21 de outubro de 2015

Artigo recomendado: Best position and depth of anaesthesia for laryngeal mask airway removal in children

A prospective randomised controlled trial

George Thomas-Kattappurathu, Ananth Kasisomayajula and Judith Short

BACKGROUND: There is a wide variation in clinical practice amongst clinicians in the process of removal of the laryngeal mask airway (LMA) in children. Some of the airway complications during recovery are associated with the position of the child as well as the depth of anaesthesia and are potentially avoidable.

OBJECTIVES: We wished to determine whether removal of the LMA in the lateral position reduces the incidence of airway complications, either in a deep plane of anaesthesia or awake.

DESIGN: A prospective randomised trial.

SETTING: A tertiary children’s hospital.

PATIENTS: The study population comprised 216 American Society of Anesthesiologists (ASA) 1 to 2 patients aged 1 to 16 years scheduled for elective surgery under general anaesthesia using an LMA. Exclusion criteria were children less than 1 year old, ASA 3 or above, presence of congenital heart disease or gastro-oesophageal reflux, anticipated difficult airway and patients undergoing airway or dental surgery.

INTERVENTION: We randomly allocated 212 children into one of four groups for LMA removal, deeply anaesthetised or awake in either the lateral or supine position. Various airway complications were recorded after removal of the LMA.

MAIN OUTCOME MEASURES: The primary outcome measure was the number of patients experiencing one or more complication in each group. We also devised a novel ‘Clinical Importance’ score on the basis of the clinical relevance of airway complications.

RESULTS: There were significant differences among groups (P¼0.001); the fewest complications occurred when the LMA was removed in a deep plane of anaesthesia in the lateral position. There was a significant difference among groups in the "Clinical Importance" scores (P < 0,001); the greatest risk occurred when the LMA was removed in deeply anaesthetised supine patients.

CONCLUSION: The results of the present study suggest that lateral positioning of children for removal of the LMA provides the safest conditions if the LMA is to be removed at a deep plane of anaesthesia.

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2 de outubro de 2015

Artigo recomendado: Ultrasound Improves Cricothyrotomy Success in Cadavers with Poorly Defined Neck Anatomy

A Randomized Control Trial

Naveed Siddiqui, Cristian Arzola, Zeev Friedman, Laarni Guerina, Kong Eric You-Ten

ABSTRACT
Background: Misidentification of the cricothyroid membrane in a “cannot intubate-cannot oxygenate” situation can lead to failures and serious complications. The authors hypothesized that preprocedure ultrasound-guided identification of the cricothyroid membrane would reduce complications associated with cricothyrotomy.

Methods: A group of 47 trainees were randomized to digital palpation (n = 23) and ultrasound (n = 24) groups. Cricothyrotomy was performed on human cadavers by using the Portex® device (Smiths Medical, USA). Anatomical landmarks of cadavers were graded as follows: grade 1—easy = visual landmarks; 2—moderate = requires light palpation of landmarks; 3—difficult = requires deep palpation of landmarks; and 4—impossible = landmarks not palpable. Primary outcome was the complication rate as measured by the severity of injuries. Secondary outcomes were correct device placement, failure to cannulate, and insertion time.

Results: Ultrasound guidance significantly decreased the incidence of injuries to the larynx and trachea (digital palpation: 17 of 23 = 74% vs. ultrasound: 6 of 24 = 25%; relative risk, 2.88; 95% CI, 1.39 to 5.94; P = 0.001) and increased the probability of correct insertion by 5.6 times (P = 0.043) in cadavers with difficult and impossible landmark palpation (digital palpation 8.3% vs. ultrasound 46.7%). Injuries were found in 100% of the grades 3 to 4 (difficult–impossible landmark palpation) cadavers by digital palpation compared with only 33% by ultrasound (P < 0.001). The mean (SD) insertion time was significantly longer with ultrasound than with digital palpation (196.1 s [60.6 s] vs. 110.5 s [46.9 s]; P < 0.001).

Conclusion: Preprocedure ultrasound guidance in cadavers with poorly defined neck anatomy significantly reduces complications and improves correct insertion of the airway device in the cricothyroid membrane.

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