International Journal of Clinical Medicine, 2011, 2, 328-331
doi:10.4236/ijcm.2011.23057 Published Online July 2011 (
Copyright © 2011 SciRes. IJCM
Safety and Efficacy of Pediatric General
Anesthesia by Laryngeal Mask Airway without
Intravenous Access
Benjamin A. Lin1, Zakaria S. Messieha2*, William E. Hoffman3
1Chief resident, Oral and Maxillofacial Surgery, University of Illinois, Chicago, USA; 2Associate Professor, Anesthesiology, Univer-
sity of Illinois, Chicago, USA; 3Research Associate Professor, Anesthesiology, University of Illinois, Chicago, USA.
Email: *
Received January 9th, 2011; revised May 29th, 2011; accepted June 7th, 2011.
The safety and efficacy of the laryng eal mask airway (LMA) has been reported by numerous large-scale studies. How-
ever, they do not address the issue of whether an intravenous (IV) is required for pediatric general anesthesia (GA)
where access is challenging due to anatomical considerations and a lack of cooperation. The aims of this study are to
determine whether pediatric GA by LMA without IV access affected placement rates, procedure times and rates of an-
esthetic complications. Children who met these criteria at the UIC Surgicenter in the two year period prior to August
30, 2005 were selected. A retrospective chart review was conducted to determine patient demographics, ASA class,
procedure, placement success, IV placed if any, time to incision, and any anesthetic comp lica tions. 241 patien ts without
IV access and 41 patients with IV access were included. No significant differen ces were found between the groups in the
rates of LMA placement or anesthetic complications. Significant differen ces were found in times to incision overa ll and
for ophthalmology exams under anesthesia and lacrimal duct probings. Pediatric GA by LMA without IV access dem-
onstrated a similarly high placement rate, shorter procedure times and a low rate of complications in comparison with
the control group.
Keywords: Pediatric Anesthesia, Anesthesia Efficacy, LMA Safety, General Anesthesia without Intravenous
1. Introduction
The laryngeal mask airway (LMA) is a device used to
secure an airway in an unconscious patient and is widely
and routinely used in the operating room for general
anesthesia (GA). GA in children differs than that for
adults as children tend not to tolerate the placement of
an intravenous (IV) line pre-operatively, which would
allow for the injection of medication. In addition to be-
ing uncooperative, children possess veins that are corre-
spondingly smaller than that of an adult making IV
placement technically more challenging. Typically, an
IV is placed once the child is asleep, depending on the
preference of the anesthesiologist. Elimination of this
step entirely would shorten operating room time and be
more cost effective.
There are no published accounts of GA by LMA used
in the specific context of no IV access; however, the
safety and efficacy of GA by LMA is well established
by the literature. In a retrospective study, Verghese et al.
describe the successful use of the LMA with IV access
in 11,910 adults and children with an overall placement
success rate of 99.81%, a risk of laryngospasm of 0.07%,
bronchospasm of 0.025%, and vomiting of 0.017% [1].
Mason et al. describe in a prospective study, the use of
the LMA with either Halothane or Isoflurane in 200
children with IV access for a variety of surgical proce-
dures with a successful placement rate of 97.5%, laryn-
gospasm in 2.5% and vomiting in 1.5% [2]. Lopez-Gil et
al. in another prospective study consisting of 1400 chil-
dren with LMA usage with Isoflurane and IV access
found successful placement in 98% of patients, 2.7%
with upper airway stimulation, including laryngospasm/
bronchospasm and vomiting/regurgitation/aspiration in
0.07% [3]. Conclusions of this study were that the inci-
dence of problems is similar to those of adults but that
there were a significantly higher complication rate (p <
Safety and Efficacy of Pediatric General Anesthesia by Laryngeal Mask Airway Without Intravenous Access 329
0.001) for ENT procedures and when using the size 1
There has been only one report in the literature (Hau-
pert et al. 2004) that addresses the issue of whether an
IV is even required for pediatric general anesthesia
where access is technically challenging due to anatomi-
cal considerations and a lack of patient cooperation. This
randomized controlled study had 100 ASA statuses I or
II children aged 2-12 who underwent bilateral myringo-
tomies with pressure equalizing tube placement [4]. One
group received IV access and the other did not. Both
groups had mask induction and maintenance with oxy-
gen, nitrous oxide, and Sevoflurane. All children re-
ceived Fentanyl intramuscularly and spontaneous venti-
lation was maintained. Patients with IV access received
Lactated Ringer’s solution. Their study concluded that
intravenous access in otherwise healthy children in my-
ringotomy procedures provided no added benefit [4].
