i-gel (Intersurgical Ltd., Wokingham, UK) is a new supraglottic airway device with a cuff made of thermoplastic elastomer gel. We retrospectively studied easiness of insertion and troubles in ventilation when this dev...i-gel (Intersurgical Ltd., Wokingham, UK) is a new supraglottic airway device with a cuff made of thermoplastic elastomer gel. We retrospectively studied easiness of insertion and troubles in ventilation when this device was used by less experienced anesthesiologists. Consecutive eleven cases undergoing surgery under general anesthesia were studied. i-gel was successfully inserted in 7 cases (63%) at the first attempt, 2 cases at the second attempt without changing the size. In one case, the size was changed at the second attempt, which resulted in the successful insertion. There was one case of failed insertion even at the second attempt. Fiberoptic observation of the glottis showed direct contact of the cuff to the arytenoids cartilage in cases with successful insertion, however, spastic glottis, defined as contact of vocal cords was observed in 4 cases, and down-folding of the epiglottis was observed in 2 cases. During maintenance of anesthesia, ventilation trouble was observed in 3 cases. We conclude that i-gel should only be used with sufficient knowledge, preparations, skills or support from experienced physician to solve problems related to the safe use of supraglottic airway devices.展开更多
Study Objective: We studied the overall efficacy of fiberoptic aided intubation using three different supraglottic airways (SGA) as intubation conduits with a standard endotracheal tube (ETT) to determine which, if an...Study Objective: We studied the overall efficacy of fiberoptic aided intubation using three different supraglottic airways (SGA) as intubation conduits with a standard endotracheal tube (ETT) to determine which, if any, is superior as an intubation conduit. Design: After induction of general anesthesia, subjects were randomized to one of three groups: Air-Q ILATM, LMA Classic ExcelTM, and LMA UniqueTM. Subjects were intubated with a fiberoptic aided technique with continuous ventilation with FiO2 = 1.0 through one of these SGAs. The primary endpoint was the overall efficacy of the intubation procedure. In addition, the following data were collected: demographic data, intubation times, grade of view of the larynx, and a visual analog scale (VAS) score of difficulty as determined by the primary anesthesiologist performing the procedure. Data were analyzed using a Kruskal-Wallis one-way analysis of variance and Post hoc analysis was done using Dunn’s Multiple Comparison Test. Results: 126 total subjects were studied. Intubation success rates were 100%, 87.8%, and 95% with the Air-Q ILATM, LMA Classic ExcelTM, and LMA UniqueTM respectively. There was no significant difference among the three different SGAs when comparing the times to place the SGA (T1), the true intubating time (T2), the time to remove the SGA (T3), or the total time (T4). Data were also stratified by the grade of view of the larynx;all grade I views, grade II views, and grade III views were grouped together regardless of the type of the SGA used. The grade I view of the larynx group had significantly faster true intubation times (T2 = 75.1 sec, p = 0.01) and significantly lower VAS scores (VAS = 1.9, P = TM provides the best view of the larynx and is the easiest one to use as an intubation conduit.展开更多
Background: The fluid seal of supraglottic airway devices (SGA) protects the airway from fluid contamination. We evaluated the suitability of indicator dye placement in the upper digestive tract of anesthetized patien...Background: The fluid seal of supraglottic airway devices (SGA) protects the airway from fluid contamination. We evaluated the suitability of indicator dye placement in the upper digestive tract of anesthetized patients combined with fiberoptical tracing to investigate the fluid seal of SGA. Methods: Patients swallowed a capsule of indigo carmine green (ICG) prior to induction of anaesthesia. After induction of anesthesia, one of two different SGA (either an i-GelTM or an LMA-SupremeTM (LMA-S)) was inserted after randomization. Methylene blue stained normal saline was injected through the proximal opening of drainage tube during mechanical ventilation as well as spontaneous breathing. We monitored regurgitation of ICG with a flexible fiberscope (FO) inserted through the drainage tube and checked for the appearance of methylene blue in the mask bowl with the FO inserted through the airway tube. Results: In thirty-six patients with an i-GelTM and 37 with a LMA-S no regurgitation of ICG was observed at the level of the upper oesophageal sphincter (UES). Methylene blue stained saline was not visible in any patient during pressure-controlled ventilation, but was detected in two of the 36 patients with the i-GelTM during spontaneous breathing. Conclusion: Instilling dye through the drainage tube of SGA models with a built-in drainage tube represents a useful method to examine and to compare the fluid seal of different SGA. Our protocol presented in this study proved to be an easy and reproducible approach for future studies. Furthermore, the clinical results gained during this evaluation highlight the necessity for further investigations regarding the fluid seal competencies of SGAs in humans under clinical conditions.展开更多
