Masseter muscle rigidity

[24858]

Question
Say you were to cancel a case for MMR. I would imagine you would admit the patient to telemetry to watch for tachycardia/tachydysrhythmias? Anything else? Foley? Lytes? CK? Or would you just observe in PACU for a few hours and then discharge if all is well?

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[cchoukal]

I've been led to believe that a very high percentage of people w/ masseter rigidity from succ are MH-susceptible. Would you refer such a patient for testing before proceeding w/ a GA?

 

[24858]

I've been led to believe that a very high percentage of people w/ masseter rigidity from succ are MH-susceptible. Would you refer such a patient for testing before proceeding w/ a GA?

Good question, I would revisit what happened in my mind. Was there a problem with sux getting to the patient? Does the patient have TMJ? Would a lab draw that came back for a CK elevation or no elevation sway me one way or another?
I think I was observe the patient for 6-8 hrs and then send home. If I truly believed it was MMS I would instruct the patient to get a muscle biopsy.

 

[fakin' the funk]

I think I was observe the patient for 6-8 hrs and then send home. If I truly believed it was MMS I would instruct the patient to get a muscle biopsy.

This is kinda theoretical, let's make it a little practical. I'm gonna try to fill in the blanks.

If there's masseter spasm after succinylcholine, you notify the surgeons that the case is cancelled, ventilate with 100% O2 until recovery from anesthesia/NMB, and then to PACU... right?

Is there any further immediate workup (ABG, Chem7) to be done?

What additional postop workup needs to be done?

 

[nitroglycerine]

This is kinda theoretical, let's make it a little practical. I'm gonna try to fill in the blanks.

If there's masseter spasm after succinylcholine, you notify the surgeons that the case is cancelled, ventilate with 100% O2 until recovery from anesthesia/NMB, and then to PACU... right?

Is there any further immediate workup (ABG, Chem7) to be done?

What additional postop workup needs to be done?

I would think if the masseter spasm was serious enough to cancel the case than I would keep the patient on telemetry overnight and do a baseline CK and a couple of follow up samples. I would also call MHAUS for advice.

 

[proman]

Here's what MHAUS has to say:

Q: Is Masseter Muscle Rigidity a response to Succinylcholine?
A: Masseter (jaw) muscle rigidity (MMR) denotes trismus to the extent that it is difficult or impossible to open the jaw. Mild and/or transient MMR is a normal response to succinyicholine and is considered to be of no prognostic significance with respect to MH. [Longnecker et al. Anesthesiology. Pg 1969. 2008. McGraw Hill, New York] Approximately 1% of children receiving anesthesia induced by halothane or sevoflurane and then given succinylcholine develop MMR. [Rosenberg, 2007] If a patient has received succinyicholine and his/her jaw cannot be opened or the patient has peripheral muscle rigidity, the clinician should assume this is an MH event and immediately begin MH treatment. Generalized rigidity may not be present, but when it is, it is regularly associated with MH susceptibility.



The actual physiologic changes associated with the onset of MH such as rise in ETCO2 may be delayed for up to 15 minutes after MMR, but will occur if trigger agents are continued. Hence whenever MMR occurs following succinyicholine, elective surgery should be postponed. If the procedure is emergent, the anesthetic may continue with nontrigger agents.



All patients who develop succinylcholine-induced MMR will experience rhabdomyolysis over the ensuing 24 hours. Hence the patient should remain in the hospital and be monitored for signs of rhabdomyolysis such as myoglobinuria and myoglobinemia. CK levels and electrolytes should be checked every 8 hours until returning to normal.

 

[jwk]

Good question, I would revisit what happened in my mind. Was there a problem with sux getting to the patient? Does the patient have TMJ? Would a lab draw that came back for a CK elevation or no elevation sway me one way or another?
I think I was observe the patient for 6-8 hrs and then send home. If I truly believed it was MMS I would instruct the patient to get a muscle biopsy.

So, reading ProMan's quote from MHAUS, and with the assumption being that it's an MH event...

Does the patient need the muscle bx and associated testing, or do you simply let them know they should be considered MH susceptible and take appropriate measures in the future? As long as you know to treat the pt. as an MH patient, is there any real need to go through formal testing?

 

[24858]

So, reading ProMan's quote from MHAUS, and with the assumption being that it's an MH event...

Does the patient need the muscle bx and associated testing, or do you simply let them know they should be considered MH susceptible and take appropriate measures in the future? As long as you know to treat the pt. as an MH patient, is there any real need to go through formal testing?

