Obesity and the LMA Classic

VentdependenT · Apr 19, 2006

WHats the heaftiest person you've comfortably used an LMA in? Lets say they deny any pmhx of severe gerd or hiatal hernia.

Also whats your time limit on a case for the use of one? Is there such a thing?

We are doing a 350lb woman for a 2hr ankle surgery and I nixed the idea of a LMA classic on my current vent (which lacks pressure support). Although we did a fem pop block there was a thigh turnicate so I knew she'd need the narcs. Then I knew shed a stop breathing and I have to throw that non-compliant chest on a pressure limited mode with these old dinosaurs.

Anypoops lemme know.

jetproppilot · Apr 19, 2006

VentdependenT said:
WHats the heaftiest person you've comfortably used an LMA in? Lets say they deny any pmhx of severe gerd or hiatal hernia.

Also whats your time limit on a case for the use of one? Is there such a thing?

We are doing a 350lb woman for a 2hr ankle surgery and I nixed the idea of a LMA classic on my current vent (which lacks pressure support). Although we did a fem pop block there was a thigh turnicate so I knew she'd need the narcs. Then I knew shed a stop breathing and I have to throw that non-compliant chest on a pressure limited mode with these old dinosaurs.

Anypoops lemme know.

There was a recent study (6-8 mos ago) that I came across that actually showed benefits of using an LMA in the morbidly obese...one of the advantages shown was being able to avoid laryngoscopy/paralysis which as you know can be frought with problems in that patient population.

I've used an LMA on several morbidly obese patients without sequelae..the key is to use minimal resp depression stuff(benzos opiods) so they start breathing on their own immediately. Just a stick of propofol, slip it in, crank on a little gas, and as J.P. said, Go With The Flow.

I dont consider time of operation as a determinant of using an LMA or not.

jetproppilot · Apr 19, 2006

jetproppilot said:
There was a recent study (6-8 mos ago) that I came across that actually showed benefits of using an LMA in the morbidly obese...one of the advantages shown was being able to avoid laryngoscopy/paralysis which as you know can be frought with problems in that patient population.

I've used an LMA on several morbidly obese patients without sequelae..the key is to use minimal resp depression stuff(benzos opiods) so they start breathing on their own immediately. Just a stick of propofol, slip it in, crank on a little gas, and as J.P. said, Go With The Flow.

I dont consider time of operation as a determinant of using an LMA or not.

One more thing Venty,

Once the pt is breathing, if the tourniquet is affecting her while she's asleep i.e. resp rate going up you can titrate in some opiod...if you do it in small enough increments (like 25ug fentanyl at a time) she wont stop breathing.

And if BP/HR starts to go up from the tourniquet, as long as you've got >1.3 mac on board use labetolol or something similar for hemodynamic control.

jwk · Apr 19, 2006

jetproppilot said:
There was a recent study (6-8 mos ago) that I came across that actually showed benefits of using an LMA in the morbidly obese...one of the advantages shown was being able to avoid laryngoscopy/paralysis which as you know can be frought with problems in that patient population.

I've used an LMA on several morbidly obese patients without sequelae..the key is to use minimal resp depression stuff(benzos opiods) so they start breathing on their own immediately. Just a stick of propofol, slip it in, crank on a little gas, and as J.P. said, Go With The Flow.

I dont consider time of operation as a determinant of using an LMA or not.

I can see some benefit in the LMA over the ETT, but I think the risks of aspiration are significantly higher in morbidly obese patients, so personally, I wouldn't even consider an LMA on a 350 lb patient. Except for LMA's use on morbidly obese patients, I agree with JPP's other points.

As far as length of the case - the longer the case, the less likely I am to use an LMA. I'll qualify that by saying the group I work for frowns on using vents with LMA's. So if I have a choice of a 3hr LMA case, spontaneously breathing patient, but etCO2's in the 60's vs. ETT with controlled vent, I'll opt for the tube. Do I think vents and LMA's are OK? Sure, but I don't always get to make that choice 😉 . Erring on the side of caution is fine.

What's your feeling about prone LMA's? I'm dead-set against them, but a couple of our docs don't see the problem (on those cases I invite them to do the case personally since I won't do it).

Gator05 · Apr 19, 2006

Classic LMA?

