Prone LMAs

[imfrankie]

I use them and like them in prone cases for the "right case and right patient"
Anybody else like prone LMAs?

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[Lee123]

I would never consider any patient to be the right patient for placing an LMA in the prone position. What is so bad about placing an ETT that you are willing to risk losing the airway during the middle of the case? If the LMA dislodes, chances are you will not be able to get it back in place, you will have to flip supine, risk infection, and race against time before the patient desaturates.

I think it is a bad idea.

 

[bostonblaz]

Do them all the time. Have the pt postion themselves on the or table and then give some propofol. Lift them by their hair and slide it in. Always a great seal. I will only for go it if they are totally bald as i have nothing to tilt their head with. Blaz

 

[ssmallz]

I would never consider any patient to be the right patient for placing an LMA in the prone position. What is so bad about placing an ETT that you are willing to risk losing the airway during the middle of the case? If the LMA dislodes, chances are you will not be able to get it back in place, you will have to flip supine, risk infection, and race against time before the patient desaturates.

I think it is a bad idea.

It might not be a good first plan but certainly has a place as a backup. An attending in residency told me about a case he was doin as a prone MAC. Pt needed so much propofol to keep from moving that he started to go apneic. An ETT would've been too difficult so he decided to place an LMA to support the airway. Pt kept breathing and the case finished uneventfully. The lesson learned was that airway management and anesthetic plans can be 2 separate pieces of the puzzle that work together. We so often think about it as MAC = no airway and GA = LMA/ETT.

 

[jetproppilot]

I would never consider any patient to be the right patient for placing an LMA in the prone position. What is so bad about placing an ETT that you are willing to risk losing the airway during the middle of the case? If the LMA dislodes, chances are you will not be able to get it back in place, you will have to flip supine, risk infection, and race against time before the patient desaturates.

I think it is a bad idea.

Not disagreeing with you but I can tell you one of my residency buddies did a six month externship in the United Kingdom.

Prone LMAs with The Brits is ubiquitous.

My current day practice involves many

patients positioned on their sides or in sitting positions

with LMAs.

I've yet to do a prone case with an LMA.

Let's evaluate that....I've been in this biz for quite a while and the thought of a

COMPLETELY PRONE LMA

kinda concerns me...

doesn't mean it's wrong...hell as my residency buddy reported from the UK it was readily accepted...

I see this subject as a medium for all of us to consider...which is

THINK OUTSIDE THE BOX.

It's soooooo easy to get really comfortable inside your little world, to ignore new ideas, to consider cutting edge technology

ABSURD....

I'm not suggesting you CA-2 residents out there throw in an LMA for your next prone hemorrhoid case.

I'm suggesting you

be open to new ideas.

There's alotta

DIAMONDS IN THE ROUGH OUT THERE

in clinical anesthesia.

Your job as a resident

is to find them.

 

[Lee123]

For those who use an LMA prone I would like to know from that person's perspective:

what advantage the LMA has over the ETT in the prone position
how is it equally safe or more safe than an ETT in that position
why they would choose the LMA over an ETT for a prone case

Simply saying others do it I do not find acceptable.
I am talking about starting the case with the LMA and not using it as a rescue technique.

 

[ProwlerturnGas]

BostonBlaz,

No disrespect but if I found out you lifted me by the hair to insert an LMA.... I would punch you

PTG

 

[Oggg]

Pretty sure Boston blaz is joking right?

Prone LMA is used a lot in Australia I hear. One of my partners does prone LMA. Foam headrest. Seems like a Flexible LMA would be the way to go, but my partner uses a regular disposable LMA. I went to a talk, years ago, about the Proseal LMA and they showed some picturs of probe Proseal.

 

[Planktonmd]

Lift them by their hair and slide it in. Always a great seal. I will only for go it if they are totally bald as i have nothing to tilt their head with. Blaz

 

[ProwlerturnGas]

Maybe I should have said Donkey Punch Hee Hee

 

[Mac4]

What if airway complication happened? How can you defend youself? Is there any literature backing it up?

 

[dhb]

What kind of prone cases are you doing?? The only ones i do are backs.