If that is MHAUS' take on it then the patient needs a muscle biopsy. If the muscle biopsy is negative I would have no qualms about using volatile in that patient or their family members.

 

[Idiopathic]

this patient spends the night in the hospital, possibly in the ICU.

i label them as MH+ based on this event, and their first order family relatives should have genetic testing, i believe is the indication...they can bypass muscle biopsy

edit: i left the above, because i thought these were more current recommendations, but this is not on MHAUS site, so CHCT for all, apparently.

 

[24858]

this patient spends the night in the hospital, possibly in the ICU.

i label them as MH+ based on this event, and their first order family relatives should have genetic testing, i believe is the indication...they can bypass muscle biopsy

edit: i left the above, because i thought these were more current recommendations, but this is not on MHAUS site, so CHCT for all, apparently.

From the clinical situation described on MHAUS' website I would agree with you Idiopathic, but in real life MMR has a high false positive rate, so wouldnt the best course be to obtain a definitive diagnosis first in this patient, you may be sparing a number of people from muscle biopsies and travel expenses, and you may be sparing an individual from being diagnosed inappropriately.

 

[proman]

From the clinical situation described on MHAUS' website I would agree with you Idiopathic, but in real life MMR has a high false positive rate, so wouldnt the best course be to obtain a definitive diagnosis first in this patient, you may be sparing a number of people from muscle biopsies and travel expenses, and you may be sparing an individual from being diagnosed inappropriately.

You didn't mention it but we're all assuming the patient received succinylcholine, right? Trismus can happen without getting sux, and that has no correlation with MH.

I don't know what the value of genetic testing would be. In a patient with a prior suspected MH event, or primary relative with an MH episode, a negative genetic test would not change my practice: I'd do a non triggering anesthetic. The specificity of genetic testing is very high, but according to MHAUS, only about 30% of MH susceptible patients have positive genetic test. We don't know all the mutations that cause MH, so the genetic test as a screen is not valid. The caffeine halothane contracture test does have a very high sensitivity, enough to exclude MH. Due to the cost of the genetic test (around $5,000) the CHCT is still the first line screen.

I'd recommend the patient get a muscle biopsy. The following are centers in North America: The Ottawa Hospital - Clinic, Toronto General Hospital, USUHS in Bethesda, UC Davis, University of MN, Wake Forest. Unless presented with a negative CHCT I'd use a non triggering anesthetic.

 

[Idiopathic]

i know all that. my mistake was forgoing the CHCT in this patient. if he/she should test positive then he should get genetic testing and his first-order relatives can bypass CHCT (which is a painful procedure, done at a few places, and typically requires a general anesthetic) to "rule-in" MH. Otherwise they are considered MH-susceptible

 

[jwk]

You didn't mention it but we're all assuming the patient received succinylcholine, right? Trismus can happen without getting sux, and that has no correlation with MH.

I don't know what the value of genetic testing would be. In a patient with a prior suspected MH event, or primary relative with an MH episode, a negative genetic test would not change my practice: I'd do a non triggering anesthetic. The specificity of genetic testing is very high, but according to MHAUS, only about 30% of MH susceptible patients have positive genetic test. We don't know all the mutations that cause MH, so the genetic test as a screen is not valid. The caffeine halothane contracture test does have a very high sensitivity, enough to exclude MH. Due to the cost of the genetic test (around $5,000) the CHCT is still the first line screen.

I'd recommend the patient get a muscle biopsy. The following are centers in North America: The Ottawa Hospital - Clinic, Toronto General Hospital, USUHS in Bethesda, UC Davis, University of MN, Wake Forest. Unless presented with a negative CHCT I'd use a non triggering anesthetic.

So the genetic test is $5k. What about the CHCT? That can't be cheap either.

So - you have a patient with MH potential. Why not simply instruct the patient that although there are tests available, it would also be just as easy for them to let their anesthesia provider know in the future that there is MH potential and it has been recommended to them that they be treated as such. Sure, you don't have a definitive diagnosis, but...so what?

 

[24858]

So the genetic test is $5k. What about the CHCT? That can't be cheap either.

So - you have a patient with MH potential. Why not simply instruct the patient that although there are tests available, it would also be just as easy for them to let their anesthesia provider know in the future that there is MH potential and it has been recommended to them that they be treated as such. Sure, you don't have a definitive diagnosis, but...so what?

