This controlled study randomised 212 children to either deep plane-of-anesthesia or awake, and either supine or lateral position, for removal of their laryngeal mask at the completion of surgery.

"Deep anesthesia" was defined as ET-sevoflurane 2.2%, stable for 1 minute. The "awake" group had their LMA removed by the PACU nurse after eye opening and/or obeying commands.

Airway complications included desaturation < 90%, stridor, laryngospasm, retching/vomiting, excess secretions and biting. A secondary outcome was also studied, assigning a 'clinical significance score' to the range of complications.

Deep removal in the lateral position was associated with the fewest complications. Deep removal when supine was associated with the most complications.

This study was a follow-up to a two-centre observational audit from 2008.

summary

• George Thomas-Kattappurathu, Ananth Kasisomayajula, and Judith Short.
• From the Rotherham NHS Foundation Trust, Rotherham (GT-K), Mid Yorkshire Hospitals NHS Trust, Dewsbury (AK) and Sheffield Children's NHS Foundation Trust, Sheffield, UK (JS).
• Eur J Anaesthesiol. 2015 Sep 1; 32 (9): 624-30.

BackgroundThere is a wide variation in clinical practice amongst clinicians in the process of removal of the laryngeal mask airway (LMA) in children. Some of the airway complications during recovery are associated with the position of the child as well as the depth of anaesthesia and are potentially avoidable.ObjectivesWe wished to determine whether removal of the LMA in the lateral position reduces the incidence of airway complications, either in a deep plane of anaesthesia or awake.DesignA randomised trial.SettingA tertiary children's hospital.PatientsThe study population comprised 216 American Society of Anesthesiologists (ASA) 1 to 2 patients aged 1 to 16 years scheduled for elective surgery under general anaesthesia using an LMA. Exclusion criteria were children less than 1 year old, ASA 3 or above, presence of congenital heart disease or gastro-oesophageal reflux, anticipated difficult airway and patients undergoing airway or dental surgery.InterventionWe randomly allocated 212 children into one of four groups for LMA removal, deeply anaesthetised or awake in either the lateral or supine position. Various airway complications were recorded after removal of the LMA.Main Outcome MeasuresThe primary outcome measure was the number of patients experiencing one or more complication in each group. We also devised a novel 'Clinical Importance' score on the basis of the clinical relevance of airway complications.ResultsThere were significant differences among groups (P = 0.001); the fewest complications occurred when the LMA was removed in a deep plane of anaesthesia in the lateral position. There was a significant difference among groups in the 'Clinical Importance' scores (P < 0.001); the greatest risk occurred when the LMA was removed in deeply anaesthetised supine patients.ConclusionThe results of the present study suggest that lateral positioning of children for removal of the LMA provides the safest conditions if the LMA is to be removed at a deep plane of anaesthesia. Sheffield Children's NHS Foundation Trust Study number CA08014.

This article appears in the collection: Paediatric.

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