 

[Lee123]

What if airway complication happened? How can you defend youself? Is there any literature backing it up?

I don't see how this can be defended. I am still waiting to hear from others the advantage of a prone LMA over an endotracheal tube. If anyone out here knows someone that does this, please ask them this question.

 

[Arch Guillotti]

I use them and like them in prone cases for the "right case and right patient"
Anybody else like prone LMAs?

Nope I think they are silly.

 

[jwk]

I don't see how this can be defended. I am still waiting to hear from others the advantage of a prone LMA over an endotracheal tube. If anyone out here knows someone that does this, please ask them this question.

It's not defendable, regardless of how the Aussies and Brits do things. I have few absolutes in the way I practice, but this is one of them. I think it's absolutely foolish. If the doc covering my room wants a prone LMA, they'll have to do the case themselves.

 

[Lee123]

It's not defendable, regardless of how the Aussies and Brits do things. I have few absolutes in the way I practice, but this is one of them. I think it's absolutely foolish. If the doc covering my room wants a prone LMA, they'll have to do the case themselves.

As I have told others, just because someone does something and it works does not mean it was the right thing to do. All you need to do is lose one airway that should not have been lost and you are screwed. Try explaining to the family why you decided to put the LMA in instead.

 

[BLADEMDA]

Insertion of a Laryngeal Mask Airway in the Prone Position


Authors

To the Editor:

I read with interest the article by Ng et al. (1) regarding induction of anesthesia and insertion of a laryngeal mask airway (LMA) in the prone position. Some earlier reports on the placement of LMA in the prone position should be cited as references (2,3). In the figure, the anesthesiologist does not wear gloves, which may harm the relevant physician. The standard precautions for health-care workers should be taken during all encounters with patients. Additionally, the LMA cuff does not appear to be adequately collapsed. This practice may produce soft tissue trauma to the airway, induce laryngospasm and/or push down the epiglottis (4). In addition, the LMA does not appear to be secured, which may lead it to dislodge due to gravity and cause it to be squeezed up out of the pharynx when nitrous oxide diffuses into the cuff. Lastly, if properly oxygenated, ventilation via a face mask is not necessary during anesthesia induction with propofol without the use of muscle relaxants (2,3,5,6). Both apnea and airway obstruction, the main disadvantages of propofol, can be overcome with the insertion of an LMA (5,6). Thus, I do not think that ventilation via a mask should be performed before LMA insertion especially in the awkward prone position because LMA itself can provide a better airway, with respect to ventilation and oxygenation, than a conventional mask and oropharyngeal airway (7,8).

During LMA insertion in the prone position, keeping the neck flexed and the head extended does not seem to be needed because the tongue falls anteriorly by gravity (1,3), and the head may be slightly turned to the side (1) or extended (2,3). Besides, LMA can be inserted in the same way as recommended in the supine position except that we may grasp it with the aperture facing the intubator. While inflating the cuff, we should hold the LMA passively to prevent it from being withdrawn by the weight of LMA and anesthetic hosing and to yield to a small outward movement during cuff inflation. A spare trolley should be available to move the patient to a supine position in case of airway emergency (1,3). However, patients may be allowed to recover in the prone position until the return of reflexes allows removal of the LMA (2).

http://m.anesthesia-analgesia.org/content/96/4/1241.1.full#ref-list-2
References

1. ↵ Ng A, Raitt DG, Smith G. Induction of anesthesia and insertion of a laryngeal mask airway in the prone position for minor surgery. Anesth Analg 2002; 94: 1194–8.
   Abstract/FREE Full Text
   
   
2. ↵ Milligan KA. Laryngeal mask in the prone position. Anaesthesia 1994; 49: 449.
   
   
   
3. ↵ McCaughey W, Bhanumurthy S. Laryngeal mask placement in the prone position. Anaesthesia 1993; 48: 1104–5.
   Medline
   
   
4. ↵ Brain AIJ. The Intravent laryngeal mask instruction manual, 2nd ed. Henley-on-Thames, England: Intravent International, 1993.
   
