Safety and Efficacy of Pediatric General Anesthesia by Laryngeal Mask Airway Without Intravenous Access

doi:10.4236/ijcm.2011.23057

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International Journal of Clinical Medicine, 2011, 2, 328-331

doi:10.4236/ijcm.2011.23057 Published Online July 2011 (http://www.SciRP.org/journal/ijcm)

Safety and Efficacy of Pediatric General

Anesthesia by Laryngeal Mask Airway without

Intravenous Access

Benjamin A. Lin1, Zakaria S. Messieha2*, William E. Hoffman3

1Chief resident, Oral and Maxillofacial Surgery, University of Illinois, Chicago, USA; 2Associate Professor, Anesthesiology, Univer-

sity of Illinois, Chicago, USA; 3Research Associate Professor, Anesthesiology, University of Illinois, Chicago, USA.

Email: *[email protected]

Received January 9th, 2011; revised May 29th, 2011; accepted June 7th, 2011.

ABSTRACT

The safety and efficacy of the laryng eal mask airway (LMA) has been reported by numerous large-scale studies. How-

ever, they do not address the issue of whether an intravenous (IV) is required for pediatric general anesthesia (GA)

where access is challenging due to anatomical considerations and a lack of cooperation. The aims of this study are to

determine whether pediatric GA by LMA without IV access affected placement rates, procedure times and rates of an-

esthetic complications. Children who met these criteria at the UIC Surgicenter in the two year period prior to August

30, 2005 were selected. A retrospective chart review was conducted to determine patient demographics, ASA class,

procedure, placement success, IV placed if any, time to incision, and any anesthetic comp lica tions. 241 patien ts without

IV access and 41 patients with IV access were included. No significant differen ces were found between the groups in the

rates of LMA placement or anesthetic complications. Significant differen ces were found in times to incision overa ll and

for ophthalmology exams under anesthesia and lacrimal duct probings. Pediatric GA by LMA without IV access dem-

onstrated a similarly high placement rate, shorter procedure times and a low rate of complications in comparison with

the control group.

Keywords: Pediatric Anesthesia, Anesthesia Efficacy, LMA Safety, General Anesthesia without Intravenous

Cannulation

1. Introduction

The laryngeal mask airway (LMA) is a device used to

secure an airway in an unconscious patient and is widely

and routinely used in the operating room for general

anesthesia (GA). GA in children differs than that for

adults as children tend not to tolerate the placement of

an intravenous (IV) line pre-operatively, which would

allow for the injection of medication. In addition to be-

ing uncooperative, children possess veins that are corre-

spondingly smaller than that of an adult making IV

placement technically more challenging. Typically, an

IV is placed once the child is asleep, depending on the

preference of the anesthesiologist. Elimination of this

step entirely would shorten operating room time and be

more cost effective.

There are no published accounts of GA by LMA used

in the specific context of no IV access; however, the

safety and efficacy of GA by LMA is well established

by the literature. In a retrospective study, Verghese et al.

describe the successful use of the LMA with IV access

in 11,910 adults and children with an overall placement

success rate of 99.81%, a risk of laryngospasm of 0.07%,

bronchospasm of 0.025%, and vomiting of 0.017% [1].

Mason et al. describe in a prospective study, the use of

the LMA with either Halothane or Isoflurane in 200

children with IV access for a variety of surgical proce-

dures with a successful placement rate of 97.5%, laryn-

gospasm in 2.5% and vomiting in 1.5% [2]. Lopez-Gil et

al. in another prospective study consisting of 1400 chil-

dren with LMA usage with Isoflurane and IV access

found successful placement in 98% of patients, 2.7%

with upper airway stimulation, including laryngospasm/

bronchospasm and vomiting/regurgitation/aspiration in

0.07% [3]. Conclusions of this study were that the inci-

dence of problems is similar to those of adults but that

there were a significantly higher complication rate (p <

Safety and Efficacy of Pediatric General Anesthesia by Laryngeal Mask Airway Without Intravenous Access 329

0.001) for ENT procedures and when using the size 1

LMA.

