Laryngeal Mask Airway Placement Methods in Pediatric Care

Laryngeal Mask Airway Placement Methods in Pediatric Care Laryngeal Mask Airway Placement: Comparison Between a Traditional and Alternative Methods in Pediatric Practice ============================================================ Emil Batarseh , MD , JBA* Zahi Majali , MD , JBA Basel D.Makhamreh , MD , JBA Abstract Objective To compare the quality of laryngeal mask airway placement between an alternative and a traditional methods in children. Methods Our prospective ,double-blind investigation enrolled 105 children subjects , aged 3months-15 years,of both genders,ASA I(American society of anesthesiologists), and assigned for different elective minor superficial operations under general halothane inhalational spontaneous laryngeal mask airway anesthesia at Princess Haya hospital-Aqaba-Jordan,during the period July 2007-July 2008. Subjects were randomized into two groups.Group I subjects (n=50) received laryngeal mask airway (LMA) through an alternative method,and group II subjects (n=55) received laryngeal mask airway via the traditional method. The number of placement attempts and duration required for success to attain a patent airway in both groups were recorded. Results Placement method made no difference in terems of first trial success (P>0.05).First trial successful placement was 85.5% and 90% in groups II and I respectively. Conclusion The alternative placement method is an acceptable solution to the traditional method. Key words:Anesthesia:general,spontaneous;LMA:traditional,alternative;children. +++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++ *Corresponding author: Department of anesthesia , intensive care and pain management , KHMC , AMMAN , JORDAN. E-mail: [emailprotected]yahoo.com 1 Introduction Use of laryngeasl mask airway permits the maintenance of a patent airway with successful insertion rates of the LMA on the first attempt , varying between 67-92% in pediatric practice (1).Since its introduction in 1983 by Brain,the LMA has achieved increasing popularity (2). The laryngeal mask airway has achieved a great popularity also in pediatric anesthesia practice.The laryngeal mask airway is a novel device that fills the gap in airway management between endotracheal intubatio and the use of face mask.The laryngeal mask airway is inserted blindly into the pharynx,forming a low pressure seal aroud the laryngeal inlet. Because the insertion of the laryngeal mask airway by the standard technique is not always easy in children due to the posterior pharyngeal curvature,some different maneuvers have been described to minimize this problem(3):Innserting the LMA laterally,applying the mask firmly against the hard palate,pulling the tongue forward,repositioning the head,adding or removing air to the cuff,applying continuous positive airway pressure,usig a laryngoscope and inserting the LMA like a Guedel oropharyngeal airway. The ability to maintain a patent airway and provide effective ventilation is the main objective of pediatric anesthesiological procedures.This is achieved mainly with the use of a face mask or an endotracheal tube.Both of these devices have major limitations from a strictly anatomical point of view and require adequate operator skills.The aim of LMA was of producing an airway device that would be more practical than the face mask and less invasive than the tracheal tubes.The functional ehegance of the LMA is that it forms a low pressure airtight seal against the glottis rather than plugging the pharynx,thus combining ease of insertion and adequaqte airway patency (4). Airway management is more successful with LMA technique.This is because transoral passage of instrumentation into the hypopharynx is easier than into the glottic inlet.There are four reasons:Firstly,the hypopharynx is a posterior structure and is easier to locate.Secondly,it is wider providing a bigger target.Thirdly,it is funnel-rather than tubular –shaped ,so that imprecisely positioned instrumentation will be redirected to the target and fourthly,it is better aligned with the oropharyngeal axis,making instrumentation less likely to get snagged (3). The objective of our invewstigation was to asses the effectiveness of the modified procedure in comparison to the standard procedure regarding LMA insertion. 