Masking for cases

[Maverikk]

Anyone do this? For short cystos or the like do you ever just mask them down, keep them spontaneous and transfer to PACU deep. I realize the risks: phase 2 in pacu etc. I was speaking with someone that said at a cysto center that's all they did, it was mostly ASA1/2. Just mask, oral airways for a lot (supraglottic airway), good suctioning, wake up deep in pacu. Said it was faster and over time saved money on lmas/equipment

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[NoodleIncident]

Anyone do this? For short cystos or the like do you ever just mask them down, keep them spontaneous and transfer to PACU deep. I realize the risks: phase 2 in pacu etc. I was speaking with someone that said at a cysto center that's all they did, it was mostly ASA1/2. Just mask, oral airways for a lot (supraglottic airway), good suctioning, wake up deep in pacu. Said it was faster and over time saved money on lmas/equipment

I do this for short cysto/stents, none for stone cases. The difference is that I get the patient to emerge while they’re finishing and awake before I leave the room. That way there is no Phase 2 in PACU, pollution of PACU with exhaled agents, wasting PACU’s time and space (sending Pt’s to PACU deep does not save time), and it looks more slick as the patient is talking as we roll in. As far as the equipment cost over an LMA? I don’t know.

 

[secants]

If you're masking, doesn't that tie your hands down from doing the chart, preparing for the next case etc?

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[NoodleIncident]

If you're masking, doesn't that tie your hands down from doing the chart, preparing for the next case etc?

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It can be tough for the very fast cases, but for the most part their tidal volumes are such that my hand is not on the bag except for giving an intermittent sigh.

 

[psychbender]

I've done it for podiatry or Ortho shock wave cases. The machine runs for precisely 7 minutes per site, and the operator gives a two minute warning, at which point I generally turn off the gas. Pt breathing spontaneously throughout the case, deep enough not to budge, but waking up before we leave the room.

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[jonessoda1212]

Why not just do propofol with native airway like for an other "sedation" case like EGD, colonoscopies, D+Cs, etc. Masking down an adult takes time, at least compared to the kiddos, especially compared to an IV agent. Plus no OR contamination with gases, able to get ready for next case, decrease incidence of stage 2 during the induction phase. In kids where there is no IV, sure it makes sense, but in an adult with a pre-induction IV, seems like more hassle than anything.

 

[NoodleIncident]

I don’t think we’re talking about doing an inhalation-only induction. I do a mixed IV/Inhalational induction and just mask them for maintenance and emergence.

 

[Arch Guillotti]

I've done it for podiatry or Ortho shock wave cases. The machine runs for precisely 7 minutes per site, and the operator gives a two minute warning, at which point I generally turn off the gas. Pt breathing spontaneously throughout the case, deep enough not to budge, but waking up before we leave the room.

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What is an ortho shock wave case?

 

[psychbender]

What is an ortho shock wave case?

Extracorporeal shockwave therapy for tennis elbow, patellar tendonopathy, and other MSK complaints. We mostly did them for plantar fasciitis and Achilles tendon with Podiatry.

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[teeva]

Seems unnecessary for the skilled practitioner. Propfol induction, maintenace with gas, spontaneous respiration the whole time, two hands free to chart, one hand to occasionally ventilate if you’ve overdosed propfol or fentanyl, turn off the gas at the appropriate and optimal time, and have the patient move himself over to the gurney.

In solo practice I have no desire to leave a non-awake patient unattended in PACU for the 0.1% chance something can go wrong. I’m also skilled enough to know when to turn off the gas.

 

[jwk]

Anyone do this? For short cystos or the like do you ever just mask them down, keep them spontaneous and transfer to PACU deep. I realize the risks: phase 2 in pacu etc. I was speaking with someone that said at a cysto center that's all they did, it was mostly ASA1/2. Just mask, oral airways for a lot (supraglottic airway), good suctioning, wake up deep in pacu. Said it was faster and over time saved money on lmas/equipment

Mask anesthesia is a lost art. Pre-LMA, our choices were mask or tube. If they didn't need NMB, then the case was almost always a mask. It just takes getting used to. It's really not that difficult to do it all.

And as a couple others indicated - turn the gas off at the right time.

 

[Noyac]

Any case under 30 minutes is a good mask case.

I did all my plastics cases this way when I was at the plastic surgeons office because they would reuse the disposable LMAs and I thought that was gross.

