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topical anesthesia adequate for laryngeal mask airway use in the critically ill patient?
324
Abstracts
Table 2
Extubation and postoperative complications Group 1 (n = 50)
Blood on device % Postoperative sore throata % 2h 24 ha a
Group 2A (n = 50)
Group 2B (n = 100)
4.1
34.0
37.8
28.6 5.1
28.0 29.2
27.8 16.5
P b 0.05.
and 2B, respectively. Cuff pressures remained constant throughout the surgery for all groups. Postoperative complications are noted in Table 2. Discussion: Using the traditional insertion method in anesthetized nonparalyzed adult patients, the SoftSeal laryngeal mask was similar to the LMA-Unique with respect to placement success and ease of insertion. Although the LMAUnique was faster to insert, the SoftSeal laryngeal mask provided a better seal. The incidence of blood on the device was significantly higher when the SoftSeal was inserted with the cuff fully deflated; however, this incidence was greatly reduced by the alternative technique. The increased incidence of blood on the device appeared to have little effect on the incidence of postoperative sore throat. We concur with the manufacturer’s revised recommendations of insertion of the SoftSeal laryngeal mask with a partially inflated cuff. doi:10.1016/j.jclinane.2006.05.006 References [1] [2] [3] [4]
Anesth Analg 1998;87:921-4. Anesthesiology 2003;99:1066-71. J Clin Anesth 2002;14:462-3. Paediatr Anaesth 2002;12:416-9.
Is light sedation/topical anesthesia adequate for laryngeal mask airway use in the critically ill patient? T.C. Mort (MD), Anesthesiology and Critical Care Medicine Simulation Center at Hartford Hospital Hartford Hospital, Hartford, CT, USA Introduction: Airway management of patients with a suspected or a history of a difficult airway outside the operating room (OR) presents considerable challenges to anesthesiologists. Securing the airway during topical anesthesia and/or light sedation to maintain airway patency and spontaneous ventilation should be considered for some of these patients. Recently, it has been demonstrated that the FasTrach laryngeal mask airway (LMA) facilitates management in patients with known or expected difficult airways [1]. This report reviews the use of the classic LMA/ILMA in the emergent setting outside the OR when patient preparation involved topical anesthesia or a minimal level of sedative hypnotics while preserving spontaneous ventilation.
Methods: An emergency intubation QI database (19942005) was analyzed, and it isolated those patients who underwent emergency airway management in the remote location (outside the OR) with a classic LMA/ILMA during topical or light sedation with continuation of spontaneous ventilation. Light sedation was defined as midazolam (0.010.04 mg/kg) typically one to 3 mg, propofol (0.4-1.4 mg/kg titrated) typically 30 to 120 mg, and etomidate (0.050.12 mg/kg) typically 2 to 12 mg. A total of 108 patients met these criteria. The method of patient preparation, the success rate of ventilation and intubation via the LMA, any rescue devices required, and complications were reviewed. Results: The average age of the patients was 51 years (range, 19-91 y); average weight, 110 kg (range, 40-242 kg); and average height, 173 cm (range, 140-185 cm). Only 10% of patients had a body mass index (BMI) lower than 25, and 72% had a BMI higher than 30 (obese), of which over half were morbidly obese (BMI N 40). Patient preparation included topical only (20%), midazolam (24%), propofol (20%), and limited doses of etomidate (32%) while maintaining spontaneous ventilation. Conventional direct laryngoscopy reveals 30% with a Lehane-Cormack grade III view and 68% with a grade IV view (no glottic view), prompting the use of the LMA. Seventeen cases (16%) of LMA use were in the role of a rescue device for bougieassisted intubation failure. Thirty-six percent of patients had the LMA/ILMA placed primarily as the sole method of managing the airway (w/o attempting laryngoscopy), and most were patients with limited cervical range of motion or obesity. The LMA established ventilation/oxygenation in 84% on the first attempt, 13% on the second attempt, and in one case, 3 attempts, and 2 patients required Combitube rescue when the LMA failed (overall success, 98%). The intubating model was used in 86 cases and classic, 21 cases. Twenty of 21 classic LMA had successful fiberopticassisted intubation within 2 attempts (one case—no attempt, used as support during a surgical airway). Fiberoptic intubation via the ILMA was successful in 14 of 14 cases. Blind ETT placement via the ILMA succeeded in 60 of 72 patients (60%, first attempt; 23%, second attempt; 6%, third attempt). Laryngeal mask airway intubation failures were rescued by the Combitube (n = 10) and 2 surgical airways with the LMA in place supporting oxygenation. Thirty-two percent of the patients suffered desaturation to less than 90% during the airway procedure. There was only one case of possible regurgitation of gastric contents without aspiration. Discussion: The LMA/ILMA is practical as both primary and rescue airway device under topical anesthesia or light sedation in the clinical arena of emergency airway management outside the OR. A backup strategy is imperative for optimal airway care. doi:10.1016/j.jclinane.2006.05.007 Reference [1] Anesthesiology 2005;103:A290.