Significant differences included more pain medication
required (p < 0.001), lower parental satisfaction (p <
0.001) and more time spent in both the operating room
(p = 0.02) and recovery (p = 0.02) for the group of chil-
dren with IV access [4].
The purpose of this study was to determine if general
anesthesia by laryngeal mask airway without intrave-
nous access is safe and efficacious, resulting in highly
successful placement rates, shorter procedure times and
a low rate of anesthetic complications in a pediatric
population. Our study would be the first to highlight the
benefits of using general anesthesia by LMA without IV
access for short pediatric procedures in the head and
neck region such as bilateral myringotomies and tube
placement (BMT), ophthalmologic exams under anes-
thesia (EUA), nasolacrimal duct probing and chalazion
2. Methods
After receiving institutional review board approval, the
surgery schedule at the University of Illinois Medical
Center Surgicenter was used to select patients aged 0-17
who underwent GA by LMA between the dates of Sep-
tember 1, 2003 to August 30, 2005. A retrospective chart
review was performed and the following documents
were gathered for each potential subject: anesthesia re-
cords, operative reports, and if applicable, Surgicenter
reports, hospital admission notes and recovery room
notes. Subjects having complete records were then cho-
sen for inclusion. Subjects lacking the appropriate docu-
mentation were excluded from the study. Eligible pa-
tients were then assigned into 2 groups, based on
whether they had an IV placed after mask induction with
Sevoflurane. Group 1 had no IV access, and group 2 had
IV access. The following data was then collected and
compared between the two groups:
Age, gender, weight, medical conditions and ASA
Procedure done and operating room (OR) time to
LMA type used and whether successfully placed
Type of anesthetic used, method of ventilation
Type and location of intravenous placed if any
Medications given pre-, peri- and post-operatively
and route of administration
Anesthesia complications and management
Statistical analysis was performed using the software
program SigmaStat for Windows. Z-tests were utilized
for analysis of both LMA placement success rates and
complication rates between the groups 1 and 2. T-tests
were utilized for analysis of time to incision between the
groups. Statistically significant differences were consid-
ered achieved at p < 0.05.
3. Results
A total of 282 eligible pediatric patients were included
in this study. Group 1 had 241 patients and group 2 had
41 patients. 43.2% of the patients in group 1 and 46.3%
of the patients in group 2 were female. Figure 1 shows
the age distribution of the patients in each group. Figure
2 shows the distribution of patients according to Ameri-
can Society of Anesthesiologists (ASA) classification.
Table 1 shows the placement success rates between
the groups and according to LMA size as well as overall.
Group 1 had a 99.6% rate of successful LMA placement
while group 2 had a 97.6% success rate. There was no
significant difference between the groups in terms of
overall LMA placement success rates by Z-test (p =
Table 2 lists the mean OR time to incision for each of
the procedures and overall performed between the two
Number of Patients
Age (Years)
Figure 1. Age distribution.
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Safety and Efficacy of Pediatric General Anesthesia by Laryngeal Mask Airway Without Intravenous Access
Nu mbe r of Patients
Physi cal St atus
Figure 2. ASA distribution.
groups as well as the mean time saved. There were sig-
nificant differences between the two groups for the pro-
cedures EUA (p = 0.02) and lacrimal duct probing (p <
0.001) as well as overall (p < 0.001). No statistical dif-
ference was observed for BMT (p = 0.07) and chalazion
excision (p = 0.47).
Table 3 shows the types and overall rate of anesthetic
complications by group. Group 1 had a 1.66% complica-
tion rate while group 2 had a 4.88% complication rate.
There was no significant difference between the groups
in terms of overall anesthetic complication rates by
Z-test (p = 0.47).
4. Discussion
Children represent a unique challenge to the anesthesi-
ologist due to their lack of co-operation and difficult
anatomy. Placement of an IV is not innocuous and mul-
tiple attempts at establishing one can take up a signifi-
cant amount of OR time as well as introduce additional
sites for post operative pain and scarring.
