Laryngeal Mask Airway Supreme Research Articles

A comparison of i-gel™ and Laryngeal Mask Airway Supreme™ during general anesthesia in infants.

BackgroundThe i-gel™ (i-gel) and Laryngeal Mask Airway Supreme™ (LMA Supreme) have been safely used in children. We compared the airway performance of the i-gel and LMA Supreme in infants undergoing general anesthesia.MethodsSixty infants with American Society of Anesthesiologists physical status I or II were randomly assigned to place either the i-gel or the LMA Supreme. The size 1 or 1.5 of each airway was selected by the weight of infants. The primary outcome variable was oropharyngeal leak pressure (OLP). We also assessed insertion success rate, insertion time, fiberoptic view of the larynx, airway quality, airway manipulations, and perioperative complications.ResultsDemographic data did not differ between the two groups. Insertion success rate was similar in both groups. OLP for the i-gel (26.0 ± 3.8 cmH2O) was higher than for the LMA Supreme (23.7 ± 3.2 cmH2O) (P = 0.016). Insertion time for the i-gel (16.4 ± 2.8 s) was shorter than for the LMA Supreme (18.5 ± 2.7 s) (P = 0.002). There were no differences in fiberoptic view of the larynx, airway quality, airway manipulations, and complications between the two groups.ConclusionsThis study demonstrated that the i-gel and LMA Supreme provided a similar performance of airway in infants. Compared with the LMA Supreme, the i-gel provided shorter insertion time and higher OLP in infants.

Sore throat following three adult supraglottic airway devices: A randomised controlled trial.

Sore throat is a common complaint after surgery. It affects patient satisfaction and can affect activity after discharge. The supraglottic airway device (SAD) offers an alternative to traditional tracheal intubation with potential benefit in preventing sore throat. The aim of this study was to compare the incidence of sore throat following three different SADs, the laryngeal mask airway Unique (LMA-U) and the more recent LMA Supreme (LMA-S) and the I-gel. A randomised single-blind controlled three parallel-group trial. University Hospital of Nîmes, Division of Anaesthesia Intensive Care Pain and Emergency, Nîmes, France, from April 2009 to September 2012. A total of 546 patients scheduled to undergo elective surgery of less than 2 h under general anaesthesia were randomly allocated to receive the LMA-U, the LMA-S or the I-gel. Anaesthesia was induced with propofol and sufentanil and maintained with propofol or with sevoflurane in air-oxygen. After airway device insertion, intra-cuff pressure was adjusted to less than 60 mmHg (LMA-U, LMA-S) and pressure-controlled ventilation initiated. The primary study endpoint was to compare incidence of sore throat 24 h postoperatively (H+24) following placement of the LMA-U, LMA-S and the I-gel. Secondary endpoints were clinical performance (airway leak pressure, dynamic airway compliance, complications during maintenance), ease of use (device insertion time, success on first attempt, ease of insertion and removal) and other adverse events (neck or jaw pain, dysphonia, dysphagia, nausea and vomiting). The authors analysed 177, 174 and 173 patients who received LMA-U, the LMA-S and the I-gel, respectively. The primary endpoint was assessed in 436 patients. In total, 104 patients (23.9%) patients reported a H+24 sore throat, with no difference between groups (P = 0.34). H+24 dysphagia with liquids was higher (P = 0.0065) with the LMA-S (12.1%) compared with LMA-U (5.3%) and I-gel (2.9%). Airway leak pressure (cmH2O) was lower (P < 0.0001) with LMA-U [21 (18 to 27)] compared with I-gel [26 (20 to 30)] and LMA-S [25 (21 to 30)]. Device insertion time (sec) was shorter (P < 0.0167) with the I-gel [30 (20 to 40)] compared with the LMA-U [34 (23 to 48)] and LMA-S [32 (22 to 50)]. The incidence of postoperative sore throat was not significantly different between the three SADs studied.

Comparative Assessment of Three Approaches of Teaching Nonmedically Trained Persons in the Handling of Supraglottic Airways: A Randomized Controlled Trial.

