Simulation analysis of three intubating supraglottic devices during infant chest compression

Current guidelines for pediatric cardiopulmonary resuscitation suggest that supraglottic devices are alternatives for tracheal intubation with minimal interruption of chest compression. We examined the utility of three intubating supraglottic devices, air‐Q® (air‐Q), Ambu® aura‐i (aura‐i), and i‐gel® (i‐gel), utilizing manikin simulation. Twenty‐two novice physicians performed securing of airway on an infant manikin with the three devices. We measured the rate of success on ventilation and the insertion time with or without chest compression. Successful ventilation rate did not significantly decrease with chest compression in the three devices (without chest compression: air‐Q, 21/22; aura‐i, 20/22; i‐gel, 20/22, during chest compression: air‐Q, 20/22; aura‐i, 20/22; i‐gel, 18/22). The insertion time with air‐Q and aura‐i did not extend significantly for chest compression. In contrast, the insertion time with i‐gel was significantly extended in chest compression (P < 0.05). Air‐Q and aura‐i are more useful for airway management during chest compression than i‐gel.     

Comparison of Pentax-AWS Airwayscope, Airtraq and Miller laryngoscope for tracheal intubation by novice doctors during infant cardiopulmonary resuscitation simulation: a randomized crossover trial

Recent guidelines for infant cardiopulmonary resuscitation emphasize that all rescuers should minimize interruption of chest compressions, even for endotracheal intubation. We compared the utility of the Pentax-AWS Airway Scope (AWS) with an infant-sized Intlock (AWS-I), Airtraq laryngoscope (ATQ) and Miller laryngoscope during chest compressions on an infant manikin. Twenty-three novice doctors performed tracheal intubation on an infant manikin using the AWS-I, ATQ and Miller laryngoscope, with or without chest compressions. In Miller laryngoscope trials, one participant failed to secure the airway without chest compressions, while nine failed with compressions (P < 0.05). In ATQ trials, none of the participants failed without compressions, while six failed with compressions (P < 0.05). In AWS-I trials, all participants succeeded regardless of chest compressions. Intubation time was significantly longer with chest compressions with the Miller laryngoscope and ATQ, but not with the AWS-I. The AWS-I is an effective device for endotracheal intubation during chest compressions in infant simulations managed by novice doctors.     

Facial reanimation by transposition of the masseter muscle combined with tensor fascia lata,using the zygomatic arch as a pulley

We have created a new way of reanimating the face, involving transposition of the masseter muscle combined with tensor fascia lata, and using the zygomatic arch as a trochlea to reconstruct the inferior facial paralysis. We used it on five patients who had facial palsy after excision of malignant parotid tumours. The wide skin defect that exposed the masseter muscle after total parotidectomy was reconstructed with a free flap. This method differs from those of other methods of transposing the masseter muscle in that force is applied at an upper lateral angle. Our method provided dynamic raising of the upper lip, the corner of the mouth, and the nasolabial fold in four patients. We consider it to be useful, particularly for prompt surgical reconstruction of facial palsy after total parotidectomy with a wide defect in the skin of the cheek.     

Comparison of Insertion of the Modified i-gel Airway for Oral Surgery With the LMA Flexible: A Manikin Study

