reinforced lmas for paediatric tonsillectomy
DESCRIPTION
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. - PowerPoint PPT PresentationTRANSCRIPT
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 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
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
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
• 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
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
0
1
2
3
4
5
6
7
8
9
3 4 5 6 7 8 9 10 11 12 13 14
Age
n
Weight
0
5
10
15
20
25
30
35
10 to 15 15 to 20 20 to 30 30+
Weight in Kg
LMA size
0
5
10
15
20
25
30
2 2.5 3 4
Number of insertion attempts
0
10
20
30
40
50
60
1 2 3+
Quality of fit
GoodOKPoor
57
6 1
Tolerance of Boyle-Davis Gag
GoodOK Poor
56
2 3
Reposition after BD gag insertion?
yesno
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
GoodOKPoor
56
5 2
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
• 43kg
• LMA maybe too big
• “chunky” child
Problems (2)
• Age 13
• 65kg
• Lots of insertion attempts
• LMA never fitted well
Problems (3,4,5)
• Ages 4-6
• 15-20kg
• Obstruction of LMA with BD gag
Problems (6+7)
• Ages 7+8
• 27-28kg
• LMA dislodged when BD gag removed
Problems (8)
• Age 9
• 40kg
• 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 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