LMA with paralysis

[Maverikk]

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the other lma trauma made me think of this and wanted to get some insights.
When I was a resident I worked with a dude who would put in a lma supreme for simple laparoscopic cases (choles, gyn), in private practice where they would take 45-1.5 hr (max). He'd put in an OG, and would pressure control to adequate tidal volume up to 30 until spontaneous with support. Said the OG evacuated the stomach of air/contents. He was from the EU and said it was more common over there. I did it a few times with him and it worked. The reasoning seems ok, the only real advantage I see is less sore throat. Thoughts?

 

[fakin' the funk]

I think that's a lot of rigamarole to avoid putting some plastic in the trachea.

It's not necessarily wrong to use NMB with LMA, I'm just a believer in the idea that if you *plan* to do positive pressure ventilation you should put an ETT in; that's what ETTs are designed for.

I use LMAs more like a sealed oral airway than like an ETT. In fact, they're excellent oral always for those dicey "big MAC" type cases.

 

[San Marzano]

I'm ok with giving every single one of my patients a sore throat for the rest of my career if it means I get to avoid even one preventable aspiration. If patients understood the risk and consequences of aspiration then I think they'd agree... whether or not they understand or even care to think about it is another story. I hate OG tubes and do not trust them to adequately clear stomach contents.

 

[deleted171991]

the other lma trauma made me think of this and wanted to get some insights.
When I was a resident I worked with a dude who would put in a lma supreme for simple laparoscopic cases (choles, gyn), in private practice where they would take 45-1.5 hr (max). He'd put in an OG, and would pressure control to adequate tidal volume up to 30 until spontaneous with support. Said the OG evacuated the stomach of air/contents. He was from the EU and said it was more common over there. I did it a few times with him and it worked. The reasoning seems ok, the only real advantage I see is less sore throat. Thoughts?

I hope you do realize the main reason we don't use more LMAs in the US is defensive medicine. One cannot afford even a 1 in 1000 aspiration event. All the advantages of the LMAs that the other 999 patients would experience are dwarfed by the 1 that could go wrong. Even the physicians at the VA practice defensive medicine.

The fact that the Brits use LMAs in laparoscopic surgeries suggests not that they are nuts, but that we are f-ed up.

 

[Mman]

The reasoning seems ok, the only real advantage I see is less sore throat. Thoughts?

LMAs cause plenty of sore throats, especially if they have a tight enough seal to deliver an inspiratory pressure of 30 without leaking. They cause a lot more trauma to the pharynx than ETTs do.

 

[Planktonmd]

I hope you do realize the main reason we don't use more LMAs in the US is defensive medicine. One cannot afford even an 1 in 1000 aspiration event. All the advantages of the LMAs that the other 999 patients would experience are dwarfed by the 1 that could go wrong. Even the physicians at the VA practice defensive medicine.

The fact that the Brits use LMAs in laparoscopic surgeries suggests not that they are nuts, but that we are f-ed up.

That's the bottom line!

 

[epidural man]

As Mman suggested,

LMA's actually cause worse sore throats then ET tubes. If you don't believe it, do a study and prove that it doesn't - because whenever anyone else tries, they find LMA's hurt more.

 

[anes121508]

LMAs cause plenty of sore throats, especially if they have a tight enough seal to deliver an inspiratory pressure of 30 without leaking. They cause a lot more trauma to the pharynx than ETTs do.

Exactly what I’ve read and was taught.

As a side note:

Take two patients (A and B) both with Lma and enough anesthetic on board that there is no respiratory drive. Both patients are being ventilated with positive pressure. Pt A has roc on board , pt B does not have roc on board. Is there a difference in aspiration risk?

 

[Globulinus]

As Mman suggested,

LMA's actually cause worse sore throats then ET tubes. If you don't believe it, do a study and prove that it doesn't - because whenever anyone else tries, they find LMA's hurt more.

Actually it is not factually correct. Especially for 2nd gen SAD's.
Several studies suggests that SAD's actually has fewer complications then ETT's, including sore throat, laryngospasm, and more...

