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Reinforced LMAs for paediatric tonsillectomy

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.

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Reinforced LMAs for paediatric tonsillectomy

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  1. Reinforced LMAs for paediatric tonsillectomy Lesley Aitken April 2008

  2. 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

  3. 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

  4. 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

  5. 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

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

  7. UK practice • Clarke et al, BJA 99 (3): 425-8 (2007)

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

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

  10. Age n Age

  11. Weight Weight in Kg

  12. LMA size

  13. Number of insertion attempts

  14. Quality of fit 6 1 57

  15. Tolerance of Boyle-Davis Gag 3 2 56

  16. Reposition after BD gag insertion? 5 58

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

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

  19. Overall airway quality 5 2 56

  20. Recovery • All smooth

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

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

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

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

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

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

  27. Insertion

  28. Recovery

  29. Wake-up

  30. Airway protection

  31. Controversy • Prions • Training issues • Cost

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

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

  34. 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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