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1、Reinforced LMAs for paediatric tonsillectomy,Lesley AitkenApril 2008,Day-case tonsillectomy in Epsom,98%Day-case discharge rateBenefitscost effectiveLess pressure on inpatient bedsLess psychological trauma for parents and childrenAnaesthesia 2006,61,116-122,Epsom childrens ENT day-case anaesthesia p
2、rotocol,Clear 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,Continued(Post-op),Free fluids and food on demandNursing obser
3、vations for 6hrs post-opPost-op consultant-led ward roundNurse-led discharge 6hrs post-op,Theoretical advantages of LMA,Avoids neuromuscular blockadeMinimises pharyngeal&laryngeal traumaNo endobronchial/oesophageal intubationLess airway soilingAvoids extubation risksDeepAwakeAirway protection until
4、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),Ninewells?,Prospective survey of LMA use3 critical stages:1.Insertion2.Opening of BD gag3.recovery,Methods,Simple formAll NW paeds anaesthetists with regular ENT
5、 listsMay 2007 January 200864 patients,Age,Age,n,Weight,Weight in Kg,LMA size,Number of insertion attempts,Quality of fit,57,6,1,Tolerance of Boyle-Davis Gag,56,2,3,Reposition after BD gag insertion?,5,58,Reposition success?,2 successfully repositioned3 converted to ETT,Conversion to ETT,Airway not
6、acceptable with BD gag openSuboptimal fit(?Better with smaller LMA)and“chunky”childLMA obstructed completely with BD gag,Overall airway quality,56,5,2,Recovery,All smooth,Problems,Unsatisfactory fit 2Airway compromised by BD gag 3LMA dislodged during surgery-3,Problems(1),Age 643kgLMA maybe too big“
7、chunky”child,Problems(2),Age 1365kgLots of insertion attemptsLMA never fitted well,Problems(3,4,5),Ages 4-615-20kgObstruction of LMA with BD gag,Problems(6+7),Ages 7+827-28kgLMA dislodged when BD gag removed,Problems(8),Age 940kgLMA good for tonsillectomyDislodged at end during tooth removal,Inserti
8、on,Recovery,Wake-up,Airway protection,Controversy,PrionsTraining issuesCost,Recipe for success,CommunicationAdequate depth of anaesthesiaUse correct LMA sizeBD gag blade size can influence success,Conclusions,Good evidence that LMA is safe alternativeBD gag problem areaMajority still use ETTControversy still exists,Epsom childrens ENT day-case anaesthesia protocol,Clear 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,
