A kinda boring but clinically relevant scenerio

[jetproppilot]

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Nice, 60s female here for a partial mastectomy.

History of hypertension.

Thats it.

Nothing else.

Airway exam......Mal 1, opens mouth wide, good TM distance, blah blah blah.

Full setta dentures which have been taken out.

She's kinda embarrassed by this so keeps her sheet in front of her mouth while I speak with her preoperatively.

THIRTY SECONDS INTO my preop, I already know what I'm gonna do.

She's kinda nervous so I'll slipper a cuppla milligrams of midazolam after we speak.

Then we'll roll into the room, We'll put the monitors on, have her breathe some FRESH CHALMETTE OXYGEN FOR A CUPPLA BREATHS,

I'll give her 200mg propofol as fast as I can push it,

and when she stops breathing I'll open her mouth and insert the (already inflated)

LMA #4.

Not a 3.

Not a 5.

Hear me out please.

I think the LMA company has made our lives somewhat difficult with the different sizes.

Granted, its good to have options.

BUT IN THE LMA WORLD, NOT REALLY.

USE AN LMA #4 ON EVERY ADULT is the way I run it, barring putting to sleep a DWARF, or, at the New Orleans Zoo, a GIRAFFE.

Would probably use a 3 on the dwarf.

And a 5 on the giraffe.

SO BARRING THESE ANOMALIES,

I use an LMA #4.

BUT THE STORY AIN'T OVER, LADIES AND GENTLEMEN, AND COP.

(HAHAHAHAHAHHAHAHAHAjust kiddin my man)

Get the nice lady in the back, monitors on, have her breathe some of the nice CHALMATION oxygen, slam the stikka propofol, she goes apneic,

plop in the LMA #4.

BOOM.

Hook up circuit,

QUECCHHHHH QUECHHHHHHH QUECHHHHHHHH

Chest isnt rising.

No end tidal.

Play with the LMA a little,

SAME RESULT.

GETTING LMAs to "sit" is sometimes difficult in patients with no teeth!!!

I mean, ya slam it down deftly, and it won't stay.

Kinda torques left or right.

No problem, I think, as I quickly remove the LMA, take all of my (proprietary) pre-insertion air out of it, lube it up again, and insert it the "right (read:no air) way."

PLOOP.

Falls in like a champ.

Hook up circuit.

QUEEECH QUEEECH

Same weird sound when I squeeze the bag with no resultant chest rise or ETCO2.

S HIT.

OK.

Maybe my everyone is an LMA #4 rule doesnt apply here so I pull out an LMA #3.

Kind of a little lady so I'll try it.

Slam it in.

QUEECH QUEECH QUEECH

SO, RESIDENT COLLEAGUES,

heres what I've been leading up to.

About three minutes have past while we've screwed around with this edentulous lady who won't swallow an LMA no matter what.

WHAT DO I DO NOW?

Surgeon (uhhhhh, GF) just walked in, and she's ready to operate.

And I still don't have an airway for her operation.😡

WHADDYA DO NOW?

 

[dhb]

sux tube no biggie

 

[usnavdoc]

I agree. Sux tube.

 

[Planktonmd]

Nice, 60s female here for a partial mastectomy.

History of hypertension.

Thats it.

Nothing else.

Airway exam......Mal 1, opens mouth wide, good TM distance, blah blah blah.

Full setta dentures which have been taken out.

She's kinda embarrassed by this so keeps her sheet in front of her mouth while I speak with her preoperatively.

THIRTY SECONDS INTO my preop, I already know what I'm gonna do.

She's kinda nervous so I'll slipper a cuppla milligrams of midazolam after we speak.

Then we'll roll into the room, We'll put the monitors on, have her breathe some FRESH CHALMETTE OXYGEN FOR A CUPPLA BREATHS,

I'll give her 200mg propofol as fast as I can push it,

and when she stops breathing I'll open her mouth and insert the (already inflated)

LMA #4.

Not a 3.

Not a 5.

Hear me out please.

I think the LMA company has made our lives somewhat difficult with the different sizes.

Granted, its good to have options.

BUT IN THE LMA WORLD, NOT REALLY.

USE AN LMA #4 ON EVERY ADULT is the way I run it, barring putting to sleep a DWARF, or, at the New Orleans Zoo, a GIRAFFE.

