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Use Flexible Reinforced Laringeal Mask (SUFRLM) and Wired Endotracheal Tube (WETT) in oral surgery of adult patients with regard to: surgical conditions, time of induction and emergence of anesthesia and time of discharge from the recovery room. In adition we also compared the postoperative incidence of dysphagia, dysphonia and sore throat between both devices. Materials and Methods: Prospective randomized study conducted on 28 adult patients, 14 in each group, of ASA I - III, who were submit ted to oral surgery under general anesthesia between January and December of 2011. Anesthesia was induced with fentanyl and propofol and no muscular rela xant was used. SUFRLM or WETT was inserted and cuf f inflated. Anesthesia was maintained with O2 and Sevoflurane. The data were collected by the anesthesiologist and the recovery nurse that was blind for the type of airway device used. The output data were processed by the SPSS statistical sof tware, comparing dichotomous variables with Chi2 test, at a significance level of 0.05. Results and Discussion: No statistical dif frences were found in what concerns to induction (SUFRLM 6.71 min Vs WETT 5.14 min, p= 0.27, CI 95% (0.48 - 3.6)) and emergence (SUFRLM 4.57 min Vs WETT 5.79 min, p= 0.277, CI 95% (0.46- 1.03)) times.The recovery time in the WETT group was shorter than the SUFRLM group (SUFRLM 163.15 min Vs WETT 103.21 min, p= 0.01, CI 95% (28.3 - 91.57)). There were no statistical dif ferences in the surgical conditions, the incidence of dysphonia or dysphagia and suplemental O2 needs in the recovery room. The incidence of sore throat was higher in the SUFRLM group (SURFLM n=5 (35%) vs WETT n=0 (0%), p= 0.014). Conclusion(s): The use of SUFRLM appears to be responsible for higher recovery times, and superior incidence of sore trhoat when compared with the WETT, in oral surgery in adults. Nevertheless we will continue studying this subject in order to achieve a more representative sample. References:
1. J Anesth 21:99, 2007; 2. European Journal of Anaesthesiology 27:11 pp941-946, 2010.

Airway Management

19AP3-2
Consideration of the devices which can decrease the air leakage while in using LMA
Tennichi T., Toyama K., Taki Y., Nagase N. Takaoka Cit y Hospital, Depar tment of Anaesthesiology and Intensive Care, Takaoka, Japan Background and Goal Study: Laryngeal mask airway (LMA) is the advanced airway management tools. But, when we use LMA under mechanical ventilation, we of ten encounter the air leakage. Therefore, we saw if we cant decrease the air leakage. Then, we discovered that the air leakage while in using LMA could be decreased by pressing the body surface of the neck. As the result of trial and error, we made new devices for decreasing the air leakage and evaluated the ef fect of them. Material and method: We found that the air leakage could be decreased by compressing ex ternal side between infrahyoid region on both sides and upper border of thyroid cartilage percutaneously with two cylindrical gauze (2cm thick around, 5~8cm long). Then, we made devises which can be fixed by wrapping them around their neck with Velcro. We made varied sizes of them and put it which can decrease the air leakage most ef fectively on. Eighty-one patients were undergone general anesthesia while in using LMA. When the air leakage occurred, we put it on. Then, we divided them into four groups based on amount of leaking air. Result: Air leakage was occurred in thirty-nine patients. Among them, we used the devices in thirty-six patients belonging to three groups (group2,3,4). (amount of leaking air; group1: none, group2: 7943ml, group3: 22387ml, group 4: avaluative) Af ter using the devices, the air leakage decreased significantly for every group. (amount of leaking air; group2: 3130ml, group3: 2618ml, group4: 6050ml) (P< 0.0005) Furthermore, there were no problems of the breathing, blood circulatory and nerve system. Discussion: According to a report, some people increased the amount of cuf f when the air leakage occurred. But it was pointed out the possibility of tissue perfusion abnormality. No one has reported whether the air leakage could be decreased by compressing the regions percutaneously. The regions fall under near the outside superior border of the thyroid cartilage anatomically. There were no complications. Therefore, it can be concluded that the devices are safe to use. Conclusion: While in using LMA under mechanical ventilation, the devices can decrease the air leakage safely.

