Lma to recovery

[dabears505]

Worked locum at a place it was fairly customary for them to take patient to pacu with lma still in place. Pacu nurses would pull them when patient was ready. These patients were spontaneously breathing and not on ps.

It worked well. Any other places do this?

---

Members don't see this ad.

 

[abolt18]

Worked locum at a place it was fairly customary for them to take patient to pacu with lma still in place. Pacu nurses would pull them when patient was ready. These patients were spontaneously breathing and not on ps.

It worked well. Any other places do this?

I wish. Our PACU would explode if that happened.

 

[Southpaw]

Worked locum at a place it was fairly customary for them to take patient to pacu with lma still in place. Pacu nurses would pull them when patient was ready. These patients were spontaneously breathing and not on ps.

It worked well. Any other places do this?

I used to work at a place that did this. It worked really well. Where I am currently this would be akin to taking the patient to PACU with a sword sticking out of their eye.

Culture affects what we do, accept it or not. However there’s no question in my mind that taking a patient to pacu with a LMA still in after a straightforward case is superior to yanking the LMA out and shoving a hard oral airway or soft nasal airway (which are both far inferior airways to a LMA) in and going to PACU to facilitate OR throughput.

Of note, my old practice was MD only so everyone was good at ensuring wake ups set up for success. This isn’t the case now where I supervise CRNAs. If you're going to do this you need to make sure pain is well controlled and all is stable with the patient. You also need to ensure that the LMA is ready to remove as you're finishing up your PACU signout. Don't do it if you think the patient won't be ready for 15 minutes, after you've walked away and aren't as readily available in case something happens.

In short, this works fine when people know what the f they're doing.

 

[UscGhost]

I dont really see the benefit to that. Then you have a RN who may or may not be paying attention when the patient bites down or gags on that LMA and aspirates or has a laryngospasm.

You can dial back the gas, pull the LMA deep when skin is closed...patient will be respond to commands upon arrival in the pacu. Especially if the cases are short such as in an ASC

If your patient is that deep where they still tolerate their lma in the pacu..then it takes that much longer for them to be ready for discharge. Not to mention the increase airway risk associated with that.

 

[Guillemot]

Ill leave the LMA in sometimes if I think the patient will obstruct if removed. I remain present in the PACU until LMA removed, but it doesnt slow me down as by the time I finish handoff/PACU note the LMA can be removed.

 

[sevo00]

How does this save any time? Why not pull theLMA deep when they’re in the OR while skin is being closed and then by the time you’re going to pacu patient is already wide awake

 

[Guillemot]

How does this save any time? Why not pull theLMA deep when they’re in the OR while skin is being closed and then by the time you’re going to pacu patient is already wide awake

Is it faster to:

1. Pull the LMA, have the pt obstruct, place an OA, assess if OA worked, possibly adjust OA, possibly have OA be inadequate, jaw thrust on way to PACU until pt awake

2. Leave in LMA

 

[coffeebythelake]

Why not just swap it out for an oral airway?

 

[sevo00]

Is it faster to:

1. Pull the LMA, have the pt obstruct, place an OA, assess if OA worked, possibly adjust OA, possibly have OA be inadequate, jaw thrust on way to PACU until pt awake

2. Leave in LMA

You don’t have the third option. Pull the LMA and patient doesn’t obstruct and you never have to do a jaw thrust and don’t have to place a OA. Also if you’re that concerned about obstructing then turn off the gas while skin is being closed and take the lma out once the patient is fully awake right at the end. If their pain is well controlled they shouldn’t be fighting the lma and biting it once they are awake.

 

[Guillemot]

You don’t have the third option. Pull the LMA and patient doesn’t obstruct and you never have to do a jaw thrust and don’t have to place a OA.

The third option is optimal, but doesnt always happen.

Also if you’re that concerned about obstructing then turn off the gas while skin is being closed and take the lma out once the patient is fully awake right at the end. If they’re pain is well controlled they shouldn’t be fighting the lma and biting it once they are awake.

And if they dont wake up immediately then I just leave the LMA in situ until they wake up a few mins later in PACU.

