Tips and Tricks

[Simba1711]

Anybody have any tips on putting Lmas in edentulous patients ? I don’t have any issues with patients with teeth but edentulous patients I usually require a few tries before getting it to seat adequately

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[DrZzZz]

Anybody have any tips on putting Lmas in edentulous patients ? I don’t have any issues with patients with teeth but edentulous patients I usually require a few tries before getting it to seat adequately

LMA Supreme generally seat much better. But if all you've got are the standard LMAs, sometimes making a pair of soft bite blocks with some 4x4's and sticking them on either side of the LMA in the mouth can help. But don't force it. If you don't get a good seal relatively quickly, just stick a tube in.

 

[DrN2O]

I'm not sure if I agree with all of these tips being useful for this particular scenario. Specifically where the wire is 100% in, even under US guidance, but there is difficulty threading the cannula.

I reckon an additional advancement of the needle once the wire is successfully threaded could be the underlying problem OP is having? So I wouldn't be advocating for more of it. But i might be completely wrong.

If the wire is in, and you put it in relatively flat, and there was 0 resistance... i would be hesitant to advance the needle any further after the fact. Youre risking penetrating the far wall (or any wall really) and then the cannula cannot thread over the needle's tip.

The reason for the difficulty threading the catheter AFTER wire went in smoothly is because the plastic catheter is caught on the exterior of the artery. I see this all the time, the resident tries to push off the catheter, it goes for like 5mm, it feels funny, let go, it bounces back. It has nothing to do with the friction on the catheter coming off the needle. The artery is calcified. The needle probably deformed the vessel on ultrasound (but without flash), and they needed some extra force before penetrating the wall. How is the plastic catheter going to go in? Half the time, the resident just pushes harder, and it pops in (thank god). The other half, the wire gets kinked, the artery gets traumatized, and it's a bloody mess. FLATTEN out the whole kit, advance it a few mm (like an IV), the needle won't injure the backwall, the catheter goes in like butter.

 

[Drangue]

Here's one I was showed just a few days ago. I induced a patient and placed an LMA. The patient then starts to hiccup. Nothing to disruptive but it was still pretty annoying. One of the old-timer partners walks into my room, notices the hiccuping patient, and says let me show you something. He grabs a flexible oral catheter and places it through the nose into the nasopharynx. And the patient stops hiccuping!! Just like that!! He claims it works every time.

What is a flexible oral catheter?

 

[norski]

What is a flexible oral catheter?

Used this for stopping hickups and for high BMI, OSAS patient extubations, but never heard of or seen a flexible oral. Tiny LMA?

 

[ProwlerturnGas]

Flexible oral catheter = flexible oral suctioning catheter placed nasally

 

[Radar26]

Couple of things I remember seeing during training

pediatric ETT sizing- if you’re ever in doubt the size you picked based off the formula age/4+4- hold the ETT next to the patient’s pinky- if there is a big difference in size change your ETT until it matches

fill the cuff with lidocaine rather than air for a smoother emergence as the lido will seep out and numb the airway during the case.

Put in the ENT mouth guard instead of a standard bite block for loose teeth that you don’t want to remove intra-op. The mouth guard pushes the loose tooth down into the gums and distributes any force you put on the teeth evenly (especially with TEE)

For ivs- after getting flash flip the needle 180 degrees so the bevel is at the top of the vessel rather than the bottom before you flatten out, advance, and thread the catheter off. This reduces the risk that you go through the vessel when advancing (I find this works best for getting an 18g into a questionable vessel in fat people where you can’t see/feel the vein pathway that well)

put 1% lido in the LOR syringe for labor epidurals (or the pre-made mix from the bag- I believe Salty does this). Unlikely the amount you give will cause a high spinal if intrathecal or LAST if you are intravascular. Also starts to relieve the labor pain quicker so you can thread the catheter without feeling rushed or have to sit there bolusing the catheter (there is like an entire thread on this topic)