Thyroplasty under total intravenous anaesthesia with intermittent positive pressure ventilation

BACKGROUND AND OBJECTIVES: Medialization thyroplasty is a surgical technique for improving voice quality, cough effort and laryngeal competence in patients with unilateral vocal fold paralysis. Precision surgery is enabled by operating under total intravenous anaesthesia with controlled ventilation and by using a laryngoscopic video-assisted technique. The anaesthetic challenge is to manage the shared airway with the surgeon, provide a stable operative field and ensure patient safety throughout the procedure. The objective of this case series was to evaluate the use of a modified general anaesthetic technique using the laryngeal mask airway, total intravenous anaesthesia with controlled ventilation. METHODS AND RESULTS: In all, 29 patients underwent medialization thyroplasty using a disposable laryngeal mask airway, total intravenous anaesthesia and controlled ventilation. Standard anaesthetic monitoring including capnography was used intraoperatively. Total intravenous anaesthesia was achieved using effect site target-controlled infusions of propofol and remifentanil. CONCLUSIONS: The technique proved safe with stable haemodynamic observations and only two minor complications. It also provided the surgeon with stable view of the vocal folds in order to perform this precision surgery under an operating microscope.     

Comparison of the GlideScope video laryngoscope vs. the intubating laryngeal mask for females with normal airways

BACKGROUND AND OBJECTIVE: In this randomized clinical study, we compared the intubation success rates of the intubating laryngeal mask airway with the GlideScope in patients with normal airways. The primary hypothesis was that the intubating laryngeal mask airway was equally effective as the GlideScope in terms of successful intubation times. METHODS: Sixty ASA I and II adult patients undergoing elective gynaecological surgery were randomly allocated into either the intubating laryngeal mask airway group or the GlideScope group. After a standard anaesthetic intravenous induction, orotracheal intubation was performed. Time taken for successful tracheal intubation, ease of device insertion, difficulty of tracheal intubation, manoeuvres needed to aid tracheal intubation, number of intubation attempts, haemodynamic changes every 2.5 min interval for 5 min and complications during tracheal intubation were recorded. RESULTS: Time to successful intubation was longer (mean 68.4 s +/- 23.5 vs. 35.7 s +/- 10.7; P < 0.05), mean difficulty score was higher (mean 16.7 +/- 16.3 vs. 7.3 +/- 13.1; P < 0.05) and more intubation attempts were required in the intubating laryngeal mask airway group. CONCLUSION: The GlideScope improved intubation time and difficulty score for tracheal intubation when compared with the intubating laryngeal mask airway in our patients. Blind intubation through the intubating laryngeal mask airway offers no advantages over the GlideScope in patients with normal airways. Despite its limitations, the intubating laryngeal mask airway is a valuable adjunct, especially in cases of difficult airway management when it can provide ventilation in between intubation attempts.     

A French survey of paediatric airway management use in tonsillectomy and appendicectomy

BACKGROUND: There are no epidemiological data describing tracheal intubation and laryngeal mask airway (LMATM) use in paediatric anaesthesia. This analysis focused on the factors leading to the indication for an airway management procedure, i.e. tracheal intubation and laryngeal mask airway vs face mask during general anaesthesia for tonsillectomy and appendicectomy. METHODS: The data were recorded in the French survey of Practical Anaesthesia performed in 1996. Two main types of surgical procedures were selected: tonsillectomy and appendicectomy because of the number of patients and the need to use an invasive airway management technique. RESULTS: During a 1-year period, 627 anaesthetics for appendicectomy and 653 anaesthetics for tonsillectomy were recorded in the sample under consideration. Tracheal intubation or laryngeal mask airway was undertaken in 66% of tonsillectomies and 84% of appendicectomies. Univariate analysis showed that tracheal intubation/laryngeal mask were used significantly more often in older children, with long duration of anaesthesia, in nonambulatory procedures and in procedures performed at an academic centre. When these variables were included in a multivariate analysis, the duration of anaesthesia over 30 min was a factor linked to the use of tracheal intubation/laryngeal mask airway for the two types of surgery (P < 0.0001). For tonsillectomy, inpatients were 2.9 times more likely to be intubated (or have an laryngeal mask airway) than were outpatients. For appendicectomy, older children were 3.4 times more likely to be intubated (or have an laryngeal mask airway) than younger children. CONCLUSIONS: This large French survey shows that the use of tracheal intubation/laryngeal mask airway in this country is primarily related to a predicted long duration of anaesthesia.     