The use of supraglottic airways has been recommended in combat trauma airway management. To ensure an adequate airway management on the battlefield, suitable training concepts are sought to efficiently teach as many soldiers as possible. Our aim was to compare three approaches of teaching laypersons in the handling of supraglottic airways in a mannequin model. In this prospective randomized blinded study, 285 military service men without any medical background were divided into three groups and trained in the use of the Laryngeal Mask Airway Supreme (LMA) and the Laryngeal Tube Disposable (LT-D). The first group received a theoretical lecture, the second group was shown an instruction video, and the third group underwent a practical training. Immediately after instruction participants were asked to place the supraglottic airway and ventilate the mannequin within 60 seconds. The entire test was repeated 3 months later. Test results were evaluated with regard to success rate, insertion time, ability to judge the correct placement, and degree of difficulty. Practical training showed the highest success rate when placing supraglottic airways immediately after the instruction (lecture: 68%, video: 74%, training: 94%); (training vs. lecture and training vs. video, p < 0.001) as well as 3 months later (lecture: 63%, video: 66%, training: 78%); (training vs. lecture, p = 0.019 and training vs. video, p = 0.025). Immediately after the instruction practical training was also superior in terms of insertion time, ability to judge the correct placement, and the self-rated degree of difficulty (p < 0.001). These effects were significantly reduced 3 months after the instruction. In comparison between supraglottic airways LT-D was superior to LMA regarding all the outcome parameters mentioned above (p < 0.001). In this study, performed with personnel of the German Armed Forces, we have shown that persons without any medical and paramedical background are able to successfully place a supraglottic airway immediately following minimal instruction and after 3 months as well. Study participants achieved the best results after practical training followed by video presentation and finally lecture regardless of the airway device used. There are two possible reasons why practical training is the superior method. Firstly, the success is tied to more time spent with the learners. Secondly, practical training seems to be the best teaching method for various types of learners such as visual, auditory, reading/writing, and kinesthetic type. In addition the results of our study show that the LT-D is an ideal supraglottic airway in the hands of people inexperienced in airway management. In conclusion, our results show that practical training is the superior instruction method compared to theoretical lecture and presentation of an instruction video. Nevertheless, the presentation of an instruction video is a promising approach of teaching a maximum number of laypersons with minimal effort to correctly place supraglottic airways. To optimize the success rate of such a concept LT-Ds instead of LMAs should be used for airway management. The presented concepts hold promise for combat as well as for civilian emergency medicine.

New complication of LMA supreme and orogastric tube (OGT)

The Sri Lankan Journal of Anaesthesiology is the official journal of the College of Anaesthesiologists of Sri Lanka. It publishes clinical investigations, research articles, audits, case reports, review articles and CME articles relating to anaesthesiology, critical care and pain. It is published bi annually in January and June. Sri Lankan Journal of Anaesthesiology is included on DOAJ and Scopus.

Competence in the use of supraglottic airways by Australian surf lifesavers for cardiac arrest ventilation in a manikin.

Lifesavers in Australia are taught to use pocket mask (PM) rescue breathing and bag valve mask (BVM) ventilation, despite evidence that first responders might struggle with these devices. Novices have successfully used the Laryngeal Mask Airway (LMA) Supreme and iGel devices previously, but there has been no previous comparison of the ability to train lifesavers to use the supraglottic airways compared to standard techniques for cardiac arrest ventilation. The study is a prospective educational intervention whereby 113 lifesavers were trained to use the LMA and iGel supraglottic airways. Comparisons were made to standard devices on plastic manikins. Successful ventilation was defined as achieving visible chest rise. The median time to first effective ventilation was similar between the PM (16 s, 95% confidence interval 16-17 s), BVM (17 s, 16-17 s) and iGel devices (18 s, 16-20 s), but longer for the LMA (36 s, 33-38 s). The iGel frequently failed to achieve ventilation (10%) compared with the PM (1%, P < 0.01) and LMA (3%, P < 0.01) but was not worse than the BVM (3%, P < 0.57). Hands-off time was similar between the BVM, LMA and iGel (10 s for each device), but worse for the PM (13 s, P = 0.001). Lifesavers using the PM and BVM perform ventilation for cardiopulmonary resuscitation well. There appears to be a limited role for supraglottic airway devices because of limitations in terms of time to first effective ventilation and reliability. Clinical validation of manikin data with live resuscitation performance is required.

