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Pai SL, Grech D, Gayer S, Rodriguez L, Joshi GP, Rajan N. Should rocuronium and sugammadex replace succinylcholine for airway emergencies in class B ambulatory anesthesia settings? Minerva Anestesiol 2023; 89:197-205. [PMID: 36326774 DOI: 10.23736/s0375-9393.22.16852-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
INTRODUCTION In class B surgical facilities, where only oral or intravenous (IV) sedation is employed without the administration of volatile anesthetics, laryngospasm is among the most common airway complications. However, these facilities generally do not stock succinylcholine to avoid the cost of storing dantrolene for the treatment of malignant hyperthermia (MH). High dose IV rocuronium with sugammadex reversal has been suggested as an alternative to succinylcholine for airway emergencies. The aim of this paper was to evaluate the clinical utility, patient safety, and financial implications of replacing succinylcholine with rocuronium and sugammadex in lieu of stocking dantrolene in class B facilities. EVIDENCE ACQUISITION A systematic review of the literature concerning neuromuscular blockade for airway emergencies in class B settings in adult patients was conducted. The MEDLINE and EMBASE databases were searched for published studies from January 1, 1990, to October 1, 2021. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) system was used to assess the certainty of evidence. EVIDENCE SYNTHESIS The search strategy yielded 1124 articles. After review, 107 articles were included, with 49 graded as "strong" evidence to provide recommendations for the posed questions. CONCLUSIONS The use of succinylcholine in isolation without volatile agents has a low incidence of triggering MH. Laryngospasm is a common airway emergency that requires immediate treatment to avoid morbidity and mortality. Both succinylcholine and rocuronium-sugammadex provide adequate treatment of airway emergencies and rapid return of spontaneous ventilation, but succinylcholine has a superior economic and clinical profile.
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Affiliation(s)
- Sher-Lu Pai
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Jacksonville, FL, USA -
| | - Dennis Grech
- New Jersey Medical School, Department of Anesthesiology, Rutgers, Newark, NJ, USA
| | - Steven Gayer
- Miller School of Medicine, Department of Anesthesiology, University of Miami, Miami, FL, USA
| | - Leopoldo Rodriguez
- Anesthesiology and Perioperative Medicine, Boulder Valley Anesthesiology PLLC, Boulder, CO, USA
| | - Girish P Joshi
- Department of Anesthesiology and Pain Management, UT Southwestern Medical Center, Dallas, TX, USA
| | - Niraja Rajan
- Department of Anesthesiology and Perioperative Medicine, Penn State Health, Hershey, PA, USA
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Cosgrove P, Krauss BS, Cravero JP, Fleegler EW. Predictors of Laryngospasm During 276,832 Episodes of Pediatric Procedural Sedation. Ann Emerg Med 2022; 80:485-496. [PMID: 35752522 DOI: 10.1016/j.annemergmed.2022.05.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 04/22/2022] [Accepted: 04/29/2022] [Indexed: 11/01/2022]
Abstract
STUDY OBJECTIVE Laryngospasm is a rare but potentially life-threatening complication of sedation. The objective of this study was to perform a predictor analysis of biologically plausible predictors and the interventions and outcomes associated with laryngospasm. METHODS Secondary analysis of prospectively collected data from consecutively sedated patients, less than or equal to 22 years of age, at multiple locations at 64 member institutions of the Pediatric Sedation Research Consortium. The primary outcome was laryngospasm. The independent variables in the multivariable model included American Society of Anesthesiologists category, age, sex, concurrent upper respiratory infection, medication regimen, hospital sedation location, whether the procedure was painful, and whether the procedure involved the airway. The analysis included adjusted odds ratios (aORs) and predicted probabilities. RESULTS We analyzed 276,832 sedations with 913 reported events of laryngospasm (overall unadjusted prevalence 3.3:1,000). A younger age, a higher American Society of Anesthesiologists category, a concurrent upper respiratory infection (aOR 3.94, 2.57 to 6.03; predicted probability 12.2/1,000, 6.3/1,000 to 18.0/1,000), and airway procedures (aOR 3.73, 2.33 to 5.98; predicted probability 9.6/1,000, 5.2/1,000 to 13.9/1,000) were associated with increased risk. Compared with propofol alone, propofol combination regimens had increased risk (propofol+ketamine: aOR 2.52, 1.41 to 4.50; predicted probability 7.6/1,000, 3.1/1,000 to 12/1,000; and propofol+dexmedetomidine: aOR 2.10, 1.25 to 3.52; predicted probability 6.3/1,000, 3.7,/1,000 to 8.9/1,000). Among patients with laryngospasm, the resulting outcomes included desaturation less than 70% for more than 30 seconds (19.7%), procedure not completed (10.6%), emergency airway intervention (10.0%), endotracheal intubation (5.3%), unplanned admission/increase in level of care (2.3%), aspiration (1.1%), and cardiac arrest (0.2%). CONCLUSION We found increased associations of laryngospasm in pediatric procedural sedation with multiple biologic factors, procedure types, and medication regimens. However, effect estimates showed that the laryngospasm prevalence remained low, and this should be taken into consideration in sedation decisionmaking.
