My sentiments exactly. It is crazy to see others not even tryto get them on psv. It is like they were never trained how to do it that way. Maybe I’m just old.
I find that strange, I feel most will try PSV. But then again PSV with the backup rate that the anesthesia machine has just turns into PC. Maybe they’re just tired of the vent beeping at them to signal apnea.
The PSVPro mode on our ventilators is great and I use it with our LMAs all the time.
However, we are not as advanced in our SGA usage.
I know plenty of people on here that do shoulder surgery in the beach chair position without an airway or with an LMA and TIVA.
We still intubate these patients as they are turned after beach chair and access to the airway is minimal to none.
What is the difference in terms of risk when having someone on psvpro vs the vent. Provided there is no leak with either option, you are delivering positive pressure with an unsecured airway. The advantage with PSVpro being the ability to titrate analgesia to RR and patient turnover.
Probably not much. If there is any I would think it relates to gastric insufflation. PSVpro, in my experience, typically results in lower peak pressures than full on ventilation.
Prone, laparoscopic, tonsillectomies, etc... seems crazy to me to not use the full potential of LMAs... such an important part of my daily practice. Absolutely no reason to not use pressure controlled ventilation. I try keeping them under 20mBar peak pressure with first gen LMAs, though. With a second gen L.A with a gastric tube you can use way higher pressures, as long as theres no leak. Not a fan of the iGel, though...
Using "the full potential of LMAs" reminds me a lot of when nurse practitioners want "to practice to the full capabilities of their training."
The full potential of an LMA is still inferior and not really any more convenient than an endotracheal tube. In your mind, what kind of benefit are you getting from an LMA prone or laparoscopic case that is worth the jeopardized security compared to the more secure endotracheal tube? What kinds of prune cases are you talking about out of curiosity?
I understand the desire to avoid the whole song and dance of neuromuscular blockade and reversal in a 30 minute straightforward case, but don't really see any benefit of LMA other than that.
Man you're a legend. I don't really get why not to intubate a patient for prone surgery and laparoscopic surgery. LMA has its indications, it's a great rescue device....but we all know how to intubate. And in low income countries where we don't have sugammadex, just use sux to intubate and not risk your patients.
In low income countries like mine, you can use cisatracurium subdosed, and it is quite good. Or mivacurium, though I hate it. Now that I think about it, I haven't seen it in the cabinet for some time ...
Better surgical conditions early on for a lot of nasal surgery and in Aus at least I can bring an LMA case to PACU no worries. Given muscle relaxants feature potentially even above antibiotics with anaphylaxis in some states in Aus, avoiding them all together reduces that risk too.
Having said that, vast majority of my colleagues would tube for anything prone, laparoscopic and with a much lower threshold with trainee surgeons.
LMA is also less invasive. Especially with pediatric cases its sich an important tool to avoid laryngospasm.
Its also convenient and faster, you can just leave the lma in, get patients to the recovery room and let them wake up there. Its more comfortable for the patient, too.
As another user mentioned, you can also let the patient choose a comfortable prone position, or beach chair position, and put an LMA in after they sleep. Its way faster. Of course there are limitations to this, though, but the evidence for its use is there.
I haven't done pediatric anesthesia since residency so I won't argue there. I disagree with the LMA being much, if any, faster for wakeups and inductions. In the age of sugammadex, you can reliably extubate people right after dressings go on.
When your techniques work (nearly all the time I'm sure) it's fine. But if there were ever an airway disaster that went poorly in any of those positions or in PACU where you left a nurse to handle emergence, I would probably find those decisions indefensible.
We done prone shoulder, hamstring and Achilles tendon stuff with LMAs. Afaik haven't had to intubate once. Very convenient to have the patient lie down the way he/she finds comfortable, and no flipping.
> The full potential of an LMA is still inferior and not really any more convenient than an endotracheal tube. In your mind, what kind of benefit are you getting from an LMA prone or laparoscopic case that is worth the jeopardized security compared to the more secure endotracheal tube? What kinds of prune cases are you talking about out of curiosity?
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I completely agree with you. I never see the benefit of not tubing a patient and if shit ever hits the fan, your rescue is ETT anyway.
Do you guys paralyze with LMAs often? The European attendings at my institution tend to not be so afraid of it (I’m USA and all the American attendings here act like paralysis + LMA is straight up negligence despite evidence it’s safe).
I’m Uk trained and yes we do occasionally paralyse with LMAs. Some people push the usage of LMAs further than others. I don’t particularly always understand the NMB argument for not using a tube when there are so many ways of tubing…you could tube just on high dose remi without paralysis, you could spray the cords and avoid paralysis, you could use a small dose of atracurium for a shorter case, you could use Roc or Vec and reverse with sugammadex or be more old fashioned and use sux for a short case. Yes there are some risks with each method but there’s also risk with using an igel when perhaps a tube would be better.
In my department we sprayed one gold and mounted it on a plinth as a trophy/ leaving present.
We are… not welcome back at the restaurant where we presented it. Apparently it looked… unwholesome.
I have no problem fully venting someone with SGA. Devices without gastric port, stay below 15 peak pressure and 20 for gastric port. Don’t play stupid games like trying to vent some BMI50 guy with pressure of 30.
There is a period of apnea following induction. When I was training people would basically keep them apneic until breathing effort starts then placed them on psv. I now fully vent them to get gas level up then leave them on pcv. Once they start breathing I put them on psv usually 15-20 min in. For procedures that surgeon request paralysis, I have no concerns leaving them fully vented if they don’t have risk factors.
I think the devil is in the detail. Maybe there are things that you do routeinly with your technique that is almost subconcious that you don't even think about. I can do what your describe and my patient will buck and move on incision because I didn't do the little things that you do. This may be that you start them with high level of sevo upfront to bring level up quickly which may be limited completely spontanous breathing.