 

[drmwvr]

Seems unnecessary for the skilled practitioner. Propfol induction, maintenace with gas, spontaneous respiration the whole time, two hands free to chart, one hand to occasionally ventilate if you’ve overdosed propfol or fentanyl, turn off the gas at the appropriate and optimal time, and have the patient move himself over to the gurney.

In solo practice I have no desire to leave a non-awake patient unattended in PACU for the 0.1% chance something can go wrong. I’m also skilled enough to know when to turn off the gas.

Who says masked cases need to go to recovery deep? You can turn the agent off the at same time you would with a tube or lma (sooner in most cases, because there is nothing around the glottis). And what needs charting that requires 2 hands?

 

[Maverikk]

For charting I would use the face mask strap

 

[btbam]

Do this all the time in peds. Hold mask with one hand, use EMR/chart with free hand. Adding a touch of PSV-pro is a nice addition as well. We transport directly to PACU, but I suppose peds PACU nurses are more familiar with stage 2 and emergence overall.

 

[Psai]

Any case under 30 minutes is a good mask case.

I did all my plastics cases this way when I was at the plastic surgeons office because they would reuse the disposable LMAs and I thought that was gross.

???

wat

 

[btbam]

???

wat

Sterilize them. The flesh colored rubber ones I assume is what he means.

 

[teeva]

Who says masked cases need to go to recovery deep?

The original post.

 

[drmwvr]

The original post.

Rhetorical

 

[fakin' the funk]

Mask anesthesia is a lost art. Pre-LMA, our choices were mask or tube. If they didn't need NMB, then the case was almost always a mask. It just takes getting used to. It's really not that difficult to do it all.

Teasing you here, but in those halcyon pre-LMA days, patients were admitted to the hospital prior to elective surgeries and stayed for 10 days postop and surgical site infection rates were 20% in colorectal and patients were kept NPO until flat and and and...

 

[fakin' the funk]

Anyone do this? For short cystos or the like do you ever just mask them down, keep them spontaneous and transfer to PACU deep. I realize the risks: phase 2 in pacu etc. I was speaking with someone that said at a cysto center that's all they did, it was mostly ASA1/2. Just mask, oral airways for a lot (supraglottic airway), good suctioning, wake up deep in pacu. Said it was faster and over time saved money on lmas/equipment

The line between deep sedation (usually with IV rx) and GA (usually with volatile) is blurry...obviously. These types of cases (short, peripheral, typically healthier patients) really demonstrate that.

You can try any variation. Mask + volatile, propofol + LMA, propofol + simple mask, volatile through a nasal airway, whatever.

For the cases you described, if truly less than 5-10 minutes, I'd probably do propofol, simple mask, perhaps a bit of fentanyl. No need to introduce volatile for such short cases, it's too slow.

 

[Noyac]

Sterilize them. The flesh colored rubber ones I assume is what he means.

Nope, the clear disposable ones.
They would sterilize them and they looked awful after a few uses. I wouldn’t want one in my mouth so therefore I wouldn’t place one in my pt’s mouth.

 

[anbuitachi]

Do this all the time in peds. Hold mask with one hand, use EMR/chart with free hand. Adding a touch of PSV-pro is a nice addition as well. We transport directly to PACU, but I suppose peds PACU nurses are more familiar with stage 2 and emergence overall.

You must type really fast with 1 hand...

Actually over here i can't even reach the computer w my other hand if im holding the mask. and it's annoying cause the computer is behind me

 

[coffeebythelake]

Nope, the clear disposable ones.
They would sterilize them and they looked awful after a few uses. I wouldn’t want one in my mouth so therefore I wouldn’t place one in my pt’s mouth.

ugh. there's a reason why single use is single use. reminds me of this recent article about that colorectal surgeon who used single use anal catheters for multiple patients.

 

[deleted126335]

Mask anesthesia is a lost art. Pre-LMA, our choices were mask or tube. If they didn't need NMB, then the case was almost always a mask. It just takes getting used to. It's really not that difficult to do it all.

And as a couple others indicated - turn the gas off at the right time.

It is a lost art. One that does not need to be rediscovered.

 

[The Physician Philosopher]

ugh. there's a reason why single use is single use. reminds me of this recent article about that colorectal surgeon who used single use anal catheters for multiple patients.

I just vomited inside my mouth. Disgusting.

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[Psai]

I just vomited inside my mouth. Disgusting.

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Well it's not like I've used mine only once either