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deleted875186
Does anyone feel comfortable using muscle relaxant with a well fitting LMA? Why or why not. Most attendings I work with will never do it, and will even switch to ETT during the case if the surgeon asks for relaxation.
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I do it all the time. It works very well.
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Same here. Academic dogma. Don't do it in a 375 lb. IDDM pt. with a hiatal hernia who sleeps on 4 pillows or anything but otherwise....non-issue.
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deleted59964
Being a doctor means you should think and use your tools to solve problems creatively ... not just blindly follow rules.
Eg. In patients with no cvs reserve if you can do the case with a lma, it’s quite elegant to give enough propofol to get them to close their eyes then paralyse to ease lma placement.
Eg. In patients with no cvs reserve if you can do the case with a lma, it’s quite elegant to give enough propofol to get them to close their eyes then paralyse to ease lma placement.
THIS. If a patient is such an aspiration risk that they can’t tolerate 10-15 mins of PPV through an LMA then you shouldn’t have placed one in the first place...
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I had an attending who used to give sux when LMA insertion was not as smooth as he/she would like. Worked well.
If I know that Im going to need muscle relaxation, I tube.
If im doing a case with an LMA and the surgeon unexpectedly needs muscle relaxation transiently, I will give 10-20 of roc with an LMA
Never would I paralyze for LMA insertion with sux or roc
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deleted697535
I cut it even further than 10mg roc. Id give like 4mg or 5mg. Whiney surgeons notice the difference and 5 mins later it's gone again...
But yeah aspiration is nothing to be joked about.
But yeah aspiration is nothing to be joked about.
My exact practice
I never paralyze from the get-go for LMA insertion, and 99.99% of the time you don't need it. Once in a blue moon, however, I have found paralytic to be useful to help seat it properly. Very, very rare circumstance though.
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If you want to maintain spontaneous ventilation and you are sorta worried about a borderline LMA candidate, the 2nd generation (LMA Supreme, iGel) have gastric ports you can pass an OG down and suck out the stomach.
It's not as litigious an environment, but I am almost positive there are many European papers about using LMAs for all sorts of intrabdominal cases requiring paralysis. If I get bored I'll try to link some of them later.
It's not as litigious an environment, but I am almost positive there are many European papers about using LMAs for all sorts of intrabdominal cases requiring paralysis. If I get bored I'll try to link some of them later.
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deleted875186
But what is your reasoning? If it’s a short case and surgeon needs muscle relaxant, such as a simple ORIF, why not ventilate through an LMA in a skinny person who has been NPO? If concerned about aspiration, is the aspiration risk that much greater with muscle relaxant on board compared to another patient without muscle relaxant but on PSV?
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Interesting to hear everyone's real world experiences. Still living in the land of academic dogma, any of us residents would get smacked out of residency for trying something so blasphemous.
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Pretty sure we train at the same place, and yep, I would get smacked.
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Not sure if this has been mentioned... but doesn't eurpore do lap choles with NMB?
Role of laryngeal mask airway in laparoscopic cholecystectomy
In my practice, with Suggamadex, it really is a no brainer to tube these patients who are getting lap choles... but that doesn't mean that I don't push some short acting NMB on selected LMA cases.
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Yep. Colon resection, small bowel resections, prostatectomy, gyn surgery, all sorts of abdominal surgery.
In my practice I tube all intraabdominal cases. But if I’m doing an orthopedic case that will require NMB I will usually lma. Also if I’m doing an inguinal hernia repair with an lma and the patient starts breathing heavy, I will paralyze them and start PPV which produces a very quiet surgical field.
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I also trained at that place, and we (once) used roc for an eye case that the opthalmologist wanted relaxation mid-case for (with a certain attending who likes to break into song). Everything was fine. Same so far in practice for any case that unexpectedly calls for relaxation with an LMA in place.
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I use LMAs in patients I want to breath spontaneously from the outset- never use NMB. ETT for all who are at risk of aspiration or when NMB are needed. Only once have I had to switch to an ETT from LMA- knowing your surgeons preferences up front helps.
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I ijel and roc all the time..... In the right patient it works like a champ. Usually seat get spontaneous. Surgeon needs relaxent roc 30 or less. A little sugga at the end. Smooth case.
Im OK with giving PPV through an LMA. I often do PCV without muscle relaxation when pt is apneic with an LMA. But I dont want to rely on this for a long time. And Why? To save someone the terrible trauma of being intubated? Im not worried at all about a couple of extra coughs to have a protected airway and not inflate the stomach slowly over time. I would also worry about the LMA seal changing during the case, and volumes dropping at 20 of pressure, and now i have to stop the case and intubate.
