Novel technique for placement of laryngeal mask airway in difficult pediatric airways

The main responsibility of an anesthesiologist is to safely maintain an open airway and preserve sufficient gas exchange in the lungs. This role becomes more significant when managing children especially those with difficult airways [DA]. In such cases, a quick appropriate action can decrease the related mortality and morbidity. Laryngeal mask airway [LMA] is a device used in cases with difficult airways. Its placement is much more difficult in children especially those with DA. There is a greater risk of malpositioning and its insertion with routine techniques is sometimes impossible. In this article, we introduce a new method for replacement of LMA in difficult pediatric airways [DPA]. In this before and after, pre and post design clinical trial, we evaluated 30 children with congenital anomalies and difficult airways who were candidates for elective eye surgery [short term]. A written consent was obtained from the parents or the legal guardians of those who met the inclusion criteria. Inhalation anesthesia was induced by sevoflurane. The patients had assisted spontaneous respiration. No muscle relaxant was administered. LMA was inserted using the classic method in the anesthesia depth of BIS=35-40. After 2 unsuccessful attempts according to the criteria for adequate function of LMA, we tried placing the LMA using our innovated method after meeting the primary requirements and reaching the anesthesia depth of 35-40. In this method, the index finger of the left hand was placed on the tongue pushing it downwards [towards the floor of the mouth] when inserting the LMA. This way, we assisted LMA passing down the pharynx resulting in its adequate positioning. Criteria for adequate function of LMA in both classic and innovated insertion methods included monitoring of easy ventilation, no resistance during exhalation, adequate chest movement, no air leakage, optimal airway pressure, optimal lung compliance, level of oxygenation of arterial blood and level of CO[2] at the end of exhalation. In case of presence of air leakage with bag pressure below 15 cm of water, lack of chest movement during inhalation, upper airway pressure over 20 cm of water, SPO[2] lower than 90% and low compliance of the lung, LMA placement would be considered a failure. In such cases, LMA would be immediately extracted and the required depth of anesthesia would be reached using an oxygen mask and required inhalations. Complications occurring during the procedure and after LMA extraction would be recorded. Our understudy population included 30 children in the age range of 1.5 months to 10 yrs [11 girls and 19 boys] who had clear DA criteria due to syndromes and severe congenital anomalies and were candidates for elective eye surgery. Duration of the operation was 30 to 60 minutes. In all 30 cases, LMA placement with the classic method was not successful after 2 attempts by an expert. LMA was successfully inserted for all cases by the same person using the innovated method after meeting the required criteria [BIS=35-40]. All ventilation indices were met and the operation was performed successfully with no complication. There is always a risk of unsuccessful LMA placement in difficult pediatric airways using the classic method of insertion. The innovated method recommends pushing down the tongue by the index finger of the left hand. Considering the hypersensitivity of children to hypoxia and risk of unsuccessful LMA placement by the classic method, the innovated placement method is advised in children suffering from anomalies associated with macroglossia

Simultaneous pancreas and kidney transplantation: first report from Shahid Beheshti University of Medical Sciences and review of anesthesia considerations

We report a 33 year-old woman presented with signs and symptoms of severe uncontrolled diabetes mellitus and chronic renal failure [diabetic nephropathy]. She was prepared for emergency simultaneous pancreas and kidney transplantation [SPK] using hemodialysis and after compensating for the acid - base abnormality. She was discharged from the hospital about 3 week after the surgery with good renal and pancreatic function. A 2-month follow-up revealed no complication and a good renal and pancreatic function. Due to the importance of this kind of treatment and several anesthetic considerations of SPK we present this case report along with some pearls about related anesthetic view points

