From Kunal Sualy, MD, Children’s Nebraska on future LMAs
We actually trialed these the Children’s Nebraska in September of 2022, from a company called UE Medical Devices. They worked fairly well.
The larger-sized ones worked great to facilitate ETT placement. The smaller sized ones did not work as well, and it was difficult to get the ETT separated from the LMA secondary the pilot balloon (though you could cut it). The clarity of the images was great. I thought if they could figure out the issue with the smaller LMAs, they would be worthwhile to have some on-hand, especially for difficult airways. Sizes ranged from <5kg to adult. The cost of the LMA was around $9.99 each, which I think I near double a traditional one.
From Matthias Koenig, Children's Hospital of the King's Daughters on A better LMA in our future?"
If the company rep leaves a box of these for me to play with for free, I would be happy to try them. But as far as I can tell from my vantage point, there are not too many in the pediatric anesthesia community clamoring for a "new and improved" LMA. In my - by definition - limited personal experience I have almost exclusively seen the use of the Aura Once LMA's in three different institutions over the past 20-odd years. They seem to work surprisingly well, even though few people seem to follow the manufacturer's instructions to first deflate the cuff before insertion and then reinflate it. And let's remember, these are old-school 1st generation LMA's. Despite all the fanfare and advertising, few institutions have even moved on to 2nd generation LMAs, as far as I can tell. So why now move to fiber optic LMA's? I simply don't see the appetite for such a new device in the market since the old ones simply work too well. Instead of investing in 3rd or 4th generation LMA's, I would rather buy video laryngoscopes for all of our OR's or hand-held devices for every practitioner.
From Bill Greeley MD on how low is low
I am pretty sure in this PAAD that CO = Pressure / Resistance i.e. CO = BP - MCP/ SVR
Perhaps authors were thinking that CO = SV x HR
From Elliot Krane MD on reference to precordial stethoscope
I donated my precordial stethoscope to the Smithsonian’s history of medicine exhibit.
From David A. Rosen, MD, FAAP, Professor, Departments of Anesthesia and Pediatrics, Pediatric Cardiac Anesthesia Vice Chair for Anesthesia Research, WVU Medicine Children’s West Virginia University on precordial stethoscope
Remember when we were peds residents in the delivery room on cases we were called in for? They handed you the baby and after a quick wipe down you put your precordial on. There was no ECG and pulse oximeters…they did not exist.. The precordial was your lifeline to how the baby was doing. Adequate tubing length even allowed you to move around the baby to care for it. When I was a fellow at DC kids, they did a study and demonstrated the ability to predict the blood pressure and heart rate within 5 % just by learning how to listen with a precordial. I still use it every day when I put pediatric heart patients to sleep. Just listening I can hear the cardiac function going down long before the blood pressure cuff cycles to let you know there is a problem. I can hear changes in shunt flow, I can hear that the endotracheal tube ventilating the left lung. I can hear wheezing. I have even used it to predict when we are going to need CPR and been able to say “ lets get ready to do CPR” before other monitors have. I continue to feel like Dr Ferrari alluded to, it is a part of the past that we should not abandon. Maybe if they made a small Bluetooth one there would be a resurgence in their use.
From Kyle J. Kramer, DDS, MS, Editor-in-Chief, Anesthesia Progress on precordial
I’ve been following along with the daily PAADs (always insightful), but today’s comments from Dr. Ferrari prompted me to write.
She wrote regarding her absolute love of the precordial stethoscope which you discussed in your TEF PAAD. The precordial stethoscope is a critical piece of equipment that we use for every case both in with the residents and in my private practice. I find it absolutely indispensable and feel completely vulnerable should it be nonfunctional. My question to you is whether most physician anesthesiologists are aware of the incredible technological advances that have been incorporated into contemporary precordial stethoscopes? Mine is not only Bluetooth enabled but also acts to clearly amplify airway sounds so clearly that it isn’t even in the same universe as “old-school” analogue precordial stethoscopes. I’ve written previously about the importance of precordial stethoscopy, so its fair to say this is a passion of mine. I’m just curious if most in medicine are aware of these newer, amazing monitoring systems? My gut is that many probably are not and would likely become fans if made aware, especially for any open airway/sedation case given the real-time airway monitoring it provides.
Additionally, I also found your PAAD on blood pressure quite interesting. It got me thinking about how my approach and comfort with hypotension has changed throughout my career. As you mentioned in your article, I was quite uncomfortable with any “significant” hypotension as a resident and typically gave ephedrine or phenylephrine so commonly that it was almost reflexive. This was during my time working in the hospital OR, so I must point out the patients in some cases were certainly sicker with less reserve than we commonly see in the dental clinic setting. However, these days I find the need for vasopressors exceedingly rare. Given the fact that 95% of my patients are ASA 1 or 2 with no underlying significant cardiac issues (I take care of mainly kids in my private practice), a MAP <60 isn’t concerning at all. We tend to use TIVA techniques to provide DS/GA for our dental cases, which gives me even more comfort since any hypotension is likely to be quite transient. Additionally, most of the oral surgery cases are 20-30 minutes in length. Modest hypotension is simply no major concern for the majority of these cases, hence the drastic reduction of vasopressor use. I simply don’t see as dramatic a shift in BP with TIVA as can easily be produced with volatile agents, and I also am way more tolerant of hypotension given my experience and knowledge that it is likely to be transient (or so I think). It certainly still gets my attention though… I just don’t typically act much on it other than maybe slowing down my propofol boluses.
One added point here is that the rarity of needing vasopressors due to all of these factors is that my OMS residents are NOT as comfortable determining what vasopressors are indicated nor are they able to reflexively draw up and dilute the various vasopressors. I find that I have to discuss and review the dosing and necessary dilutions of phenylephrine, ephedrine, and epi (those are our common vasopressors in the dental clinic) multiple times each year simply because 1) they don’t routinely administer these meds during dental sedation/GA cases, and 2) the hospital in which they train during their anesthesia OR rotations uses prefilled syringes. In short, they rarely get practice diluting and drawing up vasopressors as it is rare and it’s done for them in the OR. However, most of them will not use prefilled syringes in their respective private practices due to the increased costs. Given these challenges, I continue to bring vasopressor use up every few months as a refresher during our monthly anesthesia conferences. Curious if you have seen similar challenges in hospitals that may use prefilled syringes for all drugs.
From Lynne Maxwell MD
https://stemoscope.com/pages/stemoscope-pro-the-best-precordial-stethoscope-for-anesthesiologists
From Lynne Ferrari, MD a teaching moment at the Boston Children’s Hospital, a resident, fellow, and attending (Lynne) all listening in during an anesthetic!
From Dale F Szpisjak, MD, MPH (Private Practice) on Addisonian crisis
I agree with you about the sufficiency of dexamethasone for stress dose coverage. That's what I've been doing ever since I read it in the c. 2008 version of Dr. Coté's text book. I also asked an adult endocrinologist about it who said it was fine. We give appropriate electrolyte solutions perioperatively, so I don't see the lack of mineralcorticoid effects as relevant.
If a patient comes to the OR with hydrocortisone, I give it and not dexamethasone, too. But otherwise, just the latter.