Awake Lma placement

[narcusprince]

Today I had a young patient 25 with bmi 40 ish come for cysto w stent and stone manipulation. Healthy otherwise MP4 large neck extra large head. Topicalized with lido 2 of versed 25 mcg fent and had him huffing a touch of Gas maybe 2% sevo until he felt giggly. Had him open his mouth placed the Ijel. Turned up the vapor kept him spontaneously breathing. Woke him up no with no knowledge of lma placement. A unique approach....

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[dhb]

 

[MoMoGesiologist]

Why did you decide to do it this way? Just to try it, or to avoid DL and ETT in potential difficult airway?

Also I thought you had to get ppl pretty deep for LMA to seat well and get good seal?

 

[gasdoc77]

Reminds me of a time i pushed propofol on an older gentleman, eyes were shut, slid in an LMa and turned on some gas. He never opened his eyes and we then noticed that his IV was out and he hadn't received a drop of the prop. Oh, and he hadn't been premedicated at all He probably thought "anesthesia has changed these days".

 

[narcusprince]

Tried it because I am a huge fan of the ijel. I knew I could probably DL this guy and get it done. I saw how well patients tolerated it going out and so I decided to topicalize and go in. It seated like a champ. I wanted to avoid DLing him and knew If I had to I could. He tolerated it well.

 

[nimbus]

I’ve mentioned in a previous post that Joseph Brimacombe use to give talks where he showed slides of himself running a 5k, snorkeling in a hotel swimming pool and bronching himself all thru an LMA. But he’s a crazy Aussie.

 

[Psai]

Reminds me of a time i pushed propofol on an older gentleman, eyes were shut, slid in an LMa and turned on some gas. He never opened his eyes and we then noticed that his IV was out and he hadn't received a drop of the prop. Oh, and he hadn't been premedicated at all He probably thought "anesthesia has changed these days".

Does he have a daughter?

 

[AdmiralChz]

Reminds me of a time i pushed propofol on an older gentleman, eyes were shut, slid in an LMa and turned on some gas. He never opened his eyes and we then noticed that his IV was out and he hadn't received a drop of the prop. Oh, and he hadn't been premedicated at all He probably thought "anesthesia has changed these days".

This story is even better when imagining your avatar involved with it.

 

[deleted162650]

FWIW, I have been awake for every LMA I've ever placed.

 

[caligas]

Does he have a daughter?

Yeah, she’s 72.

 

[narcusprince]

Yeah, she’s 72.

Edentulous?

 

[deleted171991]

Doctors, please!

 

[Iso4ane]

Igels are really slick, easier to place and seals much better than LMA/other SGAs

 

[dhb]

Edentulous?

Velvet BJ

 

[leaverus]

Reminds me of a time i pushed propofol on an older gentleman, eyes were shut, slid in an LMa and turned on some gas. He never opened his eyes and we then noticed that his IV was out and he hadn't received a drop of the prop. Oh, and he hadn't been premedicated at all He probably thought "anesthesia has changed these days".

Nice. Reminds of the time I had to push 600mg of propofol (IV definitely working) on a 30yr old guy before he was deep enough for the LMA. He wasn't even a druggie. Pharmacy questioned me afterwards whether my charting was accurate.

 

[deleted171991]

Nice. Reminds of the time I had to push 600mg of propofol (IV definitely working) on a 30yr old guy before he was deep enough for the LMA. He wasn't even a druggie. Pharmacy questioned me afterwards whether my charting was accurate.

Pharmacy questioned you? WTH, do you have propofol on the controlled substance list?

 

[Lecithin5]

Not to hijack the thread, but related to this topic: back in residency, I ran across two schools of thought-one was to induce with enough propofol to render a patient apnic, THEN place lma (and afterwards, either continue ppv with the pt deep, or get the pt to spont. breathe); the other with enough prop to get them asleep, but still breathing, and then insert lma while pt is breathing (a la OP's scenario)- that way, the patient is it spontaneously breathing from the get go. Pros/cons of both ways? What do you do in practice? Laryngospasm implications?

 

[deleted171991]

Not to hijack the thread, but related to this topic: back in residency, I ran across two schools of thought-one was to induce with enough propofol to render a patient apnic, THEN place lma (and afterwards, either continue ppv with the pt deep, or get the pt to spont. breathe); the other with enough prop to get them asleep, but still breathing, and then insert lma while pt is breathing (a la OP's scenario)- that way, the patient is it spontaneously breathing from the get go. Pros/cons of both ways? What do you do in practice? Laryngospasm implications?