Comparative Study of Two Laryngeal Mask Airways: Proseal Laryngeal Mask Airway and Supreme Laryngeal Mask Airway in Anesthetized Paralyzed Adults Undergoing Elective Surgery.

Context:Supraglottic airway devices can act as an alternative to endotracheal intubation in both normal and difficult airway. LMA Proseal (P-LMA) and LMA Supreme (S-LMA) alongwith acting as effective ventilating device, provide port for gastric drainage.Aim:The objective of this study was to compare the two devices for effective ventilation and complications.Setting and Design:A prospective, randomized, single-blinded study was conducted in a tertiary care teaching hospital. Methods: 100 patients of ASA grade I–II undergoing elective surgery under general anaesthesia were included after ethical committee clearance and written consent. Patients were randomly allocated size 4 P-LMA (Group P) or S-LMA (Group S) (50 patients in each group). Insertion attempt, insertion time, oropharyngeal leak pressure (OLP) and complications were compared.Results:There was no difference demographically. The first insertion attempts were successful in 92% with P-LMA and 96% with S-LMA. Insertion time was faster in S-LMA. The mean OLP was 24.04 cmH2O in Group P and 20.05 cmH2O in Group S. Complications were cough, mild blood staining.Conclusion:Both can act as an effective ventilatory devices. But where LMA Proseal provides a more effective glottic seal by having a greater OLP, single use LMA Supreme provides acceptable glottic seal with easier and faster insertion, therefore, it can be accepted as better alternative to LMA Proseal.

Comparison of i-gel™ and Laryngeal Mask Airway Supreme™ in Different Head and Neck Positions in Spontaneously Breathing Pediatric Population.

Background:Although the advantages of ventilation with i-gel™ and laryngeal mask airway Supreme (LMA-Supreme™) has been well documented, they are still under debate for surgeries requiring flexion and extension of neck such as thyroid surgery, tonsillectomy, and neck exploration. Hence, we conducted a study to demonstrate the effect of neck flexion and extension in spontaneously breathing anesthetized pediatric patients utilizing i-gel™ and LMA-Supreme™.Methods:A prospective, randomized comparative study was conducted on sixty children, thirty each in i-gel™ and LMA-Supreme™ group. Oropharyngeal leak pressure (OPLP), fiberoptic view of vocal cords, and exhaled tidal volume were evaluated in neutral, flexion, and extension neck positions in spontaneously breathing children.Results:OPLP for i-gel™ was found to be significantly higher in flexion (29.00 ± 1.95 cmH2O, P < 0.001) and lower in extension (21.07 ± 2.08 cmH2O, P < 0.001) as compared to neutral (24.67 ± 2.08 cmH2O). Similar results were observed for LMA-Supreme™ which showed significantly higher OPLP in flexion (24.73 ± 2.26, P < 0.001 respectively) and lower in extension (18.67 ± 1.42 cmH2O, P < 0.001) as compared to neutral (20.87 ± 1.80 cmH2O). Worsening of fiberoptic view occurs for i-gel™ and LMA-Supreme™ in flexion (10/12/5/3/0 and 11/14/2/2/1, P < 0.05) as compared to neutral position (17/10/2/1/0 and 15/12/1/1/1), respectively. Significant change did not occur in extension. Ventilation worsening occurred in flexion as compared to neutral position evidenced by significant decrease in exhaled tidal volume (92.90 ± 11.42 and 94.13 ± 7.75 ml, P < 0.05) as compared to neutral (100.23 ± 12.31 and 101.50 ± 8.26 ml) for i-gel™ and LMA-Supreme™, respectively.Conclusion:Neck flexion caused a significant increase in leak pressure in both i-gel™ and LMA-Supreme™. With deterioration of fiberoptic view and ventilation, both devices should be used cautiously in pediatric patients in extreme flexion.

Randomised Comparison of the Effectiveness of the Laryngeal Mask Airway Supreme, I-Gel and Current Practice in the Initial Airway Management of Out of Hospital Cardiac Arrest

(Abstracted from Br J Anaesth, 116(2):262–268, 2016) Effective ventilation is a crucial component of cardiopulmonary resuscitation (CPR) after cardiac arrest, but what constitutes effective ventilation is unclear. Although tracheal intubation has traditionally been viewed as the best airway management during out-of-hospital cardiac arrest (OHCA), this assumption has been challenged by the use of supraglottic airway devices (SGAs), which are faster and easier to insert.