Would probably use a 3 on the dwarf.

And a 5 on the giraffe.

SO BARRING THESE ANOMALIES,

I use an LMA #4.

BUT THE STORY AIN'T OVER, LADIES AND GENTLEMEN, AND COP.

(HAHAHAHAHAHHAHAHAHAjust kiddin my man)

Get the nice lady in the back, monitors on, have her breathe some of the nice CHALMATION oxygen, slam the stikka propofol, she goes apneic,

plop in the LMA #4.

BOOM.

Hook up circuit,

QUECCHHHHH QUECHHHHHHH QUECHHHHHHHH

Chest isnt rising.

No end tidal.

Play with the LMA a little,

SAME RESULT.

GETTING LMAs to "sit" is sometimes difficult in patients with no teeth!!!

I mean, ya slam it down deftly, and it won't stay.

Kinda torques left or right.

No problem, I think, as I quickly remove the LMA, take all of my (proprietary) pre-insertion air out of it, lube it up again, and insert it the "right (read:no air) way."

PLOOP.

Falls in like a champ.

Hook up circuit.

QUEEECH QUEEECH

Same weird sound when I squeeze the bag with no resultant chest rise or ETCO2.

S HIT.

OK.

Maybe my everyone is an LMA #4 rule doesnt apply here so I pull out an LMA #3.

Kind of a little lady so I'll try it.

Slam it in.

QUEECH QUEECH QUEECH

SO, RESIDENT COLLEAGUES,

heres what I've been leading up to.

About three minutes have past while we've screwed around with this edentulous lady who won't swallow an LMA no matter what.

WHAT DO I DO NOW?

Surgeon (uhhhhh, GF) just walked in, and she's ready to operate.

And I still don't have an airway for her operation.😡

WHADDYA DO NOW?

Did you try to mask ventilate in between attempts?
I am just wondering if there is something obstructing the airway.
A little sux might have helped if it was laryngospasm.
I would have intubated her after the second attempt though 😉
But I agree, toothless people are a challenge for LMA's sometimes.

 

[Apollyon]

Then we'll roll into the room, We'll put the monitors on, have her breathe some FRESH CHALMETTE OXYGEN FOR A CUPPLA BREATHS,

Get the nice lady in the back, monitors on, have her breathe some of the nice CHALMATION oxygen, slam the stikka propofol, she goes apneic,

Hahaha - "Chalmatians"!

(For those who don't know, Chalmette is a community outside NO, and the residents of Chalmette are known as "Chalmatians" (rhymes with "Dalmatian"), and some locals regard them as proto- or sub-human.)

 

[urge]

Bronchospasm? Laryngo spasm?

Thread hijack:

Is cop a man or woman? I vote for woman.

End thread hijack.

 

[Jeff05]

i would establish that you can mask ventilate.
then intubate.

jeff

 

[radslooking]

Hahaha - "Chalmatians"!

(For those who don't know, Chalmette is a community outside NO, and the residents of Chalmette are known as "Chalmatians" (rhymes with "Dalmatian"), and some locals regard them as proto- or sub-human.)

🙂 Chalmatian girls are uh.....usually have bangs and high top LA gears, have pants that are tight at the ankles, and are ready to go at a moments notice. 🙂

 

[Apollyon]

🙂 Chalmatian girls are uh.....usually have bangs and high top LA gears, have pants that are tight at the ankles, and are ready to go at a moments notice. 🙂

Hey, Big Hair will get you EVERYWHERE!

 

[radslooking]

Hey, Big Hair will get you EVERYWHERE!

Sorry to hijack Jet. West bank is the best bank. 😉 Ok, clinical scenario resuming in 3....2....1....

 

[ZA_Gasman]

Why struggle on with the LMA? I usually give the LMA 3 strikes. It doesn't work 3 times.... It gets binned and the patient gets a definitive airway. No mess, no fuss. The LMA is a useful device, I'm not gonna argue that point. But if it gives me ****, it goes. I know I'm good at intubations, so I'd intubate. Give some Mivacurium/Atracurium or, if you feeling frisky, 2mg Alfentanil and slam that snorkel in. I find that problems with the LMA don't go away and you spend the whole case messing around with it.

