1Department of Neurosurgery, Section of Anaesthesia and Intensive Care, A.S.L. Città di Bologna, Ospedale Bellaria-C.A. Pizzardi, via Altura 3, Bologna, Italy. 2Institute of Anaesthesiology and Intensive Care, University of Bologna, Ospedale Policlinico S. Orsola Malpighi, Italy*Corresponding author: via Renata di Francia 44, I-44100 Ferrara, Italy
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Accepted for publication: December 12, 2001
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Abstract |
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Br J Anaesth 2002; 88: 7268
Keywords: complications, dysgenesia; airway, complications
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Introduction |
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The laryngeal mask airway (LMA) has become an accepted aid in cases of difficult tracheal intubation in both adults and children.49 In addition the LMA has been used successfully as a conduit for fibrescope-assisted tracheal intubation in patients with congenital syndromes such as Pierre-Robin, Treacher-Collins, and Goldenhar, known to present with difficult airways.1014 We describe the use of an LMA as a part of the anaesthetic strategy in an infant with congenital centrofacial dysgenesia.
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Case report |
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The presenting problem with airway management was the inability to use a correctly sized facemask because of the large asymmetrical cleft cheek as well as the need not to exert pressure on the other eyeball (Fig. 1).
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A second corrective surgical procedure was carried out on this infant with the same technique at the age of 5.5 months (weight 6 kg). On this occasion the patient was pre-medicated with oral diazepam 0.3 mg kg1 and atropine 0.01 mg kg1 given 30 min before surgery. After 5 min of preoxygenation, i.v. access was obtained. After administration of oropharyngeal topical anaesthesia (lignocaine 1 mg kg1) a size 2 LMA was inserted using the standard insertion technique. Once again the airway was secured easily and the ability to apply positive pressure ventilation was confirmed. Anaesthesia was induced with 2.5% sevoflurane and nitrous oxide (FIO2 50%) and further venous access established. Propofol 10 mg, fentanyl 20 µg, and vecuronium 0.2 mg kg1 were administered and an additional minute of manual ventilation with 100% oxygen was carried out. Laryngoscopy revealed a good view of the vocal cords (Cormack-Lehane I) and the trachea was intubated with a flexible, uncuffed size 4 tracheal tube (Rusch®). Pulse oximetry and NIAP were unchanged, and an arterial line was placed for perioperative monitoring during the 4.5 h surgical procedure. There were no perioperative problems and the infant was observed for 1 h in the postoperative surgical unit. He was discharged to the ward 1 h after extubation of the trachea and discharged home after 4 days.
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Discussion |
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The use of an LMA has been advocated in children with potentially difficult anatomy in order to avoid excessive airway instrumentation, thereby minimizing the risk of trauma and airway obstruction. Insertion of an LMA while our patient was still awake secured a patent airway before the induction of general anaesthesia. Once the infant was anaesthetized, we were able to proceed calmly with the task of tracheal intubation.
We were prepared for laryngospasm, coughing, or breath holding. If laryngospasm is encountered during the insertion of the LMA, we would recommend the use of succinylcholine and subsequent ventilation through the LMA, striving for an adequate depth of anaesthesia.
As LMA failure to ventilate children with abnormal airway anatomy has also been reported, equipment to deal with difficult intubation and emergency tracheostomy should be available.1719
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Conclusions |
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References |
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