2 Methods Our prospective,double blind investigation included 105 children patients,aged 3months-15 years,ASA I,of both sexes and scheduled for various elective minor superficial surgical procedures under general halothane inhalational spontaneous laryngeal mask airway anesthesia at Princess Haya hospital-Aqaba-Jordan,during the period July 2007-July2008,after obtaining approval from the local ethics committee of the Jordanian royal medical service directorate and written informed consent from the parents..Subjects were randomly divided into two groups using sealed envelopes.Group I children (n=50) received LMA using the modified method and group II children (n=55) received LMA via the standard method.The size of the LMA used was indicated using the patients body weight;size 1,1.5,2,2.5 ad 3 masks for 30 kgof body w2eight ,respectively. The LMA was lubricated with saline before insertion.Induction of inhalational anesthesia was performed with 3-5%halothane mixed with70% nitrous oxidein 30%oxygen.Before insertion of the LMA ,anesthesia was maintained using 2-3%halothanne in oxygen.No muscle relaxants were used.An anesthesia technician opened the patients mouth by pulling down the jaw.Intravenous cannulation was done after child is anesthetized,if The standard insertion procedure was illustrated by Brain(5).The LMA was inserted with the cuff fully deflated and against the palate,then the cuff was inflated after insertion.In the modified insertion procedure,a two-thirds moderately inflated LMA (using 2,4,6,8 and 12 ml air for size 1,1.5,2,2.5 and 3 masks respectively) was inserted with its lumen facing laterally left.While rotated clockwise 90 D,it was passed downward into position behind the larynx.Then the cuff was fully inflated.Successful insertion was clinically called for if manual ventilation with the reservoir bag was easy and the chest wall movement was smooth. The number of trials on LMA onnsertion and the duration to achieve good airway were recorded.Vital signs including heart rate and pulse oximeter readings were recorded.In case of failed LMA insertion,endotracheal intubation was achieved.An observer blinded to the insertion procedure evaluated the two procedures. Statistics Parametric data were analyzed using Students t test.P-value 3 Results There were no significant differences in terms of gender,age,weight,duration of anesthesia and size of the LMA.Table 1.Overall study group was 110 children patients,but 5 were excluded from the investigation ,who were ASA II and III physical status classified. Successful insertion was attained in 85.5% of subjects in group II and in 90% of patients in group I,at first trial.The two groups were comparable regarding the successful insertion rate,the number of trials at insertion(Second trial;GII,4 and GI,3.P>0.05.Third trial;GII,3 and GI,2,P>0.05) and the duration required for insertion (GII,0.4 minutes and GI,0.37 minutes,P>0.05). Endotracheal intubation was achieved in 1 case in GII and in no case in GI,P>0.05.In the present study,the LMA standard approach success rate was 85.5% at first trial ,increasing to 92.7% at second trial and 98.2% at third trial.In the modified approach,the success rate was 90% at first trial but was 96% at second trial and 100% at third trial. 4 Table 1. Patients characteristics. 5 Table 2. LMA insertion comparison. 6 Discussion The LMA has become popular in pediatric aesthesia practice.Nagai S,et al showed the potency of the modifiedmethod of LMA insertion (6).LMA advantages over conventional laryngoscope guided tracheal intubation are more rapid insertion and increased success rate.The modified method can be used in this investigation as an alternative procedure to the standard method of insertion.Brimacombe and Berry (7) stated that if the standard approach is used correctly,the first time success rate should be >98% in less than 20 seconds. Wakeling et al(8) demonstrated that deflating the cuff first would allow more difficult insertion due to the presentation of a softer edge to the posterior pharyngeal wall.Lopez-Gil,et al(9) used a lubricant ,whereas we moistened the LMA with saline only.He demonstrated that there was a rapid improvement in LMA skills in pediatric anesthesia practice when the standard technique was used.Gaining more experience may decrease the rate of unsuccessful insertion.Airway trauma was less frequent with the LMA than with ETI.This is not surprising as more force is required to see the glottic inlet than the hypopharynx.Perhaps the pharyngeal/esophageal mucosa is stronger than the laryngeal/tracheal mucosa as it has evolved to accommodate solid bodies and not just passaqge of gas. This modified technique I which a two –thirds inflated LMA is inserted with its lumen facing laterally forces the patients mouth to open wider and keeps the tongue from being pushed back into the air passage.These technical features result