The use of laryngeal mask airway in pediatric patient with massive post-tonsillectomy hemorrhage

Corresponding author: Kyung-Tae Kim, M.D., Department of Anesthesiology and Pain Medicine, Ilsan Paik Hospital, Inje University School of Medicine, Daehwa-dong, Ilsanseo-gu, Goyang 411-706, Korea. Tel: 82-31-910-7160, Fax: 82-31-910-7184, E-mail: [email protected] This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http:// creativecommons.org/licenses/by-nc/3.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. CC The Laryngeal Mask Airway (LMA) is not only used in patients who have a difficult airway with a conventional laryngo scope, but it is also used in children who have a tonsillectomy to manage the airway [1]. However, cases related to the airway management of young children with massive post-tonsillectomy hemorrhage (PTH) have not been reported yet. Here, we report a case in which we have successfully performed airway management using LMA during severe ventilatory difficulty, which had occurred in a young child patient with massive PTH, in which we failed to perform an endotracheal intubation under general anesthesia. A 6-year old female patient visited the hospital complaining of massive hematemesis. A physical examination confirmed acute oozing bleeding in the left tonsillar fossa. We decided to perform an emergent operation under general anesthesia for surgical ligature. After arrival to the operating room, we continuously carried out oral suction in the patient, who was in the trendelenburg position, in order to prevent aspiration caused by the hematemesis, while also providing her with 100% oxygen via a mask. A rapid sequence intubation (RIS) could be performed. We performed an endotracheal intubation immediately under the Sellick’s maneuver, but constant intraoral bleeding inhibited us from securing a clear view, so we failed to intubate. After which, we performed a blind intubation by inserting a stylet, but we failed to do this as well. Meanwhile, the patient’s oxygen saturation plunged to 79%, so another doctor performed the intubation procedure, but was also unsuccessful. After which, the oxygen saturation decreased to 52%, so a cricothyrotomy and tracheostomy were planned for an instant surgical airway. Because of intraoral bleeding that occurred in the tonsil and that the surgical airway was difficult due to differences in anatomical structures compared to adults, in addition, our hospital routinely prepares a LMA to general anesthesia;thus, we attempted to insert the LMA before the surgical airway. Number two of the LMA (LMA Supreme, LMA Company Ltd, UK) was inserted immediately under the Sellick’s maneuver. After the successful insertion of the LMA, ventilation was performed well without any air leakage, and the auscultation sound was normal. Oxygen saturation normalized, increasing from 48% to 100%. With a Yankauer suction catheter, we suctioned by inducing pressure with a gauze on the site of bleeding, and thus, we were able to secure our view. And then, we removed the LMA, and successfully performed a RIS. A blood clot was found behind the cuff of the removed LMA (Fig. 1). After the operation, we confirmed that the patient recovered from her unconsciousness with oxygen saturation maintained at 99-100%. Afterwards, since the lung sounds was normal, the patient was extubated, and was transferred to the recovery room. One hour later, the patient was then transferred to the ward since oxygen saturation was maintained at 100% without oxygenation. The results of the chest radiograph performed after the operation was normal, and the patient was discharged without any particular problems ten days later. In general, a surgical airway is not widely used in children aged 8 years or younger in contrast to adults [2]. The reasons for this is that the cricothyroid membrane of adults is 13.7 mm in length and 12.4 mm in width on average [3], whereas the membrane of children is merely 2.6 mm in length and 3 mm in