喉罩的使用麻醉（英文）

Using the Laryngeal Mask Airway Norman L. Goody, MD Objective uUsing the LMA uLMA and the Difficult Airway uLMA and Pediatric Anesthesia uLMA and OB Anesthesia uAdvantages of Using the LMA uDisadvantages of the LMA uComplications Arising from Use of the LMA uContraindications to Using the LMA History of the LMA development began in 1981 at Royal London Hospital by Dr. Archie Brain modification of the Goldman Dental Mask available commercially in UK since 1988 and in the US since 1992 now used in 50% of general anesthetics in some centers in UK (and probably US, too- especially ambulatory surgery) Characteristics of the LMA uLatex free, medical-grade silicone uAperture bars uSizes #1 6.5 kg 2-5 ml #2 6.5-25 kg 7-10 ml #2 1/2 20-30 kg 14 ml #3 25-70 kg 15-20ml #4 70+ kg 25-30ml Using the LMA uPreparation of the LMA Check patency of cuff Lubricate POSTERIOR surface only Surgilube v. lidocaine jelly uInduction uInsertion of the LMA Common Problems Cricoid Pressure uSecuring the LMA Using the LMA uMaintenance of Anesthesia uRemoval of the LMA uCleaning, Sterilization and Re-use Determining Life Span of LMA uintended for 40-50 uses, but highly over- manufactured tube remains translucent aperture bars remain intact cuff deflates correctly no valve leakage cuff remains symmetric pilot balloon retains shape connector remains tight/ not broken THE LMA IS NOT DISPOSABLE LMA and the Difficult Airway uAwake Intubation uDifficult MASK Airway uBlind Intubation uFailed Intubation uFiberoptic Bronchoscopy and the LMA uEmergent Intubation by an Unskilled Provider LMA and Pediatric Anesthesia uDL82 (2) :247-50 LMA and OB Anesthesia Questionnaire to 250 anesthesiologists in the UK LMA was available in 91.4% of obstetric units 72% were in favor of using LMA for failed intubation with inadequate ventilation via face mask 24 had experience with LMA in such a situation, 8 of which stated that LMA had proved to be a “lifesaver” Authors believed that we should use LMA before cricothyroidotomy for failed intubation/ventilation Can J Anaesth Gataure, et al. 1995 Feb;42(2):130-3 Advantages of Using the LMA Meta-analysis comparing advantages of the LMA over the tracheal tube or face mask Reviewed 858 LMA publications identified to December 1994, of which 52 met criteria for analysis 32 different issues were tested Can J Anaesth Brimacombe 1995 Nov;42(11):1017-23 Advantages of LMA over ETT uincreased speed and ease of placement by inexperienced personnel uincreased speed of placement by anesthetists uimproved hemodynamic stability at induction and during emergence uminimal increase in intraocular pressure following insertion Can J Anaesth Brimacombe 1995 Nov;42(11):1017-23 Advantages of LMA over ETT ureduced anesthetic requirements for airway tolerance ulower frequency of coughing during emergence uimproved oxygen saturation during emergence ulower incidence of sore throats in adults Can J Anaesth Brimacombe 1995 Nov;42(11):1017-23 Advantages of LMA over Face Mask ueasier placement by inexperienced personnel uimproved oxygen saturation uless hand fatigue uimproved operating conditions during minor pediatric otological surgery Can J Anaesth Brimacombe 1995 Nov;42(11):1017-23 Additional Advantages of Using the LMA uleaves providers hands free upatient can produce effective cough uallows spontaneous ventilation ueven malpositioned can adequately ventilate Disadvantages of LMA over the ETT ulower seal pressure uhigher frequency of gastric insufflation Can J Anaesth Brimacombe 1995 Nov;42(11):1017-23 Disadvantages of LMA over the FM uesophageal reflux more likely Can J Anaesth Brimacombe 1995 Nov;42(11):1017-23 Contraindications to Using the LMA uFull Stomach Non-fasted 34+ week pregnant trauma acute abdomen thoracic injury opiate premedication autonomic neuropathy patient unable to follow instructions any condition known to delay gastric emptying Contraindications to Using the LMA uFull Stomach uPatients with a history of GE reflux Contraindications to Using the LMA uFull Stomach uPatients with a history of GE reflux uPatients with low pulmonary compliance needing positive pressure ventilation Complications Arising from Use of the LMA uAspiration Passive Regurgitation and the LMA Study looked at gastric regurgitation during GA in different positions with the LMA 15 minutes before induction, patients swallowed a 75 mg methylene blue capsule. supine, Trendelenburg and lithotomy positions post-op, LMA and oropharynx were inspected for bluish discoloration No blue dye was detected in the supine group but it was observed in one patient in each of the other two groups Anaesthesia Strong, et al. 1995 Dec;50(12):1053-5 Passive Regurgitation: LMA v. ETT Study at UT Dallas comparing incidence of reflux for spontaneously breathing anesthetized patients with either an ETT or LMA by continuous measurement of hypopharyngeal pH “Continuous monitoring.failed to detect evidence of pharyngeal regurgitation.” Anesth Anal Joshi, et al. 1996 Feb;82(2):254-7 Complications Arising from Use of the LMA uAspiration uCoughing Complications Incidence of airway complications following GA using either ETT or LMA Significantly greater incidence of coughing PRIOR to extubation, AT extubation and AFTER extubation in the ETT group than in the LMA group No airway complications were seen in either group JR Soc Med Denny, et al. 1993 Sep;86(9):521-2 Complications Arising from Use of the LMA uAspiration uCoughing uSore Throat Sore Throat incidence of sore throat looked at in 327 patients who had GA mild/moderate soreness 7% of patients with LMA 10% who had FM and oral airway 47% of had ETT 24 hours later, 3% of intubated group still c/o severe soreness, while NONE of the other patients had