turbinate surgery

[halflife94]

Turbinate surgery with cautery. What type of ETT armored/laser tube or regular?

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[IlDestriero]

Regular cuffed oral RAE. O2 under 30%.

 

[somedumbDO]

+1

 

[pgg]

Yeah, they're not burning anything anywhere near the tube. With the cuff on the tube up, oxygen will be at 21% in their work area, but using a lower FiO2 / no nitrous for ENT cases is never a bad idea. No need for a special tube. Oral rae if one is within arm's reach.

 

[Noyac]

Anyone using a well seated LMA for these cases?

 

[OUAnesthesia]

Anyone using a well seated LMA for these cases?

Our ENTs spin 180 for cases so we just tube them

 

[Noyac]

Our ENTs spin 180 for cases so we just tube them

Is that a reason to not use an LMA?

 

[Mman]

Is that a reason to not use an LMA?

Does an LMA offer some benefit I'm unaware of that would make you want to use it in a patient that you can't get near their airway? Honestly if there is cautery anywhere near an airway I'd rather not have an LMA which even in a perfect world can't offer the same protection against a leak that an ETT does.

 

[OUAnesthesia]

Is that a reason to not use an LMA?

I agree with the above...although I understand your point...just a preference that with the bed turned away from me and the surgeons playing around with the head, I'd just prefer to not potentially be messing with an LMA should it start to act up in the middle of the case...you gain nothing by putting in an LMA in that situation IMHO.

 

[jwk]

Is that a reason to not use an LMA?

Absolutely.

 

[Noyac]

Absolutely.

would you put an LMA in a pt in the beach chair position?

I'm not saying these are the same per se. But it does give some perspective.

 

[Noyac]

Does an LMA offer some benefit I'm unaware of that would make you want to use it in a patient that you can't get near their airway? Honestly if there is cautery anywhere near an airway I'd rather not have an LMA which even in a perfect world can't offer the same protection against a leak that an ETT does.

I don't know. What is the usual benefit of an LMA?
Why are you worried about a leak? Is it the FiO2?
Cautery is in the nose. Not the oropharyngeal area where your LMA is planted.

 

[Noyac]

There is a downside to the LMA in nasal surgery tho.

 

[jwk]

would you put an LMA in a pt in the beach chair position?

I'm not saying these are the same per se. But it does give some perspective.

I do not - if access to the airway is not easy and immediate, I think an LMA is contraindicated. Many of the people in my own group disagree with me. But as the saying goes, I've never been sorry I put an ETT in, but there have been numerous times I didn't and wish I had.

 

[Noyac]

I do not - if access to the airway is not easy and immediate, I think an LMA is contraindicated. Many of the people in my own group disagree with me. But as the saying goes, I've never been sorry I put an ETT in, but there have been numerous times I didn't and wish I had.

I hear you.
I'll just say that I have put an LMA in just about every possible case that can be done with one without any regrets that I can remember. I may have intubated a shoulder case once a year for the past 10 yrs. Hundreds of seated position LMAs and they are nice. A good block and an LMA and I can usually skip recovery room and go straight to phase 2. It also saves valuable time when it's the last case if the day and everyone is itching to go home.

 

[pgg]

Anyone using a well seated LMA for these cases?

No.

It may not stay "well seated" with the ENT swinging his elbows and scope and other instruments around the nose.

Not infrequently these turbinate & FESS cases send a fair amount of blood down the posterior oropharynx. I feel better with an ETT's good seal and an easy deep suction.

I don't do LMAs in beach chairs, or lateral, or prone, or in ENT cases turned 180.

I think LMAs are the second most overused thing in the OR, right after midazolam. I use them for simple cases where they can simplify the anesthestic a bit. I don't try to shoehorn them into everything else.

 

[Noyac]

Fair enough. The reason I don't use them in sinus surgery is because the tube is in the way of the surgery. And the blood does worry me some. But if there isn't a leak with good pressure then the risk of blood leaking around is low. Still an ETT is probably better and definitely safer.
But I am surprised that more don't use LMAs in 180 turned cases, etc. I just don't see the problem. They don't come out all that easily. I will use it in the lateral position on occasion. Not a fan of it in here prone position but I have used it once like this. It went fine but I don't recommend it.

 

[Mman]

I'm not a huge fan of LMAs. They have a use, but they don't really offer much benefit over an ETT. LMAs cause sore throats. LMAs don't prevent aspiration. LMAs are more easily dislodged mid case than an ETT. An LMA can make your job a little easier in some instances, but it doesn't make the experience any better or safer for the patient.