 

[Southpaw]

You don’t have the third option. Pull the LMA and patient doesn’t obstruct and you never have to do a jaw thrust and don’t have to place a OA. Also if you’re that concerned about obstructing then turn off the gas while skin is being closed and take the lma out once the patient is fully awake right at the end. If they’re pain is well controlled they shouldn’t be fighting the lma and biting it once they are awake.

Correct. And they won’t fight it or bite it a few min later in the PACU either when they voluntarily open their eyes and open their mouth and you take out the LMA. Pulling LMAs deep misses out on the great benefit of how great an oral airway it is. People whose pain is controlled, breathing 12 or so times a min on emergence, wake up fine on LMAs when they’re ready. We don’t need to make it harder than it is.

 

[jwk]

I'm perfectly happy doing the emergence in the OR as god intended, with everything I could possibly need immediately available.

We've got some pretty good PACU nurses, but they're not the airway experts. Have you never seen someone have a laryngospasm with an LMA? Ever seen an LMA bitten in half (I have - impressive). Sorry. Emergence is part of the anesthetic, not part of the recovery.

 

[UscGhost]

I'm perfectly happy doing the emergence in the OR as god intended, with everything I could possibly need immediately available.

We've got some pretty good PACU nurses, but they're not the airway experts. Have you never seen someone have a laryngospasm with an LMA? Ever seen an LMA bitten in half (I have - impressive). Sorry. Emergence is part of the anesthetic, not part of the recovery.

It'd also extremely difficult to ventilate a patient once they get a little light in pacu and dislodge their lma halfway or bite it. Can't get the face mask to fit when the LMA is hanging out so you just have to wait and hope they break their spasm on their own.

I dont see the benefit vs a patient responding to verbal commands upon arrival to pacu. Oral airway aren't nearly as stimulating as LMAs are..I have had patients talking while the OA is still in their mouth

 

[pgg]

Why not just swap it out for an oral airway?

An LMA is a great soft supraglottic airway. If I'm going to take someone to PACU with an airway, I don't see a good reason to swap it out for a crappy uncomfortable hard plastic supraglottic airway.

 

[narcotics999]

An LMA is a great soft supraglottic airway. If I'm going to take someone to PACU with an airway, I don't see a good reason to swap it out for a crappy uncomfortable hard plastic supraglottic airway.

Is LMA more comfortable than oral airway? I can imagine putting up an oral airway, but a LMA???

 

[MalloryWeiss]

Have a partner who sent a few patients to the PACU with an LMA. Don’t think there’s anything wrong with it especially if you give nursing some guidance along with strict precautions: “call me or do ___ if XYZ happens.”

As for preventing NPPE from biting down on the LMA - in this scenario my partner will also place an oral airway that hangs slightly lateral to the LMA.

Definitely doesn’t look pretty, but I suppose it gets the job done.

 

[MalloryWeiss]

But in general, I think if you’re sending patients to PACU with an LMA that means you made an error in timing your anesthetic. I don’t think this should be routine practice - but if needed, not unreasonable.

 

[Southpaw]

Is LMA more comfortable than oral airway? I can imagine putting up an oral airway, but a LMA???

The emerging, comfortable patient tolerates a LMA better than an oral airway.

 

[coffeebythelake]

Is LMA more comfortable than oral airway? I can imagine putting up an oral airway, but a LMA???

I would think thate LMA more likely to provoke laryngospasm than an OA, ??

 

[Southpaw]

I would think thate LMA more likely to provoke laryngospasm than an OA, ??

Not my experience

 

[nimbus]

We routinely took our patients to pacu with lma in and a soft bite block. It was safe and it saved a couple minutes in the OR. The rationale was “why mess with a perfectly good, well tolerated airway?” Sadly we stopped when Covid hit.

 

[nimbus]

But in general, I think if you’re sending patients to PACU with an LMA that means you made an error in timing your anesthetic. I don’t think this should be routine practice - but if needed, not unreasonable.

We’d perfectly time the anesthetic to leave the OR as soon as the drapes are down and pull the lma when the BP was cooked in PACU. That was the workflow by design.

 

[Zekchar]

I disagree with this practice. The vast majority of anesthesiologists would agree that your anesthetic is not over if the LMA is still in place. Not so if "extubated" from the LMA and an oral airway is in place. We are skilled at managing airways. PACU nurses are not. It is our responsibility and I would never give that up.

