Airway management in pediatric patients using the Glidescope Cobalt®: a feasibility study.

BACKGROUND: Video laryngoscopes are claimed to improve airway management. Several studies showed an equal or better glottic view using the Glidescope® compared with direct laryngoscopy in adults and in paediatric patients. Many case reports also described successful intubation in patients with a difficult airway. The Glidescope Cobalt® is a modified Glidescope® with a disposable sheath. Data on clinical application in paediatric patients is insufficient. METHODS: Twenty-four pediatric patients with a mean age of 27 months [range, 1-142] undergoing general anesthesia were included into this feasibility study. Cormack and Lehane grade was evaluated using a Macintosh blade. Tracheal intubation was performed using the Glidescope Cobalt®. Number of attempts, time to intubation, Cormack and Lehane (C&L) grade and a subjective score were noted for both a resident and an attending anesthesiologist. RESULTS: With the Glidescope Cobalt® the C&L grade improved in all patients with grade 2 or 3 to 1 and deteriorated in one case from C&L grade 1 to 2. The C&L grade remained unchanged in 15 patients (62.5%). C&L grades between resident and attending anesthesiologist were equal. Tracheal intubation was successful in 92% with a stylet-armed tube and in 8% using an unarmed tube with a Magill forceps, respectively. Time to intubation was median 50.5 [range, 22-93] seconds. CONCLUSION: The Glidescope Cobalt® presented suitable for use in children. C&L grade was significantly improved in all patients with a C&L grade of 2 or 3. Especially for educational purposes in pediatric anesthesia it provides a good view for all participants.

A comparison of the i-gel with the LMA-Unique in non-paralysed anaesthetised adult patients.

SUMMARY: This study assessed two disposable devices; the newly developed supraglottic airway device i-gel and the LMA-Unique in routine clinical practice. Eighty patients (ASA 1-3) undergoing minor routine gynaecologic surgery were randomly allocated to have an i-gel (n = 40) or LMA-Unique (n = 40) inserted. Oxygen saturation, end-tidal carbon dioxide, tidal volume and peak airway pressure were recorded, as well as time of insertion, airway leak pressure, postoperative sore-throat, dysphonia and dysphagia for each device. Time of insertion was comparable with the i-gel and LMA-Unique. There was no failure in the i-gel group and one failure in the LMA-Unique group. Ventilation and oxygenation were similar between devices. Mean airway pressure was comparable with both devices, whereas airway leak pressure was significantly higher (p < 0.0001) in the i-gel group (mean 29 cmH(2)O, range 24-40) compared with the LMA-Unique group (mean 18 cmH(2)O, range 6-30). Fibreoptic score of the position of the devices was significantly better in the i-gel group. Post-operative sore-throat and dysphagia were comparable with both devices. Both devices appeared to be simple alternatives to secure the airway. Significantly higher airway leak pressure suggests that the i-gel may be advantageous in this respect.

Neurochemical monitoring using intracerebral microdialysis during systemic haemorrhage.

BACKGROUND: Intracerebral microdialysis is a sensitive tool to analyse tissue biochemistry, but the value of this technique to monitor cerebral metabolism during systemic haemorrhage is unknown. The present study was designed to assess changes of intracerebral microdialysis parameters both during systemic haemorrhage and after initiation of therapy. METHODS: Following approval of the Animal Investigational Committee, 18 healthy pigs underwent a penetrating liver trauma. Following haemodynamic decompensation, all animals received a hypertonic-hyperoncotic solution and either norepinephrine or arginine vasopressin, and bleeding was subsequently controlled. Extracellular cerebral concentrations of glucose (Glu), lactate (La), glycerol (Gly), and the lactate/pyruvate ratio (La/Py ratio) were assessed by microdialysis. Cerebral venous protein S-100B was determined. Haemodynamic data, blood gases, S-100B, and microdialysis variables were determined at baseline, at haemodynamic decompensation, and repeated after drug administration. RESULTS: Microdialysis measurements showed an increase of La, Gly, and La/Py ratio at BL Th compared to BL (mean +/- SEM; La 2.4 +/- 0.2 vs. 1.4 +/- 0.2 mmol x l(-1), p < 0.01; Gly 37 +/- 7 vs. 27 +/- 6 micromol x l(-1), n.s.; La/Py ratio 50 +/- 8 vs. 30 +/- 4, p < 0.01), followed by a further increase during the therapy phase (La 3.4 +/- 0.3 mmol x l(-1); Gly 69 +/- 10 micromol x l(-1); La/Py ratio 58 +/- 8; p < 0.001, respectively). Cerebral venous protein S-100B increased at decompensation and after therapy, but decreased close to baseline values after 90 min of therapy. CONCLUSIONS: In this model of systemic haemorrhage, changes of cerebral energy metabolism detected by intracerebral microdialysis indicated anaerobic glycolysis and degradation of cellular membranes throughout the study period.