General anaesthesia or spinal anaesthesia for outpatient urological surgery

BACKGROUND AND OBJECTIVE: A variety of drugs and techniques have been introduced into ambulatory anaesthesia. The technique as well as the drugs used may hasten or delay home discharge. We compared recovery profiles and side-effects of spinal anaesthesia and total intravenous anaesthesia. METHODS: Forty unpremedicated ASA I-II patients (18-65 yr) undergoing varicocele repair were randomly divided into two groups. Spinal anaesthesia (26-G atraumatic needle) with hyperbaric bupivacaine 0.5% 5 mg and fentanyl 25 microg were given to patients in Group Spinal (n = 20). Patients in Group TIVA (n = 20) received total intravenous anaesthesia with propofol and remifentanil given by continuous infusion; a laryngeal mask was used to secure the airway. The duration of surgery, time to home readiness and side-effects were recorded. RESULTS: The two groups were comparable with respect to patients' characteristics and duration of surgery. The times to achieve ambulation were similar between groups (Spinal = 78.4 +/- 40.9 min, TIVA = 75.9 +/- 13.8 min). Urinary voiding was a requirement for discharge after spinal anaesthesia and the time for home readiness was longer in Group Spinal (158.0 +/- 40.2 versus 94.9 +/- 18.8 min) (P < 0.05). Two patients reported pruritus and one reported postdural puncture headache in Group Spinal, whereas two patients reported nausea in Group TIVA. Patients in Group TIVA had a greater need for analgesia postoperation (P < 0.05). CONCLUSIONS: In healthy unpremedicated men undergoing minor urological operations, total intravenous anaesthesia with remifentanil and propofol provided as safe and effective anaesthesia as spinal block with the advantage of earlier home readiness.     

A comparison of laryngeal mask airway with tracheal tube for intra-ocular ophthalmic surgery

The use of the laryngeal mask was compared with tracheal intubation in 30 patients who underwent intra-ocular ophthalmic surgery and who received intravenous anaesthesia with propofol. Changes in intra-ocular pressure, heart rate and mean arterial pressure after the insertion of the laryngeal mask airway or the tracheal tube were not significantly different. However, at the end of the procedure, a significantly higher percentage of patients with a tracheal tube coughed, reacted to head movement and suffered breath-holding. In addition, significantly more patients in this group complained of a sore throat (p less than 0.05). During intravenous propofol anaesthesia, the laryngeal mask airway does not offer any advantage over tracheal intubation in the control of intra-ocular pressure for intra-ocular ophthalmic surgery. However, there were fewer complications immediately following surgery in the laryngeal mask group.     

Minimal-flow anaesthesia with controlled ventilation: comparison between laryngeal mask airway and endotracheal tube.

BACKGROUND AND OBJECTIVE: Minimal- and low-flow anaesthesia (fresh gas flow below 1 L min(-1)) provide many advantages, including reduced cost, conservation of body heat and airway humidity. An airtight seal is essential between the airway device and the airway of the patient. Therefore, we investigated whether the airtight seal created by a laryngeal mask airway allows controlled ventilation of the lungs when the fresh gas flow is reduced to 0.5 L min(-1) and compared this with an endotracheal tube. METHODS: In a prospective clinical study, 207 patients were managed using a laryngeal mask or an endotracheal tube. After intravenous induction of anaesthesia and 15 min of high fresh gas flow, the flow was reduced to 0.5 L min(-1). The breathing system was monitored for airway leaks, and the patients were assessed for complications after airway removal and postoperative discomfort. RESULTS: Both the laryngeal mask and endotracheal tube allowed fresh gas flow reduction to 0.5 L min(-1) in 84.7% and 98.3% of cases respectively (small leaks: 12% laryngeal mask, 1.7% endotracheal tube). Three patients with the laryngeal mask (3.3%) had airway leaks that were too large to permit any reduction in the fresh gas flow. CONCLUSIONS: The use of the laryngeal mask airway was more likely to be associated with a gas leak than use of an endotracheal tube; however, if modern anaesthesia machines and monitors are used, in 96.7% of the patients managed with a laryngeal mask a reduction in the fresh gas flow to 0.5 L min(-1) was possible. The incidence of coughing and postoperative complaints (sore throat, swallowing problems) was higher after use of an endotracheal tube.     

