Shoulder Arthroscopy with an LMA

[Doughy315]

I had an interesting case today, 6'1 330lbs male present for a right shoulder arthroscopy with rotator cuff repair. He has a large neck 3 FB TMD. He says he never has been to the doctor. He doesn't believe he has OSA. The orthopedic surgeon book him at their surgery center because he has good insurance. The case position is the left lateral decubitus position with a bean bag. I am curious how many PP docs would do this case with LMA or would you say it needs to be done as an inpatient?

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[Ezekiel2517]

Eh, I'd probably just tube him.

 

[caligas]

Eh, I'd probably just tube him.

People do these (as well as beach chair) with LMA but I prefer a secure airway when I don't have decent access.

 

[Ezekiel2517]

People do these (as well as beach chair) with LMA but I prefer a secure airway when I don't have decent access.

I love the LMA for shoulders but this dude is pretty big , bmi close to 45. Just tube him

 

[deleted171991]

This guy's BMI is 43.5. I would do it only with a very well-fitting LMA (probably Supreme 5) or an ETT.

Post-op is a different story. This guy probably has undiagnosed OSA, so he would need prolonged observation in the PACU. I would also minimize any sedatives and long-acting opiates in him, and stick to fentanyl and non-opiate analgesia. It can be done in an ASC, although not the ideal place.

 

[Ezekiel2517]

This guy's BMI is 43.5. I would do it only with a very well-fitting LMA (probably Supreme 5) or an ETT.

Post-op is a different story. This guy probably has undiagnosed OSA, so he would need prolonged observation in the PACU. I would also minimize any sedatives and long-acting opiates in him, and stick to fentanyl and non-opiate analgesia. It can be done in an ASC, although not the ideal place.

With a block he won't need anything in the pacu. This case with this type of pt is done all the time in surgicenters

 

[Planktonmd]

A big patient like this one in the semi sitting position can be done with an LMA safely if you are going to do the case by yourself and be in the room all the time.
If a CRNA is involved I would place an ETT.

 

[anbuitachi]

A big patient like this one in the semi sitting position can be done with an LMA safely if you are going to do the case by yourself and be in the room all the time.
If a CRNA is involved I would place an ETT.

Why? Are you worried the crna would take out the LMA in the middle of the case??

 

[Arch Guillotti]

This guy's BMI is 43.5. I would do it only with a very well-fitting LMA (probably Supreme 5) or an ETT.

Post-op is a different story. This guy probably has undiagnosed OSA, so he would need prolonged observation in the PACU. I would also minimize any sedatives and long-acting opiates in him, and stick to fentanyl and non-opiate analgesia. It can be done in an ASC, although not the ideal place.

Just do a block and no narcotics at all.

 

[Planktonmd]

Why? Are you worried the crna would take out the LMA in the middle of the case??

No, I am worried that they won't notice that the patient is not breathing adequately, or the LMA has been partially dislodged, or maybe the patient is vomiting in the middle of the case.
No offence meant to any mid-level colleague.

 

[dhb]

Go easy on the block: a diaphragmatic block + abdominal restriction is going to be hard to tolerate for the fat guy.

 

[Noyac]

Why? Are you worried the crna would take out the LMA in the middle of the case??

Yes

 

[Noyac]

I would probably tube this guy because of his size and position. I would consider the LMA if the surgeon was good enough and no messin around and no crna involved. As stated above, a good seal that I can ventilate him with is a must.
If this was beach chair position then it's am LMA all the way.

 

[Shimmy8]

My experience with LMAs and beach chair (I know that's not what this thread is specifically addressing, but I digress) is that though we all seem to favor the Supreme for larger patients, it's much harder material and doesn't seem to "fit" in the patient well once they're moved from supine to sitting.

I've had multiple Supreme's with a great fit on induction that clearly didn't seat well once sitting. Not fun to tell the surgeon half way through we need to break sterile and intubate after readjusting doesn't work. Never had that issue with a unique LMA.

