Unsatisfactory LMA and the ever changing plan

[Licoricestick]

So I'm in one of our emerg theatres yesterday and the next case up is a closed reduction + K-wires to # distal radius in a 90yo F, demented (no way we would have been able to manage a regional with her). No Hx from patient, essentially no history from family (who weren't present anyway). LMO contacted - but didn't have notes in front her, drug chart and brief problem list available from nursing home notes.

As best as I can piece together PMH consists of:
Dementia
OA
scoliosis
GORD - on PPI, LMO thinks pt had no further complaints after this
HTN
Previous episode of CCF ("years ago", no problems since according to LMO)
?may have had previous MI
never smoked, no known resp issues

Mobilises with walker at NH, reportedly never complains of chest pain, most recent drug chart shows not receiving any PRN nitrate doses

Appropriately fasted, almost no opioids since injury and injury was 3 days prior (we had a little backlog to clear over new years).

Meds (abbreviated list of the important ones - can't remeber then all):
beta blocker
PPI
ACE inhibitor
thiazide
paracetamol
doxepin

O/E: obs all OK (can't remember the numbers but nothing out of the ordinary)
skinny
HS dual + nil
chest clear
no peripheral oedema
JVPNE
small mouth/jaw/face overall, all own teeth, MP 3, good MO, reasonable neck extension (TMD >6cm)

Case discussed with consultant (our training rules require me, at this stage, to discuss all cases with supervising consultant before proceeding) and he agrees with my plan of gentle induction (little bit of propofol, little bit of sevo), #3 supreme LMA (no way I can get a #4 into her mouth), pressure support ventilation, maintenance on sevo and a little fentanyl titrated to RR.

Wonderful - we attempt to get underway - except I can't get the damn LMA in - beautifully easy facemask ventilation, but every time I place the LMA I either can't get CO2 or get really pathetic TV with a very obstructed trace. Finally try to place it using the laryngoscope to confirm that I'm posterior to the epiglottis - still no luck, but I do note that she's a grade 3 larynx.

Surgeon is fast (did the same case on the previous patient in 15min)

What would you guys do next?

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[2win]

So I'm in one of our emerg theatres yesterday and the next case up is a closed reduction + K-wires to # distal radius in a 90yo F, demented (no way we would have been able to manage a regional with her). No Hx from patient, essentially no history from family (who weren't present anyway). LMO contacted - but didn't have notes in front her, drug chart and brief problem list available from nursing home notes.

As best as I can piece together PMH consists of:
Dementia
OA
scoliosis
GORD - on PPI, LMO thinks pt had no further complaints after this
HTN
Previous episode of CCF ("years ago", no problems since according to LMO)
?may have had previous MI
never smoked, no known resp issues

Mobilises with walker at NH, reportedly never complains of chest pain, most recent drug chart shows not receiving any PRN nitrate doses

Appropriately fasted, almost no opioids since injury and injury was 3 days prior (we had a little backlog to clear over new years).

Meds (abbreviated list of the important ones - can't remeber then all):
beta blocker
PPI
ACE inhibitor
thiazide
paracetamol
doxepin

O/E: obs all OK (can't remember the numbers but nothing out of the ordinary)
skinny
HS dual + nil
chest clear
no peripheral oedema
JVPNE
small mouth/jaw/face overall, all own teeth, MP 3, good MO, reasonable neck extension (TMD >6cm)

Case discussed with consultant (our training rules require me, at this stage, to discuss all cases with supervising consultant before proceeding) and he agrees with my plan of gentle induction (little bit of propofol, little bit of sevo), #3 supreme LMA (no way I can get a #4 into her mouth), pressure support ventilation, maintenance on sevo and a little fentanyl titrated to RR.

Wonderful - we attempt to get underway - except I can't get the damn LMA in - beautifully easy facemask ventilation, but every time I place the LMA I either can't get CO2 or get really pathetic TV with a very obstructed trace. Finally try to place it using the laryngoscope to confirm that I'm posterior to the epiglottis - still no luck, but I do note that she's a grade 3 larynx.

Surgeon is fast (did the same case on the previous patient in 15min)

What would you guys do next?