Anesthesia management in an 11-month old infant with pompe disease

Pompe disease is a glycogen storage disease [GSD] type II. Infantile-onset Pompe disease is fatal presenting with cardiac and skeletal myopathies and has an autosomal recessive pattern of inheritance with the prevalence rate of 1 in 40,000 live births [1]. Its common symptoms include cardiomegaly, hypotonia, failure to thrive [FTT] and hepatomegaly [1].The patient was a 4 kg, 11-month-old infant with the history of jaundice and recurrent seizures under treatment with phenytoin [15 mg/day] and phenobarbital [15 mg/day]. He was hypotonic, cachectic and pale [Hb=9.5] when presented to the anesthesia clinic of Labbafi Nejad Hospital for bilateral lensectomy. Induction and maintenance of anesthesia were carried out via the inhalation anesthesia method [N[2]O/O[2] and sevoflurane]. Laryngeal mask airway [LMA] was placed when achieving the appropriate depth of anesthesia. Bilateral lensectomy took 2 hours. After completion of the operation, the patient regained consciousness. His vital signs were stable and he was transferred to the recovery room and then to the ward. He was discharged from the hospital the day after the operation with no complications

Management of anesthesia in Goldenhar syndrome: case-series study

Goldenhar syndrome or oculo-auriculo-vertebral dysplasia [OAVD] is characterized by a wide range of congenital anomalies including ocular, auricular, facial, cranial, vertebral and cardiac abnormalities. It is associated with the anomalous development of the first and second branchial arches. Patients with this syndrome usually suffer from unilateral maxillary and mandibular hypoplasia and vertebral anomalies which often result in limitation of neck movement. For this reason, intubation is very difficult in these patients and anesthesiologists usually face difficulty in airway management. Newborns with this syndrome often have premature internal organs, low birth weight and airway disorders. As a result, a safe anesthesia in such patients requires a complete knowledge regarding the metabolism and side effects of anesthetic drugs. Our first case was a preterm 28-day old female with a fetal age of 28 weeks, birth weight of 1,200 g and gestational age of 32 weeks. At the time of admission, she weighed 1,500 g. She developed jaundice shortly after birth for which she underwent exchange transfusion. She was hospitalized in NICU for 14 days. Our second case was a 2 kg, 20-day old newborn with a fetal age of 37 weeks. Our third case was a full term 10-month old infant weighing 8 kg and our forth case was a 14 kg, 29- month old child who was a candidate for emergency surgery of dermoid cyst and bilateral upper lid coloboma. Anesthesia induction was performed by inhalation anesthesia with N2O/O2= 50% and sevoflurane [0.5-3.5%]; and in BIS [Bispectral Index] = 43, the appropriate size LMA [laryngeal mask airway] was inserted. Anesthesia was maintained by using N2O/O2=50% and sevoflurane [1-2.5%]. The BIS value was maintained in the range of 42-47. The surgical operations lasted for about 60-150 minutes. Patients regained consciousness 5 minutes after the completion of surgery and were transferred to the recovery room with stable vital signs. They were transferred to the ward 90 minutes later. Patients were discharged from the hospital the next morning with no post-up complications

Familiarity of physicians with the aims of pre-operative anesthesia evaluation clinics

The role of the anaesthesiologist in the quality of care rendered to patients during the pre-operative period is well known. The role of pre-operative anesthesia clinics in providing better conditions for patients undergoing anesthesia is now well documented. This study was performed to evaluate the familiarity of Iranian physicians with the aims of anesthesia clinics 10 years after the establishment of such clinics in Iran. Materials and All physicians working in 2 university medical centers were selected. A questionnaire was given to them and answers were analyzed and interpreted by statistical methods. Three-hundred forty-four Iranian physicians were questioned about their knowledge regarding anesthesia clinics out of which, 38% were faculty members, about half of them had working experience more than 10 yrs., 57.3% of them were surgeons, 27.6% of them were non-surgical clinical physicians, 6.4% were paraclinicians and the remaining were general practitioners. Forty-one percent of physicians were familiar with the aims of anesthesia clinics. Only 34% of physicians had referred patients to such clinics. The most important goals of establishment of these clinics from the physicians' point of view were to prepare the patients for operation [71%], reduce the complications of surgery [54%], reduce the time required for preparing patients for surgery [36%] and reducing the costs [34%]. Considering the results, it seems that a great majority of Iranian physicians are still unfamiliar with the aims of anesthesia clinics. Direct communication between anaesthesiologists and medical staff and stressing the benefits of establishing such clinics in medical congresses are beneficial and highly recommended by the authors

