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We read with great interest the article published by Rossi et al., entitled “Safety aspects of desflurane anesthesia and laryngeal mask airway.”1 We would like to comment on the patient-related factors limiting laryngeal mask airway (LMA) usage. LMA is usually used in children under 15 years of age and is proven to be safe and effective. Actually, there is a growing interest in its use in association with desflurane. Despite desflurane is less commonly used in this range of population, recent studies reported a relative safe use of this halogenated also in children whose airways were supported with laryngeal mask. For example, Lerman et al. report a frequency of airway events with desflurane similar to those with isoflurane after LMA removal with an awake patient.2 Furthermore, the difference in events removing LMA in awake patients or deep anesthesia is similar in desflurane and sevoflurane use.3 Lastly, in our experience, the safe LMA profile together with desflurane pharmacokinetic, permits to perform anesthesia in young patients undergoing orthopedic surgery also in association with loco-regional analgesia. Second-generation supraglottic airway devices have contributed to the increase in LMA use, therefore these show that obesity is not a factor limiting its use. A Cochrane Review published in 2013 reported a failure positioning LMA rate of 3% to 5% in obese patients but also a good oxygenation with this device.4 According to 2011 NAP4, the limitation regarding LMA use in obese patients includes patients whose surgery was performed in the lithotomy position and/or head down position.5 In addition, in a group of “cervical disorder” like neck flexing difficulty, we suppose that, with caution and surgery related possibilities, LMA can prevent difficulties during intubation and also results as ventilation device bridging to the orotracheal intubation when it is mandatory. In conclusion, we want to congratulate the authors for a clear and well written paper. However

1118 Minerva Anestesiologica N November 2017 I n this issue of Minerva Anestesiologica, Brumby et al.8 report an observational pilot study assessing the incidence of failure to recover at day 1 and in subsequent days and weeks after either colonoscopy, gastroscopy, or both procedures combined in 102 patients of over the age of 18 years. Recovery was evaluated not only using physiologic endpoints but also evaluating other aspects such as nociception, emotion, activities of daily living (ADL), and cognition on the following day as well as over a 1-month follow-up period using the multidimensional Postoperative Quality of Recovery Scale (PostopQRS ). All the patients received total intravenous anesthesia with propofol alone or in combination with opioids. Some participants received midazolam or opioids in the pre-operative period. The authors have seen that incomplete recovery is common after colonoscopy, gastroscopy or both procedures. Failure to recover was mainly due to failure in nociceptive and cognitive recovery at day 1 with modest but clinically important differences in early quality of recovery between the procedures. C orrectly, the authors underline that recovery after endoscopic procedures should be defined by a multidimensional tool able to assess emotive, functional and cognitive domains. T his is particularly important because the patients must be discharged as soon as possible and should return to preoperative levels of independency in activities of daily living. Anesthesia demand for colonoscopy and gastroscopy is increasing each year and this is due to need of diagnostic or screening programs and therapeutic management of acute pathologies or neoplastic diseases. Because of the air or CO 2 insufflation for adequate distention and visualization of the gastrointestinal lumen, the endoscopic procedures are associated with significant pain and discomfort, therefore sedation is often required to improve patient tolerance and safety.1, 2 Propofol alone or c

A. Cardone, E. Congedo, P, Aceto, R. Sicuranza, E. Chinè, F. Caliandro, G. De Cosmo Ann.Ital.Chir 2007; Vol. 78 / 5 – pag. 359-366 Myasthenia gravis (MG) is the prototype of antibody mediated autoimmune disease and results from the production of autoantibodies against the acetylcholine receptor (AChR) of the neuromuscular synapse. Adequate preoperative evaluation of the myasthenic patient must be carried out carefully. Age, sex, onset and duration of the disease as well as the presence of thymoma may determine the response to thymectomy. Specific attention should be paid to voluntary and respiratory muscle strength. The preoperative preparation of MG patients is essential for the success of surgery. It depends on the severity of clinical status and changes if myasthenic patients receive anticholinesterase therapy. Myasthenic patients may have little respiratory reserve, and hence depressant drugs for preoperative premedication should be used with caution and avoided in patients with bulbar symptoms. The anaesthetic management of myasthenic patient must be individualized in according to the severity of the disease and the type of surgery required. The use of regional or local anaesthesia seems warranted whenever possible. General anaesthesia can be performed safely when patient is optimally prepared and neuromuscular transmission is adequately monitored during and after surgery. Adequate postoperative pain control, pulmonary toilet, and avoidance of drugs that interfere with neuromuscular transmission will facilitate tracheal extubation. Myasthenia gravis is a disease with many implications for the safe administration of anaesthesia. The potential for respiratory compromise in these patients requires the anaesthesiologist to be familiar with the underlying disease state, as well as the interaction of anaesthetic and non-anaesthetic drugs with MG.