If a biopsy came back negative I would use agent and sux in these individuals, also I would consider their relatives able to receive triggering agents as well. To label a patient positive by virtue labels their blood relatives as positive as well, thereby limiting the anesthetize their relatives may receive. It also limits job opportunities, such as with the military.
I feel it would be poor practice to allow uncertainty in such an issue, to have the patient just tell future anesthesiologists that they may be susceptible? This is your practice? Why even do we bother to have muscle biopsies then? I feel that succinylcholine is a vital paralytic to be able to give to patients and to potentially take that away from a whole family seems poor practice. Where did you learn this?

 

[proman]

I agree with MeaCulpa. A screening test for a disease ideally should have a high sensitivity while a confirmatory test should have a high specificity. It's unusual for one test to have both high sensitivity and high specificity. Sensitivity is the number of patients with the disease who have a positive test. Specificity is the number of healthy patients. without the disease who have a negative test.

The sensitivity of the contraction test is about 97%. I did some digging and found the sensitivity of the genetic test is about 65%. From the maker of one of these tests, PreventionGenetics:

Indications for Test: Ideal MH test candidates have a family history of MH along with either a positive in vitro contracture test or a clear MH event. The hunt for the causative mutation should begin in such a family member. If a causative mutation is identified, other family members can be screened at much reduced cost. Other, less ideal candidates for the test are those with just a family history of MH or those with a “MH-like” event and no family history. Tier 2 testing is not generally recommended for less ideal MH candidates. CCD test candidates are patients with myopathy and characteristic cores upon microscopic examination of skeletal muscle biopsy.
Sensitivity of Test: Based on results from both the literature and PreventionGenetics, we estimate that the full gene test will detect likely causative mutations in roughly 65% of ideal MH test candidates. Sensitivity will be lower for non-ideal MH candidates. Similarly, the full gene test will detect likely causative mutations in ~70% of patients with Central Core Disease (Wu et al. Brain 129:1470-1480, 2006).

97% sensitivity is high enough to reliably exclude a life-threatening disease, 65% is not. I would not treat a patient with a negative genetic test (absent muscle test) any different than a known MH. Great thread BTW, I've learned a ton.

 

[pgg]

I feel it would be poor practice to allow uncertainty in such an issue, to have the patient just tell future anesthesiologists that they may be susceptible?

I had a patient last week who said her grandfather's uncle died under anesthesia. She assumed it was MH. She assumed she was susceptible. She'd had 3 prior non-triggering anesthetics.

I drew a picture. We talked about how many generations back the gene was in her family (if it was indeed MH, and it wasn't a new mutation in the great-great-uncle) and her 1:16 odds of having the gene, if indeed it was MH. We talked about how anesthesia was different that long ago and how dying under anesthesia back in those dark ages usually wasn't because of MH. We talked about testing (not interested).

Then I gave her a non-triggering anesthetic.

She's going to get TIVAs for the rest of her life, and that's just the way it is ...

 

[jwk]

If a biopsy came back negative I would use agent and sux in these individuals, also I would consider their relatives able to receive triggering agents as well. To label a patient positive by virtue labels their blood relatives as positive as well, thereby limiting the anesthetize their relatives may receive. It also limits job opportunities, such as with the military.
I feel it would be poor practice to allow uncertainty in such an issue, to have the patient just tell future anesthesiologists that they may be susceptible? This is your practice? Why even do we bother to have muscle biopsies then? I feel that succinylcholine is a vital paralytic to be able to give to patients and to potentially take that away from a whole family seems poor practice. Where did you learn this?

I think my point is somehow escaping you.

So I think my patient has MH, and I tell them they need to have the CHCT to confirm this. And oh, by the way, there are only four centers in the US that can do this test, and you have to go there to have it done, because the tissue has to be fresh. The test will cost several thousand dollars for the procedure in the hospital, the pathologist, and the surgeon, and of course you have to pay the travel expenses yourself.

I fully understand and appreciate what the "board answer" is, but I'm not sure you appreciate the time and costs involved to the patient.

Here's the real-world non-academic way of doing things. Our recommendation would be that the patient be tested. Can I force the patient to do that? No. Can I anesthetize the patient safely if there is a possibility that they're MH susceptible? Absolutely, and with ease. Would it be nice to know for sure? Of course. Do I have to know for sure? Of course not. We ask every patient at their pre-op evaluation if they or anyone in their family have had a problem with anesthesia including high temperatures or MH? And if they say yes, do we cancel their surgery? Of course not. We simply do a non-triggering anesthetic and enjoy the rest of the day.