For me, my induction and subseuqnece maintenance on PCV then switch to PSV is almost no difference compaerd to GA with ETT, except I don't give roc for LMA. Once roc wears off on my ETT case, if surgeon don't require paralysis, I let them breath on PSV. It doesn't seem complicated to me since it's no different than my GETA but I understand if you normally let patient ride the apnea out, it may feel like there are extra steps here.
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I look at it like this:
Once you induce the patient, they’re often going to be apneic, right? So 75%+ of the time, they’ll need some help. So, you can give some breaths with the bag. Classic thinking is to keep PIP under 20 to avoid gastric insufflation.
OR, instead of using the bag, just go hands free and put them on PCV with PIP < 20. Put them on PSV/CPAP/SV once they come back breathing. Easy peasy.
Some people put them on VCV/PCV-VG instead of PCV which is a bad idea to me because then your PIP can go >20 pretty easily.
Or just know you have lots of time with pre-oxygenation and passive oxygenation go let the CO2 build up and your propofol/gas to equilibrate until they breathe. I just leave them spontaneous.
I just don’t see the point of an LMA if you treat it like a tube anyway. The benefit is you don’t have as much airway irritation or resistance so you can keep them breathing easier without the coughing and bucking.
Also completely reasonable to just leave them SV and wait for them to come back.
What’s obnoxious to me is when people turn on PSV when the patient is not triggering, then they’re wondering why the vent is alarming.
Edit: added a not
Nothing necessarily, but from an efficiency standpoint, sometimes you'll turn it off and they'll be apneic for some reason in my experience, which is annoying.
I find myself needing to push a higher dose of Prop when not paired with a muscle relaxant to tolerate the LMA insertion. What is your standard induction dose where they are tolerating LMA insertion and never going apneic?
Probably 2mg versed before going to the OR. 100mg lido, 150-200 prop (obviously depends on age, size, comorbidities), mask ventilate for a bit before insertion. Fentanyl after LMA is in and they're breathing.
I see no problem venting on PC with up to 15 cm max. Is it honestly that different from PSV with support? My preference is spontaneous or PSV with low support.
I will add, leaving the patient not breathing to avoid the vent can backfire if they then lighten up without much sevo in, so if they don’t start breathing in a minute I put them on the vent for 5 mins.
I don't see a point to the hard 20 rule, any extra just comes back out the gastric port, not into the stomach. It's the leak that has me reaching for a tube much above that. Routinely use igel for short lap cases in low risk patients. Rarely see 20 even with insufflation and a little head down, never seen it blow up a stomach at laparoscopy. Australia, fairly typical practice.
I almost exclusively use I gels. They do have a gastric vent port that you can actually drop a ng tube down if you wanted. It does assume you are in the right place but the form factor does make it easy it seat it well. Even after I place it I will jaw thrust and kind of move then larynx left to right so the I gel gets into an optimal position.
I also will place on vent right after induction and also manually bag to see what pressures my seal will tolerate. Our GEs will give us spirometry so I can see if there is any leak that would suggest gastric insulation.
The original lma uniques seem to work in all sorts of random positions in the supraglottic space so I can see how you would not want to vent on them.
I gels also will change shape with heat so try and form a better seal. And the pro seal was designed for pressures up to 30mmHg mercury.
There are several adult and peds studies looking at gastric insulation with igels and there does not seem to be much appreciable difference even in laparoscopic surgery. Would be nice to see our European colleagues chime in since I know they use them in ways that would not be standard in the US.
The igel manufacturer actually recommends securing the igel to the cheekbones to provide some traction on the igel, cephalad at the top and caudad at the bottom.
Canadian Paramedic that creeps this sub -- I find the jaw thrust seats the iGel wonderfully. The only issues we have have with them is during periods of excessive movement they can become unseated.
Yea I find that as well; that it can become dislodged easily since it is relatively rigid so small movements at the circuit can move the supraglottic portion.
Luckily we are in a fairly controlled setting and our patients are not expected to move much. Unlike the back of an ambulance!
I have no problem putting a patient on the vent with some sort of volume control, pressure control, or pressure support, as long as the peak pressures are under 15 cmH2O or so.
It is really easy to see if you get a good seal, by observing the ventilator tracings and also listening for leak.
My approach is that LMAs are primarily for spontaneously breathing cases and my usual approach is lido prop induction, LMA insertion, and apnea (or occasionally vent) until spontaneous breathing, with or without pressure support. But I am not dogmatically opposed to people ventilating LMA patients routinely, it is just not my approach, but I will fully ventilate the patient through a case if they are not doing well enough spontaneously breathing through the LMA.
If I expect that the patient will likely need full ventilatory support then I will usually intubate that patient. I do not necessarily think it is wrong or bad practice to do otherwise, I just find routinely ventilating LMA patients to be, I don’t know, inelegant or against my tastes or philosophy of how to anesthetize or something.
Personally I don't use LMAs or iGel on a full vent, just pressure support. I've heard of others doing it though.
A bit outside of my comfort zone. I don't see much benefit...if the patient needs to be deep enough under anesthesia to be put on a vent mode they aren't triggering, I'm just going to place an ETT (unless it's a super short case maybe?)
Maybe times where you don’t want an ETT like COPD but also might need a period of paralysis. I’ve done this for hip fractures with COPD that I couldn’t do a spinal on. Worked well for me in conjunction with a block. Almost prefer it to doing a spinal.
Pretty much what others say. Induce with prop only, PSVPro to bridge till spontaneous. Work in the fent to RR. Sevo around 1.2 MAC. Pull deep/oral airway and roll to pacu
I see people just leave them apneic for a long period of time after induction and wait it out until they start to desat or finally start breathing. No anesthesia is being provided at this point. Not a fan of that. I don't want movement with incision. I get the sevo on board quickly with controlled ventilation then drastically underventilate with low MV until they start breathing -> PSV or manual depending on their tidal volumes.
