LMA vs ETT

[Planktonmd]

Anyone use those LMAs that you can pass an OG through to suction out the stomach?

As Noyac said... I don't see the reasoning in placing an LMA in a patient who would require OG tube to suction the stomach.
But some people use these LMAs routinely because they believe the hole at the tip would help drain any regurgitated gastric fluids and decrease the risk of aspiration.

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[deleted162650]

As Noyac said... I don't see the reasoning in placing an LMA in a patient who would require OG tube to suction the stomach

Hey, now on this we agree!

 

[Noyac]

As Noyac said... I don't see the reasoning in placing an LMA in a patient who would require OG tube to suction the stomach.
But some people use these LMAs routinely because they believe the hole at the tip would help drain any regurgitated gastric fluids and decrease the risk of aspiration.

Yeah that just makes me laugh. As if that little hole will help prevent any aspiration at all is ridiculous.

 

[AdmiralChz]

Haha, was just seeing if anyone has used them! A rep came to our institution and claimed it's an option for possible full stomachs...

No thanks.

 

[WholeLottaGame7]

I can't believe an LMA vs ETT thread got to 3 pages in less than 2 days. I was sure I was seeing things.

Plankton, I respect your preference for LMA but your logic for getting there is whack. If the surgical stimulation for a case is a 7, and the stimulation from an ETT is a 3, the total stimulation is a 7, not a 3. Unless you routinely park your ETTs on the carina, which is not "the best anesthetic possible."

You definitely have to run LMA cases on a higher MAC than an ETT to prevent laryngospasm. Many of the things you quote as riskier should be accounted for by an experienced anesthesiologist. If your ETT patients are going up to BPs of 240/120 on intubation, or are taking longer to wake up at the end of the case, that is a problem with YOUR technique. A master craftsmen should never blame the wood.

The question of PONV rates is a fair one. My anecdotal experience is that a 2 hour case with paralysis and 0.6MAC of volatile results in less PONV than a 2 hour case with 1.2 MAC of volatile, but if your personal experience varies, I'm not going to argue with you on that one.

I also have grown less fond of LMAs as time has gone on, especially as you get better placing/managing ETTs. I am well aware that many parts of the world use LMAs with muscle relaxant, and laparascopic cases, and prone, and yadda yadda, I just personally choose not to as the benefit:risk ratio is just not high enough for me.

 

[Mman]

ETT requires deeper anesthetic levels to maintain anesthesia and that leads to more PONV and longer PACU stay!
Unskilled anesthesiologists and CRNAs like to intubate and paralyze every patient and as a result they get more PONV and longer PACU stays.
These are simple facts that everyone knows!

Unfortunately your "facts" are not proven by scientific evidence.

Using an LMA does not lead to less PONV. It does not lead to shorter PACU stays. It does not lead to less emergence delirium. It does not lead to fewer cardiac complications.

That you think it does is just some combination of hilarious and sad. Although I kinda think you are just screwing with us.

 

[pgg]

Although I kinda think you are just screwing with us.

I think he's serious.

 

[Mman]

I think he's serious.

well that sort of scares me then

 

[anes121508]

Yea, I didn't understand the awake intubation statement... unless of course he does his awake intubations with an LMA... which would be questionable in itself. But agreed that regardless of LMA or ETT an awake patient ain't tolerating either one of them!

Wait, so you talk about how stimulating an ETT in an awake patient with an improperly anesthetized airway and you compare it to an LMA with an anesthetized airway? I thought most physicians would understand the difference.

I'm also curious to hear the scenarios when you've felt the need/desire to place an LMA in an awake patient. I can't imagine one.

Case where I used the LMA after topicalization and small bumps of ketamine:

Esophageal stent eroded through the trachea. CT shows obliteration/major of the trachea halfway between the cords and the carina by the stent with obvious fistula. Patient is in ICU with PNA and an incredible wheeze but obviously able to move air past the esophageal stent. Surgeon isn't sure what the plan is and needs to look at exactly what is going on until he decides what he wants to do.

