Jetpearl Number 17: LMAs

[jetproppilot]

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LMAs are more versatile than what you are being taught.

I'm leaving this Jetpearl ambiguous on purpose, so you can respond unbiased by my initial post....BUT...

why would I say that?

What are we taught about the indications for an LMA?

 

[Mman]

What are we taught about the indications for an LMA?

What you are taught about the indications for an LMA depends largely on where the person teaching you trained.

 

[countingdays]

What you are taught about the indications for an LMA depends largely on where the person teaching you trained.

True. What I've been told has varied between 'you can do a prone lma if you want' and 'we can't do an lma for this long case' (45 minutes!).

 

[sevoflurane]

You beat me to it. 👍 Sometimes it depends on your attending for the day:

I know some that would intubate just about everyone: god forbid the case goes longer than 1 hour.😱

Some would do Kypho's with lma's. Have the patient position themselves, Pre-O2, propofol, LMA.🙄

Here is a case I had last Friday afternoon:

Thursday: Orthopod buddy and I are talking it up in the OR listening to some good tunes. He says: I have a TFN tomorrow that you are not going to want to do. I say OK. What's the deal? He has bad COPD. No problem. I think to myself: LMA or spinal catheter.

He goes on to reveal the rest of his history: 66 y/o Stage 4 lung ca, mets to liver, bone and brain. Still smoking. Mentally competent. Mod-Severe AS. Previous MI's, CABG x2 in '88. Multiple stents. EF 25%. AAA 7cm. 2 Strokes within a 5 year period. Around the clock O2 at 6l/m. Type 1 DM with known gastroperesis. Hiatal hernia + reflux and h/o perf gastric ulcer. On admission he's got AF with RVR and an INR of 2.6. Na+ 128 from SIADH. Chronic.

Wow... I stop him right there. I say... "Um... this guy is checking out. We don't have to do this". He nods... "I know". His family doesn't want him to do it either, BUT HE DOES. He doesn't want to be bed bound for the rest of his short life. We tell him that he will be lucky if he gets to walk again: "I want it done if there is a chance". You have a real chance of dying while having this operation. "I want a chance at walking again Dr." That night he gets vit K and later FFP. RVR is controlled by intensivist.

I see him the next morning: Tachypnic, weak cough, waxy skin, cachectic, barrel chest. 84% on 6l/m. Take O2 off. Drops to 72%. Put NC back on. Spinal catheter is way out of the question. Take him to the room. R2 pads. A-line. Mask induction with O2 and Sevo. Phenylephrine in hand. Sats start to pick up. Slow 4 cc's of prop. Gently place LMA #4. SV throughout. Quick Fascia-iliaca. Add a little PS of 10cm H20. Sats pick up to 97% over the next 5 minutes. Do the case over 1 hr. 25 mcgs of fent. Wean PS 10 minutes before I pull the LMA.

Moral of the story: LMA was paramount for this case despite hiatal hernia, reflux, gastroperesis and all the other crap this guy has. I would have not liked to place an ETT for this guy despite it's indications. Some would, but I think that might have bought him a ventilator in the ICU.

 

[Bertelman]

Moral of the story: LMA was paramount for this case despite hiatal hernia, reflux, gastroperesis and all the other crap this guy has. I would have not liked to place an ETT for this guy despite it’s indications. Some would, but I think that might have bought him a ventilator in the ICU.

And many would say your anesthetic might have bought you an M&M instead of a Case Report.

It sounds like it was all well and good in the end, but man, that took balls.

 

[ProRealDoc]

LMAs are more versatile than what you are being taught.

I'm leaving this Jetpearl ambiguous on purpose, so you can respond unbiased by my initial post....BUT...

why would I say that?

What are we taught about the indications for an LMA?

Never to use it during a c-section. lame huh?

 

[vegas]

Sevo, great job!

But I'm curious to know what were your thoughts on deciding to proceed with this elective case? Also, was cards involved and was the patient optimized from a pulmonary standpoint at best?

 

[hoyden]

And many would say your anesthetic might have bought you an M&M instead of a Case Report.

It sounds like it was all well and good in the end, but man, that took balls.

Actually not that much ( I am talking real life here and no way an oral board answer))). Aspiration risk with LMA/masks is overblown, IMHO. I would use pro-seal LMA and suction the stomach content out after I place it.
However, it took balls to do this elective case altogether 😉

 

[countingdays]

Did insurance pre-approve that case?