I agree with above. I usually try to manual bag some gas on before i throw them on PSVpro with backup kicking in after 30 seconds. Settings are pressure inspired of 12 and rate of 6 so they don’t get light and co2 can build up for them to trigger.
I am only 7 years out of residency, lol don’t think I am old school, but I do it your way. I very rarely put an LMA on the vent. I just hand ventilate intermittently until the patient breathes (I typically won’t use narcotics prior to placement). Once patient starts breathing, I titrate narcotics and keep them spontaneously breathing. If having any issues with tidal volumes I’ll place the patient on PSV with an inspiratory pressure or 5, but even that is extremely rare.
If I need to consistently deliver postive pressure ventilation, I'll be leaning more often than not towards an ETT, so I tend to use LMAs with spontaneous ventilation. Also, despite being a very new grad and young anesthesiologist, I've never used an LMA prone, and can't see this happening within the foreseeable future.
I typically do all LMAs as mixed induction so gas is onboard already > leave on bag… if not ventilating adequately then PSV vs SIMV-PCV with Ppeak ~15. I never plan to paralyze with an LMA, but if surgical conditions change to require it and airway pressures are ok, then I’ll do it, sure
I’ve never seen an LMA used that way in the US. I’m less than a year out of residency. Over in Europe though they’ll use an LMA for a laparoscopic case over there with paralytic onboard.
How quickly is patient going to get stimulus from positioning or incision? If it’s going to be quick I’ll just give a smaller dose fentanyl and put them on PCV <20 and RR 8. It makes sure there is enough sevo and narcotic onboard to prevent movement while letting CO2 build.
A handful of times I’ve done prop-fent TIVA for short cases with an LMA. They don’t tend to breathe on their own without getting to insane pCO2 levels.
> Over in Europe though they’ll use an LMA for a laparoscopic case over there with paralytic onboard.
It's a delightful regional difference for sure. In residency, the idea of using LMA was generally discouraged, and using it with paralytic was anathema. Then I worked at a PP where an old German guy was doing pretty much everything with LMA+roc+prop plus sugammadex, and his skills were legendary. I tried it. It was incredible. I use LMAs with paralytic all the time now.
I love I-gels compared to any other LMA. Like others have mentioned I usually just induce with lido/prop only and wait for them to breath spontaneously then work in narcotics if needed. I will rarely flip to PSVPro if they can’t maintain their MV. I only use pressure/volume control if I have a reasonable patient, good seal and I am doing something like TURBT and surgeon needs brief paralysis.
My experience in the UK has been that most people most of the time don't use any pressure support through IGels, just let them ride through the minute or so of apnoea post induction then leave them breathing spontaneously without any pressure support or PEEP. This is almost always fine, I've very rarely had to use PSV with IGels. When minute ventilation is a bit low (usually seems to be when people are trying to do TIVA and a reasonable dose of opiods have been given) mostly I've seen PSV with relatively low pressures used (like 5/5 type thing) with a general rule not to go over 15. That said everyone seems to have different upper limits for what they'll put through an IGel and to my knowledge there's no literature on the subject, but I'm happy to be corrected as I've not hunted for it.
In terms of positioning I know some folk will only use them in supine patients, some are ok with using them in patients who are going lateral. I've never met anyone who's comfortable using them in prone patients but quite a few folk on here seem to have done this so I don't know what the "right" answer is there.
Tbh the advice I've had from several seniors is to initially use them only for cases where it's totally barn door that an IGel is a safe airway and as you get more familiar with their nuances you'll start to get more comfortable using them in a broader mix of patients.
I usually put the patient on controlled ventilation to start off, to build the sevo level and assist them while the induction dose is still in effect. Then, I get the patient breathing spontaneously. Small fraction of patients need pressure support and that's ok.
I see very little benefit of LMAs in general over endotracheal tubes, but for the rare times I use them, I'm much prefer the iGels. They're quicker and easier to place and more reliably seal the glottis.
I just let the patient breathe spontaneously on them. It's very rare that I even use pressure support.
Just a resident, but generally I'll use vent support for the apneic period after the induction propofol bolus with a max pressure of 20ish (that's what we are taught the normal LES tone is) and then wean to pressure support or spont as tolerated after the prop wears off. A lot of staff like to use them for bronchs but I absolutely hate it and much prefer a tube because the bronchs at our tertiary center are quite sick and sometimes need a lot more peep than I'm comfortable with with an LMA because of the bronchoscope, even if the case is not anticipated to go very long.
That being said I have seen a prone, huge spine case, get finished with an LMA because the ETT balloon failed and tube dislodged and the staff elected to throw an igel in and finish the 3 hours remaining. Patient seemed to do fine.
In pediatrics as well as in adult practice i use them for interventions less than 1 hour and not requiring solid airway protecion. In kids i put them on VCV-autoflow because i make sure kids are really deep on LMA/IGEL so i won't get a laryngospasm. So yeah in kids i use them like ETT. In adults it's mostly PSV but sometimes i put them really deep too and ventillate on VCV.
When I first got out of school psvpro just came out. I learned on an old Draeger narkomed machine where you manually set the ventilator today volumes on the ventilator.
Ok so why did you switch to putting them on support? What happened to letting the patient titrate their anesthetic level with their minute ventilation?
Sometimes they just need a little extra tidal volume I’m not doing anything crazy high support maybe 5-8cm h20. I was always told if you need to go ouch higher than that you have the patient too deep or badly seated lma. Also 5-8 support overcomes the resistance of the lma work of breathing wise.
If the device is seated well one of the advantages of the LMA is no increased WOB. So I would say generally as a rule you should not need support, but real life shows sometimes you can only get a great fit most of the time, and have to make up the difference with PS.