Fast-track eligibility, costs and quality of recovery after intravenous anaesthesia with propofol-remifentanil versus balanced anaesthesia with isoflurane-alfentanil

BACKGROUND AND OBJECTIVE: The randomized, patient- and observer-blinded study was performed in 120 patients undergoing ear, nose and throat surgery to test the hypothesis that intravenous anaesthesia with propofol-remifentanil when compared with a balanced anaesthesia technique using isoflurane-alfentanil improves the speed of recovery, minimizes postoperative side-effects and, thus, leads to an improved quality of recovery without increasing total costs. METHODS: The total costs for each anaesthesia technique were calculated considering drug acquisition costs, personnel costs for the additional time spent in the operating room and the postanaesthesia care unit until fast-tracking eligibility, and the costs to treat the side-effects during and after operation. RESULTS: The times from the end of surgery to tracheal extubation and the time until leaving the operating room were not different between the two groups. However, more patients receiving intravenous anaesthesia (80 versus 49%) were eligible for fast tracking and thus could bypass the recovery room. This was associated with an average cost saving of 6.00 euros per patient. However, intravenous anaesthesia was associated with higher total costs (89 euros versus 78 euros) mainly because of higher acquisition costs of the anaesthetics (34.60 euros versus 16.50 euros). There was no difference in the quality of recovery as measured by a Quality of Recovery score and patient satisfaction between the two groups. CONCLUSIONS: The higher acquisition costs of the intravenous anaesthetics propofol and remifentanil cannot be compensated for by improved speed of recovery. This anaesthesia technique is more cost intensive than balanced anaesthesia using isoflurane and alfentanil.     

Electroencephalographic arousal response during tracheal intubation and laryngeal mask airway insertion after induction of anaesthesia with propofol

Laryngoscopy and tracheal intubation, or insertion of a laryngeal mask airway may lead to an arousal response on the electroencephalogram. We studied whether more intense stimulation (laryngoscopy and tracheal intubation) causes a greater arousal response than less intense stimulation (laryngeal mask airway insertion). Thirty-four patients (ASA I-II) were anaesthetised with propofol 3 mg.kg-1, followed by vecuronium 0.15 mg.kg-1 and a propofol infusion of 10 mg.kg-1.h-1. Three minutes after induction of anaesthesia, either laryngoscopy and tracheal intubation (n = 18), or laryngeal mask airway insertion (n = 16) was performed. Laryngoscopy and tracheal intubation caused a significantly greater increase in blood pressure (but not heart rate) than laryngeal mask airway insertion (p < 0.05). Electroencephalogram responses were not different. More intense stimulation does not cause a greater arousal response during propofol anaesthesia.     

General anaesthesia for ophthalmic surgery

The majority of ophthalmic surgeries are performed as day cases under topical or regional anaesthesia with or without intravenous sedation. However, general anaesthesia is necessary in certain circumstances e.g. local anaesthetic allergy or patients who are unable to cooperate or to lie flat or still. Patients for ophthalmic surgery are frequently elderly with multiple comorbidities, such as diabetes and hypertension. Patients with rare genetic syndromes may present for eye surgery. Therefore adequate preoperative evaluation and preparation will minimize perioperative complications. The goals of general anaesthesia are smooth induction and emergence, with stable intra-ocular pressure (IOP) and akinesia of the globe. These can be achieved with a combination of intravenous and inhalational agents with or without muscle relaxants and opiates. Use of the laryngeal mask airway has the advantage of causing a smaller rise in IOP on insertion and less coughing on emergence. Total intravenous anaesthesia with propofol and remifentanil has the advantages of causing less postoperative nausea and vomiting (PONV), reduced stress response to airway intervention, rapid recovery and smooth emergence. Some eye procedures require special consideration, for example, strabismus and vitreoretinal surgery involves traction of the rectus muscles producing a higher incidence of oculocardiac reflex and PONV. Most ophthalmic surgery produces mild to moderate pain amenable to non-opioid analgesics. Intraoperative topical and regional anaesthesia reduce postoperative pain and opiate requirement. Open globe injury and a full stomach present unique challenges to prevent increase in IOP as well as protecting the airway.     