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Affiliation(s)
- Peter Cosgrove
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA; Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, MA; Department of Pediatric Emergency Medicine, Royal Belfast Hospital for Sick Children, Belfast, UK.Dr Cosgrove is currently affiliated with Wellcome-Wolfson Institute for Experimental Medicine, Queens University Belfast, Belfast, UK.
| | - Baruch S Krauss
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA; Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, MA
| | - Joseph P Cravero
- Department of Anesthesia, Boston Children's Hospital, Boston, MA; Department of Anesthesia, Harvard Medical School, Boston, MA; Departments of Pediatrics and Emergency Medicine, Harvard Medical School, Boston, MA
| | - Eric W Fleegler
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA
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Jamal D, Powell C. Paediatric procedural sedation in the emergency department: is ketamine safe? Arch Dis Child Educ Pract Ed 2021; 106:120-124. [PMID: 32522748 DOI: 10.1136/archdischild-2019-318610] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Revised: 03/31/2020] [Accepted: 05/12/2020] [Indexed: 11/03/2022]
Affiliation(s)
- Dried Jamal
- Pediatric Emergency, Sidra Medical and Research Center, Doha, Qatar
| | - Colin Powell
- Emergency Medicine, Sidra Medical and Research Center, Doha, Qatar .,Division of Population Medicine, Cardiff University School of Medicine, Cardiff, UK
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Lucchesi M, Silverman JB, Sundaram K, Kollmar R, Stewart M. Proposed Mechanism-Based Risk Stratification and Algorithm to Prevent Sudden Death in Epilepsy. Front Neurol 2021; 11:618859. [PMID: 33569036 PMCID: PMC7868441 DOI: 10.3389/fneur.2020.618859] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Accepted: 12/30/2020] [Indexed: 12/13/2022] Open
Abstract
Sudden Unexpected Death in Epilepsy (SUDEP) is the leading cause of death in young adults with uncontrolled seizures. First aid guidance to prevent SUDEP, though, has not been previously published because the rarity of monitored cases has made the underlying mechanism difficult to define. This starkly contrasts with the first aid guidelines for sudden cardiac arrest that have been developed based on retrospective studies and expert consensus and the discussion of resuscitation challenges in various American Heart Association certificate courses. However, an increasing amount of evidence from documented SUDEP cases and near misses and from animal models points to a consistent sequence of events that starts with sudden airway occlusion and suggests a mechanistic basis for enhancing seizure first aid. In monitored cases, this sudden airway occlusion associated with seizure activity can be accurately inferred from inductance plethysmography or (depending on recording bandwidth) from electromyographic (EMG) bursts that are associated with inspiratory attempts appearing on the electroencephalogram (EEG) or the electrocardiogram (ECG). In an emergency setting or outside a hospital, seizure first aid can be improved by (1) keeping a lookout for sudden changes in airway status during a seizure, (2) distinguishing thoracic and abdominal movements during attempts to inspire from effective breathing, (3) applying a simple maneuver, the laryngospasm notch maneuver, that may help with airway management when aggressive airway management is unavailable, (4) providing oxygen early as a preventative step to reduce the risk of death, and (5) performing cardiopulmonary resuscitation before the limited post-ictal window of opportunity closes. We propose that these additions to first aid protocols can limit progression of any potential SUDEP case and prevent death. Risk stratification can be improved by recognition of airway occlusion, attendant hypoxia, and need for resuscitation.
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Affiliation(s)
- Michael Lucchesi
- Department of Emergency Medicine, State University of New York Health Sciences University, Brooklyn, NY, United States
| | - Joshua B Silverman
- Department of Otolaryngology, North Shore Long Island Jewish Medical Center, New Hyde Park, NY, United States
| | - Krishnamurthi Sundaram
- Department of Otolaryngology, State University of New York Health Sciences University, Brooklyn, NY, United States
| | - Richard Kollmar
- Department of Otolaryngology, State University of New York Health Sciences University, Brooklyn, NY, United States.,Department of Cell Biology, State University of New York Health Sciences University, Brooklyn, NY, United States
| | - Mark Stewart
- Department of Neurology, State University of New York Health Sciences University, Brooklyn, NY, United States.,Department of Physiology & Pharmacology, State University of New York Health Sciences University, Brooklyn, NY, United States
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Sibert KS, Long JL, Haddy SM. Extubation and the Risks of Coughing and Laryngospasm in the Era of Coronavirus Disease-19 (COVID-19). Cureus 2020; 12:e8196. [PMID: 32440387 PMCID: PMC7237060 DOI: 10.7759/cureus.8196] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
The coronavirus disease-19 (COVID-19) pandemic has prompted new interest among anesthesiologists and intensivists in controlling coughing and expectoration of potentially infectious aerosolized secretions during intubation and extubation. However, the fear of provoking laryngospasm may cause avoidance of deep or sedated extubation techniques which could reduce coughing and infection risk. This fear may be alleviated with clear understanding of the mechanisms and effective management of post-extubation airway obstruction including laryngospasm. We review the dynamic function of the larynx from the vantage point of head-and-neck surgery, highlighting two key concepts: 1. The larynx is a complex organ that may occlude reflexively at levels other than the true vocal folds; 2. The widely held belief that positive-pressure ventilation by mask can “break” laryngospasm is not supported by the otorhinolaryngology literature. We review the differential diagnosis of acute airway obstruction after extubation, discuss techniques for achieving smooth extubation with avoidance of coughing and expectoration of secretions, and recommend, on the basis of this review, a clinical pathway for optimal management of upper airway obstruction including laryngospasm to avoid adverse outcomes.
