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Resumo Justificativa A intubacao guiada por fibra optica (IGFO) atraves de dispositivo supraglotico (DSG) tem sido descrita como um procedimento seguro e facil para o manejo de via aerea dificil. No entanto, a visibilizacao da abertura da glote e essencial para a IGFO. Varios DSGs diferentes estao comercialmente disponiveis e podem oferecer diferentes condicoes para a IGFO. O objetivo deste estudo foi comparar a melhor visao obtida da abertura da glote com o uso de diferentes DSGs. Metodos Com a aprovacao do Comite de Etica local, 52 pacientes adultos submetidos a anestesia eletiva foram randomicamente designados para um dos DSGs: tubo laringeo (TL), mascara laringea (ML) I‐Gel, ML Unique, ML Supreme, ML AuraOnce. Apos a inducao padronizada da anestesia, o DSG foi colocado de acordo com as recomendacoes do fabricante. Apos ventilacao bem‐sucedida, a posicao do DSG em relacao a abertura da glote foi examinada com um endoscopio flexivel. Uma abertura da glote total ou parcialmente visivel foi considerada como adequada para a IGFO. A adequacao para a IGFO foi comparada entre os grupos (teste‐H, teste‐U; p Resultados Os dados demograficos nao foram diferentes entre os grupos. A colocacao do DSG e a ventilacao adequada foram bem‐sucedidas em todas as tentativas. A visao da glote adequada para a IGFO diferiu entre os dispositivos, variou de 40% para o TL, 66% para a ML Supreme, 70% para a ML I‐Gel e 90% para ambas as mascaras laringeas Unique e AuraOnce. Conclusao Nenhum dos DSG usados ofereceu uma visao total ou parcial da glote em todos os casos. Porem, as mascaras laringeas Unique e AuraOnce pareceram mais adequadas para a IGFO em comparacao com os outros dispositivos.

Previous and more recent studies show that cholinesterase inhibitors (ChE-Is) are an important possibility for therapeutic intervention in Alzheimer's Disease, sepsis and other inflammatory syndromes. ChE-Is maintain high levels of acetylcholine (ACh) determining beneficial effects on the disease process. Despite numerous efforts to identify the appropriate choice of agents and dose of ChE-Is, a common protocol regarding concentration- and species-dependent differences in inhibitory potency (IC 50) of clinical relevant ChE-Is is still not available. To evaluate the in vitro sensitivity of Acetyl- and Butyrylcholinesterase (AChE, BChE), we compared the concentration-response effects of physostigmine and neostigmine on cholinesterases in whole blood from rat and human. A spectrophotometrical test system based on in vitro Ellman's reagent has been used to determine the kinetic properties of clinical relevant ChE-Is. In vitro, the enzyme activity of human AChE and BChE was inhibited in a concentration-dependent manner until a residual activity of 4-6% for AChE and 20-30% for BChE (IC 50 human AChE: 0.117 ± 0.007 μM physostigmine, 0.062 ± 0.003 μM neostigmine; IC 50 human BChE: 0.373 ± 0.089 μM neostigmine; 0.059 ± 0.012 μM physostigmine). The inhibition curve of rat BChE in contrast showed no concentration-dependency for physostigmine and neostigmine (87% residual activity even at high inhibitor concentrations). Rat AChE was inhibited in a concentration-dependent manner until a residual activity of 53%. The results suggest that cholinesterases from human and rat show marked species- and inhibitor-dependent differences in sensitivity to physostigmine and neostigmine. Knowledge of such differences may be critical in assessing the possible therapeutic effects of ChE-Is in both species and may guide researchers in the optimal design of future experiments regarding the application of ChE-Is.

