Removal of Contaminated Personal Protective Equipment With and Without Supervision. A Randomized Crossover Simulation-Based Study

INTRODUCTION

Personal protective equipment (PPE) reduces the risk of pathogens reaching the skin and clothing of health care personnel. We hypothesize that doffing PPE following verbal instructions by a supervisor is more effective in reducing contamination compared with doffing without verbal instructions. Our primary aim was to determine contamination rates with and without supervised doffing. The secondary aim was to determine the number and localization of contaminated body sites and PPE removal times in both groups.

METHODS

Staff members of Bnai Zion Medical Center participated in this single-center, randomized simulation study (NCT05008627). Using a crossover design, all participants donned and doffed the PPE twice, once under guidance from a trained supervisor and then independently without supervision (group A), or vice versa (group B). Participants were randomized to either group A or B using a computer-generated random allocation sequence. The PPE was "contaminated" with Glo Germ on the thorax, shoulders, arms, hands, legs, and face shield. After doffing the PPE, the participant was examined under ultraviolet light to detect traces of contamination. The following variables were collected: contamination rates, the number and localization of contaminated body sites, and PPE doffing time.

RESULTS

Forty-nine staff members were included. In group A, the contamination rate was significantly lower (8% vs. 47%; χ2 = 17.19; p < 0.001). The sites most frequently contaminated were the neck and hands. Mean PPE doffing time under verbal instructions was significantly longer [mean (SD): 183.98 (3.63) vs. 68.43 (12.75) seconds, P < 0.001] compared with unsupervised doffing.

CONCLUSIONS

In a simulated setting, PPE doffing following step-by-step verbal instructions from a trained supervisor reduces the rate of contamination but prolongs doffing time. These findings could have important implications for clinical practice and could further protect health care workers against contamination from emerging and high-consequence pathogens.

Ventilation with the esophageal-tracheal Combitube during general anaesthesia: assessing complications in 540 patients

Background

The esophageal-tracheal Combitube (ETC) was developed for the management of difficult airways but can also be used for general anaesthesia.

Methods

This clinical study collected data from patients undergoing anaesthesia with the ETC in order to assess the rate of complications.

Results

Five hundred forty patients were ventilated with the ETC. In 94.8% (512/540), insertion was performed for the first time by the respective physician. The following minor complications were observed: 38.7% sore throat, 30.9% blood on tube as sign of mucosal lesions and 17.0% cyanotic tongue. Experience decreased the risk of mucosal lesions (odds ratio [OR]: 2.3, 95% confidence interval [CI]: 1.5-3.5). A higher than recommended volume of the oropharyngeal cuff was associated with blood on the ETC (OR: 1.5, 95% CI: 1.0-2.3) and tongue cyanosis (OR: 2.3, 95% CI: 1.4-3.7). Ventilation for more than 2 h was associated with tongue cyanosis (OR: 2.2, 95% CI: 1.6-3.1) and tongue protrusion (OR: 1.4, 95% CI: 1.1-1.9).

Conclusion

We conclude that the Combitube may be used for short procedures requiring general anaesthesia, but the high rate of minor complications limits its value when other alternatives such as a laryngeal mask airway are available. The tested method appears safe regarding major complications, but minor complications are common. Adherence to recommended cuff volumes, experience with the ETC and limiting its use to surgeries lasting less than 2 h might reduce the rate of complications.

Electrical stimulation of the whole hypoglossal nerve in patients with obstructive sleep apnea

PURPOSE

Electrical stimulation of the whole hypoglossal nerve (HGp-ES) has been demonstrated to enlarge the pharynx and improve pharyngeal stability and patency to airflow in all animals studied, but not in humans. The present study was undertaken to better understand the effect of HGp-ES on the human pharynx.

METHODS

Eight patients with obstructive sleep apnea who had implanted stimulators with electrodes positioned proximally on the main truck of the hypoglossus were studied under propofol sedation. Pharyngoscopy and air flow measurements at multiple levels of continuous positive airway pressure (CPAP) were performed before and during Hgp-ES.

RESULTS

HGp-ES that activates both tongue protrusors and retractors narrowed the pharyngeal lumen at the site of collapse (velopharynx in all subjects) from 1.38 ± 0.79 to 0.75 ± 0.44 cm², p < 0.05 (measured at mid-range of CPAP levels) and lowered airflow (from 8.88 ± 2.08 to 6.69 ± 3.51 l/min, p < 0.05). Changes in critical pressure (Pcrit) and velopharyngeal compliance were not significant, but oropharyngeal compliance decreased (from 0.43 ± 0.18 to 0.32 ± 0.13 cm²/cmH2O, p < 0.05). No correlation was found between the pattern of change in luminal shape (determined as the ratio of a-p vs. lateral diameter when lowering CPAP) or changes in cross-sectional area and airflow during Hgp-ES.

CONCLUSIONS

Our findings indicate that human retractors dominate when stimulated together with the protrusors during HGp-ES. While co-activation of retractors may be beneficial, it should be limited. We speculate that exercises that augment protrusor force may improve the response to hypoglossal stimulation. The exclusion of patients with concentric pharyngeal obstruction should be re-evaluated.

Combined epidural-general anaesthesia vs general anaesthesia in neonatal gastrointestinal surgery: A randomized controlled trial

BACKGROUND

Post-operative ileus is a frequent complication of gastrointestinal surgery under general anaesthesia. The aim of this study was to investigate whether combined epidural-general anaesthesia is associated with expedited gastrointestinal function recovery in neonates undergoing elective gastrointestinal surgery.

METHODS

A randomized controlled trial including 60 neonates who underwent gastrointestinal surgery at a university hospital was performed. Thirty neonates received combined epidural-general anaesthesia (CEGA), and 30 neonates received general anaesthesia (GA) alone. The primary outcome was the post-operative time to tolerance of full enteral nutrition. The secondary outcomes were the post-operative time defaecation, the duration of nasogastric drainage, and infections.

RESULTS

After excluding two neonates from the CEGA group, where repeated attempts at epidural catheterization were unsuccessful, a total of 58 patients completed the study (CEGA: 28; GA: 30). Full enteral nutrition was tolerated earlier in CEGA vs the GA group (4.0 vs 8.0 days; P = .0001). Time to defaecation was shorter in the CEGA group (3.5 vs 5.0 days; P = .0001). Duration of nasogastric drainage was similar between groups (7.0 vs 7.0 days; P = .9502). Fewer patients in the CEGA group experienced post-operative infection (35.7% vs 60.0%; P = .038).

