for difficult cases. Wherever possible, in DA cases, spontaneous ventilation, avoidance of muscle relaxant and “not to burn bridges” is a sensible, safe approach.[3] Age and weight appropriate “standby” equipment should be immediately available for rescue, such as in our case. Soft skills, for example, team work and communication play an important role in crisis management. Debriefing with the entire team is equally important after critical events to assess and improve team performance and to promote a culture of safety. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

COMPARISON BETWEEN TWO SUPRA GLOTTI CAIR WAY DEVICE SI-GEL AND LMA-SUPREME IN SHORT LAPROSCOPIC SURGERIES UNDER GENERAL ANAESTHESIA

Aims And Objectives: In short laproscopic surgeries , 2nd generation supraglottic airway devices are recommended as good and safe alternative to intubation .We compared I gel and LMA supreme in short laproscopic surgeries under general anaesthesia with respect to ease and time for insertion ,the number of attempts, seal pressure under general anaesthesia Secondary- To compare hemodynamic changes and post of complications like sore throat ,blood staining of device ,bronchospasm , laryngospasm . Materials And Method Study Design: Randomized , prospective, single blind, comparative interventional study METHODS- Eighty patients between 18-60 years of age of either sex, BMI &lt; 30, ASA- I and ASA- II undergoing short laproscopic surgeries of less than one hour duration under general anaesthesia were included in this study after approval of institutional ethical committee. They were randomly allocated to I gel [ n=30] and supreme [n= 30] group .They were compared with respect to primary and secondary objectives ANALYSIS PLAN- Collected data were analysed using statistical package IBM SPSS version 16. Result: Both groups were comparable with respect to demographic data , number of attempts, incidence of complications and hemodynamic response. Insertion of LMA supreme was significantly easy than I gel[ p =0.038] Conclusion: LMA-Supreme is safe and effective device which is easier to insert than I-GEL and causes less airway trauma.