Happened for me too - and this is what I did - no problems with the outcome:
If the case will be around 30 minutes (though you never know) I will ventilate with the facemask. It was used in the past for hours - but I don't have the skills to keep it more than one hour. If in 30 minutes there is no sign that the procedure will be over I will intubate (gentle and so on).
The grade 3 - either blade or FOB. I forgot the freaking glydescope (reason for editing) which brought eqaulity regarding the intubating skills between us and the environmental people...
I noticed that the "anterior larynx" is one of the problems for LMA placement.

 

[dhb]

Ventilate with face mask: nothing wrong with this.

 

[dhb]

.

 

[hoyden]

My typical pt population is the one above ))))

LMA problems happen all the time - either try to manipulate it gently( sometimes withdrawal of it helps), mask ventilate ( gently) or intubate. If you decide to go with the third option and have grade 3 view - just use a small tube( 6.5 I would say for this particular one).

 

[Planktonmd]

The most common reason for failing to position an LMA properly is usually light anesthesia, is it possible that you did not give enough Propofol?
If you think that the patient is not going to tolerate a real induction dose of Propofol then you might consider giving a small dose of Sux to facilitate placement of the LMA.
I would have pulled the LMA out, gave a little more Propofol and 40 mg of Sux.
If this does not help I would not keep traumatizing the airway with the LMA and it would be time to intubate the patient.
Finishig the case with mask anesthesia is also a good choice but it might be tough to do that and document or do other tasks simultaneously.

 

[coprolalia]

The most common reason for failing to position an LMA properly is usually light anesthesia, is it possible that you did not give enough Propofol?

"Not enough" propofol? In a 90-year-old? Give me a break. You probably didn't give enough circulation time. My bet is that if you waited another 30 seconds (and if this was actually the problem... I wasn't there), you would've gotten to an adequate plane where you could've stuck the LMA with no problem.

If you think that the patient is not going to tolerate a real induction dose of Propofol then you might consider giving a small dose of Sux to facilitate placement of the LMA.
I would have pulled the LMA out, gave a little more Propofol and 40 mg of Sux.
If this does not help I would not keep traumatizing the airway with the LMA and it would be time to intubate the patient.
Finishig the case with mask anesthesia is also a good choice but it might be tough to do that and document or do other tasks simultaneously.

No! Don't sux her. There are a VARIETY of reasons why you don't need to use sux here. And, you don't necessarily need to hit her with a sledgehammer (i.e., more propofol).... I wasn't there, though.

The rest of your statements I actually agree with. And, as Mil would say, "It really doesn't matter what you ultimately do... this is a 'no-lose/no-brainer' case."

-copro

 

[periopdoc]

Mask or intubate. Don't make a suboptimal airway situation into a no airway situation by traumatizing the airway with more LMA attempts. If the LMA doesn't go on two good attempts it is time to change plans.

- pod

 

[SleepIsGood]

I think you should just intubate her!

Masking her at this point..i'm just not sure you want to sit there and mask, damn it you gotta chart!

But also, lots of these nursing home patients, especially the semi-obtunded ones like this, silently aspirate all the time. Therefore, you may need higher O2 levels and Pos Pressure Vent...This is why I would go directly with intubation..perhap get a glidescope into the room if she's a Gr3, take care of the business.

 

[coprolalia]

I think you should just intubate her!

Here's something I want you to seriously think about, because I've seen this happen WAY too many times in this type of patient...

Say you intubate. Then, say, due to "questionable" pulmonary status at the end of the case, you ring up the ICU and tell them, "You know, I had this tough airway on this lady who's 90-years-old, and now we're at the end of the case and I'm not sure I should extubate her. Can you guys watch her overnight with the tube in?"

Now, say, the next day comes and this lady is having difficulty meeting weaning parameters. So, they keep the tube in. Now, not to mention the fact, that you've given her probably 24 hours (or close to it) of propofol and/or midazolam plus fentanyl for "sedation" while the tube is in. Plus, you can't really assess her mental status when you wean sedation because of her dementia. The ICU attending is a little chickensh*t to pull the tube, and he'll quote you ten papers that show "re-intubation" is an independent risk factor for increased 30-day mortality.

This "overnight" intubation has now turned into a week. You're talking with the family and deciding whether or not to trach and PEG what was otherwise a relatively simple case a week ago. The family, insteads, decides to withdraw care... after a week of special "ICU treatment" where the patient was oversedated, underfed, and positive-pressure breathed with the requisite beating-up of her pulmonary condition in the process. And, you've just tacked on an additioanl $45,000 to her bill.