Case went like this: sitting up, topicalize airway, small bit of ketamine, spontaneously breathing, pt is glazed, slide in lma, tolerates lma without dificulty, scope through LMA down through cords and see a nasty esophageal stent starting at us in the face with a tiny little slit for the trachea. Felt that stent would tear of the ETT and be hard to get past. Aintree over the scope through the lma down past the stent. Jet ventilate through the aintree while the surgeon used forceps to remove the esophageal stent. With that ugly stent out, ETT over aintree into the trachea. Surgeon replace esophageal stent (different less ugly type). Surgeon now wants to place tracheal stent to seal everything up. Remove ETT from trachea and slide LMA back in so the surgeon can work through the LMA and place the tracheal stent. Kissing stents (esophageal and tracheal). Woke up patient with LMA and transfered back to ICU in what appeared to be better shape than before.

Probably many different ways to do this case, but felt that the awake LMA was helpful in order to see exactly what it was we were dealing with.

 

[Arch Guillotti]

Case where I used the LMA after topicalization and small bumps of ketamine:

Esophageal stent eroded through the trachea. CT shows obliteration/major of the trachea halfway between the cords and the carina by the stent with obvious fistula. Patient is in ICU with PNA and an incredible wheeze but obviously able to move air past the esophageal stent. Surgeon isn't sure what the plan is and needs to look at exactly what is going on until he decides what he wants to do.

Case went like this: sitting up, topicalize airway, small bit of ketamine, spontaneously breathing, pt is glazed, slide in lma, tolerates lma without dificulty, scope through LMA down through cords and see a nasty esophageal stent starting at us in the face with a tiny little slit for the trachea. Felt that stent would tear of the ETT and be hard to get past. Aintree over the scope through the lma down past the stent. Jet ventilate through the aintree while the surgeon used forceps to remove the esophageal stent. With that ugly stent out, ETT over aintree into the trachea. Surgeon replace esophageal stent (different less ugly type). Surgeon now wants to place tracheal stent to seal everything up. Remove ETT from trachea and slide LMA back in so the surgeon can work through the LMA and place the tracheal stent. Kissing stents (esophageal and tracheal). Woke up patient with LMA and transfered back to ICU in what appeared to be better shape than before.

Probably many different ways to do this case, but felt that the awake LMA was helpful in order to see exactly what it was we were dealing with.

Nice job on what sounds like a nightmare. One question though - why did you choose to jet through the Aintree instead of hand ventilating and how did it work? Seems like the caliber would be big enough that you wouldn't have to jet. I am curious because I have used the Aintree a few times but never had to ventilate through it.

 

[WholeLottaGame7]

Case where I used the LMA after topicalization and small bumps of ketamine:

Esophageal stent eroded through the trachea. CT shows obliteration/major of the trachea halfway between the cords and the carina by the stent with obvious fistula. Patient is in ICU with PNA and an incredible wheeze but obviously able to move air past the esophageal stent. Surgeon isn't sure what the plan is and needs to look at exactly what is going on until he decides what he wants to do.

Case went like this: sitting up, topicalize airway, small bit of ketamine, spontaneously breathing, pt is glazed, slide in lma, tolerates lma without dificulty, scope through LMA down through cords and see a nasty esophageal stent starting at us in the face with a tiny little slit for the trachea. Felt that stent would tear of the ETT and be hard to get past. Aintree over the scope through the lma down past the stent. Jet ventilate through the aintree while the surgeon used forceps to remove the esophageal stent. With that ugly stent out, ETT over aintree into the trachea. Surgeon replace esophageal stent (different less ugly type). Surgeon now wants to place tracheal stent to seal everything up. Remove ETT from trachea and slide LMA back in so the surgeon can work through the LMA and place the tracheal stent. Kissing stents (esophageal and tracheal). Woke up patient with LMA and transfered back to ICU in what appeared to be better shape than before.

Probably many different ways to do this case, but felt that the awake LMA was helpful in order to see exactly what it was we were dealing with.

Great case, thanks for sharing.

 

[Planktonmd]

well that sort of scares me then

I did not mean to scare you!

 

[Planktonmd]

Unfortunately your "facts" are not proven by scientific evidence.

