Is it possible to titrate paralytics?

gaspassah · Aug 3, 2004

i can appreciate the lma as an alternative airway, hoever could you clarify

something for me gotosleepy....

in fact, i had two silent aspirations in no-risk factor young patients (both were okay after all), but still LMA isn't perfect.

if you had 2 silent aspirations in no risk patients *that you know of* why would you use one in a population that most literature says you should use an oett on? if i understand you correctly. like c sections done in europe....we're taught all pregnant mothers after (i think) 16 weeks are concidered full stomachs, but if you yourself had 2 silent aspirations in no risk pop, doesnt that sorta say it shouldnt be done?

secondly, lma wont provide protection against a laryngospam, and if a bronchospasm is severe enough can you generate enough positive pressure to ventilate the patient enough to deepen the anesthetic or to deliver aerosolized bronchodilators?

i'm not being sarcastic, just seeking more knowledge.

d

Gotosleepy · Aug 3, 2004

the reason i still use lmas despite my 2 silent aspirations is based on scientific grounds (ie: literature based).... just because i have 2 adverse reactions with a device doesn't mean i shouldn't use it anymore (imagine if you had 2 carotid sticks with central line placement, that wouldn't stop you from doing IJs instead of subclavians)... of course it has definitely made me far more cautious, and if i can think of a sound argument for an ETT i will usually use an ETT instead.

actually LMAs in the pediatric population has a lower incidence of laryngospasm and bronchospasm than with ETT :) however, should laryngospasm occur the LMA is just as good as a mask airway to provide positive pressure - as we both agree that laryngospasm is impossible with an ETT

if a pt w/ LMA goes into laryngospasm - which isn't rare, as it just takes an overzealous surgeon to stimulate your patient while they still aren't deep enough, all i do is give a bolus of propofol or even better a small dose of succinylcholine (or mivacurium)....

if a pt w/ LMA goes into bronchospasm that is severe enough, then the right moves include switching to an ETT, bronchodilators, or even better a small dose of epinephrine IV.

athomas91 · Aug 3, 2004

i see both sides of the argument....

i will give my 2 cents...

when that patient aspirates and the attorney for the patient says.....so you took their control of their airway away from them and then didn't secure it in the most secure way you have.......why is that???

i know LMA's have their place - i just feel that I have a responsibility to protect the airway when i have rendered someone unable to do so....and LMA's even when placed properly still do not protect the airway as does an ETT.

Gotosleepy · Aug 3, 2004

athomas...

what is the incidence of aspiration with general anesthesia, what is the incidence of aspiration for LMAs and for ETT.... you'd be surprised by what you find...

athomas91 · Aug 3, 2004

i know the stats...

the incidence of aspiration (signifigant) is between 1-7 per 10,000 patients

it is 20-30% of all anesthesia related deaths....

that is not my point - aspiration can obviously happen with any patient....but it is my point that an ETT is a better protector of the airway. A combitube is a better protector of the airway. I just have a problem with NOT using the best method of protection for my patients...

and by the way - outpts are at a signifigantly higher risk than their inpatient counterparts as they have proven in multiple studies to have a higher gastric volume and lower gastric pH even when guidelines (published in 1999) are instituted. These are the people we are using LMA's on.

deepz · Aug 3, 2004

Brits also have been known to use LMAs for patients whose surgery is performed in the prone position.

deepz

jwk · Aug 3, 2004

Brits also have been known to use LMAs for patients whose surgery is performed in the prone position.
deepz

Yet another way to get sued by using an LMA inappropriately. It's already happened.

gaspassah · Aug 3, 2004

to clarify my statement.

i was not saying to stop using the lma because 2 ppl you know of aspirated.

i'm saying, if 2 ppl you know of aspirated, and they were perfect candidates for the lma, why advocate using the lma in a population that has a significant higher incidence of gastric aspiration.

i may have misunderstood you. but it sounded like you supported the use of the lma in patients like c/s as they do in england.

i hope this is more clear.

thanks

d

Gotosleepy · Aug 4, 2004

gaspassah.... i see your point, and I have become far more selective in which patients i use LMAs... And no, i don't advocate the use of LMAs for c/s as they do in England.... not because i don't believe their literature (which shows it is safe), but because there are some things that still scare me...

athomas... there are many setting where using an LMA is advantageous - it has been shown to expedite anesthesia emergence/turnover (not necessarily an important thing), have less bronchospasm/laryngospasm in children with reactive airway disease, etc... I agree with you that the ETT is the best airway protector out there, but aspiration happens either on induction (even before you have the tube in) or on emergence (after the tube is out), so you can see statistically the ETT is great to cover your bases once it is in, but doesn't cover you for when aspiration actually happens.... And to prove my point even further, it is a fact that you can still aspirate with an ETT in place.

what conclusions can you draw from this? well, assess your patients pre-operatively, assess their risks and be careful.... the bad news is that you are more likely to run into a difficult intubation then you are to see aspiration

deepz... as usual your contributions to clinical discussions are meager, why don't you go back to the other thread where you can wax philosophical on your insecurities

athomas91 · Aug 4, 2004

point taken.... :)

SCSRNA · Aug 4, 2004

actually the lethal part of the injection is a bolus of Potassium Chloride - the paralytic is just to make the patient look at peace for the witnesses...

Almost right. They use propofol and KCl. That gets the job done and, not that they need it, but makes for a more pleasent death. How kind.

deepz · Aug 4, 2004

........ deepz... as usual your contributions to clinical discussions are meager, why don't you go back to the other thread where you can wax philosophical on your insecurities

I'm crushed -- crushed, I tell you! "Meager"! Oh, how could you?!

In case you haven't noticed, Doctor Sunshine, ain't nobody died and made you boss. We don't need no stinking badges here, and this CRNA BB don't need no condescending stupervision from the likes of you, despite your cocksure certitude that you know it all. We've seen many like you before, come and strut their MD Major Diety hour upon our stage, lording it over the nurses; eventually they tire of intellectual masturbation and go away.

As to your admonitions, Teresa-Heinz-Kerry them where the sun don't shine.

!