Routine Prone LMA Insertion

[Aether2000]

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I am a troglodyte, learning anesthesiology during the Pleistocene epoch. During a locums assignment recently, I came upon what I believe is a curious practice at a surgery center. Patients for prone surgery are routinely placed in that position on the OR table, then are given 200mg propofol plus 100mg lidocaine after which have an LMA placed (by CRNAs). The reason for this appears to be self serving by the surgery center staff in order to save their backs from having to roll patients into the prone position. I refused to let them do this maneuver, and required a supine placement of the LMA.
Question: Is it reasonable to do routine prone LMA placement or is this just dangerous??

 

[deleted171991]

I am a troglodyte, learning anesthesiology during the Pleistocene epoch. During a locums assignment recently, I came upon what I believe is a curious practice at a surgery center. Patients for prone surgery are routinely placed in that position on the OR table, then are given 200mg propofol plus 100mg lidocaine after which have an LMA placed (by CRNAs). The reason for this appears to be self serving by the surgery center staff in order to save their backs from having to roll patients into the prone position. I refused to let them do this maneuver, and required a supine placement of the LMA.
Question: Is it reasonable to do routine prone LMA placement or is this just dangerous??

If you are comfortable with doing prone cases with LMAs, you should get comfortable with placing them prone (not that I ever have). What if the LMA gets displaced in the middle of the surgery?

As long as the patient can be easily turned supine, if needed, I don't see why placing the LMA while prone is more dangerous than doing the entire prone case with an LMA.

 

[Arch Guillotti]

I refused to let them do this maneuver, and required a supine placement of the LMA.

So you did the case prone with an LMA?

 

[facted]

If you are comfortable with doing prone cases with LMAs, you should get comfortable with placing them prone (not that I ever have). What if the LMA gets displaced in the middle of the surgery?

As long as the patient can be easily turned supine, if needed, I don't see why placing the LMA while prone is more dangerous than doing the entire prone case with the LMA.

I had never done this or seen this until I started at a new gig and almost everyone does it this way and had been doing this for quite a while. They all assure me it works great. I did it once with a CRNA and it was fine. But I think I would only go this route if I had an extra pair of hands if **** hit the fan.

But to be honest, not sure I'm a fan of prone LMA as it is. That ETT thing works great.

 

[deleted171991]

So you did the case prone with an LMA?

It's probably prone with the head turned, like here (see the images under "Patients and methods").

 

[nimbus]

I do it all the time for for shorter cases like hemorrhoids, fistulas etc, not for spine cases. It works great. It's "slick" and streamlined.

 

[Arch Guillotti]

It's probably prone with the head turned, like here (see the images under "Patients and methods").

I get it, I was just wondering if the OP refused to put the LMA in with the patient prone and instead put the LMA in with the patient supine, then flipped them prone!

 

[Aether2000]

That is what we did, but given the feedback here, perhaps I should consider the prone placement as possibly acceptable. I suppose there would be patients who you would not consider prone placement such as limited neck rotation, high BMI, etc. My concerns were slamming 200mg propofol into a prone patient who may not be optimally pre-oxygenated, and trying to place these LMAs and not be able to ventilate. I appreciate your feedback on this. The issue for me is not as much having an LMA in the prone position since we have done MAC then later TIVA for years in the prone position without any artificial airway using titrated dosages and infusion rates. My concern was more the placement of the LMA with the patient already in the prone position. Thanks for your feedback.

 

[BLADEMDA]

ProSeal laryngeal mask airway™ insertion in the prone position: Optimal utilization of operation theatre personnel and time?


Prone LMAs (read the thread)


http://www.aana.com/newsandjournal/Documents/0414-update-laryngeal-mask-devices-prone-p101-107.pdf (yes, it's the AANA but just a simple literature review)

 

[sevoflurane]

I have done prone LMAs in the past. Do lateral all the time. I personally don't want to fumble around with a displaced LMA in the prone position or dealing with laryngospasm with an LMA in place. For quick cases I still occasionally do it... but we all know quick cases can sometimes not be so quick if surgical issues arise. I prefer PVC through the cords for my prone cases.