I understand that when the surgeon asks for relaxation in a simple ORIF it is frustrating to have to intubate that patient. But if its a long case requiring relaxation (whether appropriate or inappropriate) Im intubating the guy and protecting him from the idiot at the other side of the curtain who is putting them in a dangerous situation because of their own poor technique. And lastly, If i have an LMA and surgeon asks for relaxation and its the end of the case and I think its silly and ridiculous, you can always just give prop instead and say they have 0 twitches.
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deleted162650
If the plan is to paralyze, then what are you gaining by using an LMA?? I don’t think PPV through an LMA is a mortal sin or anything, I just don’t get the upside in this situation.
I've never understood the unfounded fear some people have with intubating people. Just makes no sense to me. I don't know if these people are regularly breaking off patients' front teeth or what.
Then again it probably comes from the same place where people think it's malpractice to put an LMA in a patient with a spinal...
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In Scandinavia, PPV through an LMA with TIVA is the most widely practiced method of anesthesia. Rarely need muscle relaxant with TIVA.
How does TIVA substitute for muscle paralysis if it is needed for optimal conditions?
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deleted162650
How does TIVA substitute for muscle paralysis if it is needed for optimal conditions?
Agree. Volatiles will generate some muscle relaxation all by themselves (more pronounced at levels > 1MAC but still). I’ve never read that propofol or natcotics have a similar effect. I think Scandinavian surgeons just aren’t primadonnas.
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deleted59964
I very very rarely use nmb with lma ... but
Sometimes a fair amount of propofol is needed to make placing an lma easy and make it seat well.
Putting an ett in the trachea of a lightly anaesthetised patient can cause significant tachycardia.
In a small group of patients, in whom you want to avoid using much propofol (eg for its hemodynamic consequence) or patients who won’t tolerate tachycardia ... a small dose of induction agent, a small dose of nmba, and an lma is one way to do a stable, elegant induction.
It’s not for everyone
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We tube all patients getting laparoscopic cases because our SGAs aren't as fancy as yours. No gastric poet to decompress the stomach. Also a lot of our surgeons are very whiney
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Oh come on, just buy some fancy ones and just wash them off in the sink between patients...
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Oh come on, just buy some fancy ones and just wash them off in the sink between patients...
That's what the techs are for.
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I absolutely do it and have not had any problems. Often it's a nominal amount such as 5 or 10 of rocuronium. If I need to plan on deep or prolonged paralysis, then I'll ETT. But, I have no problem using a little roc with an LMA.
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Laprascopic cases tube regardless too easy for the lawyers. Open hernias/minor gyno less then 2 hours minus laparoscopic surgery/ any hernia open/ ortho minus lateral position/ all lma cases, even beach chair. I would not paralyize in morbidly obese or severe gerd or steep trendelenburg. Also with suggamadex if you keep your paralytic low your less then 2 min from a spontaneous breathing patient.
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deleted162650
Nothing wrong with lateral LMA’s. I do >90% of my shoulder scopes that way.
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deleted59964
with sugammadex you can be profoundly paralysed and be spontaneously ventilating in 1 min
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Some of my attendings drop 40 mg of sux in to "facilitate LMA insertion"... others, heavy propofol, like 3-4/kg provided they can tolerate it. Then you just wait for them to relax a bit. Bag em. Or... as one of my attendings says "sux sucks, ketamine rocks". I've seen 100 kg muscular young guys go down with 2 of midaz, 20 of ketamine and 150 of propofol. Wait an appropriate amount of time. The drugs work.... sometimes you just need to wait a bit longer. Slip the LMA in and turn on the gas. Off to the races. 1000s of different ways to skin the cat.
I don't like giving sux, try to avoid it as much as possible. I've had sux myalgias myself as a patient, and they are not fun.
Moral of the story: as a resident, I've learned it's always easy to give more drug... really hard to take it back.
I don't like giving sux, try to avoid it as much as possible. I've had sux myalgias myself as a patient, and they are not fun.
Moral of the story: as a resident, I've learned it's always easy to give more drug... really hard to take it back.
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So have I. It was worse than the surgical pain from my radius & ulna ORIF. Won't use it unless I need it.
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Yes, you can do it and many people do. Just don't say it in your boards, that will fail you! LOL
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You won't fail your oral boards if you tell them you would use relaxant and PPV with a LMA. That's ridiculous. The examiners aren't idiots.
You might fail if the LMA is contraindicated for other reasons.
And in general, the kind of cases you're presented with during the oral exam really aren't the straightforward uncomplicated scenarios where you'd be electively using a LMA in the first place. Outside of the difficult airway algorithm, I don't think there are a lot of LMAs being used by examinees. It's a test of knowledge, judgment, adaptability, and safety. Stick a tube in and get on to the next question.
