1、Reinforced LMAs for paediatric tonsillectomyLesley AitkenApril 2008Day-case tonsillectomy in Epsom 98%Day-case discharge rate Benefits cost effective Less pressure on inpatient beds Less psychological trauma for parents and childrenAnaesthesia 2006,61,116-122Epsom childrens ENT day-case anaesthesia
2、protocolClear fluids up to 2hrs pre-opEMLA or ametopPropofol inductionIV ondansetronOxygen/air/sevofluranerLMA in children aged 3 or olderSpontaneous ventilationIV dexamethasonePR diclofenacPR paracetamolIM codeineIV crystalloids 10ml/kgContinued(Post-op)Free fluids and food on demand Nursing observ
3、ations for 6hrs post-op Post-op consultant-led ward round Nurse-led discharge 6hrs post-opTheoretical advantages of LMA Avoids neuromuscular blockade Minimises pharyngeal&laryngeal trauma No endobronchial/oesophageal intubation Less airway soiling Avoids extubation risks Deep Awake Airway protection
4、 until awakeEvidence Canadian paeds study(1993)English adult&paeds study(1993)Meta-analysis(1996)UK practiceClarke et al,BJA 99(3):425-8(2007)Airway management3yrs3-16AdultETT87%79%73%Reusable LMA0.60.61Single-use LMA127Reusable flexi LMA696Single use flexi LMA698Ninewells?Prospective survey of LMA
5、use 3 critical stages:1.Insertion 2.Opening of BD gag 3.recoveryMethods Simple form All NW paeds anaesthetists with regular ENT lists May 2007 January 2008 64 patientsAge0123456789345678910 11 12 13 14AgenWeight0510152025303510 to 1515 to 2020 to 3030+Weight in KgLMA size05101520253022.534Number of
6、insertion attempts0102030405060123+Quality of fitGoodOKPoor5761Tolerance of Boyle-Davis GagGoodOK Poor5623Reposition after BD gag insertion?yesno558Reposition success?2 successfully repositioned 3 converted to ETTConversion to ETT1.Airway not acceptable with BD gag open2.Suboptimal fit(?Better with
7、smaller LMA)and“chunky”child3.LMA obstructed completely with BD gagOverall airway qualityGoodOKPoor5652Recovery All smoothProblems1.Unsatisfactory fit 22.Airway compromised by BD gag 33.LMA dislodged during surgery-3Problems(1)Age 6 43kg LMA maybe too big“chunky”childProblems(2)Age 13 65kg Lots of i
8、nsertion attempts LMA never fitted wellProblems(3,4,5)Ages 4-6 15-20kg Obstruction of LMA with BD gagProblems(6+7)Ages 7+8 27-28kg LMA dislodged when BD gag removedProblems(8)Age 9 40kg LMA good for tonsillectomy Dislodged at end during tooth removalInsertionRecoveryWake-upAirway protectionControver
9、sy Prions Training issues CostRecipe for success Communication Adequate depth of anaesthesia Use correct LMA size BD gag blade size can influence successConclusions Good evidence that LMA is safe alternative BD gag problem area Majority still use ETT Controversy still existsEpsom childrens ENT day-case anaesthesia protocolClear fluids up to 2hrs pre-opEMLA or ametopPropofol inductionIV ondansetronOxygen/air/sevofluranerLMA in children aged 3 or olderSpontaneous ventilationIV dexamethasonePR diclofenacPR paracetamolIM codeineIV crystalloids 10ml/kg
