LMA in peds strabismus surgery

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sbhfl

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As far as I know, peds strabismus surgery is generally done with LMAs. Aren't you terrified of the kid moving and getting his eye literally poked out?

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LMA works very well. Just have the surgeon give lots of local and run them deep. The surgical instruments are never really poking into the globe.
 
Kids should be deep with any LMA. Besides there’s not much stimulation in the strabismus surgery. Also, a full MAC of volatile produces some immobility on he spinal cord.
 
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We tube ours. The LMA sits too much in the field, just pop a RAE in and make your day easier.
 
Just to give a little perspective, I go once or twice a year with a charity group where we do 50-60 strabismus cases/day. The surgeon is not whiny and fast. The technique we use is zofran ODT in preop, mask sevo—>deep, eye drops, lma in, +-intranasal fentanyl, IM toradol, surgery, local. For larger patients (teens) we will start IV’s but smaller kids don’t even get an IV. The whole process takes about 10-15min per case.
 
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Just to give a little perspective, I go once or twice a year with a charity group where we do 50-60 strabismus cases/day. The surgeon is not whiny and fast. The technique we use is zofran ODT in preop, mask sevo—>deep, eye drops, lma in, +-intranasal fentanyl, IM toradol, surgery, local. For larger patients (teens) we will start IV’s but smaller kids don’t even get an IV. The whole process takes about 10-15min per case.

no iv sounds dicey
 
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As far as I know, peds strabismus surgery is generally done with LMAs. Aren't you terrified of the kid moving and getting his eye literally poked out?
no because non cardiac kids tolerate being deep very well.
 
no because non cardiac kids tolerate being deep very well.

With (healthy) kids, you should make them prove to you you’re giving too much anesthetic.

With adults, you should make them prove to you you’re giving too little.
 
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We tube ours. The LMA sits too much in the field, just pop a RAE in and make your day easier.

Our group uses these flexible LMAs. They can sometimes be a pain to put in because they are so flimsy but they stay out of the surgical field nicely and can be taped down the chin just like an oral RAE

. Ultra Flex Silicon | Reusable LMA
 
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no iv sounds dicey
Hmmm, doesn't sound much different than doing ear tubes - we don't do IVs on those kids, and most of us do it with a mask and not an LMA. Although I guess I'd be at least a little concerned about not having IV access if that oculocardiac reflex decides to show up.
 
Hmmm, doesn't sound much different than doing ear tubes - we don't do IVs on those kids, and most of us do it with a mask and not an LMA. Although I guess I'd be at least a little concerned about not having IV access if that oculocardiac reflex decides to show up.
The no IV is interesting for kids. I suppose if the case is really only 10-15 mins, then skipping the IV can really save time. I don’t think it would fly in my hospital because the PACU nurses would make a big deal out of it. We typically don’t even wake any kids up deep because of the PACU staff.
 
Our group uses these flexible LMAs. They can sometimes be a pain to put in because they are so flimsy but they stay out of the surgical field nicely and can be taped down the chin just like an oral RAE

. Ultra Flex Silicon | Reusable LMA


We take a bunch of those but also use the classics too. We route the circuit so it’s not in the way.
 
The no IV is interesting for kids. I suppose if the case is really only 10-15 mins, then skipping the IV can really save time. I don’t think it would fly in my hospital because the PACU nurses would make a big deal out of it. We typically don’t even wake any kids up deep because of the PACU staff.


This is in another country and it is really 10-15minutes per case. Sometimes less if it is just 1 muscle. We set up 2 workstations the same room. While the surgeon is operating on one child, another child is is being induced or waking up. He literally turns around, changes gloves, I hold up the chart/folder so he can look at the preop photo and his preop note, then he starts operating. The pacu nurses also experienced and know the score. Most of them have been going on these trips for 10-20+ years.
 
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Hmmm, doesn't sound much different than doing ear tubes - we don't do IVs on those kids, and most of us do it with a mask and not an LMA. Although I guess I'd be at least a little concerned about not having IV access if that oculocardiac reflex decides to show up.
10-15 mins is longer than a typical ear tube that I am used to, which is usually < 5mins... i mean we are giving ODT zofran, IM toraol, Intranasal fentanyl, if im giving all that stuff im just going to put an IV in and give it IV, this sounds like a surgeon-concocted anesthestic
 
10-15 mins is longer than a typical ear tube that I am used to, which is usually < 5mins... i mean we are giving ODT zofran, IM toraol, Intranasal fentanyl, if im giving all that stuff im just going to put an IV in and give it IV, this sounds like a surgeon-concocted anesthestic

It’s not, it’s been concocted over the years by a group of very experienced double and triple boarded pediatric anesthesiologists. It works.
 
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It’s not, it’s been concocted over the years by a group of very experienced double and triple boarded pediatric anesthesiologists. It works.
I like the concoction. I assume the OC reflex doesn’t show up because of the local eye drops. Am I correct?
 
Wouldn’t count on that. The drops won’t keep you out of a trip to Vaso Vegas. In fact all the phenylephrine they dump into the eye can make the propensity for bradycardia worse...
 
I like the concoction. I assume the OC reflex doesn’t show up because of the local eye drops. Am I correct?


I’m not sure but I haven’t experienced a single instance in hundreds (maybe over 1000) of cases. My theory is that gentle handling of the eye by the surgeon may have something to do with it.
 
I’m not sure but I haven’t experienced a single instance in hundreds (maybe over 1000) of cases. My theory is that gentle handling of the eye by the surgeon may have something to do with it.

Certainly could be operator dependent. Working within a system that has optho residents, we've seen and treated the brady.
 
Wouldn’t count on that. The drops won’t keep you out of a trip to Vaso Vegas. In fact all the phenylephrine they dump into the eye can make the propensity for bradycardia worse...
I have never seen topical neo cause bradycardia. I’m not sure it works that way. When we give it IV the bradycardia comes from the afterload increase.
 
Saw it in a lengthy case in a small, complex baby. I get signout that the anesthesia colleague in the room had been using increasing amounts of propofol and sevoflurane to control HTN because the patient “kept getting light.” HR was starting to dip in the meantime. Told everybody to stop, found the eye surgeon didn’t have any idea how much phenylephrine he’d been dripping into the eye.
If you look at the bottle of topical phenylephrine used in these cases it’s pretty concentrated, and there is no dose/kg running through the minds of our Optho surgery colleagues. Just an FYI.

Not triple boarded, (just double, couldn’t fathom doing the extra two years with well baby checks) but I work on a pretty busy pedi anesthesia service. Kids are great at keeping us humble and finding new ways to collectively strain our anesthesiologists’ myocardium. ;)
 
I have never seen topical neo cause bradycardia. I’m not sure it works that way. When we give it IV the bradycardia comes from the afterload increase.

You are correct about the afterload increase. That’s what we saw precipitating the bradycardia. There is systemic absorption of the topical eye drops but at lower doses/ shorter cases it’s usually not an issue.
 
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