Comparison of LMA Unique, Ambu laryngeal mask and Soft Seal laryngeal mask during routine surgical procedures.

BACKGROUND AND OBJECTIVE: This study was performed to compare three disposable airway devices, the LMA Unique (LMA-U), the Ambu laryngeal mask (Ambu LM) and the Soft Seal laryngeal mask (Soft Seal LM) for elective general anaesthesia during controlled ventilation in non-paralysed patients. METHODS: One hundred and twenty ASA I-III patients scheduled for routine minor obstetric surgery were randomly allocated to the LMA-U (n = 40), Ambu LM (n = 40) or Soft Seal LM (n = 40) groups, respectively. Patients were comparable with respect to weight and airway characteristics. A size 4 LMA was used in all patients and inserted by a single experienced anaesthesiologist. Oxygenation, overall success rate, insertion time, cuff pressure and resulting airway leak pressure were determined as well as a subjective assessment of handling and the incidence of sore throat, dysphagia and hoarseness. RESULTS: Time of insertion was shortest with the Ambu LM, while failure rates were comparable with the LMA-U, the Ambu LM and the Soft Seal LM (median 19 s; range 8-57 s; success rate 100% vs. 14; 8-35; 97% vs. 20; 12-46; 95%). Insertion was judged 'excellent' in 75% of patients in the LMA-U group, in 70% of patients in Ambu LM group and in 65% of patients in the Soft Seal LM group. There was no difference between devices with respect to postoperative airway morbidity at 6 h or 24 h following surgery. CONCLUSIONS: All three disposable devices were clinically suitable with respect to insertion times, success rates, oxygenation, airway and leak pressures, as well as to subjective handling and postoperative airway morbidity.

Airway management during cardiopulmonary resuscitation--a comparative study of bag-valve-mask, laryngeal mask airway and combitube in a bench model.

Gastric inflation and subsequent regurgitation are a potential risk of ventilation during cardiopulmonary resuscitation (CPR). In respect of recent investigations, principal respiratory components such as respiratory system compliance, resistance and lower esophageal sphincter pressure were adapted according to CPR situations. The purpose of our study was to assess lung ventilation and gastric inflation when performing ventilation with bag-valve-mask, laryngeal mask airway, and combitube in a bench model simulating an unintubated cardiac arrest patient. Twenty-one student nurses, without any experience in basic life support measures, ventilated the bench model with all three devices. Mean ( +/- S.D.) gastric inflation with the laryngeal mask airway (seven cases) was significantly lower than with the bag-valve-mask (0.6 +/- 0.8 vs 3.0 +/- 2.11 min(-1), P < 0.01). There was no gastric inflation when ventilation was performed with the combitube. Only seven of 21 volunteers exceeded 1-min lung volumes of > 5 1 when using the bag-valve-mask, whereas mean (+/-S.D.) 1-min lung volumes with both laryngeal mask airway and combitube were significantly higher (laryngeal mask airway 15.0+/-6.61, combitube 16.6 +/- 6.81 vs bag-valve-mask 4.8 +/- 2.71, P < 0.01). The time for insertion was significantly faster with both bag-valve-mask and laryngeal mask airway compared with the combitube (median: bag valve mask 22 s, laryngeal mask airway 37 s vs combitube 70 s, P < 0.01). This may tip the scales towards using the laryngeal mask airway during basic life support airway management. In conclusion, our data suggests that both laryngeal mask airway and combitube may be appropriate alternatives for airway management in the first few minutes of CPR.