There has been only one report in the literature (Hau-

pert et al. 2004) that addresses the issue of whether an

IV is even required for pediatric general anesthesia

where access is technically challenging due to anatomi-

cal considerations and a lack of patient cooperation. This

randomized controlled study had 100 ASA statuses I or

II children aged 2-12 who underwent bilateral myringo-

tomies with pressure equalizing tube placement [4]. One

group received IV access and the other did not. Both

groups had mask induction and maintenance with oxy-

gen, nitrous oxide, and Sevoflurane. All children re-

ceived Fentanyl intramuscularly and spontaneous venti-

lation was maintained. Patients with IV access received

Lactated Ringer’s solution. Their study concluded that

intravenous access in otherwise healthy children in my-

ringotomy procedures provided no added benefit [4].

Significant differences included more pain medication

required (p < 0.001), lower parental satisfaction (p <

0.001) and more time spent in both the operating room

(p = 0.02) and recovery (p = 0.02) for the group of chil-

dren with IV access [4].

The purpose of this study was to determine if general

anesthesia by laryngeal mask airway without intrave-

nous access is safe and efficacious, resulting in highly

successful placement rates, shorter procedure times and

a low rate of anesthetic complications in a pediatric

population. Our study would be the first to highlight the

benefits of using general anesthesia by LMA without IV

access for short pediatric procedures in the head and

neck region such as bilateral myringotomies and tube

placement (BMT), ophthalmologic exams under anes-

thesia (EUA), nasolacrimal duct probing and chalazion

excision.

2. Methods

After receiving institutional review board approval, the

surgery schedule at the University of Illinois Medical

Center Surgicenter was used to select patients aged 0-17

who underwent GA by LMA between the dates of Sep-

tember 1, 2003 to August 30, 2005. A retrospective chart

review was performed and the following documents

were gathered for each potential subject: anesthesia re-

cords, operative reports, and if applicable, Surgicenter

reports, hospital admission notes and recovery room

notes. Subjects having complete records were then cho-

sen for inclusion. Subjects lacking the appropriate docu-

mentation were excluded from the study. Eligible pa-

tients were then assigned into 2 groups, based on

whether they had an IV placed after mask induction with

Sevoflurane. Group 1 had no IV access, and group 2 had

IV access. The following data was then collected and

compared between the two groups:

 Age, gender, weight, medical conditions and ASA

class

 Procedure done and operating room (OR) time to

incision

 LMA type used and whether successfully placed

 Type of anesthetic used, method of ventilation

 Type and location of intravenous placed if any

 Medications given pre-, peri- and post-operatively

and route of administration

 Anesthesia complications and management

Statistical analysis was performed using the software

program SigmaStat for Windows. Z-tests were utilized

for analysis of both LMA placement success rates and

complication rates between the groups 1 and 2. T-tests

were utilized for analysis of time to incision between the

groups. Statistically significant differences were consid-

ered achieved at p < 0.05.

3. Results

A total of 282 eligible pediatric patients were included

in this study. Group 1 had 241 patients and group 2 had

41 patients. 43.2% of the patients in group 1 and 46.3%

of the patients in group 2 were female. Figure 1 shows

the age distribution of the patients in each group. Figure

2 shows the distribution of patients according to Ameri-

can Society of Anesthesiologists (ASA) classification.

Table 1 shows the placement success rates between

the groups and according to LMA size as well as overall.

Group 1 had a 99.6% rate of successful LMA placement

while group 2 had a 97.6% success rate. There was no

significant difference between the groups in terms of

overall LMA placement success rates by Z-test (p =

0.63).

Table 2 lists the mean OR time to incision for each of

the procedures and overall performed between the two

Number of Patients

012345678910+

Age (Years)

No IV

Figure 1. Age distribution.

Safety and Efficacy of Pediatric General Anesthesia by Laryngeal Mask Airway Without Intravenous Access

330

100

120

140

Nu mbe r of Patients

III III

Physi cal St atus

No IV

Figure 2. ASA distribution.

groups as well as the mean time saved. There were sig-

nificant differences between the two groups for the pro-

cedures EUA (p = 0.02) and lacrimal duct probing (p <

0.001) as well as overall (p < 0.001). No statistical dif-

ference was observed for BMT (p = 0.07) and chalazion

excision (p = 0.47).

Table 3 shows the types and overall rate of anesthetic

complications by group. Group 1 had a 1.66% complica-

tion rate while group 2 had a 4.88% complication rate.

There was no significant difference between the groups

in terms of overall anesthetic complication rates by

Z-test (p = 0.47).

4. Discussion

Children represent a unique challenge to the anesthesi-

ologist due to their lack of co-operation and difficult

anatomy. Placement of an IV is not innocuous and mul-

tiple attempts at establishing one can take up a signifi-

cant amount of OR time as well as introduce additional

sites for post operative pain and scarring.