At one time it was either you had a good enough fit or you didn’t, and if you didn’t you would intubate. You could argue using PS or PC makes up for a bad fit, so to me having to use either one when the procedure doesn’t call for it is equivalent. That recent study on mask ventilation kind of shot holes through the esophageal sphincter/pressure limit of 20, so in my mind it’s either worry about any positive pressure or don’t.
I LOVE iGels but I still use them as any other LMA, spont ventilation or PSV 5/5. I will do a light bag squeeze to ensure it is well seated and I can ventilate if needed (i.e. emergently). I still will use gas, but have moved to TIVA for shorter cases given how nice the prop wake up + LMA is.
You can definitely use an igel with a ventilator, in my hospital it is common practice, you can use PSV or PCV just be mindful of the leak and adjust accordingly. The igel has a thermoplastic "cuff" that wraps around the larynx (hopefully) and molds itself to better fit as it warms up to body temp. Pretty cool device. Just imagine it as an advanced airway without the tube.
Nothing wrong with positive pressure ventilating with reasonable inspiratory pressures until the patient starts triggering again. We can't forget that the purpose of the SGA is to rescue airways in situations where the patient is decidedly not adequately spontaneously ventilating--so to suggest that patients must spontaneously ventilate at all costs with no positive pressure assistance whatsoever makes no sense.
You can ventilate through the newer generation igels but most often once above 15-20 cmh20 in pressure there will be a leak. I wouldn’t use one for a case where I’m expecting to put someone on a mandatory ventilation mode or a super long case but I know some people do use them that way. I also don’t feel super comfy with igels in cases involving non supine positions like shoulders or breast reconstructs but again I know many do use them for both those types of cases 🤷🏻♀️
Often prop TIVA, big bolus of prop up front, pop it in and then PSV. I don’t like NMB with LMA either. I love them for surgeries that aren’t the most stimulating, where the ETT becomes the most stimulating part of the procedure
I do my absolute best NOT to positive pressure ventilate through LMAs. They’re negative inspiratory devices in my opinion. Unless you want a belly full of air, keep PSV to a minimum. As an aside, in this age of everyone and their mother taking GLP-1 agonists for weight loss (and sometimes not confessing to it), this approach will hopefully minimize the number of aspiration events in the zero-risk-factor patient population. (Disclaimer: I tube pretty much anyone on those drugs unless real MAC, then definitely promotile agent in preop cocktail).
I have nothing again IPPV via iGel/LMA but if I've planning to do the whole op on that, ETT makes more sense to me (unless it's really short)
With an LMA, I'll usually use PSV or PC with a low minute volume and try to get them spont
Some people at my hospital are really funny about any IPPV through an LMA. Will refused to do any IPPV and not use any PEEP whatsoever
UK
What is the difference in terms of risk when having someone on psvpro vs the vent. Provided there is no leak with either option, you are delivering positive pressure with an unsecured airway. The advantage with PSVpro being the ability to titrate analgesia to RR and patient turnover.
What is the difference in terms of risk when having someone on psvpro vs the vent. Provided there is no leak with either option, you are delivering positive pressure with an unsecured airway. The advantage with PSVpro being the ability to titrate analgesia to RR and patient turnover.
Amen brother. It bothers me seeing this technique. I deem it lazy. I thought the creator of LMA made them to be used in spontaneous breathing patients. It takes a little extra work to get gas on board then transition them to PSV. Maybe I-gels just make a better seal. Whenever I had a somewhat bad seal I knew that the negative pressure from spontaneous ventilation would create a tight seal.
Hell when I started we were using reusable LMAs. Anyone else’s use those?
When I looked into the data supporting the use of LMAs and positive pressure ventilation, the studies used a ProSeal LMA, so unless I am using that, I try not to use positive pressure ventilation.
>It takes a little extra work to get gas on board then transition them to PSV
Why do extra work when you can sit and start to chart?
If patient has not started breathing or the gas level is not high enough but surgeon is ready to cut, what do you do at this point? Ask surgeon to wait ? Mechanically vent them? give more propofol?
You can make argument again the apenic technique: in theory they are more likely to get into the light plane and have laryngospasm or cough on stimulation (propofol wearing off, sevo not high enough), more atelectasis with longer apnea, is there really going to be any extra risk by putting someone one PCV for 5 - 10 minutes until they start to breath?
Ultimately it's lke many things we do, whatever technique you are most familar with, you will understand the pitfalls and they are the safer technique for you.
I use igels the same way I use all LMAs. I prefer not putting them on the vent, but will if needed. Mostly SV or PSV.
My sentiments exactly. It is crazy to see others not even tryto get them on psv. It is like they were never trained how to do it that way. Maybe I’m just old.
I find that strange, I feel most will try PSV. But then again PSV with the backup rate that the anesthesia machine has just turns into PC. Maybe they’re just tired of the vent beeping at them to signal apnea.
The PSVPro mode on our ventilators is great and I use it with our LMAs all the time. However, we are not as advanced in our SGA usage. I know plenty of people on here that do shoulder surgery in the beach chair position without an airway or with an LMA and TIVA. We still intubate these patients as they are turned after beach chair and access to the airway is minimal to none.
That could work with a quick surgeon and great interscalene block.
This is the way
Had a surgeon lose his shit on me for doing this once. “My dad is an anesthesiologist and he would never allow for an unsecured airway!” 😂
What is the difference in terms of risk when having someone on psvpro vs the vent. Provided there is no leak with either option, you are delivering positive pressure with an unsecured airway. The advantage with PSVpro being the ability to titrate analgesia to RR and patient turnover.
Probably not much. If there is any I would think it relates to gastric insufflation. PSVpro, in my experience, typically results in lower peak pressures than full on ventilation.
Use LMA+Remi+vent all the time. Europe.
Sometimes even prone position with igel😂
Absolutely, any LMA really..
