Fibreoptic assessment of paediatric sized laryngeal mask airways.

Laryngeal mask airways (LMA) are commonly used in paediatric anaesthesia. A well-placed LMA should provide a direct view of the vocal cords facilitating bronchoscopy or fibreoptic intubation. The aim of this audit was to assess the bronchoscopic view of the glottis obtained through an LMA with regard to its size. We prospectively assessed the position of LMAs in relation to the glottic aperture in 350 children (zero to seven years) undergoing elective fibreoptic examination of the upper and/or lower airways. Following induction of anaesthesia and positioning of the LMA, a fibreoptic evaluation of the view of the glottis was performed (complete, partial or no visualisation). Chest movement on manual ventilation was judged as good in the majority of patients and adequate for the remainder. No overt signs of airway obstruction were noted in any patient. However, a complete view of the glottic aperture was present in only 50% of size 1 LMAs, 57.5% of size 1.5, 72.7% of size 2 and 77.8% of size 2.5. The epiglottis impinged on the LMA opening, partially obstructing the view of the glottis in 36.3% of size 1 LMAs, 31.5% of size 1.5, 21% of size 2 and 17.8% of size 2.5. In 13.7% of size 1 LMAs, 11% of size 1.5, 6.3% of size 2 and 4.4% of size 2.5, the epiglottis was completely downfolded, obstructing the view of the glottic aperture. The findings indicate that even if ventilation is judged as adequate, smaller paediatric LMAs are more commonly associated with suboptimal anatomical positioning with partial obstruction of the glottic aperture than larger LMAs, and therefore may require repositioning more often.

Patterns of sevoflurane use in a children's hospital: the effects of a simple educational intervention.

We conducted a prospective observational study of sevoflurane use over a four-week period at our tertiary referral children's hospital. Sevoflurane vaporisers were weighed before and after all general anaesthesia sessions and anaesthesia time intervals recorded. Midway through the audit, the initial findings were presented to the department with a brief reminder of ways to reduce sevoflurane use. These included recommendations for fresh gas flows and use of alternative agents during maintenance. Sevoflurane use then continued to be audited over a further two-week period. Anaesthesia in induction rooms accounted for 60% of total sevoflurane use but involved only 15% of total general anaesthetic time. Thus sevoflurane was used eight times faster in the induction rooms when compared to operating theatres. There was a 53% reduction in the rate of use of sevoflurane after the educational intervention, with an 87% reduction in in-theatre use and a 31% reduction in induction room use. This represents a potential saving of $108,120 per annum in our institution. Workloads before and after the educational intervention were comparable. A more complete cost benefit analysis of this initiative would include the costs of alternative agents and any clinical disadvantages incurred and would be seen in the context of the overall health budget. This was beyond the scope of this project. Clinicians can be relatively complacent about financial accountability. In this study, a simple educational reminder halved sevoflurane use in the short term. This study suggests that specific reminders or recommendations about anaesthetic technique in the induction rooms may be indicated.