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Affiliation(s)
- Karen S Sibert
- Anesthesiology and Perioperative Medicine, University of California, Los Angeles (UCLA) Health, Los Angeles, USA
| | - Jennifer L Long
- Head and Neck Surgery, University of California, Los Angeles (UCLA) Health, Los Angeles, USA.,Surgery and Perioperative Medicine, Veterans Administration Greater Los Angeles Healthcare System, Los Angeles, USA
| | - Steven M Haddy
- Anesthesiology, Keck School of Medicine of the University of Southern California, Los Angeles, USA
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Sayce LJ, Powell ME, Kimball EE, Chen P, Gartling GJ, Rousseau B. Continuous Rate Infusion of Ketamine Hydrochloride and Dexmedetomidine for Maintenance of Anesthesia during Laryngotracheal Surgery in New Zealand White Rabbits ( Oryctolagus cuniculus). JOURNAL OF THE AMERICAN ASSOCIATION FOR LABORATORY ANIMAL SCIENCE : JAALAS 2020; 59:176-185. [PMID: 32005295 PMCID: PMC7073403 DOI: 10.30802/aalas-jaalas-19-000076] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Revised: 06/17/2019] [Accepted: 08/23/2019] [Indexed: 11/05/2022]
Abstract
New Zealand white rabbits (Oryctolagus cuniculus) are an established in vivo model for the study of structural and functional consequences of vocal-fold vibration. Research design requires invasive laryngotracheal procedures, and the presence of laryngospasms or pain responses (or both) hinder phonation-related data collection. Published anesthesia regimens report respiratory depression and muscle tone changes and have been unsuccessful in mitigating autonomic laryngeal responses in our protocol. Infusion of ketamine hydrochloride and dexmedetomidine hydrochloride in pediatric medicine provides effective analgesia and sedation for laryngotracheal procedures including intubation and bronchoscopy; however, data evaluating the use of ketamine-dexmedetomidine infusion in rabbits are unavailable. This study reports a new infusion regimen, which was used in 58 male New Zealand white rabbits that underwent a nonsurvival laryngotracheal procedure to induce phonotraumatic vocal-fold injury. Animals were sedated by using ketamine hydrochloride (20 mg/kg IM) and dexmedetomidine (0.125 mg/kg IM). Maintenance anesthesia was provided by using continuous rate intravenous infusion of ketamine hydrochloride (343 μg/kg/min) and dexmedetomidine (1.60 μg/kg/min). A stable plane of anesthesia with no autonomic laryngeal response (laryngospasm) was achieved in 32 of the 58 rabbits (55%). Laryngospasms occurred in 25 of 58 animals (43%) and were controlled in 20 cases (80%) by providing 0.33 mL 2% topical lidocaine, incremental increase in infusion rate, or both. Continuous rate infusion of ketamine hydrochloride-dexmedetomidine with prophylactic topical lidocaine provides a predictable and adjustable surgical plane of anesthesia, with minimal confounding respiratory and autonomic laryngeal responses, during extended-duration laryngotracheal surgery in rabbits. This regimen should be considered as an alternative to injection maintenance for prolonged, invasive procedures.