CONCLUSION

Combined epidural-general anaesthesia is associated with expedited gastrointestinal function recovery and a lower infection risk after gastrointestinal surgery in neonates.

Relationship between the activity of the genioglossus, other peri-pharyngeal muscles and flow mechanics during wakefulness and sleep in patients with OSA and healthy subjects

INTRODUCTION

In patients with OSA, substantial increases in genioglossus (GG) activity during hypopneas/apneas usually fail to restore normal airflow. The present study was undertaken to evaluate if this phenomenon can be explained by reduced activation of other peri-pharyngeal muscles.

METHODS

We recorded EMGs of the GG and four other peri-pharyngeal muscles (accessory dilators, AD), in 8 patients with OSA and 12 healthy subjects, during wakefulness and sleep. Repetitive events of flow limitation were induced during sleep. The events with the highest increases in AD activity were evaluated, to assess if combined activation of both the GG and AD to levels higher than while awake ameliorate airflow reduction during sleep.

RESULTS

Flow limitation triggered large increases in GG-EMG, but only modest augmentation in AD activity. Nevertheless, phasic EMG activity was present in 40 % of the ADs during sleep. In multiple events, increases of both GG and AD activity to levels substantially higher than while awake were not associated with improvement in airflow.

CONCLUSIONS

We conclude that sleep-induced reduction in AD response to airway obstruction cannot completely explain the failure of upper airway dilators to maintain pharyngeal patency. We speculate that reduction in dilator muscle efficacy may be due to the alterations in motor units recruitment patterns during sleep.

Fiberoptic-Guided and Blind Tracheal Intubation Through iLTS-D, Ambu® Auragain™, and I-Gel® Supraglottic Airway Devices: A Randomized Crossover Manikin Trial

BACKGROUND

The use of supraglottic airway devices (SADs) is becoming more widespread. However, there is little evidence to show which device is best in an emergent clinical scenario.

OBJECTIVE

We compared both fiberoptic-guided and blind tracheal intubation through the Intubating Laryngeal Tube Suction-Disposal (iLTS-D), the AuraGain™, and the i-gel® in an airway manikin.

METHODS

Thirty residents were included in a randomized trial to perform both fiberoptic-guided and blind tracheal intubation using the iLTS-D, the AuraGain, and the i-gel. The main endpoint was the total time taken to achieve successful fiberoptic intubation through the SAD. Additional endpoints included total time for blind intubation, SAD insertion time, tracheal tube insertion time, intubation success rate, fiberoptic view, and maneuvers performed to achieve tracheal intubation.

RESULTS

All participants performed fiberoptic intubation using all three SADs on the first attempt. The total time to fiberoptic tracheal intubation using the i-gel, AuraGain, and iLTS-D was 42 s, 56 s, and 56 s, respectively. The blind tracheal intubation success rate was 80% with the iLTS-D, 43% with the i-gel, and 0% with the AuraGain. The total time for blind tracheal intubation through the i-gel and the iLTS-D was 29 s and 40 s, respectively. Laryngeal view grades were significantly poorer with the iLTS-D compared to the other devices. The iLTS-D required significantly more maneuvers to achieve successful tracheal intubation.

CONCLUSIONS

In an airway manikin, the iLTS-D, AuraGain, and i-gel appear to be reliable devices for airway rescue and fiberoptic-guided tracheal intubation. The iLTS-D is recommended for blind tracheal intubation.

Postoperative analgesia by adding acupuncture to conventional therapy, a non-randomized controlled trial

Background Postoperative pain is common in patients hospitalized in surgical departments, yet it is currently not sufficiently controlled by analgesics. Acupuncture, a complementary medical practice, has been evaluated for its benefits in postoperative pain with heterogeneous results. We tested the feasibility of a controlled study comparing the postoperative analgesic effect of acupuncture together with standard-of-care to standard-of-care only. Methods In this pilot non-randomized controlled study conducted at a tertiary medical center in Israel, patients received either acupuncture with standard-of-care pain treatment (acupuncture group) or standard-of-care treatment only (control group) following surgery. Visual Analogue Scale (VAS) ratings for pain level at rest and in motion were evaluated both at recruitment and two hours after treatment. Acupuncture-related side effects were reported as well. Results We recruited 425 patients; 336 were assigned to the acupuncture group and 89 to the control group. The acupuncture group exhibited a decrease of at least 40% in average level of pain both at rest (1.8±2.4, p<0.0001) and in motion (2.1±2.8, p<0.0001) following acupuncture, whereas the control group exhibited no significant decrease (p=0.92 at rest, p=0.98 in motion). Acupuncture's analgesic effect was even more prominent in reducing moderate to severe pain at baseline (VAS ≥4), with a decrease of 49% and 45% of pain level at rest and in motion respectively (p<0.001), compared with no significant amelioration in the control group (p=0.20 at rest, p=0.12 in motion). No major side effects were reported. Conclusion Integrating acupuncture with standard care may improve pain control in the postoperative setting.

Peri-pharyngeal muscle response to inspiratory loading: comparison of patients with OSA and healthy subjects

Upper airway patency to airflow and the occurrence of obstructive sleep apnea involve a complex interplay between pharyngeal anatomy and synergic co-activation of peri-pharyngeal muscles. In previous studies we observed large differences in the response to sleep-associated flow limitation between the genioglossus and other (non-GG) peri-pharyngeal muscles. We hypothesized that similar differences are present also during wakefulness. In the present study we compared the response to inspiratory loading of the genioglossus electromyogram and four other peri-pharyngeal muscles. Studies were performed in eight obstructive sleep apnea patients, seven age-matched healthy subjects and five additional younger subjects. Electromyogram activity was evaluated over a range of negative oesophageal pressures and expressed as % of maximal electromyograms. In healthy subjects, the slope response to inspiratory loading (electromyogram/pressures) was similar for the genioglossus and non-GG muscles studied. However, the electromyogram responses were significantly higher in the young subjects compared with older subjects. In contrast, in the obstructive sleep apnea patients, the electromyogram/pressure response of the non-GG muscles was similar to that of the age-matched healthy subjects, whereas the slope response of the genioglossus electromyogram was significantly higher than non-GG muscles. We conclude that both age and the presence of obstructive sleep apnea affect the response of peri-pharyngeal muscles to inspiratory loading. In patients with obstructive sleep apnea the genioglossus seems to compensate for mechanical disadvantages, but non-GG muscles apparently are not included in this neuromuscular compensatory mechanism. Our current and previous findings suggest that attempts to improve obstructive sleep apnea with myofunctional therapy should put added emphasis on the training of non-GG muscles.

