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patients if there is significant tissue pressure on the chest and
abdomen at the end of the procedure. High-BMI patients may be bor-
derline when you're deciding between endotracheal and LMA airway
maintenance. You may also need to consider whether patients have
GERD or gastroparesis, since they can compromise airway manage-
ment.
When the surgeon is closing, or the procedure is nearing the end,
deflate the LMA (no adjustment to inhalation agent is made at this point),
and remove it. Leaving the inhalation agent on ensures that if patients are
deep enough to tolerate the LMA, they'll be deep enough to tolerate
removal. After the LMA is removed, apply the facemask to the breathing
circuit and control ventilation with the facemask. You can then titrate
the anesthetic down, based on when the surgeon expects to finish and
when the patient will be ready to be transported. Usually, patients will
awaken as if the entire procedure was performed under mask ventila-
tion. There's complete airway control, little coughing and no question
as to whether they're ready for transport, because they're as con-
scious as patients who were extubated awake.
Before or after?
So, should you remove LMAs before or after the patient wakes up?
That decision should always be based on patient safety and the
provider's comfort level.
OSM
Mr. Ruspantine (perryr@anesprof.com) is clinical compliance manager for
Anesthesia Professionals, Inc., in Dartmouth, Mass.
Anesthesia Alert
AA
Some feel that leaving the LMA in place until the
patient is fully awake can actually stimulate coughing
and give patients the feeling that they can't breathe.
