The Proseal™ laryngeal mask airway (PLMA™, Laryngeal Mask Company, UK) was designed to improve ventilatory characteristics and offer protection against regurgitation and gastric insufflation. The PLMA is a modified laryngeal mask airway with large ventral cuff, dorsal cuff and a drain tube. These modifications improve seal around glottis and enable better ventilatory characteristics. The drain tube prevents gastric distension and offers protection against aspiration. There were occasional problems, like failed insertion and inadequate ventilation, in placing PLMA™ using the classical digital technique. To overcome these problems, newer placement techniques like thumb insertion technique, introducer tool placement and gum elastic bougie (GEB)-aided placement were devised. We compared classical digital placement of PLMA™ with gum elastic bougie-aided technique in 60 anaesthetised adult patients (with 30 patients in each group) with respect to number of attempts to successful placement, effective airway time, airway trauma during insertion, postoperative airway morbidity and haemodynamic response to insertion. The number of attempts to successful placement, airway trauma during insertion and haemodynamic response to insertion were comparable among the two groups, while effective airway time and oropharyngeal leak pressure were significantly higher in bougie- guided insertion of PLMA. Postoperatively, sore throat was more frequent with digital technique while dysphagia was more frequent with bougie guided technique. Hence gum elastic bougie guided, laryngoscope aided insertion of PLMA is an excellent alternate to classical digital technique.

Diyafram yırtığı potansiyel olarak yaşamı tehdit eden bir klinik durumdur. Karın ve göğüse yönelik yüksek basınç-lı künt veya penetran yaralanmanın bir sonucu olarak oluş-maktadır. Diyaframın akut travmatik yırtığı, gözden kaçırı-labilir ve yaralanma ile tanı arasında sıklıkla gecikme bulunur. Hepatik koruma ve sağ hemidiyafragmaya ilişkin artmış direnç nedeniyle, sağ taraflı yırtık daha az yaygındır. Bu yazıda, travmadan 72 saat sonra nefes darlığı yakınması ile hastanemize yatırılan 28 yaşındaki bir erkek olgu sunuldu. Klinik bulgu ve semptomların spesifik olmaması nedeniyle, hastanın helikal bilgisayarlı tomografisi çekildi; gö-rüntülemede hepatotoraksla birlikte diyafram yırtığı bulunduğunu gösterdi. Diyafram yırtığını onarmak üzere acil torakotomi yapıldı. Ameliyat sonrası sorunsuz geçti ve hasta üç hafta sonra taburcu edildi.Anahtar Sözcükler: Edinsel diyafragmatik fıtık; diyafram yırtığı; travma.Diaphragmatic rupture is a potentially life-threatening clinical situation. It occurs as a result of high-velocity blunt or penetrating injury to the abdomen and thorax. Acute traumatic rupture of the diaphragm may go undetected, and there is often a delay between the injury and diagnosis. Right-sided rupture is less common due to hepatic protection and increased strength of the right hemidiaphragm. We report the case of a 28-year-old man who was admitted with breathlessness to our hospital, 72 hours after trauma. Since clinical signs and symptoms were nonspecific, helical computed tomography was done, which revealed diaphragmatic rupture with hepatothorax. Emergency thoracotomy was done to repair diaphragmatic rent. The postoperative period was uneventful, and the patient was discharged three weeks later.

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Background and Aim Percutaneous nephrolithotomy (PCNL) under epidural anesthesia has been reported to have few advantages over general anesthesia, like lower postoperative pain and less need for analgesics. There are limited studies on PCNL being performed under neuraxial anesthesia in supine position. Hence the present study was conceived to compare hemodynamic parameters in patients undergoing percutaneous nephrolithotomy (PCNL) in the supine position under combined spinal-epidural with general anesthesia (GA). Material and Methods A prospective, randomized control trial was conducted among 90 patients who were posted to undergo elective percutaneous nephrolithotomy in the the supine position, after obtaining Institutional Ethical Committee (IEC) approval and CTRI (Clinical Trial Registry - India) registration. Patients were randomly allotted to undergo surgery either under general anesthesia (group GA) or combined spinal epidural anesthesia (group CSE) by computer-generated random number method. Hemodynamic parameters, postoperative analgesic requirement and incidence of blood transfusion were recorded and analyzed. Results There was no significant difference between the two groups with respect to gender, ASA grade, surgery duration, calculus size and pulse rate. There was a statistically significant reduction in mean arterial pressure from 5 to 50 minutes of surgery and less incidence of blood transfusion in patients in the CSE group. Patients who underwent PCNL in the supine position under CSE required lesser analgesics postoperatively compared to those under general anesthesia. Conclusion Combined spinal epidural analgesia can be used as an alternative to general anesthesia for patients undergoing PCNL in the supine position in view of less MAP and reduced postoperative analgesic and blood transfusion requirement.

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