lgher

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In practice for a couple of years now...

What I'm finding is I'm using LMA's less and less than I used to. Haven't used one in a couple months.

For GA's, I find that with ETT, I don't have to worry as much about dislodgement/larygospasm when I leave the patient with a resident. I feel I can wake a patient up as quick with ETT vs LMA, and less problems on emergence too (biting on LMA/again dislodgment/unable to ventilate during stage 2 (i know there are some LMA's with bite blocks)

From what I read incidence or sore throat is similar with LMA vs ETT..

So am I crazy for choosing ett most of the time? Anyone else feel the same?
 

somedumbDO

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I use Lma more and more. For all the reasons plank has said. Look at the studies done out of the EU. They use lmas for laparoscopic cases even with the same incidence of aspiration, etc. Not telling you have to practice but you may try trusting your residents more. Besides they need to know how to handle many of these common issues with anesthesia. Fwiw, I am in busy peds PP and work 70% time w crnas, and have had no larngospasm I couldn't break or lma I could not replace.
 
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I became steadily more and more disinfatuated with LMAs over time.

They're good for keeping simple cases simple, but I've never really understood the drive to use them for more and more cases.
 

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As an attending, I've been using LMA in cases where in residency the idea of LMA instead of ETT was unfathomable.
 

Mman

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ETT requires deeper level of anesthesia, more anesthesia ----> Longer PACU stay, more PONV, more post-op delirium...
Also laryngoscopy means more likelihood of dental injury
Is there any strong evidence to suggest that LMAs are associated with less PONV, longer PACU stays, and less postop delirium? Because anecdotally I've never seen that.
 
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SaltyDog

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For GA's, I find that with ETT, I don't have to worry as much about dislodgement/larygospasm when I leave the patient with a resident. I feel I can wake a patient up as quick with ETT vs LMA, and less problems on emergence too (biting on LMA/again dislodgment/unable to ventilate during stage 2 (i know there are some LMA's with bite blocks)
First off, if you're regularly having problems on emergence with LMA's then you're not doing something right.

Second, you are doing your residents a great disservice by not "letting" them use LMA's in appropriate cases. They need to learn how to use an LMA just as much as they need to learn how to use an ETT, and that includes some instances where they want to use an LMA - you let them, and then at the end of the case they realize "Sh!t, I wish I woulda just put a fuggin tube in." Don't let your own fears/insecurities affect resident education. You need to give them a little rope sometimes knowing YOU can cut the rope in time just before they hang themselves. That's how they learn.
 
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SaltyDog

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ETT requires deeper level of anesthesia, more anesthesia
Sorry, but that is just plain not true. Yes the LMA is less stimulating than an ETT, but remember - the patient is also having surgery at the time. Unless you have a block in place, an LMA requires more anesthesia to prevent pt movement since they aren't relaxed. With a tube you can run them much lighter and rely on some paralytic to keep them still.
 

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Sorry, but that is just plain not true. Yes the LMA is less stimulating than an ETT, but remember - the patient is also having surgery at the time. Unless you have a block in place, an LMA requires more anesthesia to prevent pt movement since they aren't relaxed. With a tube you can run them much lighter and rely on some paralytic to keep them still.
Are you saying that you can't use a "paralytic" with an LMA? Why is that???
And do you give a "paralytic" to every patient who has an ETT?
 
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Planktonmd

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Is there any strong evidence to suggest that LMAs are associated with less PONV, longer PACU stays, and less postop delirium? Because anecdotally I've never seen that.
No... but there is evidence that higher concentrations of inhaled agents and more opiates that are required to make the patient tolerate a foreign body in the trachea do cause all those things that you mentioned.
Is that really so complicated?
 

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When I started on my own post-residency I was using LMAs way more often than I did as a trainee. Over time I began using them less, especially after experiencing a few cases where I really wish I had an ETT in place rather than an LMA (like, for instance, one case where I went prone with an LMA in place. Not the smartest decision and had my sphincter clinched the entire time, but the patient ended up doing okay. That being said, I'm never going to do it again).

In my current state I use a combination of both LMAs and ETTs. It simply boils down to listening to my gut. If I have any inclination or tickle in the back of my head to put an ETT in, I do not second guess myself and put it in. However, if there is literally no reason to not use an LMA, I drop one in (even in cases such as total hips where we are full lateral).

At the end of the day, I have never regretted having an ETT in place, but HAVE regretted not having an ETT in place. That being said, LMAs are still wonderful devices in the right patient that have a permanent place in my practice.
 