A comparison between the Supreme laryngeal mask airway and the laryngeal tube suction during spontaneous ventilation: A randomized prospective study

BACKGROUND AND AIMS

The Supreme laryngeal mask airway (SLMA) and the laryngeal tube suction-disposable (LTS-D), both second-generation supraglottic airway devices, have a record of efficiency when used for airway management in mechanically ventilated patients, during general anesthesia. There is no published data comparing these two devices in patients breathing spontaneously during general anesthesia.

MATERIAL AND METHODS

Eighty patients with normal airways undergoing elective general anesthesia with spontaneous ventilation were randomized to airway management with a SLMA or LTS-D. Efficacy and adequacy of oxygenation and ventilation were compared.

RESULTS

No cases of desaturation of oxygen saturation (SpO2) values of less than 95% occurred with either device. The mean difference for SpO2 between the two devices (0.7%) has no clinical significance. Slight hypercapnia was noted with both devices to acceptable values during spontaneous ventilation.

CONCLUSIONS

Both SLMA and LTS-D are suitable and effective for airway management in patients breathing spontaneously during general anesthesia for minor surgery of short duration.

Alteration in upper airway dilator muscle coactivation during sleep: comparison of patients with obstructive sleep apnea and healthy subjects

In patients with obstructive sleep apnea (OSA), substantial increases in genioglossus (GG) activity during hypopneas/apneas usually fail to restore normal airflow. We have previously suggested that sleep-induced alteration in tongue muscle coordination may explain this finding, as retractor muscle coactivation was reduced during sleep compared with wakefulness. The present study was undertaken to evaluate whether these alterations in dilator muscle activation during sleep play a role in the pathogenesis of OSA and whether coactivation of additional peripharyngeal muscles (non-GG muscles: styloglossus, geniohyoid, sternohyoid, and sternocleidomastoid) is also impaired during sleep. We compared GG and non-GG muscle electromyographic (EMG) activity in 8 patients with OSA and 12 healthy subjects during wakefulness while breathing through inspiratory resistors with the activity observed during sleep toward the end of flow limitation, before arousal, at equivalent esophageal pressures. During wakefulness, resistive breathing triggered increases in both GG and non-GG muscle activity. During sleep, flow limitation was associated with increases in GG-EMG that reached, on average, >2-fold the level observed while awake. In contrast, EMGs of the non-GG muscles, recorded simultaneously, reached, on average, only ~2/3 the wakefulness level. We conclude that during sleep GG activity may increase to levels that substantially exceed those sufficient to prevent pharyngeal collapse during wakefulness, whereas other peripharyngeal muscles do not coactivate during sleep in both patients with OSA and healthy subjects. We speculate that upper airway muscle dyssynchrony during sleep may explain why GG-EMG activation fails to alleviate flow limitation and stabilize airway patency during sleep.

NEW & NOTEWORTHY Pharyngeal obstruction during sleep may trigger genioglossus activity to levels substantially exceeding those observed during wakefulness, without ameliorating flow limitation. In contrast, other peripharyngeal muscles exhibit a much lower activity during sleep in both patients with obstructive sleep apnea and healthy subjects. Coordinated muscular synergy stabilizes the pharynx despite relatively low activity while awake, yet even higher genioglossal activity allows the pharynx to obstruct when simultaneous activity of other dilator muscles is inadequate during sleep.

Guidelines and algorithms for managing the difficult airway

The difficult airway constitutes a continuous challenge for anesthesiologists. Guidelines and algorithms are key to preserving patient safety, by recommending specific plans and strategies that address predicted or unexpected difficult airway. However, there are currently no "gold standard" algorithms or universally accepted standards. The aim of this article is to present a synthesis of the recommendations of the main guidelines and difficult airway algorithms.

Effect of intravenous paracetamol as pre-emptive compared to preventive analgesia in a pediatric dental setting: a prospective randomized study

BACKGROUND

Efficacy of pre-emptive analgesia compared to preventive regimen, managing postoperative pain is still controversial.

AIM

Evaluating the efficacy of intravenous (IV) paracetamol as pre-emptive analgesia compared to preventive post-treatment administration in pediatric dental setting.

DESIGN

In a prospective trial, 60 noncooperative children of ASA I, II aged 3-10 years who underwent dental rehabilitation under general anesthesia were randomly divided into two groups. Pre-emptive group (n = 30) received 15 mg/kg of IV paracetamol before the start of treatment. Preventive group (n = 30) received 15 mg/kg of paracetamol at the end of treatment. Analgesic efficacy was measured by visual analog scale of faces (VASOF), percentage of children received postoperative analgesia.

RESULTS

The VASOF results in the pre-emptive group were significantly lower compared to the preventive group at 4, 8, 12, and 24 h (0.0146, 0.0188, 0.0085, and 0.0001, respectively). Less children in the pre-emptive group received supplemental fentanyl postoperatively compared to the preventive group (27.6%, 58.6%, respectively, P = 0.0170). Time to first rescue dose of fentanyl postoperatively in the pre-emptive group was later than in the preventive group (P = 0.0432).

CONCLUSIONS

Administration of IV paracetamol pre-emptively provides lower pain scores, and a decreased percentage of children required pain relief and less amount of postoperative opioids, compared to preventive administration.

Alteration in upper airway dilator muscle coactivation during sleep: comparison of patients with obstructive sleep apnea and healthy subjects

In patients with obstructive sleep apnea (OSA), substantial increases in genioglossus (GG) activity during hypopneas/apneas usually fail to restore normal airflow. We have previously suggested that sleep-induced alteration in tongue muscle coordination may explain this finding, as retractor muscle coactivation was reduced during sleep compared with wakefulness. The present study was undertaken to evaluate whether these alterations in dilator muscle activation during sleep play a role in the pathogenesis of OSA and whether coactivation of additional peripharyngeal muscles (non-GG muscles: styloglossus, geniohyoid, sternohyoid, and sternocleidomastoid) is also impaired during sleep. We compared GG and non-GG muscle electromyographic (EMG) activity in 8 patients with OSA and 12 healthy subjects during wakefulness while breathing through inspiratory resistors with the activity observed during sleep toward the end of flow limitation, before arousal, at equivalent esophageal pressures. During wakefulness, resistive breathing triggered increases in both GG and non-GG muscle activity. During sleep, flow limitation was associated with increases in GG-EMG that reached, on average, >2-fold the level observed while awake. In contrast, EMGs of the non-GG muscles, recorded simultaneously, reached, on average, only ~2/3 the wakefulness level. We conclude that during sleep GG activity may increase to levels that substantially exceed those sufficient to prevent pharyngeal collapse during wakefulness, whereas other peripharyngeal muscles do not coactivate during sleep in both patients with OSA and healthy subjects. We speculate that upper airway muscle dyssynchrony during sleep may explain why GG-EMG activation fails to alleviate flow limitation and stabilize airway patency during sleep. NEW & NOTEWORTHY Pharyngeal obstruction during sleep may trigger genioglossus activity to levels substantially exceeding those observed during wakefulness, without ameliorating flow limitation. In contrast, other peripharyngeal muscles exhibit a much lower activity during sleep in both patients with obstructive sleep apnea and healthy subjects. Coordinated muscular synergy stabilizes the pharynx despite relatively low activity while awake, yet even higher genioglossal activity allows the pharynx to obstruct when simultaneous activity of other dilator muscles is inadequate during sleep.