DON'T BELIEVE ME? I used to see this kind of madness all the time.

So, bottom line: THINK LONG AND HARD BEFORE YOU STICK A TUBE IN A 90-YEAR-OLD PATIENT! You'll go home at the end of the day. Your patient maybe never will. And, chances are you won't know the difference, because anesthesiologists are terrible at following-up on their patients.

-copro

 

[militarymd]

He made it look really hard, but you get the idea.

[YOUTUBE]http://www.youtube.com/watch?v=WvatNBas_hc[/YOUTUBE]

 

[hoyden]

Here's something I want you to seriously think about, because I've seen this happen WAY too many times in this type of patient...

Say you intubate. Then, say, due to "questionable" pulmonary status at the end of the case, you ring up the ICU and tell them, "You know, I had this tough airway on this lady who's 90-years-old, and now we're at the end of the case and I'm not sure I should extubate her. Can you guys watch her overnight with the tube in?"

Now, say, the next day comes and this lady is having difficulty meeting weaning parameters. So, they keep the tube in. Now, not to mention the fact, that you've given her probably 24 hours (or close to it) of propofol and/or midazolam plus fentanyl for "sedation" while the tube is in. Plus, you can't really assess her mental status when you wean sedation because of her dementia. The ICU attending is a little chickensh*t to pull the tube, and he'll quote you ten papers that show "re-intubation" is an independent risk factor for increased 30-day mortality.

This "overnight" intubation has now turned into a week. You're talking with the family and deciding whether or not to trach and PEG what was otherwise a relatively simple case a week ago. The family, insteads, decides to withdraw care... after a week of special "ICU treatment" where the patient was oversedated, underfed, and positive-pressure breathed with the requisite beating-up of her pulmonary condition in the process. And, you've just tacked on an additioanl $45,000 to her bill.

DON'T BELIEVE ME? I used to see this kind of madness all the time.

So, bottom line: THINK LONG AND HARD BEFORE YOU STICK A TUBE IN A 90-YEAR-OLD PATIENT! You'll go home at the end of the day. Your patient maybe never will. And, chances are you won't know the difference, because anesthesiologists are terrible at following-up on their patients.

-copro

I'd be a little cynical here and assume the family wanted that from the very beginning, given her initial status.
Otherwise I agree and respiratory management in the standard ICU is abysmal....

 

[dhb]

Here's something I want you to seriously think about, because I've seen this happen WAY too many times in this type of patient...

Say you intubate. Then, say, due to "questionable" pulmonary status at the end of the case, you ring up the ICU and tell them, "You know, I had this tough airway on this lady who's 90-years-old, and now we're at the end of the case and I'm not sure I should extubate her. Can you guys watch her overnight with the tube in?"

Now, say, the next day comes and this lady is having difficulty meeting weaning parameters. So, they keep the tube in. Now, not to mention the fact, that you've given her probably 24 hours (or close to it) of propofol and/or midazolam plus fentanyl for "sedation" while the tube is in. Plus, you can't really assess her mental status when you wean sedation because of her dementia. The ICU attending is a little chickensh*t to pull the tube, and he'll quote you ten papers that show "re-intubation" is an independent risk factor for increased 30-day mortality.

This "overnight" intubation has now turned into a week. You're talking with the family and deciding whether or not to trach and PEG what was otherwise a relatively simple case a week ago. The family, insteads, decides to withdraw care... after a week of special "ICU treatment" where the patient was oversedated, underfed, and positive-pressure breathed with the requisite beating-up of her pulmonary condition in the process. And, you've just tacked on an additioanl $45,000 to her bill.

DON'T BELIEVE ME? I used to see this kind of madness all the time.

So, bottom line: THINK LONG AND HARD BEFORE YOU STICK A TUBE IN A 90-YEAR-OLD PATIENT! You'll go home at the end of the day. Your patient maybe never will. And, chances are you won't know the difference, because anesthesiologists are terrible at following-up on their patients.

-copro

Couldn't agree more

Otherwise I agree and respiratory management in the standard ICU is abysmal....

As is pain management

 

[Planktonmd]

In the hands of an anesthesiologist who knows how to give GA properly there is no increased risk from an ETT over an LMA regardless of the age.
And certainly an ETT is a better choice than continuing to traumatize the airway hoping the LMA will eventually work!
If you understand what you are doing you can extubate the patient at the end as smoothly as you do with an LMA and all that BS about "we should not intubate because we will have trouble extubating" is imaginary and only valid in the hands of people with little or no experience.
I wish people would try to learn some basics before giving free anesthesia advice on the internet.