 

[hoyden]

Never to use it during a c-section. lame huh?

My classmate just has used it during a cs on her oral board a month ago, and she passed ))))

 

[GasEmDee]

My classmate just has used it during a cs on her oral board a month ago, and she passed ))))

There are very few hard and fast rules in anesthesia. If you need to do a GA for c/s, it is probably not the first choice for airway management, but it beats death if you cannot otherwise ventilate the patient!!

 

[hoyden]

There are very few hard and fast rules in anesthesia. If you need to do a GA for c/s, it is probably not the first choice for airway management, but it beats death if you cannot otherwise ventilate the patient!!

I am trying not to talk too much here 😉
But they were pushing her towads the option of removing working LMA in order to repeat failed intubation or do a trach.
She resisted until the scenario led to LMA not working anymore ( inevitable, obviously))))

 

[sevoflurane]

Sevo, great job!

But I'm curious to know what were your thoughts on deciding to proceed with this elective case? Also, was cards involved and was the patient optimized from a pulmonary standpoint at best?

Is the patient optimized?

Yes. Optimized. This does not imply healthy. Only that there is nothing else you could do. He is tuned up:
Seen by cardiologist and intensivist. Controlled RVR. Reversed INR. Nothing else to offer from a heart point of view. Not gonna touch that AAA.
CT angio showed: no PE, small bilateral pleural effusions and atelectasis. Atelectasis partly due to tumor, pain and the fact that he has been laying supine for 3 days. Old PFT’s a year ago showed FEV1 at 1.4 liters. So, lungs were not to good before he got to us. Getting pulm therapy ATC. Could have argued to intubate him electively, but I did not want to go down that road.

Does the patient understand and accept the risks and benefits of the procedure?

Long talks with surgeon and then myself.

A couple more thoughts about the case:

I have taken care of lots of these type of patients. That helps. This is what I have learned:
They usually do OK with SV. This tends to optimize V/Q. Inhaled anesthetics are good bronchodilators which is why I chose a mask induction. MAC was like 1.6 for the case. I also added 4 gms of Mag and 15mg of ketamine. Adding PS to try and deliver a larger TV with higher FiO2 really helps. Their sats almost always go up (unless you rupture a bleb or paralyze and implement PPV or do something of that flavor).

Did a bunch of bronchopulmonary lavage cases for alveolar proteinosis as a resident. These patients come in with sats not much different than the guy I took care of. Then, you isolate one lung as you literally drown the patient with liters, upon liters, upon liters of NS. It was not too infrequent to see sats drop below 70% before you resumed 2 lung ventilation.

Besides his lung cancer, the rest of his issues were stable and optimized. The key is to have a good plan and backup plan. The case went smoothly. Residency has provided much harder cases than the one I described.

Did insurance pre-approve that case?

No Idea. I don’t look at those issues. 😍

 

[GasEmDee]

I am trying not to talk too much here 😉
But they were pushing her towads the option of removing working LMA in order to repeat failed intubation or do a trach.
She resisted until the scenario led to LMA not working anymore ( inevitable, obviously))))

I personally would not remove it a working LMA in a patient after a failed intubation. If anything, I would intubate through it fiberoptically. If the LMA is not working and you cannot trouble shoot it, then there is no choice but to remove it and try an alternative (of which there are numerous).

 

[hoyden]

I personally would not remove it a working LMA in a patient after a failed intubation. If anything, I would intubate through it fiberoptically. If the LMA is not working and you cannot trouble shoot it, then there is no choice but to remove it and try an alternative (of which there are numerous).

I agree completely. I would do the same. But the LMA/CS stigma from residency connected to orals is out there ))) My friend was fearing her fate just because of this stigma, since she resisted all the attempts of removing the working LMA. Until it stopped working.

 

[Arch Guillotti]

I think I had the failed airway during crash c/s as well during the grab bag. I can't remember the details exactly but I left it in since oxygenation and ventilation were OK and the baby was not doing well.

 

[Dryacku]

Can someone explain some of the benefits of spotaneous ventilation vs positive pressure?

One my concerns with using an LMA with ESRD or COPD patients is resp acidosis while waiting for the patient to breath on their own

I guess you could always ventilate the patient even with an LMA

 

[IlDestriero]

Can someone explain some of the benefits of spotaneous ventilation vs positive pressure?