in easy insertion through the pharynx for inexperienced anesthesiologists.In addition,the softer edge of the partially inflated LMA protects the pharyngeal mucosae from trauma during insertion.Causes of difficulty with LMA onsertion include choice of wrong LMA size and difficulty in maneuvering through the posterior curvature of the pharynx (10).Differences in the airway anatomy and the frequent presence of tonsillar hypertrophy can complicate LMA insertion in children.Maneuvers to overcome this difficulty include increased head extension,jaw thrust maneuvers puuling the tongue forward,firm pressure on the LMA and using the index finger to guide the mask(10). Oneil et al (11) have reported an alternative method of insertion with the LMA partially inflated in children.They described improved ease of insertion and explained that the softness of the inflated cuff allows for easier adaptation to the differing pharyngeal characteristics of the pediatric airway. Nevertheless,Braincompared insertion techniques concerning the mechanisms of deglutition and recommended the standard technique. Although both methods of insertion were satisfactory,partial inflation of the LMA improved the ease of insertion in children as assessed by time to insertion and success rate on the first attempt.Inflation of the cuff at the smaller sized LMA after insertion often displaces the LMA and alters its position while the inflated LMA tends to insert to the proper depth and requires no further adjustment.In the standard technique,however,insertion of the LMA is not always easy.Therefore,it is reasonable that anesthesiologists devise other insertion techniques.We believe that this technique is to be recommended in certain situations. 7 Trevisanuto et al (12) found that the occurrence of first time failure decreased overtime in their study and they thought that the change represented an element of familiarization with the LMA insertion technique.The relatively small but statistically significant difference is meaningful,sice problems associated with insertion can be attributed to inadequate depth of anesthesia which may occur with prolonged placement.Our 1.8% incidence of problems that resulted in abandonment of the LMA is comparable to that reported in similar study evaluating uses of the LMA in pediatric practice(1). In Conclusion This modified techniqueia an acceptable alternativeto the standard technique I children.Thie techniqueis likelyto allow easy insertion of the LMA for unskilled anesthesiologists.Insertion of the LMA with the cuff inflated is equallysuccessfulto the standard uninflated techiquein experienced anesthesiologists.This implies that the modified inflated approach would be accepted to the general population of LMA users. 8 References 1.Shahin NJ , Mehtab A , Hammad U , et al. A study of the use of laryngeal mask airway (LMA) in children and its comparison with endotracheal intubation.Indian journal of anaesthesia 2009;53(2):174-8. 2.Pennant JH , White PF. The laryngeal mask airway.Its uses in anesthesiology. Anesthesiology 1993;79:144-63. 3.Benumof JL. Laryngeal mask airway.Indications and contraindications.Anesthesiology 1992;77(5):843-6. 4.Ghai B , Wig J . Comparison of different techniques oh laryngeal mask placement in children. Curr opin Anesthesiol 2009;22(3):400-4 5.Patel B, Bingham R.Laryngeal mask airway and other supraglottic airway devices in pediatric practice.BJA 2009;9(1):6-9 6.Nagai S , Inagaki Y , Hirosawa J , et al. Modified insertion technique of the laryngeal mask airway in children:a comparison with standard technique. Anaesthesia 2003:59-61. 7.Brimacombe J , Berry A. The laryngeal mask airway :anatomical and physiological implications. Acta Anesthesiol scand 1996;40(2):201-9. 8.Wakeling HG , Butler PJ , Baxter PJC.The laryngeal mask airway:a comparison between two insertion techniques.Anesth Analg 1997;85:687-90. 9.Lopez GM , Brimacombe J , Cebrian J , et al.Larygeal mask airway in pediatric practice. Anesthesiology 1996;84(4):807-11. 10.Ghai B , Makkar JK , Bhardwai N, et al.Larygeal mask airway insertion in children:comparison between rotational,lateral and standard techniques. Pediatric anesthesia 2008;18(4):308-12 11.Oneill B , Templeton JJ , Caramico L, et al.The laryngeal mask airway in pediatric patients:factors affecting ease of use during insertion and emergence. Anesth Analg 1994;78:659-62. 12.Trevisanuto D , Micaglio M , Ferrarese P , et al.The laryngeal mask airway:potential applications in neonates. Fn.bmj.com 2008.www.archdischild.com. 9

Jordan craters :: essays research papers

