AL-SHAIKH, B

DIXIT, V

Van Zundert, Adrien

English

Ghent University Academic Bibliography

812 Correspondencehyperalgesia. Furthermore, they suggested thatremifentanil in association with ketamine was useflilin patients pretreated with opioids.One possibility for this patient's pain in thepostoperative period — and in our view the mostlikely one - however is not discussed, namely opioid-withdrawal hyperalgesia. Postoperative analgesia inpatients who receive opioids for chronic pain isundoubtedly a challenge for anaesthesiologists andpain therapists. In clinical practice, chronic painpatients receiving strong opioids preoperatively showhigh inter-individual variability and sometimesextremely high postoperative demand for opioids.Depending on the chronic opioid dose, total ctimu-lative doses of 30-45 mg piritramide within thefirst 1-2 h are common in these patients. Theseobservations are in accordance with Rapp andcolleagues [2], who found a more than three-fold(135.8 vs. 42.8 mg) increase in opioid demand in thefirst 24 h after surgery in patients with preoperativeopioid consumption as compared with opioid-naivepatients.In addition, we feel that postoperative analgesiais much more difficult to handle in chronic painpatients receiving remifentanil as sole opioidintraoperatively as compared with those receivinglong-acting |x-opioid agonists like fentanyl orsufentanil. Irrespective of the fact whether thispatient's fentanyl patch was removed before surgeryor not, we feel that the administration of 10 mgpiritramide and 4mg morphine for postoperativeanalgesia in this patient was simply not enough toprovide sufficient analgesia.It has been shown that enhanced pain sensationsafter cessation of a remifentanil infusion are due to anacute withdrawal response,, which cannot be modu-lated by N-methyl-D-aspartic acid receptor antago-nists [3,4]. Therefore, we think that the therapeuticeffect of ketamine observed by Dumont and collea-gues is most likely due to its direct analgesic orhypnotic effect and not based on the reversal ofpronociceptive mechanisms induced by remifentanil.The increasing evidence for opioid-induced hyper-algesia should not lead to a restricted use of opioidsin the perioperative period, especially not in patientswho have a history of chronic opioid administration.A, Z, Tzabazis, W. KoppertAndsthesiologische KlinikUniversitd'tsklinikum ErlangenGermanyReferences1. Dumont H, Guntz E, Sosnowski M, Talla G. Opioid-inducedhyperalgesia. EurJ Anaesthesiol 2007; 24(2): 205-207.2. Rapp SE, Ready LB, Nessly ML. Acute pain managementin patients with prior opioid consumption: a case-controlledretrospective review. Pain 1995; 61(2): 195-201.3. Koppert W, Sittl R, Scheuber K, Alsheimer M, Schmelz M,Schuttler J. Differential modulation of remifentanil-inducedanalgesia and postinfusion hypetalgesia by S-ketamine andclonidine in humans. Anesthesiology 2003; 99: 152-159.4. Koppert W, Angst M, Alsheimer M et al. Naloxoneprovokes similar pain facilitation as observed after short-term infusion of remifentanil in humans. Pain 2003;106(1-2): 91-99.Comparison of LMA Unique, Ambu laryngeal mask and SoftSeal laryngeal mask during routine surgical proceduresdoi: 10.1017/S0265021507000518EDITOR:We read with interest the paper by Francksen andcolleagues [1] comparing the LMA Unique, Ambularyngeal mask and Soft Seal laryngeal mask. In arandomized controlled study, we compared theCorrespondence to: Baha Al-Shaikh, Department of Anaesthesia, WilliamHarvey Hospital, Kennington Road, Ashford, Kent TN24 OLZ Ashford, UK.E-mail: bal_shaikh@yahoo.com; Tel: +1233 633331, ext 86041Accepted for publication 11 March 2007 EJA 4468First published online 7 June 2007performance of the LMA Unique with the Soft Seallaryngeal mask and the Cobra Perilaryngeal Airway[2]. We studied 320 consecutive patients in thethree groups and found that the LMA Unique andSoft Seal laryngeal mask were of equal clinicalperformance. Ease of insertion between the twodevices was very similar using a partially inflatedcuff. In the Unique LMA group, a successful pri-mary airway was established in 96% of patients onthe first attempt, and in 4% of patients insertionfailed at the second attempt. In the Soft Seal© 2 0 0 7 Copyright European Society of Anaesthesiology, European Joumai of Anaesthesiology 