General anaesthesia for ophthalmic surgery

The majority of ophthalmic surgeries are performed as day cases under topical or regional anaesthesia with or without intravenous sedation. However, general anaesthesia is necessary in certain circumstances e.g. local anaesthetic allergy or patients who are unable to cooperate or to lie flat or still. Patients for ophthalmic surgery are frequently elderly with multiple comorbidities, such as diabetes and hypertension. Patients with rare genetic syndromes may present for eye surgery. Therefore adequate preoperative evaluation and preparation will minimize perioperative complications. The goals of general anaesthesia are smooth induction and emergence, with stable intra-ocular pressure (IOP) and akinesia of the globe. These can be achieved with a combination of intravenous and inhalational agents with or without muscle relaxants and opiates. Use of the laryngeal mask airway has the advantage of causing a smaller rise in IOP on insertion and less coughing on emergence. Total intravenous anaesthesia with propofol and remifentanil has the advantages of causing less postoperative nausea and vomiting (PONV), reduced stress response to airway intervention, rapid recovery and smooth emergence. Some eye procedures require special consideration, for example, strabismus and vitreoretinal surgery involves traction of the rectus muscles producing a higher incidence of oculocardiac reflex and PONV. Most ophthalmic surgery produces mild to moderate pain amenable to non-opioid analgesics. Intraoperative topical and regional anaesthesia reduce postoperative pain and opiate requirement. Open globe injury and a full stomach present unique challenges to prevent increase in IOP as well as protecting the airway.     

Recovery of older patients undergoing ambulatory anaesthesia with isoflurane or sevoflurane

BACKGROUND: Delayed recovery of cognitive function is a well-recognized phenomenon in older patients. The potential for the volatile anaesthetic used to contribute to alterations in postoperative cognitive function in older patients following minor surgical procedures has not been determined. We compared emergence from isoflurane and sevoflurane anaesthesia in older surgical patients undergoing urological procedures of short duration. METHODS: Seventy-one patients, 60 yr of age or older, undergoing anaesthesia expected to last less than 60 min for ambulatory surgery, were randomly assigned to receive isoflurane or sevoflurane. A standardized anaesthetic protocol was used, with intravenous fentanyl 1 microg kg(-1) and propofol 1.5-2.0 mg kg(-1) administered to induce anaesthesia. Anaesthesia was maintained with either sevoflurane or isoflurane in 65% nitrous oxide and oxygen. Early and intermediate recovery times were recorded. The Mini Mental State Examination and digit repetition forwards and backwards were administered at baseline, and at 1, 3 and 6 h postoperatively, to assess cognitive function. RESULTS: There were no between-group differences in (sevoflurane vs. isoflurane, mean +/- standard error of the mean) times to removal of the laryngeal mask airway (7.7 +/- 0.6 vs. 7.1 +/- 0.4 min), verbal response time (10.1 +/- 0.7 vs. 9.9 +/- 0.7 min) and orientation (12.1 +/- 0.7 vs. 12.1 +/- 0.7 min). Intermediate recovery, as measured by time to readiness for discharge from the post anaesthesia care unit (44.9 +/- 1.5 vs. 44.3 +/- 1.5 min), was similar in the two groups. Postoperative indices of cognitive function and attention were comparably reduced at 1 h, but returned to baseline in both groups at 6 h. CONCLUSIONS: Isoflurane and sevoflurane anaesthesia resulted in similar clinical and neurocognitive recovery profiles in older patients undergoing ambulatory surgical procedures of short duration.     

The laryngeal mask airway in obstetrical anaesthesia

The laryngeal mask airway (LMA) has been used extensively to provide a safe airway in spontaneously breathing patients who are not at risk from aspiration of gastric contents. The role of the LMA in the event of a failed intubation in an obstetrical patient, and its place in a failed intubation drill remains unclear. Two hundred and fifty consultant obstetric anaesthetists in the United Kingdom were asked to complete an anonymous questionnaire regarding their views about using the laryngeal mask airway (LMA) in obstetrical anaesthesia. The LMA was available in 91.4% of obstetric units. Seventy-two per cent of anaesthetists were in favour of using the LMA to maintain oxygenation when tracheal intubation had failed and ventilation using a face mask was inadequate. Twenty-four respondents had had personal experience with the LMA in obstetrical anaesthesia, eight of whom stated that the LMA had proved to be a lifesaver. We believe that the LMA has a role in obstetrical anaesthesia when tracheal intubation has failed and ventilation using a face mask proves to be impossible, and it should be inserted before attempting cricothyroidectomy.     