As a side note, I had a co-resident that was led down this path by his attending. LMA stopped working, a bunch of crap happened and said attending then threw him under the bus at the M&M. Threw him under the bus so hard that he is now in PP as a Pathologist.

 

[Ezekiel2517]

What cases are these? If they don't need to be tubed, pretty sure they can be done under MAC

 

[IlDestriero]

I have no problems using and/or placing an LMA lateral. I'm not doing them prone. Though I have done unsecured airway spontaneously breathing patients prone with a prop infusion for radiation in the past. I don't do that anymore though. 🙂


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Il Destriero

 

[anbuitachi]

I have no problems using and/or placing an LMA lateral. I'm not doing them prone. Though I have done unsecured airway spontaneously breathing patients prone with a prop infusion for radiation in the past. I don't do that anymore though. 🙂


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Il Destriero

im guessing spinal fusions

 

[nimbus]

What cases are these? If they don't need to be tubed, pretty sure they can be done under MAC

We used to do all our butt cases as big MACs. We get less coughing, airway obstruction, necessity for jaw holding with an LMA.

 

[Ezekiel2517]

We used to do all our butt cases as big MACs. We get less coughing, airway obstruction, necessity for jaw holding with an LMA.

hmm, I do these under MAC frequently bc of surgeon preference and never have had any problems

 

[nimbus]

hmm, I do these under MAC frequently bc of surgeon preference and never have had any problems

In my experience the LMA is smoother, easier and more hands off with less fiddling on my part. With the LMA, the patients are also nice and deep with a good airway when the surgeon injects local. They never move. But I agree either way works.

 

[Ignatius J]

I do perirectal abscesses, back I&Ds, and occasional ESWL with a prone LMA. I love it.

Easy to place prone LMAs when patients are on their stomach.

 

[kidthor]

I'd heard of prone LMA placement before but wouldn't have ever dared to try it. I'm actually surprised it seems to work so well, based on comments here.

I wonder though is this standard of care... or a big deviation from standard of care? When a complication occurs (unanticipated difficult airway / LMA placement, aspiration, laryngospasm, surgery goes wrong unrelated to anesthesia) is prone LMA placement a defensible practice?

 

[dhb]

smoother, easier and more hands off with less fiddling on my part also nice and deep

You are a play'a

 

[twoliter]

What benefit is there to placing the LMA prone? I can't imagine the time difference being more than 60 seconds (in OR, monitors, drugs, asleep on stretcher, LMA, roll patient to prone on the bed vs in OR, roll to bed, monitors, drugs, asleep on bed, LMA).

What if the LMA gets displaced in the middle of the surgery?

What if the ETT gets displaced in the middle of surgery? Sure, it may be rare, but it's happened. Should we start intubating prone cases in the prone position?

 

[anbuitachi]

What benefit is there to placing the LMA prone? I can't imagine the time difference being more than 60 seconds (in OR, monitors, drugs, asleep on stretcher, LMA, roll patient to prone on the bed vs in OR, roll to bed, monitors, drugs, asleep on bed, LMA).



What if the ETT gets displaced in the middle of surgery? Sure, it may be rare, but it's happened. Should we start intubating prone cases in the prone position?

happened here to one of my colleagues, ett fell out, did a prone intubation w fiberoptic.

 

[nimbus]

What benefit is there to placing the LMA prone? I can't imagine the time difference being more than 60 seconds (in OR, monitors, drugs, asleep on stretcher, LMA, roll patient to prone on the bed vs in OR, roll to bed, monitors, drugs, asleep on bed, LMA).



What if the ETT gets displaced in the middle of surgery? Sure, it may be rare, but it's happened. Should we start intubating prone cases in the prone position?

