Baby cuff as a reason for laryngeal mask airway cuff malfunction during airway management for anesthesia

Placement of laryngeal mask airway [LMA] is a blind procedure without requiring laryngoscopy. The reported success rate for LMA insertion at the first attempt is almost 95%; however, many functioning LMAs may not be in an ideal anatomic place. It seems that disposable LMAs have more stable cuff pressure compared to reusable LMAs; therefore, Anesthesiologists should bear in mind this fact when using reusable LMAs to achieve a proper sealing and safe airway management. In this report, we introduced a case with malfunction of LMA cuff during the airway management

Comparison of three methods in improving bag mask ventilation

Increasedlife expectancy in populations has brought along specific new scenarios in the fields of medicine for the elderly; prevalence of physical complications such as edentulism and patients with dentures is growing. Management of anesthesia and ventilation in this group of patients has turned into a great challenge. Some researchers suggest dentures to be left in place during bag-mask ventilation; yet, no unanimous agreement exists in this regard. In a single blind randomized clinical trial, we studied 300 patients with ASA class I, II [American Society of Anesthesiologists], Mallampati class [I, II] and aged over 55 years in three groups. After induction of anesthesia, in group G dentures were removed and in each buccal space an eight-layer 10x10 cm gauze and an oral airway were placed. In group D, the dentures and an oral airway were left in place. In group C [control], after removing dentures just an appropriate oral airway was placed. Then, each three group underwent bag-mask ventilation. Success of bag-mask ventilation [BMV] was considered as increase in end-tidal carbon dioxide to more than 20 mmHg and back to baseline with fresh gas flow of 3 L/min and adjustable pressure limiting valve pressure of 20 cm H[2]O. Success rates were evaluated between groups. Effective BMV was possible in 91 [91%], 64 [64%] and 41 [41%] patients in groups G, D and C respectively. The differences were statistically significant. Successful BMV rate was significantly higher in female patients in group G compared to group C; 43/44 versus 25/46 individuals, P = 0.0001, odds ratio = 0.03, 95% confidence interval [0.00, 0.22]. Leaving dentures in place in edentulous patients after inducing anesthesia improves bag-mask ventilation. However, placing folded compressed gauze in buccal space leads to more significant improvement in BMV compared to leaving dentures in place

Sensitivity of palm print, modified mallampati score and 3-3-2 rule in prediction of difficult intubation

This study evaluated the performance of modified Mallampati score, 3-3-2 rule and palm print in prediction of difficult intubation. In a prospective descriptive study, data from 500 patients scheduled for elective surgery under general anesthesia were collected. An anesthesiologist evaluated the airway using mentioned tests and another anesthesiologist evaluated difficult intubation. Laryngoscopic views were determined by Cormack and Lehane score. Grades 3 and 4 were defined as difficult intubation. Sensitivity, specificity, positive predictive value, negative predictive value and Youden index were determined for all tests. Difficult intubation was reported in 8.9% of the patients. There was a significant correlation between body mass index and difficult intubation [P: 0.004]; however, other demographic characteristics didn't have a significant correlation with difficult intubation. Among three tests, palm print was of highest specificity [96.46%] and modified Mallampati of highest sensitivity [98.40%]. In a combination of the tests, the highest specificity, sensitivity and Youden index were observed when using all three tests together. Palm print has a high specificity for prediction of difficult intubation, but the best way for prediction of difficult intubation is using all three tests together

Modified cricothyroidotomy in skill laboratory

Unsuccessful tracheal intubation is considered the most common cause of anesthesia death or brain damage. This study delineates our experience recommending modifications in the cricothyroidotomy technique. Thirty emergency medicine residents of participated in a study performed on the human simulator moulage in Skill Laboratory of Tabriz University of Medical Science. The cricothyroid membrane was punctured using a 16-gauge cannula. Later, J guide wire was advanced into trachea and standard 16-gauge intravenous cannula with a removable needle stylet withdrawn after the puncture being dilated by a dilator. Consequently, a cuffed tracheal tube [ID= 6] was introduced from the foramen. From 30 residents, 18 residents performed cricothyroidotomy within 1 minute, 7 residents in 2 minutes and 5 residents failed to fulfill the procedure. Several studies using cadavers and human simulators have demonstrated the pre-hospital feasibility of this technique. However, descriptions of clinical pre-hospital experience with percutaneous cricothyroidotomy are limited. This study shows that skill lab may help residents to acquire techniques required in management of difficult airway.

Digital intubation training in residency program as an alternative method in airway management

Digital intubation is a method for airway management in patients with distorted anatomy and cervical or skull fractures wherein movement is undesirable. This study was designed to determine whether digital intubation training is effective for airway control by emergency medicine or anesthesiology residents. A prospective descriptive study of clinical education was carried out in the Nikoukari Hospital. In this study 15 anesthesiology and 15 emergency medicine residents received digital intubation training. Then they were asked to intubate patients with grade I or II Mallampati class, with no more than two attempts. Digital intubation was attempted after induction of anesthesia. Tube placement was confirmed by direct laryngoscopy. The total time for all attempts was recorded. In 18 of 30 trainees, intubation was successful in first attempt [60%]. The success rate was 80% for all attempts. The average time required for digital intubation [either success or failure] was 22 seconds. A 100% success rate was observed in trainees with long fingers. Any trauma induced bleeding in oral cavity was not reported. Although the gold standard for endotracheal intubation is direct laryngoscopy, digital intubation training might be considered as an easy and life-saving adjunction for airway management

Comparison of hemodynamic changes in administration of ondansetron and metoclopramide to preventing post-operative nausea and vomiting after strabism surgery

The aim of the present study was to compare the hemodynamic changes of intravenous ondansetron and metoclopramide for prevention of post-operative nausea and vomiting in patients undergoing strabism surgery under general anesthesia. This is a randomized double blind clinical trial performed on 96 patients with average age of 6-12y/o, ASA [American Society of Anesthesiologists] physical status I and 11 candidates for strabism surgery with general anesthesia between the years 2009 till July 2010. After the hospital's Ethic Committee approval, the study was conducted in Tabriz University of Medical Sciences, Tabriz, Iran. The patients were randomized into two groups, ondansetron [n=48] and metoclopramide [n =48]. In this study ondansetron 50pg/kg and metoclopramide 150pg/kg administered intravenously five minutes before induction of general anesthesia after routine monitoring. Systolic and diastolic blood pressure and heart rate were measured as hemodynamic variables in both groups. In recovery room Aldrete scoring system employed as the patients' discharge criteria. Incidence and severity of post-operative nausea and vomiting documented in recovery room and in different times in surgical ward by using a specified scoring system and getting information from patients and their caregivers. There were not significant differences between two groups in demographics, hemodynarnic parameters and anesthesia length. There was not also significant difference about the incidence and severity of nausea and vomiting between two groups. It is concluded that preoperative administration of both ondansetron and metoclopramide can decrease frequency and also intensity of post-operative nausea and vomiting without having significant difference and prominent complication