Reinforced LMAs for paediatric tonsillectomy Lesley Aitken April 2008.
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Transcript of Reinforced LMAs for paediatric tonsillectomy Lesley Aitken April 2008.
![Page 1: Reinforced LMAs for paediatric tonsillectomy Lesley Aitken April 2008.](https://reader036.fdocuments.net/reader036/viewer/2022062408/56649ec85503460f94bd5d24/html5/thumbnails/1.jpg)
Reinforced LMAs for paediatric tonsillectomy
Lesley Aitken
April 2008
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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
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Epsom children’s ENT day-case anaesthesia protocol
• Clear fluids up to 2hrs pre-op• EMLA or ametop• Propofol induction• IV ondansetron• Oxygen/air/sevoflurane• rLMA in children aged 3 or older• Spontaneous ventilation• IV dexamethasone• PR diclofenac• PR paracetamol• IM codeine• IV crystalloids 10ml/kg
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Continued (Post-op)
• Free fluids and food on demand
• Nursing observations for 6hrs post-op
• Post-op consultant-led ward round
• Nurse-led discharge 6hrs post-op
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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
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Evidence
• Canadian paeds study (1993)
• English adult & paeds study (1993)
• Meta-analysis (1996)
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UK practice
• Clarke et al, BJA 99 (3): 425-8 (2007)
Airway management
<3yrs 3-16 Adult
ETT 87% 79% 73%
Reusable LMA 0.6 0.6 1
Single-use LMA 1 2 7
Reusable flexi LMA 6 9 6
Single use flexi LMA 6 9 8
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Ninewells?
• Prospective survey of LMA use
• 3 critical stages:– 1. Insertion– 2. Opening of BD gag– 3. recovery
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Methods
• Simple form
• All NW paeds anaesthetists with regular ENT lists
• May 2007 – January 2008
• 64 patients
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Age
0
1
2
3
4
5
6
7
8
9
3 4 5 6 7 8 9 10 11 12 13 14
Age
n
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Weight
0
5
10
15
20
25
30
35
10 to 15 15 to 20 20 to 30 30+
Weight in Kg
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LMA size
0
5
10
15
20
25
30
2 2.5 3 4
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Number of insertion attempts
0
10
20
30
40
50
60
1 2 3+
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Quality of fit
GoodOKPoor
57
6 1
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Tolerance of Boyle-Davis Gag
GoodOK Poor
56
2 3
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Reposition after BD gag insertion?
yesno
5
58
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Reposition success?
• 2 successfully repositioned
• 3 converted to ETT
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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
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Overall airway quality
GoodOKPoor
56
5 2
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Recovery
• All smooth
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Problems
1. Unsatisfactory fit – 2
2. Airway compromised by BD gag – 3
3. LMA dislodged during surgery - 3
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Problems (1)
• Age 6
• 43kg
• LMA maybe too big
• “chunky” child
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Problems (2)
• Age 13
• 65kg
• Lots of insertion attempts
• LMA never fitted well
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Problems (3,4,5)
• Ages 4-6
• 15-20kg
• Obstruction of LMA with BD gag
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Problems (6+7)
• Ages 7+8
• 27-28kg
• LMA dislodged when BD gag removed
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Problems (8)
• Age 9
• 40kg
• LMA good for tonsillectomy
• Dislodged at end during tooth removal
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Insertion
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Recovery
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Wake-up
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Airway protection
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Controversy
• Prions
• Training issues
• Cost
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Recipe for success
• Communication
• Adequate depth of anaesthesia
• Use correct LMA size
• BD gag blade size can influence success
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Conclusions
• Good evidence that LMA is safe alternative
• BD gag problem area
• Majority still use ETT
• Controversy still exists
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Epsom children’s ENT day-case anaesthesia protocol
• Clear fluids up to 2hrs pre-op• EMLA or ametop• Propofol induction• IV ondansetron• Oxygen/air/sevoflurane• rLMA in children aged 3 or older• Spontaneous ventilation• IV dexamethasone• PR diclofenac• PR paracetamol• IM codeine• IV crystalloids 10ml/kg