We previously modified the i-gel airway to enable its use in the field of oral and maxillofacial surgery and reported its fabrication methods. In general, the standard i-gel airway is quick to insert and has a high success rate, but the modified i-gel airway has yet to be assessed for these attributes. We, therefore, set out to compare the ease of insertion of the modified i-gel airway with the LMA Flexible to investigate the usefulness of the modified i-gel airway. The study participants, who included 20 new interns with no experience using either the LMA Flexible or the modified i-gel airway, inserted each device 3 times into an intubation practice manikin. The variables measured in this study were insertion time and rate of successful insertions. Mean insertion time over 3 attempts was significantly shorter for the modified i-gel™ airway (18.9 ± 4.7 seconds) than the LMA Flexible (24.9 ± 5.1 seconds, P < .001). The rate of successful insertions as a total of all 3 attempts was significantly higher for the modified i-gel airway (56/60 times, 93.3%) than the LMA Flexible (45/60 times, 75%; P = .012). When used by an inexperienced operator, the modified i-gel™ airway is faster and has a higher success rate than the LMA Flexible, suggesting that it can be easily manipulated during insertion.Key Words: Oral and maxillofacial surgery, Supraglottic airway device, Modified i-gel™ airwayThe first laryngeal mask (LMA) was the LMA Classic, developed by Dr Brain. It was later followed by a number of groundbreaking new products, such as the LMA ProSeal, which features a high-pressure seal and a gastric tube orifice, and the LMA Fastrack that can be used to pass an endotracheal tube into the trachea. Today, these and other products comprise the LMA family. One of them, the LMA Flexible (Laryngeal Mask Company, Jersey, UK; Figure 1: top) was developed for oral and maxillofacial surgery and other types of head and neck surgery. The flexible wire-reinforced airway tube of this device has the advantages of avoidance of interference with the operative field, even in oral surgery, and being able to withstand pressure from surgical manipulation.^1,2 Thus, the LMA Flexible is currently the gold standard supraglottic device in the field of oral and maxillofacial surgery. The flexibility of the shaft of the reinforced airway tube, however, makes it difficult to exert any force on the shaft,^1,2 making insertion more difficult than with the LMA Classic.³Open in a separate windowFigure 1.LMA Flexible (top) and modified i-gel airway (bottom).The i-gel airway (Intersurgical Ltd, Wokingham, UK) is a disposable supraglottic device that was developed by Dr Nasir. It consists of an airway tube with a noninflatable gel-like cuff designed to fit perfectly over the larynx and also has a gastric tube orifice. The i-gel airway features a high-pressure seal (pharyngeal leak pressure),⁴ potentially preventing leakage of blood and water into the airway, which is a frequent problem during dental treatment and in oral and maxillofacial surgery. Hence, although this device may be very useful in oral and maxillofacial surgery, its use is limited by the thickness of the shaft of the airway.We previously modified the i-gel airway (modified i-gel airway; Figure 1: bottom) to enable its use in the field of oral and maxillofacial surgery and reported its fabrication methods.⁵ In general, the standard i-gel airway is quick to insert and has a high success rate, but the modified i-gel airway has yet to be assessed for these attributes. We, therefore, set out to compare the ease of insertion of the modified i-gel airway and the LMA Flexible to investigate the usefulness of the modified i-gel airway.     

RUBINSTEIN-TAYBI'S SYNDROME—A CASE REPORT

An autopsy case of Rubinstein-Taybi's syndrome is described. Since the mental retardation is considered to be a part of the syndrome, central nervous system was carefully examined, illustrating a moderate degree of the cerebral cortical and callosal hypoplasia and diffusely distrlbuted neuronal anoxic changes possibly associated with cardio-pulmonary insufficiency. As far as the pathognomony of the facio-osseal deformities, no convinciable causative factors have been obtained.     

Comparison of tracheal intubation by the Macintosh laryngoscope and Pentax-AWS (Airway Scope) during chest compression: a manikin study

To compare tracheal intubation with the Pentax Airway Scope (AWS) and the Macintosh laryngoscope (McL) during chest compression, 25 anesthesiologists (including 12 specialists having >5 years of experience and 13 trainees having <2 years of experience) performed tracheal intubation using either the McL or the AWS, with or without chest compression, on a manikin. Using the McL, both specialists and trainees took a significantly longer time (P < 0.01) to secure the airway with chest compression (17.3 ± 3.7 and 22.5 ± 8.0, respectively) and than without chest compression (11.3 ± 2.9 and 13.9 ± 4.4 s, respectively). No significant difference was observed in time needed to secure the airway using the AWS with or without chest compression in both groups. From the standpoint of experience, time to complete intubation for specialists using the McL during chest compression was significantly shorter than that for trainees. In contrast, the difference in time to complete intubation with the AWS during chest compression was not significantly different between the two groups. Based on these results, we conclude that the use of the AWS may reduce the time needed to secure the airway during chest compression.     