Our institution has been performing EUAs, BMTs, na-
solacrimal duct probings and chalazion excisions with-
out IV access for numerous years. Our patient demo-
graphics show that the majority of our cases were under
the age of 6 and ASA class I or II.
Our retrospective chart review demonstrated that there
was no significant difference between the groups in
terms of overall LMA placement success rates and that
the rates were comparable to those found in the literature.
This is understandable since all of the LMAs in our
study, regardless of IV status, were placed after mask
induction with Sevoflurane. One of the advantages of
the LMA is that muscle relaxation is not required for
placement [5]. In the rare event that the LMA could not
Table 1. LMA placement success rates.
Size No IV (n = 241) Placement
Success IV (n = 41)Placement
1.5 43 (17.84%) 97.7% 3 (7.31%) 100%
2.0 137 (56.84%) 100% 26 (63.41%)96.2%
2.5 43 (17.84%) 100% 9 (21.95%)100%
3.0 15 (6.22%) 100% 3 (7.31%) 100%
4.0 2 (0.83%) 100% 0 N/A
5.0 1 (0.41%) 100% 0 N/A
Total*241 99.6% 41 97.6%
*No significant difference (p = 0.63).
Table 2. Times to incision.
Procedure IV
(n = 41)
(n = 241)
Exam under
14.92 167
11.13 3.79 0.02
duct probing
28.42 20
12.55 15.87<0.001
27.4 5
23 4.4 0.47
B/l myringo-
tomy +
tube placement
15.23 49
12.8 2.43 0.07
Total 41 11.84 241 18.88 7.04 <0.001
Table 3. Anesthetic complication rates.
No IV (n = 241) IV (n = 41)
Complications Laryngospasm ×3
Bronchospasm ×1
Larygospasm ×1
Intra-op regurgitation ×1
Overall Rate*: 1.66% 4.88%
*No significant difference (p = 0.47).
be successfully placed, then alternative methods such as
mask or endotracheal tube placement were used to
maintain general anesthesia.
It is standard at our institution to record time to inci-
sion for each procedure by the circulating nurse and this
marker was felt to better reflect the time taken for the
anesthesiologist to place the LMA without having op-
erative circumstances affect the results. Our study
showed that overall, as well as for EUAs and nasolacri-
mal duct probings, there was a significant difference in
time to incisions between the IV and no IV groups. Al-
though not significant for BMTs, it is to be noted that
this was barely so and perhaps a larger sample size
would have bore this out. There appears to be no sig-
nificant difference in chalazion excision times to inci-
sion but this could have been due to more extensive
prepping and draping requirements prior to incision.
There were no significant differences between the two
groups in terms of anesthetic complications. The com-
plications were all managed successfully without any
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Safety and Efficacy of Pediatric General Anesthesia by Laryngeal Mask Airway Without Intravenous Access
Copyright © 2011 SciRes. IJCM
long term sequelae. In the no IV group, the laryn-
gospasms were managed with jaw thrust and positive
pressure ventilation or placement of an IV and an en-
dotracheal tube.
Prior to mask induction of the patient, all intubation
equipment, an IV kit and setup and medications includ-
ing a succinylcholine/atropine dart are prepared.
Although IV is the preferred route for medications,
other routes such as intramuscular, tracheal and rectal
are available to deliver medications. Our patients were
routinely given rectal Acetaminophen or im Ketorolac
for post operative analgesia. This also does not preclude
us from placing an IV if one is required later on. The
disadvantages of not having an IV include the inability
to administer fluids. However, our procedures were
short and involved minimal to no blood loss. In addition,
children possess a greater cardiac reserve and the lack of
IV fluids did not affect our hemodynamic stability.
From these results, pediatric GA by LMA without IV
access is a feasible option for the anesthesiologist in
ASA class I or II patients for short head and neck pro-
cedures and demonstrates a high placement rate, shorter
procedure times and a low rate of complications in
comparison with controls. Future studies could encom-
pass prospective studies, randomization, larger sample
sizes, and other procedures such as suture removal.
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[3] M. Lopez-Gil and M. Alvarez, “Safety and Efficacy of
the Laryngeal Mask Airway: A Prospective Survey of
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969-972. doi:10.1111/j.1365-2044.1996.tb14968.x
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