 

[Planktonmd]

I also wish the ignore function would also remove quoted statements of the sleazy people you wish to ignore!

 

[coprolalia]

In the hands of an anesthesiologist who knows how to give GA properly there is no increased risk from an ETT over an LMA regardless of the age.
And certainly an ETT is a better choice than continuing to traumatize the airway hoping the LMA will eventually work!
If you understand what you are doing you can extubate the patient at the end as smoothly as you do with an LMA and all that BS about "we should not intubate because we will have trouble extubating" is imaginary and only valid in the hands of people with little or no experience.
I wish people will try to learn some basics before giving free anesthesia advice on the internet.

The only things that are clear from this thread are:

(1) You don't understand pharmacokinetics/pharmacodynamics in the extreme elderly.

(2) Your arrogance and overconfidence, not only in yourself but in the "system" in place to care for these kinds of patients, is breathtaking.

But, this is about what I'd expect from an average anesthesiologist. Yes, I read your posts. It's not too hard to usually figure out what you're thought process is. You are average.

-copro

 

[coprolalia]

But, this is about what I'd expect from an average anesthesiologist. Yes, I read your posts. It's not too hard to usually figure out what you're thought process is. You are average.

Let me just say one additional thing about this comment...

It's okay to be average. It's better than being lousy, and I'm sure even many junior residents can already attest that they've probably worked with their fair share of lousy attendings (haha).

But, recognize that you are just offering your opinion on how you would do the case. You have certainly demonstrated on this forum that you are not stellar (unlike posters such as pgg and POD, and even Dr. Robert (who only rarely posts) whom I would put in that category).

So, that's basically what I have primarily objected to with your modus operandi here. It is that you have held out, and continue to hold yourself out, as one of the true experts of anesthesiology on this forum, and that we should all be grateful that you participate.

You're not and we're not.

Fact is, you're just an average private practice dude that is offering your opinion on what you would do. And, there's nothing wrong with that. Your problem becomes, however, that you often take the arrogant air that your way of doing things is really the only correct way, and that's the solely thing that's gotten under my skin in the entire time I've had to endure your attitude since you've posted here... and is what made me go into attack mode on your ass.

Lighten up. You're not that great, Plankton. You're okay. I've met dudes with decades of experience that were just average, too. I invite you to get over yourself.

-copro

 

[nap$ter]

In the hands of an anesthesiologist who knows how to give GA properly there is no increased risk from an ETT over an LMA regardless of the age.
And certainly an ETT is a better choice than continuing to traumatize the airway hoping the LMA will eventually work!
If you understand what you are doing you can extubate the patient at the end as smoothly as you do with an LMA and all that BS about "we should not intubate because we will have trouble extubating" is imaginary and only valid in the hands of people with little or no experience.
I wish people would try to learn some basics before giving free anesthesia advice on the internet.

i agree with this (except for the last sentence).

why perform laryngoscopy to place an LMA? the only benefit i can see is fewer hemodynamic changes during emergence/removal of airway, but we train to manage hemodynamics. if you stick a laryngoscope in, place a tube. i wouldn't want to muck/flail with an LMA in this lady if it didn't go smoothly from the get-go. just proceed gently with laryngoscopy, bougie, ETT, let her breathe during the case, extubate. no need for paralytics in a 90 year old; we're all infants twice in life.

 

[BDanes]

I've had cases similar to this. I find it much easier to minimize. This is especially true when working with a fast surgeon. If it were my patient I would just give a propofol/ketamine mixture in a slow titration.

Usually I put 100-200mg of ketamine (1-2cc) in a 20cc syringe with the rest made up with propofol. +/- glyco if you wish. My exprience has been that you do not have to give a significant amount of drug for a case such as this, especially if your surgeon gives local.

Hemodynamics are usually very stable.

But, if in the predicament you described I'd just mask her.

 

[hoyden]

In the hands of an anesthesiologist who knows how to give GA properly there is no increased risk from an ETT over an LMA regardless of the age.
And certainly an ETT is a better choice than continuing to traumatize the airway hoping the LMA will eventually work!
If you understand what you are doing you can extubate the patient at the end as smoothly as you do with an LMA and all that BS about "we should not intubate because we will have trouble extubating" is imaginary and only valid in the hands of people with little or no experience.
I wish people would try to learn some basics before giving free anesthesia advice on the internet.

