OB Scenario: What would you do?

[okayplayer]

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I have done stat c sections with LMA in difficult to intubate and ventilate patients several times over the years without a single problem.

Utilizing an LMA with a gastric port?

 

[Planktonmd]

Utilizing an LMA with a gastric port?

No... just a good old LMA

 

[deleted59964]

No... just a good old LMA

what was your plan if the LMA failed during the surgery?

 

[nimbus]

what was your plan if the LMA failed during the surgery?

This is akin to asking, "what would you do if the ETT failed?"

In many parts of the world the LMA is considered a definitive airway. American dogma says it is not.

 

[deleted59964]

This is akin to asking, "what would you do if the ETT failed?"

In many parts of the world the LMA is considered a definitive airway. American dogma says it is not.

its not just american, and its not just dogma.

nap4 heavily criticises several occurrences where patients have died after cases were undertaken with LMAs where there was known or suspected difficult airway - and there was no contingency plan.

 

[nimbus]

its not just american, and its not just dogma.

nap4 heavily criticises several occurrences where patients have died after cases were undertaken with LMAs where there was known or suspected difficult airway - and there was no contingency plan.

It depends on the situation. Sometimes the LMA is the best imperfect solution to the problem. I'm willing to bet it's saved many more lives and prevented many more clusterf***'s than it's caused.

 

[urge]

I just found it laughable that somebody did a "study" to prove that LMAs are safe to be used in elective C-sections on healthy thin gravidas not in labor. Seriously? Like we don't already know that the main risk of aspiration is during labor, not the third

I wouldn't dismiss the study like that. It's one of those that might make your life less unpleasant in court one day.

 

[caligas]

I know w/ the LMA that keeping them deep is key to avoid emesis. So how would you handle emergence? I suppose get them breathing and remove LMA deep, plenty of narcotic.

 

[caligas]

Personally if glidescope failed id probably go the fastrach LMA, keep em deep, use F.O.S. to pass ett thru fastrach. Could do the same with the proseal I guess.

 

[deleted171991]

I know w/ the LMA that keeping them deep is key to avoid emesis. So how would you handle emergence? I suppose get them breathing and remove LMA deep, plenty of narcotic.

I would be conservative with the narcotics. 100 mcg of fentanyl/hour should suffice. They are the most related to PONV (and possibly nausea/vomiting on emergence), not the N2O that I tend to use daily without consequences. If I am really concerned about emesis, I do a mostly propofol-based anesthesia.

I wouldn't remove the LMA deep. I want the patient to have good airway protective reflexes when that LMA comes out. It also makes them less prone to laryngospasm, which make them less prone to coughing, which make them less prone to vomiting. If the LMA is the right kind and size, most patients will wake up pretty comfortably with it in their mouth. I regularly use them as pseudo-oral airways at the end of my cases, if the patients are still asleep despite minimal expiratory anesthetic levels. I remove them just before/as the patient wakes up. Best preoxygenation for transport to the PACU, too (since I use nitrous intraop).

For a smoother emergence, one can also use a 25-50 mcg/kg/min infusion of propofol, started 15 minutes before. Less stimulation from the LMA (despite recovery of airway reflexes), almost awake patient on LMA removal.

 

[Planktonmd]

what was your plan if the LMA failed during the surgery?

How does an LMA fail during the surgery?
You should be able to tell if an LMA is working or not immediately after insertion.

 

[deleted171991]

How does an LMA fail during the surgery?
You should be able to tell if an LMA is working or not immediately after insertion.

Atelectasis.

 

[deleted59964]

How does an LMA fail during the surgery?
You should be able to tell if an LMA is working or not immediately after insertion.

LMAs often work perfectly, sometimes they work OK, sometimes they don't work at all.

LMAs that work "OK" are often tolerated -- sometimes because it's the best airway you've got, and sometimes because people are too lazy to fix it / try something else.

LMAs that result in partially obstructed airways tend to deteriorate into complete obstruction.

I agree that LMA is a great back up plan ... it's in my CICO plan - which is what this thread was about.

nap4 illustrates that if you dodge a difficult intubation and place an LMA - you'd better have a plan for what to do if your LMA stops working. nap4 is another one of those studies that could make your life unpleasant in court... or you could just take on board the recommendations.

 

[Planktonmd]

Atelectasis.

Just give some pressure support

 

[BLADEMDA]

Personally if glidescope failed id probably go the fastrach LMA, keep em deep, use F.O.S. to pass ett thru fastrach. Could do the same with the proseal I guess.

If the Glidescope failed and the LMA was adequate I would proceed with the EMERGENT C Section. If it was an elective C section which I couldn't intubate with the glidescope I would consider doing a Fiberoptic exchange to an ETT via the LMA although I believe most would just do the case. The Chief of Ob anesthesia at Columbia would support your decision to leave the Proseal LMA in place and do the case provided the LMA was functioning well. I would not wake the patient up and try to place a spinal or do an awake fiberoptic intubation in an already anesthetized patient with a good airway even if that airway was an LMA.

 

[deleted59964]

Personally if glidescope failed id probably go the fastrach LMA, keep em deep, use F.O.S. to pass ett thru fastrach. Could do the same with the proseal I guess.

proseal and supreme LMAs -- still possible but more difficult than fastrach or classic