Perioperative Risks of Dietary and Herbal Supplements

BACKGROUND

Patients undergoing surgery often use Dietary and Herbal Supplements (DHS). We explored the risk of DHS-drug interactions in the perioperative setting.

METHODS

In this cross-sectional prospective study, participants hospitalized for surgery completed a questionnaire regarding DHS use. We used pharmacological databases to assess DHS-drug interactions. We then applied univariate and multivariate logistic regression analyses to characterize patients at risk for DHS-drug interactions.

RESULTS

Of 526 interviewees, 230 (44%) patients reported DHS use, with 16.5% reporting using DHS that could potentially interact with anesthesia. Twenty-four (10%) patients used DHS that could potentially interact with antithrombotic drugs taken perioperatively. The medical files of three patients included reports of intraoperative bleeding. The patient files of only 11% of DHS users documented DHS use.

CONCLUSIONS

DHS use poses a significant health risk due to potential interactions. Guidelines should emphasize perioperative management of DHS use.

Inter-center comparison of EasyTube and endotracheal tube during general anesthesia in minor elective surgery

Background

The EasyTube^® (EzT) is a supraglottic airway device (SAD) enabling ventilation irrespective of its placement into the esophagus or trachea. Data obtained on SADs from multicenter studies, performed in highly specialized centers cannot always be transferred to other sites. However, data on comparability of different sites are scarce. This study focused on inter-site variability of ventilatory and safety parameters during general anesthesia with the EzT.

Methods

400 patients with ASA physical status I-II undergoing general anesthesia for elective surgery in four medical centers (EzT group (n = 200), ETT group (n = 200)). Mallampati classification, success of insertion, insertion time, duration of ventilation, number of insertion attempts, ease of insertion, tidal volumes, leakage, hemodynamic parameters, oxygenation, and complications rates with the EasyTube (EzT) or endotracheal tube (ETT) in comparison within the sites and in between the sites were recorded.

Results

Intra-site and inter-site comparison of insertion success as primary outcome did not differ significantly. The inter-site comparison of expiratory minute volumes showed that the volumes achieved over the course of anesthesia did not differ significantly, however, mean leakage at one site was significantly higher with the EzT (0.63 l/min, p = 0.02). No significant inter-site differences in heart rate, blood pressure, or oxygenation were observed. Sore throat and blood on the cuff after removal of the device were the most frequent complications with significantly more complications at one site with the EzT (p = 0.01) where insertion was also reported significantly more difficult (p = 0.02).

Conclusion

Performance of the EzT but not the ETT varied between sites with regard to insertion difficulty, leakage, and complications but not insertion success, ventilation, hemodynamics, and oxygenation parameters in patients with ASA physical status 1–2 during general anesthesia undergoing minor elective surgery.

Protective multimodal analgesia with etoricoxib and spinal anesthesia in inguinal hernia repair: a randomized controlled trial

BACKGROUND

Inguinal hernia repair is a common procedure, and can be performed under spinal anesthesia. Although adequate analgesia is crucial to postoperative recovery, the optimal protective analgesic regimen remains to be established.

PURPOSE

To investigate the effects of preoperative etoricoxib within a protective multimodal analgesic regimen with respect to pain control following open inguinal hernia repair.

METHODS

Sixty adult patients undergoing open inguinal hernia repair participated in a single-center, randomized, double-blinded, placebo-controlled trial in a general academic medical center. The intervention group (n = 30) received 120 mg of oral etoricoxib 1 h preoperatively, and 10-12 mg bupivacaine with 25 μg fentanyl as spinal anesthesia. The control group (n = 30) received oral placebo 1 h preoperatively, and spinal anesthesia as above. Postoperative Visual Analog Scale pain scores at rest and on active straight leg raise were recorded and analyzed.

RESULTS

Resting pain scores were significantly lower in the intervention than the control group at 16 h, 24 h, and on discharge (3.00 vs. 4.35; 1.57 vs. 4.00; 1.24 vs. 3.76, respectively; p < 0.05). Pain scores on active straight leg raise were significantly lower in the intervention than the control group at 16 h, 24 h, and on discharge (3.85 vs. 5.59, p < 0.01; 2.84 vs. 4.90, p < 0.05; 3.55 vs. 5.32, p < 0.05, respectively).

CONCLUSION

The addition of etoricoxib to spinal anesthesia as a multimodal protective regimen can improve pain control after inguinal hernia repair. The optimal dose and applicability to other operations remains to be established.

A randomized prospective controlled trial comparing the laryngeal tube suction disposable and the supreme laryngeal mask airway: the influence of head and neck position on oropharyngeal seal pressure

Background

The Laryngeal Tube Suction Disposable (LTS-D) and the Supreme Laryngeal Mask Airway (SLMA) are second generation supraglottic airway devices (SADs) with an added channel to allow gastric drainage. We studied the efficacy of these devices when using pressure controlled mechanical ventilation during general anesthesia for short and medium duration surgical procedures and compared the oropharyngeal seal pressure in different head and-neck positions.

Methods

Eighty patients in each group had either LTS-D or SLMA for airway management. The patients were recruited in two different institutions. Primary outcome variables were the oropharyngeal seal pressures in neutral, flexion, extension, right and left head-neck position. Secondary outcome variables were time to achieve an effective airway, ease of insertion, number of attempts, maneuvers necessary during insertion, ventilatory parameters, success of gastric tube insertion and incidence of complications.

