SummaryThe laryngeal mask airway is included as a first line airway device during adult resuscitation by first responders. However, there is little evidence for its role in paediatric resuscitation. Using anaesthetised children as a model for paediatric cardiopulmonary arrest, we compared the ability of critical care nurses to manually ventilate the anaesthetised child via the laryngeal mask airway compared with the facemask and oropharyngeal airway. The airway devices were inserted in random order and chest expansion was measured using an ultrasound distance transducer. The critical care nurses were able to place the laryngeal mask airway and achieve successful ventilation in 82% of children compared to 70% using the facemask and oropharyngeal airway, although the difference was not statistically significant (p = 0.136). The median time to first successful breath using the laryngeal mask airway was 39 s compared to 25 s using the facemask (p < 0.001). In this group of nurses, we did not show a difference in ventilation via a laryngeal mask airway or facemask, although facemask ventilation was achieved more quickly.

In adults, first responders to a cardiopulmonary arrest provide better ventilation using a laryngeal mask airway than a facemask. It is unclear if the same is true in children. We investigated this by comparing the ability of 36 paediatric ward nurses to ventilate the lungs of 99 anaesthetised children (a model for cardiopulmonary arrest) using a laryngeal mask airway and using a facemask with an oropharyngeal airway. Anteroposterior chest wall displacement was measured using an ultrasonic detector. Nurses achieved successful ventilation in 74 (75%) of cases with the laryngeal mask airway and 76 (77%) with facemask and oropharyngeal airway (p = 0.89). Median (IQR [range]) time to first breath was longer for the laryngeal mask airway (48 (39-65 [8-149])) s than the facemask ⁄ airway (35 (25-53 [14-120]) s; p < 0.0001). In 10 cases (10%) the lungs were ventilated using the laryngeal mask airway but not using the facemask ⁄ oropharyngeal airway. We conclude that ventilation is achieved rapidly using a facemask and oropharyngeal airway, and that the laryngeal mask airway may represent a useful second line option for first responders. The laryngeal mask airway (LMA) has been advocated as a device for airway management during the resuscitation of adults following cardiopulmonary arrest [1] but its role in the resuscitation of children is less clear. Tracheal intubation, the gold standard for securing the airway, is a difficult skill to acquire and maintain and can lead to further complications if an unsuccessful intubation is not recognised [2,3]. In contrast, insertion of the LMA can be learnt quickly and easily by inexperienced personnel [2, 4-6]; however, the LMA is not currently recommended for first line airway management in children requiring resuscitation [7].In an attempt to establish the utility of the LMA during resuscitation of children by first responders untrained in tracheal intubation, we have previously studied paediatric critical care nurses [8]. Their ability to ventilate the lungs of an apnoeic, anaesthetised child using an LMA was compared with that using a facemask and oropharyngeal airway. We found no difference in the efficacy of ventilation between the two methods; however, ventilation with the LMA took significantly longer to achieve. Two main limitations of that study are first, the practitioners were relatively experienced with facemask ventilation and as such may not be representative of first responders to cardiopulmonary arrests in children. Second, the method of LMA insertion that was taught was the method advocated by Brain in adults and this may not be optimal, studies having shown that the lateral insertion technique has a higher success rate in children [9][10][11].In view of these limitations we have repeated our randomised crossover trial, comparing the LMA with the facemask and oropharyngeal airway for manual ventilation of the lungs of apnoeic anaesthetised children. We studied ward based paediatric nurses as our cohort of practitioners as we felt their skills were more likely to...

Anaesthetists are being asked to look after increasing numbers of older patients. This brings more complexity, and means that issues such as frailty and cognitive impairment, which are associated with adverse post-operative outcomes, have to be acknowledged and managed more frequently [1,2]. Pre-operative assessment does not traditionally tend to identify and manage such issues proactively, but new guidance suggests a more comprehensive approach [3].Having delivered joint anaesthetic and geriatric assessments in the pre-operative clinic, we believe there are several measures that can and should be undertaken by preoperative teams and offer some practical advice from our experience.

visualisation of relevant neuraxial structures, predicting depth of epidural space from skin, reduction in bony contact and faster epidural placement. The visibility of neuraxial structures declines in patients as age increases. To date, there are no studies looking at the extent of spread of local anaesthetic solution in the epidural space and its correlation to the volume used, under ultrasound guidance. We report the results of our audit on spread of local anaesthetic solution in the epidural space in single shot caudal blocks. This abstract is based on the first 17 patients, the presentation will be based on all 50 patients. Methods: This audit was approved by the local audit committee. We aimed to follow the extent of the spread of local anaesthetic within the epidural space with real time ultrasonography. Patients were selected when the planned anaesthetic included a single shot caudal block. The anaesthetists performing the anaesthetic and the caudal block consented to our ultrasound visualisation. All patients were below 5 years of age. No attempt was made to standardise the technique, the dose, or the speed of injection. After the placement of the caudal cannula by the primary anaesthetist involved in patient care, a separate anaesthetist, experienced in using ultrasound, visualised the neuraxial structures and subsequent spread of the local anaesthetic solution with real time ultrasound. The spread was followed during the injection and for 10 s after the 3 completion of the injection. A 5 cm 7.5-12 MHz linear array was used longitudinally with either midline or paramedian approach. Results: We are reporting the preliminary results from 17 patients. Patients were aged between 1 day and 1 year 10 months. They weighed between 3.3 kg and 14.6 kg. Either 22 gauge Jelco or Abbocath were used to perform the procedure; 0.25% or 0.20% Lbupivacaine was used on all occasions. The volume administered per kg ranged between 0.33 and 1.27 ml. The visibility of neuraxial structures was good on all occasions. On calculating the Spearmans correlation coefficient, the extent of spread of local anaesthetic in the epidural space was positively correlated with the volume used by a correlation coefficient of 0.64, with a P value of 0.008. The postoperative pain score in recovery was 0 in 16 out of the 17 cases. The one failure occurred when the observed spread would not have been expected to provide analgesia for the performed operation.Conclusions: Among children below 5 years of age, there seems to be a positive correlation between the volume of local anaesthetic injected into the epidural space and the extent of its spread. This needs to be further investigated by a prospective randomised control trial. The utility of real time ultrasound to allow a reliable achievement of a desired level of sensory block, should be investigated i.e, whether the volume used in achieving a desired level of local anaesthetic spread, as guided by ultrasound, provides superior analgesia and fewer adverse effects compared with the volume calcul...

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