Abstracts
Table 2
Extubation and postoperative complications Group 1 (n = 50)
Blood on device % Postoperative sore throata % 2h 24 ha a
Group 2A (n = 50)
Group 2B (n = 100)
4.1
34.0
37.8
28.6 5.1
28.0 29.2
27.8 16.5
P b 0.05.
and 2B, respectively. Cuff pressures remained constant throughout the surgery for all groups. Postoperative complications are noted in Table 2. Discussion: Using the traditional insertion method in anesthetized nonparalyzed adult patients, the SoftSeal laryngeal mask was similar to the LMA-Unique with respect to placement success and ease of insertion. Although the LMAUnique was faster to insert, the SoftSeal laryngeal mask provided a better seal. The incidence of blood on the device was significantly higher when the SoftSeal was inserted with the cuff fully deflated; however, this incidence was greatly reduced by the alternative technique. The increased incidence of blood on the device appeared to have little effect on the incidence of postoperative sore throat. We concur with the manufacturer’s revised recommendations of insertion of the SoftSeal laryngeal mask with a partially inflated cuff. doi:10.1016/j.jclinane.2006.05.006 References [1] [2] [3] [4]
Anesth Analg 1998;87:921-4. Anesthesiology 2003;99:1066-71. J Clin Anesth 2002;14:462-3. Paediatr Anaesth 2002;12:416-9.
Is light sedation/topical anesthesia adequate for laryngeal mask airway use in the critically ill patient? T.C. Mort (MD), Anesthesiology and Critical Care Medicine Simulation Center at Hartford Hospital Hartford Hospital, Hartford, CT, USA Introduction: Airway management of patients with a suspected or a history of a difficult airway outside the operating room (OR) presents considerable challenges to anesthesiologists. Securing the airway during topical anesthesia and/or light sedation to maintain airway patency and spontaneous ventilation should be considered for some of these patients. Recently, it has been demonstrated that the FasTrach laryngeal mask airway (LMA) facilitates management in patients with known or expected difficult airways [1]. This report reviews the use of the classic LMA/ILMA in the emergent setting outside the OR when patient preparation involved topical anesthesia or a minimal level of sedative hypnotics while preserving spontaneous ventilation.
Methods: An emergency intubation QI database (19942005) was analyzed, and it isolated those patients who underwent emergency airway management in the remote location (outside the OR) with a classic LMA/ILMA during topical or light sedation with continuation of spontaneous ventilation. Light sedation was defined as midazolam (0.010.04 mg/kg) typically one to 3 mg, propofol (0.4-1.4 mg/kg titrated) typically 30 to 120 mg, and etomidate (0.050.12 mg/kg) typically 2 to 12 mg. A total of 108 patients met these criteria. The method of patient preparation, the success rate of ventilation and intubation via the LMA, any rescue devices required, and complications were reviewed. Results: The average age of the patients was 51 years (range, 19-91 y); average weight, 110 kg (range, 40-242 kg); and average height, 173 cm (range, 140-185 cm). Only 10% of patients had a body mass index (BMI) lower than 25, and 72% had a BMI higher than 30 (obese), of which over half were morbidly obese (BMI N 40). Patient preparation included topical only (20%), midazolam (24%), propofol (20%), and limited doses of etomidate (32%) while maintaining spontaneous ventilation. Conventional direct laryngoscopy reveals 30% with a Lehane-Cormack grade III view and 68% with a grade IV view (no glottic view), prompting the use of the LMA. Seventeen cases (16%) of LMA use were in the role of a rescue device for bougieassisted intubation failure. Thirty-six percent of patients had the LMA/ILMA placed primarily as the sole method of managing the airway (w/o attempting laryngoscopy), and most were patients with limited cervical range of motion or obesity. The LMA established ventilation/oxygenation in 84% on the first attempt, 13% on the second attempt, and in one case, 3 attempts, and 2 patients required Combitube rescue when the LMA failed (overall success, 98%). The intubating model was used in 86 cases and classic, 21 cases. Twenty of 21 classic LMA had successful fiberopticassisted intubation within 2 attempts (one case—no attempt, used as support during a surgical airway). Fiberoptic intubation via the ILMA was successful in 14 of 14 cases. Blind ETT placement via the ILMA succeeded in 60 of 72 patients (60%, first attempt; 23%, second attempt; 6%, third attempt). Laryngeal mask airway intubation failures were rescued by the Combitube (n = 10) and 2 surgical airways with the LMA in place supporting oxygenation. Thirty-two percent of the patients suffered desaturation to less than 90% during the airway procedure. There was only one case of possible regurgitation of gastric contents without aspiration. Discussion: The LMA/ILMA is practical as both primary and rescue airway device under topical anesthesia or light sedation in the clinical arena of emergency airway management outside the OR. A backup strategy is imperative for optimal airway care. doi:10.1016/j.jclinane.2006.05.007 Reference [1] Anesthesiology 2005;103:A290.