I get a little nervous.

Pro-Seal LMA? Sure, why not?

I too have gotten burned (already) with the narcotic issue. One of our attendings likes to push a little ketamine for highly-stimulating parts of procedures. which works pretty well sometimes (more if he's directing).

By the by, anyone find a difference between the Ambu-LMA and the Classic? How many of you "test" your seal after placement? Anyone (with an IV in place) do Sevo inductions for LMA cases?

jwk · Apr 19, 2006

Gator05 said:
Anyone (with an IV in place) do Sevo inductions for LMA cases?

Except for kids, what's the point?

rn29306 · Apr 19, 2006

I'm hesitant to use an LMA on anyone over say, 280lbs, but that's just me. Height also comes into play. There is a difference in body build in someone that is 280lbs and 5 foot 2 vs 6 foot 3.

Time is certainly a factor for me. Two hours is about my limit for LMAs, esp someone with such mass. My personal concern is the amount of effort such a massive person has to breathe in the supine position and degree of fatigue (and hypercarbia) that may ensue. With such mass combined with a supine position, attempting to ventilate this person to aid them will not be of much use.

I totally agree with the posts about going minimal with the narcotics prior to LMA insertion. Having the pt bounce right back from induction and breathing within 15-40 seconds sure beats ventilating these dudes/dudettes.

No research, just my limited opinion.

Hey Jet and JWK, are you concerned in your practice about anything I just posted, or do you think I am just being too conservative?

rn29306 · Apr 19, 2006

jwk said:
Except for kids, what's the point?

Just a side question concerning sevo:

Has anyone attempted the vaulted "single-breath induction" technique of sevo? I have asked alot of people about this, but never found anyone that has. It seems like such a crappy way to go to sleep (vs IV induction) that I have never tried this on any of my patients.

IN2B8R · Apr 19, 2006

"'Although we did a fem pop block there was a thigh turnicate so I knew she'd need the narcs. Then I knew shed a stop breathing and I have to throw that non-compliant chest on a pressure limited mode with these old dinosaurs."

Higher blocks including femoral, sciatic and obturator nerve blocks should nicely take care of any pain due to a thigh torniquet. Then if the patient is obese and needs an LMA due to a lengthy case and fear of abstruction from ketafol sedation, a pro-seal is a nice alternative.

best regards.

militarymd · Apr 19, 2006

jwk said:
I can see some benefit in the LMA over the ETT, but I think the risks of aspiration are significantly higher in morbidly obese patients, so personally, I wouldn't even consider an LMA on a 350 lb patient. Except for LMA's use on morbidly obese patients, I agree with JPP's other points.

As far as length of...do it).

Where are you getting that doo doo from?

militarymd · Apr 19, 2006

rn29306 said:
I'm hesitant to use an LMA on anyone over say, 280lbs, but that's just me. Height also comes into play. There is a difference in body build in someone that is 280lbs and 5 foot 2 vs 6 foot 3.

Time is certainly a factor for me. Two hours is about my limit for LMAs, esp someone with such mass. My personal concern is the amount of effort such a massive person has to breathe in the supine position and degree of fatigue (and hypercarbia) that may ensue. With such mass combined with a supine position, attempting to ventilate this person to aid them will not be of much use.

I totally agree with the posts about going minimal with the narcotics prior to LMA insertion. Having the pt bounce right back from induction and breathing within 15-40 seconds sure beats ventilating these dudes/dudettes.

No research, just my limited opinion.

Hey Jet and JWK, are you concerned in your practice about anything I just posted, or do you think I am just being too conservative?

So you get tired from breathing while under GA when your minute ventilation is less than when you're awake???

militarymd · Apr 19, 2006

rn29306 said:
Just a side question concerning sevo:

Has anyone attempted the vaulted "single-breath induction" technique of sevo? I have asked alot of people about this, but never found anyone that has. It seems like such a crappy way to go to sleep (vs IV induction) that I have never tried this on any of my patients.

Yes, it works great....faster than iv induction.

militarymd · Apr 19, 2006

I use them for fat people, but I don't like them for long cases. I have seen pretty severe atelectasis with prolonged hypoventilation....leading to post-op hypoxia and turning outpatient procedures into overnight obs.