   
   
5. ↵ Bahk JH, Sung JH, Jang IJ. A comparison of ketamine and lidocaine spray with propofol for the insertion of laryngeal mask airway in children: a double-blinded randomized trial. Anesth Analg 2002; 95: 1586–9.
   Abstract/FREE Full Text
   
   
6. ↵ Bahk JH, Han SM, Kim SD. Management of difficult airways with a laryngeal mask airway under propofol anaesthesia. Paediatr Anaesth 1999; 9: 163–6.
   Medline
   
   
7. ↵ Poltronieri J. The laryngeal mask. Ann Fr Anesth Reanim 1990; 9: 362–6.
   Medline
   
   
8. ↵ Smith I, White PF. Use of the laryngeal mask airway as an alternative to a face mask during outpatient arthroscopy. Anesthesiology 1992; 77: 850–5.
   CrossRefMedline
   
   

 

[BLADEMDA]

Minerva Anestesiol. 2007 Jan-Feb;73(1-2):33-7.
Laryngeal mask in prone position: pure exhibitionism or a valid technique.

Weksler N, Klein M, Rozentsveig V, Weksler D, Sidelnik C, Lottan M, Gurman GM.
Source

Division of Anesthesiology and Critical Care,Soroka Medical Center, Beer Sheva, Israel. [email protected]

Abstract

AIM:

The laryngeal mask airway (LMA) is used worldwide during general anesthesia with controlled or spontaneous breathing. Normally its use is limited to patients undergoing surgery in the supine but not the prone position.
METHODS:

A prospective study of 50 consecutive ASA 1 and 2 patients who underwent ambulatory surgery in the prone position. In the first 25 patients anesthesia was induced in the supine position on a transport trolley after which the patients were turned face down following tracheal intubation. The next 25 patients were asked to lie comfortably in the prone position before receiving anesthesia. Induction and insertion of LMA were performed when they were already prone.
RESULTS:

There were neither complications nor airway loss when LMA was used in the prone position. The induction-incision time was 23.6+/-3.6 min (range 21-37) in Group 1 and 7+/-2.44 min (range 5-15) in Group 2 (P<0.0001) and the manpower required for positioning (the number of medical and paramedical personnel required to place the patient prone) was considerable reduced in Group 2 (LMA) compared to Group 1 (1.0 versus 3.12+/-0.6 (range 2-4; P<0.0001). Group 2 showed also, significantly more favorable hemodynamic parameters.
CONCLUSION:

To start anesthesia with patients already prone shortens the induction-incision time, reduces the manpower involved in the positioning process and causes fewer hemodynamic changes than the standard technique of induction and intubation in the supine position followed by turning the patient facedown.

 

[sevoflurane]

Once you've placed a couple DLT's in the lateral position... you tend to loose the fear of placing LMA's for hips in the lateral position. Done a couple prone LMA cases in residency...

Not my cup of tea.

Too much to loose. Risk benefit doesn't favor it, IMO. Do enough of them and you'll eventually have a patient that will give you trouble... in the prone position.

 

[BLADEMDA]

Anesth Analg. 2005 Oct;101(4):1221-5, table of contents.
Airway management in the lateral position: a randomized controlled trial.

McCaul CL, Harney D, Ryan M, Moran C, Kavanagh BP, Boylan JF.
Source

Department of Anaesthesia and Intensive Care Medicine, St. Vincent's University Hospital, Dublin, Ireland. [email protected]

Abstract

It may be required to ensure patency of the airway in the lateral position in certain circumstances. We performed a prospective randomized clinical trial investigating the effects of left lateral patient positioning on airway anatomy and subsequent airway management. Laryngoscopic airway examination was performed in anesthetized patients, in the supine and left lateral positions, and in the presence and absence of cricoid pressure. Patients were randomized to airway management via an endotracheal tube or laryngeal mask airway (LMA). The left lateral position resulted in a deterioration of laryngoscopic view in 35% of patients and improvement in none. In the lateral position, failure of airway management occurred in more patients with the endotracheal tube versus LMA (8 of 39 versus 1 of 30; P = 0.03), and the mean time to successful completion of airway management was longer with tracheal intubation compared with the LMA (39 +/- 19 s versus 26 +/- 12 s; P = 0.002). LMA use results in more reliable airway control compared to tracheal intubation in the lateral position. The LMA should be considered as the primary airway device when instituting airway management in this position. IMPLICATIONS: Inadequate airway management may be fatal. There are recommendations for airway difficulties, but the evidence favoring any specific strategy is limited. This study suggests that, in the lateral position, a laryngeal mask airway more rapidly and reliably establishes airway control than attempts at endotracheal intubation. It further suggests that placing a patient with an inadequate airway into the lateral position will hinder, not help, airway management.

