LMA with paralysis

[WhatchaThink]

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LMA questions:
1) Has anyone seen it done or does anyone use paralysis when doing a GA case with a LMA.
2) Do you typically try to see if you can mask ventilate before placing an LMA or do you just give your induction agents and place the LMA without first seeing if you can mask the patient?

 

[countingdays]

LMA questions:
1) Has anyone seen it done or does anyone use paralysis when doing a GA case with a LMA.
2) Do you typically try to see if you can mask ventilate before placing an LMA or do you just give your induction agents and place the LMA without first seeing if you can mask the patient?

1) Yes. Fairly frequently.

2) No. Why would you?

 

[gasp]

LMA questions:
1) Has anyone seen it done or does anyone use paralysis when doing a GA case with a LMA.
2) Do you typically try to see if you can mask ventilate before placing an LMA or do you just give your induction agents and place the LMA without first seeing if you can mask the patient?

1) yes, works just fine.

2) seeing if you can mask ventilate before placing an LMA does nothing. You could mask easy and not have a good seal LMA or you cant mask at all and place an LMA that ventilates with ease. In other words, it is not a predictor of how well your LMA will work.

 

[WholeLottaGame7]

Also, think about the difficult airway algorithm. If you can't ventilate, you....place an LMA.

 

[periopdoc]

1) Yes

2) No

3) I usually don't mask ventilate prior to intubating either

- pod

 

[pgg]

1 yes, though I avoid it in patients or cases that are likely to need higher pressures to ventilate

2 no

 

[sevoflurane]

LMA questions:
1) Has anyone seen it done or does anyone use paralysis when doing a GA case with a LMA.
2) Do you typically try to see if you can mask ventilate before placing an LMA or do you just give your induction agents and place the LMA without first seeing if you can mask the patient?

1). Yes and no. Some get paralysis BUT most don't (or just 5-15 mcgs). V/Q match is nice and pure and what I aim for. I'll turn down my trigger and add PS if need be..... but that all depends on the "patient".
Evaluate every LMA. (ETT is 4 sure and therefore safer in certain populations).... But it's NOT a silver bullet.

2). Love LMAs, but don't be fooled with a false sense of security (paralyzed or not). Most times they are solid. Sometimes they need a min after placing them (don't freak!) ....sometimes they are not worth the trouble.

Who here has seen NPPE w/ LMA (super rare). My first one was with an anticipated DA for a short case (15 min.). I choose LMA in this DA.

Frothy sputum. Fortunately I'd seen it before. Things were fine and appropriate treatment was quickly instituted.

Rare event... But it sucks when trying to avoid anticipated difficult intubation with an LMA.

Love LMA's. But... Be aware of the pit falls.

Know their limitations.

 

[Mman]

never seen NPPE with LMA, but have seen laryngospasm in the middle of the case requiring succinylcholine to break it. 60 minutes into the case on a spontaneously breathing patient with LMA. Started hearing high pitched sounds and seeing decreased TV on vent. Wasn't sure what was happening. Tried adding air to cuff and it didn't fix. Tried manually ventilating and couldn't. Pulled the LMA and masked and still not moving much air. Gave sux, problem solved. I think the LMA must've been tickling something sensitive. Either that or some secretions got down on to the cords.

 

[leaverus]

never seen NPPE with LMA, but have seen laryngospasm in the middle of the case requiring succinylcholine to break it. 60 minutes into the case on a spontaneously breathing patient with LMA. Started hearing high pitched sounds and seeing decreased TV on vent. Wasn't sure what was happening. Tried adding air to cuff and it didn't fix. Tried manually ventilating and couldn't. Pulled the LMA and masked and still not moving much air. Gave sux, problem solved. I think the LMA must've been tickling something sensitive. Either that or some secretions got down on to the cords.

was the patient light? laryngospasm in a deeply anesthetized patient is pretty rare and i generally keep my pts with LMA fairly deep. either way, can be a scary situation.

as for paralyzing, i do it, but when needed and not routinely. i feel using nmb with an lma is defeating the purpose of using an lma in the first place.

 

[jwk]

LMA questions:
1) Has anyone seen it done or does anyone use paralysis when doing a GA case with a LMA.
2) Do you typically try to see if you can mask ventilate before placing an LMA or do you just give your induction agents and place the LMA without first seeing if you can mask the patient?

I don't routinely use NMB with LMA's but I'm not against it if necessary.

I pretty much always mask ventilate my patients, whether LMA or ETT. Why wouldn't you? Masking a patient is/was anesthesia bread and butter. However, just like using a glidescope as a matter of routine will likely decrease your skills at endotracheal intubation (which I already see happening), using an LMA without attempting to ventilate your patient with a mask will likely decrease your skills at a mask airway. Does anyone ever do a case with a mask anymore besides me? I'm one of 5 or less in my department of 150 that would.