One my concerns with using an LMA with ESRD or COPD patients is resp acidosis while waiting for the patient to breath on their own

I guess you could always ventilate the patient even with an LMA

Pressure support ventilation.👍
I use it every day.

 

[sevoflurane]

Can someone explain some of the benefits of spotaneous ventilation vs positive pressure?

One my concerns with using an LMA with ESRD or COPD patients is resp acidosis while waiting for the patient to breath on their own

I guess you could always ventilate the patient even with an LMA

Look up west lung zones in any anesthesia text book.

Bottom line:

Under SV: Blood flows to the base of the lungs where alveoli are more compliant and better ventilated, optimizing V/Q.

Under PPV: you loose compliance of the chest wall, diaphragm moves cephalad causing compression of the base of the lungs. Blood still flows to the base of the lungs but compliance is now reduced decreasing V/Q and therefore increasing shunt.

 

[dhb]

One my concerns with using an LMA with ESRD or COPD patients is resp acidosis while waiting for the patient to breath on their own

That's why you do an inhalation induction anyway these patients are used to respiratory acidosis

 

[gaspasser2004]

What’s the deal? He has bad COPD. No problem. I think to myself: LMA or spinal catheter.

At this point, an LMA seems reasonable. No need to instrument an airway on a patient with COPD unless you have to.

Type 1 DM with known gastroperesis. Hiatal hernia + reflux and h/o perf gastric ulcer.

In my opinion, the information above is the part where a failed LMA is indefensible.

Moral of the story: LMA was paramount for this case despite hiatal hernia, reflux, gastroperesis and all the other crap this guy has. I would have not liked to place an ETT for this guy despite it’s indications. Some would, but I think that might have bought him a ventilator in the ICU.

No doubt Sevoflurane is a competent anesthesiologist, based on his posts and experience. He certainly has a versatile practice doing hearts, blocks, etc.

I was not there and can only judge based on the post itself. In this case, I think Sevoflurane took a chance and got lucky. If the patient goes to the unit blowing plastic, at least you can say to the family (and yourself) that you did everything to keep him safe. If the patient aspirates with an LMA, it is indefensible given his known comorbidities.

People argue here a lot over what is standard of care and what is not. Medicolegally, the standard of care is whatever the expert witnesses (plaintiff or defense) can sell to the jury. That being said, I think one would have a hard time finding a credible witness who would argue vigorously that it is perfectly acceptable to take a known diabetic with gastroparesis and hiatal hernia to the OR for a general anesthetic with an LMA.

We can certainly agree to disagree, but I don't think the benefits justified the risks of putting an LMA in this patient.

 

[IlDestriero]

People argue here a lot over what is standard of care and what is not. Medicolegally, the standard of care is whatever the expert witnesses (plaintiff or defense) can sell to the jury. That being said, I think one would have a hard time finding a credible witness who would argue vigorously that it is perfectly acceptable to take a known diabetic with gastroparesis and hiatal hernia to the OR for a general anesthetic with an LMA.

We can certainly agree to disagree, but I don't think the benefits justified the risks of putting an LMA in this patient.

I would tend to agree. If C-section mom aspirates with her LMA or some healthy knee scope with "only after spicy foods" reflux, they're likely to be FINE. Likely no problems at all, maybe some O2 for a day or 2. If this dude aspirated he would be leaving in a box, 100%. But, we weren't there.

 

[sevoflurane]

Excellent points and issues that certainly had my undivided attention. 👍

These circumstances can be difficult and you have to take the entire picture into account.

Risks vs benefits:

LMA:

The patient is cachectic, without an appetite, on reglan 15 mg tid. Room time was 14:00. That is 17 hours since he last nibbled at his food the night before. Duration of surgery/anesthesia was 1 hr. If the case went longer than perhaps an ETT would have been better. Not an abdominal procedure. V/Q relationship favors LMA over ETT in a patient that has minimal reserve. More stable hemodynamics placing LMA vs ETT. We all have tricks to blunt the hemodynamic response to intubation but I would bet most agree that, overall, LMA has less variability in B.P. swings than ETT. The man has a known 7cm AAA and has a bad heart. The flip side is aspiration and possible deterioration of pulm fxn.