I go with the former method, most of the time. I want to know the LMA can take 20 cmH2O of pressure without leaking. Then I'm not afraid even to use muscle relaxants. This way I can get and keep the patient much deeper (and fast). I go the latter way only during really short procedures, where I treat the LMA like an oral airway.

There are two main causes of laryngospasm: the patient is light during surgery (e.g. rectal surgery), or the LMA was removed with the patient in stage II and some secretions ended up on the cords. I never experience laryngospasm on insertion, just maybe pushing out the LMA with the tongue, bucking or biting, if there isn't enough propofol on board. Laryngospasm in adults is overrated (i.e. easy to treat).

 

[Lecithin5]

I go with the former method, most of the time. I want to know the LMA can take 20 cmH2O of pressure without leaking. Then I'm not afraid even to use muscle relaxants. I go the latter way only during really short procedures, where I treat the LMA like an oral airway.

There are two main causes of laryngospasm: the patient is light during surgery, or the LMA was removed with the patient in stage II. I never experience laryngospasm on insertion, just maybe bucking.

Thanks FFP. I haven't been practicing as long as a lot of you guys have been, but my experience during training was predominantly the former as well. But more and more, I see my colleagues doing the latter. The latter seems to work well, but I'm just a little bit ambivalent about adopting that approach-there's just something about wanting a patient completely relaxed and deep prior to the insertion of an lma, to avoid spasm (but perhaps that concern is overstated)

 

[deleted171991]

Do whatever makes you feel comfortable. Myself, I want to know I can use that airway for controlled PPV if I need to.

I put an i-gel 5 in an obese guy recently, and I tolerated it even with a leak at 12-15, just because it was working with PSV and the patient was the bronchospastic kind. Let's just say that I wasn't happy for those 2 hours, especially once he became atelectatic and the sats started going South. God bless PEEP/CPAP and my CCM education; he was breathing better on 0/8 (100% sat) than on 10/5 (95% trending downwards).

 

[dhb]

In my experience patients that are light are more likely to spasm when you are using PPV vs SV. In SV they tend to raise their respiratory rate.

 

[deleted697535]

Former for me too.

I don't understand why there is this drive to get to the lowest dose of hypnotic possible in robust patients. Sure it's cool and all but in my mind it is fraught with danger with minimal benefits.

Propofol is cheap and has almost 0 side effects we can't manage in stronger patients.

I have no problem giving 300, 400, 500mg to that lad after good preox and if the LMA sits he'll be breathing before the surgeons have his legs in the stirrups. If it doesn't sit perfect first go he's getting a tube. Either way I'm sitting back in my chair 4 mins later without a care in the world.

Someone else can do dose finding studies, thank you very much

 

[Planktonmd]

That is a a slick plan and it does work unless you have a CRNA involved

 

[Ezekiel2517]

Nothing wrong with giving one or two cc's of succinylcholine if you're worried about pt being too light on LMA placement. Great for if they spasm with it too

 

[deleted59964]

Not to hijack the thread, but related to this topic: back in residency, I ran across two schools of thought-one was to induce with enough propofol to render a patient apnic, THEN place lma (and afterwards, either continue ppv with the pt deep, or get the pt to spont. breathe); the other with enough prop to get them asleep, but still breathing, and then insert lma while pt is breathing (a la OP's scenario)- that way, the patient is it spontaneously breathing from the get go. Pros/cons of both ways? What do you do in practice? Laryngospasm implications?

like most, i usually give a generous dose of propofol and then place the LMA. If you don't give much opioid you can often get them to keep breathing with surprisingly large propofol doses.

I give a small dose of propofol and maintain spontaneous breathing in fragile elderly patients (NOFs mostly) ... getting them to swallow the LMA while barely asleep takes a bit more skill but it gives smoother hemodynamics

 

[narcusprince]

My curiosity in anesthesia is defining at which point are my actions not reversable(or reversing would require a large amount of time). This plan allowed me to securly place an airway without burning bridges. If the LMA did not seat go to sleep and secure with whatever device you choose.

 

[deleted697535]

My curiosity in anesthesia is defining at which point are my actions not reversable(or reversing would require a large amount of time). This plan allowed me to securly place an airway without burning bridges. If the LMA did not seat go to sleep and secure with whatever device you choose.

That is where we differ.

I don't think your method allows a way of securing the airway without burning bridges.

If he starts fighting you while he's light and then maybe spasms a bit there is a potential for a real mess really quickly. I have seen that many times with LMA placement.

Then you have to 2 handed face mask a bucking broncho. Disaster in my opinion. And not uncommon.

