1. Reinforced LMAs for paediatric tonsillectomy Lesley Aitken April 2008

3. 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

4. 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

5. 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

6. 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

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

8. UK practice Clarke et al, BJA 99 (3): 425-8 (2007) Airway management <3yrs3-16Adult ETT 87%79%73% Reusable LMA 0.6 1 Single-use LMA 127 Reusable flexi LMA 696 Single use flexi LMA 698

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

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

11. Age n

12. Weight Weight in Kg

13. LMA size

14. Number of insertion attempts

15. Quality of fit 57 61

16. Tolerance of Boyle-Davis Gag 56 2 3

17. Reposition after BD gag insertion? 5 58

18. Reposition success? 2 successfully repositioned 3 converted to ETT

19. 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

20. Overall airway quality 56 52

21. Recovery All smooth

22. Problems 1.Unsatisfactory fit – 2 2.Airway compromised by BD gag – 3 3.LMA dislodged during surgery - 3

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

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

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

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

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

28. Insertion

29. Recovery

30. Wake-up

31. Airway protection

32. Controversy Prions Training issues Cost

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

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

35. 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