reinforced lmas for paediatric tonsillectomy增强小儿扁桃体切除术昆布多糖硫酸酯

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1、ReinforcedLMAsforpaediatrictonsillectomyLesleyAitkenApril2008Day-casetonsillectomyinEpsom98%Day-casedischargerateBenefitscost–effectiveLesspressureoninpatientbedsLesspsychologicaltraumaforparentsandchildrenAnaesthesia2006,61,116-122Epsomchildren’sENTday-caseanaesthesiaprotocolClear

2、fluidsupto2hrspre-opEMLAorametopPropofolinductionIVondansetronOxygen/air/sevofluranerLMAinchildrenaged3orolderSpontaneousventilationIVdexamethasonePRdiclofenacPRparacetamolIMcodeineIVcrystalloids10ml/kgContinued(Post-op)FreefluidsandfoodondemandNursingobservationsfor6hrspost-opPost

3、-opconsultant-ledwardroundNurse-leddischarge6hrspost-opTheoreticaladvantagesofLMAAvoidsneuromuscularblockadeMinimisespharyngeal&laryngealtraumaNoendobronchial/oesophagealintubationLessairwaysoilingAvoidsextubationrisksDeepAwakeAirwayprotectionuntilawakeEvidenceCanadianpaedsstudy(19

4、93)Englishadult&paedsstudy(1993)Meta-analysis(1996)UKpracticeClarkeetal,BJA99(3):425-8(2007)Airwaymanagement<3yrs3-16AdultETT87%79%73%ReusableLMA0.60.61Single-useLMA127ReusableflexiLMA696SingleuseflexiLMA698Ninewells?ProspectivesurveyofLMAuse3criticalstages:1.Insertion2.OpeningofBD

5、gag3.recoveryMethodsSimpleformAllNWpaedsanaesthetistswithregularENTlistsMay2007–January200864patientsAgeAgenWeightWeightinKgLMAsizeNumberofinsertionattemptsQualityoffit5761ToleranceofBoyle-DavisGag5623RepositionafterBDgaginsertion?558Repositionsuccess?2successfullyrepositioned3conv

6、ertedtoETTConversiontoETTAirwaynotacceptablewithBDgagopenSuboptimalfit(?BetterwithsmallerLMA)and“chunky”childLMAobstructedcompletelywithBDgagOverallairwayquality5652RecoveryAllsmoothProblemsUnsatisfactoryfit–2AirwaycompromisedbyBDgag–3LMAdislodgedduringsurgery-3Problems(1)Age643kgL

7、MAmaybetoobig“chunky”childProblems(2)Age1365kgLotsofinsertionattemptsLMAneverfittedwellProblems(3,4,5)Ages4-615-20kgObstructionofLMAwithBDgagProblems(6+7)Ages7+827-28kgLMAdislodgedwhenBDgagremovedProblems(8)Age940kgLMAgoodfortonsillectomyDislodgedatendduringtoothremovalInsertionRec

8、overyWake-upAirwayprotecti