[About laryngeal mask: is the lowest price material the better cost-efficacy choice?]. / Comparaison de quatre masques laryngés à usage unique pour la chirurgie carcinologique du sein: une approche médico-économique.

OBJECTIVE: The main goal of this study was to achieve a medico-economic comparison between four disposable laryngeal masks (LM) (LMA-Unique™, Ambu AuraOnce™, I-Gel™ and LMA-Suprême™). STUDY DESIGN: A prospective, randomized, monocentre study. MATERIAL AND METHODS: In a center, using routinely LMA-Unique masks, scheduled breast surgery patients were allocated into four groups according to the LM model. After the induction, the modalities of use were collected, as well as the intraoperative events that required additional anesthetic equipment. The real cost of each model was calculated (cost of the mask+extra cost related to complications). Using the LMA-Unique as a reference, we performed a cost-efficacy analysis. We realized a cost-efficiency analysis putting in parallel the impact on the cost and the incidence of the events. RESULTS: A total of 178 patients were included. According to the cost-efficacy analysis, the dominant model was the Ambu AuraOnce™ (Δreal cost: -34.2%, Δevents: -30.6%). The LMA-Unique™ was dominated because of a high morbidity rate. The I-Gel™ and LMA-Suprême™ models were more efficient but more expensive (Δreal cost: +16% and +22.5% respectively). To compensate for additional costs, it would be necessary to apply a price reduction of at least 50%. CONCLUSIONS: Despite their better efficiency and safety, the latest generation laryngeal masks are still expensive in spite of a low rate of complication. These results do not take into account very rare and severe complications not met in this study in the limited size; then the economic and medical impact can influence the choice beyond the simple analysis cost-efficiency.

Comparative life cycle assessment of disposable and reusable laryngeal mask airways.

BACKGROUND: Growing awareness of the negative impacts from the practice of health care on the environment and public health calls for the routine inclusion of life cycle criteria into the decision-making process of device selection. Here we present a life cycle assessment of 2 laryngeal mask airways (LMAs), a one-time-use disposable Unique™ LMA and a 40-time-use reusable Classic™ LMA. METHODS: In life cycle assessment, the basis of comparison is called the "functional unit." For this report, the functional unit of the disposable and reusable LMAs was taken to be maintenance of airway patency by 40 disposable LMAs or 40 uses of 1 reusable LMA. This was a cradle-to-grave study that included inputs and outputs for the manufacture, transport, use, and waste phases of the LMAs. The environmental impacts of the 2 LMAs were estimated using SimaPro life cycle assessment software and the Building for Environmental and Economic Sustainability impact assessment method. Sensitivity and simple life cycle cost analyses were conducted to aid in interpretation of the results. RESULTS: The reusable LMA was found to have a more favorable environmental profile than the disposable LMA as used at Yale New Haven Hospital. The most important sources of impacts for the disposable LMA were the production of polymers, packaging, and waste management, whereas for the reusable LMA, washing and sterilization dominated for most impact categories. DISCUSSION: The differences in environmental impacts between these devices strongly favor reusable devices. These benefits must be weighed against concerns regarding transmission of infection. Health care facilities can decrease their environmental impacts by using reusable LMAs, to a lesser extent by selecting disposable LMA models that are not made of certain plastics, and by ordering in bulk from local distributors. Certain practices would further reduce the environmental impacts of reusable LMAs, such as increasing the number of devices autoclaved in a single cycle to 10 (-25% GHG emissions) and improving the energy efficiency of the autoclaving machines by 10% (-8% GHG emissions). For both environmental and cost considerations, management and operating procedures should be put in place to ensure that reusable LMAs are not discarded prematurely.

Respiratory face mask: a novel and cost-effective device for use during the application of myocardial ischemia in rats.

To shorten operation time and improve survival rate of rats with myocardial ischemia or myocardial infarction, we use a novel device comprised of a face mask and a head/neck retainer in this study. We report the basic design of the novel respiratory face mask (RFM) and evaluate its performance in a rat model of myocardial ischemia. The device is cost-effective and easier to handle than other devices, such as tracheal intubation. Compared with conventional tracheal intubation, we found that RFM shortens operation time significantly while keeping blood indices normal; the mean operation time for rats in the mask group was (32+/-3) min, and that for the intubation group was (45+/-7) min (P<0.05). Moreover, the size and shape of the RFM can be changed according to the body weight of rats. In conclusion, RFM is an appropriate device for the establishment of myocardial infarction or ischemia-reperfusion in rats.

[Disposable vs reusable laryngeal mask airway: a cost-minimization analysis]. / Masques laryngés à usage unique vs réutilisable : une étude de minimisation de coûts.