I haven't done any at my new group, but my preference for these shoulders will be standard LMA (iGel or Unique) or ETT. No supreme for me.

 

[dannyboy1]

No, I am worried that they won't notice that the patient is not breathing adequately, or the LMA has been partially dislodged, or maybe the patient is vomiting in the middle of the case.
No offence meant to any mid-level colleague.

If this is your concern then you should tube them regardless, why would you want to mess around with a dislodged LMA under the drapes in beach chair, CRNA or not

 

[Noyac]

My experience with LMAs and beach chair (I know that's not what this thread is specifically addressing, but I digress) is that though we all seem to favor the Supreme for larger patients, it's much harder material and doesn't seem to "fit" in the patient well once they're moved from supine to sitting.

I've had multiple Supreme's with a great fit on induction that clearly didn't seat well once sitting. Not fun to tell the surgeon half way through we need to break sterile and intubate after readjusting doesn't work. Never had that issue with a unique LMA.

I haven't done any at my new group, but my preference for these shoulders will be standard LMA (iGel or Unique) or ETT. No supreme for me.

I agree. I hate the Supreme. I use the old fashion one every time. I guess I'm "old fashion". 😉

 

[Planktonmd]

No, I am worried that they won't notice that the patient is not breathing adequately, or the LMA has been partially dislodged, or maybe the patient is vomiting in the middle of the case.
No offence meant to any mid-level colleague.

When I am doing the case by myself I tend to do what I think is the least invasive and better tolerated by the patient. On the other hand, when I am working with a CRNA I try to pick a plan that has the smallest number of screwing up opportunities.

 

[dA pilot]

As the OP stated, this patient is not going to be in the sitting position, the patient will be lateral on a bean bag. I would have intubated the patient no matter the position. Does lateral change anyone else's opinion versus sitting?

I would not have any qualms about doing this case in a surgicenter with limited narcotics and more prolonged pacu stay.

 

[GA8314]

I had an interesting case today, 6'1 330lbs male present for a right shoulder arthroscopy with rotator cuff repair. He has a large neck 3 FB TMD. He says he never has been to the doctor. He doesn't believe he has OSA. The orthopedic surgeon book him at their surgery center because he has good insurance. The case position is the left lateral decubitus position with a bean bag. I am curious how many PP docs would do this case with LMA or would you say it needs to be done as an inpatient?

I would do it via LMA. Do it quite frequently. Make sure you have a good seal/seat before turning. Use pressure support to maintain adequate MV.

 

[Ronin786]

If this is your concern then you should tube them regardless, why would you want to mess around with a dislodged LMA under the drapes in beach chair, CRNA or not

How well do you trust a CRNA to tell your hotshot ambulatory shoulder surgeon that he needs to stop the scope because the LMA isn't cutting it?

 

[deleted162650]

I do lateral shoulder scopes with LMA's all the time. I would tube this guy.


Oh, and Unique LMA's all day. I hate the Supremes.

 

[Noyac]

As the OP stated, this patient is not going to be in the sitting position, the patient will be lateral on a bean bag. I would have intubated the patient no matter the position. Does lateral change anyone else's opinion versus sitting?

I would not have any qualms about doing this case in a surgicenter with limited narcotics and more prolonged pacu stay.

No qualms doing him at surgicenter.
I'm just not as big of a fan of lateral LMA's ( did one last week and it was fine). Left side down I'm more comfortable with. I guess my insecurity here is that none of my surgeons do lateral shoulders. They all do seated so I get no practice here.

 

[Noyac]

I would do it via LMA. Do it quite frequently. Make sure you have a good seal/seat before turning. Use pressure support to maintain adequate MV.

I also have become a fan of PS with the LMA. I let tempt breath. I dial my anesthetic to RR and TV. I understand that you can do,the same with PS but I don't ever see a need for it. It confuses me.

 

[fakin' the funk]

Dude is severely obese, has undiagnosed OSA, lateral position in a bean bag. This is the hand you're dealt. Tube him.