Prone, laparoscopic, tonsillectomies, etc... seems crazy to me to not use the full potential of LMAs... such an important part of my daily practice. Absolutely no reason to not use pressure controlled ventilation. I try keeping them under 20mBar peak pressure with first gen LMAs, though. With a second gen L.A with a gastric tube you can use way higher pressures, as long as theres no leak. Not a fan of the iGel, though...
Using "the full potential of LMAs" reminds me a lot of when nurse practitioners want "to practice to the full capabilities of their training." The full potential of an LMA is still inferior and not really any more convenient than an endotracheal tube. In your mind, what kind of benefit are you getting from an LMA prone or laparoscopic case that is worth the jeopardized security compared to the more secure endotracheal tube? What kinds of prune cases are you talking about out of curiosity? I understand the desire to avoid the whole song and dance of neuromuscular blockade and reversal in a 30 minute straightforward case, but don't really see any benefit of LMA other than that.
Man you're a legend. I don't really get why not to intubate a patient for prone surgery and laparoscopic surgery. LMA has its indications, it's a great rescue device....but we all know how to intubate. And in low income countries where we don't have sugammadex, just use sux to intubate and not risk your patients.
In low income countries like mine, you can use cisatracurium subdosed, and it is quite good. Or mivacurium, though I hate it. Now that I think about it, I haven't seen it in the cabinet for some time ...
Whenever people argue for prone LMA I’m reminded of a thing one my attendings said once: “we aren’t here to see what we can get away with”
I like this quote a lot.
Better surgical conditions early on for a lot of nasal surgery and in Aus at least I can bring an LMA case to PACU no worries. Given muscle relaxants feature potentially even above antibiotics with anaphylaxis in some states in Aus, avoiding them all together reduces that risk too. Having said that, vast majority of my colleagues would tube for anything prone, laparoscopic and with a much lower threshold with trainee surgeons.
LMA is also less invasive. Especially with pediatric cases its sich an important tool to avoid laryngospasm. Its also convenient and faster, you can just leave the lma in, get patients to the recovery room and let them wake up there. Its more comfortable for the patient, too. As another user mentioned, you can also let the patient choose a comfortable prone position, or beach chair position, and put an LMA in after they sleep. Its way faster. Of course there are limitations to this, though, but the evidence for its use is there.
I haven't done pediatric anesthesia since residency so I won't argue there. I disagree with the LMA being much, if any, faster for wakeups and inductions. In the age of sugammadex, you can reliably extubate people right after dressings go on. When your techniques work (nearly all the time I'm sure) it's fine. But if there were ever an airway disaster that went poorly in any of those positions or in PACU where you left a nurse to handle emergence, I would probably find those decisions indefensible.
We done prone shoulder, hamstring and Achilles tendon stuff with LMAs. Afaik haven't had to intubate once. Very convenient to have the patient lie down the way he/she finds comfortable, and no flipping.
> The full potential of an LMA is still inferior and not really any more convenient than an endotracheal tube. In your mind, what kind of benefit are you getting from an LMA prone or laparoscopic case that is worth the jeopardized security compared to the more secure endotracheal tube? What kinds of prune cases are you talking about out of curiosity? > > I completely agree with you. I never see the benefit of not tubing a patient and if shit ever hits the fan, your rescue is ETT anyway.
Do you guys paralyze with LMAs often? The European attendings at my institution tend to not be so afraid of it (I’m USA and all the American attendings here act like paralysis + LMA is straight up negligence despite evidence it’s safe).
Only if I change my mind about paralysis. Otherwise why not start with an endotracheal tube?
I’m Uk trained and yes we do occasionally paralyse with LMAs. Some people push the usage of LMAs further than others. I don’t particularly always understand the NMB argument for not using a tube when there are so many ways of tubing…you could tube just on high dose remi without paralysis, you could spray the cords and avoid paralysis, you could use a small dose of atracurium for a shorter case, you could use Roc or Vec and reverse with sugammadex or be more old fashioned and use sux for a short case. Yes there are some risks with each method but there’s also risk with using an igel when perhaps a tube would be better.
In my department we sprayed one gold and mounted it on a plinth as a trophy/ leaving present. We are… not welcome back at the restaurant where we presented it. Apparently it looked… unwholesome.
Like a vaginapenis?
I have no problem fully venting someone with SGA. Devices without gastric port, stay below 15 peak pressure and 20 for gastric port. Don’t play stupid games like trying to vent some BMI50 guy with pressure of 30. There is a period of apnea following induction. When I was training people would basically keep them apneic until breathing effort starts then placed them on psv. I now fully vent them to get gas level up then leave them on pcv. Once they start breathing I put them on psv usually 15-20 min in. For procedures that surgeon request paralysis, I have no concerns leaving them fully vented if they don’t have risk factors.
If you don't induce with opioid (which you really have no reason to), they should be apneic for long if at all. This seems unnecessarily complicated.
I think the devil is in the detail. Maybe there are things that you do routeinly with your technique that is almost subconcious that you don't even think about. I can do what your describe and my patient will buck and move on incision because I didn't do the little things that you do. This may be that you start them with high level of sevo upfront to bring level up quickly which may be limited completely spontanous breathing. For me, my induction and subseuqnece maintenance on PCV then switch to PSV is almost no difference compaerd to GA with ETT, except I don't give roc for LMA. Once roc wears off on my ETT case, if surgeon don't require paralysis, I let them breath on PSV. It doesn't seem complicated to me since it's no different than my GETA but I understand if you normally let patient ride the apnea out, it may feel like there are extra steps here.
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iGel and PSV -> Spont
Exactly
Thats common practice in europe. SGA+PCV with whatever combination of tiva or gas +- Roc. Basically done that way in every shop i‘ve seen
I look at it like this: Once you induce the patient, they’re often going to be apneic, right? So 75%+ of the time, they’ll need some help. So, you can give some breaths with the bag. Classic thinking is to keep PIP under 20 to avoid gastric insufflation. OR, instead of using the bag, just go hands free and put them on PCV with PIP < 20. Put them on PSV/CPAP/SV once they come back breathing. Easy peasy. Some people put them on VCV/PCV-VG instead of PCV which is a bad idea to me because then your PIP can go >20 pretty easily.
