LMA extubation for adults - deep or awake?

[Xeta]

Anyone have any preferences one way or another?

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[criticalelement]

deep
i hate waking patients up and they start coughing on an lma. PLus theybiteit.

 

[Doctor4Life1769]

Depends.

 

[G-Man82]

The LMA is the ultimate oral airway. Granted I haven't used one yet since residency, I'd still take it out deep unless I think the guy is or was difficult to ventilate.

The airway wasn't protected anyway, so what does it matter if you take it out deep or awake as long as they're spontaneously breathing?

 

[Noyac]

Just a small grammatical correction. Pulling an LMA is not called extubation.

For the record, I do it both ways.

But if I'm gonna pull it awake and the pt seems like they might bite down on it then I just let the pt pull it out. But be sure to,tell the nurses that you want the pt to pull it out or else they will fight the pt trying to keep them from reaching up for the LMA.

 

[sevoflurane]

Almost always deep. About a year ago or so I deviated from my usual and the patient ended up in NPPE as she was waking up. She did fine (although admitted to the ICU for obs), but then... I had the pleasure to have her again... pulled it deep and everything after was easy-cheese.

 

[deleted162650]

For the record, I do it both ways

I've always had my suspicions.

 

[Phyrst]

Mostly awake...use an LMA with a built-in bite block to prevent NPPE.

 

[GatorBait1548]

Just curious about the NPPE case, did it present just like the textbook with the pink frothy sputum or did you just notice abnormally low sats, both?

 

[pgg]

Usually awake. Some brands of LMAs have a rigid built-in bite block. If I'm not using one of those, I put in a soft bite block, ie roll of gauze wrapped with tape.

 

[PonyUp]

Whatever my attending wants. Personally I prefer deep with a nasal airway in, especially if the hospital I'm at uses regular LMAs or LMA supremes [as opposed to an iGel, which I'm happy to pull awake]. I hate fighting biters.

 

[gasp]

Usually awake. Some brands of LMAs have a rigid built-in bite block. If I'm not using one of those, I put in a soft bite block, ie roll of gauze wrapped with tape.

+ 1

 

[teeva]

Deep. Unless I think pt will obstruct when I pull it asleep, then I just wait til awake. I used to preemptively put in a nasal trumpet and pull deep, but now solo and managing my own pacu pts, I prefer to reduce chances of trouble.

With the occasional biter (happens rarely for me, maybe seen it 2 times this year), I pull the LMA out a little without damaging teeth, so they can breath around the LMA and not get NPPE, and just wait til they're calm enough to open the mouth. Also use LMA Supreme when it's available.

 

[Noyac]

I hate fighting biters.

Keep working on your wake ups. Pts should not fight and/or bite when waking up. It is a rare occasion when I see this.
I know you are a resident and the fundamentals are what's important now but once those are mastered the art comes into play.

 

[Twiggidy]

Deep. Just about always. I usually pull it, slide in an oral airway, throw on a mask and roll to PACU. Usually by the time we hit PACU they're more awake and I take the oral out (or the patient does).

+1 to what Noyac just said. As you go from resident to attending, waking up a patient really does become an art and I'd even put my money to say that most surgeons and nurses just us by how we wake people up (whether that judgment really matters or not).

 

[Doctor4Life1769]

I'd prefer deep. I had patients pull their own LMAs at times too. Those with thick necks/OSA types - awake.

 

[Ignatius J]

Have them spit it out in Pacu. Put a bite block there or use a Supreme if you're worried about biting down.

Usually for me, they bite down if they're being screwed with- "Hey! Open your mouth and I'll take this out!!!"

Easy cheesy.

 

[pgg]

Deep. Just about always. I usually pull it, slide in an oral airway, throw on a mask and roll to PACU. Usually by the time we hit PACU they're more awake and I take the oral out (or the patient does).

I don't see the point of taking out an LMA just to replace it with an oral airway.

 

[nap$ter]

I don't see the point of taking out an LMA just to replace it with an oral airway.

2 reasons for replacing with oral airway - patients can't bite and occlude a guedel (I had a case of NPPE in a 16yo from this with an attending during residency who insisted on "awake extubations" with LMA's). also, all pacu nurses feel comfortable with oral airways, but not all pacu nurses feel comfortable with LMA's, and I want all pacu nurses to feel comfortable. my group works at 5 different sites and i am not interested in changing the culture/s.

there is no reason to pull LMA's awake or deep - i pull mine in between at 0.5-1.0 etsevo (or the equivalent with other anesthetics).

i do this because i want the pt deep enough not to bite the lma (and i place an oral airway) but light enough so that i don't have to support the airway for long if at all.