Results

The oropharyngeal seal pressure achieved with the LTS-D was higher than the SLMA in, (extension (p=0.0150) and right position (p=0.0268 at 60 cm H₂O intracuff pressures and nearly significant in neutral position (p = 0.0571). The oropharyngeal seal pressure was significantly higher with the LTS-D during neck extension as compared to SLMA (p= 0.015). Similar oropharyngeal seal pressures were detected in all other positions with each device. The secondary outcomes were comparable between both groups. Patients ventilated with LTS-D had higher incidence of sore throat (p = 0.527). No major complications occurred.

Conclusions

Better oropharyngeal seal pressure was achieved with the LTS-D in head-neck right and extension positions , although it did not appear to have significance in alteration of management using pressure control mechanical ventilation in neutral position. The fiberoptic view was better with the SLMA. The post-operative sore throat incidence was higher in the LTS-D.

Trial registration

ClinicalTrials.gov ID: NCT02856672, Unique Protocol ID:BnaiZionMC-16-LG-001, Registered: August 2016.

Establishing a definitive airway in the trauma patient by novice intubators: A randomised crossover simulation study

BACKGROUND

Establishing a definitive airway, defined as a tube placed in the trachea with cuff inflated below the vocal cords, is standard of care in pre-hospital airway management of the trauma patient. However, in this setting, and using manual in-line stabilisation of the neck, success rate of intubation by inexperience providers is suboptimal. The use of supraglottic airway devices that allow blind tracheal intubation has been suggested as an alternative method by the Advanced Trauma Life Support (ATLS) programme of the American College of Surgeons. We aimed to compare intubation with the standard intubation technique (direct laryngoscopy [DL]) with blind intubation through an intubating-laryngeal mask airway (I-LMA) during manual in-line stabilisation of the neck.

MATERIALS AND METHODS

A randomised, crossover manikin study was performed with 29 emergency medical technicians undergoing training for paramedic status. Outcome measures were success rate in one intubation attempt, duration of intubation, and assessment of ease-of-use.

RESULTS

Study subjects had a higher success rate of tracheal intubation with I-LMA than with DL (27/29 vs. 18/29, p<0.025), and I-LMA was assessed as easier to use (4 vs. 3, p<0.0001). Longer duration of intubation was found with I-LMA compared to DL (54.2 vs. 42.8s, p<0.002). Success rate of correct placement of I-LMA within the airway was 28/29 (96.5%). Time to achieve correct placement of I-LMA within the airway was shorter than duration of tracheal intubation with DL (26.9 vs. 42.8s, p<0.0001).

CONCLUSIONS

Novice intubators had a higher success rate of intubation with I-LMA than with DL, but duration of intubation was longer with I-LMA. Time to achieve correct placement of I-LMA within the airway was shorter than duration of tracheal intubation with DL. Findings of this simulation study suggest that in the presence of manual in-line stabilisation of the neck, I-LMA-guided intubation is the preferred technique for novice intubators.

A comparison of two different dosages of oral midazolam in the same pediatric dental patients

PURPOSE

The purpose of this paper was to compare the efficacy and safety of two doses of oral midazolam (0.5 mg/kg and 0.75 mg/kg) on the same children when no cooperation could be achieved with the 0.5 mg/kg dose.

METHODS

Twenty-three healthy three- to eight-year-olds who were initially unable to tolerate dental treatment using nonpharmacologic behavioral management (sometimes in combination with nitrous oxide) participated in the study. Level of sedation, cooperation, parental satisfaction, parental prediction of child's future anxiety, and outcome of sedation with the two doses were evaluated. All treatments and behavioral evaluations were conducted by the same nonblinded dentist. Parental evaluations were nonblinded as well.

RESULTS

No respiratory events or other adverse effects were observed with either regimen. There was no gender difference in any parameter regarding the two doses of midazolam. No treatment was aborted with the 0.75 mg/kg dose. Sedation and cooperation were significantly higher at baseline and after 15, 30, and 45 minutes (P=.001) for the 0.75 mg/kg group. Parental satisfaction with the treatment was significantly greater with the higher dose.

CONCLUSION

Midazolam at 0.75 mg/kg with 100 percent oxygen can enhance outcomes for pediatric dental patients who did not cooperate satisfactorily with a dose of 0.5 mg/kg.

Optimising the dose of oral midazolam sedation for dental procedures in children: a prospective, randomised, and controlled study

BACKGROUND

Midazolam sedation poses a significant dilemma in paediatric dentistry, which is to find out the optimal dosing with minimal undesirable adverse events. In this study, we aimed to compare the effect of three doses of oral midazolam (0.5, 0.75, and 1 mg/kg) on the sedative state and cooperative behaviour of children during dental treatment. We further compared completion rates, parent satisfaction, and all adverse events.

DESIGN

Ninety children aged 3-10 years were randomised to three equal groups. Groups A, B, and C received 0.5, 0.75, and 1 mg/kg of oral midazolam, respectively. Levels of sedation, cooperative behaviour, procedures completion rates, parent satisfaction, and adverse events were prospectively recorded.

RESULTS

Sedation scores in B and C were higher (P < 0.001) than in A. Cooperation scores (CS) in B and C were higher (P < 0.001) than in A. Significant increase in completion rates was observed between A and C (P = 0.025). Parent satisfaction was greater in B and C (P < 0.001) compared to A. Adverse events were higher in C (P < 0.05) than in A or B.

CONCLUSION

Amount of 0.75 mg/kg oral midazolam appears to be the optimal oral dose in terms of effectiveness, acceptability, and safety for dental treatments in paediatric patients, when administered by an experienced, paediatric anaesthetist.

Totally laparoscopic resection of a rare duodenal tumour

A 39-year-old woman presented to the gastroenterology clinic with recurrent right-upper-quadrant pain and elevated liver enzymes. Endoscopy revealed a small submucosal mass at the edge of the major duodenal papilla, which was not amenable to endoscopic resection. The mass was successfully resected by laparoscopy. The papilla was subsequently reconstructed and a cannula inserted in the common bile duct. The postoperative period was uneventful and the patient was discharged on the third postoperative day. Subsequent pathological examination of the excised mass revealed a gangliocytic paraganglioma. Six weeks later, the patient was free of symptoms and the cannula was removed by duodenoscopy.

The postoperative occurrence of cardio-respiratory adverse events in small infants undergoing gastrointestinal surgery: a prospective comparison of general anesthesia and combined spinal-epidural anesthesia

INTRODUCTION

This study was designed to compare the occurrences of postoperative cardio-respiratory adverse events during an 8-day follow-up period in the neonatal intensive care unit in small infants who underwent elective gastrointestinal surgery under general and combined spinal epidural anesthesia.