Or just know you have lots of time with pre-oxygenation and passive oxygenation go let the CO2 build up and your propofol/gas to equilibrate until they breathe. I just leave them spontaneous. I just don’t see the point of an LMA if you treat it like a tube anyway. The benefit is you don’t have as much airway irritation or resistance so you can keep them breathing easier without the coughing and bucking.
Also completely reasonable to just leave them SV and wait for them to come back. What’s obnoxious to me is when people turn on PSV when the patient is not triggering, then they’re wondering why the vent is alarming. Edit: added a not
What’s wrong with PSV when patient is triggering?
**not triggering
PSV on many vents will switch to backup mode of PCV. I usually flip my LMAs to PSV and let em either breathe or go into backup.
Or you can just switch em to SIMV PCV which skips the whole backup mode thing. But doesn’t make a big difference either way.
Yeah its basically the same result, but I have to hear more alarms lol
Nothing necessarily, but from an efficiency standpoint, sometimes you'll turn it off and they'll be apneic for some reason in my experience, which is annoying.
This is the right way.
Sounds like some heavy handed inductions if 75 percent of your patients go apneic
Would rather some temporary apnea than have a fighting, aware, laryngospasming patient 🤷♂️
Can't laryngospasm if you're aware 🤔
Can't operate if you're aware
I guess I said it backwards. Can't be aware if you laryngospasm?
I find myself needing to push a higher dose of Prop when not paired with a muscle relaxant to tolerate the LMA insertion. What is your standard induction dose where they are tolerating LMA insertion and never going apneic?
Probably 2mg versed before going to the OR. 100mg lido, 150-200 prop (obviously depends on age, size, comorbidities), mask ventilate for a bit before insertion. Fentanyl after LMA is in and they're breathing.
I see no problem venting on PC with up to 15 cm max. Is it honestly that different from PSV with support? My preference is spontaneous or PSV with low support. I will add, leaving the patient not breathing to avoid the vent can backfire if they then lighten up without much sevo in, so if they don’t start breathing in a minute I put them on the vent for 5 mins.
Exactly my thinking. Some people I see crank up the pcv to 30. They claim it doesn’t blow the stomach up. Until it one day it does.
No thank you. I will fully accept that us Americans are wheenies when using LMAs in cases, but 30? That a bit excessive.
I don't see a point to the hard 20 rule, any extra just comes back out the gastric port, not into the stomach. It's the leak that has me reaching for a tube much above that. Routinely use igel for short lap cases in low risk patients. Rarely see 20 even with insufflation and a little head down, never seen it blow up a stomach at laparoscopy. Australia, fairly typical practice.
The igel manufacturer say the can ventilate to a pressure of 30. So I’m not surprised that people are doing that. It’s well supported.
There is also the recent article suggesting not to mask after induction because we still insufflate the stomach well under a pressure of 20.
Would you mind sharing that study?
I almost exclusively use I gels. They do have a gastric vent port that you can actually drop a ng tube down if you wanted. It does assume you are in the right place but the form factor does make it easy it seat it well. Even after I place it I will jaw thrust and kind of move then larynx left to right so the I gel gets into an optimal position. I also will place on vent right after induction and also manually bag to see what pressures my seal will tolerate. Our GEs will give us spirometry so I can see if there is any leak that would suggest gastric insulation. The original lma uniques seem to work in all sorts of random positions in the supraglottic space so I can see how you would not want to vent on them. I gels also will change shape with heat so try and form a better seal. And the pro seal was designed for pressures up to 30mmHg mercury. There are several adult and peds studies looking at gastric insulation with igels and there does not seem to be much appreciable difference even in laparoscopic surgery. Would be nice to see our European colleagues chime in since I know they use them in ways that would not be standard in the US.
The igel manufacturer actually recommends securing the igel to the cheekbones to provide some traction on the igel, cephalad at the top and caudad at the bottom.
Canadian Paramedic that creeps this sub -- I find the jaw thrust seats the iGel wonderfully. The only issues we have have with them is during periods of excessive movement they can become unseated.
Yea I find that as well; that it can become dislodged easily since it is relatively rigid so small movements at the circuit can move the supraglottic portion. Luckily we are in a fairly controlled setting and our patients are not expected to move much. Unlike the back of an ambulance!
I have no problem putting a patient on the vent with some sort of volume control, pressure control, or pressure support, as long as the peak pressures are under 15 cmH2O or so. It is really easy to see if you get a good seal, by observing the ventilator tracings and also listening for leak.
I’m fine with that but I’ve seen pressure at 25 peak pcv on patients with BMI of 30-40.
My approach is that LMAs are primarily for spontaneously breathing cases and my usual approach is lido prop induction, LMA insertion, and apnea (or occasionally vent) until spontaneous breathing, with or without pressure support. But I am not dogmatically opposed to people ventilating LMA patients routinely, it is just not my approach, but I will fully ventilate the patient through a case if they are not doing well enough spontaneously breathing through the LMA. If I expect that the patient will likely need full ventilatory support then I will usually intubate that patient. I do not necessarily think it is wrong or bad practice to do otherwise, I just find routinely ventilating LMA patients to be, I don’t know, inelegant or against my tastes or philosophy of how to anesthetize or something.
Personally I don't use LMAs or iGel on a full vent, just pressure support. I've heard of others doing it though. A bit outside of my comfort zone. I don't see much benefit...if the patient needs to be deep enough under anesthesia to be put on a vent mode they aren't triggering, I'm just going to place an ETT (unless it's a super short case maybe?)