JUSTIFICATION: According to French regulations concerning the risk of Creutzfeldt-Jakob disease transmission, traceability procedures of all sterile medical devices which need to be reused are mandatory. Despite sterilization processes, the reusable laryngeal mask airway (LMA) prion disease transmission remains possible. As a result, the disposable LMA has been introduced. OBJECTIVE: Assuming clinical equivalence was achieved, the cost of disposable vs reusable LMA was studied in a university hospital. STUDY DESIGN: A Cost-minimization analysis of disposable vs reusable laryngeal mask airway was realised. METHODS: Disposable LMA cost was calculated as the sum of product cost and elimination cost. Reusable LMA were autoclaved after hospital purchasing in two separate sterilizing processing units of the same hospital. Reusable LMA cost was determined combining materiel and labor costs. RESULTS: The reusable LMA cost depended on the sterilizing processing unit concerned and varied between 9.59 Euros and 9.69 vs 8.38 Euros for the single-use LMA. CONCLUSION: With the cost savings made possible by use of disposable LMA in both labor and consumables, this practice should be considered.

Randomized evaluation of the single-use SoftSeal and the re-useable LMA Classic laryngeal mask.

A number of laryngeal masks are available, including both re-usable and single-use masks. Single-use laryngeal masks may decrease the risk of transmitting prion infections. We performed a single-blind randomized trial in 200 spontaneously breathing female patients under general anaesthesia with nitrous oxide, to compare a new single-use laryngeal mask, the SoftSeal (Portex Ltd, U.K.), with a re-usable laryngeal mask, the LMA Classic (Laryngeal Mask Company Ltd., Cyprus). The primary outcome was successful insertion at the first attempt. Size 4 single-use (n = 99) or re-usable (n = 100) laryngeal masks, inserted by experienced anaesthetists, were equivalent for successful placement at the first attempt (90% versus 91% respectively). The single-use mask was less easy to insert (47% difficult versus 9%, P < 0.001). Clinical and anatomical tests of position and function were similar. The cuff pressure of the re-usable mask increased significantly compared with the single-use mask (median +10 cm versus -2 cm H2O, P < 0.001). Forty per cent of patients allocated the single-use mask and 20% of those allocated the re-usable mask experienced sore throat at 24 hours postoperatively (P < 0.05). An estimation of cost per patient use was greater for the re-usable mask. We conclude that the SoftSeal single-use laryngeal mask and the LMA Classic re-usable laryngeal mask airway are of similar clinical utility in terms of successful insertion and airway maintenance. The re-usable laryngeal mask was easier to insert and associated with less postoperative sore throat, but costs were higher.

A comparison of endotracheal intubation and use of the laryngeal mask airway for ambulatory oral surgery patients.

PURPOSE: This study compared current experience with the laryngeal mask airway (LMA) to previous experience with endotracheal intubation for ambulatory patients receiving general anesthesia. PATIENTS AND METHODS: A retrospective comparison of 157 patients (50 endotracheal intubation [ET] and 107 LMA cases) was conducted. The subjects were American Association of Anesthesiologist (ASA) Class I and II patients who underwent outpatient general anesthesia for dentoalveolar surgery. Procedure time, recovery time, and cost of techniques were compared. RESULTS: The patients undergoing a variety of outpatient dentoalveolar surgical procedures under general anesthesia in the LMA group had a shorter procedure time than the ET group (40 vs 44 minutes) and had a significantly shorter recovery time (54 vs 67 minutes). In addition, compared with the cost of delivering care with ET, the LMA provided slightly lower cost per case ($20 to $30 per case compared with $35 to $80 per case), depending on the anesthetic technique used. Comparing the 2 techniques for removal of 4 impacted third molars (25 patients ET and 68 patients LMA) revealed a similar procedure time of 39 minutes for both groups, but a shorter recovery time for the LMA group (54 vs 68 minutes). CONCLUSIONS: Use of the LMA has advantages over endotracheal intubation for outpatients receiving general anesthesia for dentoalveolar surgery.

Experience in the use of laryngeal mask airway in Tikur Anbessa Hospital.

The study was designed to make an initial observation in the use of laryngeal mask airway with the only existing drug, i.e., ketamine, for induction of anaesthesia. Its effective use should be determined to maintain patients airway following induction of anaesthesia with the only available drug for induction than the drug that is commonly used for its insertion. There were a total of 64 patients included in the study in a period of seven weeks with a male to a female ratio of 1 to 1.33 and age range of 6-70 years. A successful insertion following induction of anaesthesia with ketamine was achieved in 40 patients at the 1st attempt and in 23 patients at the 2nd attempt. Successful insertion of laryngeal mask airway was considered when it was achieved on the first attempt. Deepening anaesthesia with halothane/O2 by mask or adding small dose of relaxant (Succinylcholine) was necessary in 33 patients. The fact that a second insertion attempt was necessary and a large number of cases needed additional anaesthesia or relaxation indicated ketamine alone was not a good drug as an induction agent for laryngeal mask airway insertion.

Sevoflurane-N2O versus propofol/isoflurane-N2O during elective surgery using the laryngeal mask airway in adults.