Ketamine and its stereoisomer S(+)-ketamine are widely used for sedation in pediatric anesthesia and intensive care medicine. Numerous experimental studies indicate that ketamine is potentially toxic to the developing brain. Here, we examined the long-term effects of NMDA receptor blockade on NMDA receptor subunit expression, alterations in neuronal Ca(2+)-oscillations and apoptosis. Hippocampal neurons, 15 days in culture, were exposed to either S(+)-ketamine or the NMDA receptor blocker MK801 for 24h. Cytosolic Ca(2+)-concentration was determined by fluorescence microscopy and the expression of the NMDA subunits NR1, NR2A and 2B was assessed by qRT-PCR, whereas Western blots and activated Caspase-3 served to measure the extent of apoptosis. Long-term incubation with MK801 or higher doses of S(+)-ketamine resulted in a dose-dependent decreased ability of MK801 to reduce amplitude and frequency of the Ca(2+)-oscillations 15min following washout of the drug. This was accompanied by an increase in NR1 mRNA but not the NR2A and B subunit expression at the same time point. 24h following washout of the specific drug, a significant elevation of the pro-apoptotic marker BAX, as well as activated Caspase-3 positive neurons, could be detected in cultures exposed to 100μM MK801 and 25μM S(+)-ketamine. Here, we show that long-term blockade of the NMDA receptor in developing rat hippocampal neurons significantly increased NR1 subunit expression, and that this was associated with an alteration in neuronal activity. Apoptosis was only induced 24h after withdrawal of long-term blockade for high doses of S(+)-ketamine.

Background The use of lipid emulsions to reduce cardiac toxicity of local anaesthetics (LAs) has shown success in experimental studies and some clinical cases, and thus has been implemented in clinical practice. However, lipid treatment is usually given after the occurrence of neurological or cardiovascular symptoms of systemic intoxication. The aim of this study was to determine if pretreatment with lipid emulsion reduces cardiac toxicity produced by bupivacaine or mepivacaine. Methods Isolated rat hearts were perfused with or without lipid emulsion (0.25 ml kg −1 min −1 ) before administration of equipotent doses of bupivacaine (250 µM) or mepivacaine (1000 µM). Haemodynamic parameters and times from start of perfusion LA to a 1 min period of asystole and recovery were determined. Results Pretreatment with lipid emulsion extended the time until occurrence of asystole and decreased times to recovery in bupivacaine-induced cardiac toxicity but not in mepivacaine-induced cardiac toxicity compared with control. Lipid pretreatment impaired rate–pressure product recovery in mepivacaine-intoxicated hearts. Conclusions This study confirms that pretreatment with a lipid emulsion reduces cardiac toxicity of LAs. The efficacy of pretreatment with lipid emulsion was LA-dependent, so pharmacokinetic properties, such as lipophilicity, might influence the effects of lipid emulsion pretreatment.

Cholinesterase inhibitors (Ch-I) improve survival in experimental sepsis consistent with activation of the cholinergic-anti-inflammatory-pathway. So far, less is known about whether Ch-I have a direct immunomodulatory effect on immune cells (polymorphonuclear neutrophils, PMN) in the absence of cholinergic neurons. We investigated the concentration-response-effects of physostigmine and neostigmine on the oxidative burst activity (human and rat PMN) and the expression of adhesion molecules on the surface of human PMN under in vitro conditions.PMN from 10 healthy humans or 10 rats were pretreated with 2, 10, 24, 97 μM physostigmine or 3, 15, 30, 150 μM neostigmine, primed with tumor-necrosis-factor-alpha (TNF-alpha) followed by stimulation with n-formyl-methionyl-leucylphenylalanine (fMLP) or stimulated with phorbol-12-myristate-13-acetate (PMA). Human and rat samples were assessed by flow cytometry for the generation of oxidative free radicals. Stimulated human PMN were additionally incubated with antibodies against Mac-1 (CD11b) or L-selectin (CD62l).Physostigmine and neostigmine did not alter oxidative burst activity or the expression of adhesion molecules of PMN induced by receptor-dependent activators like fMLP or TNF-alpha/fMLP (rat and human PMN, p=n.s.). Physostigmine, but not neostigmine, inhibited the protein-kinase-C-mediated oxidative burst activity by PMA in a dose-dependent manner (rat and human PMN, p0.05). Physostigmine, in the concentration range tested, suppressed the expression of CD11b following stimulation with PMA not significantly (human PMN: control: 63.1±10.7 vs. 97 μM physostigmine: 49.9±12.8 MESF, p=n.s.).While neostigmine has no effect on functional and phenotypic changes of PMN, the lipid soluble Ch-I physostigmine causes a dose dependent reduction in PMA-induced oxidative burst, independent of neuronal released acetylcholine.

