No abstract

The PLMA is a reliable airway management device that can give an effective glottic seal in paralysed and non-paralysed patients. The device allows the easy passage of a gastric tube, causes a minimal haemodynamic response to insertion, and an acceptable incidence of sore throat.

HIV has reached pandemic proportions in Southern Africa. Great emphasis is placed on the prevention and containment of HIV transmission by suppressing virus replication using highly active anti-retroviral therapy (HAART). HAART has proven to be highly effective if taken correctly, and has lead to increased life expectancy. Increasing numbers of HIV-positive patients on antiretroviral (ARV) therapy or HIV-exposed individuals taking prophylaxis present for surgery and critical care management. The anaesthesiologist should be familiar with the anaesthetic implications of HIV as well as the possible drug interactions while on ARV treatment. This article focuses specifically on the anaesthetic implications of the patient on HAART.HAART is HIV treatment with a combination of three or more ARV drugs from five broad classes. The specific HAART regimen in use in South Africa is considered in detail in this article. The pharmacokinetics of the ARV drugs is complex, and subject to interactions at many different sites. Serious drug interactions are possible, including drugs commonly used in anaesthesia. Drug interactions and recommendations are discussed in detail.ARVs are known to cause multiple systemic side effects, including lactic acidosis, Immune Reconstitution Inflammatory Syndrome (IRIS), premature atherosclerosis and increased cardiovascular risk, hyperlipidaemia, insulin resistance, skeletal disorders, hepatotoxicity, lipodystrophy, mitochondrial abnormalities, allergic reactions and pancreatitis.Non-compliance is common, and leads to the rapid development of resistance. The anaesthesiologist may inadvertently exacerbate this in the perioperative period. Recommendations regarding the interruption of treatment and fasting are made. Alternative routes for HAART administration are also explored. The management of the critically ill patient on a HAART regimen is discussed.

Background:The re-usable Classic laryngeal mask airway (LMA ® ) is widely used. There are concerns regarding the transmission of pathogens. Disposable airway devices provide a cost-effective alternative. We performed a side by side clinical comparison of these devices applicable to the South African context. Methods:Adult ASA 1-3 patients (30 -100 kg) presenting for elective peripheral surgery in Tygerberg Academic Hospital were randomised to receive the gold standard Classic LMA ® , or one of four disposable devices. They all received a standardised anaesthetic with propofol, fentanyl and isoflurane in 40% O2/N2O. Insertion technique, mask sizes and maximum cuff volumes were per manufacturer's instructions. The cuff was inflated to achieve an adequate airway seal (no audible leak at an airway pressure of 20cm H2O), or to the maximum recommended volume. Cuff and airway pressures were measured continuously. A protocol was followed for repeated or failed attempts. 115 of the proposed 130 patients were recruited. Categorical data was analysed using Chi squared tests, and one-way ANOVA was performed on parametric data. An alpha level of 0.05 was accepted. Results:The patients were of comparable age, weight, ASA grade and airway grading. There were no statistical differences in the number of times the airway device size had to be changed (p = 0.627), ease of insertion (p = 0.357) or insertion attempts (p = 0.909). Only the Cobra PLA™ was graded as "Grade 4: impossible to establish an airway" in 10% of cases, and the insertion time with this device was prolonged (p = 0.018). The Cobra PLA™ predictably differed from the other groups in cuff volumes (p = 0.001). Cuff pressures were significantly higher in the Ambu™ and LMA Unique™ (p = 0.001). Maximum airway pressure attainable after 5 minutes was significantly higher in the Ambu™ (p = 0.036). Airway trauma as graded by visible blood on the device was low, and similar between groups (p = 0.237). Secretions were negligible in 67.8% patients and there was no difference in the amount of suctioning required (p = 0.094). Patient comfort was exceptional and comparable, achieving similar visual analogue scores for sore throat (p = 0.742), dysphagia (p = 0.760) and hoarseness (p = 0.258). No complications were noted. Conclusions:We found no difference in routine clinical practice between the Classic LMA ® , LMA Unique™, Portex Soft Seal ™, Ambu™ and Cobra PLA™ in terms of ease of insertion, number of attempts, size changes, patient comfort or airway trauma. The Ambu device allowed an airway seal at higher pressures. The Cobra devices had a prolonged average insertion time. The Cobra devices were the only ones found impossible to achieve a satisfactory airway after 3 attempts in 10% of cases, although this did not reach statistical significance.