The Jordan Craters volcanic field is located on the Owyhee-Oregon Plateau at the southeastern end of a series of young basalt fields extending from near Bend, Oregon, through Diamond Craters in south-central Oregon (Volcanoes of the World). The Jordan Craters field is limited to the northern most and youngest portion of a larger (250 square kilometers) Quaternary alkaline basalt field. There are three major vent areas aligned north to south along surficial and inferred expressions of the regional Basin and Range faulting (Hart, W.K., and Mertzmann, S.A.). Fluid pahoehoe basalt flows emanated from each of these sources, with pyroclastic activity confined to small scatter cones and to a larger crater-cone complex (Coffeepot Crater) at the northernmost edge of the Jordan Craters portion of this field (Volcanoes of the World). This entire Quaternary alkaline basalt field is part of a larger field (nearly 800 square kilometers) that includes Pleistocene and Pliocene olivine tholeiite to t ransitional basalt flows and vents. Jordan Craters is a wonderful sight mainly because of its well-preserved vents and striking flow features. Near Coffeepot Crater, the flow surfaces are vesicular shelly pahoehoe, which grade to massive tube-fed ropy pahoehoe in the distal regions. A 75-square-kilometer coffeepot Crater is a heart-shaped tephra cone constructed of numerous overlapping lobes of alternating densely to weakly welded scoriaceous lapilli and bombs (Volcanoes of the World). The walls of the crater show good evidence for a fluctuating lava pond, which appears to have broken through and rafted away portions of the northeastern and southeastern crater walls. Backflow of the lava pond into the conduit is indicated by pahoehoe crust on the present crater floor. The Jordan Craters lava flow field is mineralogically and chemically homogeneous, whereas proximal tephra and flow deposits exhibit significant chemical heterogeneity which correlates with the eruptive history. Also noteworthy are the many excellent examples of basalt flow

Case Law and the Doctrine of Precedent Essay

In this essay I will be discussing several points of interest that will help me answer the given question. My first point is on the Hierarchy of the courts. In this point I will explain the different ‘levels’ there are in the English system. My second point is Stare Decisis and what it is. This point is made up of several questions that I will answer; why have binding precedent? What has to be followed? That is Obiter Dicta and Ratio Decidendi? What is persuasive precedent and who uses it and how it is used? When is a judge bound? Can the Stare Decisis be avoided? And lastly: How has Stare Decisis handicapped the development of the English law? The hierarchy of the courts The English system is made up of a hierarchy of courts. Hierarchal means that the courts which are high in the system hear appeals from the ones below them. The decisions made in the higher courts are of great importance. The bottom courts are known as foot soldiers and are at the bottom of the system. Some courts in this rank are the Magistrates court, the Youth court, the Coroners court and the County court. These courts hear cases daily and are which the average person will find themselves in for debt, injuries, car accidents and low level criminal offences. They are of a good amount of importance because they make decisions for justice daily. These courts however have little impact on the development of law except as a source for cases which may then be heard or appealed to higher courts. Since these courts are the lowest they do not bind any other court except themselves. There are two courts on the higher level. The High court which deals with cases pertaining to civil matter of unlimited value and the Crown court which deals with serious criminal offences. The High court has four sections: the Chancery division which deals with matters pertaining to equity, the Family division which deals with family matters, the Queen’s Bench division which deals with civil matters and the Divisional court who hears the appeals from civil prerogatives of the lower courts. The High court is not bound by its previous decisions but it can make precedents for the courts below it. Like the High court, the Crown court is bound by all higher courts. It doesn’t make binding precedents but their judgments form persuasive precedents when a High court judge sits in the Crown court. It also is not bound by its past decisions. The Court of Appeal is the next step higher. This court is the most important of the hierarchy even though it is not at the top of the system. This