 

[nimbus]

The patient could be obese or he could just be huge.

I haven't intubated a shoulder scope in many years but I might in this case based on his body habitus. That said, I might regret intubating him at the end of the case if I encounter laryngospasm or breath holding. Remember an ETT has some disadvantages compared to an LMA and some of them occur at the end of an anesthetic. IME an ISB+LMA for shoulder scopes are soooo smooth that I have to have a convincing reason not to do it that way. Often they open their eyes pain free asking when surgery is going to start. In real life I haven't encountered a situation where I haven't done it. But honestly I haven't had any 6'1" 330lbers come through for shoulder arthroscopy. I'm not in a practice that takes care of a bunch of football players. Would love to hear from those that do and what works for them.

 

[nimbus]

If this is your concern then you should tube them regardless, why would you want to mess around with a dislodged LMA under the drapes in beach chair, CRNA or not

I do it all the time and have never seen an lma dislodge. I use tape. Why would an lma be more likely to dislodge than a tube?

 

[nimbus]

My experience with LMAs and beach chair (I know that's not what this thread is specifically addressing, but I digress) is that though we all seem to favor the Supreme for larger patients, it's much harder material and doesn't seem to "fit" in the patient well once they're moved from supine to sitting.

I've had multiple Supreme's with a great fit on induction that clearly didn't seat well once sitting. Not fun to tell the surgeon half way through we need to break sterile and intubate after readjusting doesn't work. Never had that issue with a unique LMA.

I haven't done any at my new group, but my preference for these shoulders will be standard LMA (iGel or Unique) or ETT. No supreme for me.

I sit them up first, make sure they're nice n comfy, then induce, then insert an lma unique. Have had zero failures.

 

[Ezekiel2517]

The patient could be obese or he could just be huge.

I haven't intubated a shoulder scope in many years but I might in this case based on his body habitus. That said, I might regret intubating him at the end of the case if I encounter laryngospasm or breath holding. Remember an ETT has some disadvantages compared to an LMA and some of them occur at the end of an anesthetic. IME an ISB+LMA for shoulder scopes are soooo smooth that I have to have a convincing reason not to do it that way. Often they open their eyes pain free asking when surgery is going to start. In real life I haven't encountered a situation where I haven't done it. But honestly I haven't had any 6'1" 330lbers come through for shoulder arthroscopy. I'm not in a practice that takes care of a bunch of football players. Would love to hear from those that do and what works for them.

You're hesitant to intubate bc of laryngospasm or breath holding at the end? Lol, extubating isn't that hard especially for a case like this with a good block and no narcs. I can use lma or ett and extubate just as smoothly in either circumstance. Also, 6'1, 330 lbs isn't a football player, 6'6 330 is more like it. 6'1, 330 is just a really morbidly obese man.

 

[nimbus]

You're hesitant to intubate bc of laryngospasm or breath holding at the end? Lol, extubating isn't that hard especially for a case like this with a good block and no narcs. I can use lma or ett and extubate just as smoothly in either circumstance. Also, 6'1, 330 lbs isn't a football player, 6'6 330 is more like it. 6'1, 330 is just a really morbidly obese man.

No reason to get snarky.

I agree extubating is not hard. I've done it successfully a couple of times. But in my hands the chance of a super smooth wake up is higher with an LMA than with an ETT. My point is that an LMA does have some advantages over an ETT. Otherwise there is no reason ever to use an LMA for these cases but people still do.

 

[Noyac]

I do it all the time and have never seen an lma dislodge. I use tape. Why would an lma be more likely to dislodge than a tube?

The only reason I can think of is that it wasn't seated properly in the first place.

 

[Noyac]

For those that would intubate this guy, would you extubate him the lateral position?