Acquaintance of patients with the aims of pre-operative anesthesia evaluation clinics

Anesthesia is peri-operative medicine. The role of anesthesiologist in the quality of care rendered to patients during the pre-operative period is well known. The role of pre-operative anesthesia clinics in providing better conditions for patients undergoing anesthesia is now well documented. This study was performed to evaluate the familiarity of Iranian patients with the aims of anesthesia clinics 10 years after the establishment of such clinics in Iran. All patients referred to anesthesia clinics in two university medical centers were evaluated during a 2-week period. A questionnaire was given to them and answers were analyzed and interpreted by statistical methods. Of the 286 patients who participated in this study, 56% were males and 44% were females; 43% of them were familiar with the goals of pre-op anesthesia, 83% of the patients mentioned that pre-op evaluation was the reason of their referral and 67% gave a positive feed-back on the clinic. The need for creating more motivation in patients and physicians was mentioned by 83% of the patients. Considering the statistical results, it seems that there is a great need to familiarize patients with the goals of these clinics and to create some motivation in them. By doing so, we can hope to offer better services to patients and reduce the anesthesia complications and anxiety

Comparison between classic laryngeal mask and cobra perilaryngeal airway during mechanical ventilation

Selection of an optimal method for the safe preoperative airway management is the base of a successful general anaesthesia. To achieve this goal various methods and devices are used including endotracheal tube and laryngeal mask airway, each has its own advantages and disadvantages. In this study, we compared a new supraglottic instrument [cobra perilaryngeal airway] with laryngeal mask airway [LMA], considering each one's abilities specially their role in preventing intraocular pressure rise during insertion. In a prospective randomized clinical trial 200 ASA class I, II patients with no history of glaucoma, cardiovascular or respiratory diseases and susceptibility to difficult intubation were randomly divided into two similar groups [100 subjects each]. None of them [age range 6-70 yrs] received premedication after preoxygenation and induction with sodium thiopental, fentanyl and atracurium. The patient was ventilated manually then one of the devices was inserted. After assurance of the correct position, its cuff was filled with air. In this study various factors including intraocular pressure [IOP], systolic blood pressure [SBP], SPO2, end tidal CO2 [ETCO2], heart rate, peak airway pressure and end expiratory tidal volume were recorded exactly before the induction [time 1], after the induction [time 2], 5 minutes after the induction [time 3], 15 minutes after the induction [time 4], and 5 minutes after releasing the device [time 5]. Cuff pressure was measured immediately after insertion and at the end of operation. Quality of insertion [1: simple 2: relatively simple 3: difficult 4: unsuccessful], their complications [bleeding, no bleeding] and sore throat 2 and 24 hours after the operation were detected by interview. Fitness of LMA or Cobra PLA on airway for prevention of air leakage were recorded as well. Qualitative data with chi-square and quantitative data with t-test and SPSS software [version 11] were analyzed. There was no clinical significant difference between the two groups regarding age, sex, ASA class, weight, duration of surgery, SPO2, heart rate and blood pressure. Cobra PLA offered advantages in regard to easy insertion [p=0.005], sore throat [p < 0.0001] and bleeding [p < 0.0001]. Mean rise of intraocular pressure and mean increase of systolic blood pressure [at the time 3] was higher in LMA [p=0.02]. Regarding ETCO2 [p=0.0001], peak airway pressure [p < 0.0001], ability to fitness on airway [p=0.01] and cuff pressure [p < 0.0001] cobra significantly offered advantages over LMA. Cobra PLA is a useful device for airway management in general anaesthesia during mechanical ventilation with minimal post-up complication and simplicity of usage offering high potential ventilation. More studies are required in regard to use of Cobra tube in different ages