 

[PonyUp]

1). Yes and no. Some get paralysis BUT most don't (or just 5-15 mcgs). V/Q match is nice and pure and what I aim for. I'll turn down my trigger and add PS if need be..... but that all depends on the "patient".
Evaluate every LMA. (ETT is 4 sure and therefore safer in certain populations).... But it's NOT a silver bullet.

2). Love LMAs, but don't be fooled with a false sense of security (paralyzed or not). Most times they are solid. Sometimes they need a min after placing them (don't freak!) ....sometimes they are not worth the trouble.

Who here has seen NPPE w/ LMA (super rare). My first one was with an anticipated DA for a short case (15 min.). I choose LMA in this DA.

Frothy sputum. Fortunately I'd seen it before. Things were fine and appropriate treatment was quickly instituted.

Rare event... But it sucks when trying to avoid anticipated difficult intubation with an LMA.

Love LMA's. But... Be aware of the pit falls.

Know their limitations.

Saw it a couple of weeks ago. Saturday I&D with WVE while taking a call to make up for an interview day, broken out of our room by another resident for a break, come back to the room with patient on his hospital bed, blue. Kid laryngospasmed while being moved after LMA was pulled. 13 year old, 180lb, clearly could generate a lot of negative pressure based on muscle mass and size. Kid did fine after reintubation in PACU and PICU for the night. But yeah, pink frothy sputum everywhere.

 

[pgg]

I don't routinely use NMB with LMA's but I'm not against it if necessary.

I pretty much always mask ventilate my patients, whether LMA or ETT. Why wouldn't you? Masking a patient is/was anesthesia bread and butter. However, just like using a glidescope as a matter of routine will likely decrease your skills at endotracheal intubation (which I already see happening), using an LMA without attempting to ventilate your patient with a mask will likely decrease your skills at a mask airway. Does anyone ever do a case with a mask anymore besides me? I'm one of 5 or less in my department of 150 that would.

😕

I have zero doubt that all of us still mask ventilate patients and are not in any danger of losing that skill. Maybe you're confusing the practice of not testing mask ventilation before giving a NMB, with never ever mask ventilating at all?

I generally avoid succinylcholine if possible, so for every nondepolarizer-receiving patient I intubate, I mask ventilate while waiting for the muscle relaxant to kick in.

For the rare very short case, I'll do a mask anesthetic with volatile, sure. It's a fine technique, but there's something to be said for having both hands free to make charting easier or allow me to set up the next case. I'm over doing things the hard / old-school way just because I can.

 

[Mman]

was the patient light? laryngospasm in a deeply anesthetized patient is pretty rare and i generally keep my pts with LMA fairly deep. either way, can be a scary situation.

as for paralyzing, i do it, but when needed and not routinely. i feel using nmb with an lma is defeating the purpose of using an lma in the first place.

I don't recall all the details as this was several years ago, but they were definitely not light. Somewhere between 1-1.5 MAC of gas on board in addition to narcotics. But I won't forget the high pitched sound coming from the LMA and the tiny tidal volumes that were being generated in a patient that had been completely stable for >45 minutes.

 

[gasp]

Gas is the devil. If you have barely any gas and good narc on board before removing an LMA, chances of spasm are much much less.

 

[pgg]

Gas is the devil. If you have barely any gas and good narc on board before removing an LMA, chances of spasm are much much less.

Yeah, that's because they're awake at that point. 😀

 

[periopdoc]

pretty much always mask ventilate my patients, whether LMA or ETT.

Why?

Masking a patient is/was anesthesia bread and butter.

Yep and it is kind of like riding a bicycle.

Using an LMA without attempting to ventilate your patient with a mask will likely decrease your skills at a mask airway.

Unlikely.

I wil do short cases with a mask on occasion, but I prefer to have both hands free for massaging the immigrant circulators after we catch eyes from across the room.


The way I look at it. With even a modicum of pre-oxygenation, I gain very little by masking the patient between induction and routine intubation or LMA placement (maybe maintain normo-carbia). In the routine patient, mask ventilation becomes progressively easier as the induction and neuromuscular blocking agents approach the point where laryngoscopy or LMA placement becomes reasonable. Ease or difficulty of masking prior to this point is unlikely to change my plan or give me reassurance about what things might be like if I can't intubate.

So I do the case. Have a plan for can't intubate can't ventilate, and carry out that plan if I get to that point.

Obviously there are patients who cannot tolerate brief periods of apnea without becoming hypoxic. I treat these patients differently.