Using an LMA does not lead to less PONV. It does not lead to shorter PACU stays. It does not lead to less emergence delirium. It does not lead to fewer cardiac complications.

That you think it does is just some combination of hilarious and sad. Although I kinda think you are just screwing with us.

Let me ask you this genius: Why do you think the Europeans use LMAs for just about everything?
Are they just stupid and don't understand the obvious lack of benefit you have convinced yourself of?
If that's the case then maybe we should go on a crusade to teach the world that an invisive airway is superior to a supraglottic airway for routine anesthesia cases!
I also can't believe you just said that the stress from laryngoscopy would not contribute to more cardiac risk! Do you really believe that?
Do this experiment: Take tow comparable not beta blocked patients
Case one: give induction dose of propofol and insert LMA, observe hemodynamic changes.
Case two: give induction dose of propofol with muscle relaxant if you want, do lryngoscopy and insert ETT, record vitals.
Now compare the numbers!
Now you are scaring me!

 

[Arch Guillotti]

I also can't believe you just said that the stress from laryngoscopy would not contribute to more cardiac risk! Do you really believe that?

The stress from laryngoscopy can easily be attenuated if you take your time and do it right.

 

[Planktonmd]

The stress from laryngoscopy can easily be attenuated if you take your time and do it right.

If you "take your time" that means you probably are going to give more inhaled agent or add an opiate... more anesthesia that you don't need otherwise!

 

[Arch Guillotti]

If you "take your time" that means you probably are going to give more inhaled agent or add an opiate... more anesthesia that you don't need otherwise!

Try esmolol or remi.

 

[medking]

Let me ask you this genius: Why do you think the Europeans use LMAs for just about everything?
Are they just stupid and don't understand the obvious lack of benefit you have convinced yourself of?
If that's the case then maybe we should go on a crusade to teach the world that an invisive airway is superior to a supraglottic airway for routine anesthesia cases!
I also can't believe you just said that the stress from laryngoscopy would not contribute to more cardiac risk! Do you really believe that?
Do this experiment: Take tow comparable not beta blocked patients
Case one: give induction dose of propofol and insert LMA, observe hemodynamic changes.
Case two: give induction dose of propofol with muscle relaxant if you want, do lryngoscopy and insert ETT, record vitals.
Now compare the numbers!
Now you are scaring me!

It's all about knowing your medications and finesse with intubation. Hemodynamics stability can be achieved in either situation.

 

[deleted171991]

Europeans have discovered that they can achieve more with less, plus they don't get sued for every bent strand of hair. When one is not financially incentivized to increase anesthetic time and OR time, and practice defensive medicine, but to finish stuff and go home early, magical things happen, as the classical FedEx shift story teaches. It's all a matter of incentives. Plus they have less obesity.

 

[deleted162650]

Europeans have discovered that they can achieve more with less, plus they don't get sued for every bent strand of hair. When one is not financially incentivized to increase anesthetic time and OR time, and practice defensive medicine, but to finish stuff and go home early, magical things happen, as the classical FedEx shift story teaches. It's all a matter of incentives.

I think the defensive medicine part is spot on. A system which reimburses based on productivity though encourage FAAAAR more efficiency than a salary based one. You ever tried to get things moving at the VA??

Remember, our billing includes start up units which makes it financially beneficial to keep things moving and get the next case in the room rather than spend an extra 5 minutes on each case.

 

[nimbus]

Europeans have discovered that they can achieve more with less, plus they don't get sued for every bent strand of hair. When one is not financially incentivized to increase anesthetic time and OR time, and practice defensive medicine, but to finish stuff and go home early, magical things happen, as the classical FedEx shift story teaches. It's all a matter of incentives. Plus they have less obesity.

So who's doing it right? Which would you prefer?

