SummaryWe compared the efficacy of the inflatable cuff of the LMA Supreme TM against the non-inflatable i-gel TM cuff in providing an adequate seal for laparoscopic surgery in the Trendelenburg position in 100 female patients. There was no difference in our primary outcome, oropharyngeal leak pressure, between the LMA Supreme and the i-gel (mean (SD) 26.4 (5.1) vs 25.0 (5.7) cmH 2 O, respectively; p = 0.18). Forty-seven (94%) LMA Supremes and 48 (96%) i-gels were successfully inserted on the first attempt, with similar ease, and comparable times to the first capnograph trace (mean (SD) 14.3 (4.7) s for the LMA Supreme vs 15.4 (8.2) s for the i-gel; p = 0.4). Gastric tube insertion was easier and achieved more quickly with the LMA Supreme vs the i-gel (9.0 (2.5) s vs 15.1 (7.3) s, respectively; p < 0.001). After creation of the pneumoperitoneum, there was a smaller difference between expired and inspired tidal volumes with the LMA Supreme (21.5 (15.2) ml) than with the i-gel (31.2 (23.5) ml; p = 0.009). There was blood on removal of two LMA Supremes and one i-gel. Four patients in the LMA Supreme group and one patient in the i-gel group experienced mild postoperative sore throat.

AimThe aim of this study was to investigate the role of peripartum analgesic and psychological factors that may be related to postpartum depression (PPD).MethodsThis case–control study was conducted in pregnant females who delivered at KK Women’s and Children’s Hospital from November 2010 to October 2013 and had postpartum psychological assessment. Demographic, medical, and postpartum psychological status assessments, intrapartum data including method of induction of labor, mode of labor analgesia, duration of first and second stages of labor, mode of delivery, and pain intensity on hospital admission and after delivery were collected. PPD was assessed using the Edinburgh Postnatal Depression Scale and clinical assessment by the psychiatrist.ResultsThere were 62 cases of PPD and 417 controls after childbirth within 4–8 weeks. The odds of PPD was significantly lower (33 of 329 [10.0%]) in females who received epidural analgesia for labor compared with those who chose nonepidural analgesia (29 of 150 [19.3%]) ([odds ratio] 0.47 (0.27–0.8), P=0.0078). The multivariate analysis showed that absence of labor epidural analgesia, increasing age, family history of depression, history of depression, and previous history of PPD were independent risk factors for development of PPD.ConclusionThe absence of labor epidural analgesia remained as an independent risk factor for development of PPD when adjusted for psychiatric predictors of PPD such as history of depression or PPD and family history of depression.

Introduction: Bleeding from mucosal edges is known to decrease surgical visibility and increase the risk of complications in Endoscopic sinus surgery (ESS). A variety of strategies, including modifying anesthetic techniques have been proposed to create a bloodless field. A recent survey in anesthesiologist revealed that a vast majority neither use controlled hypotension nor believe that modifying the anesthetic techniques will improve the outcome of ESS. This study investigates the different anesthetic techniques used for ESS and their effect on the haemodynamic variables achieved intra-operatively. Methods: Data were retrospectively collected from an electronic anesthesia database on 233 consecutive adult patients who underwent endoscopic sinus surgery in a tertiary hospital in Singapore from January 2014 to August 2015 and statistical analysis was performed using SPSS. Results: Inhaled anesthetics (IA) were used for 93% (49% with morphine or fentanyl, 42% with remifentanil) and total intravenous anesthesia (TIVA) for 7% of the cases respectively. The airway was secured with endotracheal tube in 94.6% and the rest were having LMA. Average Mean Arterial Pressure (MAP) lower than 70 mmHg was achieved in 74.4%. Antihypertensive drugs were used only in 5 cases (2.3%). Distribution of intra operative MAP and Heart rate (HR) were similar among different anesthetic techniques. Lowest MAP and HR achieved were significantly lower in IA with remifentanil use. Conclusion: Inhaled anesthesia is the preferred maintenance technique used for ESS. The desired MAP range was achieved in about 75% of the cases without needing anti hypertensives. Use of remifentanil reduces the MAP and HR further which might potentially improve the quality of surgical field and the outcome.

Introduction: Critically ill patients often require sedation for comfort and to facilitate therapeutic interventions. Sedation practice guidelines provide an evidencebased framework with recommendations that can help improve key sedation-related outcomes. Materials and Methods: We conducted a narrative review of current guidelines and recent trials on sedation. Results: From a practice perspective, current guidelines share many limitations including lack of consensus on the definition of light sedation, optimal frequency of sedation assessment, optimal timing for light sedation and consideration of combinations of sedatives. We proposed several strategies to address these limitations and improve outcomes: 1) early light sedation within the first 48 hours with time-weighted monitoring (overall time spent in light sedation in the first 48 hours—sedation intensity—has a dose-dependent relationship with mortality risk, delirium and time to extubation); 2) provision of analgesia with minimal or no sedation where possible; 3) a goal-directed and balanced multimodal approach that combines the benefits of different agents and minimise their side effects; 4) use of dexmedetomidine and atypical antipsychotics as a sedative-sparing strategy to reduce weaning-related agitation, shorten ventilation time and accelerate physical and cognitive rehabilitation; and 5) a bundled approach to sedation that provides a framework to improve relevant clinical outcomes. Conclusion: More effort is required to develop a practical, time-weighted sedation scoring system. Emphasis on a balanced, multimodal appraoch that targets light sedation from the early phase of acute critical illness is important to achieve optimal sedation, lower mortality, shorten time on ventilator and reduce delirium. Ann Acad Med Singapore;49:215–25 Key words: Analgesia, Benzodiazepine, Critical Care, Dexmedetomidine, Propofol

We describe a rare complication of acute unilateral submandibular gland swelling following the use of laryngeal mask airway (LMA) in two patients with otherwise uneventful perioperative airway management. This is likely to be a consequence of the pressure exerted by the airway cuff on the tissues within the submandibular triangle. As this complication is rarely reported, its true incidence may in fact be higher, suggesting a need for greater attention on LMA cuff pressures and degree of cuff inflation. We discuss the presenting clinical features, pathophysiology and utilisation of ultrasonographic confirmation of sialadenopathy, and review the current anaesthetic literature to raise awareness of this unusual and under-reported complication of LMA. This complication can be mitigated by incorporating routine manometric checks and limiting intracuff pressures to < 60 cmH 2 O, potentially avoiding LMA insertions in patients with sialolithiasis and avoiding the use of nitrous oxide.