Purpose: This study was designed to study the effect of early use of the King Airway (KA) and impedance threshold device (ITD) in out-of-hospital cardiac arrest on ETCO2 as a surrogate measure of circulation, survival...Purpose: This study was designed to study the effect of early use of the King Airway (KA) and impedance threshold device (ITD) in out-of-hospital cardiac arrest on ETCO2 as a surrogate measure of circulation, survival, and cerebral performance category (CPC) scores. After analysis of the first 9 month active period the KA was relegated to rescue airway status. Methods: This was a prospective pre-post study design. Patients >18 years with out-of-hospital cardiac caused arrest were included. Three periods were compared. In the first “non active” period conventional AHA 30/2 compression/ventilation ratio CPR was done with bag mask ventilation (BMV). No ITD was used. After advanced airway placement the compression/ventilation ratio was 10/1. In the second period continuous compressions were done. Primary airway management was a KA with an ITD. After placement of the KA the compression/ventilation ratio was 10/1. In the third period CPR reverted to 30/2 ratio with a two hand seal BMV with ITD. CPR ratio was 10/1 post endotracheal intubation (ETI) or KA. The KA was only recommended for failed BMV and ETI. Results: Survival to hospital discharge was similar in all three study periods. In Period 2 there was a strong trend to CPC scores >2. The study group hypothesized that the KA interfered with cerebral blood flow. For that reason the KA was abandoned as a primary airway. Comparing Period 1 to Period 3 there was a trend to improved survival in the bystander witnessed shockable rhythm (Utstein) subgroup, particularly if a metronome was used. ETCO2 was significantly increased in Period 2 and trended up in Period 3 when compared to Period 1. Advanced airway intervention had a highly significant negative association with survival. Conclusion: The introduction of an ITD into our system did not result in a statistically significant improvement in survival. The study groups were somewhat dissimilar. ETCO2 trended up. When comparing Period 1 to Period 3, the bundle of care was associated with a trend towards increased survival in the Utstein subgroup, particularly with a metronome set at 100. Multiple confounders make a definitive conclusion impossible. Advanced airways showed a significant association with poor survival outcomes. The KA was additionally associated with poor neurologic outcomes.展开更多
Background: The AmbuAuraGain is a new single-use supraglottic airway device with gastric channel designed to facilitate intubation. The aim of the study was to assess the anatomic position and the performance of the A...Background: The AmbuAuraGain is a new single-use supraglottic airway device with gastric channel designed to facilitate intubation. The aim of the study was to assess the anatomic position and the performance of the AuraGain in fresh cadavers compared to that of the Intersurgical i-gel and LMA Supreme New Cuff. Methods: The 3 devices were inserted in random order in 7 fresh cadavers without difficult airway criteria. The assessed items were: Insertion time, number of attempts and ease of insertion, airway seal pressure, ease of gastric tube insertion, endoscopic view of vocal cords, efficacy of guided tracheal intubation through the AuraGain and i-gel, and anatomic fit by lateral X-ray and neck dissections. Results: All devices were successfully inserted within 3 attempts, except for one case of the LMA Supreme. Adjusting manoeuvres were often required to accomplish correct insertion. A 16 G gastric tube was easily advanced through all AuraGain and LMA Supreme devices. Fiberoptic tracheal intubation was effectively achieved through all AuraGain and i-gel devices in less than 60 s. Lateral X-ray and neck dissections confirmed optimal alignment of all devices with the respiratory and digestive tracts. Conclusions: Insertion of the new AmbuAuraGain required adjusting manoeuvres in some cases, as observed with the other two devices, and achieved similar airway seal pressures. Passage of a large bore gastric tube was as fast as with the LMA Supreme and ease of guided intubation was similar to that of the i-gel.展开更多
