Do you have any LMA tips for me?

[axeon123]

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I didn't do many LMA cases during residency because of the slowness of the surgeons. After starting a job, I primarily utilize the AuraOnce LMA (the green one with the bend). At the beginning, I had so many LMA not seat well even though it appeared to go in smoothly, but I could not get a good seal at 20 cmH2O (or even 10 cmH2O) so I ended up intubating them. The ones that did successfully go in, I notice when I remove the LMA, on some of them the LMA is all twisted and folded over even though it seemed to be working. Even worse are some of the LMAs I remove and they are all covered in saliva.

More failures I now deflate the cuff a tiny bit and that seems to help. I've gotten successful LMA multiple times in a row now. I can get good chest rise on 20 cmH2O. Once the patient starts breathing spontaneously, however, I notice that there is an airleak when they inhale. LMA looks fine when it was removed. Some patients take good tidal volume so this leak is insignificant, but other patients they may have low sub-200cc tidal volume.

When I position the patient I just put a pillow under their head and if it looks like their head will be too extended I place more gel roll so their head is more neutral or slightly flexed. I also use a tongue depressor to help keep the tongue flat out of the way so the LMA does not get caught on it. I think at the beginning I had the tongue depressor too deep. Now I just have it 1-2 inches beyond the teeth and remove it once the LMA is clear past. Then I push the LMA until it stops and add some air.

Anyway, I wanted to ask if you had any advice for improving placement. One worry I have is with a big fat patient I can't put LMA in now they're in **** positioning-wise and intubation is going to be hard af.

 

[Ronin786]

What's the problem with the LMA being covered in saliva? That's all stuff that's going down the trachea otherwise.

 

[axeon123]

What's the problem with the LMA being covered in saliva? That's all stuff that's going down the trachea otherwise.

Bad if it's all on the inner side facing the trachea 😱

 

[caligas]

Did you know that all LMA placement tips can be converted to a “that’s what she said” joke?

It’s a proven fact.

 

[okayplayer]

Use a tongue depressor and slide the LMA over the depressor. Use an iGel.

 

[deleted162650]

Part of your problem is those POS LMA's. We have straight Aura's at our main hospital, and they're terrible. If you look closely, the tip has a but of a "recurve" to it that invariably makes it fold back on itself or twist during insertion despite good technique. The only option I have found so far is to manually reach in there and direct the tip to prevent issues.

Oh, and that's what she said.

 

[narcusprince]

Ijel all the way. Gently open the mouth scissor technique. Slide the ijel with the tip lubbed into tje mouth in a circular rotation pattern behind the tongue advance until u meet resistance. The ijel should easily slide in. Convince your team to move to ijels.

 

[nimbus]

Try extending the head and also turning to the side. With the lma unique it will slide in most of the time. Once in awhile I too will reach in with my finger and direct the tip downward.

 

[Ezekiel2517]

I'm assuming you are decently proficient at placing the LMA, since you say that they appear to go in perfectly smoothly. I would recommend pulling the LMA back some if you're having trouble getting decent volumes after placement. A lot of times the LMA is placed too deep and this will make ventilation difficult. Simply retracting it can make a world of difference. Obviously don't pull it back so far that it comes out of its "pocket", sometimes just 2-3 cm will do it. And stop messing around with the cuff so much, it's not the problem . I hardly ever put any air at all in it. I use LMA's all the time and can't remember ever having to tube bc it wasn't working

 

[caligas]

I think that sometimes the LMA is seeded well but the vocal cords are closed, briefly.

 

[deleted162650]

sometimes the LMA is seeded well

Careful. That sorta thing may land you in jail.

 

[Ezekiel2517]

I think that sometimes the LMA is seeded well but the vocal cords are closed, briefly.

1 ml of sux

 

[deleted697535]

When you're putting in an LMA make sure you give an anesthetic first! A proper anesthetic. In a young male this could be 3mg/kg prop. Go nuts. 400mg why not
Then wait!!!

I know for 99% sure my LMA will sit well when i can do a vigourous chin lift and BVM easily without any twitching from the patient. If i cant do that they prob have some airway reflexes and the LMA also wont slot in either. So i either wait or give more of the good stuff

Dont deflate the LMA prior to putting it in, or taking it out. Lube it yourself, just a small bit on the heel not on the pipe.
Get their chin up in the air when you pop it in. I come in from right to middle...

And why ventilate them at all? Give the bag 1 squeeze to make sure you've a seal, then put on PSV. Most of these guys breathe quickly anyway..

All of that goes out the window if they're old and frail, then it becomes more of a science. Bit of midaz, 1/kg prop and wait

 

[pjl]

I didn't do many...during residency...go in smoothly...are all covered in saliva...going to be hard af.

Try using your finger instead of a silly tongue depressor. If they are sleepy enough to place an LMA easily, you should feel comfortable using your finger to guide. I think the guys who pull back 2 cm are just having the tip flip the right way. If you use your finger it goes in right in the first place. Failure rate should be <<1:50 for LMA per my terribly optimistic biased guess based calculations.

 

[Psai]

Ijel all the way. Gently open the mouth scissor technique. Slide the ijel with the tip lubbed into tje mouth in a circular rotation pattern behind the tongue advance until u meet resistance. The ijel should easily slide in. Convince your team to move to ijels.

It is IGEL
Where are you getting this J from? Gesus Christ!

 

[narcusprince]

It is IGEL
Where are you getting this J from? Gesus Christ!

Ijel..... lol

 

[woopedazz]

iGel vs tongue...

I get that it sits nicer once it's in, but they're so damn bulky going in.

 

[Psai]

iGel vs tongue...

I get that it sits nicer once it's in, but they're so damn bulky going in.

Get a 4x4, pull tongue out and chin forward. Easy.

 

[propadope]

I like to take a syringe and pull the plunger out. Attach the syringe sans plunger to the pilot. The cuff is now inflated at atmospheric pressure. This gives the LMA some stability and prevents twisting and folding as it is inserted. Since the cuff is open to the atmosphere it allows some flexibility to conform to the patient’s anatomy. Best of both worlds. Once seated, take the syringe off and inflate as usual. I personally like to use a manometer to prevent under/over inflation.

 

[axeon123]

Ijel all the way. Gently open the mouth scissor technique. Slide the ijel with the tip lubbed into tje mouth in a circular rotation pattern behind the tongue advance until u meet resistance. The ijel should easily slide in. Convince your team to move to ijels.

I've seen the iGel. Do you mean rotate it back and forth to get it in? Have you noticed more trauma with the iGel? It looks stiffer/harder than the traditional LMAs I have used.

Obviously don't pull it back so far that it comes out of its "pocket", sometimes just 2-3 cm will do it. And stop messing around with the cuff so much, it's not the problem . I hardly ever put any air at all in it. I use LMA's all the time and can't remember ever having to tube bc it wasn't working

I'll keep this in mind. I have the thought that additional cuff pressure helps improve the seal.

When you're putting in an LMA make sure you give an anesthetic first! A proper anesthetic. In a young male this could be 3mg/kg prop. Go nuts. 400mg why not
Then wait!!!

At the beginning many of my patients would move when the LMA was placed, but I learned to use more. Maybe giving one breath to see if they're induced enough (maybe strong jaw thrust?) can be helpful.

 

[leaverus]

i think some LMAs aren't going to sit well no matter what you do or how expert you are. Every pt's anatomy is different but every LMA (of a particular brand) is the exact same.

 

[Psai]

Lift the tongue with a mac like you're trying to look at the cords. Slide LMA in.