 

[Mman]

Let me ask you this genius: Why do you think the Europeans use LMAs for just about everything?
Are they just stupid and don't understand the obvious lack of benefit you have convinced yourself of?
If that's the case then maybe we should go on a crusade to teach the world that an invisive airway is superior to a supraglottic airway for routine anesthesia cases!
I also can't believe you just said that the stress from laryngoscopy would not contribute to more cardiac risk! Do you really believe that?
Do this experiment: Take tow comparable not beta blocked patients
Case one: give induction dose of propofol and insert LMA, observe hemodynamic changes.
Case two: give induction dose of propofol with muscle relaxant if you want, do lryngoscopy and insert ETT, record vitals.
Now compare the numbers!
Now you are scaring me!

The fact that none of this is backed up by scientific data kinda proves it isn't true. The studies would be so simple and easy to do.

I mean do you really believe you have fewer postop MIs because of an LMA? Really? You could be world famous and win a Nobel Prize if you could prove that. Think of how easy it would be!

 

[Mman]

Europeans have discovered that they can achieve more with less, plus they don't get sued for every bent strand of hair. When one is not financially incentivized to increase anesthetic time and OR time, and practice defensive medicine, but to finish stuff and go home early, magical things happen, as the classical FedEx shift story teaches. It's all a matter of incentives. Plus they have less obesity.

Every private practice in the US has incentive to get things done fast and efficiently so they can go home early.

 

[bigtuna]

Case where I used the LMA after topicalization and small bumps of ketamine:

Esophageal stent eroded through the trachea. CT shows obliteration/major of the trachea halfway between the cords and the carina by the stent with obvious fistula. Patient is in ICU with PNA and an incredible wheeze but obviously able to move air past the esophageal stent. Surgeon isn't sure what the plan is and needs to look at exactly what is going on until he decides what he wants to do.

Case went like this: sitting up, topicalize airway, small bit of ketamine, spontaneously breathing, pt is glazed, slide in lma, tolerates lma without dificulty, scope through LMA down through cords and see a nasty esophageal stent starting at us in the face with a tiny little slit for the trachea. Felt that stent would tear of the ETT and be hard to get past. Aintree over the scope through the lma down past the stent. Jet ventilate through the aintree while the surgeon used forceps to remove the esophageal stent. With that ugly stent out, ETT over aintree into the trachea. Surgeon replace esophageal stent (different less ugly type). Surgeon now wants to place tracheal stent to seal everything up. Remove ETT from trachea and slide LMA back in so the surgeon can work through the LMA and place the tracheal stent. Kissing stents (esophageal and tracheal). Woke up patient with LMA and transfered back to ICU in what appeared to be better shape than before.

Probably many different ways to do this case, but felt that the awake LMA was helpful in order to see exactly what it was we were dealing with.

This case gets done on VV ECMO at my hospital

 

[Planktonmd]

The fact that none of this is backed up by scientific data kinda proves it isn't true. The studies would be so simple and easy to do.

I mean do you really believe you have fewer postop MIs because of an LMA? Really? You could be world famous and win a Nobel Prize if you could prove that. Think of how easy it would be!

Do you really think there is a way to do prospective double blind studies comparing LMAs to ETT in similar patients and similar surgeries?

 

[Planktonmd]

Europeans have discovered that they can achieve more with less, plus they don't get sued for every bent strand of hair. When one is not financially incentivized to increase anesthetic time and OR time, and practice defensive medicine, but to finish stuff and go home early, magical things happen, as the classical FedEx shift story teaches. It's all a matter of incentives. Plus they have less obesity.

Agree! The fear of litigation is a very important factor here.
But some people are trying to come up with silly arguments to justify their practice and avoid admitting the sad fact that it is mainly motivated by fear of lawyers not by what's best for the patient.
When enough people are afraid of lawyers they tend to practice that defensive medicine you described and as a result their way of doing things becomes the feared "standard of care" that forces the rest of us to do stupid things even against our best clinical judgement!

 

[Planktonmd]

Every private practice in the US has incentive to get things done fast and efficiently so they can go home early.

They do have the incentive but many of them don't necessarily know how!

 

[Mman]

Do you really think there is a way to do prospective double blind studies comparing LMAs to ETT in similar patients and similar surgeries?

Why would it need to be double blind? Just randomize similar patients for the same surgery to ETT vs LMA. Easy. Simple. And after 100,000 patients you'd have zero significant findings.