- pod

 

[gasp]

Yeah, that's because they're awake at that point. 😀

I meant before they're awake of course. But yes, that would help too 😉

 

[Mman]

I meant before they're awake of course. But yes, that would help too 😉

I hope you aren't pulling the LMA with them in stage 2. You know when they aren't deep nor are they awake. Because saying that having gas on board is bad and then saying you pull it before they are awake leads me to believe you aren't pulling it deep, nor are they awake.

 

[Arch Guillotti]

I pretty much always mask ventilate my patients, whether LMA or ETT. Why wouldn't you? Masking a patient is/was anesthesia bread and butter. However, just like using a glidescope as a matter of routine will likely decrease your skills at endotracheal intubation (which I already see happening), using an LMA without attempting to ventilate your patient with a mask will likely decrease your skills at a mask airway. Does anyone ever do a case with a mask anymore besides me? I'm one of 5 or less in my department of 150 that would.

I think ventilating prior to placing an LMA is silly. I don't think think mask skills are lost one bit either.

 

[Oggg]

With LMAs (more so with Proseal LMA), you can get this crowing inspiratory stridor, and reduced spontaneous tidal volumes. It can get quite severe although assisted ventilation can achieve good TV. Paralysis will remove the crowing sound until it wears off. Adjusting the cuff volume or replacing the LMA doesn't seem to work. Sometimes it correlates with slightly light anesthesia, sometimes not. Narcotics don't help or hurt. Inspiratory and not exploratory.

This problem kept recurring when I would use a proSeal LMA, so I stopped using it

 

[gasp]

I hope you aren't pulling the LMA with them in stage 2. You know when they aren't deep nor are they awake. Because saying that having gas on board is bad and then saying you pull it before they are awake leads me to believe you aren't pulling it deep, nor are they awake.

Thank you for your explanation of stage 2, I was really starting to wonder what it was 😉
What I am saying is if you have an adequate amount of narcotic on board as the gas is coming off, stage 2 spasm (with the LMA still in) is much less likely because the narc blunts the response. Some people don't give enough narcotic and therefore have a higher chance of spasm as the pt goes through stage 2 with an LMA. I have also seen when a pt opens their eyes with ~0.2 ISO on board and the LMA is removed and the pt still spasms. This would be much less likely if they had adequate narc on board and this is what I was referring to in my previous post. It all depends on how you wake up the pt before removing the LMA. Some will have a spontaneous resp rate of 20-22 (in an adult) and 0.2 - 0.3 ISO when the pt opens their eyes and some will have a spontaneous resp rate of 6-10 and 0 ISO when the pt opens their eyes. Both pt's will be sleepy but the former pt is at higher risk of spasm when the LMA is removed.

 

[fmgtiger]

I don't routinely use NMB with LMA's but I'm not against it if necessary.

I pretty much always mask ventilate my patients, whether LMA or ETT. Why wouldn't you? Masking a patient is/was anesthesia bread and butter. However, just like using a glidescope as a matter of routine will likely decrease your skills at endotracheal intubation (which I already see happening), using an LMA without attempting to ventilate your patient with a mask will likely decrease your skills at a mask airway. Does anyone ever do a case with a mask anymore besides me? I'm one of 5 or less in my department of 150 that would.

Just a lowly CA1 here but generally have been taught to not mask before placing an LMA because it is not a definitive airway and masking can inflate the stomach and predispose to aspiration.

 

[Arch Guillotti]

Just a lowly CA1 here but generally have been taught to not mask before placing an LMA because it is not a definitive airway and masking can inflate the stomach and predispose to aspiration.

Sure it can but it is almost never an issue as you describe it.

A situation where you unexpectedly have to mask someone who is a full stomach/other aspiration risk with high pressures yet crumby tidal volumes could certainly be a problem though.

 

[Doctor4Life1769]

i give 1 quick small breath prior to placing an LMA just to see if this patient is a relatively easy or difficult mask ventilation in the odd chance I stick an LMA and it doesn't have a proper seal, I know fully well i can remove the LMA, give some more breaths and try again.

I've never given paralysis when using an LMA, but my experience is relatively limited being that I'm a CA-1.

 

[periopdoc]

D4L. Not being critical here so please don't take it that way.

So you give your quick breath and it is or isn't easier than you expected. What do you do next? How did it change your management?


- pod

 

[Doctor4Life1769]

D4L. Not being critical here so please don't take it that way.

So you give your quick breath and it is or isn't easier than you expected. What do you do next? How did it change your management?


- pod

It doesn't change the management, but I don't like using the same LMA unless it's clear of secretions and it's of the right size and seeding was the only issue, then I immediately take it out and try to put it back in. However, if it's not of the right size, then I give a breath or two as I'm setting up a different LMA. One probably would not need to give any breaths since I know the LMA is used in the emergency/backup management of an airway in a "can't ventilate, can't intubate" situation and the issue with desat probably wouldn't occur in the short period of time where you're setting up another readily available LMA.