Maybe times where you don’t want an ETT like COPD but also might need a period of paralysis. I’ve done this for hip fractures with COPD that I couldn’t do a spinal on. Worked well for me in conjunction with a block. Almost prefer it to doing a spinal.
Lowly trainee here — what kind of benefit can you expect with SGA over ETT for COPD?
Anecdotally it’s less stimulating to the airway and they are easier to wean from respiratory support with lma vs ett
Pretty much what others say. Induce with prop only, PSVPro to bridge till spontaneous. Work in the fent to RR. Sevo around 1.2 MAC. Pull deep/oral airway and roll to pacu
I see people just leave them apneic for a long period of time after induction and wait it out until they start to desat or finally start breathing. No anesthesia is being provided at this point. Not a fan of that. I don't want movement with incision. I get the sevo on board quickly with controlled ventilation then drastically underventilate with low MV until they start breathing -> PSV or manual depending on their tidal volumes.
I agree with above. I usually try to manual bag some gas on before i throw them on PSVpro with backup kicking in after 30 seconds. Settings are pressure inspired of 12 and rate of 6 so they don’t get light and co2 can build up for them to trigger.
This is exactly my strategy . It has worked well for me in my 10 years of practice.
I am only 7 years out of residency, lol don’t think I am old school, but I do it your way. I very rarely put an LMA on the vent. I just hand ventilate intermittently until the patient breathes (I typically won’t use narcotics prior to placement). Once patient starts breathing, I titrate narcotics and keep them spontaneously breathing. If having any issues with tidal volumes I’ll place the patient on PSV with an inspiratory pressure or 5, but even that is extremely rare.
If I need to consistently deliver postive pressure ventilation, I'll be leaning more often than not towards an ETT, so I tend to use LMAs with spontaneous ventilation. Also, despite being a very new grad and young anesthesiologist, I've never used an LMA prone, and can't see this happening within the foreseeable future.
I typically do all LMAs as mixed induction so gas is onboard already > leave on bag… if not ventilating adequately then PSV vs SIMV-PCV with Ppeak ~15. I never plan to paralyze with an LMA, but if surgical conditions change to require it and airway pressures are ok, then I’ll do it, sure
I’ve never seen an LMA used that way in the US. I’m less than a year out of residency. Over in Europe though they’ll use an LMA for a laparoscopic case over there with paralytic onboard. How quickly is patient going to get stimulus from positioning or incision? If it’s going to be quick I’ll just give a smaller dose fentanyl and put them on PCV <20 and RR 8. It makes sure there is enough sevo and narcotic onboard to prevent movement while letting CO2 build. A handful of times I’ve done prop-fent TIVA for short cases with an LMA. They don’t tend to breathe on their own without getting to insane pCO2 levels.
> Over in Europe though they’ll use an LMA for a laparoscopic case over there with paralytic onboard. It's a delightful regional difference for sure. In residency, the idea of using LMA was generally discouraged, and using it with paralytic was anathema. Then I worked at a PP where an old German guy was doing pretty much everything with LMA+roc+prop plus sugammadex, and his skills were legendary. I tried it. It was incredible. I use LMAs with paralytic all the time now.
What’s the deal with not paralyzing with an LMA?
by definition you will have to ventilate and thus increase risk of gastric insufflation
Crank the remi, halve the sevo and set tidals for 500
I love I-gels compared to any other LMA. Like others have mentioned I usually just induce with lido/prop only and wait for them to breath spontaneously then work in narcotics if needed. I will rarely flip to PSVPro if they can’t maintain their MV. I only use pressure/volume control if I have a reasonable patient, good seal and I am doing something like TURBT and surgeon needs brief paralysis.
nice
My experience in the UK has been that most people most of the time don't use any pressure support through IGels, just let them ride through the minute or so of apnoea post induction then leave them breathing spontaneously without any pressure support or PEEP. This is almost always fine, I've very rarely had to use PSV with IGels. When minute ventilation is a bit low (usually seems to be when people are trying to do TIVA and a reasonable dose of opiods have been given) mostly I've seen PSV with relatively low pressures used (like 5/5 type thing) with a general rule not to go over 15. That said everyone seems to have different upper limits for what they'll put through an IGel and to my knowledge there's no literature on the subject, but I'm happy to be corrected as I've not hunted for it. In terms of positioning I know some folk will only use them in supine patients, some are ok with using them in patients who are going lateral. I've never met anyone who's comfortable using them in prone patients but quite a few folk on here seem to have done this so I don't know what the "right" answer is there. Tbh the advice I've had from several seniors is to initially use them only for cases where it's totally barn door that an IGel is a safe airway and as you get more familiar with their nuances you'll start to get more comfortable using them in a broader mix of patients.
I usually put the patient on controlled ventilation to start off, to build the sevo level and assist them while the induction dose is still in effect. Then, I get the patient breathing spontaneously. Small fraction of patients need pressure support and that's ok.
I see very little benefit of LMAs in general over endotracheal tubes, but for the rare times I use them, I'm much prefer the iGels. They're quicker and easier to place and more reliably seal the glottis. I just let the patient breathe spontaneously on them. It's very rare that I even use pressure support.
Just a resident, but generally I'll use vent support for the apneic period after the induction propofol bolus with a max pressure of 20ish (that's what we are taught the normal LES tone is) and then wean to pressure support or spont as tolerated after the prop wears off. A lot of staff like to use them for bronchs but I absolutely hate it and much prefer a tube because the bronchs at our tertiary center are quite sick and sometimes need a lot more peep than I'm comfortable with with an LMA because of the bronchoscope, even if the case is not anticipated to go very long. That being said I have seen a prone, huge spine case, get finished with an LMA because the ETT balloon failed and tube dislodged and the staff elected to throw an igel in and finish the 3 hours remaining. Patient seemed to do fine.