I'm sure your way is very safe and slick and don't mean to cause offense, it's just not cricket for me

 

[narcusprince]

Brother this is where knowing that if he bucks I can safetly secure his airway with succ and a tube. I can get all this done faster then the surgeon can prep the patient and smile at the OR nurse. My ninja at this point is Jedi master. My goal was to find another way to use the force....

 

[Hoya11]

Brother this is where knowing that if he bucks I can safetly secure his airway with succ and a tube. I can get all this done faster then the surgeon can prep the patient and smile at the OR nurse. My ninja at this point is Jedi master. My goal was to find another way to use the force....

Would you want an awake LMA done to you?

What if the guy did remember?

I can think of very few situations where I couldnt find a better approach.

 

[narcusprince]

Would you want an awake LMA done to you?

What if the guy did remember?

I can think of very few situations where I couldnt find a better approach.

The guy remembers nothing. Yes if it warrants it and I was sedated and well topicalized. Truly awake and no topical heck no. Before we had afoi we did awake dl. The new thing being the low profile of the Ijel lma. I was more certain of his awareness level when I put the Lma in versus when it comes out.

 

[Psai]

The guy remembers nothing. Yes if it warrants it and I was sedated and well topicalized. Truly awake and no topical heck no. Before we had afoi we did awake dl. The new thing being the low profile of the Ijel lma. I was more certain of his awareness level when I put the Lma in versus when it comes out.

Igel?

 

[nap$ter]

Today I had a young patient 25 with bmi 40 ish come for cysto w stent and stone manipulation. Healthy otherwise MP4 large neck extra large head. Topicalized with lido 2 of versed 25 mcg fent and had him huffing a touch of Gas maybe 2% sevo until he felt giggly. Had him open his mouth placed the Ijel. Turned up the vapor kept him spontaneously breathing. Woke him up no with no knowledge of lma placement. A unique approach....

why? bmi 40 mp 4 thick neck enormous noggin is pretty common... "HEAD!!!!"

generous dose of propofol and LMA or tube works great.

i usually do what i usually do cuz i'm good at it, and it's fast. "unique" unusual approaches are rarely necessary, and time consuming.

this kind of ninja anesthesia gets applause from academic folks but just eye rolling from "seasoned" private practice dude/ettes.

 

[Twiggidy]

To sort of follow up on Napster, I do also question the necessity. I brought this up in another thread, but LMA in the airway algorithm is a bridge technique for possible can't ventilate/can't intubate so I can't come up with a reason why one needs an LMA placed "awake-ish". 2% sevo is basically 1 MAC even after the fentanyl/versed it's starting to just sound like an "asleep LMA insertion".

the counterpoint is, if the LMA didn't seat, what's the next step, because now it's this guy with 2% sevo, breathing and needs an airway. my point is, if this is a big guy, you can slug him with 200 propoful, stick your LMA in whether it works or not he'll be breathing again and find himself in the same situation (either well seated LMA or not well seated LMA). i feel like maybe i'm missing something

you're skinning the cat, just seems you're doing it with a butter knife

 

[narcusprince]

So understand at any point I felt I could confidently intubate this guy. I wanted to try something different for once in a controlled fashion. Sure I could have slugged him with prop and or tube him. Try inducing a patient with 2% takes too much time. It was 2% inspired not end tidal sevo. His end tidal was far less then 2%. I was inspired by how fluid they come out.

 

[Sonny Crocket]

To sort of follow up on Napster, I do also question the necessity. I brought this up in another thread, but LMA in the airway algorithm is a bridge technique for possible can't ventilate/can't intubate so I can't come up with a reason why one needs an LMA placed "awake-ish". 2% sevo is basically 1 MAC even after the fentanyl/versed it's starting to just sound like an "asleep LMA insertion".

the counterpoint is, if the LMA didn't seat, what's the next step, because now it's this guy with 2% sevo, breathing and needs an airway. my point is, if this is a big guy, you can slug him with 200 propoful, stick your LMA in whether it works or not he'll be breathing again and find himself in the same situation (either well seated LMA or not well seated LMA). i feel like maybe i'm missing something

you're skinning the cat, just seems you're doing it with a butter knife

Thank you. 2% sevo? This was an asleep LMA placement dude.

 

[narcusprince]

If you do not know the difference between 2% inspired versus 2% end tidal you need to go back to anesthesia school. The patient took 3 breaths of 2% felt giggly able to answer questions and open his mouth then I placed it.

 

[ranvier]

FWIW, I have been awake for every LMA I've ever placed.

Even post call?

 

[ranvier]

I try and place an intubating lma every so often with the patient breathing so I don’t forget how.