I actually agree, with one comment - very old COPDers are easier managed without ETT ( mask is the best, depending on the operation, obviously and the surgeons skills), unless doing it while pt is breathing spontaneously and preserving that spontaneous breathing - tricky, but still possible.

 

[Licoricestick]

Adequate anaesthesia wasn't the problem - I managed to get a laryngoscope and LMA in simultaneously without relaxant and without much haemodynamic response - I just couldn't adequately position the LMA.

Ended up deciding to just use a mask after 3 attempts at placement (thankfully we have electronic charting so putting in the drugs and notes on the chart can all be done one handedly quite easily). This was fine until the surgeons snagged a tendon placing the 2nd K-wire. When they tried to remove the K wire, the tendon came out with it, wrapped around the wire. So it turned into an open procedure to try and identify the avulsion site and repair the tendon. At this point I decided that I didn't want to keep masking when the case duration is liable to be a lot longer. Tried a different LMA (classic - seem to have more luck positioning those in some people where the supreme doesn't work), but again no go. Ended up tubing her under 50mg of sux - still a grade 3, but easy tube with a bougie.

Overall I just wasn't happy with the case (although my consultant thought it was all reasonable), so just wondering what other suggestions people had. Oddly enough, the orthopods weren't happy either

 

[Licoricestick]

Adequate anaesthesia wasn't the problem - I managed to get a laryngoscope and LMA in simultaneously without relaxant and without much haemodynamic response - I just couldn't adequately position the LMA.

Ended up deciding to just use a mask after 3 attempts at placement (thankfully we have electronic charting so putting in the drugs and notes on the chart can all be done one handedly quite easily). This was fine until the surgeons snagged a tendon placing the 2nd K-wire. When they tried to remove the K wire, the tendon came out with it, wrapped around the wire. So it turned into an open procedure to try and identify the avulsion site and repair the tendon. At this point I decided that I didn't want to keep masking when the case duration is liable to be a lot longer. Tried a different LMA (classic - seem to have more luck positioning those in some people where the supreme doesn't work), but again no go. Ended up tubing her under 50mg of sux - still a grade 3, but easy tube with a bougie.

Overall I just wasn't happy with the case (although my consultant thought it was all reasonable), so just wondering what other suggestions people had. Oddly enough, the orthopods weren't happy either

 

[rsgillmd]

Adequate anaesthesia wasn't the problem - I managed to get a laryngoscope and LMA in simultaneously without relaxant and without much haemodynamic response - I just couldn't adequately position the LMA.

Ended up deciding to just use a mask after 3 attempts at placement (thankfully we have electronic charting so putting in the drugs and notes on the chart can all be done one handedly quite easily). This was fine until the surgeons snagged a tendon placing the 2nd K-wire. When they tried to remove the K wire, the tendon came out with it, wrapped around the wire. So it turned into an open procedure to try and identify the avulsion site and repair the tendon. At this point I decided that I didn't want to keep masking when the case duration is liable to be a lot longer. Tried a different LMA (classic - seem to have more luck positioning those in some people where the supreme doesn't work), but again no go. Ended up tubing her under 50mg of sux - still a grade 3, but easy tube with a bougie.

Overall I just wasn't happy with the case (although my consultant thought it was all reasonable), so just wondering what other suggestions people had. Oddly enough, the orthopods weren't happy either

Personally, once you knew the case was going to take longer, I would have just put in a tube. Your previous attempts at placing an LMA have already failed. I really doubt there is that much of a difference in ease of insertion between LMA Classic and LMA Supreme. If anything, in my experience the Supreme slides in easier, and I don't have to worry about a bite block. So based on my experience I wouldn't have repeated a failed technique for a 4th time out of concern for further traumatizing the airway.

If an LMA 3 wasn't working, did you guys think of going smaller? Twice in the elderly (once because my attending refused to let me just intubate, and the second time because of my previous success), I succeeded in placing an LMA 2.5 where a 3 didn't work. I'm not saying it would have necessarily solved the problem for you, but it's something to keep in the back of your head.

Don't drive yourself crazy over one case. Learn from the advice everyone has given here, and move on.