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Are you saying that you can't use a "paralytic" with an LMA? Why is that???
And do you give a "paralytic" to every patient who has an ETT?
Pretty sure I didn't say that . . . yup, just checked - I never said that. Please don't put words in my mouth. Of course you can paralyze a pt with an LMA. I've done it, but I don't see why you would do this on the reg, or why this would be your plan going in. If you plan to paralyze the pt, just put a tube in and don't worry about whether you'll have a nice seal or not. An LMA is a great tool to simplify an anesthetic where you don't want/need to use paralytic.

And no every pt with an ETT does not require a paralytic. I never said that either. Really not sure why you are attempting to pimp me like I'm a CA-1.

Despite your 2 smart-ass remarks, you didn't say anything to refute my claim that what you said is incorrect. If you wanna minimize your anesthetic dose for whatever reason, then paralytic with an ETT is a better way to do that than an LMA.
 

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I became steadily more and more disinfatuated with LMAs over time.

They're good for keeping simple cases simple, but I've never really understood the drive to use them for more and more cases.
You probably haven't worked in a PP setting. Time is money (including in the PACU), and so is patient satisfaction.
 
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No... but there is evidence that higher concentrations of inhaled agents and more opiates that are required to make the patient tolerate a foreign body in the trachea do cause all those things that you mentioned.
Is that really so complicated?
We don't give a higher percentage of ET agent or more narcotics to intubated patients compared to LMA patients. Do you? If so, why?
 
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Sorry, but that is just plain not true. Yes the LMA is less stimulating than an ETT, but remember - the patient is also having surgery at the time. Unless you have a block in place, an LMA requires more anesthesia to prevent pt movement since they aren't relaxed. With a tube you can run them much lighter and rely on some paralytic to keep them still.
So can you with an LMA, except there is even less stimulation than with an ETT. I tend to paralyze them for a number of surgeries, e.g. tummy tuck. LMA does not equal PSV.
 

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You probably haven't worked in a PP setting. Time is money (including in the PACU), and so is patient satisfaction.
LMA v. ETT should have no impact on your anesthetic time. Sore throat is > for ETT on short cases but equalizes the longer that LMA is in place.
 

SaltyDog

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So can you with an LMA. I tend to do that, for a number of surgeries, e.g. tummy tuck.
Sure you can do that, but in that instance (tummy tuck) what are you gaining by using an LMA over an ETT? It's a long case where the surgeon wants relaxation. What's the LMA doing for you there??
 

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Sure you can do that, but in that instance (tummy tuck) what are you gaining by using an LMA over an ETT? It's a long case where the surgeon wants relaxation. What's the LMA doing for you there??
Less airway stimulation intraop, meaning lighter anesthesia and I only have to paralyze for specific surgical times. Less sore throat etc. from laryngoscopy. Faster door to incision, happier private surgeons. Less paralytic, less risk for incomplete reversal (not everybody has sugammadex for every patient), less PONV from the reversal, LMA much cheaper than the cost of reversal.

This type of surgery is probably my limit for LMAs. I haven't had the guts to use it for laparoscopies, not in the land of the litigious.
 
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Planktonmd

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Pretty sure I didn't say that . . . yup, just checked - I never said that. Please don't put words in my mouth. Of course you can paralyze a pt with an LMA. I've done it, but I don't see why you would do this on the reg, or why this would be your plan going in. If you plan to paralyze the pt, just put a tube in and don't worry about whether you'll have a nice seal or not. An LMA is a great tool to simplify an anesthetic where you don't want/need to use paralytic.

And no every pt with an ETT does not require a paralytic. I never said that either. Really not sure why you are attempting to pimp me like I'm a CA-1.

Despite your 2 smart-ass remarks, you didn't say anything to refute my claim that what you said is incorrect. If you wanna minimize your anesthetic dose for whatever reason, then paralytic with an ETT is a better way to do that than an LMA.
You are trying to say that a GA with an ETT and muscle relaxant to patch a crappy anesthetic is better than a GA with an LMA and I am just telling you very honestly you are wrong!
If you consider that pimping then you are right I am pimping you!
There is a reason LMAs are so popular all over the world and there is a reason you should use a less invasive airway device every time you can, but if you don't see that reason I can't help you!
 

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We don't give a higher percentage of ET agent or more narcotics to intubated patients compared to LMA patients.
Yes you do... but you don't know it!
Unless you are depending on Opiates more or giving a muscle relaxant to make a crappy anesthetic look better!
 