Being conscious about cuff pressure helps with sore throat.
Correct positioning also helps:
Supremes should be fully deflated on insertion. I also routinely give 10-20 of Sux on induction.

I used it several times for choles. Love it.
Laparoscopic GYN, if my memory serves me, in relative contraindication to LMA....

Yes, we don't practice modern medicine in US because of bloodsucking lawyers and insurance companies 🙁

 

[epidural man]

Actually it is not factually correct. Especially for 2nd gen SAD's.
Several studies suggests that SAD's actually has fewer complications then ETT's, including sore throat, laryngospasm, and more...

Being conscious about cuff pressure helps with sore throat.
Correct positioning also helps:
Supremes should be fully deflated on insertion. I also routinely give 10-20 of Sux on induction.

I used it several times for choles. Love it.
Laparoscopic GYN, if my memory serves me, in relative contraindication to LMA....

Yes, we don't practice modern medicine in US because of bloodsucking lawyers and insurance companies 🙁

My favorite supra-glottic airway is the i-Gel....love that thing..and easy to intubate through.

 

[fakin' the funk]

Exactly what I’ve read and was taught.

As a side note:

Take two patients (A and B) both with Lma and enough anesthetic on board that there is no respiratory drive. Both patients are being ventilated with positive pressure. Pt A has roc on board , pt B does not have roc on board. Is there a difference in aspiration risk?

Not if the stomach is empty (ie it's a normal stomach)

 

[fakin' the funk]

Actually it is not factually correct. Especially for 2nd gen SAD's.
Several studies suggests that SAD's actually has fewer complications then ETT's, including sore throat, laryngospasm, and more...

Being conscious about cuff pressure helps with sore throat.
Correct positioning also helps:
Supremes should be fully deflated on insertion. I also routinely give 10-20 of Sux on induction.

I used it several times for choles. Love it.
Laparoscopic GYN, if my memory serves me, in relative contraindication to LMA....

Yes, we don't practice modern medicine in US because of bloodsucking lawyers and insurance companies 🙁

It seems like you're aware of it, but youre an outlier

 

[Mman]

Actually it is not factually correct. Especially for 2nd gen SAD's.
Several studies suggests that SAD's actually has fewer complications then ETT's, including sore throat, laryngospasm, and more...

Which studies are those? Because there are a ton of studies that show similar incidence of sore throat between ETTs and LMAs and plenty of studies showing worse sore throats with LMAs. I'd imagine there is enough data someone could do a meta analysis and find the overall incidence is about the same. And our own institution quality data doesn't see any significant difference between the 2 either in PACU or POD #1 phone call followup.

 

[Globulinus]

Which studies are those? Because there are a ton of studies that show similar incidence of sore throat between ETTs and LMAs and plenty of studies showing worse sore throats with LMAs. I'd imagine there is enough data someone could do a meta analysis and find the overall incidence is about the same. And our own institution quality data doesn't see any significant difference between the 2 either in PACU or POD #1 phone call followup.

Journal of Clinical Anesthesia 36 (2017) 142–150
Comparison of laryngeal mask airway vs tracheal intubation: a systematic review on airway complications

Good Cohrane Review Supraglottic airway devices versus tracheal intubation for airwaymanagement during general anaesthesia in obese
patients(Review)

Postoperative Respiratory Complications of Laryngeal Mask Airway and Tracheal Tube in Ear, Nose and Throat Operations

There are much more...Even couple metaanalysis...
Data about that LMA's have worse sore throats then ETT (and complications in general) mostly
- old. i.e. before 2010
- referred to 1st generations SAD. which can't be translated to 2nd generation
- does't take into consideration cuff pressure.

I am pretty sure that if at your institution you will teach and implement correct sizing, insertion technique and routine cuff pressure monitoring - you will see a good difference between ETT and 2nd generation SAD.