Gator05 · Apr 19, 2006

Done a single, single-breath technique with Sevo.

It didn't go well.

Lots of posturing, along with facial grimacing that didn't make it any easier to mask. Not sure what went wrong, which is the worst of it.

On the other hand, gradual N2O/Sevo induction worked well for LMA induction, as the patient was had spont resps throughout the entire induction. With propofol, it seems that by the time you've given enough for relaxation, they've stopped breathing for a few minutes. I'm not worred about that in skinny folk, but those with less FRC do make me a bit scared.

rn29306 · Apr 19, 2006

militarymd said:
So you get tired from breathing while under GA when your minute ventilation is less than when you're awake???

Not arguing with ya Mil, but I was picturing a fat person supine, with abdominal ascention into the diaphragm working to breathe with an LMA for a long duration case. In my mind, I was thinking a tube with controlled ventilation might be better for them. Make the vent work instead of the patient....better muscle recruitement for efficient wake-ups. Not to mention hypoventilation and atelectasis like you stated. With an LMA, it is not like you can exactly give a large re-expansion and atelectasis-clearing breaths at the end of the case.

It's not like these fatsos lie flat anytime anyway and for good reason. 😀

Certainly open to your thoughts on this..

jetproppilot · Apr 19, 2006

Gator05 said:
Classic LMA?

I get a little nervous.

Pro-Seal LMA? Sure, why not?

I too have gotten burned (already) with the narcotic issue. One of our attendings likes to push a little ketamine for highly-stimulating parts of procedures. which works pretty well sometimes (more if he's directing).

By the by, anyone find a difference between the Ambu-LMA and the Classic? How many of you "test" your seal after placement? Anyone (with an IV in place) do Sevo inductions for LMA cases?

If the Ambu is the green one with a 90 degree angle,

I hate 'em.

Our group tried them.

Alotta sealing problems.

Best on the market IMHO is the LMA disposables. The clear ones.

rn29306 · Apr 19, 2006

jetproppilot said:
If the Ambu is the green one with a 90 degree angle,

I hate 'em.

Our group tried them.

Alotta sealing problems.

Best on the market IMHO is the LMA disposables. The clear ones.

We rotated to a surgery clinic that used these Ambu POSs. First time experience with them and hated them right off the bat. If they are cheaper, then perhaps I know why. :laugh:

Main site uses the clear LMA disposables. They rock.

Noyac · Apr 19, 2006

I agree............................................with everyone here to some degree. The Fat pt LMA anesthesia when put to 10 different anesthesiologists will have as many different techniques.

I use them with Fatsos. I use them for more than 2 hrs. But I don't always use them in Fatsos for over 2hrs. Its a gut feeling kind of thing for me when it comes to these cases. Do I feel like the pt will tolerate it without aspirating?

jetproppilot · Apr 19, 2006

rn29306 said:
Just a side question concerning sevo:

Has anyone attempted the vaulted "single-breath induction" technique of sevo? I have asked alot of people about this, but never found anyone that has. It seems like such a crappy way to go to sleep (vs IV induction) that I have never tried this on any of my patients.

The "single breath" sevo induction is a buncha crap.

But don't dismiss the idea of an inhalation induction on an adult.

Sevo inductions work well....especially for LMA cases...fact is it takes several breaths, not one...but it works.

Before you refute,

on your next 175lb 20 year old ASA 1 male in for a knee scope,

dont give him a thing.

Bring him back into the OR, put your O2 flow at maximum, crank the Sevo vaporizer up to never exceed speed, and tell young dude to take some deep breaths like hes getting ready to dive underwater.

After 4-5 deep sevo breaths his eyes will begin to look like he's been sittin in a jacuzzi at Hedonism for a few too many hours.

Take him over for about a minute. Quick squeezes on the bag, sevo vaporizer still at max.

Click off the vaporizer, grab your lma, slip it in.

Nice technique.

supahfresh · Apr 19, 2006

hey jet, you ever seen a straight sux induction? wicked mean. i had an attending that did that in the unit a few months ago when he was helping me do an intubation. he didnt want to wait for me to draw up an induction agent. :scared:

rn29306 · Apr 19, 2006

jetproppilot said:
The "single breath" sevo induction is a buncha crap.