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You are trying to say that a GA with an ETT and muscle relaxant to patch a crappy anesthetic is better than a GA with an LMA and I am just telling you very honestly you are wrong!
If you consider that pimping then you are right I am pimping you!
There is a reason LMAs are so popular all over the world and there is a reason you should use a less invasive airway device every time you can, but if you don't see that reason I can't help you!
Plank, please just explain to me how you can run a pt lighter with no paralysis than you can a pt with relaxant on board. You still haven't done that.

Unless you have a block in place or the surgeon is wizard with local, the surgical stimulation will surpass the stimulation from your airway device during the case. An ETT really isn't that stimulating once its been in place for more that a few minutes provided you aren't moving things around and dragging it across the cords repeatedly.

And last I checked, we run balanced anesthetics these days. Volatile for recall/unconsciousness, opioids/LA for pain, relaxants for movement and muscle tone. I'm really not sure how that qualifies as "patching a crappy anesthetic w/ relaxant" unless of course its' your practice to overdose everybody on volatile which is way more common than most realize.

You still haven't made a case for why the "less invasive" LMA is superior to an ETT. You just keep saying "It is because I say it is you moron!" Come on man, I know you are better than this.

Yes you do... but you don't know it!
WTF does than mean?? I'm pretty sure that's something you can objectively quantify pretty easily.

Unless you are depending on Opiates more or giving a muscle relaxant to make a crappy anesthetic look better!
What makes it "crappy" if it gives you a pt that's asleep, has stable vitals, and a quiet surgical field?? I'm begging you to make a coherent argument here.
 
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OP needs to indicate what types of cases he's referring to. If you're at a surgicenter doing a bunch of knee scopes on healthy pts, you shouldn't be putting in a snorkel for all those cases. Also many surgeons do care if you use an lma vs ett, whether their rationale is correct or not. If they're accustomed to having all their cases done with an lma and you're in there tubing all of em, they won't be too pleased. I've seen quite a few surgeons complain when an anesthesiologist tubed their pt in that scenario
 
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SaltyDog

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Less paralytic, less risk for incomplete reversal (not everybody has sugammadex for every patient), less PONV from the reversal
Well you're either reversing them or your're not. You don't get to claim less risk of residual paralysis and less risk of PONV from reversal.
 

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For pete's sake, its an ETT, not a broken Coke bottle. Interchangeable in my practice. If I don't feel like working that hard and it isn't contraindicated, I'll use an LMA. Otherwise it's a tube.
 

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You probably haven't worked in a PP setting. Time is money (including in the PACU), and so is patient satisfaction.
I have, and it's why I generally favor desflurane.

ETT vs LMA makes zero difference in PACU times, provided you don't do anything silly like go overboard on paralytic sor opiates, which you don't need more of.

Don't get me wrong, I've nothing against LMAs especially for the high turnover outpatient surgery you're talking about. I just don't see why so many people like to shoehorn them into their anesthetics because LMAs-are-better.
 

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For pete's sake, its an ETT, not a broken Coke bottle. Interchangeable in my practice. If I don't feel like working that hard and it isn't contraindicated, I'll use an LMA. Otherwise it's a tube.
Exactly! And an ET tube requires less anesthesia than an LMA. A patient can be wide awake in the ICU with no sedation and tolerating a tube. This is not possible with an LMA. I use LMAs all the time but will use a tube whenever there is a doubt. I use sux with a defasiculating dose of roc If it is a short case.
 

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Plank, please just explain to me how you can run a pt lighter with no paralysis than you can a pt with relaxant on board. You still haven't done that.

Unless you have a block in place or the surgeon is wizard with local, the surgical stimulation will surpass the stimulation from your airway device during the case. An ETT really isn't that stimulating once its been in place for more that a few minutes provided you aren't moving things around and dragging it across the cords repeatedly.

And last I checked, we run balanced anesthetics these days. Volatile for recall/unconsciousness, opioids/LA for pain, relaxants for movement and muscle tone. I'm really not sure how that qualifies as "patching a crappy anesthetic w/ relaxant" unless of course its' your practice to overdose everybody on volatile which is way more common than most realize.

You still haven't made a case for why the "less invasive" LMA is superior to an ETT. You just keep saying "It is because I say it is you moron!" Come on man, I know you are better than this.



WTF does than mean?? I'm pretty sure that's something you can objectively quantify pretty easily.