Background The efficiency of cardiopulmonary resuscitation (CPR) training is dependent upon different influencing factors, such as the presented concepts, the participants' willingness to learn, and the interval between training sessions. However, the optimal interval for refreshing CPR training is less clear. Objective We evaluated the perceived need of simulator-based CPR training for nurses and correlated it with their clinical experience. Methods The 60 invited nurses were trained in simulator-based CPR. Knowledge about adult advanced life support was evaluated using a questionnaire after training, and participants rated their desired individual frequency of simulator-based training as well as the value of the presented training using a six-point Likert scale. The same questions were asked again after 1 year. Results All participants agreed about the usefulness of this type of simulator-based training. The average number of correct answers about typical facts in adult advanced life support showed an almost bell-shaped distribution, with the highest point at 6–15 years of clinical experience and the lowest points at≤5 and≥21 years. The desired training-frequency need was inversely correlated with clinical experience. Conclusions There is a high interest in CPR training among nursing staff. Self-assessment about the training-frequency need was inversely correlated with clinical experience. However, the average number of correct answers on resuscitation questions decreased with clinical experience. Therefore, the training effectiveness seems to be extremely dependent on clinical experience, and therefore, training experienced senior nurses might be more challenging than training novice nurses.

The incidence of posttraumatic acute lung injury is high and may result in increased mortality. Changes in the body position are additional measures to improve pulmonary gas exchange and to prevent pulmonary complications. We investigated the effect of a continuous lateral rotational therapy (CLRT) on the inflammatory response in patients with posttraumatic lung failure.After admission to the intensive care unit (ICU) and after randomisation, 13 patients were placed in a special motor-driven bed and CLRT was performed for 5 days. In the control group (n=14), patients were positioned conventionally. Samples from blood and from broncho-alveolar lavage fluid (BAL) were collected in both groups before study began and on day 5. The levels of cytokines (Tumour Necrosis Factor, Interleukin 6, Interleukin 8 or Intercellular Adhesion Molecule-1) were assessed and haemodynamic, pulmonary, and laboratory values were documented.On day 5, no significant differences were found in cytokine levels between groups, but a significant decrease in IL-8 (p0.01) and TNF-α (p0.05) serum levels and an increase in IL-8 BAL levels was found in the CLRT-group, but not for conventionally managed patients. In general cytokine BAL levels tended to be increased in both groups, but more pronounced during CLRT. Daily assessment of the severity of disease (SAPS-II, SOFA) was significantly reduced in the study group on days 2-4 (p0.05) in comparison to control group.CLRT may attenuate the inflammatory response to posttraumatic acute lung injury. The exact mechanism of such an effect is unknown.

