Use of Prone LMA

Discussion in 'Anesthesiology' started by Anes4life, Jul 24, 2006.

  1. Anes4life

    Anes4life Junior Member

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    Hey guys,

    I am starting on a research project on the risk of aspiration when using prone LMAs. From speaking with my PI, I got the impression that we were one of few places that use LMAs in the prone position. Most of the cases are pretty minor, such as butt pus and achilles.

    I was just wondering if the place where you work uses LMAs in the prone position. If so, how often do you have complication and what are they. If you dont use prone LMAs, why not ?

    Thanks
     
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  3. nimbus

    nimbus Member
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    I use them for short (10-20min) cases too, eg butt pus, lipoma excision. Worked fine so far. However, I am not brave enough to do a discectomy with it.

    You should look up Brimacombe. He is from New Zealand and uses LMA or LMA proseal for basically everything. He gives an entertaining lecture where he shows photos of himself snorkeling and running a 5k breathing through one. Disclaimer-he is a consultant for LMA North America.
     
  4. jwk

    jwk CAA, ASA-PAC Contributor
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    Should be an interesting study.

    We dont' - and won't - use LMA's for prone cases. We've had several patients aspirate with LMA's in place on supine cases. Put them on their stomach, in a jacknife position that is common with butt cases? Ain't gonna do it.

    Call me old fashioned - an ETT is your friend. Hell, I was one of the last people in my department to start using LMA's - they were heresy for an accomplished mask-er. ;)
     
  5. Monty Python

    Monty Python Icelandic (see avatar) doesn't translate well.
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    A partner in the group where JPP and I used to work did one year of his Tulane residency in England (at that time, the Chairman of Tulane anesthesia was a Brit). He told me they did "everything" with LMAs, including prone cases, sitting cranis, etc. He admitted that he felt some of the LMA's usages over there were "on the fringe" of his comfort level.
     
  6. nimbus

    nimbus Member
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    This depends on what alternative you are considering.

    If you are willing to do GA/ETT or saddle block for every prone hemorrhoidectomy or anal fistula, I can see this would be considered a more conservative approach. But the techniques come with there own set of morbidity.

    Where I work, many people were/are doing these with a BIG MAC eg versed/fentanyl/propofol bolus 30-100mg followed by local infiltration by the surgeon. I find versed/propofol/LMA/sevo to be preferable in most cases because I get less airway obstruction/apnea/desaturation. Usually they wake up as fast and as smoothly as the MAC patients. The incidence of vomiting appears to be the about the same between MAC and GA, and most cases of vomiting do not lead to clinically significant aspiration. The cases are typically 10 min so it's not hard to stay focused and pull the LMA and suction them when you have the inevitable patient who vomits.

    That said, if I am concerned about obstruction or aspiration, I will steer those patients to a saddle block with heavy bupiv 2.5 mg+minimal sedation.
     
  7. Anes4life

    Anes4life Junior Member

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    Thank you guys for your input.....yall rock :thumbup: :thumbup:
     
  8. joncmarkley

    joncmarkley Junior Member
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    someone help me, I am missing the point. Why LMA for prone cases? Is intubating so bad/hard? Peace of cake ....and the airway is secured...no worrys
     
  9. Noyac

    Noyac ASA Member
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    I gotta agree with you. There may be some pts you really don't want to intubate but very few. I am a fan of putting a tube in these prone cases. And I'll put an LMA in just about anyone, sometimes even a pregnant chick. :eek:
     
  10. militarymd

    militarymd SDN Angel
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    i put LMAs in pregnant chicks all the time.
     
  11. jwk

    jwk CAA, ASA-PAC Contributor
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    How pregnant? Surely not for C-Sections...
     
  12. militarymd

    militarymd SDN Angel
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    D&C...peripheral orthpedic procedures ...etc....How are they any different from say someone with a BMI of 40
     
  13. Anes4life

    Anes4life Junior Member

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    The premise of the study is that LMAs are less invasive than ETTs. They have a lower incidence of sore throats and vocal problems. In addition, we insert the LMAs prone so you dont have to worry about flipping the pt and bending some guys johnson or dislocating the shoulder of some old lady. It is also suppose to be a little easier waking up the patient because they are tolerated at lighter anesthetic planes.

    So far I have reviewed 70 prone charts. 1 pt had emesis w/o aspiration(LMA was suctioned w/o further complications), no laryngospasm and 1 needed to be converted to an ETT. All O2 sats were above 97% during and post op. Just food for thought i suppose.
     