That's pretty much what I thought. But you know how reps push things....Plus our rep is a dude and not a hot rep chick, so I can argue and fuss with him moreso than if he were a hottie.

Thanks for the heads up on the other technique.

Noyac · Apr 19, 2006

Jet, What if you turn the N20 up to 8LPM and O2 up to 4LPM and crank the sevo all the wayclosed the end of the circuit till it wants to pop the bag and then let the dude take a deep breath? I figured that if anyone could accomplish it, you could since you are "below sea level" as well as "The Master".

jetproppilot · Apr 19, 2006

Noyac said:
Jet, What if you turn the N20 up to 8LPM and O2 up to 4LPM and crank the sevo all the wayclosed the end of the circuit till it wants to pop the bag and then let the dude take a deep breath? I figured that if anyone could accomplish it, you could since you are "below sea level" as well as "The Master".

Have tried that many times, Rockstar Friend.

Heres my opinion.

And thats all it is. An opinion.

I think the whole N2O-speeding-volatile-agent-uptake-thing is more an academic description than a clinically useful tool.

It just doesnt make that much difference in induction time.

And coupled with the recent evidence formally inciting N20 as a contributor to nausea (something alotta clinicians knew already),

I can take-or-leave N20.

I dont use it that much anymore.

militarymd · Apr 19, 2006

rn29306 said:
Not arguing with ya Mil, but I was picturing a fat person supine, with abdominal ascention into the diaphragm working to breathe with an LMA for a long duration case. In my mind, I was thinking a tube with controlled ventilation might be better for them. Make the vent work instead of the patient....better muscle recruitement for efficient wake-ups. Not to mention hypoventilation and atelectasis like you stated. With an LMA, it is not like you can exactly give a large re-expansion and atelectasis-clearing breaths at the end of the case.

It's not like these fatsos lie flat anytime anyway and for good reason. 😀

Certainly open to your thoughts on this..

What your're saying is they have "ineffective" ventilation...not tiring out...big difference.

militarymd · Apr 19, 2006

jetproppilot said:
The "single breath" sevo induction is a buncha crap.

But don't dismiss the idea of an inhalation induction on an adult.

....... slip it in.

Nice technique.

It works great for me....single breath, and they are out. I did it today. 40 year old lady for TAH, BSO....No veins..

So..single breath induction....mask for 3 minutes...intubate on SEVO....then RIJ triple lumen for the case....she had no EJ's either.

Here's an observation that I have made from anesthetizing patients all over the world (Navy sent me)...there appears to be regional differences in how patient populations behave.

Example...Virigina....patients seem to require more metoprolol to achieve HR < than 70 bpm.

In Alabama...it seems that I'm always giving anticholinergics to get hr above 50 bpm....

Soooo...I believe Jet's experience that he has not had luck with single breath inductions.....but it has worked great for me in the places that I have tried them.

militarymd · Apr 19, 2006

jetproppilot said:
Have tried that many times, Rockstar Friend.

Heres my opinion.

And thats all it is. An opinion.

I think the whole N2O-speeding-volatile-agent-uptake-thing is more an academic description than a clinically useful tool.

It just doesnt make that much difference in induction time.

And coupled with the recent evidence formally inciting N20 as a contributor to nausea (something alotta clinicians knew already),

I can take-or-leave N20.

I dont use it that much anymore.

Nitrous may add nothing to SEVO, but try it with halothane.....you WILL see the difference...that's if you still have halothane.

jetproppilot · Apr 19, 2006

militarymd said:
It works great for me....single breath, and they are out. I did it today. 40 year old lady for TAH, BSO....No veins..

So..single breath induction....mask for 3 minutes...intubate on SEVO....then RIJ triple lumen for the case....she had no EJ's either.

Here's an observation that I have made from anesthetizing patients all over the world (Navy sent me)...there appears to be regional differences in how patient populations behave.

Example...Virigina....patients seem to require more metoprolol to achieve HR < than 70 bpm.

In Alabama...it seems that I'm always giving anticholinergics to get hr above 50 bpm....

Soooo...I believe Jet's experience that he has not had luck with single breath inductions.....but it has worked great for me in the places that I have tried them.