More importantly if an adverse event occurs with a PACU nurse and a patient brought out with LMA still in place and you rolling back with your next case, be ready to cut the check because you will lose that lawsuit. Removal of the LMA is a part of emergence.

*Edit: Nothing wrong with pulling LMA in PACU. I was referring to leaving and having the PACU nurse be responsible for LMA removal. That is a no-no for me.

 

[nimbus]

I disagree with this practice. The vast majority of anesthesiologists would agree that your anesthetic is not over if the LMA is still in place. Not so if "extubated" from the LMA and an oral airway is in place. We are skilled at managing airways. PACU nurses are not. It is our responsibility and I would never give that up.

More importantly if an adverse event occurs with a PACU nurse and a patient brought out with LMA still in place and you rolling back with your next case, be ready to cut the check because you will lose that lawsuit. Removal of the LMA is a part of emergence.

What’s wrong with pulling it in pacu while they clean and turn over the room?

 

[Southpaw]

I disagree with this practice. The vast majority of anesthesiologists would agree that your anesthetic is not over if the LMA is still in place. Not so if "extubated" from the LMA and an oral airway is in place. We are skilled at managing airways. PACU nurses are not. It is our responsibility and I would never give that up.

More importantly if an adverse event occurs with a PACU nurse and a patient brought out with LMA still in place and you rolling back with your next case, be ready to cut the check because you will lose that lawsuit. Removal of the LMA is a part of emergence.

Pull the lma in pacu after report. Tap on the head, say patients name, watch them open eyes, pull lma. Last I checked anesthesiologists knew how to time and run an anesthetic.

 

[Zekchar]

Pull the lma in pacu after report. Tap on the head, say patients name, watch them open eyes, pull lma. Last I checked anesthesiologists knew how to time and run an anesthetic.

Nothing wrong. I meant I wouldn't leave the PACU nurse to be responsible for the airway.

 

[UscGhost]

As long as the anesthesiologist is the one that pulls it then it's reasonable.

I have heard of a few places in my community that do this..but the way it's described to me is the anesthesiologist tends to walk away and the RNs pull it. Dangerous

 

[MirrorTodd]

In other news, I pulled a tube prone for the first time today. Super proud of myself.

 

[coffeebythelake]

In other news, I pulled a tube prone for the first time today. Super proud of myself.

But why..

 

[GassYous]

I must be doing something wrong because when the stretcher is in the room, I just pull the lma then call out the patient's name. They open their eyes, breathe well and then move themselves over.

 

[coffeebythelake]

I must be doing something wrong because when the stretcher is in the room, I just pull the lma then call out the patient's name. They open their eyes, breathe well and then move themselves over.

Same

 

[patriot6]

LMA to PACU happens all the time at my place. Good PACU nurses, high volume center. I've heard of 0 issues.

 

[MirrorTodd]

But why..

Same reason people climb Mt Everest.

 

[coffeebythelake]

Same reason people climb Mt Everest.

So.. risk of bodily injury for bragging rights?

 

[MirrorTodd]

So.. risk of bodily injury for bragging rights?

Precisely. Gotta spread that big dick energy around.

 

[Volatile]

Maybe I’m off, but I look at this as a failure to time the anesthetic correctly. You should be able to pull any lma or tube when drapes are coming down. I can see it for the occasional patient that is just sensitive and slow to wake up but that’s exceedingly rare. If we were dropping our patients off in pacu deep we would back up our pacu.

 

[DocVapor]

I feel that many things here can all be correct at the same time. My thoughts:

1. You should be timing your anesthetic to remove the LMA prior to going to PACU.
2. An LMA is nothing more than a fancy OPA and should not be thought of as equivalent to an ETT.
3. If you're comfortable with your PACU RN's managing and pulling OPA's, you should be comfortable with them managing and pulling LMA's.
4. Every once in a while a patient just won't want to wake up on time no matter how well you usually time things.
5. In that case, it's ok to send the patient to PACU with an LMA. Give the RN instructions as you see fit.

 

[Zekchar]

LMA to PACU happens all the time at my place. Good PACU nurses, high volume center. I've heard of 0 issues.