METHODS

Fifty infants who underwent elective primary gastrointestinal surgery were randomly divided into two anesthetic techniques. General anesthesia (25 patients) and combined spinal-epidural anesthesia (25 patients). The frequency and types of postoperative cardiovascular and respiratory adverse events in the two groups were recorded and compared during an 8-day follow-up period in the neonatal intensive care unit.

RESULTS

The total number of postoperative respiratory adverse events and the number of infants who experienced at least one respiratory adverse event were statistically more in infants anesthetised by general anesthesia than in infants who were anesthetised by combined spinal-epidural anesthesia, respectively (p < 0.0001) and (RR = 2.5; 95% CI 1.2-5.3). There were significantly more cardiovascular adverse events in the general anesthesia infants than in the combined spinal-epidural anesthesia (p = 0.005). These adverse cardiovascular events were also more resistant to treatment in the general anesthesia infants than in the combined spinal-epidural anesthesia infants (p = 0.001).

CONCLUSION

Compared to general anesthesia, combined spinal-epidural anesthesia reduces the frequency of postoperative respiratory adverse events and improves the postoperative cardiovascular stability in small infants who undergo elective gastrointestinal surgery.

Comparison of the CobraPLA (Cobra Perilaryngeal Airway) and the Laryngeal Mask Airway Unique in children under pressure controlled ventilation

BACKGROUND

The Laryngeal Mask Airway-Unique (LMAU) and CobraPLA (Cobra Perilaryngeal Airway) are supraglottic airway devices. There are no published studies comparing these devices in children breathing with pressure controlled ventilation (PCV).

METHODS

Eighty pediatric patients, scheduled for elective general surgery of short duration, were randomly assigned to have either a CobraPLA or a LMAU used for airway management using PCV. We compared the devices with respect to (i) ability to form an effective cuff seal, (ii) oxygenation, (iii) endtidal carbon dioxide level, (iv) time to achieve an effective airway, (v) airway interventions required for insertion, (vi) fiberoptic score, (vii) respiratory variables and (vii) adverse events.

RESULTS

Cuff seal pressure was significantly higher for CobraPLA (27.08 +/- 4.15 cmH(2)O) than for LMAU (20.91 +/- 2.47 cmH(2)O). Oxygenation was similar in both groups while the mean endtidal CO(2) in the CobraPLA group was significantly higher than in the LMAU group (36.47 +/- 1.93 mmHg vs 34.71 +/- 3.05 mmHg, P = 0.021). Time and ease of insertion were similar, with CobraPLA requiring more frequent jaw lift and LMAU requiring more frequent adjustment of the head and neck to achieve a proper position. Fiberoptic scores were excellent with both devices. Respiratory variables were similar with the exception that the plateau pressure and mean peak pressures were significantly lower with CobraPLA. There was a low rate of blood mucosal staining of the devices. No patient in either group reported a sore throat.

CONCLUSIONS

Both devices appear to be safe and effective in establishing an adequate airway in healthy children undergoing surgery of short duration with PCV.

Combined spinal-epidural anesthesia in major abdominal surgery in high-risk neonates and infants

BACKGROUND

Combined spinal-epidural anesthesia (CSE-A) is reportedly safe and effective for the pediatric population in infraumbilical surgery. Our main purpose was to describe our experience of this technique in neonates and infants undergoing elective major upper abdominal surgery.

METHODS

Spinal anesthesia was performed in 28 neonates and infants with isobaric bupivacaine 0.5%, 1 mg.kg(-1) followed by placement of a caudal epidural catheter to thoracic spinal segments. The catheter tip position was confirmed radiographically. Respiratory and hemodynamic data were collected before and after the CSE-A and throughout the operation, as a measure of anesthetic effectiveness. Complications related to the anesthesia technique were collected as a measure of the anesthetic technique safety.

RESULTS

Satisfactory surgical anesthesia was achieved in 24 neonates and infants, four patients were converted to general anesthesia. Respiratory and hemodynamic variables did not change significantly during surgery, compared with baseline values: oxygen saturation (P = 0.07), systolic and diastolic blood pressures (P = 0.143, P = 0.198 respectively), heart rate (P = 0.080) and respiratory rate (P = 0.127). However, twenty infants were fussy during the surgical procedures and were calmed with intravenous midazolam; our patients required oxygen supplementation and transient manual ventilation intraoperatively.

CONCLUSIONS

Combined spinal-epidural anesthesia could be considered as an effective anesthetic technique for elective major upper abdominal surgery in awake or sedated neonates and infants, and could be used cautiously by a pediatric anesthesiologist as an alternate to general anesthesia in high-risk neonates and infants undergoing upper gastrointestinal surgery.

Does adding intravenous fentanyl to caudal block in children enhance the efficacy of multimodal analgesia as reflected in the plasma level of catecholamines?

BACKGROUND AND OBJECTIVE

Several studies showed that single analgesic modality management can attenuate perioperative stress, but little is known about the effect of multimodal analgesia on catecholamine responses to surgical trauma in children.

METHODS

Fifty children (American Society of Anesthesiologists Grade I or II) were randomly allocated to one of two groups: one received general anaesthesia and a caudal block (control group), and one group was given general anaesthesia, caudal block and intravenous (i.v.) fentanyl 2 microg kg(-1) (fentanyl group). Plasma epinephrine and norepinephrine concentrations were measured three times during the perioperative period: at induction time (T(0)), at the end of surgery (T(1)) and when the children were fully awake in the postanaesthesia care unit (T(2)).

RESULTS

There was a significant reduction in the catecholamine levels in the two groups when (T(1)) and (T(2)) were compared with T(0). When plasma epinephrine levels (at T(0), T(1) and T(2)) between the two groups were compared, a statistically significant reduction at T(2) was obtained in the fentanyl group, when compared with the control group. However, plasma norepinephrine levels showed no statistically significant difference between the two groups (at T(0), T(1) and T(2)).

CONCLUSION

These findings suggest that the multimodal analgesic approach of adding i.v. low-dose fentanyl to a caudal block may decrease the plasma epinephrine release in children undergoing inguinal herniotomy.

The Effects of Droperidol in Perforating Keratoplasty

PURPOSE

To evaluate the intraoperative and postoperative effects of droperidol administered with general anesthesia during perforating keratoplasty.

METHODS

A prospective, randomized, double-masked clinical trial. Twenty-seven patients undergoing penetrating keratoplasty under general anesthesia were included. Patients were assigned randomly to two groups. Fifteen subjects received droperidol during induction of general anesthesia. Twelve control patients received general anesthesia without droperidol.

