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A laryngeal mask airway is one of the best rescue devices against difficult airways that we anesthesia providers have at our disposal. We also use LMAs when we don't want or need to intubate the patient. About 60% of surgeries involve intubation, but unless there's a risk of aspiration, many anesthesia providers feel that the patient is better off if they don't have to intubate. Today's LMAs deliver smoother anesthesia outcomes and promote improved patient safety and comfort. Here are a few features to consider:
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IV Ibuprofen and Acetaminophen for Opioid-Free Pain Control? |
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Soon after the FDA approved intravenous ibuprofen (Caldolor) and acetaminophen (Ofirmev) for pain and fever, many surgeons and anesthesia providers let out a collective cheer. Why are they so excited about IV formulations of over-the-counter products that have been around forever? Because now they have what some say is a much-needed option to opiates in the post-surgical setting. We all know about opiates and their side effects: excessive sedation, nausea, vomiting, constipation, urinary retention, itchiness and respiratory depression. We also know that treating opioid-related side effects increases costs and delays discharge. While these new drugs can reduce opioid use alone, the real benefit comes from using a combination, says Eugene Viscusi, MD, director of acute pain management at Thomas Jefferson University in Philadelphia, Pa. Dr. Viscusi's favorite recipe includes IV acetaminophen, an NSAID such as ketorolac or a COX-2 inhibitor, a gabapentinoid, and regional or local anesthesia. When there's time, and when a patient can swallow a pill, the regimen begins with oral medications and can be continued with IV formulations so there are no gaps, says Dr. Viscusi. Plus, he adds, "a lot of these drugs are not very expensive." "We're really taking about 2 or 3 medications, plus the opioid," says Dr. Viscusi. "Couple this with regional anesthesia, and you can come close to an opioid-free post-op regimen." Here's a quick rundown of each of the new IV agents:
A study published in the August 2010 issue of Pain Medicine showed that IV ibuprofen reduced opioid use by 31%, compared to placebo, after elective orthopedic surgery. Comparatively, a study published in the April 2005 issue of Anesthesiology found that IV acetaminophen reduced opioid use by 33% in patients after major orthopedic surgery. — Kent Steinriede |
- Built-in bite block. Many of the newer LMAs include a built-in bite block, which prevents patients from occluding the device's lumen upon their emergence from anesthesia. From a safety standpoint, this is a worthwhile feature.
- Suction port to drain gastric contents. Even patients who comply with a pre-surgical NPO order are constantly producing gastric acid and are at risk of aspiration. Some airway devices include a suction port and a second lumen through which providers can drain gastric contents, decompress the stomach and channel fluid or gas from the airway.
- Intubation conduit. Given its primary role as a rescue device, a product designed to allow the easy insertion of an endotracheal tube through its lumen also seems like a logical innovation, even enabling it to serve as a removable bridge device between a difficult airway and restored ventilation.
- Cuff pressure indicator. Cuff pressure is the key to maintaining an effective seal over the patient's larynx, and the pressure can change over the course of a procedure. The cuff can leak, lowering the pressure and compromising the placement or quality of the seal. If a provider is using nitrous oxide and this agent invades the cuff, the pressure can increase, obstructing blood flow and creating the risk of necrotic tissue. That's why some airway devices include cuff pressure indicators, valves that measure and visibly report how much air pressure is in the cuff. This feedback may not be as essential a feature as an intubation conduit, but it's not a bad idea.
- Size. LMAs are available in a wide array of sizes to accommodate the airways of patients ranging in age and body mass from infants to obese adults. You might not need to order and stock a supply of every size, but your anesthesia providers' carts will need the sizes that give them the ability to rescue any member of your patient population.
- Airway adaptability. The material an airway device is made out of is a key consideration. Some feature a curved tube and some are completely flexible. Choosing a style may be a question of provider preference: An anatomically designed device can better slide around the back of the tongue for quicker insertion without manual force. It's also an issue of patient comfort. The anatomical curves may reduce trauma, resulting in fewer sore throats in recovery.
- Inflated cuff design. The device's use also depends on the design of the inflated cuff. A larger,pre-curved cuff, for example, lets a provider position the airway faster, more accurately and with a better seal without exerting much pressure. Most manufacturers' cuffs are inflated with air, and their devices let users increase or decrease the air pressure during use. Others are gel-filled, an innovation that may promote patient comfort. The pressure in those cuffs, however, is fixed and more cannot be added if needed to adjust the seal. Incidentally, if your facility has been making efforts to avoid the risks of latex allergies, be sure to choose a product with a latex-free cuff.
- Disposable or reusable? Design matters aside, LMAs are available in single-use and reusable versions. The big advantage of single-use airway devices is that they virtually eliminate the risk of cross-contamination. They're also conveniently at hand and save time since they don't require your sterile processing department's disinfection and sterilization between uses. A word of caution: The inexpensive plastics from which the disposable devices are made are harder, don't conform as well to patient anatomy and make it more difficult to obtain a secure seal. A reusable device, on the other hand, that can be repeatedly steam autoclaved for 50 or more uses may seem a more economical option. Just make sure that staff rushing through a room turnover don't accidentally discard it before its useful life has elapsed.
First thing we reach for
In many cases, a pre-surgical assessment will alert you to the possibility that a patient will present a difficult airway, but some difficulties are a surprise. In situations where we suddenly, unexpectedly can't ventilate and can't intubate the patient, an LMA is the first thing we tend to reach for. It's an easy technique to teach and learn. Plus, laryngeal mask airways also lend themselves to rapid patient turnover and speedy recovery. A well-fitting LMA doesn't irritate the airway, lets the provider lighten up on the anesthesia and is quickly removed after surgery.
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Which Laryngeal Mask Airway Is Right for You? |
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A laryngeal mask airway, which in many versions resembles an inverted anesthesia mask at the end of a length of tubing, sits on top of the patient's larynx. The mask's inflated cuff forms a seal around the vocal cords and the tubing maintains an open airway while oxygen is insufflated through this conduit in order to ventilate the patient. Here's a look at the latest products. — Compiled by David Bernard ARC Medical BOMImed Flexicare Intersurgical King Systems LMA North America Mercury Medical Smiths Medical |
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