I usually intubate lateral cases that are longer than 90 minutes for some reason. Unless the pt just really calls for an LMA (not sure which pt that is off hand). Usually these are elbow cases for us and they tend to be longer. My last elbow was an LMA though now that I think about it. Anyway, I extubate in the lateral position probably more than supine in these cases. Especially if the pt was easy enough to mask in the beginning. I say their name, they open their eyes and mouth (following commands) and I pull the tube. I ask them to roll on their back while we slide them onto the gurney and off we go. It's not a big deal.

 

[deleted162650]

For those that would intubate this guy, would you extubate him the lateral position?

It's not a big deal.

I agree, and typically don't have a problem with lateral extubation, but I think I'd be a little more conservative with this guy, and just wait till we're supine. I would hate to get myself into a situation where we need to rapidly roll this behemoth supine.

I guess my insecurity here is that none of my surgeons do lateral shoulders.

Wait, somebody write this down - @Noyac has admitted to being insecure about something!

 

[Noyac]

Wait, somebody write this down - @Noyac has admitted to being insecure about something!

Someone hacked my account. That wasn't me. You should know better.

 

[Skip2myLou]

I do plenty of ortho cases at surgicenters. Many of them are done in lateral position . The surgicenter orthopods are generally faster than my hospital orthopods. I will block for post-op pain relief and then induce GA with LMA. I say 99% if my outpatient cases are LMA including pts like the OP described . I will intubate if the pt has history of difficult airway or looks like a bad airway.


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[deleted171991]

I sit them up first, make sure they're nice n comfy, then induce, then insert an lma unique. Have had zero failures.

Unique? Holy-moly, you have cojones.

 

[nimbus]

Unique? Holy-moly, you have cojones.

I don't understand the comment. LMA Unique works great.

 

[deleted171991]

I don't understand the comment. LMA Unique works great.

I just don't trust first generation LMAs. I like to be able to use serious PCV with my LMAs, so I can take the patient as deep as I need to, without relying on SV or worrying about ventilation. Especially in a sitting shoulder case, when it's a pain to change/reposition the airway under the drapes. I can see myself possibly using one in a thin person, but not in most overweight/obese patients, which is the American norm. But then I have never tried one in a sitting patient, plus I didn't do blocks back when I did shoulders with LMAs...

I like to use LMAs for more than just glorified MACs, with the LMA as an oral airway. That's why Uniques are not my favorites.

 

[deleted162650]

I just don't trust first generation LMAs. I like to be able to use serious PCV with my LMAs, so I can take the patient as deep as I need to, without relying on SV or worrying about ventilation. Especially in a sitting shoulder case, when it's a pain to change/reposition the airway under the drapes. I can see myself possibly using one in a thin person, but not in most overweight/obese patients, which is the American norm. But then I have never tried one in a sitting patient, plus I didn't do blocks back when I did shoulders with LMAs...

I like to use LMAs for more than just glorified MACs, with the LMA as an oral airway. That's why Uniques are not my favorites.

My experience has been that the newer/"fancier" LMA's don't work or seal any better than Uniques.

 

[nimbus]

I just don't trust first generation LMAs. I like to be able to use serious PCV with my LMAs, so I can take the patient as deep as I need to, without relying on SV or worrying about ventilation. Especially in a sitting shoulder case, when it's a pain to change/reposition the airway under the drapes. I can see myself possibly using one in a thin person, but not in most overweight/obese patients, which is the American norm. But then I have never tried one in a sitting patient, plus I didn't do blocks back when I did shoulders with LMAs...

I like to use LMAs for more than just glorified MACs, with the LMA as an oral airway. That's why Uniques are not my favorites.

I PPV fatties all the time with the Unique. It works especially well when they're sitting.

 

[Skip2myLou]

I would extubate laterally , but not with LMA, usually get him in their back and then take LMA in usual fashion unless pt is obviously awake.

I've used all the Lma, reusable (which are total crap), supreme , i-gel. I will use any one of them on this pt. Whatever is there at that particular center.


