NMBAs with LMAs

[putmetosleep]

What are your thoughts/feelings on using neuromuscular blockers during a case with an LMA in place? I know relaxants are not necessary for insertion, but are they contraindicated? I've heard yes and no...personally, I can't think of a reason why it wouldn't be okay to use a NMBA if the surgeon needed relaxation during the case. Others have said it's a big no-no. I've heard that this is done routinely in Europe, as well as mech. ventilation via LMAs (with low PIP)---another topic where there are opposing views in my current rotation.

Thoughts please:)

[starae]

I am very conservative and do not think this is a good practice. According to some references, NDNMBs can actually decrease LES pressure which combined with the chance of inflating the stomach is not a good combination.

LMAs are not a substitute for an ETT. Rather, I think of them as a substitute for a mask. The airway may be secure, but it is not protected. Like I said, I'm on the conservative side and have seen many people use LMAs in situations where I would not even consider it.

[AbeFrohman, BSN, RN]

I never said that it was a good idea legally, but this goes on ALL THE TIME. There are many providers that do this in Europe routinely and many who do it here in the states. Would I use NMB and LMA on a full stomach or a prone case NOOOO!!! But if you are reserved in your use of this technique, you can do it.

[loveanesthesia]

Using a NMBA takes away 2 of the main advantages of using an LMA, drug cost saving, and the ability to have the patient spontaneously breath so that you can turn cases over very fast. If you are using a primarily inhalation agent anesthetic, you should have pretty fair relaxation for the surgeon. Avoiding muscle relaxation also reduces the possiblity of recall. Muscle relaxation does increase the risk of aspiration, so that's why I don't like to use a NMBA with an LMA and really don't miss it. For cases such as ESWL's or MRI's where the patients's respiratory effort interferes with the procedure, I usually just over breath them to convince them they don't need to breath. A few times I have resorted to giving a touch of roc to get through.

[ssrhythm]

I never said that it was a good idea legally, but this goes on ALL THE TIME. There are many providers that do this in Europe routinely and many who do it here in the states. Would I use NMB and LMA on a full stomach or a prone case NOOOO!!! But if you are reserved in your use of this technique, you can do it.

Is Europe as litigious a society as the US?

[Dangerfish]

I personally dont give muscle relaxants if I am planning on using an LMA. If I think I will need them, then I will place an ETT. That being said, I dont really see anything wrong with it so long as the patient is NPO and not obese. My business partner will frequently do her abdominoplasty's with an LMA. For those cases, the surgeon really only needs relaxation when they tighten the muscles so she will give just a small dose of Roc for that portion of the case.

[dynamiteRN]

ETT is designed to protect the airway from aspiration with the balloon inflated. LMA is not designed to do this. LMA is a supraglottic airway that is not designed to keep any gastric content from entering the trachea. With Neuromuscular blockade, ventilation is provided via ventilator which can generate a greater pressure that can cause gastric distension, resulting to increased risk of aspiration. Therefore, LMA is not the best airway device to be used when neuromuscular blockade is to be used. In any event that LMA is in place, and there is an unanticipated requirement for neuromuscular paralysis, the best and safest approach is to switch to ETT from LMA, then paralyze.