  14. TIVA

    TIVA Member
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    Interesting study, Anes4Life. Can you provide more details on how you do the LMA prone? Is the induction more heavy handed ... in order to prevent them from waking up during the flip or going into laryngospasm during the flip? And if so, are they apneic? Or apneic for very long? If so, do you put them on the vent on pressure control? Also, are their faces facing the floor or looking to the side?


    Question for Military and Noyac:

    Regarding LMA's in pregnant women. What about their increased risk of aspiration from higher intra-abdominal pressures, delayed gastric emptying, and lowered esophageal sphincter tone? Isn't a significant regurg/asp risk considered a contraindication to the LMA? In my experience, pregant women who've fasted for even over 24 hours have a practically full stomach (I've seen it when they throw up during a C-section or delivery.)


    Cheers,
     
  15. pratik7

    pratik7 Senior Member
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    The patient positions self prone so there is no flipping involved. The LMA is inserted while the pt is in prone position. The head is simply elevated and LMA inserted. So far we havent had anyone with a laryngospasm. Their faces are positioned to the side. The patients are connected to the circuit but are usually breathing spont. Sometimes PPV is used but peak pressure is kept below 20 to prevent air from ending up in the belly.

    Determining risk of regurg is one of the goals of the study. We are going to divide the groups into fat and not fat to determine if regurg is associated with increased BMI and therefore increased intra abd pressure.

    Ohh just realized i posted under another SN ....but i am the OP
     
  16. Noyac

    Noyac ASA Member
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    I did one not to long ago for a 6 month pregnant girl with a proximal radius fx. I did a infraclavicular block and then granted her wish of been asleep. I put an LMA in and let her ride. She was NPO. ;) And another thing. When I laid her supine for the infraclavicular block she got some pretty significant IVC occlusion and almost passed out. A little LUD and all was well.
     
  17. militarymd

    militarymd SDN Angel
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    I really believe that the risk of aspiration is not dependent on NPO status....but other things....like


    1) difficulty in securing the airway
    2) difficulty with mask ventialtion or other forms of ventialtion
    3) partially anestheitzed patient who is coughing/gagging while you mess around
    4) bowel obstruction....where the patient is TRYING to expel GI contents..
    5) LARGE meal immediately prior to anesthesia...ie patient FEELS full and FEELS like he/she needs to throw up

    Short of the above listed, I believe that aspiration risk is minimal.
     
  18. militarymd

    militarymd SDN Angel
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    I anesthetize up to 6 patients a day for gastric bypass in my practice.....Almost 100% have reflux and "delayed gastric emptying" and other factors that make the "authorities" say they are at risk of aspirating.


    I WATCH as the stomach is divided.....WE pass OG tubes into these stomachs.....The stuff in there is no different from any other patient coming for surgery.
     
  19. jetproppilot

    jetproppilot Turboprop Driver
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    I agree.
     
  20. babji

    babji New Member

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    prone is not possible to maintain with LMA, first time iam hearing.. prone with LMA.. ???? aspiration
     
  21. jetproppilot

    jetproppilot Turboprop Driver
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    HArd to say "not possible" in this business....there are so many ways to tackle a case.....

    Like Trin said above, one of my former partners did a 6 month gig in England during our CA-3 year (we did our residency same time/same place) where LMA useage was very very common...and that was in 1996.

    Very interesting post about prone LMA use.

    Don't think I'll be doing any prone-generals with an LMA though....whaddya do if laryngospasm does indeed occur? Guess you could mull through it....small sux dose, turn head to side, get someone to help mask ventilate, etc...not for me though.
     
  22. jwk

    jwk CAA, ASA-PAC Contributor
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    An LMA on this patient would never have entered my mind.
     
  23. militarymd

    militarymd SDN Angel
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    On Call last night.


    87 yo woman with BMI of around 40 :

    Intermittent afib...on anticoagulation (lovenox 1 mg/kg bid)

    admitted with DM exacerbation 3 weeks ago ...glucose >1000 mg/dl

    DM exacerbation secondary to COPD/bronchitis.

    Likely has CHF....clinical diagnosis based on anasarca.

    Creatine on admission 2.5 ....now...1.5/1.6....not sure why they chose lovenox in light of significant renal insufficiency...(1.5 is high for an old lady)

    IV infiltrated in right had...massive right arm hematoma with necrotic skin over forearm and hand...

    Hand surgeon sees the patient at 6:00 pm as she finishes the last bite on her meal....

    Case booked for midnight...


    Airway exam....poor mouth opening....poor thyromental distance.....ZERO head extension ability....essentiall the stiff man syndrome.....