court is important because it hears appeals from lower courts in both the criminal and civil matters. There are three judges who sit to hear an appeal. Two of these judges must be Lord of Justices of Appeal. The third judge could either be a judge from the High Court or the Supreme Court. The name given to the head of the Court of Appeal is the Master of the Rolls. The Supreme Court is the highest appellate court in the hierarchy. It hears cases on appeal from the Court of Appeal. Sometimes the appeal will come straight from the High Court or the Crown Court. This only happens if there is a case which involves the important question of the law. The people who sit in the Supreme Court are called Justices of the Supreme Court. There are at least three to five Justices who sit to hear appeals. It the case is very important than seven sit to hear the case. There can only be at most twelve Justices in the Supreme Court. The Privy Council is the highest court in the Commonwealth nations and civil appeals. Some of the judges who sit in the Privy Council are those which make up the Supreme Court. The Privy Council is not a part of the hierarchal system and so its decisions do not bind the English Courts. Even though the decision of the Privy Council does not bind English courts, the judges are the same that make up the Supreme Court of England; there is a section of the Supreme Court that is persuasive precedent. Following the case of R v James Karimi (2006) the Court of Appeal found out that in certain circumstances the Privy Council can bind the English courts and overrule previous precedent. Stare Decisis Stare Decisis means ‘to stand by things decided.’ Stare Decisis is one of the main things that makes up the case law system. This makes judges bound to follow the previous decisions of higher courts in similar cases. This simply means that judges must obey previous judicial decisions of higher courts. This question is often asked: Why have Stare Decisis and why not let judges use their own conscience and wisdom to decide a case? As with everything there are advantages and disadvantages of creating something. The advantages of having Stare Decisis are that it promotes certainty, consistency and predictability. Professor Geldhart said that certainty is promoted by consistency of judicial making. Similar cases should have the same outcome. Certainty promotes predictability and this reduces the possibility for trial because everyone will know how certain cases will be decided.it also limits the potential for the declaratory theory to take effect. The theory is put into place to reduce judges who are not elected not to make law. The role of the judges is to apply and interpret. Law is made in Parliament and it represents the will of the people who elect the members of parliament. It also promotes justice. This type of justice is Aristotlean justice. This means that fairness is given equally of legal principles. The system is the same for everyone and so similar cases should be dealt with the same way. Disadvantages are that it makes the law rigid and inflexible. The law is not able to develop and is stuck. Precedent binds even if it is old and outdated. The discretion of the judge is that he must follow and abide by the decisions made by the judges before him no matter how old or outdated it may be. This also makes the law stuck and not develops to meet the modern day changes. The amount of case law precedent adds up to uncertainty. Case law and its precedents are contained in thousands of reports starting from the middle ages. It is difficult for lawyers and courts to go through them and find similar cases. It is not easy for judges to find the binding part (Ratio Decidendi) of any case. Ratio Decidendi is the reason for coming to the decision. This is the principle in which the court uses to make a decision. The ratio is the rule expressed by the judge to the extent that is necessary for the judge to come to his decision. Obiter Dicta are the things said by the way and other things which so not make up part of the decision making. When is a Judge Bound? As I stated earlier, a court must follow the decision of a higher court and its earlier decision. The system works in a way that makes binding precedent operate in a way to tie the hands of the judge. When the ratio binds any part of a court depends on the original decision that was made. The Supreme Court binds the Court of Appeal, which binds the High Court which binds the Magistrates, Crown and County court. Courts also bind themselves because of its earlier decisions. The only exception is