anyone ballzy enough to use LMAs with NMBA?

[CremeSickle]

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Im sure many of you have read about what the ppl in the UK are doing with LMAs these days. Full vented MB'd pts and even some in prone position.

Anyone here actually try it? I dont have the cajones...

 

[militarymd]

Fairly common.

 

[OldManDave]

Im sure many of you have read about what the ppl in the UK are doing with LMAs these days. Full vented MB'd pts and even some in prone position.

Anyone here actually try it? I dont have the cajones...

At Dartmouth, we have a guy who comes here periodically on sabbatical from Sweden. He routinely uses LMAs in MB'd pts in all positions w/ full vent support. Myself, I don't use MB with LMAs, but occasionally - esp when I was newer at this gig - would have the pt initially apneic. In that case, I would not hesitate to run the vent in a PC/SIMV format thru the LMA until they began breathing. As long as you are not requiring excessive pressures, you should be OK.

 

[VolatileAgent]

Fairly common.

ditto. i wouldn't say "common", but "fairly common" covers it. there are a cohort of european anesthesiologists i've worked with who do this fairly commonly. one also has no qualms about running nitrous during a big belly case either.

 

[urgewrx]

A little bit of sux is great to get the lma in when pts have a small mouth.

 

[VentdependenT]

Im sure many of you have read about what the ppl in the UK are doing with LMAs these days. Full vented MB'd pts and even some in prone position.

Anyone here actually try it? I dont have the cajones...

If I think I can get decent tidal volumes at pressures <20mmhg (for presumed lower esophageal sphincter pressure) on full support and the case calls for it I'll hit em with 10 of roc or some sux. Throw on Pressure control and let er rip.

 

[IceDoc]

Not part of my routine (as with most of US), but once we couldn't get ETT in with DL so stuck in LMA while waiting for FOB. Was ventilating fine, so we bagged the ETT and ventilated through LMA. Worked great. The most remarkable part of the case is that it was a 70yo patient and my attending was a pediatric intensivist who also occasionally did anesthesia (attdg even had to ask me the dose of phenylephrine).

 

[Noyac]

(attdg even had to ask me the dose of phenylephrine).

😱

Urgwrx, you beat me to it. Some of the only times I use suxx is to place a LMA. Probably not the NMBA usage that Cremesickle is looking for, however.

 

[CremeSickle]

I wonder how long until the UK has sufficient studies to really prove their contention that proseal LMA = ETT in regards to safety. Honestly, it scares me.

think it will ever be commonplace here?

 

[mille125]

I wonder how long until the UK has sufficient studies to really prove their contention that proseal LMA = ETT in regards to safety. Honestly, it scares me.

think it will ever be commonplace here?

probably is safe most of the time...but is it worth it? There have been several successful lawsuits...the lawyers will be all over you....Just put in an ETT in prone/high aspiration risk patients....what do you really have to gain otherwise....

 

[rmh149]

I second mille's opinion. Why mess with it? Stick an ETT in and be done with it.

 

[Planktonmd]

If a case crequires muscle relaxants for maintenance it's most likely a case that requires ETT.

On the other hand I don't see why you can't give muscle relaxants with an LMA.

 

[VolatileAgent]

On the other hand I don't see why you can't give muscle relaxants with an LMA.

you can. doubly so if you use a proseal.

 

[CremeSickle]

true, thats the big rage in the UK now, the proseal. To be honest I havent even seen one at my facility.

Is it catching on anywhere else?

you can. doubly so if you use a proseal.

 

[fval28]

when mivacron was still available I used to use a small dose right after putting in the LMA. I would manually vent to 1 MAC of agent until incision and watch the HR and BP to determine (roughly) if I had enough narcs on board. with the miv the pt never moved an i was able to titrate narcs. I only did this for short (<45 min) cases- usually hernia repairs and some podiatry cases. Never used LMA with prone cases or with prolonged ventilation- thats what an ETT is for (IMHO)

 

[rmh149]

true, thats the big rage in the UK now, the proseal. To be honest I havent even seen one at my facility.

Is it catching on anywhere else?

Never heard of it.....what is it?

 

[BLADEMDA]

when mivacron was still available I used to use a small dose right after putting in the LMA. I would manually vent to 1 MAC of agent until incision and watch the HR and BP to determine (roughly) if I had enough narcs on board. with the miv the pt never moved an i was able to titrate narcs. I only did this for short (<45 min) cases- usually hernia repairs and some podiatry cases. Never used LMA with prone cases or with prolonged ventilation- thats what an ETT is for (IMHO)

I did the same thing as you but used hand ventilation. I still miss the Mivacron! I have done cases with LMA's in lateral and prone positions both on and off the ventilator. I much prefer the safety of an E.T. for these situations.

Blade

 

[fval28]

I did the same thing as you but used hand ventilation. I still miss the Mivacron! I have done cases with LMA's in lateral and prone positions both on and off the ventilator. I much prefer the safety of an E.T. for these situations.

Blade

I should have been more clear in my previous post- when I wrote manually ventilate I meant hand ventilate. I have yet to get comfortable with putting LMA's on the vent. I have had one pediatric eye case laryngospasm with an LMA in and it has made me very cautious to push the envelope.

BTW I miss mivacron too...