 

[BLADEMDA]

Prospective audit on the use of the LMA Supreme&#8482; for airway management of adult patients undergoing elective orthopaedic surgery in prone position (Sharma V et al, 2010)



Results:

• Mean (range) duration of surgery was 102min (15min-5hours).​
• Regurgitation of gastric contents all via the drainage tube (n=4), was observed. No evidence of aspiration was found in these patients.​
• No patient required rotation back into the supine position due to a complication during airway management.​
• No increase in the incidence of problems with insertion of LMA Supreme&#8482; in obese patients.​
• Forty-two prone insertions of LMA Supreme&#8482; were performed by anaesthesia trainees. First-pass success was 90.5%; 100% overall success.​
• No incidence of failure to insert the LMA Supreme&#8482; and establish and maintain PPV in the prone position.
  ​
  For the full paper visit doctorevidence.com/LMA

 

[sevoflurane]

Prospective audit on the use of the LMA Supreme™ for airway management of adult patients undergoing elective orthopaedic surgery in prone position (Sharma V et al, 2010)



Results:

• Mean (range) duration of surgery was 102min (15min-5hours).​
• Regurgitation of gastric contents all via the drainage tube (n=4), was observed. No evidence of aspiration was found in these patients.​
• No patient required rotation back into the supine position due to a complication during airway management.​
• No increase in the incidence of problems with insertion of LMA Supreme™ in obese patients.​
• Forty-two prone insertions of LMA Supreme™ were performed by anaesthesia trainees. First-pass success was 90.5%; 100% overall success.​
• No incidence of failure to insert the LMA Supreme™ and establish and maintain PPV in the prone position.
  ​
  For the full paper visit doctorevidence.com/LMA

Hmmm...

Maybe I need to step outside of my box.

You doing these Blade?

 

[BLADEMDA]

Image Tools

We present a series of 74 patients who, after ruling out cervical spondylosis and obtaining informed consent, were asked to position themselves on the prone frame when awake. The patient's head was rested on a horseshoe-shaped gel pillow (Akton Polymer; Action Product, Inc.) with their face turned toward the open end of the pillow, keeping the angle of rotation less than 30 degrees. Anesthesia was induced and an LMA Supreme was introduced for airway control (Fig. 1). Anesthesia was maintained using controlled ventilation. LMA Supreme cuff pressures were monitored meticulously and maintained between 20 and 40 cmH2O. Postoperatively, patients were asked to grade the sore throat at the end of 1 hour and 4 hours using a scoring protocol of the patient's subjective analysis on a visual analogue scale (where 0 = no complaints and score 3 = severe sore throat).

Fig. 1
Image Tools

The insertion of the LMA Supreme on the first attempt was successful in 69 patients and required a second attempt in only five patients (6.75 percent). Change of the LMA Supreme was required in two patients for incorrect size. Intermittent positive-pressure ventilation could be delivered in all of the patients without any difficulty, with peak airway pressures between 12 and 27 mm. No patient had to be turned supine for failure to control the airway or inadequate ventilation. There was no evidence of regurgitation of any gastric secretions. All of the operations were uneventful. Two patients (2.7 percent) reported sore throat (score of 1) at the end of 1 hour and were easily managed with analgesics and warm liquids.
We chose the LMA Supreme because of its ease of insertion even in the prone position and lack of rotation and dislodgment because of its peculiar shape (Fig. 2). It also allows higher glottic seal pressures at lower cuff pressures. Prone induction using laryngeal mask airways has been reported as early as 2002.1 Sharma et al. have shown the viability of the LMA Supreme for airway management in the prone position in orthopedic operations.2 Positioning the patient prone when awake takes care of all the problems associated with prone positioning under anesthesia.