 

[sevoflurane]

I use LMA's often.

Benefits:

Quick induction and no need for extubation.
Lack of paralytics and therfore possibly decreased N/V via omission of neostigmine.
Mantanence of SV (better V/Q) and less atelectasis associated with PPV.
No bucking on extubation (although I don't really see bucking in my practice as I pull nearly all my ETT's deep).
Great oral AW (I can drop off a SV patient in pacu with an LMA in place).
When you remove LMAs, you usually bring out secretions as well.
Great option for those with COPD (extrememly frequent comorbid condition in my practice).



I use it for lateral cases/THA's and shoulders in the right patient.

At the ASC, it's almost entirely LMA's.

 

[sevoflurane]

Oh... and definately don't have a "rule" as to how long one should use an LMA. That is certianly academic/anesthesia dogma.
I'll do a 4+ hour case under LMA w/o any issues or concerns.

 

[sevoflurane]

LMAs cause sore throats.

Is this true? If it is, it's not my experience... but then again every single LMA I put in I depress the tongue with a tongue blade. Slips right in.

 

[sevoflurane]

Quick google search:

N = 5264

ETT: Greatest inccidence of sore throat: 45.4%
LMA: 17.5%

 

[Mman]

I have no idea what the literature shows but I see plenty of LMA patients with sore throats and I see a far higher incidence (albeit still low) of pharyngeal injury from an LMA compared to an ETT. Uvula's 3x the size they were preop from getting squished by the LMA for an hour+ or pharyngeal injury from the LMA sitting incorrectly or having too much pressure inflated.

LMAs make our life easier at times. I rarely see a patient that was glad they had an LMA postop with the exception of perhaps a bad reactive airway patient. Patient's don't feel any better postop.

 

[Noyac]

I have no idea what the literature shows but I see plenty of LMA patients with sore throats and I see a far higher incidence (albeit still low) of pharyngeal injury from an LMA compared to an ETT. Uvula's 3x the size they were preop from getting squished by the LMA for an hour+ or pharyngeal injury from the LMA sitting incorrectly or having too much pressure inflated.

LMAs make our life easier at times. I rarely see a patient that was glad they had an LMA postop with the exception of perhaps a bad reactive airway patient. Patient's don't feel any better postop.

I'm not trying to criticize here but it seems like there is room for improvement in your technique.

 

[Noyac]

Personally, I feel the greatest benefit of the LMA is the ability to not stimulate the airway in a pt with reactive airway disease. This includes children.

Obviously, you can topicalize the airway well with lido in these cases when placing a tube but if not necessary then why?

 

[BuzzPhreed]

I'm not trying to criticize here but it seems like there is room for improvement in your technique.

I agree.

I've watched CRNAs place LMAs on too many occasions to count. Invariably they grab the tongue depressor. Once I asked a very seasoned CRNA, "Why are you doing that? You do that every time."

Her somewhat-scoffing response was, "This is the way you're supposed to put an LMA in."

I told her a story about how it is very easy to scratch the uvula with the tongue depressor. I regaled her with a residency story about following-up on a patient POD1 who was complaining of a sort throat. I examined the posterior portion of the oropharynx and saw a large swollen uvula with an excoriation that I had created with a stupid f*cking tongue depressor. Determined never to do this again, I worked on my technique to the point where I never put anything but the partially-inflated soft tip of the LMA in the patient's mouth. Nothing else. Not fingers to guide it. Nothing. Even better, when you have two people (like working with a know-it-all, monkey-see-monkey-do CRNA), a gentle draw thrust proves two things to you: 1) the patient is ready to have the LMA placed and 2) the passage is facilitated much easier. Many of the other CRNAs were receptive to this technique and even liked it.

I tell her this story and you know what her response was? "That doesn't happen when I do it."

"How do you know?" I asked her. "Do you post-op your patients?"

Silence.

Do you think I ever heard a word about that again? No. And she continued to persist in her sh*tty technique. Anyone wonder why I hate militant CRNAs? Show them a superior way of doing things and this is a not atypical response you'll get from some of them.

 

[Mman]

I'm not trying to criticize here but it seems like there is room for improvement in your technique.

Since I haven't described a technique, I'm not sure what you are trying not to criticize.

I'm pointing out that fallacy of benefits some people tout in LMAs.

 

[BuzzPhreed]

Since I haven't described a technique, I'm not sure what you are trying not to criticize.

You don't have to. If you're routinely having sore throats after LMA placement, something's amiss.