It only takes 1 inexperienced PACU nurse and 1 laryngospasm (or even 1 experienced PACU nurse and 1 laryngospasm) that results in anoxic brain injury and a multimillion dollar medical malpractice lawsuit to undo years or even decades of minutes saved from having the anesthesiologist being the one to remove the LMA. Some of you on here are cowboys and fail to recognize that bad things do happen and its best not to be the bag-holder.

There is not a single jury in the world that will not find you liable for a LMA airway bad outcome in the PACU if you've walked away and allowed a PACU nurse to be forced to deal with that. I do not advise any new docs or residents who are starting out to go to PACU and leave the PACU nurse to be on LMA removal duty.

 

[Guillemot]

It only takes 1 inexperienced PACU nurse and 1 laryngospasm (or even 1 experienced PACU nurse and 1 laryngospasm) that results in anoxic brain injury and a multimillion dollar medical malpractice lawsuit to undo years or even decades of minutes saved from having the anesthesiologist being the one to remove the LMA. Some of you on here are cowboys and fail to recognize that bad things do happen and its best not to be the bag-holder.

There is not a single jury in the world that will not find you liable for a LMA airway bad outcome in the PACU if you've walked away and allowed a PACU nurse to be forced to deal with that. I do not advise any new docs or residents who are starting out to go to PACU and leave the PACU nurse to be on LMA removal duty.

Im not in the practice of leaving the PACU if the pt still has an LMA, but I get the feeling that you are making some bold, unsubstantiated assertions.

Could you please sight some case law to substantiate your claim?

 

[DrZzZz]

2. An LMA is nothing more than a fancy OPA and should not be thought of as equivalent to an ETT.
.

Disagree with this point. Patient biting down on an oral airway, maybe dental injury but the airway stays patent. Patient biting down on an LMA, potential for NPPE. No thanks. I'm not burying people for being in the camp of LMA to PACU is ok (local customs can dictate a variety of practice), but I personally wouldn't ever let a PACU RN pull an LMA.
And I don't get those saying, "well I don't leave pacu til it's out," then why are you even bothering? It's not saving you time and only adding some risk. Just pull it yourself, whether in the OR or when giving signout in PACU. Don't leave it to the nurse.

 

[Radetzky]

We do this routinely in a high volume tertiary centre- there are no issues. PACU nurses are well trained and the LMAs are the type with an in built bite block.

 

[D P356]

To paraphrase @Noyac, whoever removes the breathing tube better be able to replace it.

I’d take them to pacu only if I pull the LMA there.
Assuming risk is lower for aspiration, On a case where I’m trying to avoid tachycardia and/or htn, I’ll reverse pt. Get them breathing with PS, and switch ett for LMA with volatile agent still on. Titration of short acting beta blocker or NTG for milder hemodynamic swings than ETT.

Or use an LTA, which I find can be hit or miss.

Caveat: If I use an LTA, they have to be wide awake and able to protect airway before I pull ett, kind of obvious.

 

[DocVapor]

Disagree with this point. Patient biting down on an oral airway, maybe dental injury but the airway stays patent. Patient biting down on an LMA, potential for NPPE. No thanks. I'm not burying people for being in the camp of LMA to PACU is ok (local customs can dictate a variety of practice), but I personally wouldn't ever let a PACU RN pull an LMA.
And I don't get those saying, "well I don't leave pacu til it's out," then why are you even bothering? It's not saving you time and only adding some risk. Just pull it yourself, whether in the OR or when giving signout in PACU. Don't leave it to the nurse.

Ok, sure I see that point. I'm used to using LMAs with a built-in bite block to prevent this.

As far as those that take it to PACU and stay until it's out... won't be buying the anesthesiologist any time, but it may give some time for OR turnover that doesn't get started until out of the room. I do agree that it's probably of more dubious benefit to do it that way.

 

[Arch Guillotti]

To paraphrase @NoyacAssuming risk is lower for aspiration, On a case where I’m trying to avoid tachycardia and/or htn, I’ll reverse pt. Get them breathing with PS, and switch ett for LMA with volatile agent still on. Titration of short acting beta blocker or NTG for milder hemodynamic swings than ETT.

Sounds like a lot of work.

 

[Zekchar]

Im not in the practice of leaving the PACU if the pt still has an LMA, but I get the feeling that you are making some bold, unsubstantiated assertions.