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Affiliation(s)
- Lea J Sayce
- Department of Communication Science and Disorders, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Otolaryngology, Vanderbilt University, Nashville, Tennessee;,
| | - Maria E Powell
- Department of Otolaryngology, Vanderbilt University, Nashville, Tennessee
| | - Emily E Kimball
- Department of Hearing and Speech Sciences, Vanderbilt University, Nashville, Tennessee
| | - Patty Chen
- Animal Care and Use Review Office, US Army Medical Research and Development, Frederick, Maryland
| | - Gary J Gartling
- Department of Communication Science and Disorders, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Bernard Rousseau
- Department of Communication Science and Disorders, School of Health and Rehabilitation Sciences, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Otolaryngology, Vanderbilt University, Nashville, Tennessee
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Michelet D, Truchot J, Piot MA, Drummond D, Ceccaldi PF, Plaisance P, Tesnière A, Dahmani S. Perioperative laryngospasm management in paediatrics: a high-fidelity simulation study. BMJ SIMULATION & TECHNOLOGY ENHANCED LEARNING 2019; 5:161-166. [DOI: 10.1136/bmjstel-2018-000364] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/03/2018] [Indexed: 11/04/2022]
Abstract
AimPaediatric anaesthesia is a very specialised domain lacking training during the traditional curriculum. The laryngospasm is a stressful and life-threatening event that requires immediate action. The main objective of this study was to assess the effect of knowledge of a simple algorithm on the management of laryngospasm by trainee anaesthetists and nurse anaesthetists during a high-fidelity simulation session.MethodResidents in paediatric anaesthesia and training nurse anaesthetists with similar curriculum were randomly allocated to undergo a simulation session of laryngospasm with the help of a simple algorithm administered to them 5 min before the simulation session (group A) or as taught in their curriculum (group C). The primary endpoint was the assessment score of laryngospasm management using 10 technical items (validated in experienced paediatric anaesthetists). Secondary endpoints were: the non-technical skills using the Anaesthetists' Non-Technical Skills (ANTS) score and timing of critical management steps. The correlation between the technical and non-technical scores was also studied. Data are expressed as median (range).Results72 participants (18 teams in each group) were included in this study. There was a statistically significant difference between group A and C on the primary endpoint: 8.5 (2–10) vs 5 (2–8), respectively (p<0.0001). There was also a significant difference between the two groups for the ANTS score 12 (7–16) vs 8 (6–12), respectively (p<0.0001). No difference in timing of management was observed. Finally, there was a strong correlation between the technical skills and all the non-technical skills categories in the A group.ConclusionA simple algorithm improved the technical and non-technical skills of students during the management of a simulated laryngospasm.
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8
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Childers R, Vilke G. Ketamine for Acute Agitation. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2019. [DOI: 10.1007/s40138-019-00177-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Hill GED, Zundel MT, Pagel PS. Larson's Maneuver to Facilitate Endotracheal Intubation Using Videolaryngoscopy. J Cardiothorac Vasc Anesth 2018; 33:883-884. [PMID: 30455141 DOI: 10.1053/j.jvca.2018.10.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Indexed: 11/11/2022]
Affiliation(s)
| | - M Tracy Zundel
- Department of Anesthesiology, Medical College of Wisconsin
| | - Paul S Pagel
- Anesthesia Service, Clement J. Zablocki Veterans Affairs Medical Center, Milwaukee, WI
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Mokhtar AM, Badawy AA. Low dose propofol vs. lidocaine for relief of resistant post-extubation laryngospasm in the obstetric patient. BRAZILIAN JOURNAL OF ANESTHESIOLOGY (ENGLISH EDITION) 2018. [PMID: 28754225 PMCID: PMC9391671 DOI: 10.1016/j.bjane.2017.03.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Background Post-extubation laryngospasm is a dangerous complication that should be managed promptly. Standard measures were described for its management. We aimed to compare the efficacy of propofol (0.5 mg.kg−1) vs. lidocaine (1.5 mg.kg−1) for treatment of resistant post-extubation laryngospasm in the obstetric patients, after failure of the standard measures. Method This study was conducted over 2 years on all obstetric patients scheduled for cesarean delivery. Post-extubation laryngospasm was initially managed with a standard protocol (removal of offending stimulus, jaw thrust, positive pressure ventilation with 100% oxygen). When this protocol failed, the tested drug was the second line (lidocaine in the first year and propofol in the second year). Lastly, succinylcholine was used when the tested drug failed. Results In lidocaine group, 5% of parturients developed post-extubation laryngospasm, 31.9% of them were successfully treated via standard protocol, and 68.1% required lidocaine treatment. Among these, 65.6% of patients treated with lidocaine responded successfully and 34.4% required succinylcholine to relieve laryngospasm. In propofol group, 4.7% of parturients developed post-extubation laryngospasm, 30.1% of them were successfully treated via standard protocol, and 69.9% required propofol treatment. Among these, 82.8% of patients treated with propofol responded successfully and 17.2% required succinylcholine to relieve laryngospasm. Conclusion Small dose of propofol (0.5 mg.kg−1) is marginally more effective than lidocaine (1.5 mg.kg−1) for the treatment of resistant post-extubation laryngospasm in obstetric patients, after failure of standard measures and before the use of muscle relaxants.