Tracheal intubation through the intubating laryngeal mask in patients with unstable necks

BACKGROUND: In patients with unstable necks, the neck should be stabilized during induction of anaesthesia, but this may make tracheal intubation difficult. Awake intubation may produce straining, which could be detrimental to the unstable neck. METHODS: We studied 20 patients with unstable necks to examine the efficacy of insertion of the intubating laryngeal mask under conscious sedation (to minimize the possibility of losing a patent airway and to facilitate fibrescope-aided intubation) followed by tracheal intubation through the laryngeal mask after induction of anaesthesia (to reduce stress response to intubation). After the patient had been sedated with midazolam (up to 5 mg) and fentanyl (up to 100 microg), the intubating laryngeal mask was inserted. General anaesthesia was then induced with sevoflurane and tracheal intubation attempted. RESULTS: In all patients, tracheal intubation through the laryngeal mask succeeded without airway obstruction. Neither insertion of the mask under conscious sedation nor tracheal intubation after induction of anaesthesia caused straining, and only two patients moved upper extremities at intubation. Insertion of the laryngeal mask did not significantly alter blood pressure or heart rate. Tracheal intubation significantly increased blood pressure and heart rate, but the increase was considered to be small. CONCLUSIONS: In the patient with an unstable neck with a low risk of pulmonary aspiration, insertion of the intubating laryngeal mask while the patient is sedated may minimize difficulty in obtaining a patent airway before tracheal intubation and may facilitate a fibrescope-aided tracheal intubation; subsequent induction of anaesthesia before tracheal intubation may minimize stress response to intubation.     

Difficult airway management patterns among attending anaesthetists practising in Israel

BACKGROUND AND OBJECTIVE: In recent years, a large number of airway devices have been introduced into clinical practice as adjuncts to the management of the difficult airway. The purpose of this study was to evaluate the practices of Israeli anaesthetists in specific clinical situations and their familiarity with the use of a variety of airway devices and techniques. METHODS: A survey developed in our institution was sent to 300 attending anaesthetists representing all board-certified anaesthetists practising in Israel. RESULTS: Of the 153 respondents, 75% belonged to university hospitals. Ninety-six percent were skilled with laryngeal mask airways and 73% with fibreoptics. Seventy percent preferred regional anaesthesia with anticipated difficult intubation, continuation of anaesthesia with a laryngeal mask with failed intubation and a laryngeal mask for impossible mask ventilation. For the airway scenarios, awake fibreoptic, awake direct laryngoscopy, intubation under inhalation anaesthesia and tracheostomy were shared equally. CONCLUSIONS: There is a high degree of adherence by Israeli anaesthetists to the American Society of Anesthesiologists' difficult airway algorithm. Current airway management practice patterns in Israel are presented.     

Intubation via LMA in pediatric patients with difficult airways

PURPOSE: To report two cases of successful tracheal intubation in difficult pediatric airways using a conventional laryngeal mask airway (LMA) with an extended polyvinyl chloride (PVC) tube after laryngeal assessment with a fibreoptic device. CLINICAL FEATURES: Two cases, Dandy-Walker and Pierre Robin syndromes, were scheduled for surgery. They were premedicated with 0.5 mg x kg(-1) promethazine p.o. 90 min before surgery. Both patients arrived in the operating room sedated, with dry mouth, and without evidence of increased intracranial tension or airway obstruction. Inhalational induction with isoflurane 0.5-3% was commenced. Conventional tracheal intubation was impossible in both cases. In each an LMA was inserted to maintain ventilation, anesthesia, and to facilitate intubation. Fibreoptic bronchoscopy was used to assess the larynx, followed by blind intubation via the LMA using extended PVC tracheal tube (TT). Anesthesia was maintained during intubation using Mapleson F anesthesia circuit attached to a connector with fibreoptic bronchoscope adapter. CONCLUSION: This report describes the assessment of the airway with fibreoptic bronchoscopy after LMA insertion facilitated blind tracheal intubation in two children with difficult airways.     

Evaluation of the learning curve of a new intubation technique: intubating laryngeal mask

OBJECTIVE: Assessment of the learning curve of a new device for blind orotracheal intubation: Intubating laryngeal mask. STUDY DESIGN: Prospective clinical study. METHODS: Ten persons practicing anaesthesia (specialist, fellow, nurse) underwent videotape learning and manikin training required with the device. Each person had to carry out a tracheal intubation in ten consecutive patients undergoing scheduled surgery. No patient presented history or clinical sign of difficult airway management. Results were expressed as mean +/- SD. Main percentages were provided with their 95% confidence interval; the percentage comparison were performed using Chi 2 test. The significance level for overall analysis was p < 0.05. RESULTS: One hundred patients were included. The overall success rate of tracheal intubation with the intubating laryngeal mask was 88%. An easy learning curve was obtained according to the low failure rate that was observed. No failure was noticed after eight procedures. Significant diminution of the delay for tube insertion was observed during the practice (3 +/- 1.30 min for the first procedure and 1.16 +/- 0.60 min for the tenth procedure). Circumstances of the oral intubation were improved with muscle relaxation. Finally, all failure with the intubating laryngeal mask were followed by successful intubation using direct laryngoscopy. CONCLUSION: The intubating laryngeal mask is a new device for blind orotracheal intubation with an easy learning curve in patients without difficulty in airway management, even for non-selected operators.     