    Ohhhh...what to do...what to do....

    1) struggle at midnight with an awake intubation on an anticoagulated patient?

    2) proseal LMA...


    Guess what I did?
     
  24. TIVA

    TIVA Member
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    Propofol, LMA, full speed ahead ... ;)
     
  25. TIVA

    TIVA Member
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    Hey Mil,

    Another question for you regarding LMA's and aspiration risk:

    If you had a 68 yo female with mild CAD, DM, and significant GERD (i.e. takes ranitidine 150 bid, sleeps on 3 pillows not because of orthopnea, but because of reflux), about to undergo a colposcopy/CO2 laser excision of vaginal epithelium (scheduled on outpatient basis, expected to last < 90 minutes), would you intubate or slip in a LMA?

    European studies seem to suggest no aspiration risk with LMA's. Attendings in U.S. say, "if DM, intubate; if significant GERD, intubate."

    Thanks in advance for everyone's contributions and insights,
     
  26. HomerSimpson

    HomerSimpson Member
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    I love LMAs. They are great. I've personally used them for almost every application as well as patient type. Being that this is a resident and med student forum, I think that a little caution is in order. To me I would learn the classical way to handle a patient with a full stomach first before getting fancy with it. It may be dogma, but remember that if you put a pregnant patient to sleep with an LMA and for some reason she does aspirate and have some complication, there will be a line about a mile long of "experts" saying that you were horribly negligent. By the way there is no defense if this(above example) does happen. Therefore before listening to slick techniques of private practice anesthesiologists who have been practicing for many years, learn classical principles first. Believe me they did.
     
  27. Monty Python

    Monty Python Icelandic (see avatar) doesn't translate well.
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    Unless you couldn't get an ETT in, and the LMA was the only way to maintain an airway.
     
  28. militarymd

    militarymd SDN Angel
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    You KNOW what my answer is...why bother asking?

    LMA
     
  29. militarymd

    militarymd SDN Angel
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    When will the practice of medicine ever ADVANCE if we continue to teach DOGMA that is just plain WRONG.

    The folks in the Netherlands who published the initial study on beta blockers and decreased LV fxn CHF didn't stick with dogma....they advanced medicine SIGNIFICANTLY by applying what they observed into practice.

    Just because EVERYONE in academics teach it doesn't make it CORRECT....we need to press forward...rather than staying in the dark ages.
     
  30. HomerSimpson

    HomerSimpson Member
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    True, I'm not discouraging people from thinking outside the box. That's how science progresses, right. But you also have to balance that with current standards of practice. i mean just because you hear about a case report about something unusual like nebulized morphine for post op pain, that doesn't mean you immediately put it into your practice. i think that doctors need to learn the principles of their specialty before they can truly be able to challenge it and move it forward. just my opiniion though.
     
  31. jwk

    jwk CAA, ASA-PAC Contributor
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    Some things ya just gotta go with your gut. LMA's on pregnant, morbidly obese, prone, and/or patients with symptomatic GERD? Sorry - not my patients. I don't think that's being in the dark ages. I think it's playing it safe.

    Is an LMA as good as an ETT? Maybe. I hate maybe's.

    Do I personally think an ETT protects the airway better than an LMA? Absolutely. I've had patients aspirate with LMA's in place. It hasn't happened on my patients that have an ETT, and I've done thousands more ETT's than LMA's over the years.

    Am I going to harm a patient putting in an ETT instead of an LMA? Nope, unless I can't get the tube in, in which case the LMA is a bridge to an ETT.

    Just my 2 cents...worth no more or any less than anyone else's. ;)
     
  32. VentdependenT

    VentdependenT You didnt build thaT
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    if your LMA aint worken its because it wasn't placed correctly/wrong size. You can always slap in a proseal and insufflate the cuff big time if need be. just be sure to place the ogt to suck out all the air you'll be pushing in the gut.

    if you think that chest wall compliance is decreased causing you to break seal with PPV then try some sux or blast em with more propofol.

    Remember that you can still provide PPV with LMA but just watch your pressure gauge. Hook ye vent up to pressure control and crank yer rate n' fio2 up to keep those sats above 90. No reason to worry about hypercarbia.

    or you can avoid all of the above and do an "awake" foi. but now I'm way off the subject.
     
  33. adleyinga

    adleyinga Einstein
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    I encounter this attitude all the time-being one of those "attendings". I will use an LMA in above commonly would even do a mask case if ammenable. Only two of us do prone LMAs but for short cases.