What makes it "crappy" if it gives you a pt that's asleep, has stable vitals, and a quiet surgical field?? I'm begging you to make a coherent argument here.
When the anesthetic gets light the patient with an ETT will start bucking (regardless of how long the tube has been in) much earlier than the one with an LMA, which you are basically trying to prevent by paralyzing the patient.
When you say that an ETT is well tolerated after a few minutes have you thought about the patients that start suddenly bucking after hours of anesthesia simply because the anesthetic level has decreased? You do agree that this happens more frequently with an ETT than with an LMA unless they are paralyzed don't you?
So, basically the indication for giving muscle relaxants in your anesthetic is to tolerate the ETT and that in my opinion is not a good indication.
Muscle relaxants should be given only if the surgical procedure requires them, and the longer you practice the more you realize that muscle relaxants are not essential to the majority of your anesthetics.
I hope you also agree with me and with most of the world that every time you avoid putting a foreign body inside the trachea you are doing your patient a favor. The benefits are numerous but I can mention a few: You avoid the stress of intubation and extubation, you avoid the additional anesthetic required to maintain the tube, you minimize the likelihood of dental injury, you are less likely to irritate the airway and cause bronchospasm, you have much quicker turnover...
So, I am not sure what else you want me to say to explain why I am in favor of LMA's when possible without you accusing me of pimping you?
 
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When the anesthetic gets light the patient with an ETT will start bucking (regardless of how long the tube has been in) much earlier than the one with an LMA, which you are basically trying to prevent by paralyzing the patient.
When you say that an ETT is well tolerated after a few minutes have you thought about the patients that start suddenly bucking after hours of anesthesia simply because the anesthetic level has decreased? You do agree that this happens more frequently with an ETT than with an LMA unless they are paralyzed don't you?
So, basically the indication for giving muscle relaxants in your anesthetic is to tolerate the ETT and that in my opinion is not a good indication.
Muscle relaxants should be given only if the surgical procedure requires them, and the longer you practice the more you realize that muscle relaxants are not essential to the majority of your anesthetics.
I hope you also agree with me and with most of the world that every time you avoid putting a foreign body inside the trachea you are doing your patient a favor. The benefits are numerous but I can mention a few: You avoid the stress of intubation and extubation, you avoid the additional anesthetic required to maintain the tube, you minimize the likelihood of dental injury, you are less likely to irritate the airway and cause bronchospasm, you have much quicker turnover...
So, I am not sure what else you want me to say to explain why I am in favor of LMA's when possible without you accusing me of pimping you?
 

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There are plenty of ways to keep the patient from bucking without muscle relaxant. Sufficient short acting narcotic, propofol, pressure support, slightly reduced end tidal CO2 etc.
 

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I did a long comparison of cases (1200) with ett vs lma for tonsillectomy at our ASC and found a reduction in pacu times with lmas. OR times were reduced as well, as we took the ett out in OR but the lmas were removed by PACU staff when patient more awake. We always use a bite block (usually rolled 4x4) whenever patient awakens with lma in place. Respiratory events in the PACU and nausea and vomiting were the same in the 2 groups. This wasn't accepted for publication because of IRB, randomization, blinding etc - hard to do studies that will be accepted in private practice.
 
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I did a long comparison of cases (1200) with ett vs lma for tonsillectomy at our ASC and found a reduction in pacu times with lmas. OR times were reduced as well, as we took the ett out in OR but the lmas were removed by PACU staff when patient more awake. We always use a bite block (usually rolled 4x4) whenever patient awakens with lma in place. Respiratory events in the PACU and nausea and vomiting were the same in the 2 groups. This wasn't accepted for publication because of IRB, randomization, blinding etc - hard to do studies that will be accepted in private practice.
You know why your PONV was the same in PACU? My guess is that because you used short cases (tonsils) and I bet you the PONV would be higher in the ETT group in longer cases with longer exposure to anesthesia.
 

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So, basically the indication for giving muscle relaxants in your anesthetic is to tolerate the ETT and that in my opinion is not a good indication.
First off, thank you for a more eloquent post, however, you still have not addressed my point about the anesthetic requirement for the pt tolerate the operation, not the airway.

Of course an LMA is less stimulating than an ETT. You are getting no argument from me on that point.

But, regardless of what airway device you use, a given pt will require a certain amount of anesthetic to not move in response to the surgical stimulus. If you are relying on the volatile to accomplish this, then you need to give more than you would to a pt who is also paralyzed. That is a fact. Use of an LMA does not magically change that.