The laryngeal mask airway: its features,effects and role

The laryngeal mask airway was designed as a new concept in airway management and has been gaining a firm position in anaesthetic practice. Numerous articles and letters about the device have been published in the last decade, but few large controlled trials have been performed. Despite widespread use, the definitive role of the laryngeal mask has yet to be established. In some situations, such as after failed tracheal intubation or in anaesthesia for patients undergoing laparoscopic or oral surgery, its use is controversial. There are a number of unresolved issues, for example the effect of the laryngeal mask on regurgitation and whether or not cricoid pressure prevents placement of the mask. We review the techniques of insertion, details of misplacement, and complications associated with the use of the laryngeal mask. We discuss the features and physiological effects of the device, including the changes in intra-cuff pressure during anaesthesia and effects on blood pressure, heart rate and intra-ocular pressure. We then attempt to clarify the role of the laryngeal mask in airway management during anaesthesia, based on the current knowledge, by discussing the advantages and disadvantages as well as the indications and contraindications of its use. Lastly we describe the use of the laryngeal mask in circumstances other than airway maintenance during anaesthesia: fibreoptic bronchoscopy, tracheal intubation through the mask and its use in cardiopulmonary resuscitation.     

Inhalational induction of anaesthesia with 8% sevoflurane in children: conditions for endotracheal intubation and side-effects

BACKGROUND AND OBJECTIVE: This study was designed to assess the conditions for endotracheal intubation or insertion of a laryngeal mask airway following an inhalational induction using 8% sevoflurane and nitrous oxide without the use of muscle relaxants or opioids. METHODS: There were two groups: 30 children had endotracheal intubation and 30 children had a laryngeal mask airway inserted. Induction of anaesthesia was accomplished using an inspiratory concentration of sevoflurane 8% in a nitrous oxide and oxygen mixture. After an end-expiratory concentration of sevoflurane of at least 4% had been reached, when the pupils were miotic and centred, the trachea was intubated or a laryngeal mask inserted. The time to loss of consciousness and successful airway management was recorded. Jaw relaxation, movements, visibility, and position of the vocal cords and vital parameters were monitored. RESULTS: Jaw relaxation was complete in all children. The vocal cords were completely visible in all patients of the tracheal intubation group, whereas vocal cord relaxation was incomplete in five children. Nevertheless, all children had an atraumatic intubation or insertion of the laryngeal mask without the use of a muscle relaxant. Vital signs were stable in both groups. There were no cases of restlessness and/or postoperative shivering. Four patients in the endotracheal group (13.3%) were nauseous and three (10%) vomited, while two children (6.6%) in the laryngeal mask group experienced nausea and vomiting. CONCLUSIONS: Induction with sevoflurane in nitrous oxide and oxygen leads to fast loss of consciousness and provides ideal conditions for managing the airway without supplemental opioids or muscle relaxants. Furthermore, sevoflurane using this technique was very well tolerated, indicated by high haemodynamic stability and a reduced rate of postoperative restlessness, shivering, nausea and vomiting.     

The reinforced laryngeal mask in dental day surgery

Sixty adult patients undergoing removal of third molars under general anaesthetic in the Cambridge day surgery unit were randomly allocated to receive either a conventional anaesthetic employing nasotracheal intubation (NETT), pharyngeal gauze pack and inhalation agents or the reinforced laryngeal mask airway (RLMA) and total intravenous anaesthesia. Thirty patients were studied in each group. Immediate recovery times were significantly longer in the NETT group (P = 0.01). Surgical access was adequate in both groups. Postoperative muscle pains were significantly less in the reinforced laryngeal mask airway (RLMA) group (P= 0.0001). The RLMA provides a reliable method of airway management during removal of impacted third molars, with a reduction in postoperative morbidity when compared with conventional nasotracheal intubation involving the use of suxamethonium.