19AP3-1

The ef fect of cricoid pressure on glot tic view improvement at laryngoscopy

Maleki A., Zahedi H. Tehran Universit y/Tebi Center Hospital, Depar tment of Anaesthesiology, Tehran, Iran, Islamic Republic of Background and Goal of Study: The ef fect of cricoid pressure on the view at laryngoscopy is unknown. However, cricoid pressure may make the best view at laryngoscopy.1 Cricoid pressure is a superficially simple in practice but it is a complex manoeuvre which is dif ficult to perform optimally.2,3 The aim of the present study was to evaluate the ef ficacy of cricoid pressure on laryngeal view improvement at laryngoscopy. Materials and Methods: The investigation was carried out as a prospective randomized double blind study. A total of 84 patients undergoing standardized general anesthesia presenting for elective ophthalmic surgery in Farabi Hospital in 2010-2011 years. Then patients were randomly assigned to : Group I (with cricoid pressure) (n = 42), group II (without cricoid pressure) (n = 42) at laryngoscopy. Cricoid pressure was applied in an upward and backward direction with two fingers by the thumb and forefinger on each side of cricoid cartilage. All patients were assessed by one blind anesthesiologist for laryngoscopic views and their changes in each groups. Results were analyzed by X2 test. A P value of < 0.05 was taken as significant. Results and Discussion: Demographic data were similar in two groups (p>0.05). The grades of the in first view at Laryngoscopy was not significantly dif ference in groups (p=0.803). The changes in glot tic view show significant dif ference between two groups (p=0.000). The improved view was 69% in pressure group and 23.8% in without pressure group (p=0.000). The changes in glot tic views was bet ter with cricoid pressure in an upward and backward direction. Conclusion(s): Use of cricoid pressure in an upward and backward direction with the thumb and forefinger on each side of cricoid cartilage, can provide the best view at laryngoscopy. It is safe and ef fective by trained anesthesiologist. These data suggest cricoid pressure particularly in an upward and backward direction, should be considered when the initial glot tic view is not adequate for intubation. References:
1. Randell T, Mt tnen M, Ky t t J. The best view at laryngoscopy using the McCoy laryngoscope with and without cricoid pressure. Anaesthesia. 1998 Jun;53(6):536-9. 2. Jabalameli M, Hashemi J, Mazoochi M. The ef fect of dif ferent Sellicks maneuver on laryngoscopic view and intubation time. Journal of Research in Medical Sciences 2005; 10 (5):285-287. 3. Brimacombe J, Berry A. Review article: Cricoid pressure. CAN I ANAESTH 1997; 44: 4: 414-425.

19AP3-3

Comparison of the Laryngeal Mask Airway SupremeTM insertion techniques: reverse insertion technique vs. standard insertion technique
Tampo A., Suzuki A., Sako S., Iwasaki H. Asahikawa Medical Universit y, Depar tment of Anaesthesiology and Intensive Care, Asahikawa, Japan Background and Goal of Study: Laryngeal Mask Airway (LMA) is widely used for routine and dif ficult airway management, and also in emergency situations. Thumb insertion is a well known technique used when the anaesthesiologist is restricted to access patients head end. The latest LMA, Supreme (SLMA), has an anatomical shaped design with holding tab so that the anesthesiologist does not need to insert an index finger along with the LMA shaf t. In addition, the insertion of the SLMA from patient side is not studied yet. Thus, we conducted the manikin study to evaluate that SLMA is also useful when the performer is restricted to standard insertion approach. In this study, we compared the utility of SLMA with standard and reverse insertion techniques. Materials and Methods: Af ter institutional approval and writ ten informed consent from participants, twenty seven anesthesiologists in our department at tempted insertion of SLMA with standard and reverse (approach from the side) insertion techniques on an airway management trainer manikin (Laerdal Medical, Stavanger, Norway). Af ter brief introduction of the device and practice for inserting the SLMA into the manikin, participant performed two insertion with dif ferent techniques. For each technique, insertion time (the time that the participant hold the device to complete the first successful ventilation),

ease of insertion (scored with verbal rating scale; VRS), were evaluated. Af ter insertion, ventilation status was evaluated. SLMA position was evaluated with the percentage of glot tic opening (POGO) score by using a fiberoptic bronchoscope to observe the vocal cord via the outlet of the SLMA air conduit. For statistical analysis, paired t-test was used and P < 0.05 is considered as significant. Data are reported as mean sd. Results and Discussion: The time for insertion showed no dif ference between both techniques (13.4 2.1 sec with the standard technique, and 13.9 2.4 sec with the reverse technique). However, the ease of insertion score was grater with the standard technique (94.4 5.4) compared to the reverse technique (87.5 11.2). The ventilation status and POGO scores were not significant between the two techniques. Conclusions: Reverse insertion technique of LMA SupremeTM is equally effective compared with standard insertion technique. This technique can be used under emergency situations that the access to the patient head end is restricted.