the Supreme Court who makes its own decisions and is not bound by any other court because it is the most senior. Before 1966- Judicial Precedent HoL announced that they would no longer consider themselves absolutely bound to follow their previous decisions. Binding precedent remains the foundation of the English System of case law. The earlier decisions were based on conditions which no longer triumph and in modern conditions the law ought to be different. Judges are bound by similar cases. Judges in the latter case are bound to apply the same ratio used in early court where the two cases were based on the same issue. If the matter of a case is similar but has facts that similar to al later case, they differ and the issues are not all similar and the court is then not bound to apply the earlier precedent. This is called distinguishing. Can the Doctrine of Stare Decisis be avoided? Reversing occurs when a court higher up in the hierarchy downturns the decision of a lower court in the same case. A decision made in a certain case by the Court of Appeal will bind all future lower courts and it would bind itself. This can be avoided id the appeal went straight to the Supreme Court who would reach a different decision. The court of Appeal’s decision would have been short-lived precedent and the Supreme Court decision will take place of the previous one. Overruling is replacing one precedent with another which helps develop the law. Reversing is where a higher court substitutes a principle made by a lower court in the same case. Overruling involves a higher case substituting a principle set down by a lower court in a different and earlier case. My conclusion is thus; the principle of Stare Decisis has handicapped the development of the English Law because it makes the law rigid and inflexible. The law is not able to develop and is stuck. Precedent binds even if it is old and outdated. The discretion of the judge is that he must follow and abide by the decisions made by the judges before him no matter how old or outdated it may be. This also makes the law stuck and not develops to meet the modern day changes. The amount of case law precedent adds up to uncertainty. Case law and its precedents are contained in thousands of reports starting from the middle ages. It is difficult for lawyers and courts to go through them and find similar cases. It is not easy for judges to find the binding part (Ratio Decidendi) of any case. View as multi-pages

Fear Is Necessary By Machiavelli Aung Suu Kyi - 884 Words

Fear No political government, whether dictatorship or democracy, denies the need or role of fear in keeping its citizens obedient and responsive to order. â€Å"It is not power that corrupts but fear. Fear of losing power corrupts those who yield it and fear of the loss of power corrupts those who are subject to it.† (682) The united states rule of law is a democracy. In foreign countries dictatorship is widespread. If the loss of power corrupts, then those in power will utilize fear in maintaining power and corrupt citizens to achieve that end. Using fear for power isn t always a bad thing, if fear is used correctly then it is vital in maintaining power. Some authors who would agree that fear is necessary is Machiavelli Aung San Suu Kyi. Machiavelli would argue that fear is an absolute necessity to rule since people generally cannot be trusted to rule themselves. Leaders who would follow Machiavelli advice people as incapable of understanding their civic duty of obedience, so fear becomes the tool to enforce that obedience. The â€Å"dread of punishment† puts citizens in a type of paranoid state of mind, fearful of government authority as well as their fellow citizens. Fear overall can limit how a citizen can respond to oppression. A state run by fear and paranoia puts severe limits on the freedom citizens can enjoy as well as how they can change an oppressive government. Dictatorship work because as Machiavelli states, the fear of punishment prevents citizens fromShow MoreRelatedGovernment Must Ensure The Protection Of Individual Rights1137 Words   |  5 Pagesand habit of will for ruler ship which will develop a man whose inborn nature is predisposed for it† (172). A governor must be someone prepared for it, who understands the needs of its society and has the capacity to find solutions for them. It is necessary to have just rules to protect individual rights and that is why the efficiency of a government relies on its sense of justice . There should be an appropriate government to meet the needs of every different society. There are a several conditions