MJSBH Journal.indd 17 Medical Journal of Shree Birendra Hospital ABSTRACT Introducti on: Paediatric anaesthesia deals with Examinati on under anaesthesia to complicated surgical interventi ons. Most of the minor surgeries can be performed with Bag Valve Mask Venti lati on which avoids complicati ons of endotracheal intubati on . Methods: A retrospecti ve randomized control study was undertaken in 654 paediatric surgeries performed at Shree Birendra Hospital, Chhauni (April 2005-March 2010). The children underwent minor general, Ear nose throat and orthopaedic surgery to compare spontaneous Bag Valve Mask venti lati on in 503 pati ents (BVM Group) and controlled venti lati on in 151 pati ents (CV Group). The BVM group was done under spontaneous mask venti lati on and CV group under endotracheal intubati on. Anaesthesia was induced and maintained with oxygen and halothane, using a Mapleson F system with spontaneous venti lati on and a Rendell-Baker face mask. The durati on of anaesthesia was less than one hour. Results: In this study we noted the complicati ons like trauma to face and lips, dental trauma, laryngospasm, perforati on of tracheaor esophagus, pulmonary aspirati on of gastric contents or foreign bodies and post extubati on complicati ons. Conclusions: It is concluded that the need of controlled venti lati on with endotracheal tube is limited to only a few procedures and many of the paediatric surgeries can be performed with spontaneous mask venti lati on. Therefore anaesthesia with oxygen and halothane with spontaneous mask venti lati on is a sati sfactory method for minor procedures in children . Keywords: BVM, controlled venti llati on, paediatric surgery. Bag Valve Mask Venti lati on Versus Controlled Venti lati on for Minor Pediatric Surgery. Sunita Panta1, Nagendra Bahadur KC1. 1Department of Anaesthesiology, Shree Birendra Hospital. Kathmandu, Nepal. Correspondence: Lt. Col. Dr. Sunita Panta Department of Anaesthesiology, Shree Birendra Hospital Kathmandu, Nepal. Email: sunitapanta@gmail.com Phone: +977-9843069824 INTRODUCTION Paediatric anaesthesia embraces pati ents from the premature, naeonate to the adolescent. Children require anesthesia for a variety of procedures from minor to major surgeries. There remains a debate whether to go for spontaneous mask venti lati on or controlled tube venti lati on. Tracheal intubati on requires experti se and has more consequences in children. Minor surgeries can be carried out under spontaneous mask venti lati on which reduce opioid requirements, opioid related side eff ects and recovery ti me thus enabling pati ent to early discharge. Although both these techniques are in practi ce for a long ti me there are only a limited studies comparing these techniques. Since most of the paediatric procedures can be undertaken on mask venti lati on we chose to take Original Arti cleJan-June 2012/vol.11/Issue1 Original Arti cle 18 Medical Journal of Shree Birendra Hospital up this study to evaluate the effi cacy of spontaneous mask venti lati on and the rate of complicati ons in minor paediatric surgeries. The aim of this study was to to determine whether Bag mask Valve venti lati on is as effi cacious as endotracheal intubati on to provide anaesthesia for minor paediatric surgery and to compare the complicati ons in abovementi oned methods. METHODS This was a retrospecti ve randomized control study in 654 paediatric surgery in Shree Birendra Hospital, Chhauni (April 2005-March 2010). The study groups were divided into two Groups namely, Bag Mask Valve (BVM) Venti lati on Group and Controlled venti lati on (CV) Group. All Minor Paediatric General, ENT and Orthopaedic surgeries were included. Pati ent older than16 years, belonging to ASA III and ASA IV physical status and surgery lasti ng more than 60 minutes were excluded from the study. Results were analyzed using Microsoft Excel. Pre anaestheti c assessment of the children was done. The parents or guardians were well explained about the procedure and writt en informed consent was taken. Pati ents were kept nil per oral four hours prior to surgery. On arrival in Operati on Theater intravenous cannula was inserted in the waiti ng room in laps of parents. They were premedicated with oral midazolam 0.5 mg. Aft er taking them to the operati on theater the children were injected with Pethidine 0.5 mg/ kg, induced with Propofol 2mg/kg. Suitable sized Rendall Baker face mask was applied and venti lated with the Mapleson F circuit. The spontaneous mask group was thereaft er maintained with Halothane 1-2%. The controlled venti lati on group was injected with Inj. Vecuronium 0.1 mg/kg and aft er 3 minutes intubated with suitable sized