Comparative Study of laryngeal mask airway Supreme and laryngeal mask airway Classic in paralyzed patients

Aim and Objectives: The present study was undertaken to compare the LMA Classic with LMA Supreme in assessing the ease of insertion, number of attempts, time for insertion, any unwanted responses, stability of device, peak airway pressure, leak volume and leak fraction and postoperative complications. Methods: A total of 274 patients of ASA grade 1 and 2 were included in the study and divided into two groups with 137 patients in each group: the LMA Classic group (group C) and LMA Supreme group (group S). All patients were induced with propofol 2.5 mg/kg and atracurium 0.5mg/kg after that appropriate sized supraglottic airway device was inserted. The ease of insertion, number of attempts, duration of insertion, stability of device, peak airway pressure, leak volume and leak fraction and postoperative complications were recorded. Results: The insertion of Supreme LMA was very easy in 134 patients and was easy in 3 patients, difficult in 0 patients while the insertion of Classic LMA was very easy in 122 patients, easy in 15 patients and difficult in 0 patients. The first attempt insertion rate was more with Supreme LMA as compared to Classic LMA. The mean duration of insertion was significantly lower with Supreme LMA than with Classic LMA. The mean airway pressure was similar in both groups. Both devices were stable. Leak volume and Leak fraction was significantly higher in Classic LMA than Supreme LMA. Peri-operative complications were not significantly different between Supreme LMA and Classic LMA. Conclusions: The LMA Supreme is superior to the LMA Classic because of its ease of insertion with lesser leak volume and leak fraction and better first attempt insertion rate.

Laryngeal Mask Airway Supreme in Children: A Retrospective Audit

Background: The laryngeal mask airway (LMA) Supreme (LMAS) is a sophisticated, second-generation supraglottic airway device, with an improved seal, and gastric access. It is a capable device for use in more complex procedures and in younger children. No study has been able to analyze a large pediatric sample of patients to assess how the LMAS is being utilized. In this retrospective audit, we evaluated the use of the LMAS in routine clinical practice. In addition to this, utilization of LMAS performance test was evaluated.Methods: A retrospective audit was performed of a major tertiary children's hospital's electronic medical record database to identify all children in whom the LMAS was utilized for airway management over a two-year period. In addition to demographic data, we collected the following LMAS data: size of the LMAS, the number of insertion attempts, volume of air injected into the cuff, the cuff pressure, and the oropharyngeal leak pressure. We also recorded the performance of tests for proper position and function, the mode of lung ventilation, the use of muscle relaxants and use of any alternative airway devices.Results: The LMAS was used in 418 children accounting for only 4% of all LMA usage and only 0.6% of all usage for general anesthesia. The first-attempt placement success rate was 96.4% (382/396). Five of 418 (1.2%) insertions were reported as failures. Mechanical ventilation was used in only 26% of cases with a vast majority (74%) breathing spontaneously. Cuff pressure was measured in 74/418 (18%) of cases. Oropharyngeal leak pressures were measured in 90/418 (21.5%) cases. Maneuvers performed to verify correct placement and performance of the LMAS were rarely performed. Use of the LMAS for invasive procedures occurred in only 5 cases (1.2%).Conclusions: This study shows the LMAS to be highly successful in the hands of various cadres of anesthesia providers at a major tertiary hospital and performs reliably well. Our data reveals many areas of potential improvement for use of the LMAS in the pediatric population, as a device capable for usage in more invasive surgical procedures, younger patients, and mechanical ventilation. Citation: Nobuyuki-Hai Tran, Patrick N. Olomu, Ashley Bocanegra, Asif Khan, John Cheyney, Alexandra Handy, et al. Laryngeal mask airway Supreme in children: a retrospective audit. J Anesth Perioper Med 2016; 3: 241-6. doi: 10.24015/JAPM.2016.0033This is an open-access article, published by Evidence Based Communications (EBC). This work is licensed under the Creative Commons Attribution 4.0 International License, which permits unrestricted use, distribution, and reproduction in any medium or format for any lawful purpose. To view a copy of this license, visit http://creativecommons.org/licenses/by/4.0/.

