Anectine/Propofol for LMA insertion

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Has anyone else seen this done? Just curious, because some docs & CRNAs at my site mix 1 mL of anectine in with their propofol stick for induction prior to LMA insertion. Those that don't have VERY STRONG OPINIONS on the practice, yet those that do have just as strong opinions and, as always, I'm in the middle. Any observations? Thoughts?

Z

soliant - i see your issue - you (like jwk stated) cannot at this point argue your point.. but i wholeheartedly agree - LMA's are (in this region) utilized when no muscle paralysis is indicated - the gases cause some muscle relaxation and this is sufficient. i am aware that in europe - paralytics are used w/ lma's as well as PPV - but... the public isn't sue-happy as in the u.s - and unfortunately this must be taken into consideration. i am gathering that they are using it for jaw relaxation for insertion - but if a proper/sufficient dose of propofol is utlized - it shouldn't be needed. etomidate can be used - but it can cause myoclonus and make your life more difficult... i would say that if someone isn't stable enough for a big slug of propofol - they need a tube.

i personally use versed and propofol for insertion and turn gases on then titrate fentanyl to respiratory rate - this way they are pretty much self ventilating just after insertion.

good luck.

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While I am always open to learning new techniques, I have very healthy respect for succinylcholine. Years ago, I saw a small dose (10mg) given for an ECT and the patient vomited coffee ground fluid from a gastric bleed, aspirated and died. I was a student then, but it is something you never forget.

Personally, I think many anesthesia providers use muscle relaxants to cover up poor anesthesia. They paralyze and not anesthetize. The point is--why give one of the most dangerous drugs we use--without a very good reason to use it. I can put in an LMA without a muscle relaxant. If I have difficulty, I then give a paralyzing dose and intubate (love that secure airway).

yoga

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sux increases gastric pressure - from what yoga saw- i guess even small doses can do it.

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sux increases gastric pressure.

Usually offset by an increase in LES tone.

But hey, patients don't often play by the rules or read the same books we do. That'd be too easy - wouldn't it?

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thta brings me to another question - do you all defasiculate prior to giving sux - why or why not.

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i dont normally use defasicualting doses. i read somewhere that nmb can cause myalgia just as using sux can, and just surgery can cause it. i also like to see some twitching, just another way to know when the pat is ready.

Generally I've been taught to go light on the fentanyl, if any, and heavy on the propofol, and use some gas if they're still too light.

during the end of my training and now that i have been out about a year, i have been using narcs more heavily (i get to make more of the decisions now :) i have found in your normal ((whatever normal is really) just not elderly or infirm)) i give 5 ccs of fent before prop and lma placement and find that the patients return to spontaneous breathing in about 5 min. this is for cases as short as 45min to 1 hour, i dont titrate anymore in and they usually awake really smooth and comfortable. if you are familiar with the dose response curve, this is what i base this technique on. i do roughly the same thing for longer cases with a tube, i just give larger doses of fent.

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Thank you for the thoughtful responses. I learned a lot from this experience!

Z

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