The authors' intention was to evaluate the incidence of the three subtypes of delirium, the risk factors of the subtypes in cardiac surgery, and the impact of the subtypes on clinical outcomes.A prospective study.A university hospital.A total population of 506 patients undergoing cardiac surgery was screened for delirium.None.Patients undergoing cardiac surgery were screened by using the Intensive Care Delirium Screening Checklist (ICDSC) and the Richmond Agitation and Sedation Scale (RASS). Patients with hypoactive delirium were compared with nondelirious patients. Outcomes measured were the duration of mechanical ventilation and the length of stay in the intensive care unit. The overall delirium incidence was 11.6%, whereas the incidence of the hypoactive subtype was 9%. Age (odds ratio [OR] 1.04; 95% confidence interval [CI], 1.01-1.09, p = 0.02), a history of depression (OR = 3.57; 95% CI, 1.04-10.74; p = 0.03), preoperative therapy with diuretics (OR = 2.85; 95% CI, 1.36-6.35; p0.01), aortic clamping times (OR = 1.01; 95% CI, 1.00-1.02; p0.01) and blood transfusions (OR = 1.18; 95% CI, 1.05-1.34; p0.01) were predictors for the development of hypoactive delirium. Preoperative therapy with β-blockers (OR = 0.32; 95% CI, 0.16-0.65; p0.01) and higher hemoglobin before surgery (OR = 0.73; 95% CI, 0.60-0.91; p0.01) were associated with a lower prevalence of hypoactive delirium. Hypoactive delirium is an independent predictor for prolonged mechanical ventilation time (OR = 1.56; 95% CI, 1.25-1.92; p0.01) and the length of stay in the ICU (OR = 1.42; 95% CI, 1.22-1.65, p0.01).Hypoactive delirium itself is a strong predictor for a longer ICU stay and a prolonged period of mechanical ventilation. Some of the risk factors related to the intraoperative and postoperative setting are suitable for preventive action.

Objectives Malignant hyperthermia susceptibility is an important risk factor during general anesthesia. Affected patients have an asymptomatic but potentially lethal hypermetabolic reaction after contact with volatile anesthetics or succinylcholine. Classic symptoms include hemodynamic instability, combined with acidosis, rigor, and hyperthermia. During cardiopulmonary bypass, these signs may be obscured, delaying correct diagnosis and lifesaving treatment. Malignant hyperthermia–susceptible individuals are more sensitive to heat and stress, so rewarming and catecholamine administration may trigger an episode, necessitating prophylactic measures. Methods This systematic review identified typical malignant hyperthermia symptoms during cardiopulmonary bypass and investigated other factors in cardiac surgery that might trigger an episode in susceptible individuals. Approaches used to treat and prevent malignant hyperthermia during cardiopulmonary bypass were systematically analyzed. We conducted a systematic search for reports about malignant hyperthermia and cardiopulmonary bypass. Search terms included malignant hyperthermia and cardiopulmonary bypass, extracorporeal circulation, or cardiac surgery. Results We found 24 case reports and case series including details of 26 patients. In 14 cases, malignant hyperthermia crises during or shortly after cardiopulmonary bypass were described. Fourteen reports discussed prevention of an episode. Early symptoms of a malignant hyperthermia episode include excessive carbon dioxide production and metabolic acidosis. Massively increased creatine kinase levels are a strong indicator of a malignant hyperthermia reaction. Rewarming is associated with development of clinical signs of malignant hyperthermia. Conclusions In potentially susceptible patients, apart from avoiding classic trigger substances, aggressive rewarming should not be applied. Hemodynamic instability in conjunction with the described symptoms should result in a diagnostic algorithm.

Aim of the study Death to trauma is caused by disastrous injuries on scene, bleeding shock or acute respiratory failure (ARDS) induced by trauma and massive blood transfusion. Extracorporeal membrane oxygenation (ECMO) can be effective in severe cardiopulmonary failure, but preexisting bleeding is still a contraindication for its use. We report our first experiences in application of initially heparin-free ECMO in severe trauma patients with resistant cardiopulmonary failure and coexisting bleeding shock retrospectively and describe blood coagulation management on ECMO. Methods From June 2006 to June 2009 we treated adult trauma patients ( n =10, mean age: 32±14 years, mean ISS score 73±4) with percutaneous veno-venous (v-v) ECMO for pulmonary failure ( n =7) and with veno-arterial (v-a) ECMO in cardiopulmonary failure ( n =3). Diagnosis included polytrauma ( n =9) and open chest trauma ( n =1). We used a new miniaturised ECMO device (PLS-Set, MAQUET Cardiopulmonary AG, Hechingen, Germany) and performed initially heparin-free ECMO. Results Prior to ECMO median oxygenation ratio (OR) was 47 (36–90) mmHg, median paCO 2 was 67 (36–89) mmHg and median norepinephrine demand was 3.0 (1.0–13.5) mg/h. Cardiopulmonary failure was treated effectively with ECMO and systemic gas exchange and blood flow improved rapidly within 2 h on ECMO in all patients (median OR 69 (52–263) mmHg, median paCO 2 41 (22–85) mmHg. 60% of our patients had recovered completely. Conclusions Initially heparin-free ECMO support can improve therapy and outcome even in disastrous trauma patients with coexisting bleeding shock.

