SummaryWe studied the i-gel TM in 100 elective, anaesthetised patients (55 : 45 male:female, median age 53 years) assessing: ease of use, airway quality, positioning, seal and complications. First insertion attempt was successful in 86 patients, second attempt in 11 patients, and third attempt in three patients. Fifty three manipulations were required in 26 patients (median 1) to achieve a clear airway. Median insertion time was 15 s. During ventilation, expired tidal volume of 7 ml.kg )1 was achieved in 96 (96%) patients. Median airway leak pressure was 24 cmH 2 O. On fibreoptic examination via the device, vocal cords were visible in 87 patients (91%). During maintenance, six patients (6%) required 12 airway manipulations. There was one episode of regurgitation, without aspiration. Other complications and patient side-effects were mild and few. The i-gel is easily and rapidly inserted, providing a reliable airway in over 90% of cases. Further studies are indicated to assess safety and performance compared to other supraglottic airway devices.

SummaryWe studied the LMA Supreme TM in 100 elective, anaesthetised, healthy patients assessing: ease of use, airway quality, anatomical and functional positioning, airway leak and complications. Insertion was successful on first, second or third attempt in 90, nine and one patient respectively. Thirty manipulations were required in 22 patients to achieve a clear airway. Median [interquartile (range)] insertion time was 18 [10-25 (5-120)] s. During ventilation, an expired tidal volume of 7 ml.kgwas achieved in all patients. Median [interquartile (range)] airway leak pressure was 24 [20-28 (13-40)] cmH 2 O. On fibreoptic examination via the device, vocal cords were visible in 83 patients (85%). During maintenance, five patients (5%) required 13 airway manipulations. There was one episode of minor regurgitation, without aspiration. Other complications and patient side-effects were mild and few. The LMA Supreme is easily and rapidly inserted, providing a reliable airway and good airway seal. Further studies are indicated to assess safety and performance compared to other supraglottic airway devices.

Our results show that continuing chest compressions has a minor effect on time for tracheal intubation and until clear human data are available the recommendation to intubate without interrupting CPR is therefore justified. The PLMA and igel (SADs with a gastric drain tube) were both faster to insert than the cLMA and offer additional benefits. They should be considered for use in CPR.

SummaryA 31-year-old female with no risk factors for cardiac disease suffered a peri-operative myocardial infarction during an elective gynaecological procedure under spinal anaesthesia. The timing and nature of cardiac symptoms suggest that the myocardial infarction was caused by coronary artery vasospasm secondary to ephedrine and ⁄ or metaraminol, which were administered to treat spinalinduced hypotension. We review the recent literature and case reports on myocardial infarction attributed to sympathomimetic drugs, and recommend the use of sublingual or intravenous nitrates when signs or symptoms of coronary arterial vasospasm become evident during their use. Spinal anaesthesia is associated with cardiovascular complications, most notably hypotension and bradycardia [1], which often necessitate the use of sympathomimetic drugs such as ephedrine and metaraminol. These agents can cause coronary artery vasospasm, which is thought to be due to their action on alpha-adrenergic receptors on large epicardial arteries [2]. There have been several case reports of myocardial injury as a result of such vasospasm [3][4][5][6]. We describe a case of myocardial infarction in a fit, healthy woman, the signs and symptoms of which were closely temporally related to the administration of ephedrine and metaraminol for spinal-induced hypotension. Case reportA 31-year-old female with a history of stress incontinence was scheduled for an elective tension-free vaginal tape (TVT) procedure under spinal anaesthesia. She had previously received epidural analgesia, with no complications, for two normal vaginal deliveries. She had no history of cardiovascular disease and no risk factors. There was no history of illicit drug use. She was fit and healthy and regularly cycled 20 miles.Prior to insertion of the spinal anaesthetic, she was given 1 l of Hartmann's solution intravenously. She was very anxious about the procedure and so was given intravenous midazolam 2 mg in 1-mg increments. Blood pressure was recorded as 120 ⁄ 72 mmHg and heart rate 74 beats.min )1 . Spinal anaesthesia was induced with 2.7 ml hyperbaric bupivacaine 0.5%. Ten minutes after induction of anaesthesia, her blood pressure fell to 105 ⁄ 65 mmHg and her heart rate to 60 beats.min. She complained of feeling faint and became pale. She was treated with intravenous ephedrine 5 mg, followed by intravenous metaraminol 1 mg. Her blood pressure rose to 180 ⁄ 120 mmHg and she developed a sinus tachycardia of 120 beats.min )1 with frequent ventricular ectopic beats. This was associated with chest tightness and anxiety. She was given a further 2 mg intravenous midazolam in 1-mg increments. After 5 min, her chest discomfort had resolved and the procedure was completed without further complication or significant blood loss. She was transferred to the recovery room.

References MethodsWe will study 100 elective patients. Ventilation will initially be controlled, without neuromuscular paralysis and performance during spontaneous ventilation will also be assessed. ResultsSo far we have studied 71 patients (male 38, median age 56 years, range 18-84, median body mass index 26 kg.m )2 , range 14-40). A size 4 i-gel was used in all patients. Placement: (n = 71). Insertion and ventilation were possible on first attempt in 62 (87%) patients, second attempt in seven (10%) and two (3%) needed three attempts. Insertion was ultimately possible in all cases, taking a median of 15 s (range 5-120) and was rated easy in 67 (94% patients) and never as difficult. Airway manoeuvres were used in 19 patients (median number of manoeuvres 0, range 0-5, total 38). Complications of insertion, other than initial failure in four patients, were restricted to coughing in three (4%) patients. The airway was clear in 70 (99%) patients, partially obstructed in one (1%) and obstructed in none. All ventilatory measures were optimal in 68 (96%) and ventilation failed in one patient because of leak (1%). Positioning: The glottis was visible via airway tube in 65 ⁄ 67 (97%). Via the drain tube mucosa was visible in 51 ⁄ 66 (77%), the upper oesophagus was visible in 14 (21%, with 64% open) and in one the drain tube appeared blocked. Median airway leak pressure was 25 cm.H 2 O. A gastric tube was successfully passed at first attempt in 67 (96%) patients. The airway was clear in 66 (94%) cases, partially obstructed in three (5%) and obstructed in one (1%). Four patients required a total of seven manipulations (all chin lift) during maintenance (median 0). Six complications occurred in five patients (7%). In one patient, marked coughing was followed by regurgitation with gastric contents vented via the drain tube. The airway was not contaminated. Emergence: (n = 70). The i-gel was assessed as well tolerated by recovery staff in 66 (94%) cases. Blood was not visible on any devices. Complications were all mild with four patients coughing and one experiencing brief mild laryngospasm. Postoperatively: (n = 70) sore throat was reported by 14 (20%) patients in recovery and six (9%) at 24 h. These symptoms were mild in > 80%. Anaesthetists rated i-gel performance excellent ⁄ good in 93-94%, fair in 3-4% and poor in 1%. ConclusionsThese initial results suggest fast and easy insertion with high first time and overall success. The i-gel provides a reliable clear airway with interventions rarely required. Airway seal is 25 cm.H 2 O; between that of the LMAclassic and LMA-ProSeal. Ventilation was effective and anatomical positioning excellent. Complications throughout anaesthesia were infrequent and mild. One case of regurgitation suggested the drain tube worked effectively preventing aspiration. The i-gel was rated easy to use by anaesthetists. Pharyngeal trauma was not seen but 15% of patients had a postoperative sore throat.Acknowledgements

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