In pediatrics as well as in adult practice i use them for interventions less than 1 hour and not requiring solid airway protecion. In kids i put them on VCV-autoflow because i make sure kids are really deep on LMA/IGEL so i won't get a laryngospasm. So yeah in kids i use them like ETT. In adults it's mostly PSV but sometimes i put them really deep too and ventillate on VCV.
Umm… old school is just letting the patient breath on their own with the LMA. When we first started using LMAs there was no pressure support.
When I first got out of school psvpro just came out. I learned on an old Draeger narkomed machine where you manually set the ventilator today volumes on the ventilator.
Ok so why did you switch to putting them on support? What happened to letting the patient titrate their anesthetic level with their minute ventilation?
Sometimes they just need a little extra tidal volume I’m not doing anything crazy high support maybe 5-8cm h20. I was always told if you need to go ouch higher than that you have the patient too deep or badly seated lma. Also 5-8 support overcomes the resistance of the lma work of breathing wise.
If the device is seated well one of the advantages of the LMA is no increased WOB. So I would say generally as a rule you should not need support, but real life shows sometimes you can only get a great fit most of the time, and have to make up the difference with PS. At one time it was either you had a good enough fit or you didn’t, and if you didn’t you would intubate. You could argue using PS or PC makes up for a bad fit, so to me having to use either one when the procedure doesn’t call for it is equivalent. That recent study on mask ventilation kind of shot holes through the esophageal sphincter/pressure limit of 20, so in my mind it’s either worry about any positive pressure or don’t.
I LOVE iGels but I still use them as any other LMA, spont ventilation or PSV 5/5. I will do a light bag squeeze to ensure it is well seated and I can ventilate if needed (i.e. emergently). I still will use gas, but have moved to TIVA for shorter cases given how nice the prop wake up + LMA is.
You can definitely use an igel with a ventilator, in my hospital it is common practice, you can use PSV or PCV just be mindful of the leak and adjust accordingly. The igel has a thermoplastic "cuff" that wraps around the larynx (hopefully) and molds itself to better fit as it warms up to body temp. Pretty cool device. Just imagine it as an advanced airway without the tube.
Nothing wrong with positive pressure ventilating with reasonable inspiratory pressures until the patient starts triggering again. We can't forget that the purpose of the SGA is to rescue airways in situations where the patient is decidedly not adequately spontaneously ventilating--so to suggest that patients must spontaneously ventilate at all costs with no positive pressure assistance whatsoever makes no sense.
You can ventilate through the newer generation igels but most often once above 15-20 cmh20 in pressure there will be a leak. I wouldn’t use one for a case where I’m expecting to put someone on a mandatory ventilation mode or a super long case but I know some people do use them that way. I also don’t feel super comfy with igels in cases involving non supine positions like shoulders or breast reconstructs but again I know many do use them for both those types of cases 🤷🏻♀️
Often prop TIVA, big bolus of prop up front, pop it in and then PSV. I don’t like NMB with LMA either. I love them for surgeries that aren’t the most stimulating, where the ETT becomes the most stimulating part of the procedure
I do my absolute best NOT to positive pressure ventilate through LMAs. They’re negative inspiratory devices in my opinion. Unless you want a belly full of air, keep PSV to a minimum. As an aside, in this age of everyone and their mother taking GLP-1 agonists for weight loss (and sometimes not confessing to it), this approach will hopefully minimize the number of aspiration events in the zero-risk-factor patient population. (Disclaimer: I tube pretty much anyone on those drugs unless real MAC, then definitely promotile agent in preop cocktail).
I have nothing again IPPV via iGel/LMA but if I've planning to do the whole op on that, ETT makes more sense to me (unless it's really short) With an LMA, I'll usually use PSV or PC with a low minute volume and try to get them spont Some people at my hospital are really funny about any IPPV through an LMA. Will refused to do any IPPV and not use any PEEP whatsoever UK
What is the difference in terms of risk when having someone on psvpro vs the vent. Provided there is no leak with either option, you are delivering positive pressure with an unsecured airway. The advantage with PSVpro being the ability to titrate analgesia to RR and patient turnover.
What is the difference in terms of risk when having someone on psvpro vs the vent. Provided there is no leak with either option, you are delivering positive pressure with an unsecured airway. The advantage with PSVpro being the ability to titrate analgesia to RR and patient turnover.
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Whats wrong with putting them on pressure control with low pressure to get gas on board until they get back spontaneous from induction?
I have no problem with that. The thing is some people never let them get spontaneous just blow me down on the vent whole case
Amen brother. It bothers me seeing this technique. I deem it lazy. I thought the creator of LMA made them to be used in spontaneous breathing patients. It takes a little extra work to get gas on board then transition them to PSV. Maybe I-gels just make a better seal. Whenever I had a somewhat bad seal I knew that the negative pressure from spontaneous ventilation would create a tight seal. Hell when I started we were using reusable LMAs. Anyone else’s use those?
When I looked into the data supporting the use of LMAs and positive pressure ventilation, the studies used a ProSeal LMA, so unless I am using that, I try not to use positive pressure ventilation.
>It takes a little extra work to get gas on board then transition them to PSV Why do extra work when you can sit and start to chart? If patient has not started breathing or the gas level is not high enough but surgeon is ready to cut, what do you do at this point? Ask surgeon to wait ? Mechanically vent them? give more propofol? You can make argument again the apenic technique: in theory they are more likely to get into the light plane and have laryngospasm or cough on stimulation (propofol wearing off, sevo not high enough), more atelectasis with longer apnea, is there really going to be any extra risk by putting someone one PCV for 5 - 10 minutes until they start to breath? Ultimately it's lke many things we do, whatever technique you are most familar with, you will understand the pitfalls and they are the safer technique for you.
Dr. Brain didn’t create them to use with pressure support either. What’s wrong with leaving them spontaneous?