Confirmation of laryngeal mask airway placement by ultrasound examination: a pilot study

Study ObjectiveWe sought to validate ultrasound against other established methods of confirming laryngeal mask airway (LMA) placement. DesignAn observational study. SettingA university teaching hospital, operating department. PatientsFifty-eight patients undergoing general anesthesia using an LMA Supreme supraglottic airway device. InterventionsThe position of the LMA was assessed by ultrasound in 3 planes: the pharynx, the larynx, and along the cranial-caudal axis in the midline. The leakage test at 20 cm H2O and fiberoptic examination were also undertaken independently, with the latter being used to detect suboptimal placement (in which case, the LMA was reinserted). MeasurementsWe scored the position of the LMA based on the location of the cuff and whether it had inflated correctly in each of the 3 planes. This score was converted to correspond with the leakage test grading system. We tested the strength of the correlation between the scores and the sensitivity and specificity for predicting reinsertion. Main ResultsSeven patients (12.1%) required LMA reinsertion, and ventilation was inadequate in a further 6 (10.3%). Three patients (5.2%) developed laryngospasm and inspiratory stridor after insertion resulting in inadequate ventilation, but none needed reinsertion as optimal placement was confirmed by fiberscope. Spearman coefficient of rank correlation between the leakage test and ultrasound examination was 0.713 (P< .0001). The κ test and Bland-Altman analysis showed good agreement between the 2 scoring systems (weighted κ = 0.605, standard error = 0.086). An ultrasound examination score equating to grade 3 in the leakage test predicted the need for reinsertion with a sensitivity and specificity of 85.7% and 94.1%, respectively. ConclusionsUltrasound examination is a fast, noninvasive and reliable means of detecting LMA misplacement that agrees closely with the leakage test. Ultrasound is as effective as a fiberoptic examination to confirm LMA placement and indicate the need for reinsertion, but does not require ventilation to be interrupted.

A comparison of various supraglottic airway devices for fiberoptical guided tracheal intubation

BackgroundFiberoptical assisted intubation via placed supraglottic airway devices has been described as safe and easy procedure to manage difficult airways. However visualization of the glottis aperture is essential for fiberoptical assisted intubation. Various different supraglottic airway devices are commercially available and might offer different conditions for fiberoptical assisted intubation. The aim of this study was to compare the best obtainable view of the glottic aperture using different supraglottic airway devices. MethodsWith approval of the local ethics committee 52 adult patients undergoing elective anesthesia were randomly assigned to a supraglottic airway device (Laryngeal Tube, Laryngeal Mask Airway I-Gel, Laryngeal Mask Airway Unique, Laryngeal Mask Airway Supreme, Laryngeal Mask Airway Aura-once). After standardized induction of anesthesia the supraglottic airway device was placed according to the manufacturers recommendations. After successful ventilation the position of the supraglottic airway device in regard to the glottic opening was examined with a flexible fiberscope. A fully or partially visible glottic aperture was considered as suitable for fiberoptical assisted intubation. Suitability for fiberoptical assisted intubation was compared between the groups (H-test, U-test; p<0.05). ResultsDemographic data was not different between the groups. Placement of the supraglottic airway device and adequate ventilation was successful in all attempts. Glottic view suitable for fiberoptical assisted intubation differed between the devices ranging from 40% for the laringeal tube (LT), 66% for the laryngeal mask airway Supreme, 70% for the Laryngeal Mask Airway I-Gel and 90% for both the Laryngeal Mask Airway Unique and the Laryngeal Mask Airway Aura-once. ConclusionNone of the used supraglottic airway devices offered a full or partial glottic view in all cases. However the Laryngeal Mask Airway Unique and the Laryngeal Mask Airway Aura-once seem to be more suitable for fiberoptical assisted intubation compared to other devices.