tube. Inj. Vecuronium was topped up as per requirement and they were reversed at the end of surgery with Inj. Neosti gmine 50 mcg/kg and Atropine 20 mcg/kg. We also noted the complicati ons like trauma to face and lips, dental trauma, laryngospasm, perforati on of tracheaor oesophagus, pulmonary aspirati on of gastric contents or foreign bodies and post extubati on complicati ons. Aft er completi on of procedure, pati ents were transferred to recovery room.In recovery room pati ents vitals are monitored and any other complicati ons like nausea, vomiti ng, were noted. When pati ent was fully conscious and well oriented they were shift ed to postoperati ve wards. RESULTS The children ranged between 4 months to 15 years for BVM group and 1 year to 14 years for CV group. Regarding Sex distributi on, In BVM group out of 503 pati ents 318 (63%) were male and 185 (36%) were female, where as in CV Group out of 151 pati ents, 71 were male(47%) and 80 were female (52 %) and P Value is 0.35 which is not signifi cant. Mostly the general, orthopaedic and ear and throat surgeries were included in the study. Surgeries requiring muscle relaxati on and prolonged durati on were taken into CV group and most of the implant removals and examinati ons were carried out in BVM due to the paediatric age group. The comparision between the complicati ons among these two procedures were the crux of this study. The complicati ons noted were bradycardia, dental trauma, hypoxemia, laryngospasm and soft ti ssue injury. Bradycardia was noted in both BVM and CV groups. But in BVM group the incidence of bradycardia was less than CV group. In CV group 21 (13.90%) among 151 pati ents developed bradycardia whereas in BVM group the value was 7 (1.39 %). Dental trauma was infl icted on 5 pati ents (3.31%) in the CV group whereas it was none in the BVM group. Hypoxemia was noti ced in both the groups but the incidence was higher in the CV group. In CV group 7 children (4.63%) developed hypoxemia and in BVM group the number was 8 (1.59%). The second most important complicati on was laryngospasm which was very high in the CV group, 15 in number (9.93%) as compared to 4 in the BVM group which is (2.98%). Finally soft ti ssue injury was noted among 8 (5.29%) of the pati ents in the CV group whereas the value was 5 (0.99%) in BVM group. Table 1.Types of Operati ons Operati on GA Count IVA Count Appendectomy 51 1 Circumcision 4 83 Debridement 4 8 EUA 0 5 Excision 18 16 Explorati on 4 1 Herniotomy 8 125 Incision and Drainage 2 27 19 Medical Journal of Shree Birendra Hospital K - Wire Fixati on 7 16 Laparotomy 10 0 MUA 7 39 Myringoplasty 11 1 OR&IF 72 9 Orchidopexy 2 4 Others 33 20 Removal of Implant 13 20 Tonsillectomy 19 14 Table 2. Complicati ons Complicati ons CV BVM P value Bradycardia 21 7 0.043 Dental Trauma 5 0 Hypoxemia 7 8 Laryngospasm 15 4 Soft Tissue Injury 8 5 DISCUSSION In 1854, a singing teacher named Manuel Garcia (1805– 1906) became the fi rst man to view the functi oning glotti s in its enti rety1. Aft er World War I, further advances were made in the fi eld of intratrachealanesthesia by Sir Ivan Whiteside Magill2,3. Sir Robert Reynolds Macintosh (1897– 1989) also achieved signifi cant advances in techniques for tracheal intubati on when he introduced his new curved laryngoscope blade in 19434.The most widely used curved laryngoscope blade is named aft er Macintosh5-7. Tracheal intubati on (orotracheal, nasotracheal, cricothyrotomy, or tracheotomy) is indicated under any circumstances where the airway is unprotected8. Bag- valve-mask (BVM) venti lati on is an essenti al emergency skill. This basic airway management technique allows for oxygenati on and venti lati on of pati ents. BVM venti lati on is also appropriate for electi ve venti lati on in the operati ng room when intubati on is not required. In our study 503 pati ents were operated under spontaneous bag mask venti lati on and only 151 pati ents needed endotrachael intubati on .This explains that most of the paediatric minor surgeries can be carried out with BVM method. BVM venti lati on requires a good seal and a patent airway. Practi ce with this important skill increases the clinician’s ability to provide eff ecti ve venti lati on. Adjuncts such as oral and nasal airways can aid with venti lati on by relieving physiologic obstructi on and by opening up the hypopharynx. The masks come in many sizes, including newborn, infant, child, and adult. Choosing the appropriate size helps to create a good seal and, therefore, aids eff ecti ve venti lati on. Bags for BVM venti lati on also come in diff erent types. Newer bags are equipped with pressure valve. Some bags have one-way expiratory valves to prevent