LMA supreme for elective C-section

[Maverikk]

What are your thoughts on this? An old timer I knows says doing sux, lma, immediate placement of the OG down the supreme, if no return (which he said only happened a few times over decades) then he'll ventilate shortly and intubate. He swears by it. I've heard of the technique for light paralysis in healthy patients with 30 minute lap-chole surgeons from a few guys from europe.

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[Arch Guillotti]

Sounds dumb.

 

[anbuitachi]

why would you do this???

 

[dannyboy1]

and what is wrong with regular RSI !!!!???

 

[Fajardo04]

Terrible idea.

 

[AdmiralChz]

So using a disposable product for... no reason? Sounds expensive.

 

[Urzuz]

I'll never understand peoples' irrational fear of intubating patients. What are you gaining by putting an LMA vs an ETT? It sounds like you're just inviting potential problems.

 

[dhb]

I guess it's fine for a 15-20 min section, wouldn't do it for a 1h+ 300+ pounder.

 

[twoliter]

And if no gastric return, why not just keep using the LMA? I'm not saying you shouldn't intubate. I'm just saying choose one or the other.

 

[dhb]

Probably because he can't be sure tje og tube is passed in the stomach..

 

[Consigliere]

Remember: just because you CAN do something, doesn't mean you SHOULD.

 

[sigrhoillusion]

Before you do that think of your response you'd give when the lawyer asks you the obvious questions if something goes wrong...

 

[sleepallday]

umm what about just a spinal for an elective c-section?

 

[chocomorsel]

So LMA then intubation? Why not just stick with one or the other? How wasteful is he/she? Clearly they don't think about the unnecessary cost nor waste involved.

And as leavers says, why no spinal?

 

[Ezekiel2517]

What are your thoughts on this? An old timer I knows says doing sux, lma, immediate placement of the OG down the supreme, if no return (which he said only happened a few times over decades) then he'll ventilate shortly and intubate. He swears by it. I've heard of the technique for light paralysis in healthy patients with 30 minute lap-chole surgeons from a few guys from europe.

Username checks out

 

[Southpaw]

The only utility of LMA on OB is as a rescue device.

 

[deleted50478]

What are your thoughts on this? An old timer I knows says doing sux, lma, immediate placement of the OG down the supreme, if no return (which he said only happened a few times over decades) then he'll ventilate shortly and intubate. He swears by it. I've heard of the technique for light paralysis in healthy patients with 30 minute lap-chole surgeons from a few guys from europe.

There's just no upside to this.

 

[sigrhoillusion]

I just re-read the OP... so he puts the LMA just to ventilate and suction stomach...?!?! THEN he intubates? What kind of ass backwards voodoo anesthesia are we doing here?

And as another poster stated, why isn't he doing a spinal? This thread is just confusing me now.

 

[sigrhoillusion]

I just re-read the OP... so he puts the LMA just to ventilate and suction stomach...?!?! THEN he intubates? What kind of ass backwards voodoo anesthesia are we doing here?

And as another poster stated, why isn't he doing a spinal? This thread is just confusing me now.

And based on the logic of this method I'm not even going to assume that when he says sux, LMA, suction, ventilate, tube, that he isn't forgetting to give the propofol...

 

[GravelRider]

I don't understand placing the LMA before intubating unless needed. However, I think a more reasonable question to challenge the status quo is would you simply place a newer generation LMA (supreme, i-gel) for an elective c-section in a properly selected patient who refused a spinal? I probably wouldn't, but there may be a reasonable argument there for someone who would.

 

[deleted162650]

You just went full ******.


Never go full ******.

 

[Maverikk]

woah woah woah there fellas, I don't do this, nor would I. You had the same response I did. I just heard about it and couldn't understand the benefit, he does it when spinal is unfeasible (refusal, coagulopathy) and he'd only intubate if the OG wasn't in the stomach, as I said in the original post. Good to see everyone had the same reaction I did, it just seemed to have little benefit to me unless you couldn't place a tube initially.
I can usually show the benefits of a spinal, I rarely ever do GA just based on my population and swift OBs. I have friends in academic places that tell me about common 2 hour C-sections, which I haven't seen unless there's a problem which in that case I go straight to GA+ETT

 

[dhb]

Sad to see most people have reading deficiencies:
From op:
1. Pent sux lma
2. Og suction through lma
3. If no return then proceed to intubation.

Is it deviation from usual care yes, should it be labeled as unsafe: no.
Not when the available litterature tells you that in the right patient population this can be done safely.
I find it sad that we don't uphold our own litterature to determine safe practice but give ammunition to lawyers to determine that for us.

Maybe a good topic for the dogma lecture...

 

[anbuitachi]

Sad to see most people have reading deficiencies:
From op:
1. Pent sux lma
2. Og suction through lma
3. If no return then proceed to intubation.

Is it deviation from usual care yes, should it be labeled as unsafe: no.
Not when the available litterature tells you that in the right patient population this can be done safely.
I find it sad that we don't uphold our own litterature to determine safe practice but give ammunition to lawyers to determine that for us.

Maybe a good topic for the dogma lecture...

