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A 2-year-old boy is undergoing an orchiopexy at an ambulatory surgery center. You plan on using a laryngeal mask airway (LMA) for airway management. According to a recent study, how is the risk of at least 1 respiratory adverse event during awake removal of the LMA MOST likely affected if sevoflurane is used for induction and maintenance rather than total intravenous anesthesia with propofol?
(A) Increased ✔(B) Decreased X
(C) No difference X
Gain insight on this topic, and many others, with Summaries of Emerging Evidence (SEE) 2023 – now available. The content is aggregated from 30 international medical journals to streamline your learning and improve your practice.
Perioperative respiratory adverse events are one of the most common types of adverse events in pediatric patients. Younger age, higher American Society of Anesthesiologists (ASA) physical status score, airway surgery, obesity, certain congenital syndromes, and recent upper respiratory illness increase the risk for perioperative respiratory adverse events in children. The use of a laryngeal mask airway (LMA) may result in less laryngeal stimulation, making LMA placement attractive. However, there is a paucity of literature as to which anesthetic may minimize respiratory adverse events during LMA use as well as the optimal timing for removal of the LMA.
A prospective, randomized, double-blind study examined the rate of respiratory adverse events with volatile versus total intravenous anesthetics (TIVA) during LMA use in children. A total of 134 children aged 6 months to 7 years undergoing minor procedures lasting less than 2 hours were included in the study. Children were excluded if they had any of the following: ASA physical status of III or greater, acute asthma exacerbation, congenital heart disease, neurologic disorders, known difficult airway or airway anomalies, or more than 3 attempts for LMA placement. Children included in this study received either a mask induction with 8% sevoflurane followed by 2 µg/kg of fentanyl prior to LMA placement (sevoflurane group, n = 69) or 5 mg/kg of propofol and 2 µg/kg of fentanyl prior to LMA placement (TIVA group, n = 65). Children in the TIVA group with needle phobia could undergo a mask induction for intravenous placement. Maintenance for the sevoflurane group used exclusively 2% sevoflurane whereas the TIVA group used a propofol infusion (200–300 µg/kg/min). At the conclusion of the surgical procedure, the anesthetic was stopped and the LMA was removed when it was determined that the patient was awake. The primary outcome was the occurrence of adverse events during removal of the LMA, such as cough, LMA mask biting, breath holding, laryngospasm, bronchospasm, desaturation below 95%, and upper airway obstruction. Airway hyperreactivity severity score was also assessed. The secondary outcomes included time to LMA placement, the number of insertion attempts, difficulty at insertion, quality of anesthetic during maintenance, emergence time, postoperative nausea and vomiting, emergence agitation, maintenance of hemodynamic stability, and duration of postanesthesia care unit stay.
Respiratory adverse events were more common in patients who received sevoflurane. Overall, 36.2% of patients in the sevoflurane group had at least 1 respiratory adverse event compared with 10.8% of patients in the TIVA group. The respiratory events that occurred more commonly included coughing, laryngospasm, desaturation to below 95%, and increased airway hyperreactivity severity. There was no difference in the rate of breath holding, bronchospasm, or upper airway obstruction. Oxygen saturation following LMA removal was lower in the sevoflurane group, but these oxygen saturation levels did not appear to be clinically concerning. All airway events occurred in the operating room. Most secondary outcomes did not differ between the sevoflurane and TIVA groups. There was, however, a longer emergence time in the TIVA group (11.17 minutes vs 10.72 minutes), although it was not clinically relevant. There was also an increased rate of moderate emergence agitation in the sevoflurane group (34.8% vs 4.6%).
Overall, in children without risk factors for perioperative respiratory adverse events, the use of sevoflurane for induction and maintenance of anesthesia resulted in more adverse respiratory events upon awake LMA removal compared with TIVA with propofol. TIVA reduced coughing, laryngospasm, airway hyperreactivity, and significant desaturations to below 95%.
Reference
Date of last update: June 27, 2023
