Are you ready for private practice? -- LMAs

[Sevo]

I just recently started work as a private practice attending and found Jet's comments dead on.

I'd like to suggest that the newbies get really handy with LMAs. Where I trained, GETA was the standard and the use of LMAs were rare. See, all of my attendings were deathly scared of the nurses and the residents not keeping the patients deep enough, and therefore didn't trust us with unsecured airways. It's a lot easier to check your stocks and watch TV when the patient is tubed and paralyzed when the CA-1 is in the room doing that ORIF of the forearm.

Now I often have schedules in which I'm doing 10 or so knee scopes a day. Each one is roughly 15-20 mins long from skin to skin and it's strictly LMAs and deep removal. More often than not,I sometimes even place the patient on pressure controlled ventilation.

As a resident at the ivory tower of academics, the standard technique was to hit the patient with 2-2.5mg/kg of propofol, a cc of fentanyl, and then mask for a minute or so with sevo before placing the fully deflated LMA. Later, I and few others became proponents of the technique introduced to us by attendings who had come out of private practice that involved simply slugging the patient with propofol (usually 4mg/kg) to cause apnea, throw in the LMA partially inflated, and then hook up the patient to a circuit and wait for spontaneous ventilation to resume. Without an opioid, the patient usually resumes breathing within 1-2 minutes. I then cranked up the Sevo dial to 6-8% with good flows and allow the patient to deepen himself while prepping occurs. N2O +/-

Unfortunately, at my surgery centers, things move really fast and really efficiently. The nurses and the orthopods move in like vultures once the LMA is in and even with the stimulus of positioning, I used to see some sort of myoclonic movement (often in young men) 1-2 minutes later if I didn't quickly hit the patient with another 1-2 mg/kg more of propofol shortly after LMA placement.

The solution, in large part, has been to put patients on the vent, watching for peak inspiratory pressures greater than 20mm. The patients get a good hit of gas thus preventing the spasmic motions and movement at incision, the propofol can be avoided, the patient stays oxygenated, and by avoiding opioids, I can get them back breathing shortly after the case is started. Myoclonus still (rarely) occurs, but that's why I have extra propofol handy.

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[VolatileAgent]

we are already doing at lot of these in the "ivory towers" where i am. perhaps a lot has changed since you've been in residency, or i'm just at an exceptional program. who knows? but, on average, i do at least a few a week (depending on what i'm booked for) and have done probably 250-300 since starting residency. training on using the LMA is pretty well accepted and the norm, i would imagine, at most programs these days. we also routinely use iLMA and occassionally get to play with things like the c-track, bullard, shikani, awake/asleep fiberoptic, a few transtracheal jets here and there, cricothyroidotomies in the trauma bay... you name it. we do actually get a chance to practice with and get efficient at a wide variety of airway techniques at my program. i hope other residents have the same experience. they should.

nice post, though, and thanks for sharing your technique.

 

[TIVA]

Sevo,

Nice post. A few questions:

That's a lot of propofol (4 mg/kg) on induction and then another 2 mg/kg for the positioning and prep and drape. You must be having to give a lot of phenylephrine to maintain their pressure?

And withholding narcs will certainly bring them back breathing spontaneously sooner, but do you find that they are more tachycardic during the procedure? Do you just deepen them with gas then? And do they tend to wake up more agitated or "fighty" without narcotics on board? Do you give your narcs after they're awake?

No criticisms. I'm just interested in how others do their cases. I think anesthesia is like cooking and different chefs have different recipes and I'm always on the lookout for better recipes ... it makes anesthesia more fun and challenging.

Me personally, I usually run a narcotic heavy technique and try to use as little gas as possible (like no more than 0.6 MAC). I titrate the narcs in non-paralyzed patients to keep a RR of < 12. I find this method provides for smoother emergences (not necessarily faster admittedly), good post-op pain relief, and most importantly, happy PACU nurses.

Thanks in advance,

 

[timtye78]

narcotic-heavy technique might increase your risk of ponv, whereas propofol may have anti-emetic properties.

at ou, especially childrens hospital, we may have anywhere from 8 to 12 cases in the ENT rooms and use lma heavily. we do use lma also heavily in those nonstop orthoI&D cases. controlled ventilation is frowned upon with an lma at my place.

