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I'll share some of my experiences and thoughts.
I've used LMA's for obese, but not morbidly obese (except for emergency situations) mainly in short cases, but NEVER for an abdominal case involving a large incision. It may be ok to do it, but I don't like dealing with the additional "potential" headaches in that situation.
I always test my seal up to 19-20cm H2O. Sometimes I can only get 16-18 before a small leak, but that's ok as long as they spontaneously vent. I would NEVER use an LMA in any position where I could not have immediate and unobstructed access to the airway. Especially prone!! Why even risk it? I hate to think about practicing defensive medicine, but try to defend that one.
My experiences with LMA's and vents. Two come to mind, one of them I did earlier this week.
Case 1 150# female with smoking hx and mild snoring with bladder CA for TURBT, ureteroscopy. After everything was done on my part she still would not breathe. I got sick of waiting and giving intermittent bag breaths, so I put her on SIMV with TV of 500 rate of 5. Peak pressures never went above 15 cmH2O, I caught up on charting and wa-la 5 minutes later took her off and let her fly. No issues.
Case 2
Personal challenge from attending to use no opioid anesthesia as pt with hx of severe PONV and refused general anesthesia, but did not want to be awake at all. We did appropriate pre med for that, then Propofol infusion with tiny dose benzo and LMA. Pt about 160# in for D & C for ~ 15-20 min total time.
All was going well until insertion of scope. Pt moved. Gave propofol bolus, still moving. My attending was in ICU for emergency so I got creative. Mivacron and pressure control vent at 12 cm H2O. Smooth sailing after that. Attending returned at the end and gave me thumbs up. Said he'd never thought of that. Needless to say I was encouraged.
As far as milMD and evidence based medicine- I agree 100% with need for evidence based medicince and its intergration into practice. I do however keep an open mind to other ideas even though not necessarily proven or disproven. I think sometimes we may lose sight or disregard theories or alternatives based on being too rigid with EBM. After all, we must keep in mind how even though results may be clinically significant (p < 0.05) it is dangerous to apply these results to all patients. EBM studies are often very particular in who is allowed in studies, what are determinants of positive and negative criteria, different studies often find evidence to the contrary and it is often difficult to predict outcomes in individuals with different criteria than those in many studies.
I know mil and many on the forum understand these issues, I just was hoping to help some who may not. Off my soapbox.
Later.
I've used LMA's for obese, but not morbidly obese (except for emergency situations) mainly in short cases, but NEVER for an abdominal case involving a large incision. It may be ok to do it, but I don't like dealing with the additional "potential" headaches in that situation.
I always test my seal up to 19-20cm H2O. Sometimes I can only get 16-18 before a small leak, but that's ok as long as they spontaneously vent. I would NEVER use an LMA in any position where I could not have immediate and unobstructed access to the airway. Especially prone!! Why even risk it? I hate to think about practicing defensive medicine, but try to defend that one.
My experiences with LMA's and vents. Two come to mind, one of them I did earlier this week.
Case 1 150# female with smoking hx and mild snoring with bladder CA for TURBT, ureteroscopy. After everything was done on my part she still would not breathe. I got sick of waiting and giving intermittent bag breaths, so I put her on SIMV with TV of 500 rate of 5. Peak pressures never went above 15 cmH2O, I caught up on charting and wa-la 5 minutes later took her off and let her fly. No issues.
Case 2
Personal challenge from attending to use no opioid anesthesia as pt with hx of severe PONV and refused general anesthesia, but did not want to be awake at all. We did appropriate pre med for that, then Propofol infusion with tiny dose benzo and LMA. Pt about 160# in for D & C for ~ 15-20 min total time.
All was going well until insertion of scope. Pt moved. Gave propofol bolus, still moving. My attending was in ICU for emergency so I got creative. Mivacron and pressure control vent at 12 cm H2O. Smooth sailing after that. Attending returned at the end and gave me thumbs up. Said he'd never thought of that. Needless to say I was encouraged.
As far as milMD and evidence based medicine- I agree 100% with need for evidence based medicince and its intergration into practice. I do however keep an open mind to other ideas even though not necessarily proven or disproven. I think sometimes we may lose sight or disregard theories or alternatives based on being too rigid with EBM. After all, we must keep in mind how even though results may be clinically significant (p < 0.05) it is dangerous to apply these results to all patients. EBM studies are often very particular in who is allowed in studies, what are determinants of positive and negative criteria, different studies often find evidence to the contrary and it is often difficult to predict outcomes in individuals with different criteria than those in many studies.
I know mil and many on the forum understand these issues, I just was hoping to help some who may not. Off my soapbox.
Later.