 

[painstop]

Anyone here put their LMA patients on pressure support ventilation (low pressures of 10-15 so as not to insufflate the belly)? I routinely do this in my practice right after inserting the LMA and find a)I don't need to wait 30 seconds for them to breath on their own and b)I get larger tidal volumes than having them spontaneously ventilate.

 

[Spinach Dip]

I'm not a huge fan of LMAs. They have a use, but they don't really offer much benefit over an ETT. LMAs cause sore throats. LMAs don't prevent aspiration. LMAs are more easily dislodged mid case than an ETT. An LMA can make your job a little easier in some instances, but it doesn't make the experience any better or safer for the patient.

NO WAY!?!

You mean shoving a wedge-shaped piece of plastic the size of your foot into someone's oropharynx can cause a sore throat?

Who knew?

 

[Mman]

You don't have to. If you're routinely having sore throats after LMA placement, something's amiss.

Who said they routinely have sore throats? I said they can cause sore throats. ETTs can cause sore throats. That doesn't mean every intubated patient has a sore throat, in fact the majority don't. I'd be interested in a study comparing the incidence of sore throat between a 6.0-7.0 ETT and a #4 or #5 LMA. In my experience it's the people that always put big ETTs in people for minor procedures that end up with a lot of sore throats.

 

[IlDestriero]

Anyone here put their LMA patients on pressure support ventilation (low pressures of 10-15 so as not to insufflate the belly)? I routinely do this in my practice right after inserting the LMA and find a)I don't need to wait 30 seconds for them to breath on their own and b)I get larger tidal volumes than having them spontaneously ventilate.

All the time.

 

[psychbender]

Anyone here put their LMA patients on pressure support ventilation (low pressures of 10-15 so as not to insufflate the belly)? I routinely do this in my practice right after inserting the LMA and find a)I don't need to wait 30 seconds for them to breath on their own and b)I get larger tidal volumes than having them spontaneously ventilate.

Nearly every one of my patients who get an LMA go on PSV.

 

[pgg]

All the time.

Nearly every one of my patients who get an LMA go on PSV.

Me three.

 

[Foodie]

I like LMAs. But wouldn't use them in turbinate cases.

The only ENT cases that I do not use ETTs are myringotomies during which I just mask ventilate.

Compression of the lingual nerve from overinflated LMA cuff can lead to numbness in the back of the mouth. If your LMA pts are complaining about "sore throat" post op, they may be confusing the symptoms. Or you've traumatized the hypopharynx one way or another. I've watched some scary aggressive LMA placement maneuvers. Actually, I've witnessed traumatic nasal trumpet placements which are far scarier and bloodier than traumatic LMA placements.

 

[sevoflurane]

I rarely (if ever) inflate an LMA. I use it as it is right out of the package.

 

[dhb]

In my experience it's the people that always put big ETTs in people for minor procedures that end up with a lot of sore throats.

In an easy intubation there is no reason for bigger or smaller tube to cause more or less throat pain. I actually think you can cause more tracheal damage by having to over-inflate a cuff on a small tube to prevent leakage.

 

[Mman]

In an easy intubation there is no reason for bigger or smaller tube to cause more or less throat pain. I actually think you can cause more tracheal damage by having to over-inflate a cuff on a small tube to prevent leakage.

A larger ETT stents open the vocal cords wider and puts more pressure on them. Unless you have insanely high amounts of cuff pressure I suspect it has very little to do with a sore throat.

 

[pgg]

In an easy intubation there is no reason for bigger or smaller tube to cause more or less throat pain. I actually think you can cause more tracheal damage by having to over-inflate a cuff on a small tube to prevent leakage.

I do agree that most of the time, a really sore throat is the fault of laryngoscopy and blade trauma. But, I also believe tube size affects the incidence of pain and hoarseness.

I always use as small a tube as I think I can get away with. My default is a 6.5 in women and a 7.0 in men. Very rarely have sore throats afterwards. Don't have problems with a seal. When it's there, I use the RT's cuff pressure measuring thingy, otherwise, I adjust the cuff pressure to a bit more than the minimum to prevent a leak.

The only time I put a 7.5 or 8.0 tube in anyone is if I think they might go intubated to the ICU, and then only because the bigger tube makes bronching and suction easier.

 

[lunaire]

Sore throats aside and focusing back on the table being rotated aspect:

There is an association between intraop surgical table rotation and LMA unique failure.

http://www.ncbi.nlm.nih.gov/pubmed/22510864