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Affiliation(s)
- Ali M Mokhtar
- Cairo University, Department of Anesthesia, Cairo, Egypt.
| | - Ahmed A Badawy
- Cairo University, Department of Anesthesia, Cairo, Egypt
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Mokhtar AM, Badawy AA. [Low dose propofol vs. lidocaine for relief of resistant post-extubation laryngospasm in the obstetric patient]. Rev Bras Anestesiol 2017; 68:57-61. [PMID: 28754225 DOI: 10.1016/j.bjan.2017.03.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Accepted: 03/31/2017] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Post-extubation laryngospasm is a dangerous complication that should be managed promptly. Standard measures were described for its management. We aimed to compare the efficacy of propofol (0.5mg.kg-1) vs. lidocaine (1.5mg.kg-1) for treatment of resistant post-extubation laryngospasm in the obstetric patients, after failure of the standard measures. METHOD This study was conducted over 2 years on all obstetric patients scheduled for cesarean delivery. Post-extubation laryngospasm was initially managed with a standard protocol (removal of offending stimulus, jaw thrust, positive pressure ventilation with 100% oxygen). When this protocol failed, the tested drug was the second line (lidocaine in the first year and propofol in the second year). Lastly, succinylcholine was used when the tested drug failed. RESULTS In lidocaine group, 5% of parturients developed post-extubation laryngospasm, 31.9% of them were successfully treated via standard protocol, and 68.1% required lidocaine treatment. 65.6% of patients treated with lidocaine responded successfully and 34.4% required succinylcholine to relieve laryngospasm. In propofol group, 4.7% of parturients developed post-extubation laryngospasm, 30.1% of them were successfully treated via standard protocol, and 69.9% required propofol treatment. 82.8% of patients treated with propofol responded successfully and 17.2% required succinylcholine to relieve laryngospasm. CONCLUSION Small dose of propofol (0.5mg.kg-1) is marginally more effective than lidocaine (1.5mg.kg-1) for the treatment of resistant post-extubation laryngospasm in obstetric patients, after failure of standard measures and before the use of muscle relaxants.
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Affiliation(s)
- Ali M Mokhtar
- Cairo University, Department of Anesthesia, Cairo, Egypt.
| | - Ahmed A Badawy
- Cairo University, Department of Anesthesia, Cairo, Egypt
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Abelson D. Laryngospasm notch pressure ('Larson's maneuver') may have a role in laryngospasm management in children: highlighting a so far unproven technique. Paediatr Anaesth 2015; 25:1175-6. [PMID: 26426878 DOI: 10.1111/pan.12731] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Daniel Abelson
- Department of Anesthesiology, UCSF Benioff Children's Hospital Oakland, Oakland, CA, USA.
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13
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Diagnosis and Management of Respiratory Adverse Events in the Operating Room. CURRENT ANESTHESIOLOGY REPORTS 2015. [DOI: 10.1007/s40140-015-0103-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Abstract
The risk for complications while providing dental procedures is greatest when caring for patients having significant medical compromise. It is comforting that significant adverse events can generally be prevented by careful preoperative assessment, along with attentive intraoperative monitoring and support. Nevertheless, the office team must be prepared to manage untoward events should they arise. This continuing education article will address basic emergency drugs that should be available in all dental practices and additional agents that become essential for those practices providing various levels of procedural sedation or general anesthesia.
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Affiliation(s)
- Daniel E Becker
- Associate Director of Education, General Dental Practice Residency, Miami Valley Hospital, Dayton, Ohio
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Srinivasan M, Carlson DW. A proposed mechanism to assess knowledge of pediatric hospitalists to identify and manage rare events during procedural sedation. Hosp Pediatr 2014; 3:381-5. [PMID: 24435198 DOI: 10.1542/hpeds.2013-0045] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE The goal of this study was to assess the knowledge of pediatric hospitalists (PHs) in identifying and managing rare events during procedural sedation (PS) with ketamine and nitrous oxide (N2O). METHODS A Web-based survey with multiple choice questions and case scenarios was used to determine the knowledge of PHs in identifying infrequent contraindications and managing laryngospasm, a rare life-threatening complication during PS. The survey was sent to all PHs at St Louis Children's Hospital. RESULTS Forty percent of experienced PHs (>50 sedation procedures performed) and 5% of inexperienced PHs (<50 sedation procedures performed) identified all 4 ketamine contraindications. Twenty-one percent of experienced PHs and 4% of inexperienced PHs identified all 6 N2O contraindications. Ninety-five percent of PHs identified presence of laryngospasm in a case scenario. As the patient in the case scenario progressed from partial to complete laryngospasm, 84% and 82% of PHs chose either the preferred or acceptable strategy to manage the patient. With further deterioration in the patient's status in the scenario, 66% and 71% of PHs chose either the preferred or acceptable strategy to manage the patient. The preferred strategy at each step is one that attempted the least invasive maneuver to manage the patient. There was no significant difference between experienced and inexperienced PHs in the management of laryngospasm. CONCLUSIONS Knowledge gaps exist among PHs regarding contraindications for ketamine and N2O that are infrequently encountered in patients and for the management of laryngospasm, a rare adverse event with ketamine. Ongoing teaching tools are necessary to assess and maintain the knowledge of sedation providers regarding rare events during PS that can improve their proficiency.