Zusammenfassung Hintergrund In Deutschland ermoglichen spezialisierte ambulante “Palliative Care Teams” (PCT) nur in Ausnahmefallen eine Betreuung padiatrischer Palliativpatienten in hauslicher Umgebung. Gerade in der weit fortgeschrittenen Krankheitsphase konnen jedoch vermehrt Akutsituationen als Folge der Grunderkrankung auftreten. Diese machen eine rasche therapeutische Unterstutzung notwendig. Ziel der Arbeit war eine Evaluation der Bedeutung einer notfallmedizinischen Versorgung von padiatrischen Palliativpatienten im weit fortgeschrittenen Erkrankungsstadium. Weiterhin wird die besondere Belastungssituation fur notfallmedizinisches Personal im Umgang mit sterbenden Kindern dargestellt. Anhand der Ergebnisse werden Moglichkeiten zur Struktur-, Prozess- und Ergebnisqualitat dargestellt. Methoden An vier Notarztstandorten wurden anhand der standardisierten Einsatzprotokolle retrospektiv und multizentrisch alle padiatrischen Notfalleinsatze innerhalb eines Zeitraumes von 24 Monaten untersucht. Es wurden retrospektiv alle Einsatzdaten ausgewertet, die palliativmedizinisch motivierte Akutsituationen bei padiatrischen Patienten bis zu einem Alter von 14 Jahren betrafen. Ergebnisse Es konnten insgesamt 738 padiatrische Patienten (5,7% aller Einsatze) der definierten Altersgruppe aufgrund einer notarztlichen Versorgung integriert werden. Hiervon betrafen zwei Einsatze bei padiatrischen Palliativpatienten (0,3%) im weit fortgeschrittenen Erkrankungsstadium. Beide Patienten wurden nicht durch ein PCT betreut. Schlussfolgerung Die notarztlichen Einsatzhaufigkeiten verdeutlichen, dass palliativmedizinische Fragestellungen bei Kindern und Jugendlichen in der Notfallmedizin eher die Ausnahme darstellen. Es ist aber auch bei diesen Patienten im weit fortgeschrittenen Krankheitsstadium trotz notarztlicher Alarmierung haufig ein palliativmedizinischer Therapieansatz notwendig und sinnvoll. Im Rahmen einer Qualitatsoptimierung sollten spezialisierte PCT in die spezialisierte ambulante Behandlung der Patienten und ihrer Eltern fruhzeitig integriert werden, um eine optimale Versorgung zu gewahrleisten. Fur das notfallmedizinische Personal sind nach Einsatzen mit sterbenden Kindern besondere psychologische Hilfen sinnvoll und mussen entsprechend angeboten werden.