Self-expanding metallic stents are sometimes placed for the management of obstructing airway lesions or conditions such as airway wall malacia or tracheal stenosis. However, endoscopic removal of these devices from th...Self-expanding metallic stents are sometimes placed for the management of obstructing airway lesions or conditions such as airway wall malacia or tracheal stenosis. However, endoscopic removal of these devices from the airway can pose extreme challenges for both clinical airway management as well as for the administration of general anesthesia. We report on a 61-yearold man with a complex cardiac history presenting for endoscopic stent removal necessitated by the formation of extensive granulation tissue. Comorbidities included a history of myocardial infarction, an ischemic cardiomyopathy with severe left heart failure(ejection fraction of 25%), mild right heart failure, 2+ tricuspid regurgitation status post tricuspid valve repair, and atrial fibrillation. An automatic external(wearable) cardiac defibrillator(Zoll Life Vest) was also in place. Induction of anesthesia was carried out using etomidate, with maintenance of anesthesia carried out with a propofol infusion(total intravenous anesthesia). Rocuronium was used for neuromuscular blockade. A size 4 i Gel supraglottic airway and, later, rigid bronchoscopy formed the basis for airway management. Stable conditions were met through the 2-h procedure, and the patient recovered uneventfully. Our successful experience in this case leads us to propose further use of a supraglottic airway in conjunction with total intravenous anesthesia for these procedures.展开更多
Background:Jaw thrust has been proven as a useful test determining adequate depth of anesthesia for successful insertion of supraglottic airway device (SAD) in normal adults and children receiving intra-venous or inha...Background:Jaw thrust has been proven as a useful test determining adequate depth of anesthesia for successful insertion of supraglottic airway device (SAD) in normal adults and children receiving intra-venous or inhalational anesthesia induction.This prospective observational study aimed to determine the feasibility and validity of this test when using as an indicator assessing adequate depth of anesthesia for successful insertion of SAD in spontaneously breathing morbidly obese patients receiving sevoflurane inhalational induction.Methods:Thirty morbidly obese patients with a body mass index 40 to 73 kg/m2 undergoing bariatric surgery in Beijing Friendship Hospital from October 2018 to January 2019 were included in this study.After adequate pre-oxygenation,5% sevoflurane was inhaled and inhalational concentration of sevoflurane was increased by 1% every 2 min.After motor responses to jaw thrust disappeared,a SAD was inserted and insertion conditions were graded.The anatomic position of SAD was assessed using a fiberoptic bronchoscope.Results:The SAD was successfully inserted at the first attempt in all patients.Insertion conditions of SAD were excellent in nine patients (30%) and good in 21 patients (70%),respectively.The fiberoptic views of SAD position were adequate in 28 patients (93%).Conclusions:Jaw thrust test is a reliable indicator determining adequate anesthesia depth of sevoflurane inhalational induction for successful insertion of SAD in spontaneously breathing morbidly obese patients.展开更多
To the Editor:The supraglottic airway device (SAD) with an additional gastric drainage channel may be beneficial for patients needing gastric decompression during surgery, such as laparoscopic cholecystectomy and cesa...To the Editor:The supraglottic airway device (SAD) with an additional gastric drainage channel may be beneficial for patients needing gastric decompression during surgery, such as laparoscopic cholecystectomy and cesarean delivery. Furthermore, addition of gastric drainage channel is a typical feature of second-generation SAD. However, all of second-generation SADs have a gastric tube channel opening at the center of the distal tip. Such a design may cause some difficulty for insertion of the gastric tube if there is an inadequate position of the device tip in the upper esophageal aperture. In normal anatomy, the upper esophageal aperture is actually inclined to the left side of the trachea. Thus, we inferred that it should be much easier to insert a gastric tube into the esophagus, if the gastric drainage channel is placed at the left side of the SAD tip.展开更多
文摘i-gel (Intersurgical Ltd., Wokingham, UK) is a new supraglottic airway device with a cuff made of thermoplastic elastomer gel. We retrospectively studied easiness of insertion and troubles in ventilation when this device was used by less experienced anesthesiologists. Consecutive eleven cases undergoing surgery under general anesthesia were studied. i-gel was successfully inserted in 7 cases (63%) at the first attempt, 2 cases at the second attempt without changing the size. In one case, the size was changed at the second attempt, which resulted in the successful insertion. There was one case of failed insertion even at the second attempt. Fiberoptic observation of the glottis showed direct contact of the cuff to the arytenoids cartilage in cases with successful insertion, however, spastic glottis, defined as contact of vocal cords was observed in 4 cases, and down-folding of the epiglottis was observed in 2 cases. During maintenance of anesthesia, ventilation trouble was observed in 3 cases. We conclude that i-gel should only be used with sufficient knowledge, preparations, skills or support from experienced physician to solve problems related to the safe use of supraglottic airway devices.