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English

Comparison of the Supreme and the ProSeal laryngeal mask airway in patients undergoing laparoscopic cholecystectomy: A randomized controlled trial

ObjectiveThe single-use LMA Supreme (Teleflex, Inc., Wayne, PA, USA) and the LMA ProSeal (Teleflex, Inc., Wayne, PA, USA) laryngeal mask airway (LMA) have similar characteristics. To date, studies have not achieved a consensus regarding the oropharyngeal leak pressure (OLP) of the LMA Supreme and LMA ProSeal, and there is little information on their efficacy in laparoscopic cholecystectomy. This study compared the safety and efficacy of the LMA Supreme and LMA ProSeal devices in patients undergoing laparoscopic cholecystectomy. MethodEighty-four eligible consenting patients were randomly allocated to the LMA Supreme group or the LMA ProSeal group. Both groups received the standard anesthesia technique. The Supreme or ProSeal LMA was inserted, the cuff was inflated to 60 cmH2O, and the LMA position was confirmed. Anesthesia was maintained using propofol and 50% oxygen in air. A gastric tube was inserted through the drain tube of the LMA to deflate the stomach, and the first attempt success rate and insertion time were recorded. During surgery, the intra-abdominal pressure was maintained at 12 mmHg. The fiberoptic view of the larynx was determined by passing a flexible fiberoptic bronchoscope. The OLPs, success rate, insertion time, hemodynamic and respiratory parameters, and complications were recorded at different time points. ResultsThe mean OLP was significantly lower in the LMA Supreme group than in the LMA ProSeal group (24.9 ± 5.3 cmH2O vs. 28.4 ± 5.8 cmH2O; p < 0.01). The first attempt success rate and ease of insertion grading for LMA were higher in the Supreme group. The insertion time was lower in the Supreme group than in the ProSeal group (p < 0.01). The fiberoptic view was better with the ProSeal LMA. The hemodynamic and ventilatory parameters and postoperative sore throat were comparable in both groups. ConclusionThe LMA ProSeal has a higher OLP than the LMA Supreme. The success rate of first attempt insertion and ease of insertion were better for the LMA Supreme group and the insertion time was lower in the LMA Supreme group. The Supreme and ProSeal LMAs were both effective for positive pressure ventilation in laparoscopic cholecystectomy.

An Evaluation of Thyromental Distance-based Method or Weight-based Method in Determining the Size of the Laryngeal Mask Airway Supreme: A Randomized Controlled Study.

The successful placement of Laryngeal Mask Airway (LMA) Supreme in adults largely depends on right selection of its size. Most anesthesiologists determine the size of LMA according to patients’ body weight, which does not always work well. An alternative method should be established to guarantee higher efficacy of ventilation through LMA Supreme placement. This controlled study was designed to compare the efficacy of LMA Supreme placement, when the size of it is determined by body weight or by thyromental distance.Eighty healthy individuals with American Society of Anesthesiologists physical status 1 to 2 scheduled for elective ambulatory surgery were randomly allocated into 2 groups: thyromental distance-based group (n = 40) and weight-based group (n = 40). Efficacy of controlled ventilation through LMA, easy of device placement, and pharyngeal sealing were evaluated between the groups.The tidal volume under 10 cm H2O pressure-controlled ventilation in thyromental distance-based group was significantly higher than that in weight-based group (523.9 ± 135.4 vs 477.1 ± 185.6; P = 0.031). The number of patients who achieved “excellent” tidal volume (>8 mL/kg) were significantly more in the thyromental distance-based group (24/40 vs 13/40; P = 0.019). Among overweight patients (body mass index >23), those who achieved “excellent” tidal volume (>8 mL/kg) under 10 cm H2O pressure-controlled ventilation were also more in thyromental distanced-based group than in weight-based group (11/24 vs 2/24; P = 0.031). The time taken for successful insertion was shorter with the thyromental distance-based group compared with the weight-based group (54.6 ± 33.6 vs 87.8 ± 98.9; P = 0.021). Oropharyngeal leak pressure was pretty close between the 2 groups (26.4 ± 5.1 vs 25.0 ± 5.7 cm H2O; P = 0.180).In terms of guaranteeing better positive pressure ventilation, facilitating device placement, and reliable pharyngeal sealing, thyromental distance-based method can be a better option compared with the weight-based method for LMA Supreme size selection.