STUDY OBJECTIVES: To compare a sevoflurane-nitrous oxide (N2O) general anesthetic technique with a standard technique of propofol for induction, and isoflurane-N2O for maintenance. DESIGN: Prospective, randomized study. SETTING: University-affiliated tertiary-care hospital. PATIENTS: 62 adults undergoing elective surgery using the laryngeal mask airway (LMA). INTERVENTIONS: Patients received either the standard technique of propofol for induction and isoflurane-N2O for maintenance (controls) or sevoflurane-N2O for both induction and maintenance of general anesthesia. MEASUREMENTS: Induction and emergence times, heart rate, blood pressure, oxygen saturation, and end-tidal carbon dioxide were recorded. MAIN RESULTS: Time to loss of consciousness was faster after propofol (mean +/- SEM: 51 +/- 3 sec) than after sevoflurane-N2O (85 +/- 10 sec; p < 0.05). Ready for surgery times, were however, similar between groups (10 +/- 1 vs. 11 +/- 1 min, respectively). All patients in the control group had apnea after LMA insertion compared with 4 patients in the sevoflurane-N2O group (p < 0.05). Heart rate was lower 5 and 10 minutes after LMA insertion in the sevoflurane-N2O group (69 +/- 3 and 66 +/- 3 bpm) versus the control group (81 +/- 3 bpm and 74 +/- 3 bpm, p < 0.05). After cessation of anesthetic gases, there were no differences in time to LMA removal, eye opening, or exiting the operating room (OR) between the control group (7, 8, and 10 min) and sevoflurane-N2O groups (7, 8, and 12 min, respectively). The majority of patients in both groups (92% to 97%) rated their anesthetic experience as excellent or good. CONCLUSIONS: Sevoflurane-N2O and propofol provided comparable conditions for LMA insertion. Sevoflurane-N2O was not associated with a faster return of consciousness or faster time to exit the OR compared with isoflurane-N2O.

The PTL, Combitube, laryngeal mask, and oral airway: a randomized prehospital comparative study of ventilatory device effectiveness and cost-effectiveness in 470 cases of cardiorespiratory arrest.

PURPOSE: A prehospital study was conducted to assess and compare three alternative airway devices and the oral airway for use by non-Advanced Life Support emergency medical assistants (EMAs). METHOD: A modified randomized crossover design was used. The Pharyngeal Tracheal Lumen Airway (PTL), the laryngeal mask (LM), and the esophageal tracheal Combitube (Combi) were compared objectively for success of insertion, ventilation, and arterial blood gas and spirometry measurements performed upon hospital arrival. Subjective assessment was carried out by EMAs and receiving physicians at the time of device use, and an eight-question comparative evaluation of all devices was completed by EMAs at study conclusion. A comparative cost analysis was performed. Operating room training was compared with mannequin training for the LM. Autopsy findings and survival to hospital discharge were analyzed. The study took place in four non-ALS communities over four and a half years, and involved 470 patients in cardiac and/or respiratory arrest. EMAs had automatic external defibrillator training but no endotracheal intubation skills. RESULTS: Successful insertion and ventilation: Combi, 86%; PTL, 82%; LM, 73% (p = 0.048). No significant difference was found for objective measurements of ventilatory effectiveness (ABGs and spirometry). Significant comparative differences in subjective evaluation were found. CONCLUSIONS: The PTL, LM, and Combi appear to offer substantial advances over the OA/BVM system. Although the most costly, the Combitube was associated with the least problems with ventilation and was the most preferred by a majority of EMAs.

A cost analysis of the laryngeal mask airway for elective surgery in adult outpatients.

BACKGROUND: Since the introduction of the laryngeal mask airway (LMA) into the United States in 1991, the device has become widely used in anesthesia practice. The purpose of this economic analysis was to use existing data to evaluate the costs of the LMA relative to three other common airway management techniques and to identify the variables that had the greatest effect on cost efficiency. METHODS: We evaluated four airway management techniques for healthy adults receiving an isoflurane-nitrous oxide-oxygen anesthetic for elective outpatient surgery: (1) LMA with spontaneous ventilation; (2) face mask with spontaneous ventilation; (3) tracheal intubation after succinylcholine with subsequent spontaneous ventilation; and (4) tracheal intubation after nondepolarizing neuromuscular blockade and controlled ventilation. We analyzed published clinical studies of the LMA and obtained cost data from Stanford University Medical Center. The best available estimates of the independent variables were incorporated into a baseline case. For each airway technique we derived cost equations that excluded costs common to all four techniques. RESULTS: Relative to airway management with an LMA, calculated values for the baseline analysis included additional isoflurane costs for use of a face mask ($ 0.12/min) and for tracheal intubation with ($ 0.043/min) and without neuromuscular blockade ($ 0.06/min). With a neuromuscular blocking drug cost of $ 0.21/min and an LMA cost per use of $ 20, the face mask with spontaneous ventilation was the cost-efficient airway choice for anesthetics lasting as long as 100 min. Increasing the LMA reuse rate from 10 to 25 made the LMA the least costly airway technique for cases lasting more than 70 min. CONCLUSIONS: If the LMA is reused 40 times, the LMA is the cost-efficient airway choice for outpatients receiving an isoflurane-nitrous oxide-oxygen anesthetic lasting longer than 40 min. This finding does not change if the cost of neuromuscular blockade or the incidence of airway-related complications is varied over a clinically relevant range.