A case of advanced gastric cancer successfully treated with TS-1/CDDP combination chemotherapy, able to maintain CR for more than two years against multiple liver metastases

INTRODUCTION: In recent years, a high success rate of combination chemotherapy with TS-1/CDDP has been reported against advanced gastric carcinoma. We, this time, experienced a case of advanced hemorrhagic gastric cancer with multiple hepatic metastases for which total gastrectomy was performed, followed by postoperative combination chemotherapy with TS-1/CDDP which culminated in achieving CR for the liver metastases. CASE REPORT: The patient was a 59-year-old woman who was hospitalized for a type IV gastric carcinoma in the upper part of the gastric body. Further examination revealed liver (S 2, S 5, S 7) and lymph node metastases. Due to hemorrhage from the tumorous lesion, the treatment strategy selected was total gastrectomy followed by postoperative chemotherapy. Operative and clinicopathological findings revealed a mass lesion of MLU, type IV, 16.0x14.0 cm, sT 3 (SE), sH 1 (bilobular multiple metastases) and CY 0, and por 1, pT 2 (SS), pN 1 (+) [23/38], int, INF beta, ly 3 and v 1, respectively. Combination chemotherapy with TS-1/CDDP was instituted after surgery. As for the dosing method of combination chemotherapy,the patient was treated with a course of TS-1 80 mg daily divided into two doses over 21 days continuously, followed by a 14-day cessation of the drug,together with a dose of CDDP 70 mg on day 8. The patient received a total of four courses. At the completion of the third chemotherapy course, her multiple hepatic metastases disappeared. Further, the preoperative CA 19-9 level of 370 U/mL returned to normal after chemotherapy. Adverse events observed were leukopenia and thrombocytopenia, both of which were judged to be grade 2. At two years and nine months, the patient is being followed on an outpatient basis without any sign of postoperative recurrent disease. CONCLUSION: We experienced a patient who was successfully treated with combination chemotherapy and demonstrated disappearance of her multiple hepatic metastases, showing a clinical response of CR lasting for more than two years against the metastases. It was inferred that this regimen of TS-1/CDDP is an effective treatment modality not only as preoperative but also postoperative chemotherapy after surgery for advanced gastric carcinoma.     

Conscious sedation and amnesic effect of intravenous low-dose midazolam prior to spinal anesthesia

BACKGROUND: The pain associated with spinal puncture is severe, and the memory of this uncomfortable procedure often deters patients from undergoing the procedure again. Therefore, it is important to make the patient as comfortable as possible when this procedure is performed. METHODS: We administrated a low-dose (1-2.5 mg) of midazolam intravenously several minutes before conducting a spinal-tap in 200 patients undergoing elective surgery of the lower limb. The dose of midazolam used was based on the patient's age and weight, and we investigated remaining of a memory concerning the spinal-tap procedure and side effects of midazolam at the end of surgery. RESULTS: Memory of the spinal-tap procedure remained in 14.0%, 1.9%, and 32.7% of the patients who had received benzodiazepine preoperatively and in 25.0%, 40.0%, and 60.9% of the patients who hadn't received benzodiazepine preoperatively in the age group <60, 60-70, and > or =70 years, respectively. No patient experienced severe respiratory depression, but an excessive sedation or restlessness was experienced in 1.6%, 4.8%, and 5.2% of the patients. CONCLUSIONS: In the patients aged <70 years, intravenous administration of 0.023-0.044 mg x kg(-1) of midazolam was very effective in preventing a bad memory concerning the spinal-tap procedure; however, it is important to note that the number of side effects associated with this procedure increases in patients aged > or =60 years.     

Two cases of venous aneurysm of the intrahepatic portal vein branch: MR demonstration

Two cases are reported of congenital intrahepatic portal vein aneurysm in women who had chronic hepatitis. Ultrasound (US) and computed tomography (CT) investigations revealed vascular communication between intrahepatic portal vein and venous aneurysms in both cases. These portal vein aneurysms were fusiform in shape and two and one centimeter in diameter in each case. On angiography portal-hepatic venous shunt was observed in one case. The MR image of two cases were presented. We believe this is the first report of MR image of portal vein aneurysm.