Randomised comparison of the effectiveness of the laryngeal mask airway supreme, i-gel and current practice in the initial airway management of out of hospital cardiac arrest: a feasibility study

BackgroundThe best initial approach to advanced airway management during out of hospital cardiac arrest (OHCA) is unknown. The traditional role of tracheal intubation has been challenged by the introduction of supraglottic airway devices (SGAs), but there is contradictory evidence from observational studies. We assessed the feasibility of a cluster-randomized trial to compare the i-gel SGA vs the laryngeal mask airway supreme (LMAS) vs current practice during OHCA. MethodsWe conducted a cluster-randomized trial in a single ambulance service in England, with individual paramedics as the unit of randomization. Consenting paramedics were randomized to use either the i-gel or the LMAS or usual practice for all patients with non-traumatic adult OHCA, that they attended over a 12-month period. The primary outcome was study feasibility, including paramedic and patient recruitment and protocol adherence. Secondary outcomes included survival to hospital discharge and 90 days. ResultsOf the 535 paramedics approached, 184 consented and 171 attended study training. Each paramedic attended between 0 and 11 patients (median 3; interquartile range 2–5). We recruited 615 patients at a constant rate, although the LMAS arm was suspended in the final two months following three adverse incidents. The study protocol was adhered to in 80% of patients. Patient characteristics were similar in the three study arms, and there were no differences in secondary outcomes. ConclusionWe have shown that a prospective trial of alternative airway management strategies in OHCA, cluster randomized by paramedic, is feasible. Clinical trial registrationRegistered on the International Standard Randomised Controlled Trial Registry (ISRCTN: 18528625)

Supreme and classic laryngeal mask airway in neonatal resuscitation

Objective To study the feasibility, efficacy and safety of laryngeal mask airway (LMA) Supreme (SLMA) in neonatal resuscitation. Methods Sixty neonates, who were born at South Medical University Affiliated Maternal & Child Health Hospital of Shenzhen from June 1, 2012 to June 1, 2013 and requiring positive pressure ventilation after 30 s primary resuscitation post born, with birth weight above 2 000 g or gestational age above 34 weeks, were randomly assigned into two groups: SLMA group (n=30) and LMA Classic (CLMA) group (n=30). The outcome indicators included the curative effect, insertion time and possible adverse reactions of the two kinds of LMA, and the serum bio-markers, heart rate and percutaneous pulse oxygen saturation (SpO2) of all neonates. Independent sample t test, non-parametric test and Chi-square test were applied for statistical analysis. Results The insertion time was shorter in SLMA group than in CLMA group [(4.9±1.0) vs (7.6±1.3) s, t=8.98, P<0.05]. And more displacement occurred in CLMA group than in SLMA group [13.3% (4/30) vs 0% (0/30), Fisher exact test, P<0.05]. The successful rate of resuscitation in SLMA group was higher [100.0% (30/30) vs 90.0% (27/30), Fisher's exact test, P<0.05], and both the onset time and the total ventilation time were shorter than those in CLMA group [(12.4±3.7) vs (15.6±3.8) s, t=3.31, P<0.05; (37.3±17.0) vs (48.2±20.1) s, t=2.29, P<0.05]. The heart rate at 1 min after delivery was higher in SLMA group than in CLMA group [(93.5±20.9) vs (74.2±17.8) bpm, t=-3.86, P<0.05], and the same results were shown for SpO2 at 1, 2 and 3 min after birth [(47.1±8.4)% vs (38.7±12.1)%, t=-3.13; (68.1±9.5)% vs (52.8±10.8)%, t=-5.82; (78.3±10.0)% vs (72.1±9.7)%, t=-2.46; all P<0.05]. In the CLMA group, vomit or regurgitation occurred in three neonates, abdominal distension in two cases, aerogastria in seven cases. However, none of the above was reported in the SLMA group. No laryngeal injury was found in any of the subjects. Conclusion SLMA is more potential than CLMA in neonatal resuscitation because of its simplicity, better airtight, less adverse effect, superior efficacy and less requirement for tracheal intubation. Key words: Resuscitation; Positive-pressure respiration; Laryngeal masks; Infant, newborn

Assessment of suitability of i-gel and laryngeal mask airway-supreme for controlled ventilation in anesthetized paralyzed patients: A prospective randomized trial.

