title: Best position and depth of anaesthesia for laryngeal mask airway removal in children: A randomised controlled trial.
abstract: BACKGROUND
  There is a wide variation in clinical practice amongst clinicians in the process of removal of the laryngeal mask airway (LMA) in children. Some of the airway complications during recovery are associated with the position of the child as well as the depth of anaesthesia and are potentially avoidable.
  
  
  OBJECTIVE
  We wished to determine whether removal of the LMA in the lateral position reduces the incidence of airway complications, either in a deep plane of anaesthesia or awake.
  
  
  METHODS
  A randomised trial.
  
  
  METHODS
  A tertiary children's hospital.
  
  
  METHODS
  The study population comprised 216 American Society of Anesthesiologists (ASA) 1 to 2 patients aged 1 to 16 years scheduled for elective surgery under general anaesthesia using an LMA. Exclusion criteria were children less than 1 year old, ASA 3 or above, presence of congenital heart disease or gastro-oesophageal reflux, anticipated difficult airway and patients undergoing airway or dental surgery.
  
  
  METHODS
  We randomly allocated 212 children into one of four groups for LMA removal, deeply anaesthetised or awake in either the lateral or supine position. Various airway complications were recorded after removal of the LMA.
  
  
  METHODS
  The primary outcome measure was the number of patients experiencing one or more complication in each group. We also devised a novel 'Clinical Importance' score on the basis of the clinical relevance of airway complications.
  
  
  RESULTS
  There were significant differences among groups (P = 0.001); the fewest complications occurred when the LMA was removed in a deep plane of anaesthesia in the lateral position. There was a significant difference among groups in the 'Clinical Importance' scores (P < 0.001); the greatest risk occurred when the LMA was removed in deeply anaesthetised supine patients.
  
  
  CONCLUSIONS
  The results of the present study suggest that lateral positioning of children for removal of the LMA provides the safest conditions if the LMA is to be removed at a deep plane of anaesthesia. Sheffield Children's NHS Foundation Trust Study number CA08014.
authors.affiliation: From the Rotherham NHS Foundation Trust, Rotherham (GT-K), Mid Yorkshire Hospitals NHS Trust, Dewsbury (AK) and Sheffield Children's NHS Foundation Trust, Sheffield, UK (JS).
authors.forename: George
authors.initials: G
authors.lastname: Thomas-Kattappurathu
authors.forename: Ananth
authors.initials: A
authors.lastname: Kasisomayajula
authors.forename: Judith
authors.initials: J
authors.lastname: Short
mesh_terms: D002648:Child; D005260:Female; D006801:Humans; D008297:Male; D000367:Age Factors; D000769:Anesthesia, Inhalation / Q000295:instrumentation / Q000379:methods; D020878:Device Removal / Q000295:instrumentation / Q000379:methods; D017214:Laryngeal Masks / Q000592:standards; D056888:Patient Positioning / Q000295:instrumentation / Q000379:methods; D010865:Pilot Projects; D016037:Single-Blind Method