Our institution has been performing EUAs, BMTs, na-

solacrimal duct probings and chalazion excisions with-

out IV access for numerous years. Our patient demo-

graphics show that the majority of our cases were under

the age of 6 and ASA class I or II.

Our retrospective chart review demonstrated that there

was no significant difference between the groups in

terms of overall LMA placement success rates and that

the rates were comparable to those found in the literature.

This is understandable since all of the LMAs in our

study, regardless of IV status, were placed after mask

induction with Sevoflurane. One of the advantages of

the LMA is that muscle relaxation is not required for

placement [5]. In the rare event that the LMA could not

Table 1. LMA placement success rates.

LMA

Size No IV (n = 241) Placement

Success IV (n = 41)Placement

Success

1.5 43 (17.84%) 97.7% 3 (7.31%) 100%

2.0 137 (56.84%) 100% 26 (63.41%)96.2%

2.5 43 (17.84%) 100% 9 (21.95%)100%

3.0 15 (6.22%) 100% 3 (7.31%) 100%

4.0 2 (0.83%) 100% 0 N/A

5.0 1 (0.41%) 100% 0 N/A

Total*241 99.6% 41 97.6%

*No significant difference (p = 0.63).

Table 2. Times to incision.

Procedure IV

(n = 41)

Avg

Time

(min)

No IV

(n = 241)

Avg

Time

(min)

Avg

Time

Saved

(min)

p-value

Exam under

Anesthesia

29.26%

14.92 167

69.29%

11.13 3.79 0.02

Nasolacrimal

duct probing

17.07%

28.42 20

8.29%

12.55 15.87<0.001

Chalazion

excision

12.19%

27.4 5

2.07%

23 4.4 0.47

B/l myringo-

tomy +

tube placement

41.46%

15.23 49

20.33%

12.8 2.43 0.07

Total 41 11.84 241 18.88 7.04 <0.001

Table 3. Anesthetic complication rates.

No IV (n = 241) IV (n = 41)

Complications Laryngospasm ×3

Bronchospasm ×1

Larygospasm ×1

Intra-op regurgitation ×1

Overall Rate*: 1.66% 4.88%

*No significant difference (p = 0.47).

be successfully placed, then alternative methods such as

mask or endotracheal tube placement were used to

maintain general anesthesia.

It is standard at our institution to record time to inci-

sion for each procedure by the circulating nurse and this

marker was felt to better reflect the time taken for the

anesthesiologist to place the LMA without having op-

erative circumstances affect the results. Our study

showed that overall, as well as for EUAs and nasolacri-

mal duct probings, there was a significant difference in

time to incisions between the IV and no IV groups. Al-

though not significant for BMTs, it is to be noted that

this was barely so and perhaps a larger sample size

would have bore this out. There appears to be no sig-

nificant difference in chalazion excision times to inci-

sion but this could have been due to more extensive

prepping and draping requirements prior to incision.

There were no significant differences between the two

groups in terms of anesthetic complications. The com-

plications were all managed successfully without any

Safety and Efficacy of Pediatric General Anesthesia by Laryngeal Mask Airway Without Intravenous Access

331

long term sequelae. In the no IV group, the laryn-

gospasms were managed with jaw thrust and positive

pressure ventilation or placement of an IV and an en-

dotracheal tube.

Prior to mask induction of the patient, all intubation

equipment, an IV kit and setup and medications includ-

ing a succinylcholine/atropine dart are prepared.

Although IV is the preferred route for medications,

other routes such as intramuscular, tracheal and rectal

are available to deliver medications. Our patients were

routinely given rectal Acetaminophen or im Ketorolac

for post operative analgesia. This also does not preclude

us from placing an IV if one is required later on. The

disadvantages of not having an IV include the inability

to administer fluids. However, our procedures were

short and involved minimal to no blood loss. In addition,

children possess a greater cardiac reserve and the lack of

IV fluids did not affect our hemodynamic stability.

From these results, pediatric GA by LMA without IV

access is a feasible option for the anesthesiologist in

ASA class I or II patients for short head and neck pro-

cedures and demonstrates a high placement rate, shorter

procedure times and a low rate of complications in

comparison with controls. Future studies could encom-

pass prospective studies, randomization, larger sample

sizes, and other procedures such as suture removal.

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