Safety and efficacy of the laryngeal mask airway A prospective survey of 1400 children

Abstract

The role of tlie laryngeal mask airway in children is supported by numerous papers (12 = 20), abstracts ( n = 33), and other reports ( i i = 88). but there are only a few large scale studies ( > I000 patients) assessing its safety and efficacy and none in which anaesthetic management was standardised. In addition, coiieeriis have been raised that placement may be more dillicult in children [4] and it has been suggested thxt the standard insertion technique recommended by Bruin may be suboptimal in infants and children [5, 61.Recently we conducted a trial assessing tlie rate of skill acquisition of trainee anaestlietists in 600 children [7]. We have continued to gather data about LMA usage by trainee anaestlietists pacdiatric anaesthetic practice and would like to present data from ii further 1400 LMA uses. The primary aim o f this further study was to provide information about insertion and complication rates using the standard recommended insertion technique. A secondary aim was to assess factors leading to an increased risk of problems with LMA usage in infants and children using a limited range of stundaidiscd anaesthetic techniques. ,\~i,lll O d \A prospective survey of 1400 consecutive pacdiati-ic anaesthetics given by trainee anxsthetists in which the LMA W;IS the planned form of airway management was iindcrtitkcn at tlie Maranon University Hospital. Data from ;I previous prospective study determining skill acquisition were excluded from the analysis [7]. Ethics committee approval W;IS not obtained sincc all aspects of management wcrc part o f routine practice.Iletailcd records were kept of all LMA uses by trainee anacsthetists tising ii predesigned data sheet. All observations were made by tlie supervising consultant involved in the case wlio was trained in the sttidy protocol and problem definitions. The supervising consultants only intervened if the oxygen saturation decreased below W%,. All trainees were individually instructed in LMA tisagc and the study protocol by one of tlie authors. wlio also ensured that the study protocol was adhered to by const;int education and supervision. The decision to LISC the LMA in each patient was made by [he supervising consultant. ;is W;IS the mode of its use. These decisions were based on tlie requirements of individual patients and the prcfcrred choice of the supervising consultant within thc confines o f tlie study protocol. The LMA was not used In patients ;it I-isk of a s pi ration o r for in t 1-21 -;I bdom i n a I. thoracic. in Li-io r head and neck 01-vascular surgery. or patients who were ASA grade 4 o r 5.Data obtained included age, sex, ASA griide. anaesthetic technique, type and duration of surgery. LMA size ;ind tlie number of attempts required for succcssftil placement. The cumulative experience of the trainee with tlic LMA in paediatric practice and predelincd problems occurring d iir i ng i lid uc ti on. main tena nee and recovery were ;I 1 so documented. Induction was delined H S the start 01' iqjcction of propofol until the beginning of surgery. M...

Supraglottic airways in children: past lessons, future directions

“…In a prospective study of 1,400 children who had LMA TM -based anesthesia conducted by supervised trainees, the device was found to be highly effective for a broad range of surgical procedures, and there was no instance where the LMA TM had to be replaced with an endotracheal tube (ETT). 2 Initial misgivings about the use of the LMA TM for head and neck procedures were shown to be largely unfounded. For example, the LMA TM was shown to be safe and effective when used for ophthalmological surgery and adenotonsillectomy in children 3,4 ; however, these situations require a surgeon with some insight that the trachea is not intubated.…”

“…In Lopez-Gil's large study, there was no difference in the incidence of complications with either mode of ventilation. 2 It remains to be seen if pressure support ventilation will lead to improved outcomes in children undergoing anesthesia via an LMA TM . There is no clear evidence as to how long an LMA TM may safely remain in situ; however, there are anecdotal reports of prolonged use in children.…”

“…Data for complications with the LMA classic TM in children show an overall incidence of complications of 12%. 2 Common problems (5-10%) include sore throat and cough. More infrequent complications (\5%) include difficulty placing the airway, airway obstruction, hypoxemia, laryngospasm, and blood staining of the device.…”

“…Dans une étude prospective portant sur 1400 enfants ayant reçu une anesthésie impliquant un LMA TM réalisée par des stagiaires supervisés, il a été observé que le dispositif était très efficace dans une vaste gamme d'interventions chirurgicales, et il n'y a pas eu de cas nécessitant le remplacement du LMA TM par une sonde endotrachéale (SET). 2 Il a été démontré que les craintes initiales concernant l'utilisation du LMA TM pour les interventions au niveau de la tête et du cou étaient largement sans fondement. Par exemple, il a été démontré que le LMA TM était sécuritaire et efficace lors de son utilisation en chirurgie ophtalmologique et pour des amygdalectomies chez les enfants 3,4 ; de telles situations nécessitent toutefois un chirurgien qui sache reconnaître que la trachée n'est pas intubée.…”

“…Dans l'étude d'envergure de LopezGil, il n'y a pas eu de différence dans l'incidence des complications entre ces deux modes de ventilation. 2 Il reste à déterminer si l'aide inspiratoire avec pression entraînera de meilleurs devenirs chez les enfants anesthésiés avec un LMA TM . Nous ne disposons d'aucune donnée claire concernant le temps pendant lequel le LMA TM peut rester en position de façon sécuritaire; toutefois, certaines présen-tations anecdotiques font état d'une utilisation prolongée chez des enfants.…”