 

[huktonfonix]

Assuming that you are still able to mask ventilate and dont feel you have overly traumatized the airway, you can also try to roll up a few 4x4s, stick one roll on each side of the LMA. this occasionally helps with fit issues. I would probably just intubate since it seems easier though unless there was some compelling reason otherwise.

 

[OB1🤙]

Give some Mivacurium/Atracurium or, if you feeling frisky, 2mg Alfentanil and slam that snorkel in.

This post reminds me just how different practices are in different countries.

Also, just how screwed are you guys now that this clown Zuma is taking over the ANC?

I agree with the above posts though- I've temporarily settled on a 2 strikes rule for LMAs, then it's Mac 3 time for this toofless lady who just doesn't wanna suck in that Pontchartrain-flavored air with an LMA flopping around in her pharynx.

 

[jetproppilot]

This post reminds me just how different practices are in different countries.

Also, just how screwed are you guys now that this clown Zuma is taking over the ANC?

I agree with the above posts though- I've temporarily settled on a 2 strikes rule for LMAs, then it's Mac 3 time for this toofless lady who just doesn't wanna suck in that Pontchartrain-flavored air with an LMA flopping around in her pharynx.

So everyone agrees that its time to intubate.

Some even gave a definitive limit of how long, or how many tries you give an LMA before you intubate.

Which makes my point that I feel is very relevant and should be instilled into budding med students/residents, a point that can be applied to medical practice in general, which is:

NEVER MARRY A DECISION YOU MAKE.

We've gotta have a plan, just like any other doc.

Mosta the time the plan works brilliantly.

Sometimes it doesnt.

I see clinicians that are sometimes "married" to their initial way of approaching something, for example:

1) A what I call the Laparoscopically Delayed Open Colectomy. Surgeon dude struggles and struggles and struggles when the chips are stacked against him, and he knows it...but he persists... one hour....two hours.....three....then says

"Nope. Aint gonna work. Lets open."

Well, uhhh, Dude, you knew that two hours ago...you just wasted two hours of your life....mine too....

2)Trying an epidural for 45 minutes. Havent seen this in a long time since I've been blessed with deft partners in private practice, but I remember well from residency......seeing people, myself included, be given an unlimited amount of time to do an epidural for, say, a total knee, a procedure that can be done under general. I've done it, very early in my career. I don't anymore. I give myself about ten minutes with a difficult epidural. If I cant get it, I call a partner. Or put them to sleep.

3)And back to the OP example, LMAs. I agree with all of you, which is to try a cuppla times and if it doesnt work, MOVE TO PLAN B which is of course endotracheal intubation.

Engrain this concept in your head, my colleague premed/med student/residents.

Don't marry your first approach to anything. Be able to change course to Plan B after a reasonable amount of time.

Its definitely not a sign of weakness.

Its a sign of clinical maturity.

 

[mick2003]

This is a geat point and this adaptability and maturity keeps patients from getting hurt.

Don't make a failed or failing procedure "personal." Can't get the blind IJ - use US or SC before you thread the wire into the carotid. Can't get a DL - use FOI or some other means before you bloody the airway.

With experience, I'm starting to realize that we blame ourselves too much for failed procedures in difficult or aberrent patients. In addition, experienced hands quickly know when things aren't going to work the "regular" way and plan B needs to take effect.

Long story short, don't F around just because "it was supposed to work this way."

Mick

 

[coprolalia]

Is cop a man or woman? I vote for woman.

Cop's definitely a man... maybe not a gentleman... but definitely a man. I've got the twig and berries to prove it.

I'd have put her teeth back in and shoved in a #6 LMA, by the way.

-cop

 

[DrDre']

This is such an important concept.

I have been involved in many flails already. Some of mine, some cxed by others.

The last one, the attending was married to our access plan. WE had planned to do a left IJ as the right had issues (cant remember what). We really only needed large bore access but the pt was morbidly obese. THought an introducer would do me good... The pt had messed up anatomy and the mojo in the room was bad. I kept wanting to change to a different site or strategy and she wanted me to continue.

I felt that the risk/benefit ratio had changed plus the clock was ticking! 45 minutes later, I had ruined my day, tortured the pt and had a L IJ. I could have placed a RICC on the preexisting IV in 2 minutes!

So everyone agrees that its time to intubate.