Could you please sight some case law to substantiate your claim?

I'm merely presenting a counter argument. I doubt there's a case I can quote since this would unlikely ever go to trial and most assuredly would get settled early. Let's demonstrate how this would go:

Plaintiff Lawyer: The standard we're seeking is "what would the average anesthesiologist with the same background and training do in a similar situation." With that said, who usually extubates and thus removes the endotracheal tube or the LMA? Is it the anesthesiologist or the PACU nurse?

Expert Witness: The anesthesiologist is responsible for extubation and not a PACU nurse.

Defense Lawyer: We'd like to settle.

 

[patriot6]

I'm merely presenting a counter argument. I doubt there's a case I can quote since this would unlikely ever go to trial and most assuredly would get settled early. Let's demonstrate how this would go:

Plaintiff Lawyer: The standard we're seeking is "what would the average anesthesiologist with the same background and training do in a similar situation." With that said, who usually extubates and thus removes the endotracheal tube or the LMA? Is it the anesthesiologist or the PACU nurse?

Expert Witness: The anesthesiologist is responsible for extubation and not a PACU nurse.

Defense Lawyer: We'd like to settle.

I was skeptical of this practice (LMA to PACU) as a new grad, but it is the clinical culture at my job. I've been pleasantly surprised at how smooth it is. I agree it's bad form to not be immediately available for its removal (emergence). Your above court room exchange is somewhat annoying -- aren't we really on the hook for any adverse outcome in the patient's peri-operative course? It's just as safe for a patient to emerge in peace in PACU with an LMA with me immediately available, as it is for me to personally take the LMA out in the OR. I do find it quickens turnover time. Yes, it's a little lazy of a strategy. But I don't have to time a thing. And I don't have to worry about stage 2 laryngospasm moving over to the stretcher or stage 2 patients getting slapped around by the circulating RN during emergence. You're coming down too hard on a safe practice. There's so much emphasis on who removes the LMA in your posts, but, are you cool with dropping off a patient with an OPA in PACU who's not eye opening yet?

 

[Urzuz]

Pull the lma in pacu after report. Tap on the head, say patients name, watch them open eyes, pull lma. Last I checked anesthesiologists knew how to time and run an anesthetic.

If you knew how to time your anesthetic you would have the LMA out in the room

 

[patriot6]

If you knew how to time your anesthetic you would have the LMA out in the room

I think Southpaw timed his anesthetic perfectly. Meanwhile, you're jaw thrusting with an OPA in the hall on the way to recovery.

 

[Guillemot]

I'm merely presenting a counter argument. I doubt there's a case I can quote since this would unlikely ever go to trial and most assuredly would get settled early. Let's demonstrate how this would go:

Plaintiff Lawyer: The standard we're seeking is "what would the average anesthesiologist with the same background and training do in a similar situation." With that said, who usually extubates and thus removes the endotracheal tube or the LMA? Is it the anesthesiologist or the PACU nurse?

Expert Witness: The anesthesiologist is responsible for extubation and not a PACU nurse.

Defense Lawyer: We'd like to settle.

I dont claim to be an expert in the area of litigating med mal cases, but it it is apparent through your posts that you do not understand some of the fundamentals: the role of expert witnesses(Both plaintiff and defense would have their own), the concept of standard of care, case law, etc.

 

[epidural man]

Biting down on an LMA enough to occlude it? That happens? I have never seen it.....what kind of supraglottic airways do you use that allows them to occlude them biting down? Lots of times I can't get the thing out - but never occluded it before I started removing it.

When I was a resident at Children's here in San Diego, 99% of patients were taken to the PACU with ETT in place. I joke that I never learned how to extubate a kid because of this. It was very fast. Nurses felt confident and it worked great. I can't remember, but I think most LMA's were pulled deep (anybody else from SD remember this era that could comment?)

I just found out recently that this practice was changed. Apparently, the nurses (probably new from turn over) complained and decided that it was outside their credentialing.

So now I hear from the residents that they pull everything deep and let the PACU deal with that.

Personally, I think it would be safer for the nurse to pull the tube in the PACU rather than send them deep. Deep patients with no airway in an environment where people are loud, moving cords around, being busy - is very dangerous.