Maybe we're experiencing the same thing, bro...

you said you induced with one breath but masked for three minutes ....

thats telling me that the one breath they took didnt "induce" them...

what I'm trying to relay is that one breath doesnt render the patient ready for airway manipulation.

It takes a little longer. A minute, two minutes, whatever.

militarymd · Apr 19, 2006

jetproppilot said:
Maybe we're experiencing the same thing, bro...

you said you induced with one breath but masked for three minutes ....

thats telling me that the one breath they took didnt "induce" them...

what I'm trying to relay is that one breath doesnt render the patient ready for airway manipulation.

It takes a little longer. A minute, two minutes, whatever.

Induction ....to me does not equate ready for surgery...or ready for intubation...

After 200 mg of propofol and 500mg of STP....a patient is not ready for DL or surgery.....so I guess it depends on how you define "induction"...

I'm equaling the sevo single breath to say....one syringe of propofol.

jetproppilot · Apr 19, 2006

militarymd said:
Induction ....to me does not equate ready for surgery...or ready for intubation...

After 200 mg of propofol and 500mg of STP....a patient is not ready for DL or surgery.....so I guess it depends on how you define "induction"...

I'm equaling the sevo single breath to say....one syringe of propofol.

Gotcha Mil.

But still,

I've yet to see a patient's eyes roll back on one breath of sevo, even if you prime the circuit with the s hit like Noy described.

militarymd · Apr 19, 2006

jetproppilot said:
Gotcha Mil.

But still,

I've yet to see a patient's eyes roll back on one breath of sevo, even if you prime the circuit with the s hit like Noy described.

and I believe you......I'll bet if I came to NOLA, I won't be able to do the same thing that I can do here....

Regional and population differences....I'm sold on that.

I had a ton of bad A/W in Virginia but very little in Alabama....I think Navy people are funny looking and they marry other funny looking people...causing my a/w difficulties in Virginia....but the hillbillies in Alabalma...although funny looking...don't have teeth.

jetproppilot · Apr 19, 2006

militarymd said:
and I believe you......I'll bet if I came to NOLA, I won't be able to do the same thing that I can do here....

Regional and population differences....I'm sold on that.

I had a ton of bad A/W in Virginia but very little in Alabama....I think Navy people are funny looking and they marry other funny looking people...causing my a/w difficulties in Virginia....but the hillbillies in Alabalma...although funny looking...don't have teeth.

HAHAHHAHAHAHAHAHAHAHAHHAHAHAHAH

uhhhhh... excuse me bro.....your post made me soil myself....I'll be right back....

rn29306 · Apr 19, 2006

militarymd said:
What your're saying is they have "ineffective" ventilation...not tiring out...big difference.

In your first post on this you say that you use them for fatsos, but not with long cases for concerns of atelectasis... Sure, I'm saying they do have "ineffective" ventilation in the supine position with all that goes with that position. Are you saying they won't get tired with long duration spont resps? These tankasses can't, for the most part, climb two flights of stairs w/o getting short of breath, but for some reason, some practitioners expect them to breathe spont for over two hours in the supine position, fighting abdominal encroachment on the lungs and beer bellies. It doesn't make sense to me, but perhaps at this point, that may not mean much.

Is it not your opinion that they do have "ineffective" ventilation which could lead to tiring over the course of two hours in a supine, spont breathing lardass?

militarymd · Apr 19, 2006

rn29306 said:
In your first post on this you say that you use them for fatsos, but not with long cases for concerns of atelectasis... Sure, I'm saying they do have "ineffective" ventilation in the supine position with all that goes with that position. Are you saying they won't get tired with long duration spont resps? These tankasses can't, for the most part, climb two flights of stairs w/o getting short of breath, but for some reason, some practitioners expect them to breathe spont for over two hours in the supine position, fighting abdominal encroachment on the lungs and beer bellies. It doesn't make sense to me, but perhaps at this point, that may not mean much.

Is it not your opinion that they do have "ineffective" ventilation which could lead to tiring over the course of two hours in a supine, spont breathing lardass?

They don't tire out....they breath like that all night...however, pulmonay mechanics will change over time (atelectasis)...which may increase the work of breathing...then they will tire out....not from anesthesia persay...but from stiffening lungs that develop over time under anesthesia.

rn29306 · Apr 19, 2006

militarymd said:
They don't tire out....they breath like that all night...however, pulmonay mechanics will change over time (atelectasis)...which may increase the work of breathing...then they will tire out....not from anesthesia persay...but from stiffening lungs that develop over time under anesthesia.

