The development of Horner's syndrome during routine neuraxial anaesthesia suggests anatomic, technical or physiologic variance. Even more importantly, it warrants immediate cessation of the anaesthetic intervention.

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Background:The laryngeal mask airway (LMA) Supreme (LMAS) is a sophisticated, second-generation supraglottic airway device, with an improved seal, and gastric access. It is a capable device for use in more complex procedures and in younger children. No study has been able to analyze a large pediatric sample of patients to assess how the LMAS is being utilized. In this retrospective audit, we evaluated the use of the LMAS in routine clinical practice. In addition to this, utilization of LMAS performance test was evaluated. Methods: A retrospective audit was performed of a major tertiary children's hospital's electronic medical record database to identify all children in whom the LMAS was utilized for airway management over a two-year period. In addition to demographic data, we collected the following LMAS data: size of the LMAS, the number of insertion attempts, volume of air injected into the cuff, the cuff pressure, and the oropharyngeal leak pressure. We also recorded the performance of tests for proper position and function, the mode of lung ventilation, the use of muscle relaxants and use of any alternative airway devices. Results: The LMAS was used in 418 children accounting for only 4% of all LMA usage and only 0.6% of all usage for general anesthesia. The first-attempt placement success rate was 96.4% (382/396). Five of 418 (1.2% ) insertions were reported as failures. Mechanical ventilation was used in only 26% of cases with a vast majority (74% ) breathing spontaneously. Cuff pressure was measured in 74/418 (18% ) of cases. Oropharyngeal leak pressures were measured in 90/418 (21.5% ) cases. Maneuvers performed to verify correct placement and performance of the LMAS were rarely performed. Use of the LMAS for invasive procedures occurred in only 5 cases (1.2%). Conclusions: This study shows the LMAS to be highly successful in the hands of various cadres of anesthesia providers at a major tertiary hospital and performs reliably well. Our data reveals many areas of potential improvement for use of the LMAS in the pediatric population, as a device capable for usage in more invasive surgical procedures, younger patients, and mechanical ventilation.

Background and objectivesLimitations in manpower in health care facilities, both in civilian and military settings, can severely affect patient safety as well as overall outcomes. Regional anesthesia via neural blockade is an effective means of managing uncontrolled acute pain, which has been associated with cardiopulmonary, endocrine, immunologic, and hematologic derangement in addition to the development of potentially life-threatening coagulopathy. We have designed a remote-controlled injection device that may expedite the performance of regional nerve blocks in these situations.MethodsThis work examines how the device affects the ability of the operator to act independently with respect to various block component times by statistically comparing device-assisted blockade with usual or clinically relevant techniques. The classic or two-person technique was compared with the foot-controlled technique.ResultsThe results validated the hypothesis that the novel mechanism of performing a nerve block is not inferior to the classic technique with regard to the specified endpoints within our experimental design.ConclusionThis confirmation indicates that the use of this device may be feasible when the use of another technique could be cumbersome, or otherwise untenable.

Citation: Daryl Irving Smith, Svetlana Pyatigorskya, Nobuyuki-Hai Tran. Delay in diagnosis of vertebrobasilar insufficiency: the masking effect of headache and coexisting pain syndromes.