The advantage is that the patient is already prone so you don't need to flip them. No need to call or wait for moving help. Less work. I was hesitant to try it at first but after seeing one of my partners do it and trying it myself, I am sold. It's EASY. I've been doing it at least 10 years now...maybe 12. It's a lot smoother than the heavy MACs we used to do and those of us who do it have surgeons asking why everyone doesn't do it.

And if an ETT became dislodged in the prone position I would put an LMA in😉. One of my partners has actually done that too and it worked well.

 

[nimbus]

What if the LMA gets displaced in the middle of the surgery?

.

Put it back in😉

 

[deleted162650]

@nimbus , are you just doing this with the head turned on a regular pillow?

 

[nimbus]

@nimbus , are you just doing this with the head turned on a regular pillow?

Yes. Head is always turned to patient's left side facing the machine. You do need to reach into the mouth and make sure the LMA tip is directed over and not under the tongue. But it slides in remarkably easy with their head turned, even easier than when they are facing the ceiling while supine. I also never secure it since they are shorter cases and I am stool sitting right there. They stay put and have never dislodged to date. It would be a hassle to tape it with the face smushed against the pillow.

 

[Maverikk]

Putting in an LMA prone/lateral is easier, tongue is out of the way, you get the patient to position themselves, document they've no paresthesias. I had an attending who would do it for 2-3 hour spine cases, he was smart and good but I didn't understand it, patients are less prone to atelectasis and it worked until one time it didn't and he intubated upside down with a glidescope on a Jackson table. Even for short quick prone cases I lube up the tube with lidocaine jelly, RSI, keep them deep and spontaneously breathing, little/no narcs if the surgeon knows how to use local. There is no advantage to a prone LMA that I can see. Even for our colonoscopies done in the main OR (BMI>60 usually) about half the time I tube if I don't know/trust the person doing sedation, getting called in to see Santa Claus with a sat of 80 and dropping just isn't worth it. For lateral I do an LMA, I know I have the option to mask and can put them prone a lot easier

 

[deleted59964]

I lube up the tube with lidocaine jelly, RSI, keep them deep and spontaneously breathing, little/no narcs if the surgeon knows how to use local

Huh? I must be doing something wrong with my rsi's - they all go apneic.... maybe I'm being a goose hey maverick ?

 

[Maverikk]

Huh? I must be doing something wrong with my rsi's - they all go apneic.... maybe I'm being a goose hey maverick ?

You're not doing strong enough abdominal thrusts to get end tidal

 

[deleted171991]

Putting in an LMA prone/lateral is easier, tongue is out of the way, you get the patient to position themselves, document they've no paresthesias. I had an attending who would do it for 2-3 hour spine cases, he was smart and good but I didn't understand it, patients are less prone to atelectasis and it worked until one time it didn't and he intubated upside down with a glidescope on a Jackson table. Even for short quick prone cases I lube up the tube with lidocaine jelly, RSI, keep them deep and spontaneously breathing, little/no narcs if the surgeon knows how to use local. There is no advantage to a prone LMA that I can see. Even for our colonoscopies done in the main OR (BMI>60 usually) about half the time I tube if I don't know/trust the person doing sedation, getting called in to see Santa Claus with a sat of 80 and dropping just isn't worth it. For lateral I do an LMA, I know I have the option to mask and can put them prone a lot easier

Why would you lube up the tube with lidocaine jelly? To me, this is CRNA stuff, no offense.
1. If it produces local anesthesia, it also causes decreased airway reflexes during emergence, hence increased risk for aspiration.
2. It may cause local vasodilation, ergo edema, which may actually increase the adverse effects of an overinflated cuff.

 

[Hoya11]

Why would you lube up the tube with lidocaine jelly? To me, this is CRNA stuff, no offense.
1. If it produces local anesthesia, it also causes decreased airway reflexes during emergence, hence increased risk for aspiration.
2. It may cause local vasodilation, ergo edema, which may actually increase the adverse effects of an overinflated cuff.

