Airway

LMA-S vs. i-Gel in Elderly

In paralyzed elderly patients both the LMA-S and i-gel were used successfully and safely. However, the i-gel demonstrated better airway sealing than the LMA-S at insertion and during maintenance of anaesthesia. Less manipulation at insertion and superior fiberoptic laryngoscopy grades were observed in the i-Gel group, and inspiratory pressures lower with higher leak pressures. The I-Gel’s simplicity without the need for cuff inflation make it an attractive option in ER settings also for the ‘occasional anesthesiologist’!

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Remifentanil with Desflurane for LMA GA

While Sevoflurane is the standard agent for a non-irritating inhalational and spontaneously breathing anesthetic, the irritating effects of Desflurane  may be mitigated by the use of a Remifentanil infusion. This study showed that in the presence of a continuous infusion of remifentanil, desflurane is superior in terms of faster emergence and is similar in terms of intra-operative cough to sevoflurane or propofol infusion. Recovery time differences were of marginal clinical significance (2 minutes) but more predictable and less variable than other agents.

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Obstetric Failed Intubation

A literature review since 1970 of failed obstetric intubation at Cesarean delivery under general anesthesia reveals some themes.  Some salient features that emerged were the increasing tendency to continue GA usually with supraglottic airways, especially second generation devices like the ProSeal LMA.

The conflicting priorities of urgency, safety, maternal and fetal wellbeing make the decision on how to proceed difficult. Front of neck airway scenarios were sparse, but they are often done too late. There is surprisingly no data on videolaryngoscopy use in this review.

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Intubation in OR vs ICU

A Spanish study compares OR vs ICU intubation by direct laryngoscopy. Everything was somewhat worse in  the ICU: worse view, lower first attempt success, higher rate of difficult intubation and use of airway adjuncts,  and higher complication rate. They suggest that patient and environmental factors may be of more importance than the operator (even previously known easy intubations were more difficult in ICU). Despite all that, their success rate was better than other studies, which they attribute to high use of neuromuscular blocking agents, an increasingly recommended practice. Videolaryngoscopy has met with better success in many but not all studies.

At the least, greater preparation, optimized positioning and airway equipment,  and trained assistance should be available for non-OR intubation

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Sedation and Pediatric NPO in ER

“In this study, there was no association between fasting duration and any type of adverse event. These findings do not support delaying sedation to meet established fasting guidelines”.

An observational study sparse on details on what sedation was used, depth of sedation and the procedures in ER. And the rate of vomiting was 5% but they evidently mostly got away with it. A study unlikely to convince anesthesiologists to abandon ASA and other fasting guidelines in this Pediatric population (or adults).

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Cook Staged Extubation

Many successful difficult airway cases become undone at extubation, where disasters and deaths have occurred. Even seemingly routine ICU extubations may go awry. Moderate success was reported with the Cook Airway Exchange Catheter but the next generation device is the Cook Staged Extubation Set, a device with wire and bougie – link to Cook

This small study is encouraging in its use and tolerability up to 4 hours with no major adverse effects and further studies should occur  link