Septic shock (SS) has recently been identified as stimulus of N-terminal pro-brain natriuretic peptide (NT-proBNP) release. We tested whether SS mediates NT-proBNP release through cardiomyocyte necrosis. Moreover, the discriminative value of NT-proBNP for the distinction between SS and non-septic shock (NSS) was assessed.The study included 50 ICU patients with SS (n=25) and NSS (n=25), 40 patients with acute coronary syndrome and elevated troponin-I (ACStrop+) and 16 patients with unstable angina and normal troponin-I (UAtrop-). Eleven subjects without inflammation or cardiac disease served as controls. NT-proBNP levels of coronary patients were measured on admission, those of ICU patients 48 h after onset of shock symptoms.ACStrop+ (1525 [25th-75th percentile: 790-3820] pg/L) and NSS (687 [254-1552]) patients showed increased NT-proBNP levels above those of UAtrop- patients (107 [43-450], p0.001) and controls (52 [42-99], p0.001), but SS patients exhibited still higher levels (11,335 [4716-25,769], p0.001 vs all others). Among ICU patients with shock symptoms, NT-proBNP discriminated SS and NSS with high sensitivity and specificity (area under ROC curve: 0.946 [95% confidence interval, 0.872-1.019]). NT-proBNP correlated with troponin-I, as marker of cardiomyocyte damage, among ACStrop+ (p0.001) and SS patients (p=0.013). But, whereas SS patients showed the greatest NT-proBNP values, ACStrop+ patients had higher troponin-I levels (p0.001), suggesting different mechanisms by which myocardial ischemia and SS mediate NT-proBNP release.SS is a more potent stimulus of NT-proBNP release than myocardial ischemia. NT-proBNP reliably distinguishes SS from other forms of shock. SS-related NT-proBNP release appears to involve cardiomyocyte damage but not genuine cardiomyocyte necrosis.

Cor triatriatum sinister is a rare congenital anomaly accounting for 0.1% of all congenital cardiac malformations. An incomplete incorporation of the common pulmonary vein into the left atrium is considered to be the cause of the disease. Fewer than 250 cases have been reported in the literature [Alphonso N, Norgaard MA, Newcomb A, d’Udekem Y, Brizard CR, Cochrane A. Cor triatriatum: presentation, diagnosis and long-term surgical results. Ann Thorac Surg 2005;80:1666–71], approximately 50 cases in adults [Modi KA, Senthilkumar A, Kiel E, Reddy PC. Diagnosis and surgical correction of cor triatriatum in an adult: combined use of transesophageal and contrast echocardiography, and a review of literature. Echocardiography 2006;23:506–9]. Although rare, the malformation is important to recognize because it may be easily correctable with good long-term surgical results [1]. We present the most relevant images of a woman with a classical cor triatriatum and discuss the different imaging modalities (first table of this paper).

ObjectiveThe Ross procedure has gained increasing interest as an attractive alternative for aortic valve replacement. Despite its advantages, there is a certain risk of structural valve deterioration, especially of the pulmonary homograft as a result of shrinkage and subsequent stenosis predominantly at the muscular annulus. Theoretically, reduction of homograft muscle tissue could reduce this risk.MethodsFrom February 1996 through December 2002, a total of 238 patients (mean age 44 ± 13.2 years) underwent the Ross procedure with the subcoronary technique with follow-up investigations before discharge and after 12 and 24 months. To estimate the importance of homograft muscle reduction within our institution-specific risk factor scale for change of transhomograft pressure gradient with time, we performed a generalized estimating equation approach, which identified homograft muscle reduction, higher body surface area in male patients, younger patient age, smaller homograft diameter, blood transfusions, and follow-up time as independent risk factors demonstrating a high β value (−2.8638) for muscle reduction. To find out whether muscle reduction influences transhomograft pressure gradient, we compared patients with (group A, n = 39) and without (group B, n = 199) muscle reduction. The other mentioned independent risk factors were not different between groups, except for blood transfusions (group A greater than B, P < .01), indicating a negative bias for group A.ResultsThe maximum pressure gradient across the homograft was lower in patients with muscle reduction before discharge (4.5 ± 2.8 mm Hg group A vs 6.2 ± 3.8 mm Hg group B, P = .004) and after 1 (9.3 ± 5.8 vs 13.1 ± 8.4 mm Hg, P = .028) and 2 years (10.8 ± 7.6 vs 13.7 ± 7.5 mm Hg, P = .013). No significant differences were found concerning homograft insufficiency.ConclusionsWe provide some evidence that transhomograft pressure gradient can be reduced significantly within the first 2 years after operation by homograft muscle reduction. Longer term follow-up is necessary to evaluate this promising operative technique further.