Smaller tidal volumes during cardiopulmonary resuscitation: comparison of adult and paediatric self-inflatable bags with three different ventilatory devices.

Gastric inflation and subsequent regurgitation of stomach contents is a major hazard of bag-valve-face mask ventilation during the basic life support phase of cardiopulmonary resuscitation (CPR). Recent investigations suggested that use of a paediatric self-inflating bag may reduce stomach inflation while ensuring sufficient lung ventilation. The purpose of our study was to examine whether use of a paediatric self-inflating bag in association with laryngeal mask airway, combitube, and bag-valve-face mask may provide adequate lung ventilation, while reducing the risk of gastric inflation in a bench model simulating the initial phase of CPR. Sixteen intensive care unit registered nurses volunteered for our study. Use of a paediatric versus adult self-inflating bag resulted in a significantly (P < 0.01) lower mean (+/- S.D.) tidal lung volume with both the laryngeal mask airway and combitube (laryngeal mask airway 349 +/- 149 ml versus 725 +/- 266 ml, combitube 389 +/- 113 ml versus 1061 +/- 451 ml). Lung tidal volumes were below the European Resuscitation Council recommendation with both self-inflatable bags in the bag-valve-face mask group (paediatric versus adult self-inflatable bag 256 +/- 77 ml versus 334 +/- 125 ml). Esophageal tidal volumes were significantly (P < 0.05) lower using the paediatric self-inflatable bag in the bag-valve-face mask group; almost no gastric inflation occurred with the laryngeal mask airway, and none with the combitube. In conclusion, use of the paediatric self-inflating bag may reduce gastric inflation, but measured lung tidal volumes are below the European Resuscitation Council recommendation when used with either, the laryngeal mask airway, combitube, or bag-valve-face mask.

A comparison of the cuffed oropharyngeal airway (COPA) with the laryngeal mask airway (LMA) during manually controlled positive pressure ventilation.

STUDY OBJECTIVE: To examine the cuffed oropharyngeal airway (COPA) during positive pressure ventilation (PPV) and to compare its reliability and efficacy with the laryngeal mask airway (LMA). DESIGN: Prospective, randomized, controlled trial. SETTING: University Hospital. PATIENTS: 60 adult ASA physical status I and II patients scheduled for urologic surgery. INTERVENTIONS: Patients were randomly assigned to be ventilated with a COPA (n = 33) or a LMA (n = 27) during a standardized anesthetic procedure. Following preoxygenation and induction with alfentanil and propofol, the respective airways were inserted. Patients were ventilated manually with the reservoir bag of the anesthesia respirator. Inspiratory airway pressure was limited to 20 cm H2O, and the target tidal volume was 7 ml/kg. Respiratory rate was adjusted to achieve an end-tidal pressure of carbon dioxide of 35 mmHg. Anesthesia was maintained with propofol, nitrous oxide in oxygen, and alfentanil, as appropriate. MEASUREMENTS AND MAIN RESULTS: We evaluated ease of insertion (nominal scale: easy, moderate, difficult, or impossible) and recorded the number of maneuvers performed during insertion until an airtight seal of the airway was achieved. Reliability for "hands free" ventilation--defined as ventilation without the need to further augment the position of the airway device manually--was determined (nominal scale: adequate ventilation, adequate ventilation with manual assistance, and inadequate ventilation leading to airway change). Ventilation and oxygenation parameters were derived from the anesthesia respirator and a capillary blood gas sample, respectively. The incidence of laryngopharyngeal discomfort and the amount of salivation were assessed by nominal scales. The COPA was easier to insert than the LMA (p < 0.001), but more positional maneuvers (p < 0.001) were necessary with this device. "Hands free" ventilation was achieved less often with the COPA (p < 0.02). Ventilation and oxygenation were comparable with both devices. The COPA was associated with less salivation (p < 0.01) and laryngopharyngeal discomfort (p < 0.05) than the LMA. CONCLUSION: Although effective ventilation can be accomplished with both devices, the LMA is more reliable for "hands free" ventilation than the COPA. The lower incidence of laryngopharyngeal discomfort and salivation with the COPA may be beneficial for patients at risk for developing laryngospasm.