 

[Mman]

I am pretty sure that if at your institution you will teach and implement correct sizing, insertion technique and routine cuff pressure monitoring - you will see a good difference between ETT and 2nd generation SAD.

already done. Still no difference. Incidence of significant sore throat should not be terribly high with either an ETT or an LMA. We see around 5% with both. I wonder if people that see a lot of sore throats with ETTs just have a lot of inexperienced people doing the laryngoscopies since prolonged or repeated laryngoscopy is a strong predictor of sore throat.

edit: also note that article you linked mentions no statistically significant difference in the rates of sore throat, certainly nothing clinically significant

 

[Globulinus]

already done. Still no difference. Incidence of significant sore throat should not be terribly high with either an ETT or an LMA. We see around 5% with both. I wonder if people that see a lot of sore throats with ETTs just have a lot of inexperienced people doing the laryngoscopies since prolonged or repeated laryngoscopy is a strong predictor of sore throat.

Hmmm...
Have you guys published data?
Because in studies below(even old ones) they found in LMA's favor.
I agree that experience with DL is important in sore throat incidence.
But, what is ignored by majority - correct technique and experience with LMA placement play even bigger role for complications incidence and outcome..

 

[Mman]

Hmmm...
Have you guys published data?
Because in studies below(even old ones) they found in LMA's favor.
I agree that experience with DL is important in sore throat incidence.
But, what is ignored by majority - correct technique and experience with LMA placement play even bigger role for complications incidence and outcome..

Publish? There are dozens of studies showing anything from worse sore throats to equivalent sore throats to less sore throats with LMAs vs ETTs. I mean even a simple google search shows a bunch on the 1st page of search results. Unfortunately we are a busy private group and adding another data point to already pre-existing data isn't worth our time.

My experience tells me if you find a significant difference with one compared to the other, you are doing something wrong.

 

[deleted171991]

Hmmm...
Have you guys published data?
Because in studies below(even old ones) they found in LMA's favor.
I agree that experience with DL is important in sore throat incidence.
But, what is ignored by majority - correct technique and experience with LMA placement play even bigger role for complications incidence and outcome..

The 3 big factors for sore throat: multiple intubation attempts, mis-sized/positioned/inflated LMAs/ETTs, and too much/brutal SUCTIONING! People tend to forget about the latter, which is virtually absent with LMAs.

 

[anes121508]

Not if the stomach is empty (ie it's a normal stomach)

So isn’t the question really about positive pressure ventilation and LMA? Not necessarily Lma and paralytic?

 

[narcusprince]

I find that the incidence of sore throat is directly related to which pacu nurse is asking the questions. How do you quantify or score a sore throat. Everyone has some degree of laryngeal trauma with lma placement or laryngoscopies. Be careful what you are looking for.

 

[fakin' the funk]

So isn’t the question really about positive pressure ventilation and LMA? Not necessarily Lma and paralytic?

Not sure what we're even talking about anymore

 

[San Marzano]

I find that the incidence of sore throat is directly related to which pacu nurse is asking the questions. How do you quantify or score a sore throat. Everyone has some degree of laryngeal trauma with lma placement or laryngoscopies. Be careful what you are looking for.

Do you regularly tell the patient about the sore throat in preop when you’re interviewing the patient? I do it every time because it’s the most reliable side effect they’re most likely to experience. Sometimes this results in the patient giving me an incredulous look and asking “are you sure you have to place a breathing tube? I had surgery before and I know they did not need the breathing tube.”

 

[itwasalladream]

All of us can of course induce and tube before the OR door closes, and pull the tube as drapes are coming down...
So the LMA argument is that a small increase in aspiration risk is worth the (debatable) decrease in sore throat? I don't think it's defensive medicine to say I'll take sore throats all career long to avoid an aspiration death. That particular issue has nothing to do with lawyers. The surgeons are cutting organs, and we're worried about sore throat. VC dysfunction is on the radar, but not enough to change what I do on otherwise routine cases.
My opinion - if you're planning to paralyze, just put a tube in. If you're considering putting a tube in, just put a tube in. What you can do and what you should do are two different things (see prone LMA).

 

[T-burglar]

Aspiration is one of the few ways an otherwise healthy person can become critically desaturated with no recourse except emergency ECMO or CPB. Remember that.

I’ve intubated people that look like shrek through a geyser of vomit shooting out of their heads, but those cases could have easily been unrecoverable. We’ve all gotten lucky.