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Affiliation(s)
- Mythili Srinivasan
- Department of Pediatrics, Washington University School of Medicine/St Louis Children's Hospital, St Louis, Missouri
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Two cases in which the effectiveness of "laryngospasm notch" pressure against laryngospasm was confirmed by imaging examinations. J Anesth 2013; 27:761-3. [PMID: 23494677 DOI: 10.1007/s00540-013-1592-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2013] [Accepted: 02/28/2013] [Indexed: 10/27/2022]
Abstract
We report two cases in which development of laryngospasm and release of the spasm immediately after applying pressure in the "laryngospasm notch" was confirmed by ultrasonographic and fiberoptic examinations. A bronchoscopy was planned under propofol sedation using a laryngeal mask airway for a 61-year-old man after subtotal esophagotomy. When a bronchoscope was advanced into the trachea, the vocal cords suddenly closed. Immediately after pressure with the fingertips was applied to the "laryngospasm notch," the vocal cords opened, which was observed through the bronchoscope in real time. A 22-year-old woman presented for emergency caesarean section under general anesthesia. After the completion of the procedures, the patient was not yet following commands but her breathing was steady. Thus, extubation was performed; however, she began to display signs of respiratory stridor. An ultrasonographic examination revealed that the vocal cords were noted to close, which suggested that she was developing laryngospasm. With this diagnosis, pressure at the "laryngospasm notch" was applied. Immediately after this maneuver, the vocal cords opened. We reconfirmed that applying pressure in the "laryngospasm notch" was effective to release laryngospasm. Imaging studies, especially ultrasonographic examination, were useful for making the decision to apply pressure in the "laryngospasm notch."
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Levine AI, Govindaraj S, DeMaria, Jr. S. Pediatric Otolaryngology. ANESTHESIOLOGY AND OTOLARYNGOLOGY 2013. [PMCID: PMC7121951 DOI: 10.1007/978-1-4614-4184-7_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Otolaryngologic procedures are commonly performed on children. In fact, pressure equalizing tube placement (ear tubes) and adenotonsillectomy are among the most frequent surgical interventions in the pediatric population. Therefore, every anesthesiologist who manages children undergoing otolaryngologic procedures must be familiar with the special implications of sharing the pediatric airway with an otolaryngologist working in the head and neck region. In addition, it is imperative to be skilled in the challenges of compassionately yet safely managing anxious young patients and their parents from the time of preoperative assessment until discharge from the post anesthesia care unit.
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Affiliation(s)
- Adam I. Levine
- Otolaryngology, and, Structural & Chemical Biology, Department of Anesthesiology,, The Mount Sinai School of Medicine, New York, 10029 New York USA
| | - Satish Govindaraj
- Head and Neck Surgery, Department of Otolaryngology -, The Mount Sinai Medical Center, New York, 10029 New York USA
| | - Samuel DeMaria, Jr.
- Department of Anesthesiology, The Mount Sinai School of Medicine, New York, 10029 New York USA
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Cooper RM, Khan S. Extubation and Reintubation of the Difficult Airway. BENUMOF AND HAGBERG'S AIRWAY MANAGEMENT 2013. [PMCID: PMC7158180 DOI: 10.1016/b978-1-4377-2764-7.00050-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
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Ujuzi Practical Pearl/Perle Pratique. Afr J Emerg Med 2012. [DOI: 10.1016/j.afjem.2012.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Hamaekers AE, Henderson JJ. Equipment and strategies for emergency tracheal access in the adult patient. Anaesthesia 2011; 66 Suppl 2:65-80. [DOI: 10.1111/j.1365-2044.2011.06936.x] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Abstract
OBJECTIVE The objective of this study was to assess predictors of emergency department (ED) ketamine-associated laryngospasm using case-control techniques. METHODS We performed a matched case-control analysis of a sample of 8282 ED ketamine sedations (including 22 occurrences of laryngospasm) assembled from 32 prior published series. We sequentially studied the association of each of 7 clinical variables with laryngospasm by assigning 4 controls to each case while matching for the remaining 6 variables. We then used univariate statistics and conditional logistic regression to analyze the matched sets. RESULTS We found no statistical association of age, dose, oropharyngeal procedure, underlying physical illness, route, or coadministered anticholinergics with laryngospasm. Coadministered benzodiazepines showed a borderline association in the multivariate but not univariate analysis that was considered anomalous. CONCLUSIONS This case-control analysis of the largest available sample of ED ketamine-associated laryngospasm did not demonstrate evidence of association with age, dose, or other clinical factors. Such laryngospasm seems to be idiosyncratic, and accordingly, clinicians administering ketamine must be prepared for its rapid identification and management. Given no evidence that they decrease the risk of laryngospasm, coadministered anticholinergics seem unnecessary.
