Case discussion

[deleted1147063]

Recently had an LMA on spont vent/sevo go south after a TURBT. Must be said I do keep two capped vials of sug, roc 50mg predrawn and a tube ready at hand for any and all cases involving urologists. This pt had pretty decent hyperkalemia(5.5), so doc didn't want sux anywhere near. Pt had poor dentition, big tongue, huge head, thick neck, but mallampati 2. 125kg, BMI of 40.

1) after induction with my doctor (pt was ASA3,whole host of issues, but no pulmonary ones), became apparent that controlled PP ventilation with the LMA wasn't going to happen. Mask ventilation with bilateral Larson's maneuver, two oropharyngeal airways and the doc on the bag was possible, but difficult.
After two minutes of fiddling with the LMA, though, got the patient to draw breath, used PSV at something like 2cmH2O, which was enough to stay away from hypercarbic country, but not so much that the LMA started leaking. At the start of surgery, got enough drive from the patient to turn off the PS completely, just had 3cmH2O of PEEP.

2) Surgery went well, as did the anesthetic, until the second the urologist decided she was done, and withdrew the scope. Patient at this point was at MAC 0.8,had received 50 mcg of fent a few minutes earlier(total of 150mcg, 65minutes). FiO2 at 0.5.

3) Laryngospasm, oh joy. Remember this pt responding badly to PPvent on the LMA? Sats dropped from 95 to 73 in a short minute. Called for help, pushed roc and intubated, had to bag with 30cmH2O to recruit for a minute.Sats up to 92. When doc arrived,we pushed 400mg sugammadex, back to 100% TOF after a total of 4 minutes since induction dose of roc. Woke the pt, extubated, no issues either at emergence or postop.

Lessons learned: LMAs are evil. Urologists are more often than others just suddenly done. It's better to have an anesthesiologist a max of three minutes away than further.

I believe we'd be fine with just one vial of sugammadex, but erred on the side of caution.

Apologies for a further derailing of this thread.

This is for the trainees and junior attendings:

If fat patient and severe laryngospasm, especially during emergence -> push 20 mg of succinylcholine the moment the sat drops 5%. Don't waste time with BS maneuvers, or even propofol (you cutt off their NPV, now you may have a big problem even if the laryngospasm is over). And don't worry about K with that dose (especially with K of 5.5). They will not fasciculate (and they won't feel weak even if awake). It's a matter of benefits >>> risks.

Also, if fat patient and short procedure, especially if NPV -> 100% O2 during the entire case will save one's butt much more frequently than produce harm (e.g. atelectasis). And this is coming from an intensivist.

I wouldn't bother with LMAs in that position and that kind of patient/airway. Our coronaries are worth an ETT, unless one doesn't have access to a videolaryngoscope. I aim for being able to bag 6-8 ml/kg IBW of tidal volume, with a PIP of well under 20 cmH2O, with all my LMAs. I seldom count on NPV/PS, except for the shortest procedures I would otherwise do with an oral airway and mask.

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[pgg]

Our coronaries are worth an ETT

Words to live by

Every year that goes by, I use fewer and fewer LMAs.

 

[norski]

Words to live by

Every year that goes by, I use fewer and fewer LMAs.

Agree with you both. Also becoming a lot easier to say no to an LMA, I'd rather have GETA, spinal, regional or deep sedation where appropriate. I just prefer my job to be boring 99% of the time.

 

[DesiredMemberName?]

There are no absolutes in this game, but no LMAs for patients over 100kg (except for rescue ventilation/intubation scenarios) is one rule of thumb that I have never regretted following.

 

[coffeebythelake]

Words to live by

Every year that goes by, I use fewer and fewer LMAs.

Agree

 

[norski]

This is for the trainees and junior attendings:

If fat patient and severe laryngospasm, especially during emergence -> push 20 mg of succinylcholine the moment the sat drops 5%. Don't waste time with BS maneuvers, or even propofol (you cutt off their NPV, now you may have a big problem even if the laryngospasm is over). And don't worry about K with that dose (especially with K of 5.5). They will not fasciculate (and they won't feel weak even if awake). It's a matter of benefits >>> risks.

Also, if fat patient and short procedure, especially if NPV -> 100% O2 during the entire case will save one's butt much more frequently than produce harm (e.g. atelectasis). And this is coming from an intensivist.

I wouldn't bother with LMAs in that position and that kind of patient/airway. Our coronaries are worth an ETT, unless one doesn't have access to a videolaryngoscope. I aim for being able to bag 6-8 ml/kg IBW of tidal volume, with a PIP of well under 20 cmH2O, with all my LMAs. I seldom count on NPV/PS, except for the shortest procedures I would otherwise do with an oral airway and mask.

Thanks for the pearls of wisdom. Doubt I'd be yelled at or written up for pushing sux, just grabbed the quickest route to relief available, being roc.

I get palpitations by seeing peak airway pressures above 15cm with LMAs, even 2.gen, so your threshold of 20 is admirable.

Have a nice weekend,everyone. Great thread.

 

[deleted1147063]

Agree with you both. Also becoming a lot easier to say no to an LMA, I'd rather have GETA, spinal, regional or deep sedation where appropriate. I just prefer my job to be boring 99% of the time.

Boring is great.

 

[nimbus]

This is for the trainees and junior attendings:

If fat patient and severe laryngospasm, especially during emergence -> push 20 mg of succinylcholine the moment the sat drops 5%. Don't waste time with BS maneuvers, or even propofol (you cutt off their NPV, now you may have a big problem even if the laryngospasm is over). And don't worry about K with that dose (especially with K of 5.5). They will not fasciculate (and they won't feel weak even if awake). It's a matter of benefits >>> risks.

Also, if fat patient and short procedure, especially if NPV -> 100% O2 during the entire case will save one's butt much more frequently than produce harm (e.g. atelectasis). And this is coming from an intensivist.

I wouldn't bother with LMAs in that position and that kind of patient/airway. Our coronaries are worth an ETT, unless one doesn't have access to a videolaryngoscope. I aim for being able to bag 6-8 ml/kg IBW of tidal volume, with a PIP of well under 20 cmH2O, with all my LMAs. I seldom count on NPV/PS, except for the shortest procedures I would otherwise do with an oral airway and mask.

Words to live by

Every year that goes by, I use fewer and fewer LMAs.

Especially with VL and sugammadex, I intubate many more patients than I used to.