The use of laryngeal mask airway for tonsillectomy and adenoidectomy.

PURPOSE: Patients undergoing tonsillectomy and adenoidectomy traditionally receive anesthesia with endotracheal intubation (ETT) for airway management. The laryngeal mask airway (LMA) may be used instead and may be associated with less airway stimulation and shorter operating room times. The purpose of this study was to report on a large cohort of patients undergoing tonsillectomy and/or adenoidectomy while using the LMA for airway maintenance during anesthesia. METHODS: Patients undergoing tonsillectomy and adenoidectomy between January 6, 2017 and January 6, 2020 with a LMA were reviewed for safety outcomes. We compared two cohorts of patients with LMA and ETT to analyze the effect on operating room times. RESULTS: Our study identified 1042 patients who met criteria for review. The incidence of cases requiring conversion to ETT (1.2%) and laryngospasm (0.3%) in our cohort is lower than previously suggested by the literature. The patients who underwent surgery with the LMA spent less time in the operating room (p = 0.004) compared to the ETT group. CONCLUSION: The use of the LMA may be a safe and effective option for airway management during tonsillectomy and adenoidectomy. There may be a benefit of OR time reduction in patients undergoing anesthesia with an LMA compared to ETT.

Point-of-care ultrasound for the pediatric regional anesthesiologist and pain specialist: a technique review.

Point-of-care ultrasound (PoCUS) has been well described for adult perioperative patients; however, the literature on children remains limited. Regional anesthesiologists have gained interest in expanding their clinical repertoire of PoCUS from regional anesthesia to increasing numbers of applications. This manuscript reviews and highlights emerging PoCUS applications that may improve the quality and safety of pediatric care.In infants and children, lung and airway PoCUS can be used to identify esophageal intubation, size airway devices such as endotracheal tubes, and rule in or out a pulmonary etiology for clinical decompensation. Gastric ultrasound can be used to stratify aspiration risk when nil-per-os compliance and gastric emptying are uncertain. Cardiac PoCUS imaging is useful to triage causes of undifferentiated hypotension or tachycardia and to determine reversible causes of cardiac arrest. Cardiac PoCUS can assess for pericardial effusion, gross ventricular systolic function, cardiac volume and filling, and gross valvular pathology. When PoCUS is used, a more rapid institution of problem-specific therapy with improved patient outcomes is demonstrated in the pediatric emergency medicine and critical care literature.Overall, PoCUS saves time, expedites the differential diagnosis, and helps direct therapy when used in infants and children. PoCUS is low risk and should be readily accessible to pediatric anesthesiologists in the operating room.

Fentanyl versus remifentanil-based TIVA for pediatric scoliosis repair: does it matter?

INTRODUCTION: Opioid-induced hyperalgesia (OIH) and acute opioid tolerance have been demonstrated extensively in patients undergoing adolescent idiopathic scoliosis (AIS) repair. Remifentanil infusion has been strongly linked to both tolerance and OIH in these patients; however, the impact of using an intraoperative fentanyl infusion has not been well studied. This study aims to determine if patients undergoing operative management of AIS have decreased opioid consumption and pain scores when an intraoperative fentanyl infusion is used as compared with a remifentanil infusion. METHODS: This is a retrospective chart review of patients with AIS who underwent posterior spinal fusion. During the period January 2012-June 2013, patients received remifentanil infusion as part of total intravenous anesthesia. From July 2013 to June 2015, remifentanil was replaced by fentanyl as standard protocol. The remifentanil cohort included 37 patients and the fentanyl cohort included 25 patients. The primary outcome was the total opioid consumption (morphine equivalents) in the first 24 hours postsurgery. Secondary outcomes included mean postoperative pain score in the first 24 hours postsurgery, postoperative opioid consumption 24-48 hours after surgery, time to extubation, time to assisted ambulation, length of stay, and incidence of postoperative nausea and vomiting. RESULTS: Compared with the remifentanil group, the fentanyl group had significantly higher postoperative opioid usage during the first 48 hours and significantly higher postoperative mean pain score during the first 24 hours. There was no difference between the two groups in mean pain score for 24-48 hours, extubation time, time to assisted ambulation, length of stay, or postoperative nausea and vomiting. DISCUSSION: Despite concerns for hyperalgesia and acute tolerance, remifentanil is widely used for intraoperative opioid infusions for surgical correction of AIS. This retrospective study examined a practice change from intraoperative remifentanil to intraoperative fentanyl as a potential approach to avoid OIH. Surprisingly, patients receiving fentanyl intraoperatively showed increased postoperative opioid use and pain scores in the first 24 hours postsurgery compared with the prior cohort receiving remifentanil. Substitution of fentanyl for remifentanil during surgical correction of AIS does not appear to solve the problem of OIH or acute tolerance. Prospective studies are needed to confirm this unexpected result.

The use of laryngeal mask airway for adenoidectomy.

OBJECTIVES: Airway management during adenoidectomy is traditionally performed through endotracheal intubation (ETT). Laryngeal mask airway (LMA) may be less stimulating to the airway and allow for shorter overall operating room time. Previous studies report LMA use during adenotonsillectomy. There has been no prior evaluation of LMA use during adenoidectomy alone. In this study, we attempt to identify the rate and contributing factors of LMA failure during adenoidectomy. METHODS: All pediatric patients undergoing adenoidectomy between January 1, 2016 and June 30, 2017 were reviewed. Demographic and clinical data were collected and analyzed to determine the need for conversion to ETT and the occurrence of any complications. RESULTS: Our study revealed 139 pediatric patients who underwent adenoidectomy during the study period. 110 patients had adenoidectomy performed with LMA and 27 patients had ETT. Two patients (1.8%) required conversion to ETT because of difficulty with ventilation when the mouth gag was in place. There were no complications. Mean operating room time was 20 min less in the LMA group (P < 0.05). CONCLUSIONS: The use of an LMA in adenoidectomy may be a safe and effective alternative to ETT. More study is required to determine overall complication rates.