Reinforced LMAs for paediatric tonsillectomy Lesley Aitken April
- Slides: 35
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
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
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