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To compare patient controlled inhalational induction (PCI) with the most commonly used sevoflurane induction technique, vital capacity inhalational induction (VCI).Following approval of the Research Ethics Board, 124 outpatients undergoing knee arthroscopy were randomly assigned to receive either PCI or VCI sevoflurane followed by laryngeal mask airway (LMA) insertion and sevoflurane maintenance. In the PCI group, the circle circuit was not primed. The patients were asked to hold the facemask themselves and breathe normally with sevoflurane 8% in oxygen at a flow rate of 4 L x min(-1). In the VCI group, the circle circuit was primed and patients were asked to take vital capacity breaths with sevoflurane 8% at an oxygen flow rate of 8 L x min(-1). The LMA was inserted as soon as the patient's jaw was relaxed. Time from induction to LMA insertion was recorded and insertion conditions rated. The amount of sevoflurane used for LMA insertion was calculated. Vital signs were monitored at one-minute intervals until ten minutes after LMA insertion.Demographic data were comparable. There were no differences with respect to LMA insertion time (PCI - 3.4 min vs VCI - 3.3 min), laryngospasm (PCI - 7% vs VCI - 5%), mean arterial pressure, heart rate, SaO(2) as well as patient's overall satisfaction.PCI was comparable to VCI in sevoflurane induction with respect to the speed of induction, side effects during induction and patient satisfaction. However, PCI requires no special training and is widely applicable to all patient populations.

To report a non-fatal case of intraoperative venous air embolism (VAE) during an awake craniotomy. VAE presented with unusual clinical features. VAE during an awake craniotomy has not been reported frequently. The patient we describe presented with persistent coughing followed by tachypnea, hypoxia and reduction in end-tidal CO2 during dural opening while undergoing an awake craniotomy in the supine position. Cardiovascular variables were stable during the episode except for transient hypertension. Having ruled out airway obstruction and low cardiac output, we concluded that air embolism was the cause. The patient responded immediately to the standard treatment of air embolism and recovered without any complication. This case illustrates a VAE during an awake craniotomy and emphasizes the importance of early diagnosis in the management.

To the Editor: In a 65-yr-old man undergoing elective cystolithopaxy anesthesia was induced and a size 4 LMA (Intavent, Oxon, UK) inserted. At emergence, the patient bit on the LMA shaft, shearing it into two pieces (Figure). The proximal shaft outside his clenched teeth was severed. The distal shaft and the inflated LMA remaining inside the patient’s mouth. A facemask with oxygen was applied. He maintained spontaneous breathing but did not open his mouth. One minute later, his mouth opened and the LMA was removed using McGill forceps after cuff deflation. Examination of the LMA showed a spiral fracture of the distal shaft and marked yellowish discoloration of the shaft. The manufacturing date was the second quarter of 1991. Autoclaving (steam, 134°C) at our hospital conforms to the manufacturer’s recommendations.1 We estimate that this LMA had been autoclaved over 400 times. The Canadian supplier (Vitaid, Toronto) recommended the following to ensure safety:1,2 first, record each autoclaving and discard after 40 uses; second, before each use, check colour of shaft, aperture bars, competency of pilot balloon valve, competency of LMA cuff, 15 mm connector fit; third, flex the shaft 180° and observe for kinking; fourth, use a bite block. This case illustrates the potential risk of a fractured LMA due to excessive re-use. Although dramatic in presentation, the patient had no sequlae. It is important to retrieve all pieces of the fractured LMA and that none is aspirated into the lungs.

D ESPITE our extensive clinical experience, anesthesiologists still encounter unexpected difficult intubations. We need to be prepared with an organized plan such as the ASA algorithm ~s for management of the difficult airway. In a "can't intubate/can't ventilate" situation, emergency methods of oxygenation and ventilation must be rapidly available. There are many anecdotal reports of intubating 'tricks'. The ASA task force 2 and a recent review 4 recommend the general types of equipment that should be stocked on a difficult intubation kit. There are commercially available trays specifically designed for certain aspects of airway management. In a university teaching hospital department, we found it necessary to organize a comprehensive difficult intubation cart due to the preferences of different anesthesiologists. Since we do not practice pediatric anesthesia, our intubation cart is designed for adult patients. There is one clearly labeled difficult intubation cart in the operating room area and two portable kit bags. Adult and pediatric fiberoptic bronchoscopes and the BuUard laryngoscope are stored on a separate portable cart. Our purpose is not to mention all possible airway management equipment. We hope this listing will help others formulate and organize their own difficult intubation cart. It is important that anesthesiologists and trainees be familiar with the indications and limitations of these devices. Having previously thought through the steps of emergency airway management and with the equipment readily available, the anesthesiologist will be better prepared to deal efficiently with difficult airway situations. Equipment for airway management and intubation

The aim of our study was to compare the complication rate of convenional surgical and percutaneous dilational tracheostomies performed under general anaesthesia in critically ill patients. Fifty-three consecutive patients whose lungs were mechanically ventilated and who required tracheostomy were randomised to undergo either conventional surgical tracheostomy (n = 28) in the operating room or percutaneous dilational tracheostomy (n = 25) in the intensive care unit under general anaesthesia. All of the procedures were successfully completed. No deaths were related to the performance of either tracheostomy technique. Three patients in each group required a dressing change for minor bleeding at the tracheostomy site. There was no major bleeding requiring blood transfusion. One patient in each group developed atelectasis detected on chest x-ray post-operatively. In the surgical tracheostomy group, there were two patients with cuff leaks, one with a stomal infection and one with a pneumothorax. None of these complications occurred after percutaneous, dilational tracheostomy. We conclude that the low incidence of complications in both groups indicates that percutaneous dilational tracheostomy can be performed as safely in the intensive care unit with general anaesthesia as surgical tracheostomy can be performed in the operating room.