LMA into position. You can also insert them with the cuff partially or fully
deflated, or with the aperture facing posterior, and then turned 180
degrees after passing behind the tongue. Putting water-based lubricant on
the posterior surface decreases resistance. There may be some pharyn-
geal bleeding with LMAs, and some children may end up with sore
throats, but those are less common than they are after endotracheal intu-
bation.
Laryngoscopy is also relatively straightforward and technically easy
in most children 2 or older, because the glottis is usually easy to see in
children. But in neonates and small infants, laryngoscopy can be chal-
lenging, because the anesthesiologist's optimal position differs from
that of adults. The line of sight should be nearly directly over the
child's airway, and to gain the easiest view of the glottis, insert the
blade more perpendicular to the OR table than with older children or
adults.
Tracheal intubation
Unless I have to, I try not to intubate or use a laryngoscope. But when nec-
essary, tracheal intubation is straightforward, unless the child has altered
facial or airway anatomy. If you anticipate a difficult intubation, I advise
against attempting direct laryngoscopy. Each unsuccessful direct attempt
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DENTAL CHECKUP
Any Loose, Chipped Teeth?
After induction of general anesthesia, but before airway instrumentation, check for
loose or chipped teeth and remove primary teeth that are very loose. Grasp the tooth
firmly with gauze and rock it back and forth while pulling or twisting. You can stop
minor bleeding with firm pressure. And all personnel in attendance should be
required to contribute to the tooth fairy fund. — Ronald S. Litman, DO