19AP3-5

Airway Management

233

Real-time changes of pressure-volume curve provide objective information on ef ficiency of face mask ventilation during induction of anaesthesia: an observational study
Hascilowicz T., Kiyama S., Hobo S., Ohashi Y., Yoshioka S., Uezono S. Jikei Universit y School of Medicine, Depar tment of Anaesthesiology and Intensive Care, Tok yo, Japan Background and Goal of Study: Face mask ventilation (FMV) is one of essential skills of anaesthetists. Opioids, sedatives and neuromuscular blocking agents (NMBA), as well as patient- and anaesthetist-related factors, influence ef ficiency of FMV. However, no objective methods to assess ef ficiency of FMV have been established. The purpose of the present study was to examine whether real-time visualization of pressure-volume curve (P-V curve) changes enables objective assessment of FMV during induction of anaesthesia. Materials and Methods: Ten anaesthetists (trainees and staf f-grade) ventilated lungs of 26 patients following induction of general anaesthesia. P-V curves continuously drawn on the spirometry display of Aisys Carestation (GE Healthcare, Helsinki, Finland) were video-recorded. Shape and tilt of diagonal line of P-V curves were graphically processed and analysed. Results: 1) Changes of P-V curve were easily recognised in a real-time fashion. 2) P-V curve changed significantly during FMV in 11 patients (42%). 3) P-V curve changes corresponded well with the subjective feel of easier FMV af ter administration of NMBA. 4) In patients with subjectively more dif ficult but possible FMV, shape of P-V curves showed characteristic sequential increase of tilt angle, which reflected ef fects of drugs used for induction as well as gradually improving fit ting of a face mask. Conclusion(s): Real-time observation of the P-V curve during induction of anaesthesia provides objective information on the ef ficiency of FMV. Compared to other parameters used to assess FMV ef ficiency (e.g. V Ti/V Te ratio, Pma x), P-V curve can be a visual objective proof of ease or dif ficulty of FMV.

19AP3-4

Evaluation of the LMA position using ultrasound in pediatric patients

Kim J.M., Kil H.-K. Yonsei Universit y College of Medicine, Depar tment of Anaesthesiology and Pain Medicine, Seoul, Korea, Republic of Background and Goal of Study: Although the LMA insertion is not dif ficult and the majority of cases with LMA fare well in ventilation, the fiberscopic assessment demonstrates a high incidence of LMA malpositioning. The fiberscopic grading of Rowbot tom et al. is commonly used for positioning LMA, but the rotated degree of LMA is not considered in that grading. We hypothesized that the LMA can af fect the position of the ary tenoids/thyroid cartilages and it may be detected on ultrasound. This study was designed to assess the predictability of detecting the rotated LMA according to the position change of ary tenoids/thyroid cartilages using the ultrasound. Materials and Methods: Children, aged 1 ms - 6 years, undergoing infraumbilical surgery were enrolled. Ultrasound was performed on the supraglot tic and vocal cords area before and af ter the LMA insertion. Transverse images were obtained on the end-expiratory phases. LMA-position was evaluated with Bonfils fiberscope. Position grading was made as usual. If grade >3 was showed, LMA was repositioned while observing with fiberscopy. If the face of LMA was rotated to one-side, the LMA was rotated to the opposite side a lit tle. The ultrasound findings of pre- and post-LMA were compared. On fiberscopic images, conventional LMA grade and the degree of rotation were measured. Results and Discussion: A total of 26 cases were completed in the study. In 9/26 cases, LMA was rotated to lef t or right side in a range of 10-40. In 8/9 cases, ultrasound showed asymmetrical elevation of the ary tenoids/thyroid cartilage af ter the LMA insertion.
LMA- grade II I Number 13 6 3 0 4 Rotated LMA 6 2 0 0 1 US-detectable 5 2 0 0 1

[PV cur ve changes during mask ventilation]

IV V

III

19AP3-6
Jet speed: subjective and objective review of speed at which anaesthetists can perform needle cricothyroidotomy and jet ventilation
Shonfeld A., Boynton C., Vaughan D. Nor thwick Park Hospital, Depar tment of Anaesthesiology, London, United Kingdom Background and Goal of Study: Needle cricothyroidotomy (NCTO) is an important rescue technique in cant intubate, cant ventilate scenarios [1]. NAP4 highlighted the dif ficulty in performing NCTO and lack of successful oxygenation [2]. This projects aim was to look at performance of anaesthetists of all grades in performing the procedure. Materials and Methods: We constructed a model larynx from a sheeps larynx and trachea and medical adhesive tape and gained consent from participants. We instructed the participants to perform a NCTO and at tempt to oxygenate. We then gave an example demonstration of how to perform a NCTO and use the Sanders jet ventilator. The participants were then asked to perform a NCTO and oxygenate again and the first and second times were compared. The candidates completed a questionnaire before and af ter the practical assessment. Results and Discussion: The candidates ranged from 1st year trainees to senior consultants. 20% of anaesthetists had previously performed a NCTO

[Table1. Patients characteristics]

[Sonographic findings and fiberscopic finding] Conclusion(s): Real-time ultrasound can be useful in positioning of the rotated LMA