Die Anwendung der Spiral-Larynxmaske zur Adenotomie bei Kindern - Ein retrospektiver Vergleich zur Intubationsnarkose

Deep or awake removal of laryngeal mask airway in children at risk of respiratory adverse events undergoing tonsillectomy-a randomised controlled trial

BACKGROUND

Laryngeal mask airways (LMA) are widely used during tonsillectomies. Contrasting evidence exists regarding the timing of the removal and the risk of perioperative respiratory adverse events. We assessed whether the likelihood of perioperative respiratory adverse events is influenced by the timing of LMA removal in children with at least one risk factor for these events.

METHODS

Participants (n=290, 0-16 yr) were randomised to have their LMA removed either deep (in theatre by anaesthetist at end-tidal sevoflurane >1 minimum alveolar concentration) or awake (in theatre by anaesthetist or in postanaesthesia care unit by anaesthetist or trained nurse). The primary outcome was the occurrence of perioperative respiratory adverse events over the whole emergence and postanaesthesia care unit phases of anaesthesia. The secondary outcome was the occurrence of perioperative respiratory adverse events over the distinct phases of emergence and postanaesthesia care unit.

RESULTS

Data from 283 participants were analysed.

PRIMARY OUTCOME

even though a higher occurrence of adverse events was observed in the awake group, no evidence for a difference was found [45% vs 35%, odds ratio (OR): 1.5, 95% confidence interval (CI): 0.9-2.5, P=0.09]. Secondary outcome: there was no evidence for a difference between the groups during emergence [19 (14%) deep vs 25 (18%) awake, OR: 0.74, 95%CI: 0.39-1.42, P=0.37]. However, in the postanaesthesia care unit, children with an awake rather than deep removal experienced significantly more adverse events [55 (39%) vs 37 (26%); OR: 1.85, 95%CI: 1.12-3.07, P=0.02].

CONCLUSION

We found no evidence for a difference in the timing of the LMA removal on the incidence of respiratory adverse events over the whole emergence and postanaesthesia care unit phases. However, in the postanaesthesia care unit solely, awake removal was associated with significantly more respiratory adverse events than deep removal.

TRIAL REGISTRATION NUMBER

ACTRN12609000387224 (www.anzctr.org.au).

The use of flexible laryngeal mask airway for Adenoidectomies: An experience of 814Paediatric patients

OBJECTIVE

To assess flexible laryngeal mask airway (F-LMA) use during pediatric adenoidectomies in terms of patient safety, comfort, complication rates and surgeon satisfaction levels.

METHODS

Patients who had undergone an elective adenoidectomy after receiving general anesthesia using F-LMA from June 2012 to November 2015 were included. Patients' demographics and the incidence of perioperative complications were investigated. The surgeon's satisfaction level was also evaluated by questionnaire.

RESULTS

Eight hundred fourteen patient were included in the study. Conversion from F-LMA to an endotracheal tube was carried out in two patients (0.2%). Airway complications were identified in two patients. The mean duration of stay in the postoperative anesthesia care unit was 17 minutes. All patients were discharged the same day. According to the otolaryngologists F-LMA applications provide a significant reduction in the processing time (100%), postoperative patient comfort is better than when using endotracheal intubation (83.3%) and the consensus was that there should be a complete continuation of the use of the F-LMA (100%) in subsequent adenoidectomies.

CONCLUSION

Our data show that the use of F-LMA for pediatric adenoidectomies has well tolerability profile and resulted in a lower incidence of complications. We think that the use of F-LMA for pediatric adenoidectomy is safer, simpler and speeder method.

The laryngeal mask airway for pediatric adenotonsillectomy: predictors of failure and complications

OBJECTIVES

We hypothesize that the laryngeal mask airway (LMA) is a safe technique for airway management in pediatric adenotonsillectomy (T&A).

METHODS

After institutional review board (I.R.B.) approval, we conducted a retrospective review of 1199 medical records of children who underwent T&A from 2002 to 2006 at Doernbecher Children's Hospital, a teaching institution in Portland, OR. There were no significant demographic differences between the LMA (n=451), endotracheal tube (ETT) (n=715), and failed LMA groups (n=33). Outcome variables were LMA failure (LMA replaced with endotracheal tube), and any complication. We collected demographic and medical data to determine the incidence and predictors of LMA failure, and to characterize the failed LMA group.

RESULTS

The incidence of LMA failure was 6.8%. Patients who underwent adenoidectomy had significantly lower odds of LMA failure compared to patients who had a tonsillectomy or adenotonsillectomy (OR 0.28, 95% CI 0.15-0.52, P<0.0001). One of the surgeons (OR 0.46, 95% CI 0.45-0.48, P<0.0001) was also associated with decreased odds of LMA failure. Controlled ventilation (OR 7.17, 95% CI 4.99-10.32, P<0.0001), and younger patients (OR 1.05 for each year decrease in age, 95% CI 1.03-1.07, P ≤ 0.0001) were associated with increased odds of LMA failure. The complication rate was 14.2% in the LMA group and 7.7% in the ETT group. Increased odds of developing any complication were seen in male patients (OR 1.4, 95% CI 1.01-1.7, P=0.04), and in patients with co-morbidities other than obstructive sleep apnea syndrome or upper respiratory tract infection (OR 4.2, 95% CI 1.03-17.2, P=0.04). The odds of developing a complication were lower in the ETT group compared to the LMA group (0.63, 0.46, 0.8, P=0.005).

CONCLUSIONS

LMA use for pediatric T&A is associated with a higher incidence of complications, mainly as a result of airway obstruction following insertion of the LMA or McIvor gag placement. Complications were more likely if tonsillectomy was performed when compared to adenoidectomy alone. Appropriate patient selection, careful insertion, and avoidance of controlled ventilation may decrease the incidence of LMA failure, especially if tonsillectomy is performed. The ability of surgeons to work around the LMA can modify the failure rate significantly.