    Even worse than fear of LMAs - recently encounters a fellow faculty member would not do a MAC on someone who had coffee 4 hrs previously- some dogma never dissapears.
     
  34. hokie

    hokie Junior Member
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    Check this out (can't say I'm this bold):

    Can J Anaesth. 2001 Dec;48(11):1117-21.
    The laryngeal mask airway is effective (and probably safe) in selected healthy parturients for elective Cesarean section: a prospective study of 1067 cases. Han TH, Brimacombe J, Lee EJ, Yang HS.
    Department of Anesthesiology Samsung Medical Center, SungKyunKwan University School of Medicine, Seoul, Korea.

    PURPOSE: To report on the use of the laryngeal mask airway (LMA) for elective Cesarean section in 1067 consecutive ASA I-II patients preferring general anesthesia. METHODS: Patients were excluded if they had pharyngeal reflux, a pre-pregnancy body mass index >30, or had a known/predicted difficult airway. Patients were fasted for six hours and given ranitidine/sodium citrate. A rapid sequence induction was performed with thiopentone and suxamethonium. The LMA was inserted by experienced users. Anesthesia was maintained with N(2)O and 50% O(2) and a volatile agent. Cricoid pressure was maintained until delivery, but was relaxed if insertion/ventilation was difficult. Patients were intubated if an effective airway was not obtained within 90 sec, or SpO(2) <94%, or end-tidal CO(2) >45 mmHg. Postdelivery, vecuronium and fentanyl were administered. RESULTS: An effective airway was obtained in 1060 (99%) patients, 1051 (98%) at the first attempt and nine (1%) at the second or third attempt. Air leakage or partial airway obstruction occurred in 22 (21%) patients, and seven (0.7%) patients required intubation. There were no episodes of hypoxia (SpO(2) <90%), aspiration, regurgitation, laryngospasm, bronchospasm or gastric insufflation. Surgical conditions were satisfactory and all APGAR scores were >/=7 after five minutes. CONCLUSION: We conclude that the LMA is effective and probably safe for elective Cesarean section in healthy, selected patients when managed by experienced LMA users.

    PMID: 11744589 [PubMed - indexed for MEDLINE]
     
  35. paulzi

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    Hi there,
    My answer comes very late as I only now became aware of this site. LMA in the prone position is a good option...when it is really indicated. Until not very long ago we were afraid of this device used in this position because...we had in fact no idea what to do. The limiting factor, in fact, is that in most of the cases the patien's head was turnes aside so we were concerned of the possible injuries of the brachial plexus in longer procedures. However, if the head/face support allows middle(neutral) head position this is not a problem. Obese people in prone position? Ok, this is a debateble issue, as obesity is a risk factor for regurgitation, so, the LMA should not be used. But otherwise? We live with the impression that an ETT passed between the vocal cords is the safest way to ventilate a prone patient. Why? Because we are the "victims" of the same traditional teaching that is afraid of new things. Take a short search on airway emergency saving procedures in a prone patient and you'll see that in most of the cases the LMA was the best, fastest and most reliable solution. Even in posterior fossa surgery or spine surgery. The prone patient is usually positioned so that the head is slightly angeled down as compared to the thoracal spine. Even if there are secretions, like saliva, they are usually driven down by gravity. Ann, finally, even if there is some aspiration...of what? None would use LMA in non-elective cases, unless in life-saving circumstances. So, what are we talking about? I use the LMA without any problem in laparascopies (cholecyst, hysterectomies), face down short cases, as you mentioned (because in the institution where I work some upper decision persons are not familliar with the method). To the extent of my knowledge no one tried the LMA for, e.g. long spine surgeries, but, in fact, what could be the broblem? I don't see any. Just for your informstion, there are articles describing the insertion of a classic LMA with an NG tube and perfect seal. There is absolutely no problem using NDMR with the LMA. So, in fact, the only difference is that teh LMA is supraglottic. There apperared recently a retrospective study, from Italy, comparing the aspitarion rate while using the ETT and the LMA, over 60000 patients. It seems that the LMA is in a slightly better position. So?
    Good luck and don't be afraid. Read, practice and apply. Othewise you'll be mere copies of your techers.
     
  36. bostonblaz

    bostonblaz ASA Member
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    i use the igel which is almost the same thing as an lma. I do a lot of cases with the igel prone. I put them on their belly and then i induce and put in the igel. if they are npo from home i have no problem putting an lma in. only people i will not is people who have just eaten, and people with known gastroperisis. like mil i use then all the time in pregos, even for c/s.
     

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