possible proseal lma use

[USAnesthesiaDoc]

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Here's a case: 50 year old thin male with hx of type II diabetes (5 years on oral hypoglycemic agent, which he now only uses 2 times/week after losing 30 pounds and glucoses run around 120), borderline HTN on no medications, smoker, GI bleed years ago treated medically, and heartburn 2 times/month associated with drinking beer. Preop labs and EKG are normal except for LVH. The patient has good exercise tolerance. This patient needs hand surgery for a tendon laceration (refuses regional anesthesia and the case cannot be done under local/MAC), and has been NPO. The case should take about 1.5 hours. Also, he has never had anesthesia before, and his airway is a mallampati 2 with good mouth opening, full cervical range of motion, slight overbite, and a short chin. Who is in favor of LMA proseal and who would favor intubation and why?

 

[Trisomy13]

Here's a case: 50 year old thin male with hx of type II diabetes (5 years on oral hypoglycemic agent, which he now only uses 2 times/week after losing 30 pounds and glucoses run around 120), borderline HTN on no medications, smoker, GI bleed years ago treated medically, and heartburn 2 times/month associated with drinking beer. Preop labs and EKG are normal except for LVH. The patient has good exercise tolerance. This patient needs hand surgery for a tendon laceration (refuses regional anesthesia and the case cannot be done under local/MAC), and has been NPO. The case should take about 1.5 hours. Also, he has never had anesthesia before, and his airway is a mallampati 2 with good mouth opening, full cervical range of motion, slight overbite, and a short chin. Who is in favor of LMA proseal and who would favor intubation and why?

for the love of god, don't forget your BIS.





sorry, thought i was in the BIS forums for a second there.

 

[Planktonmd]

Here's a case: 50 year old thin male with hx of type II diabetes (5 years on oral hypoglycemic agent, which he now only uses 2 times/week after losing 30 pounds and glucoses run around 120), borderline HTN on no medications, smoker, GI bleed years ago treated medically, and heartburn 2 times/month associated with drinking beer. Preop labs and EKG are normal except for LVH. The patient has good exercise tolerance. This patient needs hand surgery for a tendon laceration (refuses regional anesthesia and the case cannot be done under local/MAC), and has been NPO. The case should take about 1.5 hours. Also, he has never had anesthesia before, and his airway is a mallampati 2 with good mouth opening, full cervical range of motion, slight overbite, and a short chin. Who is in favor of LMA proseal and who would favor intubation and why?

LMA and not necessarily proseal.

 

[zippy2u]

I have to agree with Plankton on this one. This case is a dime o' dozen in the surgery centers-- don't wring your hands on this one--- throw in a regular LMA and go on down the road. Regards, ---Zip

 

[VentdependenT]

I agree with straight up LMA. You wanna give pepcid and reglan at the start for emergence great. It won't help much but it looks good on paper.

However if it was between a Tube or a Proseal, I'd go Proseal. Minimal stimulation on insertion of invasive airway device to rev-up his sympathetics (like a big steel blade and a thick rigid PVC ETT) and removal. If he was BMI >35 with OSA and daily GERD sx then maybe I'd force him to have a regional or take his tail to the Main OR. You could still get away with a Proseal in this case...in fact it'd be a good choice.

No High Intrabd pressures (although Proseal you supposedly can go up to 30mmhg on PPV) with a hand surgery. You can put the dude in a slight head up position to take the pressure of the chest wall and aid in ventilation with the proseal. This has no bearing here because he's a thin guy.

The surgeon can always give local during the case too. Or if you are feeling super-fly, you can do a ax-block/supraclav block with the U/S before emergence. Send his butt home pain free.

 

[USAnesthesiaDoc]

Is there anyone here who thinks this guy should be intubated because he is a potentially difficult airway (due to the short chin) on top of an aspiration risk (although slight)? A colleague argued that if an lma is an place and the guy vomits or goes into laryngospasm, then you are in a very difficult situation if you can't intubate.

 

[Planktonmd]

Is there anyone here who thinks this guy should be intubated because he is a potentially difficult airway (due to the short chin) on top of an aspiration risk (although slight)? A colleague argued that if an lma is an place and the guy vomits or goes into laryngospasm, then you are in a very difficult situation if you can't intubate.

If you feel that you will not be able to intubate this guy then you probably should not put him to sleep and insist on regional anesthesia or tell him he will need awake fiberoptic intubation ( he'll probably pick the regional).
Otherwise LMA is perfectly fine.

 

[Noyac]

Is there anyone here who thinks this guy should be intubated because he is a potentially difficult airway (due to the short chin) on top of an aspiration risk (although slight)? A colleague argued that if an lma is an place and the guy vomits or goes into laryngospasm, then you are in a very difficult situation if you can't intubate.

I don't put a tube in everyone that I think may be difficult. If I can do the case with an LMA on a difficult airway then thats what I do. Have you ever had anyone aspirate with an LMA in place? I haven't. IMHO a difficult airway is not a contraindication to an LMA. It may be an INDICATION for an LMA.