Longest LMA case?

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IlDestriero

IlDestriero

Ether Man
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Physician
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15+ Year Member
Just curious what your record is for longest case with an LMA. Some of the CRNAs I work with don't like them for anything longer than about an hour. I started a breast biopsy with one a few years ago that should have been no longer than 1.5 hours, went a little longer...🙄
What's your personal record?
 
I went for 4 hours; cysto with stent removal. Surgeon initially told me it would be an hour, but kept on going and going and going. No issues. I've read some reports where it's been used for 12 hours with no ill-effects, but then again, some reports also have used them for T&A's. Def wouldn't do that...
 
Personally, about 3 hrs.

At my institution last year there was a case scheduled for 2 hours that ended up lasting 13 hours. The LMA was removed after hour 12 (surgeon kept insisting over the entire case that she was 20 minutes from being done; ironically, once the LMA was removed she finished in 20 minutes). The patient did fine.

I was not involved in any way other than coming in to take a curious peek at the oropharyngeal swelling (not that bad) when the LMA was exchanged for an ETT.
 
IlDestriero said:
Just curious what your record is for longest case with an LMA. Some of the CRNAs I work with don't like them for anything longer than about an hour. I started a breast biopsy with one a few years ago that should have been no longer than 1.5 hours, went a little longer...🙄
What's your personal record?
Click to expand...

about 3 hours....had the patient on Prssure Support with the LMA..did fine...prolly could have gone longer. Personally, though I'd rather use a ETT if it's going to be over 2 hours.
 
From the LMA, North America website:
LMA-Classic™, LMA-Flexible™, LMA-Unique™, & LMA-ProSeal™

The maximum duration for which an LMA™airway can safely be used is not yet known; however, there is increasing evidence that the LMA™ airway may be safe for elective procedures in healthy patients lasting 4 to 8 hours in the hands of experienced users. If the LMA™ airway is used for prolonged periods, the respiratory function must be closely monitored, and a heat and moisture exchanger should be used. Also, intracuff pressures should be checked periodically and maintained at 60 cm H2O. Nitrous oxide diffusion tends to cause a rise in intracuff pressure in the LMA™ cuffs made of silicone. This may result in malposition, postoperative sore throat, or other adverse events.

Brain AIJ, Denman W, Goudsouzian N.G., LMA-Classic and LMA-Flexible Instruction Manual, LMA North America, Inc.

Ferson D, Brimacombe JR, Brain AIJ. International Anesthesiology Clinics: The Laryngeal Mask Airway. Lippincott-Raven, Volume 36, Number 2, 1998.

I always considered it safe and defensible for extended periods, probably for an upper limit around 3 or (cringe) 4 hours. Have used them semi-regularly in 2 hour cases with wide ranging success (N = approx. 300) Funny deal about cuff pressures though. Never seen a manometer in any OR....just the occasional ICU, and even then, RT usually had them hidden away. Just anecdotal evidence FWIW.
 
SleepIsGood said:
Personally, though I'd rather use a ETT if it's going to be over 2 hours.
Click to expand...
Hello,

Personally, I'd rather use an ETT any time. I love to have good control of the airway and not worry about unknown and unexpected things.

However, I use LMAs frequently for cases ranging from a few minutes to a few hours. I don't have data at hand, but I may have done cases up to four or five hours long with them.

During residency our attendings used to make us do cases with face mask lasting four or five hours, just to teach us how to hold a mask and how to maintain an open airway. I imagine the LMA can't be worse than that.

That having been said, I have a very low threshold for intubating children for any length of surgery. Unless it is somethng that can be done in a few minutes with a mask, such as PE tubes, quick closed reductions or easy elbow pinnings, everybody else gets intubated (and sometimes even those get intubated). I hate how unstable and unreliable LMAs can be in children.

Of course you can brag about your technique being better than mine and pontificate that a properly placed LMA doesn't have to be unstable, and I will not argue that you may be right, like one of my coworkers who has anesthetized prone children with LMAs and brags about his skills, but I don't like it.

Greetings
 
soonerfrog said:
Funny deal about cuff pressures though. Never seen a manometer in any OR....just the occasional ICU, and even then, RT usually had them hidden away.
Click to expand...

You can transduce the cuff pressure of an LMA or ETT if you really want to know what the pressure is. In long cases with NO2, it will rise steadily.
 
Salt Creep said:
You can transduce the cuff pressure of an LMA or ETT if you really want to know what the pressure is. In long cases with NO2, it will rise steadily.
Click to expand...

And there is at least one LMA type available with a little indicator in place of a pilot balloon - green for recommended pressures, red for overinflation, yellow for under.
 
I also thought there were case reports of them being used for prolonged periods in time in places like ICU - I have a vague memory of one being used for several days in a child with a very difficult airway. Not sure if it was real or rumour.

Of course, just cause it's been done by necessity doesn't mean it should be considered acceptable.
 
soorg said:
I went for 4 hours; cysto with stent removal. Surgeon initially told me it would be an hour, but kept on going and going and going. No issues. I've read some reports where it's been used for 12 hours with no ill-effects, but then again, some reports also have used them for T&A's. Def wouldn't do that...
Click to expand...

Use LMA's for T&A's in our outpatient peds ENT room day in day out, works great. Our ENT's prefer them to ETT's-- less stridor, smooth wake up, pull em out deep and the LMA scoops out all the goop. Give it a try, I think you'll be impressed.
 
I'm neither kidding nor endorse this behavior, but I had a partner do a 6 hour back with the patient prone with foam headrest with an LMA.

Crazy in my opinion.
 
I have no problem doing a case of any duration with an LMA as long as we are providing some pressure support or mechanical ventilation and not going with straight spontaneous ventilation.
The concern about pressure on the soft tissues is theoretical and should not be an issue if the LMA is seated properly.
We do 5-6 hours plastic surgery cases with LMA all the time with no problems.
 
People often mention N2O as an agent that will expand the ETT and LMA cuff. But consider heat. Have you ever had a cold empty plastic bottle, then taken it and placed it in a car, or vice-versa? Notice how it expands/contracts? I bet that if you inflate an LMA with OR temp air, then let the pt's body temp expand that air . . . . Viola. I wonder what would account for more expansion, N20 or an almost 40 degree increase temp. (60 degree OR to 98 degree core temp.)

With regard to length of use of LMA, I typically place an ETT if I think the case will last longer than 3 hours.

Tuck
 
tucker27705 said:
I wonder what would account for more expansion, N20 or an almost 40 degree increase temp. (60 degree OR to 98 degree core temp.)
Click to expand...

Temp increase from 60 to 98 F would account for only about a 7% volume expansion (309 K / 288 K = 1.073).

Potential volume increase from N2O is much greater, with the upper limit of the expanded volume being (starting volume) / (1 - FiN2O) ... looking at up to a 30% increase with 25% nitrous to a 400% increase with 80% nitrous.
 
tucker27705 said:
people often mention n2o as an agent that will expand the ett and lma cuff. But consider heat. Have you ever had a cold empty plastic bottle, then taken it and placed it in a car, or vice-versa? Notice how it expands/contracts? I bet that if you inflate an lma with or temp air, then let the pt's body temp expand that air . . . . Viola. I wonder what would account for more expansion, n20 or an almost 40 degree increase temp. (60 degree or to 98 degree core temp.)
Click to expand...

n2o
 
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