I think MACs are underutilized as well as cases using mask ventilation for maintainance as well as induction at my institution. But I think the OP was correct that it is easier for the attending to go to sleep theirself in the lounge at 9 am when their little vaginal lesion removal 26 yo healthy is tubed and paralyzed by their resident.

 

[TIVA]

narcotic-heavy technique might increase your risk of ponv, whereas propofol may have anti-emetic properties. :

True, but propofol is purely a hypnotic, it's not an analgesic. The four parts of anesthesia are: analgesia, amnesia, hypnosis, and paralysis (read: a quiet surgical field). Although you can certainly use propofol to stop someone from moving upon surgical stimulation, the mechanism is by deepening their hypnosis, thereby blunting their sympathetic response to an assault. I would suggest it's better to treat pain with painkillers (or nerve blocks) and not with hypnotics.

 

[timtye78]

I used the term narcotic heavy because you did, but I did not mean to imply we don't use any narcotic.

Some references say using narcotics (specifically opioids) at all are a risk factor for PONV, while at the same time I do believe the risk of PONV is also dose-dependent of narcotic, so we use fentanyl typically titrated to clinical effect.

Happy PACU nurses are the ones 1)arent doing anything (j/k)
2)have a patient comfortable and stable. 3) and have patients who aren't nauseated postop.

I enjoyed reading your technique and enjoy the discussion.

 

[EV-Stentor]

Hey great post Sevo.
At my institution we use the LMA like u wouldn't believe and here is my M.O:
1mg Versed, 2.5 -3.5mg Propofol and 50mcg fentanyl, LMA inserted immediately (inflated with touch of lube on the tip). Pt place on vent with SIMV and sevo flowing @ 2 -3%. Spontaneous vent generally resumes in about 2 mins and the rest is history. I turn the sevo OFF the minute they start closing and by the time the drape is down LMA is out & FM on....works pretty well for me....no PONV issues or delayed awaking...that is why the gas goes off as soon as the Home Depot dude starts closing

 

[TIVA]

Some references say using narcotics (specifically opioids) at all are a risk factor for PONV, while at the same time I do believe the risk of PONV is also dose-dependent of narcotic, so we use fentanyl typically titrated to clinical effect.

Tim, I can't argue with that. It's true. Narcs are associated with PONV in a dose-dependent fashion. And most studies show that patients find PONV to be the most damning part of their operative experience. In fact, some would rather trade their nausea for pain. Thus, for me, it's a rare situation not to give zofran or dexamethasone to try to preempt some of that nausea.

 

[MTGas2B]

I just recently started work as a private practice attending and found Jet's comments dead on.

I'd like to suggest that the newbies get really handy with LMAs. Where I trained, GETA was the standard and the use of LMAs were rare. See, all of my attendings were deathly scared of the nurses and the residents not keeping the patients deep enough, and therefore didn't trust us with unsecured airways. It's a lot easier to check your stocks and watch TV when the patient is tubed and paralyzed when the CA-1 is in the room doing that ORIF of the forearm.

Now I often have schedules in which I'm doing 10 or so knee scopes a day. Each one is roughly 15-20 mins long from skin to skin and it's strictly LMAs and deep removal. More often than not,I sometimes even place the patient on pressure controlled ventilation.

As a resident at the ivory tower of academics, the standard technique was to hit the patient with 2-2.5mg/kg of propofol, a cc of fentanyl, and then mask for a minute or so with sevo before placing the fully deflated LMA. Later, I and few others became proponents of the technique introduced to us by attendings who had come out of private practice that involved simply slugging the patient with propofol (usually 4mg/kg) to cause apnea, throw in the LMA partially inflated, and then hook up the patient to a circuit and wait for spontaneous ventilation to resume. Without an opioid, the patient usually resumes breathing within 1-2 minutes. I then cranked up the Sevo dial to 6-8% with good flows and allow the patient to deepen himself while prepping occurs. N2O +/-

Unfortunately, at my surgery centers, things move really fast and really efficiently. The nurses and the orthopods move in like vultures once the LMA is in and even with the stimulus of positioning, I used to see some sort of myoclonic movement (often in young men) 1-2 minutes later if I didn't quickly hit the patient with another 1-2 mg/kg more of propofol shortly after LMA placement.