Definitely didn't take it the wrong way. I may even abandon these extra steps as I get even more experience.

 

[Arch Guillotti]

"Seeding"?

It doesn't change the management, but I don't like using the same LMA unless it's clear of secretions and it's of the right size and seeding was the only issue, then I immediately take it out and try to put it back in. However, if it's not of the right size, then I give a breath or two as I'm setting up a different LMA. One probably would not need to give any breaths since I know the LMA is used in the emergency/backup management of an airway in a "can't ventilate, can't intubate" situation and the issue with desat probably wouldn't occur in the short period of time where you're setting up another readily available LMA.

Definitely didn't take it the wrong way. I may even abandon these extra steps as I get even more experience.

 

[periopdoc]

Seating

- pod

 

[Doctor4Life1769]

Typo.

I'm on the iphone, first time. It's taking some getting used to typing.

 

[DannyB]

D4L. Not being critical here so please don't take it that way.

So you give your quick breath and it is or isn't easier than you expected. What do you do next? How did it change your management?


- pod

If the LMA didn't sit well or if something else happens he knows not to waste valuable time trying to mask them and just go straight to a different size LMA or just intubate them. It's never a bad thing to know if a patient is maskable, also helps if it's on the anesthetic record for future procedures

 

[sevoflurane]

If the LMA didn't sit well or if something else happens he knows not to waste valuable time trying to mask them and just go straight to a different size LMA or just intubate them. It's never a bad thing to know if a patient is maskable, also helps if it's on the anesthetic record for future procedures

Not sure if I'm reading you right... but If your LMA isn't fitting right, there is NO problem taking it out and placing an OA and then mask ventilating. In the meawhile, you can easily get another size LMA ready to go. 99% of the time you'll be able to effectively ventilate.

 

[periopdoc]

If the LMA didn't sit well or if something else happens he knows not to waste valuable time trying to mask them and just go straight to a different size LMA or just intubate them. It's never a bad thing to know if a patient is maskable, also helps if it's on the anesthetic record for future procedures

So I should waste time trying to figure out if he is maskable now so that I don't waste time later in the algo? Hmmm.

Would you also recommend testing to see if an LMA works on a patient before I intubate them so as not to waste valuable time trying to place an LMA after a failed laryngoscopy?

Even ignoring the fact that the ability, or lack thereof, to mask ventilate pre-LMA placement has very little predictive power on how easily he can be masked after a failed attempt at LMA placement (mask ventilation may be easier or, more likely, harder) it just doesn't make much sense to me. Why waste time at any point in the algo?

My usual sequence - induce, attempt LMA#4, attempt LMA#5, intubate. If at any point it becomes necessary to mask ventilation, I do so. If at any point another technique seems appropriate, I head that direction. I don't waste time trying to figure out if something that I am not going to use for the anesthetic will work or not. The predictive value for future anesthetics is marginal at best and misleading at worst.


- pod

 

[sevoflurane]

...
My usual sequence - induce, attempt LMA#4, attempt LMA#5, intubate. If at any point it becomes necessary to mask ventilation, I do so. If at any point another technique seems appropriate, I head that direction. I don't waste time trying to figure out if something that I am not going to use for the anesthetic will work or not. The predictive value for future anesthetics is marginal at best and misleading at worst.


- pod

There it is... 👍

Ninja flow...

 

[amyl]

Ill paralyze w an LMA if i need to - no reason not to as long as you keep airway pressures low. i sometimes mask before LMA to get some gas in those occasional pts that need elephant doses of induction drugs... can be faster than pulling up more propofol.
one of the guys i work with started doing lap choles here with an LMA. not something im going to try any time soon. i will let you know if he has any issues come up.

 

[HollywdAnesth]

There was an attending where I went to residency who claimed that many of the staff in the UK where he trained would place an LMA for laparoscopic surgery, as well as prone cases.

That being said. I don't paralyze with LMA. I only use them for cases when it's ok for the patient to ventilate spontaneously.

I don't mask prior to placing an LMA. I don't see the point either.

I have had kids laryngospasm in the middle of an MRI with an LMA in place. The best solution is to leave the LMA in place, and give propofol to deepen your anesthetic. If that doesn't work, use sux. If the LMA was seated correctly to begin with, why remove a functioning airway to deal with laryngospasm?

 

[Arch Guillotti]

I have had kids laryngospasm in the middle of an MRI with an LMA in place. The best solution is to leave the LMA in place, and give propofol to deepen your anesthetic. If that doesn't work, use sux. If the LMA was seated correctly to begin with, why remove a functioning airway to deal with laryngospasm?

Agree, although sometimes an LMA can become dislodged. Have you considered propofol infusion for MRI? Works great in my experience.