Context:Laryngeal mask airway supreme (LMA-S) has an inflatable cuff while i-gel has a noninflatable cuff made of thermoplastic elastomer.Aims:To study the efficacy of ventilation and the laryngeal seal pressures (LSPs) with either device. Our secondary objectives were to compare the ease of insertion, adequacy of positioning the device, hemodynamic response to device insertion, and any postoperative oropharyngeal morbidity.Settings and Design:A prospective, randomized, single-blinded study at Teaching Medical School in South India.Materials and Methods:Forty-two patients posted for surgery under general anesthesia were randomly divided into two groups - LMA-S and i-gel. After a standardized premedication and anesthesia induction sequence, the supra-glottic devices were introduced. Ease of insertion was assessed from the number of attempts taken to insert, insertion time, and any maneuvers required to insert the device. Position of the device was assessed by the ease of gastric catheter placement and the fibreoptic grading of laryngeal visualization. Efficacy of ventilation was determined from the LSP, peak inspiratory pressure (PIP), and end-tidal carbon dioxide (EtCO2)values. Any postoperative oropharyngeal morbidity was also recorded.Statistical Analysis:Descriptive analysis was reported as a mean and standard deviation, median, and range of continuous variables. Demographics were analyzed using a unpaired t-test for parametric data and Chi-square test for nonparametric data. Respiratory and hemodynamic data was analyzed using one-way ANOVA to find statistical difference within and between the two groups.Results:LMA-S was successfully inserted in 95% of patients and i-gel in 85.5% of patients. There was a significant difference (P = 0.021) in the LSPs between the two groups (18.15 cmH2O in LMA-S and 21.28 cmH2O in the i-gel group). There was no significant difference in the PIPs, leak fraction, and the EtCO2values.Conclusion:Both devices are suitable for positive pressure ventilation (PPV) in anesthetized paralyzed patients. However, i-gel gives a better laryngeal seal when compared to LMA-S and may be chosen preferentially for PPV.

The AMBU® Aura-i™ Laryngeal Mask and LMA Supreme™: A Randomized Trial of Clinical Performance and Fibreoptic Positioning in Unparalysed, Anaesthetised Patients by Novices.

Introduction. Manikin studies' data cannot accurately be extrapolated to real-life scenarios and inherent differences in design and materials of newer products may affect their clinical performance. Methods. Hence, we compared the AMBU® Aura-i™ and LMA Supreme™ in this randomized trial involving 100 ASA 1-2 unparalysed anaesthetised patients undergoing minor gynaecological surgery. Investigators had <20 Aura-i insertions. Primary outcome was time to achieve effective ventilation and secondarily insertion parameters, oropharyngeal leak pressures (OLP), fibreoptic positioning, and pharyngeal morbidity. The position of the Ambu Aura-i was evaluated with the Ascope; the fiberoptic view of the glottis was scored on a five-point scale. Results. 43 (86%) AMBU Aura-i and 44 (88%) LMA Supremes were successfully inserted on first attempt (p = 0.59), with similar ease (p = 0.79), and comparable times to first capnogram, mean (SD) 18.2 (6.0) versus 17.3 (6.4) sec, p = 0.9. The Aura-i needed significantly less volume of air to inflate its cuff to 60 cmH2O on the manometer, 17.7 (3.5) versus 23.1 (4.4) mL, p < 0.001. Both devices exhibited similar OLP, Aura-i versus LMA Supreme, mean (SD) 28.8 (7.1) versus 27.3 (5.3) cmH2O, p = 0.24. There was no difference in ease of insertion or adjustment manoeuvres to aid ventilation. 90% of patients had good positioning of Aura-i on fibreoptic check, yielding a view of the vocal cords and epiglottis. In 5 patients (10%), the vocal cords were not seen, but ventilatory function was unaffected. Conclusions. The Aura-i handled well in novices hands, with comparable times to insert and establish ventilation, similar leak pressures, and successful first attempt insertion rates compared to the LMA Supreme.

Iatrogenic surgical emphysema and pneumomediastinum in a case of emergency lower segment caesarean section.

Incidence of difficult airway in the obstetric population is high (0.3%), but multiple reattempts should be avoided to prevent trauma and likely desaturation.[1] Proseal laryngeal mask airway (PLMA®)/LMA Supreme® (SLMA) can be the first choice after failed intubation attempts as these two devices have been shown to be effective. These devices have their own problems, however, and one such potential complication is presented in this case report.