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• W2011874461 abstract "In this issue the theme of laryngospasm is given an international flavor with four papers from various parts of the world (1–4). In collecting these articles together, we get a wide range of views and experience on the topic. This will encourage debate and may lead to the development of useful local or national guidelines for the management of laryngospasm. The papers address different aspects of laryngospasm. They peel away some of the mystery surrounding what many anesthetists would consider to be a not uncommon clinical occurrence. Some aim to quantify the incidence of laryngospam in pediatric practice whilst others address the causes, prevention and management of this condition. The national collaborative pediatric simulator group offers some solutions to the quandary of how to train anesthetists to effectively manage, an intermittent and often unpredictable event (4). The actual incidence of laryngospasm in pediatric anesthetic practice is difficult to determine. Two of the studies attempt to quantify the incidence of laryngospasm in their hospital population. Each centre has a different case mix, which is reflected in their particular experiences. Laryngospasm is probably not an unusual occurrence in most anesthetists’ practice and it is believed that laryngospasm occurs more commonly in children than adults. Olsson quoted an incidence of laryngospasm in children of about 1.7% with a higher incidence in younger patients (5). In contrast, Burgoyne (1) reports a remarkably low incidence of only 0.1% in their pediatric population. Various factors may explain this, particularly their case mix, in which the majority of children are managed outside the operating room and many have TIVA using Propofol. These major institutions collect their anesthetic data contemporaneously, it is reviewed and analyzed retrospectively and there will be difficulties in interpreting such data (1,3). This can include bias because of multiple reporters, potential differences in allocating the diagnosis of laryngospasm and the likelihood of under reporting. The definitions of a clinically reportable larnyngospasm may vary between anesthetists and reporting patterns may differ if it is mainly a voluntary process. These factors could result in under-reporting of incidents. Few definite contributing factors were identified in the case matched study of Flick et al. (3) who looked at children who had had a documented episode of laryngospasm. Upper respiratory infection, URI, with or without the presence of an airway anomaly and the use of an LMA, were identified as important factors. Surprisingly co-morbidity, the age of the child, the type of anesthetic and experience of the anesthetic team were not significant factors. Whilst reassuring, this conclusion may be premature. Whether or not the reported incidences of laryngospasm are realistic, the ability to decrease the incidence is important. This is addressed by Alalami et al. (2) who analyzed their experience, in adults and children, focusing on prevention and management. They looked at a wide spectrum of factors from ‘insufficient depth of anesthesia’ through many etiologies to ‘psychogenic larnyngospasm’. The paper provides a very useful summary of potential causative factors and treatment plans. Prevention would seem like a good idea and many varied strategies are discussed. Flick et al. did not however give credence to many of the interventions described. Both groups point out that laryngospasm can occur at any part of the perianesthetic period and that it frequently occurs during emergence from anesthesia, as many of us who have been called urgently to the Recovery area to deal with a child with acute larnyngospasm, can attest! Both Burgoyne and Flick had a preponderance of their cases of laryngospasm in children whose airway had been managed with a LMA. Flick identified use of the LMA as an independent risk factor. However, the details of the anesthetics are not available, so information such as the proportion of patients that had an LMA, or whether the LMA was used with spontaneous or assisted ventilation, are not available, nor whether the LMA was removed ‘deep’ or ‘awake’. These variations in anesthetic practice may make a difference to the incidence of laryngospasm. Probably in many clinical situations the LMA is the airway device of choice, so heightened awareness of the potential for laryngospasm, especially at emergence, is timely. Interestingly whilst no severe complications are reported in Burgoyne’s series, major complications including unplanned admission to ICU and aspiration are reported in the in-depth review of the risk factors by Flick. Whether these major complications were a direct result of the episode of spasm, its management or other separate per-operative issues, is not possible to determine. The management of established larnyngospasm is a core skill. Anesthetic training is now shortened and clinical experience reduced (6). The use of the medical simulator to train anesthetists using a clear algorithm is increasingly viewed as an effective tool for education. Designing such an algorithm is difficult, especially when there is little evidence base available and consensus is hard to achieve. It is not likely to be possible to have good quality, evidence based studies of the various management strategies for laryngospasm, to inform the development of a ‘management of laryngospasm’ guideline. Hampson-Evans reports an algorithm which has been developed for use for training anesthetists at the medical simulator and the algorithm reported by Alalami has clarity and many similar features. Each recognizes that making the early diagnosis of laryngospasm is crucial. Airway obstruction from supraglottic causes, such as loss of upper airway tone as the tongue occludes the pharynx, can produce a similar clinical picture and may be erroneously treated as laryngospasm. Each algorithm includes the use of suxamethonium at some stage and acute management of complete laryngospasm is now one of the few widely accepted uses of this relaxant (7). Most anesthetists would use it very infrequently in their routine practice. This has become a training issue, as regular experience in the use of suxamethonium has declined. Clear departmental guidelines and simulator sessions would be very useful in encouraging appropriate practice, so that the various options of dose and route of administration for suxamethonium are defined. The use of Propofol, in the acute management of larnyngospasm, is also reported widely and is incorporated into each of the algorithms. This drug is widely available and staffs are very confident with its use. In the presence of reliable venous access administration of Propofol is very likely to be a first line pharmacological strategy when an anesthetist is faced with a child with laryngospasm. Laryngospasm is an important clinical scenario which many pediatric anesthetists will encounter within their regular practice. In identifying and quantifying potential risk factors for this emergency we can reduce associated morbidity. We can ensure all trainees gain the skills to manage this condition proficiently. Overall, rapid, effective management of laryngospasm will improve the safety of pediatric anesthesia." @default.
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• W2011874461 title "Laryngospasm in pediatric practice" @default.
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