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,

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): (2007) Airway management <3yrs3-16Adult ETT 87%79%73% Reusable LMA Single-use LMA 127 Reusable flexi LMA 696 Single use flexi LMA 698

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 patients

Age n

Weight Weight in Kg

LMA size

Number of insertion attempts

Quality of fit 57 61

Tolerance of Boyle-Davis Gag

Reposition after BD gag insertion? 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 56 52

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 kg Obstruction of LMA with BD gag

Problems (6+7) Ages kg 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