Why LMA supreme and then intubate? Why truamatize the airway in a pregnant patient twice when you can do it once? I would think it has more risks than just intubate

 

[dhb]

Why LMA supreme and then intubate? Why truamatize the airway in a pregnant patient twice when you can do it once? I would think it has more risks than just intubate

Dude: "which he said only happened a few times over decades"

 

[nimbus]

Sad to see most people have reading deficiencies:
From op:
1. Pent sux lma
2. Og suction through lma
3. If no return then proceed to intubation.

Is it deviation from usual care yes, should it be labeled as unsafe: no.
Not when the available litterature tells you that in the right patient population this can be done safely.
I find it sad that we don't uphold our own litterature to determine safe practice but give ammunition to lawyers to determine that for us.

Maybe a good topic for the dogma lecture...

Think I'm finally getting the point. If the OG through the LMA is not clearly in the stomach, then he would replace the LMA with an ETT. Otherwise he would do the entire case with the LMA.

Along these lines, Joseph Brimacombe would advocate placing a bougie in the esophagus under direct laryngoscopy, then threading the bougie through the esophageal vent port as a guide for the LMA supreme. He said that would ensure proper placement of the supreme, and he did all types intraabdominal cases with it.

 

[Planktonmd]

Not a great plan IMHO!

 

[vector2]

Imo anytime you voluntarily put yourself in a situation where you potentially have to instrument the airway more than once is dumb. The first dl is the best dl. I'm not gonna f around with an lma, but if I did I certainly wouldnt pull a perfectly good airway just so I could put an OG down unless exposure absolutely demanded it.

 

[pgg]

Along these lines, Joseph Brimacombe would advocate placing a bougie in the esophagus under direct laryngoscopy, then threading the bougie through the esophageal vent port as a guide for the LMA supreme. He said that would ensure proper placement of the supreme, and he did all types intraabdominal cases with it.

OK, I guess.

But why?

If you're going to DL the person why not just stick a tube in while you're there? Is there some advantage to using LMAs over ETTs in abdominal cases that I'm missing? What's the point?

I have trouble following the thought process that tries to shoehorn LMAs into every possible case.

 

[Robotic Wis-Hipple]

Only thing I can think of for LMA is bronchospastic disease, maybe, if they don't aspirate. But if you do a GA on a pregnant woman or intraabdominal case with an LMA in this country, and have an aspiration, you're F'd. Just cut the check, and then write a blurb explaining the settlement against you in a Word document for easy copy and pasting into every licensing/credentialing document you'll ever fill out again.

 

[dhb]

Who talked about DL?
I don't see what's so complicated: put in an lma if he can't suction stomach (rare occasion) then intubate. Quite simple frankly, would it be my fist option? No, but i don't think it's unreasonable.

 

[chocomorsel]

Sad to see most people have reading deficiencies:
From op:
1. Pent sux lma
2. Og suction through lma
3. If no return then proceed to intubation.

Is it deviation from usual care yes, should it be labeled as unsafe: no.
Not when the available litterature tells you that in the right patient population this can be done safely.
I find it sad that we don't uphold our own litterature to determine safe practice but give ammunition to lawyers to determine that for us.

Maybe a good topic for the dogma lecture...

The OP has a complete run on sentence with incomplete points and parenthesis added in there. (If no return of what exactly?). So pardon us if we don't extrapolate appropriately. Doesn't mean our English comprehension sucks.

Although English is my second language I have a damn good grasp on it.

But that s hitwas confusing Mr. Litterature.

 

[Consigliere]

But that s hitwas confusing Mr. Litterature.

Hahahaha! Props

 

[nimbus]

OK, I guess.

But why?

If you're going to DL the person why not just stick a tube in while you're there? Is there some advantage to using LMAs over ETTs in abdominal cases that I'm missing? What's the point?

I have trouble following the thought process that tries to shoehorn LMAs into every possible case.

At the time he was promoting the LMA Supreme for LMA North America.

 

[pgg]

At the time he was promoting the LMA Supreme for LMA North America.

Ah

Things are back in focus for me now.

 

[pgg]

Who talked about DL?

I assumed people weren't blindly placing bougies to Seldinger LMAs into place.

It's weird and not something that would occur to most of us, I think.

I don't see what's so complicated: put in an lma if he can't suction stomach (rare occasion) then intubate. Quite simple frankly, would it be my fist option? No, but i don't think it's unreasonable.

It's a bit weird, but no, it's not more "unreasonable" than any other technique to place an LMA. I don't really see it as "necessary" either though.

But I do see it as "stupid" if you're doing it for routine airway management for c-sections in the USA, and that has more to do with choosing the LMA than whatever silly lookit-me games that are played to get it in.

Maybe in Europe you can do whimsical weird stuff out of boredom and not be setting yourself up.

 

[Laryngophed]

I also think we are all falsely secure with an OG/NG going down to evacuate the stomach. That thing is a wick for the poisons (HCl and pepsin) brewing down there, and it is just primed to provide a route directly to the larynx for that stuff. I think it is silly when we insist on one for "full stomachs" for this reason.

 

[sevoflurane]

I only use this technique if and only if they've had an egg, saussage and cheese Mcmuffin Extra value meal within 30 minutes of induction.

 

[dhb]

I assumed people weren't blindly placing bougies to Seldinger LMAs into place.

Maybe in Europe you can do whimsical weird stuff out of boredom and not be setting yourself up.

That wasn't the technique described in the op.

Maybe.