👍 Thanks for explanation.

Gator05 · Apr 20, 2006

Interesting comments on the AmbuLMA. I've found them to have a much better seal. With the reinforcement at the tip, there is less problem with epiglottic "flip" as well.

As far as the nitrous, I figure it helps "sneak" on the Sevo. If we're gonna talk about PONV, inhalational agents in general should be avoided. If you're arguing for impairment of wound healing, how many of us routinely run cases at FiO2 of 0.8+? Also (weak?) evidence that nitrous limits post-op has all those fancy post-op pain-limiting effects, although I think that's still a little bit of voo-doo at this point.

stephend7799 · Apr 20, 2006

I think the population we use LMAs in is too wide.. We use it too often.. Endotracheal tube is good safe medicine.. dont get me wrong I like the lmas for a lot of things.. but more things can go wrong with the lma which can lead to bad things. than with the ett...

militarymd · Apr 20, 2006

stephend7799 said:
I think the population we use LMAs in is too wide.. We use it too often.. Endotracheal tube is good safe medicine.. dont get me wrong I like the lmas for a lot of things.. but more things can go wrong with the lma which can lead to bad things. than with the ett...

there is no evidence to support this....the UK's experience would also not support that.

SilverStreak · Apr 20, 2006

militarymd said:
Nitrous may add nothing to SEVO, but try it with halothane.....you WILL see the difference...that's if you still have halothane.

I thought halothane was not used much anymore because of possibility of patients having undiagnosed neuromuscular problems leading to hyperkalemia issues. I shadowed anesthesia a couple of weeks back, and we talked about a lot of people not being comfortable with using it anymore. This was in the peds population though, so I don't know if this is a concern with adults or not. Am I way off base here?

jwk · Apr 20, 2006

militarymd said:
there is no evidence to support this....the UK's experience would also not support that.

totally different dentition perhaps? 😉

Noyac · Apr 20, 2006

SilverStreak said:
I thought halothane was not used much anymore because of possibility of patients having undiagnosed neuromuscular problems leading to hyperkalemia issues. I shadowed anesthesia a couple of weeks back, and we talked about a lot of people not being comfortable with using it anymore. This was in the peds population though, so I don't know if this is a concern with adults or not. Am I way off base here?

Thats true for all volatile anesthetics. Halothane is just outdated these days with the advent of the more expensive ( 😀 ) types. Thats not to say its not a good agent in right hands. I have only used it a couple of times though.

Noyac · Apr 20, 2006

stephend7799 said:
I think the population we use LMAs in is too wide.. We use it too often.. Endotracheal tube is good safe medicine.. dont get me wrong I like the lmas for a lot of things.. but more things can go wrong with the lma which can lead to bad things. than with the ett...

I'm not sure how to read this. I think there are if not as many then more things that can go wrong with ETT's. Even in the obese population.

jwk · Apr 20, 2006

SilverStreak said:
I thought halothane was not used much anymore because of possibility of patients having undiagnosed neuromuscular problems leading to hyperkalemia issues. I shadowed anesthesia a couple of weeks back, and we talked about a lot of people not being comfortable with using it anymore. This was in the peds population though, so I don't know if this is a concern with adults or not. Am I way off base here?

You're talking about malignant hyperthermia (MH). Although halothane was often implicated, MH can occur with any of the halogenated anesthetics.

Although no longer available in our hospital formulary, I've done thousands of anesthetics with halothane. It was the vapor of choice for inhalation inductions in kiddies for many many years.

stephend7799 · Apr 20, 2006

militarymd said:
there is no evidence to support this....the UK's experience would also not support that.

there is no evidence to support crossing the street with your eyes closed is unsafe either.. but intuitively you just know.
Cmon.. you cant tell me an LMA is as safe as an endotracheal tube.. t is a useful tool but i see too many people use it when they should be using endotracheal tubes...
and medicine is medicine doesnt matter if its in the UK USA OR timbuktoo

militarymd · Apr 21, 2006

stephend7799 said:
there is no evidence to support crossing the street with your eyes closed is unsafe either.. but intuitively you just know.
Cmon.. you cant tell me an LMA is as safe as an endotracheal tube.. t is a useful tool but i see too many people use it when they should be using endotracheal tubes...
and medicine is medicine doesnt matter if its in the UK USA OR timbuktoo

That's the problem with using common sense when practicing medicine.....IT DOESN'T WORK THAT WAY.....

medicine needs to be evidence based.