VS.

ETT:

ETT to the SICU. Vent + narcs/benzos. May stay intubated for days, possibly weeks. TPN/enteral nutrition. Trach? Higher chances of hospital aquired PNA in an already immunocompromised patient. PPV and it's affects. 7cm AAA carries a 20-50% annual rupture rate and a 75% 5 year rupture rate. I wonder what the rate is when you are awake, intubated and in the ICU getting ready for extubation? The flip side is a "protected airway" for one hour. Keep in mind, ETT by itself is emetogenic.


My patient wanted this procedure because he wanted quality of life in his final days. I tried to do what is best for him keeping in mind his wishes.

In my assessment of the entire picture, I felt as if an LMA could be just as safe, if not safer than ETT.

Some would send him to the ICU with ETT and move on to the next case. Maybe that was the right thing to do. If we had proseals it would be a no brainer. Place and suck out the stomach. Done deal.

If I lived in Pennsylvania or Florida, things may have been different. It is unfortunate that medical legal issues sometimes dictates how you practice.

You could argue either way and I will admitt, type I DM, hiatal hernia and gastroperesis are code words for ETT. But, not everything in medicine is black and white. I don't think this patient fits that rule IMHO.

 

[hoyden]

If I lived in Pennsylvania or Florida,
things may have been different.
It is unfortunate that medical legal
issues sometimes dictates how you practice.

Can you elaborate on those particular states?

 

[dillpickles]

Excellent points and issues that certainly had my undivided attention. 👍

These circumstances can be difficult and you have to take the entire picture into account.

Risks vs benefits:

LMA:

The patient is cachectic, without an appetite, on reglan 15 mg tid. Room time was 14:00. That is 17 hours since he last nibbled at his food the night before. Duration of surgery/anesthesia was 1 hr. If the case went longer than perhaps an ETT would have been better. Not an abdominal procedure. V/Q relationship favors LMA over ETT in a patient that has minimal reserve. More stable hemodynamics placing LMA vs ETT. We all have tricks to blunt the hemodynamic response to intubation but I would bet most agree that, overall, LMA has less variability in B.P. swings than ETT. The man has a known 7cm AAA and has a bad heart. The flip side is aspiration and possible deterioration of pulm fxn.

VS.

ETT:

ETT to the SICU. Vent + narcs/benzos. May stay intubated for days, possibly weeks. TPN/enteral nutrition. Trach? Higher chances of hospital aquired PNA in an already immunocompromised patient. PPV and it's affects. 7cm AAA carries a 20-50% annual rupture rate and a 75% 5 year rupture rate. I wonder what the rate is when you are awake, intubated and in the ICU getting ready for extubation? The flip side is a "protected airway" for one hour. Keep in mind, ETT by itself is emetogenic.


My patient wanted this procedure because he wanted quality of life in his final days. I tried to do what is best for him keeping in mind his wishes.

In my assessment of the entire picture, I felt as if an LMA could be just as safe, if not safer than ETT.

Some would send him to the ICU with ETT and move on to the next case. Maybe that was the right thing to do. If we had proseals it would be a no brainer. Place and suck out the stomach. Done deal.

If I lived in Pennsylvania or Florida, things may have been different. It is unfortunate that medical legal issues sometimes dictates how you practice.

You could argue either way and I will admitt, type I DM, hiatal hernia and gastroperesis are code words for ETT. But, not everything in medicine is black and white. I don't think this patient fits that rule IMHO.

Hey sevo, what about mask ind w sevo/O2, LTA lido, maintain SV, intubate, then PS 10 intraop. Emerge on the deeper side or with dexmed infusing? My thinking is that even if he needs a trach (may need one anyway being stage IV lung ca full press forward), he'd survive that, but not asp pneumonia. Then again, he wouldn't survive a periop 7 cm AAA rupture.

Also, can people comment on spinal caths? When they use them? I've done CSEs, but never placed a cath intrathecally. What advantage do they confer over epidural caths? Do you leave them in for a few days, and if so, any disasters with people on the floor inappropriately bolusing IT caths thinking they were epidural caths?

Lastly, to Jet, I like LMAs
(1) even though the case could be done by mask (5 min laser case or something), I want 2 hands free,
(2) when a MAC patient gets way too chatty, it's time for GA + LMA 😴

Thanks for explaining your thinking Sevo, it's really helpful.