 

[cchoukal]

The proseal is an LMA with 2 extra features:

1) a larger, specially shaped "cuff" whose purpose is to form a tighter seal (higher oropharyngeal leak pressure). The special shape is an extra bulge posteriorly to better seal off the esophagus.

2) an OG port that allows passage of (I think) as large as a 14 Fr OG tube. This can be placed after the LMA is seater to help drain the stomach. I've also placed these over an OG. You essentially stylet the LMA with the OG, run the OG in and confirm gastric secretions, then slide the LMA over the OG. This helps ensure the esohpageal port ends up in the esophagus.

When I use an LMA I use a proseal about 95% of the time. I can regularly get OLPs > 25 cmH2O, which allows the use of PS/VC/PC mechanical ventilation. I believe someone is working on a disposable model, as well.

 

[rmh149]

Never used the proseal...looked it up on the internet, looks like something useful. How much does it cost?

As far as running someone in the vent with an LMA, I prefer to hand ventilate till they are spontaniously breathing. This was good with Mivacron....sucks that it is gone. Now I use a little zemuron and ScH.

If I ever need to put the patient on the vent...they get an ETT.

 

[sevoflurane]

Never used the proseal...looked it up on the internet, looks like something useful. How much does it cost?

As far as running someone in the vent with an LMA, I prefer to hand ventilate till they are spontaniously breathing. This was good with Mivacron....sucks that it is gone. Now I use a little zemuron and ScH.

If I ever need to put the patient on the vent...they get an ETT.

The only thing holding a proseal back is cost. It even has it's own incorporated bite block. If I remember right, the proseal cost near $300. They are re-usable (like an intubating lma) I use a proseal over an lma any day

 

[stanleykristian]

I will and have. In dallas one surgeon who did many breast cases was quite adamant about using an LMA with a NDMR. At first I was thinking no way, but ultimatley an LMA is a mask and positive pressure ventilation is positive pressure ventilation ither by bag or bellows, so if the patient is not huge and I can keep my PIP to about 15 or less I will do it.

 

[VentdependenT]

Never used the proseal...looked it up on the internet, looks like something useful. How much does it cost?

As far as running someone in the vent with an LMA, I prefer to hand ventilate till they are spontaniously breathing. This was good with Mivacron....sucks that it is gone. Now I use a little zemuron and ScH.

If I ever need to put the patient on the vent...they get an ETT.

Proseal is worthwhile. Have your dept purchase one. The OG doesn't always go in no matter how friggen slick ya are.

 

[Noyac]

I will and have. In dallas one surgeon who did many breast cases was quite adamant about using an LMA with a NDMR. At first I was thinking no way, but ultimatley an LMA is a mask and positive pressure ventilation is positive pressure ventilation ither by bag or bellows, so if the patient is not huge and I can keep my PIP to about 15 or less I will do it.

So you let the surgeon direct your anesthetic?

Never, I have never and will never have a surgeon direct my anesthetic. Their knowledge is limited when it comes to anesthesia. Very limited.


We have 2 surgeons that would book a case as MAC with LMA. After laughing at them for booking it this way a number of times, we finally told them what hey were actually asking for. Damn did they feel stupid. Surgeons don't know anesthesia.

 

[mille125]

So you let the surgeon direct your anesthetic?

Never, I have never and will never have a surgeon direct my anesthetic. Their knowledge is limited when it comes to anesthesia. Very limited.


We have 2 surgeons that would book a case as MAC with LMA. After laughing at them for booking it this way a number of times, we finally told them what hey were actually asking for. Damn did they feel stupid. Surgeons don't know anesthesia.

doesnt surprise me one bit given other posts

 

[Lefty]

If you are going to use muscle relaxant, place an LMA, and then ventilate what are you gaining? I can see the decreased risk of trauma to vocal cords, sore throat, hoarseness, etc. But the trade off is less secure of an airway, i.e. increased risk of aspiration.

If pt has been given NMB they will need reversal so no benefit there. If you argue that using a smaller dose of NMB leads to more rapid return of spontaneous breathing, I don't see how that would be much different than for ETT.

What is the benefit of using LMA w/ NMB and PPV?

 

[Skrubz]

like some of the other guys, i tend to use the proseal over the classic LMA whenever i can. if i get a good seal on the proseal (which is most of the time), then i don't have qualms about using NMDBs. i recently had a couple ortho cases where i dropped a proseal and was glad i did when the surgeons asked for relaxation.

with a classic, i might use NMDBs if i had a good seal. if it was going to turn into a long surgery (like the time a LE angiogram in the OR turned into a fem-pop revision), i'd just paralyze and switch the LMA out for an ETT.

 

[jetproppilot]

I use a proseal over an lma any day

Not me.

Disposable LMA (tm) #4 is the best.

Hands down.

Inflate it B4 insertion.

That #4 can be used in any adult.

No #3/#5s needed.

 

[Teillard]

Inflate it B4 insertion.

Why do you do that? So the tip doesn't fold back?

 

[Huktonfoniks]

yup, I use a 4 on most adults too. It may just be voodoo, but I personally pull the LMA back a cm and then reinsert after I've seated it. It seems to release the epiglottis if you've caught it the first time and prevents the tip from bending. Again, no real proof but it seems to help my fit and seal.