Pregnancy and LMA/mask

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what is your absolute time cut off for non secured airway assuming GA on a pregnant patient? (Not obese, no reflux)

Personally I don't do it after 1st trimester, but others in my group do LMAs for cerclage well into 2nd.
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Most in our group is end of 1st trimester, period. I think it's probably reasonable to go a couple more weeks, but then you get into "well, if 15 weeks is OK, what about 16, and if 16 is OK, what about 17, and how much difference is there between 16 and 17...so end of 1st trimester seems like a reasonable, easily definable and fairly consistent cutoff.
 
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Another question is how long should you wait after delivery before LMA is acceptable?
 
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Noyac said:
Another question is how long should you wait after delivery before LMA is acceptable?
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I've always used 6 weeks, but I have no idea where that came from. Some attending must have said it to me 15 years ago. Probably too conservative if not obese, no reflux hx
 
Noyac said:
Another question is how long should you wait after delivery before LMA is acceptable?
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No one knows! and It probably does not matter since people usually vomit on induction or after extubation regardless of the airway device used.
But that would be the wrong answer for the oral boards.
 
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My question would be why are you doing a cerclage under GA? In today's litigious society if that kid comes out anything less than perfect the parents could blame your anesthetic. A spinal with pure local is perhaps the least invasive.
 
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Pregnancy (or more specifically progesterone) decreases LES tone. Gastric emptying is unaffected until the pt is in labor, at which point gastric emptying is greatly delayed. If there aren't any other confounding issues (morbid obesity, DM, other GI motility problems) I think mask/LMA would be fine up until the fetus itself is large enough to cause significant mass effect on the upper GI tract. Obviously that varies a fair bit with body type, but it's probably somewhere close to 20 wks. Therefore, in a FASTED non-obese otherwise healthy parturient I'd be OK up to 20wks.

DISCLAIMER: The above is what I think is medically OK. I admit that's probably not the right answer on an exam or medico-legally speaking.
 
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SaltyDog said:
Pregnancy (or more specifically progesterone) decreases LES tone. Gastric emptying in unaffected until the pt is in labor, at which point gastric emptying is greatly delayed. If there aren't any other confounding issues (morbid obesity, DM, other GI motility problems) I think mask/LMA would be fine up until the fetus itself is large enough to cause significant mass effect on the upper GI tract. Obviously that varies a fair bit with body type, but it's probably somewhere close to 20 wks. Therefore, in a FASTED non-obese otherwise healthy parturient I'd be OK up to 20wks.

DISCLAIMER: The above is what I think is medically OK. I admit that's probably not the right answer on an exam or medico-legally speaking.
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This is exactly what I do. LMA until 20 weeks.
 
Exactly Plank!
To me, it's sort of a gut feeling. But e way I look at it, it's just too damn easy to place a tube.
 
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SaltyDog said:
Pregnancy (or more specifically progesterone) decreases LES tone. Gastric emptying is unaffected until the pt is in labor, at which point gastric emptying is greatly delayed. If there aren't any other confounding issues (morbid obesity, DM, other GI motility problems) I think mask/LMA would be fine up until the fetus itself is large enough to cause significant mass effect on the upper GI tract. Obviously that varies a fair bit with body type, but it's probably somewhere close to 20 wks. Therefore, in a FASTED non-obese otherwise healthy parturient I'd be OK up to 20wks.

DISCLAIMER: The above is what I think is medically OK. I admit that's probably not the right answer on an exam or medico-legally speaking.
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Too many assumptions...
 
PainDrain said:
My question would be why are you doing a cerclage under GA? In today's litigious society if that kid comes out anything less than perfect the parents could blame your anesthetic. A spinal with pure local is perhaps the least invasive.
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agree, medico legally spinal is better
 
PainDrain said:
My question would be why are you doing a cerclage under GA? In today's litigious society if that kid comes out anything less than perfect the parents could blame your anesthetic. A spinal with pure local is perhaps the least invasive.
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I don't practice OB but what do you put in the spinal? How long does it take for them to go home?
 