Fig. 2
Image Tools

The reported incidence of sore throat is 45.4 percent3 after tracheal intubation and 7.5 percent with the LMA Supreme in prone position.4 We came across a lower incidence, possibly because of single-operator insertions, lower cuff pressures, minimal K-Y jelly, early sips of warm liquids, and routine use of dexamethasone.5
Our experience suggests that using the LMA Supreme in induction and maintenance of anesthesia in prone position provides a viable and secure alternative to endotracheal intubation in liposuction surgery. It helps to reduce the incidence of postoperative sore throat, saves time required for the change of position, and improves the patient's overall satisfaction of the surgical and anesthesia experience.
Mohan Thomas, M.D., D.D.S.
Breach Candy Hospital, Asian Heart Institute, The Cosmetic Surgery Institute
Nitin M. Bhorkar, M.D.
Breach Candy Hospital, The Cosmetic Surgery Institute
James Allan D'silva, M.S., M.Ch.
Breach Candy Hospital, Asian Heart Institute, The Cosmetic Surgery Institute
Ram M. Chilgar, M.S., M.Ch.
The Cosmetic Surgery Institute, Mumbai, India


DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article. No external funding was received.

 

[BLADEMDA]

Hmmm...

Maybe I need to step outside of my box.

You doing these Blade?

Yes. From time to time I've placed an LMA "prone" in a short case under 60 minutes in duration.

I've also rescued a few TIVA/MAC cases being done prone with an LMA.

I've got ZERO issues with an ETT in certain subgroups. Morbid Obesity with Sleep Apnea is just asking for trouble. But, a 45 kg 5'2" female going prone for a hemorrhoidectomy? LMA baby.

 

[BLADEMDA]

It's not defendable, regardless of how the Aussies and Brits do things. I have few absolutes in the way I practice, but this is one of them. I think it's absolutely foolish. If the doc covering my room wants a prone LMA, they'll have to do the case themselves.

That's too rigid; if the patient is thin and has few/minimal co-morbidities give it a try.
An old dog like you can learn a new trick or two.

 

[BLADEMDA]

http://bja.oxfordjournals.org/content/early/2011/05/13/bja.aer104.abstract



Use of the Laryngeal Mask Airway in patients positioned prone for short surgical cases in an ambulatory surgery unit in the United States

Gwinnet Medical Center
Lawrenceville, GA 30045

Journal of Clinical Anesthesia (September 2008), 20 (6), pg. 487-488

Walter C. Stevens

http://www.deepdyve.com/lp/elsevier...y-in-patients-positioned-prone-for-hdOXYlQjiv

 

[BLADEMDA]

It's not defendable, regardless of how the Aussies and Brits do things. I have few absolutes in the way I practice, but this is one of them. I think it's absolutely foolish. If the doc covering my room wants a prone LMA, they'll have to do the case themselves.

I guess the AAs at Gwinnett Medical Center are all foolish. By this time that medical center has probably done 400-500 prone cases with an LMA. (maybe more?)

 

[BLADEMDA]

As I have told others, just because someone does something and it works does not mean it was the right thing to do. All you need to do is lose one airway that should not have been lost and you are screwed. Try explaining to the family why you decided to put the LMA in instead.

Sorry Slim. An LMA for the right patient works fine prone. The studies above show the published evidence for safety (in the right patient).

 

[imfrankie]

Thank you Blade.
Was interested in seeing current popularity with this technique.

 

[urge]

As I have told others, just because someone does something and it works does not mean it was the right thing to do. All you need to do is lose one airway that should not have been lost and you are screwed. Try explaining to the family why you decided to put the LMA in instead.

Last time I mentioned losing an airway it prompted another "this forum sucks, you are a bunch of pansies" thread full of foul language with people getting banned.

The caliber of the posters in here is such that losing an airway is an unfathomable travesty.

