Reinforced LMAs for paediatric tonsillectomy Lesley Aitken April

Day-case tonsillectomy in Epsom • 98% Day-case discharge rate • Benefits – cost –

Epsom children’s ENT day-case anaesthesia protocol • • • Clear fluids up to 2

Continued (Post-op) • • Free fluids and food on demand Nursing observations for 6

Theoretical advantages of LMA • • • Avoids neuromuscular blockade Minimises pharyngeal & laryngeal

Evidence • Canadian paeds study (1993) • English adult & paeds study (1993) •

UK practice Airway management <3 yrs 3 -16 Adult ETT 87% 79% 73% Reusable

Ninewells? • Prospective survey of LMA use • 3 critical stages: – 1. Insertion

Methods • Simple form • All NW paeds anaesthetists with regular ENT lists •

Reposition success? • 2 successfully repositioned • 3 converted to ETT

Conversion to ETT 1. Airway not acceptable with BD gag open 2. Suboptimal fit

Problems 1. Unsatisfactory fit – 2 2. Airway compromised by BD gag – 3

Problems (1) • • Age 6 43 kg LMA maybe too big “chunky” child

Problems (2) • • Age 13 65 kg Lots of insertion attempts LMA never

Problems (3, 4, 5) • Ages 4 -6 • 15 -20 kg • Obstruction

Problems (6+7) • Ages 7+8 • 27 -28 kg • LMA dislodged when BD

Problems (8) • • Age 9 40 kg LMA good for tonsillectomy Dislodged at

Controversy • Prions • Training issues • Cost

Recipe for success • • Communication Adequate depth of anaesthesia Use correct LMA size

Conclusions • • Good evidence that LMA is safe alternative BD gag problem area

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Reinforced LMAs for paediatric tonsillectomy Lesley Aitken April 2008

Day-case tonsillectomy in Epsom • 98% Day-case discharge rate • Benefits – cost – effective – Less pressure on inpatient beds – Less psychological trauma for parents and children Anaesthesia 2006, 61, 116 - 122

Epsom children’s ENT day-case anaesthesia protocol • • • Clear fluids up to 2 hrs pre-op EMLA or ametop Propofol induction IV ondansetron Oxygen/air/sevoflurane r. LMA in children aged 3 or older Spontaneous ventilation IV dexamethasone PR diclofenac PR paracetamol IM codeine IV crystalloids 10 ml/kg

Continued (Post-op) • • Free fluids and food on demand Nursing observations for 6 hrs post-op Post-op consultant-led ward round Nurse-led discharge 6 hrs post-op

Theoretical advantages of LMA • • • Avoids neuromuscular blockade Minimises pharyngeal & laryngeal trauma No endobronchial/oesophageal intubation Less airway soiling Avoids extubation risks – Deep – Awake – Airway protection until awake

Evidence • Canadian paeds study (1993) • English adult & paeds study (1993) • Meta-analysis (1996)

UK practice Airway management <3 yrs 3 -16 Adult ETT 87% 79% 73% Reusable LMA 0. 6 1 Single-use LMA 1 2 7 Reusable flexi LMA 6 9 6 Single use flexi LMA 6 9 8 • Clarke et al, BJA 99 (3): 425 -8 (2007)

Ninewells? • Prospective survey of LMA use • 3 critical stages: – 1. Insertion – 2. Opening of BD gag – 3. recovery

Methods • Simple form • All NW paeds anaesthetists with regular ENT lists • May 2007 – January 2008 • 64 patients

Age n Age

Weight in Kg

LMA size

Number of insertion attempts

Quality of fit 6 1 57

Tolerance of Boyle-Davis Gag 2 3 56

Reposition after BD gag insertion? 5 58

Reposition success? • 2 successfully repositioned • 3 converted to ETT

Conversion to ETT 1. Airway not acceptable with BD gag open 2. Suboptimal fit (? Better with smaller LMA) and “chunky” child 3. LMA obstructed completely with BD gag

Overall airway quality 5 2 56

Recovery • All smooth

Problems 1. Unsatisfactory fit – 2 2. Airway compromised by BD gag – 3 3. LMA dislodged during surgery - 3

Problems (1) • • Age 6 43 kg LMA maybe too big “chunky” child

Problems (2) • • Age 13 65 kg Lots of insertion attempts LMA never fitted well

Problems (3, 4, 5) • Ages 4 -6 • 15 -20 kg • Obstruction of LMA with BD gag

Problems (6+7) • Ages 7+8 • 27 -28 kg • LMA dislodged when BD gag removed

Problems (8) • • Age 9 40 kg LMA good for tonsillectomy Dislodged at end during tooth removal

Insertion

Recovery

Wake-up

Airway protection

Controversy • Prions • Training issues • Cost

Recipe for success • • Communication Adequate depth of anaesthesia Use correct LMA size BD gag blade size can influence success

Conclusions • • Good evidence that LMA is safe alternative BD gag problem area Majority still use ETT Controversy still exists