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Jinzenji A, Maeda S, Higuchi H, Yoshida K, Mori T, Egusa M, Miyawaki T. Partial laryngospasms during general anesthesia with a laryngeal mask airway for dental treatment: a report of 5 cases. J Oral Maxillofac Surg 2010; 68:2554-7. [PMID: 20591552 DOI: 10.1016/j.joms.2009.09.083] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2009] [Revised: 08/25/2009] [Accepted: 09/23/2009] [Indexed: 10/19/2022]
Affiliation(s)
- Ayako Jinzenji
- Department of Dental Anesthesiology, Okayama University Hospital, Okayama, Japan
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Hobaika ABDS, Lorentz MN. [Laryngospasm]. Rev Bras Anestesiol 2009; 59:487-95. [PMID: 19669024 DOI: 10.1590/s0034-70942009000400012] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2008] [Accepted: 04/01/2009] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Airways management is fundamental for anesthesiologists, especially during induction of anesthesia and after extubation, when laryngeal spasm is more common. The anesthesiologist should know pharyngeal-laryngeal physiology and the risk factors for airways obstruction, since this is a potentially severe complication with a multifactorial etiology that can develop during anesthesia and whose consequences can be catastrophic. A delay in the diagnosis or treatment and its evolution can lead to hypoxemia, acute pulmonary edema, and, eventually, death of the patient. In this context, the objective of this report was to review the measures that should be taken in cases of laryngospasm because adequate oxygenation and ventilation may be compromised in this situation. CONTENTS This review article presents the mechanisms of airways management, discussing the most relevant aspects and etiology, pathophysiology, treatment, and prevention of laryngospasm. CONCLUSIONS The literature has several recommendations on the treatment or prevention of laryngospasm, but none of them is completely effective. Due to its severity, further studies on measures to prevent this complication are necessary.
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Abstract
Outcomes from pediatric surgery when carried out by trained pediatric anesthetists are excellent. This is not the case when the anesthesia provider is poorly trained. The presence of pediatric anesthetists is not only the norm but considered mandatory for children below the age of 2-3 years in developed countries. There are many reasons why trained anesthetists are not readily available in developing countries - migration to greener pastures, inadequate training facilities, poor remuneration and support services being some of them. These problems should be addressed but safety of the children should not be compromised. One should not condone poor standards to deprive children of safe anesthesia and the caregiver of much needed self-respect.
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Affiliation(s)
- Rebecca Jacob
- Department of Anesthesia, Christian Medical College, Vellore, Tamilnadu, India.
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Abstract
BACKGROUND Laryngospasm, a potentially life-threatening complication of anesthesia, is reported more commonly in children (17.4/1000) than in the general population (8.7/1000). However, there are no clinical data on the optimal type and sequence of therapeutic interventions. We therefore characterized the interventions used at St. Jude Children's Research Hospital. METHODS The institutional quality improvement database was reviewed to identify cases of laryngospasm that occurred from July 1999 through December 2002. Patient records were examined to determine the timing of laryngospasm, the airway management technique in use and the type of intervention used to treat the episode. RESULTS Twenty one cases of laryngospasm occurred (1/1000) during 21 452 anesthetics delivered in the operating room (19%) or for diagnostic and therapeutic procedures outside of the operating room (81%). Episodes occurred during emergence (47.6%), induction (28.6%) and maintenance (23.8%). Thirty-eight percent of patients responded to airway repositioning and continuous positive airway pressure. Ten patients (47.6%) were given muscle relaxants and five (23.8%) were intubated. CONCLUSIONS In the largest single-institution study to date of laryngospasm in pediatric patients, we found a rate of 1/1000 cases. Treatment followed a basic algorithm comprising continuous positive airway pressure, deepening of anesthesia, muscle relaxation and tracheal intubation.
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Affiliation(s)
- Laura L Burgoyne
- Division of Anesthesiology, St. Jude Children's Research Hospital, Memphis, TN 38105-2794, USA.
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Abstract
Laryngospasm is a common complication in pediatric anesthesia. In the majority of cases, laryngospasm is self-limiting. However, sometimes laryngospasm persists and if not appropriately treated, it may result in serious complications that may be life-threatening. The present review discusses laryngospasm with the emphasis on the different prevention and treatment modalities.
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Affiliation(s)
- Achir A Alalami
- Department of Anaesthesia, American University of Beirut Medical Center, Beirut, Lebanon.
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Abstract
Pediatric laryngospasm is an anesthetic emergency. It is a relatively common phenomenon that occurs with varying frequency dependent on multiple factors. In view of this and the clear risks to the patient when it occurs, a consensus committee has been established to determine the evidence based management of this condition. This article will cover the definition, causes and recognition of laryngospasm and the evidence behind a proposed algorithm for its' management.
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von Ungern-Sternberg BS, Erb TO, Frei FJ. Management der oberen Atemwege beim spontan atmenden Kind. Anaesthesist 2006; 55:164-70. [PMID: 16252114 DOI: 10.1007/s00101-005-0946-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
In unconscious, spontaneously breathing and anaesthetised children, a high incidence of partial or complete airway obstruction jeopardizes sufficient oxygenation. In this situation, the most important and efficient manoeuvre is to open up the upper airway. Chin lift, jaw thrust and continuous positive airway pressure (CPAP) are proven and effective methods for opening an obstructed upper airway. In addition to these simple airway manoeuvres, different techniques of body positioning (e.g., lateral positioning or supine position in combination with the "sniffing position") are effective to improve and maintain upper airway patency.
