Reduction of LMA intracuff pressure to less than 44 mmHg lowers the incidence of postoperative pharyngolaryngeal complications. The LMA cuff pressures should be measured routinely using manometry, and deflating the intracuff pressure to less than 44 mmHg should be recommended as anesthetic best practice.

The LMA Supreme has lower oropharyngeal leak pressures than the LMA ProSeal. The success of the first attempt insertion was higher for the LMA Supreme. The LMA Supreme is a safe, efficacious and easy-to-use disposable supraglottic airway device in elective ambulatory procedures. The higher rate of success on first attempt insertion may make it more suitable as an airway rescue device.

M anual in-line stabilization (MILS) is recommended during direct laryngoscopy and intubation in patients with known or suspected cervical spine instability. It was hypothesized that anesthesiologists would apply greater pressure during intubations with MILS than without because MILS impairs glottic visualization. Nine anesthetized and pharmacologically paralyzed patients underwent 2 sequential laryngoscopies and intubations, 1 with MILS and 1 without in random order. A transducer array along a Macintosh 3 laryngoscope blade continuously measured the pressures applied, and the glottic view was characterized. Using MILS, glottic visualization was worse in 6 patients, and failure of intubation occurred in 2 of these patients. Maximum laryngoscope pressure at best glottic view was greater with MILS than without (717 T 339 vs 363 T 121 mm Hg, respectively, n = 8). Other measures of pressure application also indicated comparable increases with MILS. Pressures applied to airway tissues by the laryngoscope blade are transmitted secondarily to the cervical spine and lead to craniocervical motion. In the presence of cervical instability, impaired glottic visualization and secondary increases in pressure application with MILS can potentially increase pathologic craniocervical motion. COMMENTCurrent Advanced Trauma Life Support standards state that MILS should be used when direct laryngoscopy (DL) and tracheal intubation are urgently needed in patients with known or suspected cervical spine instability. Manual in-line stabilization is designed to externally restrict head and neck movement, presumably minimizing pathologic cervical spine motion that might otherwise occur at unstable segments. This potential benefit is, however, counterbalanced by the unwelcome fact that MILS impedes glottic visualization.The current well-designed study sought to enroll patients who would be easy to intubate with a Macintosh 3 blade. Exclusion criteria were focused on eliminating patients who might be at increased risk of intubation-related and/or other study-related complications. Faculty anesthesiologists performing the intubations had 19 T 10 years (mean T SD) of postresidency experience, the anesthetic protocol was standardized with patients being given equipotent doses of nondepolarizing neuromuscular blocking agents, and the patient's head and neck were placed in the neutral position just before DL was performed. During each DL and intubation, anesthesiologists were told to obtain the best possible glottic view using only the laryngoscope. Manual in-line stabilization was applied; manual head and neck movement and external laryngeal manipulation (cricoid pressure) were not allowed, the rationale being to ensure that all pressures applied to the airway could be quantitated. (Because the investigators measured pressure directed against the anterior surface of a Macintosh blade, the intubators could not use external posteriorly directed pressure.) Use of an endotracheal tube stylet was also not permitted. The results disclosed that DL with...

Melatonin possesses sedative, hypnotic, analgesic, antiinflammatory, antioxidative, and chronobiotic properties that distinguish it as an attractive alternative premedicant. A qualitative systematic review of the literature concerning the perioperative use of melatonin as an anxiolytic or analgesic in adult patients was carried out using the recommended guidelines provided by the Cochrane Handbook for Systematic Reviews of Interventions. Nine of the 10 studies showed statistically significant reduction of preoperative anxiety with melatonin premedication compared with placebo. An opioid-sparing effect or reduced pain scores were evident in five studies whereas three studies were contradictory. Thus, melatonin premedication is effective in ameliorating preoperative anxiety in adults, but its analgesic effects remain controversial in the perioperative period. Additional well designed randomized controlled trials are necessary to compare melatonin premedication with other pharmacological interventions, investigate its effect on more varied surgical populations, and to delineate its optimal dosing regimen.

A 43-year-old Hispanic male without significant previous medical history was brought to emergency department for syncope following a blood draw to investigate a 40 lbs weight loss during the past 6 months associated with decreased appetite and progressive fatigue. The patient also reported a 1-month history of jaundice. On examination, he was hemodynamically stable and afebrile with pallor and diffuse jaundice but without skin rash or palpable purpura. Normal sensations and power in all extremities were evident on neurological exam. Presence of hemolytic anemia, schistocytosis, thrombocytopenia, and elevated lactate dehydrogenase (LDH) was suggestive of thrombotic thrombocytopenic purpura (TTP). However, presence of leukopenia, macrocytes, and an inadequate reticulocyte response to the degree of anemia served as initial clues to an alternative diagnosis. Two and one units of packed red blood cells were transfused on day 1 and day 3, respectively. In addition, one unit of platelets was transfused on day 2. Daily therapeutic plasma exchange (TPE) was initiated and continued until ADAMTS-13 result ruled out TTP. A low cobalamin (vitamin B12) level was evident at initial laboratory work-up and subsequent testing revealed positive intrinsic factor-blocking antibodies supporting a diagnosis of pernicious anemia with severe cobalamin deficiency. Hematological improvement was observed following vitamin B12 supplementation. The patient was discharged and markedly improved on day 9 with outpatient follow-up for cobalamin supplementation.

Anemia of chronic kidney disease (CKD) is common and is associated with diminished quality of life, cognitive impairment, cardiovascular morbidity, hospitalizations, and mortality. As the prevalence of end-stage renal disease continues to rise, the management of anemia represents a growing economic burden. Erythropoiesis-stimulating agents (ESA) are the mainstay of anemia management but their use is limited due to the associated cardiovascular adverse events. Prolyl hydroxylase domain enzyme (PHD) inhibitors are a new class of drugs that stabilize the hypoxia-inducible factors and are under clinical investigation for the treatment of renal anemia. The advantages of PHD inhibitors include the oral route of administration, improved iron profile, restoration of diurnal rhythm of erythropoietin secretion, and endogenous erythropoietin production near physiological range. Emerging but limited data indicates a small blood pressure lowering effect of PHD inhibitors. The effect of PHD inhibitors on cardiovascular endpoints and the potential risks of CKD progression and pulmonary hypertension remains to be addressed in the ongoing clinical trials.

Cinacalcet is the first Food and Drug Administration-approved calcimimetic for the treatment of secondary hyperparathyroidism in dialysis patients. It is effective in improving control of parathyroid hormone, serum calcium, phosphorus, and calcium-phosphorus product. The calcium-lowering effect of cinacalcet overcomes the limitations of standard therapy associated hypercalcemia. There is evidence to suggest that cinacalcet has important clinical implications, which extend beyond its relevance in the treatment of secondary hyperparathyroidism. This review summarizes the evidence regarding the role of cinacalcet in the treatment of secondary hyperparathyroidism, disrupted bone mineral metabolism, cardiovascular disease, and mortality. In addition, the cost implications of cinacalcet are briefly explored.

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