Bagging and Masking: Novice Question

[KLPM]

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So today I was practicing bagging-and-masking on patients getting bone marrow and lumbar punctures. There was a particularly adipose-rich 13yo in the lateral decubitus position. I found some difficulty achieving an adequate seal in this position. Anyone got any advice for an amateur such as myself to get a good seal? Practice practice practice? She ended up getting an LMA because the registrar seemed to be having difficulty getting a decent seal too. Didn't help that the procedure was prolonged because the haem/onc lady dropped her methotrexate so we had to get more from the pharmacy.

 

[caligas]

Oral airway helps. Obese teenager in lat position would be easier with an e.t. tube.

 

[michigangirl]

Best way to do these cases is green mask with propofol gtt, ETCO2 in line. No need to bag mask unless they are apneic, no need to intubate, and it lasts you as long as you need it to when it's taking forever for them to get into the intrathecal space/get the bone marrow. LMAs are just not worth the trouble in the lateral position, higher risk for laryngospasm if its unseated, pt is light, etc.

Yes, an ETT works well but is overkill IMHO. Get the propofol gtt started at a good dose as soon as kid comes in the room, should be asleep by the time monitors are on and the heme-onc person figures out how to put the gown and gloves on

 

[jetproppilot]

LMAs are just not worth the trouble in the lateral position, higher risk for laryngospasm if its unseated, pt is light, etc.

:

I disagree.

We prefer doing our laterally positioned shoulder surgeries with an LMA.

Great results.

Additionally, in the United Kingdom, LMA utilization in the lateral position is commonplace.

 

[aneftp]

I disagree.

We prefer doing our laterally positioned shoulder surgeries with an LMA.

Great results.

Additionally, in the United Kingdom, LMA utilization in the lateral position is commonplace.

LMAs for shoulders. When I practiced in mid Atlantic. We tubed everyone. Out in California I placed LMA on almost all shoulders. Down in Florida. I am like 50/50 what I do. Depends on my mood and patient BMI.

So different practices.

 

[Agast]

If it's a quick procedure I'd be tempted to let the patient breathe spontaneously and use two hands to get a decent seal/jaw thrust

 

[jwk]

I disagree.

We prefer doing our laterally positioned shoulder surgeries with an LMA.

Great results.

Additionally, in the United Kingdom, LMA utilization in the lateral position is commonplace.

Damn Brits! I realize they need an indication NOT to use an LMA, and that they use them for everything from laparoscopies to prone spine surgery. Glad I'm on this side of the big pond. We now have AA students doing some month-long clinical rotations in the UK - they come back amazed at what goes on in the British OR's.

I'm just too old and set in my ways. To me, an LMA is a replacement for a mask, not an ETT. So, if it's not a patient I can just as easily mask, then they generally will buy an ETT. Sitting/beach chair position? ETT. Lateral, especially if the table is turned like our remaining few lateral shoulder guys? ETT. And don't get me going on prone LMA's, because some in my group think that's fine as well. Not a chance.

I've never been sorry I placed an ETT, but there are plenty of times I've been sorry I opted for, or was talked into, an LMA instead of an ETT.

 

[ssmallz]

I've never been sorry I placed an ETT, but there are plenty of times I've been sorry I opted for, or was talked into, an LMA instead of an ETT.

This is a quote every young anesthesiologist should take to heart. There's no extra points for being a hero but mess up once and you're in deep $hit

 

[pgg]

I've never been sorry I placed an ETT, but there are plenty of times I've been sorry I opted for, or was talked into, an LMA instead of an ETT.

+1

I now use LMAs less than I used to. Outside of routine cases in supine patients, I mostly just stick tubes in people. I've decided LMAs are otherwise mostly more trouble than they're worth.

I can wake someone up just as fast and smoothly with an ETT as with an LMA, and the ETT never gives me any seating leaking PPV-limiting attitude the way LMAs do.

But to each his own. 🙂

 

[KLPM]

I am now more confused than before. Thanks everyone always great to hear differing opinions.

 

[caligas]

I am now more confused than before. Thanks everyone always great to hear differing opinions.

Then we have done our job.