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von Ungern-Sternberg BS, Erb TO, Reber A, Frei FJ. Opening the upper airway--airway maneuvers in pediatric anesthesia. Paediatr Anaesth 2005; 15:181-9. [PMID: 15725313 DOI: 10.1111/j.1460-9592.2004.01534.x] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Fodale V, Praticò C, Leto G, Caminiti V, Mazzeo AT, Lucanto T. Propofol relieves post-extubation laryngospasm in obstetric anesthesia. Int J Obstet Anesth 2004; 13:196-7. [PMID: 15321402 DOI: 10.1016/j.ijoa.2004.02.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Abstract
PURPOSE OF REVIEW Paediatric airway problems are among the most challenging clinicians will face throughout their career. Clinicians unaccustomed to dealing with children tend to approach paediatric airway problems with a disproportionate amount of fear that is often engendered by inexperience, and this fear can interfere with performance. Understanding the differences between the infant upper airway and the airway in older children is important to properly manage the airway. RECENT FINDINGS Airway manoeuvres and the important tools used for airway management, such as the laryngeal mask airway, the fibreoptic bronchoscope and the new intubating fibreoptic stylets for managing the difficult paediatric airway, have been elucidated in the literature. SUMMARY Planning, preparation, and teamwork are essential, and must include an awareness of problems that might occur in the recovery period. Special clinical situations such as management of the child with impending airway obstruction are discussed.
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Affiliation(s)
- Adrian Reber
- Department of Anaesthesiology and Intensive Care Medicine, Hospital of Zollikerberg, Zollikerberg, Switzerland.
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Gurung AM, Tomlinson AA. Pre-preparation of succinylcholine: significant waste for questionable benefit. Anaesthesia 2004; 59:211-2. [PMID: 14984515 DOI: 10.1111/j.1365-2044.2004.03701.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Saranteas T, Mourouzis C, Koumoura F, Tesseromatis C. Effects of propranolol or paracetamol on lidocaine concentrations in serum and tissues. J Oral Maxillofac Surg 2003; 61:604-7. [PMID: 12730840 DOI: 10.1053/joms.2003.50090] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE The goal of this study was to determine the interaction of lidocaine after paracetamol or propranolol administration. MATERIALS AND METHODS Group A rats received a mixture of cold lidocaine and (14)C lidocaine into the masseter muscle. Group B rats received lidocaine and paracetamol 7.5 mg/kg orally, whereas group C received lidocaine intramuscularly and propranolol 1.5 mg/kg orally. Five consecutive doses were administered. The levels of these drugs were estimated in serum and the total concentration and the percent protein binding of lidocaine in tissues (liver and mandible) were determined. The rats were killed 2 hours after the last dose. RESULTS The results suggest that lidocaine concentrations in serum were significantly increased after either paracetamol or propranolol administration. Additionally, the combined therapy of propranolol and lidocaine resulted in a significant decrease in the total concentration and the percent protein binding of lidocaine in tissues. CONCLUSIONS The coadministration of lidocaine with paracetamol or propranolol interferes with the metabolic profile, resulting in pharmacokinetic interactions that may be significant for the determination of the correct dose of lidocaine in clinical applications.
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Affiliation(s)
- Theodosios Saranteas
- Department of Pharmacology, Medical School, University of Athens, Athens, Greece
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Afshan G, Chohan U, Qamar-Ul-Hoda M, Kamal RS. Is there a role of a small dose of propofol in the treatment of laryngeal spasm? Paediatr Anaesth 2002; 12:625-8. [PMID: 12358660 DOI: 10.1046/j.1460-9592.2002.00937.x] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Propofol has been found to depress the laryngeal reflexes. We studied whether this property could be utilized to relieve laryngeal spasm. METHODS This study was conducted over a period of 3 years, and included children aged 3-10 years, ASA status I and II. Most of the children were undergoing minor surgical procedures, under general anaesthesia with Laryngeal Mask Airway (LMA trade mark ) and caudal epidural analgesia. RESULTS During this period, 20 patients developed laryngeal spasm on removal of the LMA at the end of surgery. Initially, they all were treated with 100% O2, with gentle positive pressure ventilation. Out of 20 patients, seven responded well with 100% O2 and gentle positive pressure ventilation. The remaining 13 were treated with a small dose of propofol (0.8 mg.kg-1 body weight). Laryngeal spasm was relieved successfully in 10 patients and three patients required intubation to improve their oxygenation. CONCLUSIONS Propofol in a small dose (0.8 mg.kg-1 body weight) was a useful drug to relieve laryngeal spasm in most children (76.9%) following the removal of the LMA. Because it was not found to be effective in all patients, succinylcholine still has a role to play in critical conditions. However, we recommend propofol as a suitable alternative for relieving laryngeal spasm in situations where succinylcholine is contraindicated.
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Affiliation(s)
- Gauhar Afshan
- Department of Anaesthesia, The Aga Khan University Hospital, Karachi, Pakistan.
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