 

[pgg]

2 reasons for replacing with oral airway - patients can't bite and occlude a guedel (I had a case of NPPE in a 16yo from this with an attending during residency who insisted on "awake extubations" with LMA's). also, all pacu nurses feel comfortable with oral airways, but not all pacu nurses feel comfortable with LMA's, and I want all pacu nurses to feel comfortable. my group works at 5 different sites and i am not interested in changing the culture/s.

there is no reason to pull LMA's awake or deep - i pull mine in between at 0.5-1.0 etsevo (or the equivalent with other anesthetics).

i do this because i want the pt deep enough not to bite the lma (and i place an oral airway) but light enough so that i don't have to support the airway for long if at all.

A soft bite block solves the NPPE problem. I'll grant you there's no solving the PACU nurse problem. This job would be 43% easier without nurses around.

 

[nimbus]

A soft bite block solves the NPPE problem. I'll grant you there's no solving the PACU nurse problem. This job would be 43% easier without nurses around.

Agree. Roll up a few 4x4s and they can't occlude the lma. Why mess with a perfectly good airway? All of our pacu nurses love LMAs. Granted I only work at 3 sites....but they are all trained right! Haha

 

[sevoflurane]

I know you guys know this... but just for other readers out there that are learning the trade. NPPE can and does happen with LMAs with bite blocks in place. The obstruction in these cases is NOT due to the patient biting down on the LMA. It is due to laryngospasm and development of massive negative intrathoracic pressure against a closed glottis. Pink frothy pulmonary edema usually follows.

http://www.ncbi.nlm.nih.gov/pubmed/25669092

It can happen, however, with forceful biting on the LMA (never seen this).

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3401823/

 

[fakin' the funk]

When you feel their upper airway tone increase but they're not awake yet

 

[nimbus]

I know you guys know this... but just for other readers out there that are learning the trade. NPPE can and does happen with LMAs with bite blocks in place. The obstruction in these cases is NOT due to the patient biting down on the LMA. It is due to laryngospasm and development of massive negative intrathoracic pressure against a closed glottis. Pink frothy pulmonary edema usually follows.

http://www.ncbi.nlm.nih.gov/pubmed/25669092

It can happen, however, with forceful biting on the LMA (never seen this).

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3401823/

This can also happen with an oral airway or no airway at all. The only thing that will prevent it 100% of the time is an ett.

 

[nap$ter]

I know you guys know this... but just for other readers out there that are learning the trade. NPPE can and does happen with LMAs with bite blocks in place. The obstruction in these cases is NOT due to the patient biting down on the LMA. It is due to laryngospasm and development of massive negative intrathoracic pressure against a closed glottis. Pink frothy pulmonary edema usually follows.

http://www.ncbi.nlm.nih.gov/pubmed/25669092

It can happen, however, with forceful biting on the LMA (never seen this).

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3401823/

the one case of NPPE i had was from the pt biting the LMA (traditional reusable) in a teen with a particularly good seal - deflating the LMA relieved the obstruction (albeit too late to avoid NPPE and 6 add'l hrs in the pacu...)

i have never yet had significant laryngospasm on emergence in a patient with an LMA or oral airway (that wasn't previously intubated)(but i've also only been out of training 4 years).

we don't have 4x4's readily available on most of our anesthesia carts and i don't care enough to ask for em - the only time i ever need a soft bite block is when MEP's are running.

 

[OB1🤙]

I pull them awake 100% of the time and have not encountered problems over thousands and thousands of cases. I realize that that doesn't mean problems can't happen. But in my practice this works.

If they bite the LMA waking up, I push hard on their lower frenulum and they open their mouth. That or just tell them "open your mouth" as has been said.

An LMA is an oral airway. I keep oral airways in until the patient is awake enough to spit it out or become purposefully pissed off about it. I do the same with LMAs.

I have no qualms with those who pull them deep. I just don't find it necessary.

I do pull most ETTs deep.

 

[Twiggidy]

I don't see the point of taking out an LMA just to replace it with an oral airway.

You bake your cake your way. Ill bake mine my way

 

[Sonny Crocket]

I pull some deep and some awake depending on the patient. For those of you pulling them deep, what is your definition of deep? That is the question.

 

[Ignatius J]

I pull some deep and some awake depending on the patient. For those of you pulling them deep, what is your definition of deep? That is the question.

I guess it would be enough to not move or have an airway response while you exchange a superior oral airway for an inferior one.

 

[criticalelement]

An LMA is an oral airway.

No it's not.

 

[criticalelement]

For those of you pulling them deep, what is your definition of deep? That is the question.

Deep is deep. Breathing spontaneously. No airway refelexes at all.

 

[dhb]

No it's not.

Yes it is

Deep is deep. Breathing spontaneously. No airway refelexes at all.

No it's not

 

[Frank Rizzo]

Deep. Always. Interestingly enough, I'm in the very small minority in my group that does.