文摘Study Objective: We studied the overall efficacy of fiberoptic aided intubation using three different supraglottic airways (SGA) as intubation conduits with a standard endotracheal tube (ETT) to determine which, if any, is superior as an intubation conduit. Design: After induction of general anesthesia, subjects were randomized to one of three groups: Air-Q ILATM, LMA Classic ExcelTM, and LMA UniqueTM. Subjects were intubated with a fiberoptic aided technique with continuous ventilation with FiO2 = 1.0 through one of these SGAs. The primary endpoint was the overall efficacy of the intubation procedure. In addition, the following data were collected: demographic data, intubation times, grade of view of the larynx, and a visual analog scale (VAS) score of difficulty as determined by the primary anesthesiologist performing the procedure. Data were analyzed using a Kruskal-Wallis one-way analysis of variance and Post hoc analysis was done using Dunn’s Multiple Comparison Test. Results: 126 total subjects were studied. Intubation success rates were 100%, 87.8%, and 95% with the Air-Q ILATM, LMA Classic ExcelTM, and LMA UniqueTM respectively. There was no significant difference among the three different SGAs when comparing the times to place the SGA (T1), the true intubating time (T2), the time to remove the SGA (T3), or the total time (T4). Data were also stratified by the grade of view of the larynx;all grade I views, grade II views, and grade III views were grouped together regardless of the type of the SGA used. The grade I view of the larynx group had significantly faster true intubation times (T2 = 75.1 sec, p = 0.01) and significantly lower VAS scores (VAS = 1.9, P = TM provides the best view of the larynx and is the easiest one to use as an intubation conduit.
文摘Background: The fluid seal of supraglottic airway devices (SGA) protects the airway from fluid contamination. We evaluated the suitability of indicator dye placement in the upper digestive tract of anesthetized patients combined with fiberoptical tracing to investigate the fluid seal of SGA. Methods: Patients swallowed a capsule of indigo carmine green (ICG) prior to induction of anaesthesia. After induction of anesthesia, one of two different SGA (either an i-GelTM or an LMA-SupremeTM (LMA-S)) was inserted after randomization. Methylene blue stained normal saline was injected through the proximal opening of drainage tube during mechanical ventilation as well as spontaneous breathing. We monitored regurgitation of ICG with a flexible fiberscope (FO) inserted through the drainage tube and checked for the appearance of methylene blue in the mask bowl with the FO inserted through the airway tube. Results: In thirty-six patients with an i-GelTM and 37 with a LMA-S no regurgitation of ICG was observed at the level of the upper oesophageal sphincter (UES). Methylene blue stained saline was not visible in any patient during pressure-controlled ventilation, but was detected in two of the 36 patients with the i-GelTM during spontaneous breathing. Conclusion: Instilling dye through the drainage tube of SGA models with a built-in drainage tube represents a useful method to examine and to compare the fluid seal of different SGA. Our protocol presented in this study proved to be an easy and reproducible approach for future studies. Furthermore, the clinical results gained during this evaluation highlight the necessity for further investigations regarding the fluid seal competencies of SGAs in humans under clinical conditions.
文摘Purpose: This study was designed to study the effect of early use of the King Airway (KA) and impedance threshold device (ITD) in out-of-hospital cardiac arrest on ETCO2 as a surrogate measure of circulation, survival, and cerebral performance category (CPC) scores. After analysis of the first 9 month active period the KA was relegated to rescue airway status. Methods: This was a prospective pre-post study design. Patients >18 years with out-of-hospital cardiac caused arrest were included. Three periods were compared. In the first “non active” period conventional AHA 30/2 compression/ventilation ratio CPR was done with bag mask ventilation (BMV). No ITD was used. After advanced airway placement the compression/ventilation ratio was 10/1. In the second period continuous compressions were done. Primary airway management was a KA with an ITD. After placement of the KA the compression/ventilation ratio was 10/1. In the third period CPR reverted to 30/2 ratio with a two hand seal BMV with ITD. CPR ratio was 10/1 post endotracheal intubation (ETI) or KA. The KA was only recommended for failed BMV and ETI. Results: Survival to hospital discharge was similar in all three study periods. In Period 2 there was a strong trend to CPC scores >2. The study group hypothesized that the KA interfered with cerebral blood flow. For that reason the KA was abandoned as a primary airway. Comparing Period 1 to Period 3 there was a trend to improved survival in the bystander witnessed shockable rhythm (Utstein) subgroup, particularly if a metronome was used. ETCO2 was significantly increased in Period 2 and trended up in Period 3 when compared to Period 1. Advanced airway intervention had a highly significant negative association with survival. Conclusion: The introduction of an ITD into our system did not result in a statistically significant improvement in survival. The study groups were somewhat dissimilar. ETCO2 trended up. When comparing Period 1 to Period 3, the bundle of care was associated with a trend towards increased survival in the Utstein subgroup, particularly with a metronome set at 100. Multiple confounders make a definitive conclusion impossible. Advanced airways showed a significant association with poor survival outcomes. The KA was additionally associated with poor neurologic outcomes.
