Lma to recovery

[coffeebythelake]

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.

When you sign and attest on your anesthetic record are you not attesting to be present (or immediately available) during emergence? Perhaps the culture in your hospital allows you to do this, but in my mind when wheeling an anesthetized patient to PACU with an advanced airway device the following conditions must be met:

1. continue to monitor the patient closely including obtaining vitals every 5 minutes (in of itself challenging as signouts to PACU nursing can be inefficient..)
2. have appropriate PACU nursing staff ratios (would it be appropriate for the PACU nurse to take care of more than 1 patient at a time?)
3. equate the comfort level and responsibility of the PACU nurse as a designated provider trained in advanced airway management (which may or may not be true?)

This is just not something that is standard.

A lot of the back and forth here seem to be about being quick and efficient, arguably at the expense of safety (no judgement).
But it makes me wonder what kind of times are you talking about? Is waiting 5 minutes at the end of case too much? 10 minutes? 30 minutes?
Because if it is 5 or 10 minutes then I would just wait and wake the patient up in the OR, and if it is 30 minutes then maybe you gotta work on your timing.

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[coffeebythelake]

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

This is even worse!

 

[D P356]

Sounds like a lot of work.

It can be. I very rarely do it. More so for a pt with inducible ischemia, but not a cardiac revascularization candidate. Preemptive beta blockers or vasodilators can help, but I find emergence more hemodynamically stable with no ETT.
However I’d view it the same as extubating the pt deep with the LMA serving as a superior supraglottic airway vs a plastic oral airway. It also frees up hands.
I usually reverse these sick pts with sugammadex to avoid glycopyrrolate induced tachycardia, assuming adequate egfr.

 

[MirrorTodd]

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.

Childrens in DC would have us occasionally bring an lma kid to the pacu, I don't remember bringing any tubed kids out. There was also a dedicated pacu doc who would be constantly checking on pacu kids too.

I've been trying to teach the residents where I am that it's ok to pull the tube earlier than you might think. I can't tell you how many times I had like 3 different people in the OR while the pt was thrashing around and the attending STILL wouldn't want to pull the tube. So aggravating.

 

[Zekchar]

When you sign and attest on your anesthetic record are you not attesting to be present (or immediately available) during emergence? Perhaps the culture in your hospital allows you to do this, but in my mind when wheeling an anesthetized patient to PACU with an advanced airway device the following conditions must be met:

1. continue to monitor the patient closely including obtaining vitals every 5 minutes (in of itself challenging as signouts to PACU nursing can be inefficient..)
2. have appropriate PACU nursing staff ratios (would it be appropriate for the PACU nurse to take care of more than 1 patient at a time?)
3. equate the comfort level and responsibility of the PACU nurse as a designated provider trained in advanced airway management (which may or may not be true?)

This is just not something that is standard.

A lot of the back and forth here seem to be about being quick and efficient, arguably at the expense of safety (no judgement).
But it makes me wonder what kind of times are you talking about? Is waiting 5 minutes at the end of case too much? 10 minutes? 30 minutes?
Because if it is 5 or 10 minutes then I would just wait and wake the patient up in the OR, and if it is 30 minutes then maybe you gotta work on your timing.

Well explained. Much like I believe that fraud is committed by those doing 1:4 supervision and attesting for all 7 mandatory components with 4 first start cases, I too believe that attesting that you are present for emergence when a PACU nurse is being left to extube the patient while you are elsewhere attending to another patient is fraudulent. It's "never an issue" until one unexpected laryngospasm and bad outcome, when suddenly it is.

To whomever was verbally sparring with me earlier, do not equate "this is how we do it here and have done so for X years without issues" with "this is the standard of care for anesthesiologists."

 

[Guillemot]

@Zekchar & @coffeebythelake . Your begging the question & straw man arguments are unconvincing. You can review my earlier posts in this thread and reply to them if you would like to actually address my position on the matter.

 

[jwk]

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.

Wait - extubate, then place an LMA? That goes back to my post in another thread about VL for every patient. People lose mask skills because of LMAs.

Extubate - mask +/- a little manual assist, nasal cannula on, and off to PACU. Simple and easy.

 

[nimbus]

When I first joined our practice in the early 2000s, we were a regional referral center where we did all the bariatric cases for southern ca Kaiser. We did 15-20 open RYGB/day including a lot of 500lb males. We did all those cases with ga/ETT. One day one of my smarter more experienced partners showed me how he would deep extubate to an lma for transport to PACU. That prevented a lot of transient airway obstruction, coughing, sputtering, desaturation, and other pacu problems. We adopted the practice for a reason. There’s no better oral airway than an LMA.

 

[coffeebythelake]

@Zekchar & @coffeebythelake . Your begging the question & straw man arguments are unconvincing. You can review my earlier posts in this thread and reply to them if you would like to actually address my position on the matter.

First of all, I am not singularly directing my comments to you. I was opining on the institutional acceptance of taking patients out with an LMA, why it isn't standard practice, and what it would take to do it.

You don't leave the PACU until the LMA is out? That's not what a lot of other people are doing here. Read the OP's and other comments.

I invite you to review my posts and opinions that is so utterly wrong to you to warrant such a strong negative response, and then explain in your infinite wisdom how I was "begging the question" and "making straw man arguments".

(I did read your posts, and half of it is trying to slap down other commenters who disagree with you)

 

[Urzuz]

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

I think you’re replying to the wrong person bro.
No LMA, no OPA. Just a spontaneously breathing patient.

 

[Guillemot]

First of all, I am not singularly directing my comments to you. I was opining on the institutional acceptance of taking patients out with an LMA, why it isn't standard practice, and what it would take to do it.

When you quote someone on a message board or @ them, it indicates that you are replying to them within the context of the message board thread. If you were not following typical etiquette, then it changes the meaning of your post.

You don't leave the PACU until the LMA is out? That's not what a lot of other people are doing here. Read the OP's and other comments.


I invite you to review my posts and opinions that is so utterly wrong to you to warrant such a strong negative response, and then explain in your infinite wisdom how I was "begging the question" and "making straw man arguments".

(I did read your posts, and half of it is trying to slap down other commenters who disagree with you)

The rest of your post falls into another logical fallacy called a "Red Herring." (IE it is not relevant to the topic at hand)

All of these fallacies are googleable/youtubeable and learning about them can help arguments and critical thought processes.