There are MANY anesthesiologists, CRNA's, and AA's that have sworn off using succinylcholine entirely in their practice for ANY patient due to any number of reasons, and in particular, MH potential. Many outpatient surgery centers don't stock it at all because, if they do, they feel obligated to carry dantrolene at a significant cost.

The military aspect is something I had never heard, so I looked it up. MH is indeed a potentially disqualifying disease process, although from what little I read, it appears that waivers might be possible. The main concern appears to be the potential of an MH susceptible patient in a forward operating area where dantrolene likely is not available. However - I would assume that anyone with a known family history of MH that really wants to enlist in the military would certainly find it worth their while to be tested.

 

[24858]

I think my point is somehow escaping you.

So I think my patient has MH, and I tell them they need to have the CHCT to confirm this. And oh, by the way, there are only four centers in the US that can do this test, and you have to go there to have it done, because the tissue has to be fresh. The test will cost several thousand dollars for the procedure in the hospital, the pathologist, and the surgeon, and of course you have to pay the travel expenses yourself.

I fully understand and appreciate what the "board answer" is, but I'm not sure you appreciate the time and costs involved to the patient.

Here's the real-world non-academic way of doing things. Our recommendation would be that the patient be tested. Can I force the patient to do that? No. Can I anesthetize the patient safely if there is a possibility that they're MH susceptible? Absolutely, and with ease. Would it be nice to know for sure? Of course. Do I have to know for sure? Of course not. We ask every patient at their pre-op evaluation if they or anyone in their family have had a problem with anesthesia including high temperatures or MH? And if they say yes, do we cancel their surgery? Of course not. We simply do a non-triggering anesthetic and enjoy the rest of the day.

There are MANY anesthesiologists, CRNA's, and AA's that have sworn off using succinylcholine entirely in their practice for ANY patient due to any number of reasons, and in particular, MH potential. Many outpatient surgery centers don't stock it at all because, if they do, they feel obligated to carry dantrolene at a significant cost.

The military aspect is something I had never heard, so I looked it up. MH is indeed a potentially disqualifying disease process, although from what little I read, it appears that waivers might be possible. The main concern appears to be the potential of an MH susceptible patient in a forward operating area where dantrolene likely is not available. However - I would assume that anyone with a known family history of MH that really wants to enlist in the military would certainly find it worth their while to be tested.

Your point didnt escape me I just consider it to be misinformed is all.
I work in the real world as you would call it, I work in private practice.
I am glad you and your ilk have basically sworn off the use of succinylcholine and the contracture test, seems overly short sighted to me. Sure a patient my deem the cost too high, however that is not a decision for me to make. In the best interest of future physicians who make come into contact with this patient, I feel I have a professional and ethical obligation to give the patient my best informed opinion, which would be to highly recommend a test that will affect themselves and family members in the future. I remember a few years back the FDA labeled Succinylcholine as contraindicated for pediatric patients, however this was quickly reversed when a large majority of pediatric anesthesiologists considered this entirely inappropriate. I think I will err on the side of a majority of pediatric anesthesiologists, rather than the anecodote of whomever you are. You seem to be a cavalier clinician, are you new or are you just extremely inexperienced? As far as succinylcholine goes, I have been extremely fortunate to have had it in my armamentarium. What the hell do you and your foolish partners do when a child larnygospasms and you cant break it quickly with PPV and deepening the anesthetic? You gonna wait that extra few seconds for Roc to kick in? Why not just use a few milligrams of Sux and have it break and then PPV and allow Sux to wear off in a minute or two and then everything fine? Isnt this standard of care, you dont do this?

 

[proman]

Many outpatient surgery centers don't stock it at all because, if they do, they feel obligated to carry dantrolene at a significant cost.

Do they not use volatile anesthetics either?

 

[jwk]

Do they not use volatile anesthetics either?

Some do - I don't think it's smart, and it goes against MHAUS recommendations, but apparently (from other forums I participate in) it's done. All of the operating locations in my practice including free-standing outpatient centers have fully stocked MH carts.

 

[24858]

I was curious.
When people are doing a general anesthetic for an OB patient, are you using Succinylcholine? Or have people completely abandoned succinylcholine as JWK has eluded to and now are using Rocuronium preferentially? I thought the standard of care was succinylcholine for rapid sequence intubation, not only for rapidity in onset but also for the rapidity in metabolization; allowing the patient is able to spontaneously ventilate if ventilation or intubation is an issue. Am I missing something here? JWK has stated that a number of anesthesiologists have abandoned succinylcholine all together.. is this other peoples practice as well, the abandonment of succinylcholine as a part of your anesthetic? I would appreciate people's insights into this (people who no longer use succinylcholine) and if you feel you leave yourself open to legal or board scrutiny if there is an aspiration or cant ventilate event in which you did not use succinylcholine.