 

[IlDestriero]

Can you elaborate on those particular states?

Extremely litigous and no tort reform, therefore you practice a little more conservatively or risk losing everything, literally.

 

[Laryngophed]

I would just like to point out how awesome threads like this are for me (and I assume everyone else.) I've been wearing Google out, but man, there is a crap-ton of great info here!

 

[Arch Guillotti]

Also, can people comment on spinal caths? When they use them? I've done CSEs, but never placed a cath intrathecally. What advantage do they confer over epidural caths? Do you leave them in for a few days, and if so, any disasters with people on the floor inappropriately bolusing IT caths thinking they were epidural caths?

With a spinal catheter you have an end point for determining its placement - ie withdrawing CSF you know you are subarachnoid whereas with an epidural although they almost always go in the proper space sometimes they don't. Spinal catheters can be titrated more precisely and quicker and will give you a denser block than an epidural, which can sometimes be patchy. I would pull the cath as soon as possible after the case is over - too much risk for somebody injecting something they shouldn't.

Spinal caths can be useful for persons that you don't want to put to sleep (severe lung disease, etc.).

 

[sevoflurane]

Hey sevo, what about mask ind w sevo/O2, LTA lido, maintain SV, intubate, then PS 10 intraop. Emerge on the deeper side or with dexmed infusing? My thinking is that even if he needs a trach (may need one anyway being stage IV lung ca full press forward), he'd survive that, but not asp pneumonia. Then again, he wouldn't survive a periop 7 cm AAA rupture.

That is a good suggestion and it could be done. 🙂

However, LTA does not guarentee that you will be able to avoid reflex brochoconstriction or that you will be able to extubate at the end of the case. It takes time for you to blunt the response. You can't just spray and intubate. Also, this effect may not last that long.

Here is an article that references ETT resistance vs LMA resistance in topicalized airways. I can't find Gal and Surratt's actual paper.

http://journals.lww.com/anesthesiol...rway_Resistance_with_the_Endotracheal.11.aspx

"Gal and Surratt [5] showed that tracheal intubation caused a doubling of airway resistance in awake healthy patients with topically anesthetized airways. They considered that this represented reflex bronchoconstriction because of the mechanical irritation of the tube. Patients with chronic obstructive pulmonary disease showed an even greater response. We showed that the LMA has lower pulmonary airway resistance than the ETT in paralyzed anesthetized patients, suggesting that the LMA triggers less reflex bronchoconstriction than the ETT. Pulmonary airway resistance for the LMA included glottic resistance (considered to be 33% of upper airway resistance in awake patients [11]), suggesting that the difference in the subglottic component of pulmonary airway resistance is even greater between the devices."

You are right in saying that aspiration could very well knock this guy over. But so could an ETT and it's sequelae. You have to pick the lesser of 2 evils.

That tube is a constant irritant to your entire brochopulmonary tree, which is why I'm a big fan of extubating deep as you had mentioned. 👍

 

[drccw]

I'ld do this case with a LMA too, though prob ProSeal. This is one of the cases where it's a tough judgement call. But, this is what separates the men from the boys: being able to make the call. Sevo, you examined the situation, you weighed the pros and cons and you made the decision that you felt was in the patient's best interest. That's what a physician does. The global picture is important.

Sure anyone could do this case with a tube. That's not the point. You can drop this patient off in the ICU intubated. Maybe he comes off the vent, maybe he doesn't. The point of the matter is though, once you drop him off, it's someone else's problem. That's what a technician does. Anyone can do that case.

Sometimes we get away with things. It ain't pretty, it ain't always the right answer on the boards, but for this patient it was.

drccw

 

[Bertelman]

Sometimes we get away with things. It ain't pretty, it ain't always the right answer on the boards, but for this patient it was.

drccw

This forum is a great place to brag about the awesome cases we get away with.

I wish there were a safe, litigation-free zone to talk about the cases with poor decisions and bad outcomes.

 

[Southpaw]

Sevo, you examined the situation, you weighed the pros and cons and you made the decision that you felt was in the patient's best interest. That's what a physician does. The global picture is important.