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[bullishMD]

If you are going to do a block, why don't you do a surgical block + sedation. If you are worried about a block because of phrenic paralysis and post-op respiratory status do a very small volume block for pain control plus GETA or LMA...

 

[Hoya11]

If you are going to do a block, why don't you do a surgical block + sedation. If you are worried about a block because of phrenic paralysis and post-op respiratory status do a very small volume block for pain control plus GETA or LMA...

While I have done block and sedation a few times for the right situation, a block and an LMA is so much better. Going lateral with the arm up in the air and all the stuff all over the field, its easier to have a controlled airway and GA from the start. For this heavy big guy I would tube him and I would not extubate him lateral. Why take a chance? To avoid flipping him over? that takes less than 1 minutes and adds some level of risk. We have had a problem with fluid extravasation during these cases, with more than one patient ending up in the ICU requiring time (1-2d) to let neck swelling go down before safely extubating. One of those cases started out with an LMA and had to be emergently intubated which was nearly impossible and the person almost died if not for a lucky tube placement (not my case).

So for me, a tube adds - control of this big guy with paralytic, secure airway in the event of fluid extravasation under the drapes, peace of mind during case that airway will not dislodge at wrong time. If a normal size person LMA and lateral removal.

 

[fakin' the funk]

I like to use LMAs for more than just glorified MACs, with the LMA as an oral airway. That's why Uniques are not my favorites.

I think most people do view LMAs as glorified oral airways, with a potential bonus of being able to do PPV or gastric drainage or intubation.

I must say, your opinions on LMAs are quite curious.

When my Plan A is to do positive pressure ventilation (not to mention in a morbidly obese patient in lateral position), I use an ETT, which was designed for that.

 

[skypilot]

I think most people do view LMAs as glorified oral airways, with a potential bonus of being able to do PPV or gastric drainage or intubation.

I must say, your opinions on LMAs are quite curious.

When my Plan A is to do positive pressure ventilation (not to mention in a morbidly obese patient in lateral position), I use an ETT, which was designed for that.

If I am questioning should I put in an LMA or not?... Then I put in an Endotracheal Tube. LMA is not a secure airway it is just a Mask that happens to be in Larynx. ETT is less likely to dislodge than an LMA especially in a patient that is wide awake!

 

[Noyac]

When my Plan A is to do positive pressure ventilation (not to mention in a morbidly obese patient in lateral position), I use an ETT, which was designed for that.

Bingo!!!

 

[deleted171991]

If I am questioning should I put in an LMA or not?... Then I put in an Endotracheal Tube. LMA is not a secure airway it is just a Mask that happens to be in Larynx. ETT is less likely to dislodge than an LMA especially in a patient that is wide awake!

That's like with anything in anesthesia: if in doubt whether to do something more complicated, just do it. I have never regretted going for the safer option. Cutting corners? Many times.

 

[Dawkter]

We are getting a lot of requests from surgeons to do rotator cuff surgery with block + sedation (no LMA/ett). The case duration is around 45-60 mins.

Anyone else doing this routinely for otherwise healthy patients with a favorable airway?

 

[GassYous]

We are getting a lot of requests from surgeons to do rotator cuff surgery with block + sedation (no LMA/ett). The case duration is around 45-60 mins.

Anyone else doing this routinely for otherwise healthy patients with a favorable airway.

Dumb. No difference in emergence or out of room. LMA all the way

 

[Arch Guillotti]

We are getting a lot of requests from surgeons to do rotator cuff surgery with block + sedation (no LMA/ett). The case duration is around 45-60 mins.

Anyone else doing this routinely for otherwise healthy patients with a favorable airway.

Just say no.

 

[kidthor]

We are getting a lot of requests from surgeons to do rotator cuff surgery with block + sedation (no LMA/ett). The case duration is around 45-60 mins.

Anyone else doing this routinely for otherwise healthy patients with a favorable airway.

Where I was a resident they did shoulders with a block and “sedation” (really TIVA GA + unprotected airway). This practice made no sense and led to frequent problems.