I do lido lube all the time. No issues. The cuff goes into the trachea, doesnt blunt airway reflexes or touch the cords. I think lube is helpful in general, and if your going to lube why not lido lube. I think lido lube is better than LTA because you just pass the tube and not two different things into the airway.

 

[Maverikk]

Why would you lube up the tube with lidocaine jelly? To me, this is CRNA stuff, no offense.
1. If it produces local anesthesia, it also causes decreased airway reflexes during emergence, hence increased risk for aspiration.
2. It may cause local vasodilation, ergo edema, which may actually increase the adverse effects of an overinflated cuff.

1. It produces local anesthesia where the cuff is in the trachea, the larynx is the primary site of upper airway reflexes to prevent aspiration. If something is hitting the spot that is localized it's already in the trachea. If you're banging around the tube so much during intubation that the lido jelly blunts the upper airway then that's a different problem
2. I only use the lido jelly for short cases, theoretically it could lead to more edema. The risk of edema vs the benefit of having a calmer patient when we're flipping/positioning and the induction drugs are wearing off while I'm blasting the gas seems to favor the lido jelly.

There is no 'CRNA stuff' and 'MD stuff,' there's smart stuff you can back up with a reasonable argument and then everything else people do because of culture/habit/lack of awareness, I've seen both types do both types of stuff

 

[deleted171991]

1. It produces local anesthesia where the cuff is in the trachea, the larynx is the primary site of upper airway reflexes to prevent aspiration. If something is hitting the spot that is localized it's already in the trachea. If you're banging around the tube so much during intubation that the lido jelly blunts the upper airway then that's a different problem
2. I only use the lido jelly for short cases, theoretically it could lead to more edema. The risk of edema vs the benefit of having a calmer patient when we're flipping/positioning and the induction drugs are wearing off while I'm blasting the gas seems to favor the lido jelly.

There is no 'CRNA stuff' and 'MD stuff,' there's smart stuff you can back up with a reasonable argument and then everything else people do because of culture/habit/lack of awareness, I've seen both types do both types of stuff

OK, here's some proof for you:

[Influence of endotracheal tube cuff lubrication on postoperative sore throat and hoarseness]. - PubMed - NCBI

In this study, VAS [visual analogue pain sore throat] scores at the end of anesthesia and the next day were both significantly higher in the [2% lidocaine jelly] lubricated group than in others.

EFFECTS OF LIDOCAINE AND K-Y JELLIES ON SORE THROAT, COUGH, AND HOARSENESS FOLLOWING ENDOTRACHEAL ANAESTHESIA

K-Y jelly is superior to lidocaine jelly in preventing postoperative sore throat, and in reducing the incidence of hoarseness of voice and cough

So lidocaine does produce vasodilation and tissue swelling.

I doubt one can make sure one doesn't touch the vocal cords when one places a gel-lubricated ETT. I would buy that argument for lidocaine in the cuff, but not on the outside of the tube. Plus I also doubt that the lidocaine on the cuff/tube doesn't diffuse/circulate to a mucosal nerve ending that's just a few centimeters away.

 

[deleted171991]

I do lido lube all the time. No issues. The cuff goes into the trachea, doesnt blunt airway reflexes or touch the cords. I think lube is helpful in general, and if your going to lube why not lido lube. I think lido lube is better than LTA because you just pass the tube and not two different things into the airway.

The studies I quoted above show why not to lido lube. It seems to actually increase the incidence of sore throat.

 

[deleted162650]

I went through a phase in residency where I would lido paste all my tubes. It definitely made emergence/extubation smoother as the tube was really well tolerated with a numb trachea/larynx. I stopped doing though after a few months when I noticed that patients couldn't stop coughing in PACU. Obviously the airways were getting irritated to some extent or just didn't like being numb. I figured it was stupid to minimize coughing on the tube only to create coughing fits in PACU.

I continue to use LTA's fairly regularly for certain cases, and I don't see the post-op coughing, nor do I hear about sore throats.