I'll echo these comments. Thanks for going into detail with your thought process, Sevo. You've dropped some serious knowledge on the forum recently. I've really enjoyed reading it...thanks for your efforts. 👍

 

[dhb]

"Gal and Surratt [5] showed that tracheal intubation caused a doubling of airway resistance in awake healthy patients with topically anesthetized airways. They considered that this represented reflex bronchoconstriction because of the mechanical irritation of the tube.

Wow that's a big leap from increased resistance to brochoconstriction 😕
Breathing through an ETT is like breathing through a big staw so of course resistance is higher than an LMA but it sits in the trachea so i don't understand how it could affect bronchoconstriction...
I would believe (i have no proof of this) that the LMA by design offers less resistance and allows supra-diaphragmatic muscle to participate in the work of breathing (which are important in COPDers which could explain the difference seen in that sub-group).

 

[Planktonmd]

I think that the fear of ETT's in patients with severe pulmonary disease is not realistic in many cases and there are times when the best option for the patient is to get intubated for the anesthetic even if he has respiratory failure, as long as you know how to manage the ventilation correctly intraoperatively and extubate deep.
That said, I agree that the patient Sevo described seems to be a good candidate for an LMA as long as you provide some pressure support intraop to minimize the likelyhood of atelectasis.

 

[dhb]

I think that the fear of ETT's in patients with severe pulmonary disease is not realistic in many cases and there are times when the best option for the patient is to get intubated for the anesthetic even if he has respiratory failure, as long as you know how to manage the ventilation correctly intraoperatively and extubate deep.
That said, I agree that the patient Sevo described seems to be a good candidate for an LMA as long as you provide some pressure support intraop to minimize the likelyhood of atelectasis.

Could not agree more.

 

[aredoubleyou]

I think that the fear of ETT's in patients with severe pulmonary disease is not realistic in many cases and there are times when the best option for the patient is to get intubated for the anesthetic even if he has respiratory failure, as long as you know how to manage the ventilation correctly intraoperatively and extubate deep.
That said, I agree that the patient Sevo described seems to be a good candidate for an LMA as long as you provide some pressure support intraop to minimize the likelyhood of atelectasis.

👍

I hate to sound like an a-hole, but although I agree that lmas can be safely used in almost anyone without a full stomach/ bowel obstruction/ etc, I've worked way too hard to sacrafice the headache of a lawsuit where my management was outside of the norm for this country to avoid Mr. Gomer a trip to the ICU on the vent. Considering Sevo's patient didn't have chest or upper abdominal surgery, I think there is a very high chance I could get him extubated at the end of the case, just as plank described.

 

[gaspasser2004]

👍

I hate to sound like an a-hole, but although I agree that lmas can be safely used in almost anyone without a full stomach/ bowel obstruction/ etc, I've worked way too hard to sacrafice the headache of a lawsuit where my management was outside of the norm for this country to avoid Mr. Gomer a trip to the ICU on the vent. Considering Sevo's patient didn't have chest or upper abdominal surgery, I think there is a very high chance I could get him extubated at the end of the case, just as plank described.

My disagreement with Sevo's management is that a bad outcome in this case with an LMA is indefensible.

Lets pretend for a moment that this patient did aspirate, had an anoxic event and was transferred to the ICU where care was eventually withdrawn. I think it is safe to say that Sevo built a rapport with the patient's family and they probably would not sue, but lets just say one of them saw a commerical during the Jerry Springer show about a malpractice lawyer...

Sevo's Deposition

Dr. Sevo, what was your thought process in deciding to do a general anesthetic with an unprotected airway on a patient with known diabetic gastroparesis and hiatal hernia? As a courtesy, I will remind you that our average jury member reads at a fifth grade level. (Sevo or anyone else welcome to answer)

But Dr. Sevo, our expert witness, Dr. Moneygrabber, Chairman of Anesthesia at Academic Dogma Hospital, clearly states in his deposition that a general anesthetic with an LMA in a patient with such comorbidities is below the standard of care. Must I remind you that he has written multiple journal articles and given several invited talks at national meetings regarding this very subject matter. (Sevo or anyone else welcome to answer)

Dr. Sevo, do you really think that just the fact that you obtained consent from the patient absolves you of responsibility for this bad outcome? If a patient came to you for an elective anesthetic after eating McDonald's one hour prior, would you just simply obtain consent after discussing the risks of aspiration? Don't you, as a physician, have the primary responsibility of "do no harm"? (Sevo or anyone else welcome to answer)

 

[dhb]

I see anything in his PMH that would preclude him from getting an LMA.
Reflux is certainly not a contraindication! Where I practice no one care about GERD for LMAs and patients don't do worse.
Linking GERD to aspiration is one big F@@kin myth.