The solution, in large part, has been to put patients on the vent, watching for peak inspiratory pressures greater than 20mm. The patients get a good hit of gas thus preventing the spasmic motions and movement at incision, the propofol can be avoided, the patient stays oxygenated, and by avoiding opioids, I can get them back breathing shortly after the case is started. Myoclonus still (rarely) occurs, but that's why I have extra propofol handy.

A CA-1 nearing the end of month 3. Had a good quick turn day yesterday. I managed to run seven hand cases through my room yesterday at Harborview. I would hit them with around 100 mcg of fentanyl, and about 2.5 mg/kg of propofol (although one guy I used STP and tubed him, but that really didn't slow anything down). LMA's slipped in easy the first time, every time. Then I turned on a little less than 1/2 MAC of Sevo with 50% nitrous. Then I just sent the vent on pressure control with MV on the lowish side and when they start to breath flipped the vent off. I made through the day without hearing "I think he's getting a little light". At the end with the N2O off and about 1/4 MAC of Sevo LMA out. 1 or 2 went to PACU with oral airways, but everybody went comfy.

 

[jetproppilot]

A CA-1 nearing the end of month 3. Had a good quick turn day yesterday. I managed to run seven hand cases through my room yesterday at Harborview. I would hit them with around 100 mcg of fentanyl, and about 2.5 mg/kg of propofol (although one guy I used STP and tubed him, but that really didn't slow anything down). LMA's slipped in easy the first time, every time. Then I turned on a little less than 1/2 MAC of Sevo with 50% nitrous. Then I just sent the vent on pressure control with MV on the lowish side and when they start to breath flipped the vent off. I made through the day without hearing "I think he's getting a little light". At the end with the N2O off and about 1/4 MAC of Sevo LMA out. 1 or 2 went to PACU with oral airways, but everybody went comfy.

Sounds like youre feeling THE ZONE, dude.

Great job.

 

[nimbus]

At the end with the N2O off and about 1/4 MAC of Sevo LMA out. 1 or 2 went to PACU with oral airways, but everybody went comfy.

Why mess with a perfectly good airway? Why pull the LMA?

 

[Noyac]

Why mess with a perfectly good airway? Why pull the LMA?

Because nurses sometimes freak if they have a ETT or LMA in place but not an oral airway. I know, this is no reason but I used to do it in residency b/c the nurses automatically increased their acuity when they had either one in. Therefore, I put in a oral airway.

In PP this isn't the issue really. But I still do it b/c the OR team takes the LMA's to be cleaned and if I take them to the PACU they have to go find them. Now thats a good reason.

 

[jetproppilot]

Because nurses sometimes freak if they have a ETT or LMA in place but not an oral airway. I know, this is no reason but I used to do it in residency b/c the nurses automatically increased their acuity when they had either one in. Therefore, I put in a oral airway.

In PP this isn't the issue really. But I still do it b/c the OR team takes the LMA's to be cleaned and if I take them to the PACU they have to go find them. Now thats a good reason.

We switched to the disposable LMAs, Noy. The REAL LMAs...the clear ones...

Love 'em.

 

[Noyac]

We switched to the disposable LMAs, Noy. The REAL LMAs...the clear ones...

Love 'em.

Yeah we got those and I used them all the time in La. But now we use the Proseal mostly.

 

[MTGas2B]

I think the pro-seal is the way to go. The disposable version is coming out soon. If we had more around I wouldn't even bother with the LMA classics. Pre-seal, fas-trach and flex are all you really need.

I could leave the LMA's in on my way to the PACU. In my program each facility is a little different. At Harborview the PACU nurses don't mind extubating, LMA wouldn't be a big deal. Last month when I was back at the University hospital's outpatient center, they get nervous if they see an oral airway. Getting the LMAs out was style points.