 

[jwk]

Your point didnt escape me I just consider it to be misinformed is all.
I work in the real world as you would call it, I work in private practice.
I am glad you and your ilk have basically sworn off the use of succinylcholine and the contracture test, seems overly short sighted to me. Sure a patient my deem the cost too high, however that is not a decision for me to make. In the best interest of future physicians who make come into contact with this patient, I feel I have a professional and ethical obligation to give the patient my best informed opinion, which would be to highly recommend a test that will affect themselves and family members in the future. I remember a few years back the FDA labeled Succinylcholine as contraindicated for pediatric patients, however this was quickly reversed when a large majority of pediatric anesthesiologists considered this entirely inappropriate. I think I will err on the side of a majority of pediatric anesthesiologists, rather than the anecodote of whomever you are. You seem to be a cavalier clinician, are you new or are you just extremely inexperienced? As far as succinylcholine goes, I have been extremely fortunate to have had it in my armamentarium. What the hell do you and your foolish partners do when a child larnygospasms and you cant break it quickly with PPV and deepening the anesthetic? You gonna wait that extra few seconds for Roc to kick in? Why not just use a few milligrams of Sux and have it break and then PPV and allow Sux to wear off in a minute or two and then everything fine? Isnt this standard of care, you dont do this?

You assume a little too much since you know nothing about me, and I'm not really sure why you feel being insulting is appropriate. Where did you get the idea that I don't use sux? What I said was that many don't use it anymore - I never said that I didn't.

I've been in practice for 30 years. When I started in practice, my options were sux, pavulon, and DTC. Roc and vec weren't even on the horizon. The use of succinylcholine is still a frequent part of my practice, and I probably use it more than many in my practice of more than 120 providers. As an AA, I will defer to the anesthesiologist responsible for my case, and some of my anesthesiologists will not use succinylcholine, period.

Should potential MH susceptible patients be tested? Yes. Do we recommend they do so? Yes. Will we do their anesthetic if they haven't been tested? Yes, and it's perfectly acceptable to do so according to MHAUS.

So - tell me what you do when you have a potential MH patient - one that hasn't had it, but has a fairly close relative who has. The patient hasn't been tested, nor do they want to be. Do you do the case using TIVA, regional, etc., or do you insist on having MH testing completed first?

 

[Ronin2258]

The screening question of family issues with anesthesia would be enough for me to trip over to TIVA. Having done research in this trying to find an accurate, less invasive alternative to CHCT, I would personally have a low tolerance to doing a inhalant agent flush of the machine and setting up TIVA if the questions came back positive.

Now, granted, this is from doing research on swine that were pretty much guaranteed to go into crisis with halothane and sux (hell, the running joke was that you could spook them into crisis by screaming "boo!' they were so predisposed.) Now that I am going to the clinical/practical side, I am hoping that attending experience will temper itchy trigger finger in this situation.

Miller states that any inhaled agent can trigger crisis, halothane and sux making an explosive event. Has anyone experienced/seen someone in practice go into crisis with isoflurane, sevoflurane, or desflurane? And if so, it brings the question of is it a risk that outpatient centers that use inhaled agents are putting themselves at risk for not having a MH cart?

 

[pgg]

And if so, it brings the question of is it a risk that outpatient centers that use inhaled agents are putting themselves at risk for not having a MH cart?

I wouldn't work at such a place without a MH cart. How could anyone possibly stand up in court to defend a MH-related death?

 

[24858]

Should potential MH susceptible patients be tested? Yes. Do we recommend they do so? Yes. Will we do their anesthetic if they haven't been tested? Yes, and it's perfectly acceptable to do so according to MHAUS.

So - tell me what you do when you have a potential MH patient - one that hasn't had it, but has a fairly close relative who has. The patient hasn't been tested, nor do they want to be. Do you do the case using TIVA, regional, etc., or do you insist on having MH testing completed first?

