喉罩的使用-麻醉（英文

1、Using the Laryngeal Mask AirwayNorman L. Goody, MD1ObjectiveUsing the LMALMA and the Difficult AirwayLMA and Pediatric AnesthesiaLMA and OB AnesthesiaAdvantages of Using the LMADisadvantages of the LMAComplications Arising from Use of the LMA Contraindications to Using the LMA2History of the LMAdeve

2、lopment began in 1981 at Royal London Hospital by Dr. Archie Brainmodification of the Goldman Dental Maskavailable commercially in UK since 1988 and in the US since 1992now used in 50% of general anesthetics in some centers in UK (and probably US, too- especially ambulatory surgery)3Characteristics

3、of the LMALatex free, medical-grade siliconeAperture barsSizes#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 25-30ml4Using the LMAPreparation of the LMACheck patency of cuffLubricate POSTERIOR surface onlySurgilube v. lidocaine jellyInductionInsertion of the L

4、MACommon ProblemsCricoid PressureSecuring the LMA5Using the LMAMaintenance of AnesthesiaRemoval of the LMACleaning, Sterilization and Re-use6Determining Life Span of LMAintended for 40-50 uses, but highly over-manufacturedtube remains translucentaperture bars remain intactcuff deflates correctlyno v

5、alve leakagecuff remains symmetricpilot balloon retains shapeconnector remains tight/ not broken7THE LMA IS NOT DISPOSABLE8LMA and the Difficult AirwayAwake IntubationDifficult MASK AirwayBlind IntubationFailed IntubationFiberoptic Bronchoscopy and the LMAEmergent Intubation by an Unskilled Provider

6、9LMA and Pediatric AnesthesiaDL&Btracheal stenosisdifficult airway10Accuracy of End-tidal CO2 in Pediatrics using LMA22 children, mechanically ventilated to a stable ETCO2ventilation via the LMA mean ETCO2 and PaCO2 obtained were 37.7 +/- 3.3 and 41.9 +/- 9.09, respectivelyventilation via ETTmean ET

7、CO2 and PaCO2 obtained were 35.2 +/- 2.9 and 39.2 +/- 5.25, respectivelyLMA ETCO2 is as accurate an indicator of PaCO2 as when ventilated via ETTAnesth Analg Feb;82 (2) :247-5011LMA and OB AnesthesiaQuestionnaire to 250 anesthesiologists in the UKLMA was available in 91.4% of obstetric units72% were

8、 in favor of using LMA for failed intubation with inadequate ventilation via face mask24 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/ventilationCan J Anaes

9、th Gataure, et al. 1995 Feb;42(2):130-312Advantages of Using the LMAMeta-analysis comparing advantages of the LMA over the tracheal tube or face maskReviewed 858 LMA publications identified to December 1994, of which 52 met criteria for analysis32 different issues were testedCan J Anaesth Brimacombe

10、 1995 Nov;42(11):1017-2313Advantages of LMA over ETTincreased speed and ease of placement by inexperienced personnelincreased speed of placement by anesthetistsimproved hemodynamic stability at induction and during emergenceminimal increase in intraocular pressure following insertionCan J Anaesth Br

11、imacombe 1995 Nov;42(11):1017-2314Advantages of LMA over ETTreduced anesthetic requirements for airway tolerancelower frequency of coughing during emergenceimproved oxygen saturation during emergencelower incidence of sore throats in adultsCan J Anaesth Brimacombe 1995 Nov;42(11):1017-2315Advantages

12、 of LMA over Face Maskeasier placement by inexperienced personnelimproved oxygen saturationless hand fatigueimproved operating conditions during minor pediatric otological surgeryCan J Anaesth Brimacombe 1995 Nov;42(11):1017-2316Additional Advantages of Using the LMAleaves providers hands freepatien

13、t can produce effective coughallows spontaneous ventilationeven malpositioned can adequately ventilate17Disadvantages of LMA over the ETTlower seal pressurehigher frequency of gastric insufflationCan J Anaesth Brimacombe 1995 Nov;42(11):1017-2318Disadvantages of LMA over the FMesophageal reflux more

14、 likelyCan J Anaesth Brimacombe 1995 Nov;42(11):1017-2319Contraindications to Using the LMAFull StomachNon-fasted34+ week pregnanttraumaacute abdomenthoracic injuryopiate premedicationautonomic neuropathypatient unable to follow instructionsany condition known to delay gastric emptying20Contraindica

15、tions to Using the LMAFull StomachPatients with a history of GE reflux21Contraindications to Using the LMAFull StomachPatients with a history of GE refluxPatients with low pulmonary compliance needing positive pressure ventilation22Complications Arising from Use of the LMAAspiration23Passive Regurgi

16、tation and the LMAStudy looked at gastric regurgitation during GA in different positions with the LMA15 minutes before induction, patients swallowed a 75 mg methylene blue capsule.supine, Trendelenburg and lithotomy positionspost-op, LMA and oropharynx were inspected for bluish discolorationNo blue

17、dye was detected in the supine group but it was observed in one patient in each of the other two groupsAnaesthesia Strong, et al. 1995 Dec;50(12):1053-524Passive Regurgitation: LMA v. ETTStudy at UT Dallas comparing incidence of reflux for spontaneously breathing anesthetized patients with either an

18、 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):254-725Complications Arising from Use of the LMAAspirationCoughing26ComplicationsIncidence of airway complications followin

19、g 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 groupNo airway complications were seen in either groupJR Soc Med Denny, et al. 1993 Sep;86(9):521-227Complications Arising from Use of the LMAAspirationCoughingSore Throat28Sore Throatincidence of sore throat looked at in 327 patients who had GAmild/moderate soreness 7% of patients with LMA10% who had FM and oral airway47% of had ETT24 hours later, 3% of intubated group still c/o sev