RESULTS

Droperidol significantly reduced fellow eye intraocular pressure (p < 0.0001). Intraoperative anterior chamber depth was significantly deeper with droperidol (p = 0.0002). Iris bulging was observed in 25% of the control group and 0% with droperidol. There was significantly less postoperative nausea in the droperidol group (p = 0.038). There was less postoperative vomiting in the droperidol group, although the difference was not significant (p = 0.07). Postoperative wound gaping was observed in 2 patients; both of them did not receive droperidol.

CONCLUSIONS

Droperidol effectively reduces intraoperative and postoperative complications in keratoplasty surgery.

Changes in creatine phosphokinase (CK) concentrations after minor and major surgeries in children

BACKGROUND

During surgery, damage occurs to muscles in the area of the operation. The few studies that have examined creatine phosphokinase (CK) values after surgery have been in adults. The only study in children was after cardiac surgery. Understanding the normal enzyme pattern of change may help to differentiate malignant hyperthermia, anaesthesia-induced rhabdomyolysis and elevated CK values resulting from inherited muscle disease in cases in which these are suspected. The aim of this study was to delineate the normal rise of CK after minor and major surgery in children.

METHODS

A total of 71 patients aged 1 month-17 yr were studied. From the cohort of 71 patients, 46 underwent elective surgery (14 major, 32 minor) and in 25 the surgery was designated as an emergency surgery (21 major, 4 minor). The anaesthesia protocol was similar for both groups with halothane induction and isoflurane maintenance. Owing to its possible effect on CK, succinylcholine was avoided during the study.

RESULTS

The mean values of CK concentration before and after surgery were 63.1 iu litre(-1) and 151.5 iu litre(-1), respectively. The median CK elevation (range) for the major and minor surgery groups was 43 iu litre(-1) (4-647) and 10 iu litre(-1) (-28 to 122), respectively (P<0.0001).

CONCLUSIONS

CK concentrations in the major surgery group were significantly higher than the minor surgery group. This profile can contribute to the evaluation of patients who present with the possibility of malignant hyperthermia, anaesthesia-induced rhabdomyolysis and underlying muscle disease. Any rise of CK concentration above what is expected should prompt further investigation.

Delayed ventricular fibrillation following blunt chest trauma in a 4-year-old child

A 4-year-old boy who was involved in a motor vehicle accident as a pedestrian and suffered blunt chest trauma was admitted to the emergency room. Unpredictable delayed ventricular fibrillation was diagnosed and treated successfully 2 h later. This case cannot be classified as commotio cordis as the ventricular fibrillation (VF) developed so long after the sustained chest injury. At the same time, other possible etiologies of VF such as cardiac pathology or electrolyte and metabolic disorders had been ruled out. Thus, an etiological link between the chest trauma and the subsequent VF could not be ruled out and is in fact plausible despite the late onset.

Bee stings of children: when to perform endotracheal intubation?

Hymenoptera stings account for more deaths in United States that any other envenomation. Oropharyngeal stings, although rare, may produce life-threatening airway obstruction by way of localized swelling. We present 4 cases of bee stings in children that necessitated tracheal intubation and mechanical ventilation. Two children had breathing difficulties at admission; the other 2 presented with minimal symptoms but were preventively intubated and mechanically ventilated. Orofacial bee sting victims should be given parenteral treatment with epinephrine, steroids, antihistamines, and inhalational bronchodilators even when they initially present with minimal symptoms, with general anaphylaxis management in large envenomations, as well as immediate endotracheal intubation and mechanical ventilation for at least 24 hours in patients with signs of airway compromise.

Flexible fiberoptic bronchoscopy through the laryngeal mask airway in a small, premature neonate

The laryngeal mask airway (LMA) was introduced as a supraglottic device in anesthesia for routine use in the normal adult and pediatric population. Because the distal end of properly placed LMA faces the laryngeal inlet, this device can be used as a guide to flexible fiberoptic bronchoscopy (FFB) performance. In this clinical case, we present a small premature neonate with severe congenital biphasic stridor. FFB was performed successfully through the LMA while maintaining a patent airway during general anesthesia and permitting spontaneous respiration, as well as allowing assisted ventilation when necessary. An immediately subglottic intramural mass was revealed and tracheostomy was performed.

A new supraglottic airway, the Elisha Airway Device: a preliminary study

We describe the Elisha Airway Device (EAD), a new reusable supraglottic ventilatory device. Its uniqueness consists of its ability to combine three functions in a single device: ventilation, blind and/or fiberoptic-aided intubation without interruption of ventilation, and gastric tube insertion. This study was performed in 70 ASA status I-II, Mallampati class I-II patients undergoing elective knee arthroscopy and receiving general anesthesia with mechanical ventilation. Anesthesia was induced with fentanyl and propofol and was maintained with isoflurane in N20/oxygen. Neuromuscular blockade was achieved with vecuronium. Blind insertion of the device was successful in 96% of patients, with a mean insertion time of 20 +/- 4 s. In these patients it was possible to maintain oxygenation and ventilation throughout the surgical procedure. Gastric tube insertion was successful in all cases. Endotracheal intubation via the EAD was attempted in 20 patients. Blind intubation was possible during the first and second attempts in 15 and 2 patients, respectively. Fiberoptic intubation was then successful in two of the remaining three patients. The EAD is a new alternative in the evolution of supraglottic ventilatory devices; however, further clinical studies are necessary to evaluate its efficacy.

A Randomized Controlled Trial Comparing the ProSeal™ Laryngeal Mask Airway with the Laryngeal Tube Suction in Mechanically Ventilated Patients

Background

The ProSeal Laryngeal Mask Airway (PLMA) (Laryngeal Mask Company, Henley-on-Thames, United Kingdom) is a new laryngeal mask with a modified cuff designed to improve its seal and a drain tube for gastric tube placement. Similarly, the Laryngeal Tube Suction (LTS) (VBM Medizintechnik Gmbh, Sulz a.N, Germany) is a new laryngeal tube that also has an additional channel for gastric tube placement. This study compared the placement and functions of these two devices.

Methods

One hundred fifty patients undergoing general anesthesia for elective surgery were randomly allocated to the PLMA (n = 75) or LTS (n = 75). Oxygenation and ventilation, ease of insertion, fiberoptic view, oropharyngeal leak pressure, ventilatory data, ease of gastric tube insertion, and postoperative airway morbidity were determined.