Perfect example.....beta blockers and patients with EF of 10%....what does COMMON SENSE say....DON"T USE IT.....a negative inotrope in a barely function heart?????

metoprolol package insert reflected the "COMMON SENSE" until a few years ago.....

Then EVIDENSE showed that beta blockers saved lives when your EF is 10%....so the package insert is changed to "INDICATED" for low EFs.

Bottom line your statement does not reflect the evidence that is available.

jwk · Apr 21, 2006

militarymd said:
That's the problem with using common sense when practicing medicine.....IT DOESN'T WORK THAT WAY.....

medicine needs to be evidence based.

Perfect example.....beta blockers and patients with EF of 10%....what does COMMON SENSE say....DON"T USE IT.....a negative inotrope in a barely function heart?????

metoprolol package insert reflected the "COMMON SENSE" until a few years ago.....

Then EVIDENSE showed that beta blockers saved lives when your EF is 10%....so the package insert is changed to "INDICATED" for low EFs.

Bottom line your statement does not reflect the evidence that is available.

So are there STUDIES out of the UK that support the use of LMA's in fluffies and with laparoscopies and ventilators, or is this just their "common sense" way of doing it?

jetproppilot · Apr 21, 2006

SilverStreak said:
I thought halothane was not used much anymore because of possibility of patients having undiagnosed neuromuscular problems leading to hyperkalemia issues. I shadowed anesthesia a couple of weeks back, and we talked about a lot of people not being comfortable with using it anymore. This was in the peds population though, so I don't know if this is a concern with adults or not. Am I way off base here?

Its not used anymore because research has advanced our volatile agents. In this rushed society, sevo and des's on-and-off switch is quicker with less catecholamine sensitization.

Plus they're much more expensive so they make the drug companies lots of money.

VentdependenT · Apr 21, 2006

fatties do breath all night long without crappen out (minus chf or some other equivalent condition) so why sweat the time duration of the LMA. I fear the tidal volumes with the agent on board and not being able to crack out some phat positive pressure breaths without: A) inflating the gut, or B) blowing the seal.

However I think that with timed pressure support you could leave the porcine individual on the vent for a while. With setting the pressure limit to, say, 15mm hg one doesn't have to worry about insufflating the stomach (theoretically I suppose).

As for the Proseal there seems to be a lot of resistance towards using it at my institution. Poor seals, og not threading, etc. I would like to use the thing more however.

VentdependenT · Apr 21, 2006

As for those green disposable LMA's with the 90degree turn, I love em.

supahfresh · Apr 21, 2006

almost killed one of those porcine individuals yesterday down in the GI suite.

soon2bdoc2003 · Apr 22, 2006

My hospital used LMA classics when i started but recently added the green ambu lmas.. i really love these things.. they just pop right into place every time without me having to do stupid things like stick my hands in someones mouth or struggling with a "flipped tip" which the classics love to do. As far as the seal goes.. i test up to 15mmhg and never had an appropriately sized lma of any kind leak on me. The rep who sells us the classics was here recently and apparently they have been hit real hard by the ambu product. almost all of his literature and propoganda revolved around the evils of the ambu lma and how it causes everything from glossopharyngeal nerve palsies to soft pallete necrosis. On a complete aside.. i work with a couple of very oldschool attendings who mask everyone they can and would never even consider using an LMA. I think masking has become a lost art and I stress the point with all my junior residents that learning how to mask a patient is one of the most important things you can learn in your first 6 months. Around here LMA stands for Leave Me Alone.. meaning i have better things to do than fiddle with a mask for the entire case. Last note.. my one and only case of near disaster laryngospasm came as a result of trying to pull an lma deep on a little fat kid. Called for help, gave 1cc of sux and masked him until it wore off.. took me a loooooong time before i ever stuck any kind of lma in a kid again.

Obesity and the LMA Classic

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