I would of course do TIVA. However if someone may have MH I explain to them the burden they place on other family members if they don't get tested. No child in the family will be able to have a mask induction, not a benign thing in my mind. Nor will sux be used. I use sux for almost every c/s general I hav ever done. I have never seen MH. There was a question of a case of MH during my residency. CK levels when drawn came back only marginally elevated. I have however heard of more than one case of proposal infusion syndrome during residency. One case in practicular was on a child having Harrington rod placement. The patient was on low dose roc gtt, fent gtt, low dose iso, and some iso, I'm addition 50 mcg/kg/min of prop. The child started to move toward the end of the procedure, he was given a prop bolus and quickly thereafter arrested.
So I am not as quick to write if off as, hell I am good I can do this 1 year old baby in a five hour surgery under propofol gtt. I would prefer to not do that to a future practionier taking care of family members of the MH possible patient.

But the sux issue is even more intriguing to me. Do docs here not use sux for women for c/s? If some ******* induced my wife for emergent c/s with roc and she vomited and had a hypoxic brain injury, you better believe I am going to nail his or her ass. Seconds matter in this job, don't they? Or am I just extremely paranoid? If I walk into a Room where a childs sats are in the toilet and someone has given roc instead of sux to help this child, because of fears of MH, I would be extremely pissed at that person. Because if it were my kid you bet your ass I want sux used.

 

[dhb]

If some ******* induced my wife for emergent c/s with roc and she vomited and had a hypoxic brain injury, you better believe I am going to nail his or her ass.

That makes no sense 😕

 

[pgg]

If some ******* induced my wife for emergent c/s with roc and she vomited and had a hypoxic brain injury, you better believe I am going to nail his or her ass.

I generally avoid succinylcholine, but use it when it's indicated. I use it for RSIs, and I don't hesitate to use it in male kids experiencing laryngospasm that I can't immediately break with other maneuvers.

But 1.2 mg/kg of roc is OK for an RSI; you're just stuck with the paralysis for a while. Too bad Sugammadex isn't available in the US. Rocuronium wouldn't be my first choice for an emergent c/s but I don't think it's necessarily wrong.

 

[24858]

That makes no sense 😕

Not sure why it doesn't make sense to you. If someone uses sux attempts multiple times to intubate and can't, it wears off sooner than roc, and you let patient breathe on their own, and protect their own airway. If you give roc to intubate and can't you are stuck for an extended period of time with an unprotected airway, especially if you use the RSI dose. That leaves the patient a longer period of time aspirate. Sure of sugammedex were available no big deal.

 

[deleted9493]

Not sure why it doesn't make sense to you. If someone uses sux attempts multiple times to intubate and can't, it wears off sooner than roc, and you let patient breathe on their own, and protect their own airway. If you give roc to intubate and can't you are stuck for an extended period of time with an unprotected airway, especially if you use the RSI dose. That leaves the patient a longer period of time aspirate. Sure of sugammedex were available no big deal.

I don't disagree with you, MeaCulpa. You'd just be much more easy to agree with if you weren't so deriding/demeaning in the way you're presenting yourself in this thread.

 

[dhb]

Sure of sugammedex were available no big deal.

We do have sugammadex in Europe 😉

 

[24858]

We do have sugammadex in Europe 😉

Is it true that Europeans use LMAs alot more? Such as on laparoscopic surgery? Sorry didn't realize you were from Europe.

 

[sevoflurane]

Is it true that Europeans use LMAs alot more? Such as on laparoscopic surgery? Sorry didn't realize you were from Europe.

That sounds like a bad idea.... unless you are taking about a 10 minute lap tubal ligation... and even then I'm not sure if its a good idea.

 

[dhb]

Is it true that Europeans use LMAs alot more? Such as on laparoscopic surgery? Sorry didn't realize you were from Europe.

Not in continental Europe: it's more a Aussie/NZ thing that may have some following in the UK.
I've actually never seen a Proseal.

 

[Ronin2258]

That sounds like a bad idea.... unless you are taking about a 10 minute lap tubal ligation... and even then I'm not sure if its a good idea.

It sounds like a *really* bad idea...

 

[dhb]

It sounds like a *really* bad idea...

Like giving a beta blocker to a patient w chronic heart failure?

 

[Arch Guillotti]

If some ******* induced my wife for emergent c/s with roc and she vomited and had a hypoxic brain injury, you better believe I am going to nail his or her ass. Seconds matter in this job, don't they? Or am I just extremely paranoid? If I walk into a Room where a childs sats are in the toilet and someone has given roc instead of sux to help this child, because of fears of MH, I would be extremely pissed at that person. Because if it were my kid you bet your ass I want sux used.

oh come on now