Results

After successful insertion of the devices in 96% of patients with the PLMA and in 94.4% with the LTS it was possible to maintain oxygenation, ventilation, and respiratory mechanics during the entire duration of surgery. Successful first and second attempt insertion rates were 57 patients (76%) and 15 patients (20%), respectively, for the PLMA and 60 patients (80%) and 11 patients (14.6%), respectively, for the LTS. Airway placement was unsuccessful with the PLMA in three patients and with the LTS in four patients. Time to achieve an effective airway was 36 +/- 24 s with the PLMA versus 34 +/- 25 s with the LTS. Gastric tube insertion was possible in 97.3% of patients with the PLMA and in 96% with the LTS.

Conclusions

With respect to both physiologic and clinical function, the PLMA and LTS are similar and either device can be used to establish a safe and effective airway in mechanically ventilated anesthetized adult patients.

An evaluation of the Laryngeal Tube during general anesthesia using mechanical ventilation

The Laryngeal Tube is a new supraglottic ventilatory device for airway management. It has been developed to secure a patent airway during either spontaneous or mechanical ventilation. In this study, we sought to determine the effectiveness of the Laryngeal Tube for primary airway management during routine surgery with mechanical ventilation. One-hundred-seventy-five subjects classified as ASA physical status I and II, scheduled for elective surgery, were included in the study. After the induction of general anesthesia and insertion of a Size 4 Laryngeal Tube, measurements of oxygen saturation, end-tidal CO(2) and isoflurane concentration, and breath-by-breath spirometry data were obtained every 5 min throughout surgery. The lungs were ventilated with volume-controlled mechanical ventilation. The number of attempts taken to insert the Laryngeal Tube and the insertion time were recorded. In 96.6% of patients, it was possible to maintain oxygenation, ventilation, and respiratory mechanics by using mechanical ventilation throughout the surgical procedure. The results of this study suggest that the Laryngeal Tube is an effective and safe airway device for airway management in mechanically ventilated patients during elective surgery.

IMPLICATIONS

In 96.6% of patients intubated with the Laryngeal Tube, it was possible to maintain oxygenation, ventilation, and respiratory mechanics during mechanical ventilation.

Postdural puncture headache: an imaging-guided management protocol

IMPLICATIONS

We propose an imaging-based algorithm for the management of headache caused by the inadvertent puncture of dura that occurs sporadically during epidural analgesia. Its implementation can identify those postdural puncture headache cases that cannot benefit from epidural blood patches, and their unnecessary application can consequently be avoided.

The effectiveness and safety of spinal anaesthesia in the pyloromyotomy procedure

BACKGROUND

Hypertrophic pyloric stenosis is a relatively common disorder of the gastrointestinal tract in infancy, causing projectile vomiting and metabolic abnormalities. Surgical management in the form of pyloromyotomy under general anaesthesia has been reported as safe for relieving the obstructed bowel. A number of studies have demonstrated the advantages of spinal anaesthesia over general anaesthesia in high risk infants undergoing minor infraumbilical surgery. The purpose of this study was to evaluate spinal anaesthesia as an alternative option to general anaesthesia in infants undergoing pyloromyotomy.

METHODS

Twenty-five infants undergoing pyloromyotomy under spinal anaesthesia were studied. Haemodynamic and respiratory parameters were noted before performing the spinal block, 5 min after the spinal block, and every 10 min after performing the spinal block; for a total period of 30 min. The spinal block was performed using spinal isobaric bupivacaine 0.5%, 0.8 mg.kg-1. Blood pressure, heart rate, respiratory rate and oxygen saturation values were recorded.

RESULTS

The sensory levels achieved ranged between T3-T5 thoracic segments within 6-8 min and were sufficient to perform surgery in 23 cases. There were no statistically significant differences in the oxygen saturation, systolic blood pressure and respiratory rate compared with before the spinal block and after 5, 10, 20 and 30 min.

CONCLUSIONS

This study proposes that spinal anaesthesia is an alternative option to general anaesthesia in infants undergoing pyloromyotomy, and should be considered in infants undergoing pyloromyotomy.

Effect of ilioinguinal nerve block on the catecholamine plasma levels in orchidopexy: comparison with caudal epidural block

BACKGROUND

Both caudal epidural and ilioinguinal/iliohypogastric nerve blocks have been used to provide effective intra- and postoperative analgesia. Stress response hormone levels can be used as an objective method to assess the analgesic efficacy of the anaesthetic techniques used in infraumbilical surgery in children. In this study, we compared catecholamine blood levels in children undergoing these two different supplementary analgesic/anaesthetic techniques.

METHODS

Thirty male paediatric patients undergoing orchidopexy, ASA I, received inhalation general anaesthesia, and were randomly allocated to one of two groups: a caudal group (n = 15) and an ilioinguinal/iliohypogastric nerve block group (n = 15). Plasma epinephrine and norepinephrine concentrations were measured at the induction time, at the end of surgery, and in the postanaesthesia care unit. Postoperative pain score was also assessed in the postanaesthesia care unit.

RESULTS

In both groups, there was a substantial decrease in the catecholamine blood levels; however, there were significantly higher levels of epinephrine in the ilioinguinal group at the end of surgery (P = 0.008) and in the recovery room (P = 0.02) and a significant higher level of norpinephrine in the recovery room (P = 0.008).

CONCLUSIONS

The result of this study revealed that caudal epidural block was more effective than ilioinguinal block in suppressing the stress response as reflected in epinephrine and norepinephrine blood levels in orchidopexy patients.

Simple on-line endotracheal cuff pressure relief valve

Ischemic injury of the tracheal mucosa in the endotracheally intubated patient is directly proportional to the tracheal tube cuff pressure. At a cuff pressure of 30 cm H2O, the tracheal mucosal blood flow becomes partially obstructed, and at a pressure of 45 cm H2O, the obstruction to the tracheal mucosal blood becomes total, leading to tracheal mucosal damage and subsequent complications. In our institute, we have developed a simple and very inexpensive method to gauge the cuff pressure. We use a regular 20-mL syringe attached in line with the connector of the endotracheal tube cuff. In this manner, we monitored the intracuff pressure in 120 patients who underwent ear or neck surgery. The syringe was connected to the tube cuff and inflated with 15 mL of air. The syringe was left constantly connected to the cuff. In addition, the cuff pressure was measured with the Mallinckrodt Hi-Lo aneroid pressure gauge at the beginning of surgery and hourly thereafter for the duration of surgery. At the same time, a check for leakage around the cuff was made by auscultation with a stethoscope above the sternal notch. Multiple comparisons between the repetitive intracuff pressure measurements revealed that there were no significant differences in the intracuff pressure values measured at the different times of surgery. These results indicate that there was an adequate venting of the excess intracuff pressure and also that there was no leakage around the cuff.