The standard operating procedure for STUDS like us has been established already: Extubate deep to an LMA, which you also pull deep, to an oral airway, which, btw, you also pull before the patient is awake. Make sure you have the all OR watching you while you do this. Never underestimate the power of a good show.

Didn't you get the memo?

Wish you better luck.

 

[Lee123]

By this time that medical center has probably done 400-500 prone cases with an LMA. (maybe more?)

400-500 does not convince me that it is safe.
When they've done 40-50,000 without an incident then I'll agree it is acceptable.

The caliber of the posters in here is such that losing an airway is an unfathomable travesty.

The standard operating procedure for STUDS like us has been established already

Are you saying losing an airway is not possible in the prone position with the LMA? I am not sure if that is what you really meant. If so, I disagree. The LMA can unseat and then you have to scramble to make it right.

For my practice I try to eliminate all the possible ways something can go wrong. I find this leads to a safer peri-operative experience for the patient. I still think that an LMA not seating right is a "possibility" that I don't want to take.

 

[BLADEMDA]

400-500 does not convince me that it is safe.
When they've done 40-50,000 without an incident then I'll agree it is acceptable.



Are you saying losing an airway is not possible in the prone position with the LMA? I am not sure if that is what you really meant. If so, I disagree. The LMA can unseat and then you have to scramble to make it right.

For my practice I try to eliminate all the possible ways something can go wrong. I find this leads to a safer peri-operative experience for the patient. I still think that an LMA not seating right is a "possibility" that I don't want to take.

You are young. Green. It shows. Do it your way for now. After a few thousand more cases just try an LMA in a thin ASA 2 patient. It works. The key is no paralysis and someone you would consider doing a TIVA on in any position.

For now, you can tube 'em all.

 

[Lee123]

You are young. Green. It shows. Do it your way for now. After a few thousand more cases just try an LMA in a thin ASA 2 patient. It works. The key is no paralysis and someone you would consider doing a TIVA on in any position.

For now, you can tube 'em all.

Just to clear things up, I've been doing this probably longer than you have. Just because I have 40 posts has nothing to do with my experience. Something just does not feel right about an unprotected airway in the prone position. A slightly less sore throat and a quicker "flip" time does not justify what I consider a risky practice. You can quote as many references that you want.

I would like to hear from others how many have been done at their institutions, and if there have been any issues.

 

[jwk]

I guess the AAs at Gwinnett Medical Center are all foolish. By this time that medical center has probably done 400-500 prone cases with an LMA. (maybe more?)

Geez, I thought I taught those boys and girls better than that!

 

[urge]

Just to clear things up, I've been doing this probably longer than you have. Just because I have 40 posts has nothing to do with my experience. Something just does not feel right about an unprotected airway in the prone position. A slightly less sore throat and a quicker "flip" time does not justify what I consider a risky practice. You can quote as many references that you want.

I would like to hear from others how many have been done at their institutions, and if there have been any issues.

Actually, I looked up the sore throat thing before and found LMA cause more of it.

Maybe someone wants to look it up again to see if there is new data.

I placed an LMA in myself just for kicks some time ago. My "throat" hurt like crazy for a few days.

 

[BLADEMDA]

Just to clear things up, I've been doing this probably longer than you have. Just because I have 40 posts has nothing to do with my experience. Something just does not feel right about an unprotected airway in the prone position. A slightly less sore throat and a quicker "flip" time does not justify what I consider a risky practice. You can quote as many references that you want.

I would like to hear from others how many have been done at their institutions, and if there have been any issues.

So Peer Reviewed Articles don't matter? What kind of practice are you in? How many years of experience? How many cases per year? Are you covering 4 rooms or more year after year in a busy practice?

I'm still learning new techniques every day. This includes more LMAs in the prone position. Does this mean I'd do an LMA for every patient going prone? No.
But, the longer I do this the more I realize the Brits do a lot of things right in anesthesia.

 

[BLADEMDA]

Actually, I looked up the sore throat thing before and found LMA cause more of it.

Maybe someone wants to look it up again to see if there is new data.