 

[Planktonmd]

Why would it need to be double blind? Just randomize similar patients for the same surgery to ETT vs LMA. Easy. Simple. And after 100,000 patients you'd have zero significant findings.

Well... obviously there is no need for a study since you already know the results!
But in reality it would be very difficult to eliminate observe's or provider's bias in this type of study!

 

[pgg]

Litigation fear is a red herring.

I've been virtually un-sue-able for the last 7 years (prior to going back to fellowship) and I steadily used fewer and fewer LMAs over that time, despite doing mostly outpatient surgery where turnover times and PACU discharges matter.

Well... obviously there is no need for a study since you already know the results!

You're talking to yourself here, right?

If there's anyone on this thread absolutely convinced his way is the right way, it's you.

 

[Planktonmd]

Litigation fear is a red herring.

I've been virtually un-sue-able for the last 7 years (prior to going back to fellowship) and I steadily used fewer and fewer LMAs over that time, despite doing mostly outpatient surgery where turnover times and PACU discharges matter.




You're talking to yourself here, right?

If there's anyone on this thread absolutely convinced his way is the right way, it's you.

No... it's not "my way"... it's the way of a very large number of anesthesiologists world wide!
What makes you think that what you chose to do as your personal preference is better?

 

[deleted171991]

Remember, our billing includes start up units which makes it financially beneficial to keep things moving and get the next case in the room rather than spend an extra 5 minutes on each case.

Not for the employees, which most of us are.

 

[deleted171991]

Litigation fear is a red herring.

I've been virtually un-sue-able for the last 7 years (prior to going back to fellowship) and I steadily used fewer and fewer LMAs over that time, despite doing mostly outpatient surgery where turnover times and PACU discharges matter.

I am sorry, but American doctors are educated in a defensive medicine culture starting from med school. It's in there, almost in your genes, regardless of how practice settings change. You've been brainwashed into it without knowing, by most of the people who have ever taught you, even by your knowledge tests. In Europe, many times, one treats the most probable clinical diagnosis without a ton of unnecessary testing. In the US, it's rule out MI in a 20 year-old, just because there is one case in a million.

 

[Mman]

Well... obviously there is no need for a study since you already know the results!
But in reality it would be very difficult to eliminate observe's or provider's bias in this type of study!

LOL, talk about already knowing the results. You seem quite sure of things yourself there buddy.

 

[deleted162650]

Not for the employees, which most of us are.

Then how is your motivation in an employee model any different from practicing in Europe under and employed model. What point were you trying to make??

 

[deleted171991]

Then how is your motivation in an employee model any different from practicing in Europe under and employed model. What point were you trying to make??

In Europe, healthcare is truly not for (executive/shareholder) profit, mostly. So nobody cuts your head (or your pay) if you leave earlier or study etc. after the work is done. In the US, they just invent something else for you to do, or they just send you home while counting the unworked hours as overtime due, because they are obsessed with profits before people. They would rather hire another middle manager to squeeze employees for the sake of extra 5% profit, rather than improve employee life by 25% while leaving some change on the table. In Europe, there is no such thing as your employer paying consultants to teach you how to cope with "stress", a euphemism for being exhausted from work; they just don't/can't make your work 65-70 hours/week, like 100 years ago.

Anyway, I am sure they use LMAs mostly because it's much easier, as long as one doesn't get sued for the one patient in a thousand who aspirates. I haven't practiced in Europe for ages, so this is all hearsay.

 

[Planktonmd]

LOL, talk about already knowing the results. You seem quite sure of things yourself there buddy.

Actually... Yes I am sure of things!
It's called having common sense buddy!

 

[dhb]

I don't use a lot of LMAs.
I do not believe a deeper anesthetic is needed for GETA vs LMA.
Post op hearts are quit comfortable in the icu with an ett, i woudn't bet on the same with an LMA...

 

[dhb]

Actually... Yes I am sure of things!
It's called having common sense buddy!

Common sense is not always the best treatment.

 

[pgg]

What makes you think that what you chose to do as your personal preference is better?

Actually... Yes I am sure of things!