24; 803-816Correspondence 813laryngeal mask group, a successful primary airwaywas established in 99% of patients on the firstattempt, and in 1% of patients insertion failed atthe second attempt. In agreement with the authors,the effective airway time was similar for the twodevices and the oropharyngeal leak pressure washigher in the Soft Seal laryngeal mask group. Theendoscopic score of the larynx was significantlybetter with the Soft Seal laryngeal mask group thanwith the Unique LMA group. The changes in cuffpressures and airway morbidity were similar in bothgroups.In an observational study, we inserted the SoftSeal laryngeal mask with the cuff inflated atatmospheric pressure [3] in 100 patients andachieved 97% success in the first attempt and 3% inthe second attempt. Regarding insertions, 85%were graded as very easy and 12% as easy and wereachieved within 20 s. The mean intra-cuff pressurein vivo was 40 mmHg (53 cm H2O). The leakpressure was at a mean pressure of 24.8 cm H2O, inagreement with the authors. Only six patientscomplained of mild-to-moderate sore throat in thefirst 2 h after operation.We agree with the authors' conclusion that theLMA Unique and the Soft Seal laryngeal mask are ofequal clinical suitability. We believe that insertingthe Soft Seal laryngeal mask with the cuff infiated atatmospheric pressure can achieve excellent condi-tions for insertion and removal.B. Al-Shaikh, V. DixitDepartment of AnaesthesiaWilliam Harvey HospitalAshfordKent, UKA. van ZundertDepartment of AnesthesiologyCatharina HospitalThe NetherlandsReferencesFrancksen H, Bein B, Cavus E et al. Comparison of LMAUnique, Ambu laryngeal mask and Soft Seal laryngealmask during routine surgical procedures. Eur J Anaes-thesiology 2007; 24: 134-140.van Zundert AAJ, Al-Shaikh B, Brimacombe J, Koster J,Koning D, Mortier EP. Comparison of three disposableexrraglottic airway devices in spontaneously breathingadults: the LMA-Unique ITM], the Soft Seal laryngealmask, and the Cobra perilaryngeal airway. Anesthesiology2006; 104(6): 1165-1169.Al-Shaikh B, George William M, Van Zundert AAJ.Using atmospheric pressure to inflate the cuff of thePortex laryngeal mask. Anaesthesia 2005; 60: 287-297.Conditions involving release of pro-inflammatory cytokinespredispose to ARDSdoi: 10.1017/S026502150700049XEDITOR:Sadis and colleagues [1] investigated risk factors forthe development of ARDS in patients receivingmultiple transfusions and found that it was not thenumber of transfusions but thoracic trauma andhypoxia that were associated with the subsequentdevelopment of ARDS. Patients who developedARDS received significantly more fresh frozenplasma. Previous studies showed that septicaemia isan additional predisposing factor for transfusion-related ARDS [2]. Another condition commonlyCorrespondence to: Michael Eisenhut. Luron and Dunstable Hospital NHSFoundation Trust, Luton, Bedfordshire, LU4 ODZ, UK. E-mail; michael_eisenhut@yahoo.com; Tel: +0845 1270127; Fax: +1582 497280Accepted for publication 12 March 2007 EJA 4369First published online 7 June 2007associated with pulmonary oedema during infusionof large amounts of intravenous fiuids is diabeticketoacidosis [3]. All these conditions with theirdifferent pathophysiology have in common therelease of large amounts of cytokines includingtumour necrosis factor (TNF) and interleukin-1(IL-1). Transfusion of an anti-CD28 monoclonalantibody into human volunteers stimulated T-cellsto release large amounts of these two cytokines andled to pulmonary oedema in all subjects of this trial[4]. The mechanism by which these cytokines leadto or predispose to pulmonary oedema bas recentlybeen clarified: Alveolar epithelial fluid clearance inpulmonary oedema is dependent on pulmonaryepithelial sodium and chloride transport throughthe apical alveolar epithelial sodium channel andthe cystic fibrosis transmembrane conductance© 2 0 0 7 Copyright European Society of Anaesthesiology, European Joumai of Anaesthesiology 24: 803—816

Comparison of LMA Unique, Ambu laryngeal mask and Soft Seal laryngeal mask during routine surgical procedures

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Comparison of LMA Unique, Ambu laryngeal mask and Soft Seal laryngeal mask during routine surgical procedures

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