Some even gave a definitive limit of how long, or how many tries you give an LMA before you intubate.

Which makes my point that I feel is very relevant and should be instilled into budding med students/residents, a point that can be applied to medical practice in general, which is:

NEVER MARRY A DECISION YOU MAKE.

We've gotta have a plan, just like any other doc.

Mosta the time the plan works brilliantly.

Sometimes it doesnt.

I see clinicians that are sometimes "married" to their initial way of approaching something, for example:

1) A what I call the Laparoscopically Delayed Open Colectomy. Surgeon dude struggles and struggles and struggles when the chips are stacked against him, and he knows it...but he persists... one hour....two hours.....three....then says

"Nope. Aint gonna work. Lets open."

Well, uhhh, Dude, you knew that two hours ago...you just wasted two hours of your life....mine too....

2)Trying an epidural for 45 minutes. Havent seen this in a long time since I've been blessed with deft partners in private practice, but I remember well from residency......seeing people, myself included, be given an unlimited amount of time to do an epidural for, say, a total knee, a procedure that can be done under general. I've done it, very early in my career. I don't anymore. I give myself about ten minutes with a difficult epidural. If I cant get it, I call a partner. Or put them to sleep.

3)And back to the OP example, LMAs. I agree with all of you, which is to try a cuppla times and if it doesnt work, MOVE TO PLAN B which is of course endotracheal intubation.

Engrain this concept in your head, my colleague premed/med student/residents.

Don't marry your first approach to anything. Be able to change course to Plan B after a reasonable amount of time.

Its definitely not a sign of weakness.

Its a sign of clinical maturity.

 

[911_turbo]

So this is something I've thought about and had happen to me as well. My question is this if your LMA fails and you convert to ETT what do you do if it turns out to be a difficult airway and you have no difficult airway equipment since you planned for an LMA and ETT was your backup?

 

[Planktonmd]

So this is something I've thought about and had happen to me as well. My question is this if your LMA fails and you convert to ETT what do you do if it turns out to be a difficult airway and you have no difficult airway equipment since you planned for an LMA and ETT was your backup?

Follow the difficult airway algorithm.

 

[benjamin248]

What would be wrong with - hypothetically speaking - using an ORAL AIRWAY and FACE MASK with 4-way MASK STRAP?

Thoughts????

 

[Tenesma]

i wouldn't even try the mask --- just take a quick look with a DL and throw in the tube if you got a good view...

if the view sucks, i'd give a try at mask ventilation... without deepening anesthesia... then decide if you are going to wake her up.

 

[leviathan]

What would be wrong with - hypothetically speaking - using an ORAL AIRWAY and FACE MASK with 4-way MASK STRAP?

Thoughts????

Wouldn't that lead to unnecessarily high inspiratory pressures and gastric inflation and risk for aspiration? Please enlighten me if I'm off base here.

 

[usnavdoc]

What would be wrong with - hypothetically speaking - using an ORAL AIRWAY and FACE MASK with 4-way MASK STRAP?

Thoughts????

I would have attempted to mask vent prior to LMA placment. So I would know already what the outcome was, but in this scenario, assuming good seating of the LMA, you were not able to vent.. Which means its time for the ETT. LMA is essentially the same thing as mask ventillation but you are below all the soft tissue at the glottis. If you cant vent through the LMA(again assuming it is seated well) you are not likely to be able to mask vent.

 

[Planktonmd]

Wouldn't that lead to unnecessarily high inspiratory pressures and gastric inflation and risk for aspiration? Please enlighten me if I'm off base here.

We did mask anesthesia on a daily basis a few years ago, and most of these patients did not die. 🙂

 

[jwk]

Dang, I thought this was a trick question Jet - I was just sure when your response came up that you were going to tell us you forgot to take out the dentures and you had shoved them in the back of the throat along with the LMA.

 

[leviathan]

We did mask anesthesia on a daily basis a few years ago, and most of these patients did not die. 🙂

I was always taught that this is a no-no. I guess if you can keep the pressures low enough...

 

[jwk]

I was always taught that this is a no-no. I guess if you can keep the pressures low enough...

Mask anesthesia a no-no? I still do it all the time on short cases.

 

[Planktonmd]

I was always taught that this is a no-no. I guess if you can keep the pressures low enough...

Who taught you that?