The indication for the paralytic is to tolerate the operation, not the ETT as you claim.

And I'm not some whack-a-doo that deeply paralyzes every patient. I'm just trying to say that a paralyzed pt with an ETT will require less anesthetic than one with an LMA where you're relying on the anesthetic agents to prevent movement. This is not a difficult concept.
 

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which claim is annoying you?
The fact that a cholinesterase inhibitor causes nausea or that an LMA is cheaper than reversal?
the claim that an ETT leads to these worse outcomes when objective data says it doesn't
 

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Yes you do... but you don't know it!
Unless you are depending on Opiates more or giving a muscle relaxant to make a crappy anesthetic look better!
We have a database from roughly 15 years of cases that shows we don't. ET agent and narcotic doses are all recorded and you can search by case type and duration and surgeon if you so desire.

let's be honest here, an LMA is not some super awesome piece of plastic that leads to better patient care than an ETT. LMAs cause sore throats. LMAs require general anesthesia to tolerate. If you want a patient to have a better experience, just do the case as a mask anesthetic. Then they won't get a sore throat.

And keep in mind, I'm somebody that uses LMAs at least 10x a week.
 

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First off, thank you for a more eloquent post, however, you still have not addressed my point about the anesthetic requirement for the pt tolerate the operation, not the airway.

Of course an LMA is less stimulating than an ETT. You are getting no argument from me on that point.

But, regardless of what airway device you use, a given pt will require a certain amount of anesthetic to not move in response to the surgical stimulus. If you are relying on the volatile to accomplish this, then you need to give more than you would to a pt who is also paralyzed. That is a fact. Use of an LMA does not magically change that.

The indication for the paralytic is to tolerate the operation, not the ETT as you claim.

And I'm not some whack-a-doo that deeply paralyzes every patient. I'm just trying to say that a paralyzed pt with an ETT will require less anesthetic than one with an LMA where you're relying on the anesthetic agents to prevent movement. This is not a difficult concept.
Let's say:
Total stimuli = Surgical pain + Irritation by airway device
So, if we agree as you stated that an LMA is less stimulating than an ETT then :
Surgical pain + ETT irritation > surgical pain + LMA stimulation
Does that work for you? :)
 

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Let's say:
Total stimuli = Surgical pain + Irritation by airway device
So, if we agree as you stated that an LMA is less stimulating than an ETT then :
Surgical pain + ETT irritation > surgical pain + LMA stimulation
Does that work for you? :)
No, it doesn't work for me.

With a relaxed pt: surgical stimulus + airway stimulus = NO patient movement because (wait for it). . .the pt is paralyzed. You can run them as light as want until you get down to MAC aware levels where awareness becomes a concern and that's pretty freakin' light

With an un-relaxed LMA pt: surgical stimulus + LMA stimulus = movement because the pt is not paralyzed and too light. You have to run more anesthetic to prevent movement. Get it now??
 

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No, it doesn't work for me.

With a relaxed pt: surgical stimulus + airway stimulus = NO patient movement because (wait for it). . .the pt is paralyzed. You can run them as light as want until you get down to MAC aware levels where awareness becomes a concern and that's pretty freakin' light

With an un-relaxed LMA pt: surgical stimulus + LMA stimulus = movement because the pt is not paralyzed and too light. You have to run more anesthetic to prevent movement. Get it now??
But if you decrease the stimulus by eliminating the ETT then you don't need a muscle relaxant to prevent movement!
That's the point!
You still can use a muscle relaxant if it's indicated but you are not using it to improve ETT tolerance!
Get it???
 

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No, it doesn't work for me.

With a relaxed pt: surgical stimulus + airway stimulus = NO patient movement because (wait for it). . .the pt is paralyzed. You can run them as light as want until you get down to MAC aware levels where awareness becomes a concern and that's pretty freakin' light

With an un-relaxed LMA pt: surgical stimulus + LMA stimulus = movement because the pt is not paralyzed and too light. You have to run more anesthetic to prevent movement. Get it now??
I am not sure why in your mind an LMA patient is always "unrelaxed"???
 

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But if you decrease the stimulus by eliminating the ETT then you don't need a muscle relaxant to prevent movement!
That's the point!
You still can use a muscle relaxant if it's indicated but you are not using it to improve ETT tolerance!
Get it???
An ETT is only a significantly more noxious stimulus in the trachea of someone with significantly reactive airways. Most patients do not buck any more on a small ETT than they do with an LMA. Gag reflex from LMA is the same as the gag from an ETT.
 