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Chloroprocaine 40-60mg also a good option if your shop still has it.
 
Here's a related- question that for some reason I always can't get straight (may or may not have been on some boards too).

"Doc, I'm breast-feeding. How long do I need to wait after anesthesia to breast feed?"
 
Mepivacaine 45 mg. same duration as lido, no pesky studies showing neurologic sequelae.


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B-Bone said:
Mepivacaine 45 mg. same duration as lido, no pesky studies showing neurologic sequelae.
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This is what I did during residency. I'm not sure I've done a cerclage since then, but it's what I'd do if I had one on the schedule tomorrow.

Same incidence of TNS with mepivacaine as lidocaine though.
 
Ignatius J said:
Here's a related- question that for some reason I always can't get straight (may or may not have been on some boards too).

"Doc, I'm breast-feeding. How long do I need to wait after anesthesia to breast feed?"
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Glad you bring that up. I get asked that a lot too. Usually I tell them to just go ahead because the amount of drug is so small and most stuff we use is degraded by infants first pass metabolism. Except versed. But they can enjoy the rest while baby takes a slightly longer nap than normal :D

I tell them they can pump and dump if they feel inclined but they make so little colostrum after the first couple days I highly doubt it matters.
 
ZzzPlz said:
Glad you bring that up. I get asked that a lot too. Usually I tell them to just go ahead because the amount of drug is so small and most stuff we use is degraded by infants first pass metabolism. Except versed. But they can enjoy the rest while baby takes a slightly longer nap than normal :D

I tell them they can pump and dump if they feel inclined but they make so little colostrum after the first couple days I highly doubt it matters.
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Thanks. That's essentially what I tell them as well. "There is a trace amount, but not enough to effect the baby any more than them having a good snooze." Haha. Doesn't sound right.
 
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Ignatius J said:
Thanks. That's essentially what I tell them as well. "There is a trace amount, but not enough to effect the baby any more than them having a good snooze." Haha. Doesn't sound right.
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I give them the half life of the drugs I am using, and tell them breast milk lags behind that except not much gets in there. And that the most conservative people wait 24 hours, while others are fine if they are breastfeeding during surgery. I normally recommend they follow their heart and decide what they want to do, knowing it likely wont matter. My recommendation to my wife would be to pump once ~4 hours after surgery then breastfeed, but that takes into account her avoidance of tylenol during pregnancy...

Regarding the ETT, I do it after 12 weeks, because a mom with aspiration is not worth the minimal difference in my effort for placing an LMA vs ETT. I am not sold on benefits of LMA after that point, I just dont see much difference in patient satisfaction or outcomes. I understand this is pretty conservative. I also havent seen a non-obese pregnant lady in a few years it seems like, if I did, I would likely be less strict.

Regarding cerclage, I use a low dose of bup, and they go home ~3 hours later. I havent ever heard a complaint about time spent on the floor, and our L+D can easily handle it. Rarely I will drop in a bit of propofol if they are unhappy with just this. Not a room air general amount, just an actual MAC amount to take away some of the anxiety. The propofol is ~1:10 patients.
 
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It's been a while since I've done it. I used it frequently for cysto's but the circulate is the perfect case for it. Even a knee scope does well.
It lasts about 1 hr.
I don't ever remember anyone puking.
You must mix it with 10% dextrose 1cc to 1cc 75mg Demerol (no local).
It is freaky the first couple times you use it because the pt can still move their legs somewhat at the beginning and you think it isn't working but just let the surgeon start and they don't feel it.
 
Noyac said:
It is freaky the first couple times you use it because the pt can still move their legs somewhat at the beginning and you think it isn't working but just let the surgeon start and they don't feel it.
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At the VA in residency it was common to do 15mcg of Sufenta only IT for ESWL's. Worked great, but there's no actual cutting involved there. I know Demerol is kind of a weird drug and has some local anesthetic properties. I'd like to try it but (like PGG), I think getting PF Demerol and then 10% Dextrose are gonna be more trouble than it's worth.
 
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