I'm just going to leave these two quotes right here, and let you reread what you just wrote. Are you really oblivious to how dogmatic and opinion/anecdote-based your position is on this?

 

[Planktonmd]

I'm just going to leave these two quotes right here, and let you reread what you just wrote. Are you really oblivious to how dogmatic and opinion/anecdote-based your position is on this?

You don't need studies to prove common sense especially when it is a very common practice shared by the majority of anesthesiologists all over the world!
On the other hand I think this dead horse has been sufficiently clobbered, don't you agree?

 

[Planktonmd]

Common sense is not always the best treatment.

True!

 

[WholeLottaGame7]

Another issue that might be worth bringing up: what are surgeons like in Europe? Do they bitch if the patient doesn't have 0/4 twitches for skin closure?

 

[Mman]

You don't need studies to prove common sense especially when it is a very common practice shared by the majority of anesthesiologists all over the world!
On the other hand I think this dead horse has been sufficiently clobbered, don't you agree?

the overwhelming majority disagree with you in US and worldwide

 

[Planktonmd]

the overwhelming majority disagree with you in US and worldwide

 

[Planktonmd]

Another issue that might be worth bringing up: what are surgeons like in Europe? Do they bitch if the patient doesn't have 0/4 twitches for skin closure?

Surgeons every where are similar and their perfect anesthesiologist is one who is invisible but can keep patients perfectly still while they cut on them and wake them up immediately when they are done!

 

[anes121508]

Nice job on what sounds like a nightmare. One question though - why did you choose to jet through the Aintree instead of hand ventilating and how did it work? Seems like the caliber would be big enough that you wouldn't have to jet. I am curious because I have used the Aintree a few times but never had to ventilate through it.

I just had the Sanders hand jet vent available and am comfortable using it. It worked very well. Very easy to see chest rise or even feel the chest up and down with your hand. If I do this again, i'll try and bag through the aintree and see how that works. Never done it before.

 

[drmwvr]

I just had the Sanders hand jet vent available and am comfortable using it. It worked very well. Very easy to see chest rise or even feel the chest up and down with your hand. If I do this again, i'll try and bag through the aintree and see how that works. Never done it before.

You mean jet through the Aintree.

 

[anes121508]

You mean jet through the Aintree.

correct, it (sanders - hand triggered low frequency jet ventilation) worked well.....I think someone mentioned you can hook up the anesthesia circuit to the aintree and bag through it

http://ceaccp.oxfordjournals.org/content/7/1/2.full

 

[fakin' the funk]

Anyone use those LMAs that you can pass an OG through to suction out the stomach?

I do. Reusable = "Proseal," disposable = "Supreme."

I like them. I use them maybe 10-20% of all my LMA cases. It's easy to pop a lubed 14fr OGT down the gastric suction port.

I view it as an LMA with a bonus feature, not as an alternative to an ETT where I actually suspect a "full stomach." So I use them in situations where an LMA is the appropriate airway device, but maybe just maybe I wanna empty the stomach. Say, a fasted HbA1C = 8 diabetic. Or maybe an ASA1 skinny person who ate a piece of toast *exactly* 6 hours ago. IMO, it would be silly to intubate these two patients based on a very low suspicion of "full stomach" only.

 

[deleted162650]

I do. Reusable = "Proseal," disposable = "Supreme."

I like them. I use them maybe 10-20% of all my LMA cases. It's easy to pop a lubed 14fr OGT down the gastric suction port.

I view it as an LMA with a bonus feature, not as an alternative to an ETT where I actually suspect a "full stomach." So I use them in situations where an LMA is the appropriate airway device, but maybe just maybe I wanna empty the stomach. Say, a fasted HbA1C = 8 diabetic. Or maybe an ASA1 skinny person who ate a piece of toast *exactly* 6 hours ago. IMO, it would be silly to intubate these two patients based on a very low suspicion of "full stomach" only.

I'm curious, when you do this for these "borderline" cases what's the breakdown on how many are:

"Oh ****, that guy still had a lot in his stomach"

vs

"Eh, guess I didn't need to do that"