Planktonmd

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An ETT is only a significantly more noxious stimulus in the trachea of someone with significantly reactive airways. Most patients do not buck any more on a small ETT than they do with an LMA.
I disagree!
I think an ETT is significantly more irritating to the airway in every patient!
If you don't believe me think about the last time you did an awake intubation on a poorly anesthetized airway! Or about the last time you had some water or food particle go in your airway... do you remember that feeling?
 

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But if you decrease the stimulus by eliminating the ETT then you don't need a muscle relaxant to prevent movement!
Good lord Plank. The airway device is not the only source of stimulation during an operation. The surgery itself is STIMULATING. You need to prevent movement in response to the surgical stimulus. This is true even if you did the case with a mask and NO airway device.

If the goal is to provide the least amount of anesthetic possible, the best way to do that is with the addition of muscle relaxants. Period. I don't see how you are arguing that point.

If your plan is to use an LMA along with paralysis, I just don't get it. Yes you can do it, but if the plan is PPV from the get go I think most would agree that an ETT is a better way to skin that cat.

The amount of stimulation from the airway device (ETT v. LMA) in a paralyzed pt is irrelevant since the pt is paralyzed and they aren't gonna move anyways.

Now I'm exhausted. Thanks.
 

Planktonmd

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Good lord Plank. The airway device is not the only source of stimulation during an operation. The surgery itself is STIMULATING. You need to prevent movement in response to the surgical stimulus. This is true even if you did the case with a mask and NO airway device.

If the goal is to provide the least amount of anesthetic possible, the best way to do that is with the addition of muscle relaxants. Period. I don't see how you are arguing that point.

If your plan is to use an LMA along with paralysis, I just don't get it. Yes you can do it, but if the plan is PPV from the get go I think most would agree that an ETT is a better way to skin that cat.

The amount of stimulation from the airway device (ETT v. LMA) in a paralyzed pt is irrelevant since the pt is paralyzed and they aren't gonna move anyways.

Now I'm exhausted. Thanks.
So you are saying that the airway stimulation does not add to your anesthetic requirement?
And as long as they don't move then your anesthetic is good?
That's what CRNAs do usually!
 

Planktonmd

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At the end of the day it is stimulating to have these discussions and there is many ways to skin the cat!
Sorry for being obnoxious occasionally! ;)
 

SaltyDog

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So you are saying that the airway stimulation does not add to your anesthetic requirement?
And as long as they don't move then your anesthetic is good?
That's what CRNAs do usually!
Please don't hurl insults when none are warranted. This is a civilized discussion ;)

This is not a discussion as to what is the best anesthetic. This is a discussion on how to minimize anesthetic dose which was your original point in favor of LMA's and which I disagree with.

What's "best" gets a whole lot more nuanced and a whole lot more subjective.

I'm saying that I do not have to give more anesthetic to overcome airway stimulation in a paralyzed pt.

I'm saying that I can give less volatile and less opioid to a paralyzed pt.

I'm saying that if my plan is paralyze the pt, then an ETT is a better choice than an LMA.

That is all.
 

sigrhoillusion

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This thread went of the deep end...

Fact is, neither one is "better" than the other or else the ASA would publish a standard of care staying the use of one over the other. As people said, million ways to skin a cat. Tomayto... tomahto...

If i have any concerns, i stick with an ETT. But i often use LMAs. Just today did a radius ORIF. Wanted to do MAC after doing an infra block pre-op. But we were strapped for time, so did the block right before going back to OR and hadn't set in yet, so decided to just LMA.

Guy had a great airway. LMA 4 had huge leak. LMA 5 had huge leak. So we just intubated. Saw guy in PACU. Despite 3 LMA placements and intubation, he had no sore throat, but a completely dead/numb arm. Everyone was happy.
 

Mman

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I disagree!
I think an ETT is significantly more irritating to the airway in every patient!
If you don't believe me think about the last time you did an awake intubation on a poorly anesthetized airway! Or about the last time you had some water or food particle go in your airway... do you remember that feeling?
Have you ever put an LMA in an awake patient? No? Oh, that's right, because they'd be gagging like crazy.

An LMA is probably 5-10x the diameter of a 7.0 ETT at the level of the posterior pharynx. While it doesn't touch the trachea like a lightly inflated cuff on an ETT does, it is gigantically stimulating in the upper airway.
 
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