文摘Background: The AmbuAuraGain is a new single-use supraglottic airway device with gastric channel designed to facilitate intubation. The aim of the study was to assess the anatomic position and the performance of the AuraGain in fresh cadavers compared to that of the Intersurgical i-gel and LMA Supreme New Cuff. Methods: The 3 devices were inserted in random order in 7 fresh cadavers without difficult airway criteria. The assessed items were: Insertion time, number of attempts and ease of insertion, airway seal pressure, ease of gastric tube insertion, endoscopic view of vocal cords, efficacy of guided tracheal intubation through the AuraGain and i-gel, and anatomic fit by lateral X-ray and neck dissections. Results: All devices were successfully inserted within 3 attempts, except for one case of the LMA Supreme. Adjusting manoeuvres were often required to accomplish correct insertion. A 16 G gastric tube was easily advanced through all AuraGain and LMA Supreme devices. Fiberoptic tracheal intubation was effectively achieved through all AuraGain and i-gel devices in less than 60 s. Lateral X-ray and neck dissections confirmed optimal alignment of all devices with the respiratory and digestive tracts. Conclusions: Insertion of the new AmbuAuraGain required adjusting manoeuvres in some cases, as observed with the other two devices, and achieved similar airway seal pressures. Passage of a large bore gastric tube was as fast as with the LMA Supreme and ease of guided intubation was similar to that of the i-gel.
文摘Self-expanding metallic stents are sometimes placed for the management of obstructing airway lesions or conditions such as airway wall malacia or tracheal stenosis. However, endoscopic removal of these devices from the airway can pose extreme challenges for both clinical airway management as well as for the administration of general anesthesia. We report on a 61-yearold man with a complex cardiac history presenting for endoscopic stent removal necessitated by the formation of extensive granulation tissue. Comorbidities included a history of myocardial infarction, an ischemic cardiomyopathy with severe left heart failure(ejection fraction of 25%), mild right heart failure, 2+ tricuspid regurgitation status post tricuspid valve repair, and atrial fibrillation. An automatic external(wearable) cardiac defibrillator(Zoll Life Vest) was also in place. Induction of anesthesia was carried out using etomidate, with maintenance of anesthesia carried out with a propofol infusion(total intravenous anesthesia). Rocuronium was used for neuromuscular blockade. A size 4 i Gel supraglottic airway and, later, rigid bronchoscopy formed the basis for airway management. Stable conditions were met through the 2-h procedure, and the patient recovered uneventfully. Our successful experience in this case leads us to propose further use of a supraglottic airway in conjunction with total intravenous anesthesia for these procedures.
文摘Background:Jaw thrust has been proven as a useful test determining adequate depth of anesthesia for successful insertion of supraglottic airway device (SAD) in normal adults and children receiving intra-venous or inhalational anesthesia induction.This prospective observational study aimed to determine the feasibility and validity of this test when using as an indicator assessing adequate depth of anesthesia for successful insertion of SAD in spontaneously breathing morbidly obese patients receiving sevoflurane inhalational induction.Methods:Thirty morbidly obese patients with a body mass index 40 to 73 kg/m2 undergoing bariatric surgery in Beijing Friendship Hospital from October 2018 to January 2019 were included in this study.After adequate pre-oxygenation,5% sevoflurane was inhaled and inhalational concentration of sevoflurane was increased by 1% every 2 min.After motor responses to jaw thrust disappeared,a SAD was inserted and insertion conditions were graded.The anatomic position of SAD was assessed using a fiberoptic bronchoscope.Results:The SAD was successfully inserted at the first attempt in all patients.Insertion conditions of SAD were excellent in nine patients (30%) and good in 21 patients (70%),respectively.The fiberoptic views of SAD position were adequate in 28 patients (93%).Conclusions:Jaw thrust test is a reliable indicator determining adequate anesthesia depth of sevoflurane inhalational induction for successful insertion of SAD in spontaneously breathing morbidly obese patients.
文摘To the Editor:The supraglottic airway device (SAD) with an additional gastric drainage channel may be beneficial for patients needing gastric decompression during surgery, such as laparoscopic cholecystectomy and cesarean delivery. Furthermore, addition of gastric drainage channel is a typical feature of second-generation SAD. However, all of second-generation SADs have a gastric tube channel opening at the center of the distal tip. Such a design may cause some difficulty for insertion of the gastric tube if there is an inadequate position of the device tip in the upper esophageal aperture. In normal anatomy, the upper esophageal aperture is actually inclined to the left side of the trachea. Thus, we inferred that it should be much easier to insert a gastric tube into the esophagus, if the gastric drainage channel is placed at the left side of the SAD tip.
