laryngeal mask airway lma removal

[xman25]

How to remove LMA smoothly?
Most of my patients wake up bitting the lma ( also breath holding, gross purposeful movement, fighting at the LMA) when I turned off the gas and allow the to wake up at the end of procedures. Please give me some advices how to avoid this problem. Thanks.

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[Arch Guillotti]

first of all, quit shouting😀

second of all take them out deep

 

[jetproppilot]

first of all, quit shouting😀

Yeah.

Thats patent protected.😀

 

[Arch Guillotti]

Yeah.

Thats patent protected.😀

I prefer "Jetted"

 

[jetproppilot]

I prefer "Jetted"

👍

 

[Jeff05]

pull it deep. there is a study which attempted to quantify the minimum mac for a smooth LMA removal. i think it's around 1.

the other option is to have the patient well narcotized with a RR around 10. then they'll tolerate the LMA.

 

[Planktonmd]

An LMA is a mask, when the surgeon is almost done get the patient to breath spontaneously if they are not doing it already.
Take the LMA out, place an oral airway and apply face mask.
Now you can turn off the vapor.
Finish the last few minutes of the case with mask.

 

[dhb]

Contrary to an ett i never pull an LMA deep. To me it serves no purpose: an LMA is a supraglotic device just as an oral or nasal canula except you can ventilate through it.
Very rarely do i have someone bite on an LMA; just let them breath the sevo out and pull it when they start moving. I like to leave it in and roll to the pacu, the patient always wakes up when i transfer them to their bed and the LMA comes out.
People who are afraid of the LMA biting use a syringe nozzel as a bite block.

 

[Jeff05]

i think it's risky to roll to pacu with LMA still in patient. if it shifts and triggers laryngospasm you're in trouble.

 

[aphistis]

i think it's risky to roll to pacu with LMA still in patient. if it shifts and triggers laryngospasm you're in trouble.

Have you ever rolled to the PACU with an oral airway in place? I don't think you can say the risks are appreciably different.

 

[Bertelman]

Pull the LMA as the gas is approaching the awake zone. Timed well, mine react a little as it comes out. Once you see strong, purposeful movements, it's prolly too late unless you can whip it out like Dirk Diggler. Better to ride it out and pull when they relax the jaw.

I'm not sure I would use anything as hard as a syringe for a bite block. Could cause some dental damage, plus it just doesn't look too classy.

 

[thegasman]

pull it deep, oral airway in if needed mask on with spontaneous respiration until gas is gone. Don't forget laryngospasm is always a possibility - no different with the lma still in though. It drives me nuts to walk in at the end of a case and see the crna fighting the patient to get the lma out. NOT smooth.

 

[Jeff05]

Complications associated with removal of the laryngeal mask airway: a comparison of removal in deeply anaesthetised versus awake patients

PS Gataure, IP Latto and S Rust
Department of Anaesthesia, Princess of Wales Hospital, Bridgend, Mid-Glam.

The purpose of the study was to compare the incidence of complications (coughing, biting, retching, vomiting, excessive salivation and airway obstruction) associated with removal of the laryngeal mask airway. The laryngeal mask airway was used in 100 adults undergoing urological procedures. The patients were randomly assigned to two groups. In 50 patients the laryngeal mask was removed by a nurse when the patient responded to commands in the recovery area. In the other 50 patients it was removed by the anaesthetist with the patient deeply anaesthetized in theatre. The majority of patients were elderly men who had relatively short procedures. The incidence of gastric regurgitation was assessed by measurement of pH of secretions at the tip of the laryngeal mask airway. Complications occurred more frequently in the awake patients (P < 0.01). Most were minor and occurred before removal of the laryngeal mask airway during emergence in the recovery room. Airway obstruction occurred in three patients in whom the laryngeal mask was removed in the recovery room. In two of these patients the oxygen saturation decreased below 80% and the other to 90%. No decrease in arterial oxygenation occurred in the anaesthetised patients in whom the laryngeal mask was removed by the anaesthetist. In 14 patients in the awake group the pH of secretions at the tip of the laryngeal mask was < or = 3 compared with only four patients in the anaesthetised group (P < 0.05). It is concluded that it may be safer to remove the laryngeal mask airway whilst the patients are deeply anaesthetised in the operating room than when they are awake in the recovery room.
Canadian Journal of Anesthesia, Vol 42, 1113-1116, Copyright © 1995 by Canadian Anesthesiologists' Society

just one study.

 

[Consigliere]

It's a supraglottic airway device.....think of it like your penis and pull it whenever the hell you want.

 

[dhb]

I'm not sure I would use anything as hard as a syringe for a bite block. Could cause some dental damage, plus it just doesn't look too classy.

That's why i don't do it 😀

thegasman pull it deep, oral airway in if needed

it's the same thing, i don't understand this logic

Consigliere: It's a supraglottic airway device.....think of it like your penis and pull it whenever the hell you want.

Exactly (although with care).

 

[Planktonmd]

It's a supraglottic airway device.....think of it like your penis and pull it whenever the hell you want.

😀
There are circumstances and occasions where pulling your penis might not be the best thing to do.

 

[thegasman]

That's why i don't do it 😀

Quote:
thegasman pull it deep, oral airway in if needed


it's the same thing, i don't understand this logic).

-it is the same thing - that is why there is no problem trading the lma for an oa with mask - but the advantage is that the patient cannot bite the oa and occlude it.

 

[periopdoc]

This is why the Proseal is my favorite LMA. The bite block is built in. I have gotten really comfortable with this device and normally have leaks around 40 after placement. Titrate opiates to comfort based on EtCO2. At the end of the case I turn the volatile off and let the patient wake up. ~40% of the time I just tell the patient to remove it and they pull it out and hand it to me. ~50% I have to pull out cause the patient is just looking at me and not processing what I am asking him to do. ~5% come out deep for whatever reason. ~2% make a fuss and struggle. If they bite down, no big deal the built in soft rubber bite block works great. Either I let them struggle until they are awake enough to open their mouth on command or I give them a bump of propofol and pull it. I don't struggle to pull out an LMA if the patient is biting. Just seems like asking for trouble (dental damage, partially removed LMA with airway obstruction etc)

- pod

 

[coprolalia]

This is why the Proseal is my favorite LMA.

Have you used the LMA Supreme? Much better than the Proseal (IMHO), and disposable.

-copro

 

[periopdoc]

Have you used the LMA Supreme? Much better than the Proseal (IMHO), and disposable.

-copro

Since we got them in stock my rotations have looked like this. Peds, Cardiac, Neuro, Cardiac, Pain... you get the picture. I am just getting back into ambulatory/ general OR and I can't wait to try out the Supreme.


-pod

 

[TrustMe]

LMA Supreme is great. Easy to place, almost always sets well, built in bite block.

We have a couple of attendings that look at an lma as a fancy oral airway. They have no problem rolling into PACU with lma in place if pt. is slow in emerging. Just hang a simple facemask with O2 over the end, roll into PACU, by the time I am done with paperwork and giving a quick report they have usually spit it out.