 

[sevoflurane]

You are completely right. If I was the unlucky unicorn of the universe and found myself in a court of law under those circumstances, I would have to present a good argument to convince the jury of my position. Indefensible? I don't know about that. I picked what I thought was the lesser of two evils. The guy is gonna die within the next year. That is not my fault.

I would humbly ask you: What are the chances of this actually happening and am I letting fear of a lawyer who knows nothing about anesthesia dictate how best to treat my patients? Maybe there is a lesson I have not learned here. I hope I never find myself in court of law for doing what I feel to be is right. I'm sure that burns like hell and I'm sure it has happened before. Two lines I picked up from an old attending mentor of mine still ring very true in my practice:

"Take care of the patient....and the rest will follow".
"It is the PATIENT who takes the biggest risk, not YOU."

Today I popped into my orthopod's room and asked him about our Mr. Stage 4 lung ca. with a 7cm AAA and tissue paper myocardium. To my surprise and his, he is out of bed and, although not going far with the assistance of a walker and PT, he is walking. This was his wish and it certainly could have been different if I had decided to pack him up with an ETT and sent him on his way to the ICu.

There are many out there who practice in the THEIR safety corner. As i said before, if I lived in PA or FL things may have been different. But I don't, I live in a tort reform state. I can not argue with your assessment of the situation because you are playing by the books and in AMERICA to some people, this is the SOC. Mind you, in Ireland or the UK, this law suit would NEVER fly in a billion years.

I hope this case has brought some insight to those of you in, starting or going into anesthesia. Jet's OP described the versatility of an LMA and it's use outside what is being taught during residency. It is a versatile tool for you to use when YOU feel it's indications or contraindications are appropriate. Bottom line is, if you feel it is not safe, then don't do it. The patient comes first.

Cheers to you gaspasser for bringing into the light the other side. 🙂👍👍

My disagreement with Sevo's management is that a bad outcome in this case with an LMA is indefensible.

Lets pretend for a moment that this patient did aspirate, had an anoxic event and was transferred to the ICU where care was eventually withdrawn. I think it is safe to say that Sevo built a rapport with the patient's family and they probably would not sue, but lets just say one of them saw a commerical during the Jerry Springer show about a malpractice lawyer...

Sevo's Deposition

Dr. Sevo, what was your thought process in deciding to do a general anesthetic with an unprotected airway on a patient with known diabetic gastroparesis and hiatal hernia? As a courtesy, I will remind you that our average jury member reads at a fifth grade level. (Sevo or anyone else welcome to answer)

But Dr. Sevo, our expert witness, Dr. Moneygrabber, Chairman of Anesthesia at Academic Dogma Hospital, clearly states in his deposition that a general anesthetic with an LMA in a patient with such comorbidities is below the standard of care. Must I remind you that he has written multiple journal articles and given several invited talks at national meetings regarding this very subject matter. (Sevo or anyone else welcome to answer)

Dr. Sevo, do you really think that just the fact that you obtained consent from the patient absolves you of responsibility for this bad outcome? If a patient came to you for an elective anesthetic after eating McDonald's one hour prior, would you just simply obtain consent after discussing the risks of aspiration? Don't you, as a physician, have the primary responsibility of "do no harm"? (Sevo or anyone else welcome to answer)

 

[gaspasser2004]

My compliments to Sevo for taking the time to post his case and responding to my and numerous others' comments. He has made some really good arguments and displayed a rational approach to managing this patient. While I still disagree with his decision to use a LMA, I respect his thought process.

This was a good case to discuss because people had different opinions and gave good arguments both ways.

Compliments to JPP for starting this off.

 

[IlDestriero]

My compliments to Sevo for taking the time to post his case and responding to my and numerous others' comments. He has made some really good arguments and displayed a rational approach to managing this patient. While I still disagree with his decision to use a LMA, I respect his thought process.

This was a good case to discuss because people had different opinions and gave good arguments both ways.

Compliments to JPP for starting this off.

Isn't this where we're supposed to be calling eachother names, ranting and screaming malpractice, etc.?
What a difference a few months makes.