[Removal of the laryngeal mask airway in the post-anesthesia care unit. A means of process optimization?].

BACKGROUND: Removal of the laryngeal mask airway in the post-anesthesia care unit could potentially contribute to a faster turnover from one operation to the next. The aim of this study was, therefore, to obtain an insight into the potential time saving and the safety of planned removal of the ProSeal™-LMA (PLMA) in the post-anesthesia care unit.
METHODS: In this study 120 adult patients with American Society of Anesthesiologists (ASA) classification I-II, age range 18-85 years, undergoing a surgical procedure under general anesthesia in which the PLMA was used were randomly assigned to one of two groups. In group I, the PLMA was removed in the awake patient in the operating room close to the end of the procedure. In group II, the anesthetised but spontaneously breathing patients were moved to the recovery room and the PLMA removed when the patient was awake. The anesthesia technique was standardized [balanced, sevoflurane, fentanyl, bispectral index-guided (BIS) target value=35±5] and identical in both groups until randomization. Patients were breathing room air during transport to the recovery room. Different time intervals as well as the incidence of critical incidents were compared between groups. An oxygen saturation (S(p)O(2)) value <95% was considered a clinically relevant and S(p)O(2) values <90% as clinically critical O(2)-desaturation.
RESULTS: Removal of the PLMA took place after an average of 4.9±5.1 min in group I and after 19.5±9.6 min in group II. There was no difference in the availability of the anesthetist in the operating room for the following procedure between groups (group I: 12±5.6 min vs. group II: 10.7±4.2 min, p>0.05) despite the fact that patients of group II left the operating room faster (4.9±3.9 min) than patients of group I (7.1±5.1 min, p<0.01). In group II patients were ready for discharge (White score=12) from the recovery room later (13.2±8.2 min) than in group I (3.6±4.8 min, p<0.01). There were no significant differences in other process related time intervals between group I and group II: duration of the operation (113.2±45.9 min vs. 105.3±42.6 min), duration of dressing (5.1±3.7 min vs. 4.6±2.8 min), duration of transport to the recovery room (3.9±1.3 min vs. 3.6±1.3 min) and information at end of surgery by the surgeon (22.5±9.3 min vs. 22.4±10.5 min). The incidence of clinically relevant as well as clinically critical O(2) desaturation at the time of recovery room arrival (S(p)O(2)≤90%) was increased in group II with 33.3% vs. 56.6% and 13.3% vs. 6.7%, p<0.01, respectively.
CONCLUSION: Planned PLMA removal in the recovery room after BIS-guided balanced anesthesia did not enable the anesthetist to be available earlier for induction of anesthesia in the following patient. Hence the anesthetist could not contribute to a faster turnover of cases. Obviously, with the type of close communication between surgeon and anesthetist dictated by the study protocol (announcement of expected end of surgery by the surgeon 20 min before end of surgery) it is possible for the patient to regain consciousness within a very small time window following the end of surgery. Following this kind of protocol, postponement of removal of the LMA in the recovery room does not seem to be attractive neither from a clinical nor an economic point of view. In contrast, removal of LMA in the recovery room should be restricted to occasional cases with an abrupt end of the operation or prolonged emergence from anesthesia. The obvious risk of hypoxemia necessitates continuous O(2) application and S(p)O(2) monitoring during transport to the recovery room.

RCT Entities:   Population Interventions Outcomes