I placed an LMA in myself just for kicks some time ago. My "throat" hurt like crazy for a few days.

http://www.crna.tcu.edu/docs/dnp-a ...racheal Tube Versus Laryngeal Mask Airway.pdf

A CRNA review of the literature. Extensive review and quite boring.

 

[dhb]

prone for a hemorrhoidectomy.

How the f**k (and why) do they do that? i've only seen them done in lithotomy

 

[Lee123]

So Peer Reviewed Articles don't matter? What kind of practice are you in? How many years of experience? How many cases per year? Are you covering 4 rooms or more year after year in a busy practice?

I'm still learning new techniques every day. This includes more LMAs in the prone position. Does this mean I'd do an LMA for every patient going prone? No.
But, the longer I do this the more I realize the Brits do a lot of things right in anesthesia.

Being conservative does not mean "green".

If you have a few decades yourself then we are close.

I've covered up to four rooms, which, if this is your typical day, would be an even worse case for doing prone LMAs as you are spread too thinly to deal with a problem. I usually cover two rooms, which usually includes cases like vena cava thrombectomy/nephrectomies, aortic dissections, CABGs, or port access heart cases for one room; the other room is usually filled with about 5 thoracic cases for the day. On other days I'm doing the usual stuff, which may include doing endoscopies, ERCPs (lateral and prone with TIVA if appropriate), babies or children. When covering GI, it is usally two rooms: one with EUS's/ERCPS (about 8 per day) and the other room is standard colons/EGDs/doubles and there are about 15 cases. It is a busy GI practice.

Of course there are the usual lami's, thyroidectomies, adrenalectomies, gastrectomies, TAH, cysto's, ortho, etc. I've worked in academics, private and moonlighted in surgicenters, endoscopy suites and plastic surgeons' offices when I felt like doing something extra. Experience is not a problem. The problem I have is with prone LMAs.

I plan to ask a few friends around the country what they are doing at their institutions. I think I know the answer, but I will share the results in a few months.

 

[Lee123]

How the f**k (and why) do they do that? i've only seen them done in lithotomy

Actually, some do it prone.

 

[jetproppilot]

Nope I think they are silly.

That's what the surgeons from back in the day said to

LAPAROSCOPY

Time to

check yourself before you really

WRECK YOURSELF.

 

[IlDestriero]

That's what the surgeons from back in the day said to

LAPAROSCOPY

Time to

check yourself before you really

WRECK YOURSELF.

What's your experience with prone LMAs?
As far as I recall, I've done it twice in a decade or so. Lateral all the time though.
Though my current population is not the best for them.

 

[Arch Guillotti]

How the f**k (and why) do they do that? i've only seen them done in lithotomy

Prone for roid cases seems pretty standard around here.

 

[Arch Guillotti]

I am not so dogmatic that I would never place an LMA for a prone case. It would have to be the right patient, case, etc. Nobody I work with does them and the CRNA would have a cow which is a pain to deal with when you are supervising multiple rooms.

I still think the risk benefit ratio is not worth it and I still think they are silly

It doesn't matter to me what some study in some journal says.

I do put them in for cases in the lateral position sometimes though.

 

[pd4emergence]

I think you can do it. My main issue with it is what happens if the lma doesn't seat well after turning. You gotta flip them back over mess with it, maybe intubate. The question is is it safer one way or the other? I would rather go with the tried and true method the first time. To me it adds undue risk. Sure there is that one time when all the stars aligned and someone was able to do it and it went smoothly. But I just don't think it's worth it. I may look back at this post in a few years and it's commonplace and wonder why I was such a pansy but right now, nah. I do have a question. Someday I may actually get a pt whose bmi is less than 40, is there anybody out there using lma's regularly for simple laparoscopic cases? How about t and a's?

 

[jetproppilot]

Yes. From time to time I've placed an LMA "prone" in a short case under 60 minutes in duration.

I've also rescued a few TIVA/MAC cases being done prone with an LMA.

I've got ZERO issues with an ETT in certain subgroups. Morbid Obesity with Sleep Apnea is just asking for trouble. But, a 45 kg 5'2" female going prone for a hemorrhoidectomy? LMA baby.

Dude that's

BAD A S S.