the entry of room air; these allow for delivery of greater than 90% oxygen to venti lated and spontaneously breathing pati ents. There are signifi cant diff erences in airway anatomy and respiratory physiology between children and adults. Aft er about 8 years, airway diff erence between adults and children mainly refl ect size diff erence. These anatomical and physiological diff erences gradually become less signifi cant as the human body approaches a mature age and body mass index9. Several anatomic diff erences make respirati on less effi cient for infants. The smaller diameter of the airways,high compliance and poor support by sorrounding structures lead to functi onal airway closure10. Also the high oxygen consumpti on and increased work of breathing explain the high respiratory rate and the rapid oxygen desaturati on11. In our study hypoxemia was noti ced in both the groups but the incidence was higher in the CV group. In CV group 7 children (4.63%) developed hypoxemia and in BVM group the number was 8 (1.59%). Endotracheal intubati on being an invasive procedure, there may be problems if the airway is diffi cult. There are a number of devices specially designed for assistance with diffi cult tracheal intubati on in pediatric pati ents12. Many a ti mes injuries may occur while att empti ng intubati on. Soft ti ssue injury was noted among 8 (5.29%) of the pati ents in the CV group whereas in the BVM group the value was 5 (0.99%). Dental trauma was infl icted on 5 pati ents (3.31%) in the CV group whereas it was none in the BVM group. The durati on of endotracheal intubati on att empts is also important as the paediatric pati ents tend to develop bradycardia along with hypoxemia. Although bradycardia was noted in both BVM and CV group in our study the incidence was lower in BVM than CV group. In CV group 21 (13.90%) among 151 pati ents developed bradycardia whereas in BVM group the value was 7 (1.39 %). Because the airway of a child is narrow, a small amount of edema can produce severe obstructi on. Edema can easily be caused by forcing in a tracheal tube that is too large relati ve to the diameter of the trachea. Conversely, an excessive leak can someti mes be corrected through the placement of a larger (0.5 mm larger in internal diameter) tracheal tube, and in diffi cult-to-venti late pediatric pati ents children it is oft en necessary to use cuff ed tubes to allow for high pressure venti lati on if the leak is too great to overcome with the venti lator. In our study the second most important complicati on was laryngospasm which was very high in the CV group, 15 in number (9.93%) as compared to 4 in the BVM group which is (2.98%). That explains the higher risk of airway manipulati ons as opposed to simple bag mask venti lati on. 20 Medical Journal of Shree Birendra Hospital CONCLUSIONS Bag valve mask venti lati on is an eff ecti ve method of anaesthesia. With this technique endotracheal intubati on related complicati ons like laryngospasm, bronchospasm, reintubati on and residual eff ect of paralyzing agents can be avoided. There is an added advantage of minimal drug use as less depth of anaesthesia is needed and the recovery is faster. REFERENCES 1. Stanley SW. The cheerful centenarian, or the founder of laryngoscopy.Essays on the fi rst hundred years of anaesthesia. 1961 2:95–113. 2. Rowbotham E, Magill I. Anaestheti cs in the plasti c surgery of the face and jaws. Proc R Soc Med.1921;14 (1):17–27. 3. Magill I. The provision for expirati on in endotracheal insuffl ati ons anaesthesia. The Lancet. 1923:68–9. 4. Macintosh RR. A new laryngoscope. The Lancet.1943;1:205. 5. Scott J, Baker PA. How did the Macintosh laryngoscope become so popular? Paediatric Anesthesia. 2009;19:24–9. 6. Agrò F, Barzoi G, Montecchia F. Tracheal intubati on using a Macintosh laryngoscope or a GlideScope in 15 pati ents with cervical spine immobilizati on. BritJ of Anaes. 2003;90 (5):705–6. 7. Cooper RM, Pacey JA, Bishop MJ, McCluskey SA. Early clinical experience with a new videolaryngoscope (GlideScope) in 728 pati ents. Can J of Anes. 2005;52(2):191–8. 8. American College of Surgeons Committ ee on Trauma. Airway and venti latory management. ATLS. Chicago, Illinois: 2004;7:pp41–68. 9. Cravero JP, Cain ZN. Paediatric anesthesia. ClinAnes. 2009;6:1206-20. 10. Anthonisen NR, Danson J, Robertson PC. Airway closure as a functi on of age.Respir Physiology.1969;8:58-65. 11. Cross KW, Tizard JPM, Trythall D. The gasseous metabolism of the newborn infant. Actapaediatrscand. 1957;46:265-85. 12. Borland LM, Caselbrant M. The Bullard laryngoscope: a new indirect oral laryngoscope (paediatric version). 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