The aim of this study was to examine the effect of initial hyperkalemic reperfusion (HKR), with and without added adenosine, on coronary flow, myocardial function, and endothelium-dependent and endothelium-independent coronary vascular function. Cardioplegic arrest was induced in 40 isolated guinea pig hearts by infusing oxygenated cardioplegic (high in potassium ion) Krebs solution for 5 minutes. Hearts were then stored at room temperature for 3.5 hours. On reperfusion, hearts were divided into four groups of 10 hearts each: control, reperfusion with regular Krebs solution (4.6 mmol/L potassium chloride); base hyperkalemic reperfusion, initial reperfusion with 37º C oxygenated, cardioplegic Krebs solution for 5 minutes; hyperkalemic reperfusion with addition of 1 mmol/L adenosine during HKR; and hyperkalemic reperfusion with addition of 5 mmol/L adenosine. Coronary reserve (adenosine bolus 2 mmol/L) and responses to acetylcholine (1 μmol/L) and nitroprusside (100 μmol/L) were examined before and after ischemia and reperfusion. Flow did not return to preischemic values in any group after reperfusion. Adenosine treatment during initial reperfusion increased coronary flow (percentage of baseline ± standard error of the mean) from 57% ± 4% in control and 45% ± 3% in hearts with hyperkalemic reperfusion to 79% ± 3% and 83% ± 5% in hearts with hyperkalemic reperfusion also treated with, respectively, 1 mmol/L adenosine and 5 mmol/L adenosine ( p < 0.05). At 30 and 60 minutes of reperfusion, however, flow remained elevated only in the group treated with 5 mmol/L adenosine. Coronary reserve and responses to acetylcholine and nitroprusside were equivalently depressed in all groups after reperfusion. Recovery of left ventricular systolic and diastolic function was improved in all groups after hyperkalemic reperfusion (54% ± 4% of preischemic value) compared with control (39% ± 3%), and recovery was further enhanced in the group treated with 5 mmol/L adenosine (60% ± 4%). In this ex vivo model, hyperkalemic reperfusion improved myocardial function after cardioplegic arrest and the addition of 5 mmol/L adenosine improved coronary flow. Adenosine may counteract the potassium chloride–induced vasoconstriction that occurs during hyperkalemic reperfusion and may thus improve coronary flow and myocardial function. Postischemic depression of endothelium-dependent or endothelium-independent vascular functions, however, was not alleviated by hyperkalemic reperfusion with or without adenosine. (J T HORAC CARDIOVASC SURG 1996;111:74-84)

Background: Since March 2007, a new disposable Laryngeal Mask Airway has become available. The LMA SupremeTM (LMA-S) aims to combine the LMA Fastrach'sTM feature of easy insertion with the gastric access and high oropharyngeal leak pressures (OLP) of the LMA ProSealTM (PLMA). Methods:We performed an evaluative study with LMA-S size 4 on 100 female patients to measure the ease of insertion, to determine the laryngeal fit by fiberoptic classification, to evaluate the OLP, and to report adverse events. Results: Insertion of the LMA-S was possible in 94 (94.0%) patients during the first attempt and in the remaining five (5.0%) during the second attempt. In one small patient, LMA-S could not be inserted due to limited pharyngeal space. This patient was excluded from further analysis. Insertion of a gastric tube was possible in all patients at the first attempt. Mean time for LMA-S insertion was 12.8 (8-30 ±4.7) seconds. Laryngeal fit evaluated by fiberscopic view was rated as optimal in all patients, both immediately after insertion of the LMA-S and at the end of surgery. After equalization to room pressure, mean cuff volume needed to achieve 60 cmH2O cuff pressure was 18.4 (8-31 ±3.8) mL. Mean OLP at the level of 60 cmH2O cuff pressure was 28.1 (21-35 ±3.8) cmH2O. Eight (8.1%) patients complained of a mild sore throat. No patient reported dysphagia or dysphonia. Conclusions: Clinical evaluation of LMA-S showed easy insertion, optimal laryngeal fit, and low airway morbidity. OLP results were comparable to earlier data from PLMA.