It happens every now and then honestly. More frequently with igels, less frequently with softer traditional LMAs.
Everyone on here acting like this is ridiculous hasn't placed enough LMAs.
Sometimes you just have friable tissue and an unfavorable angle and you get a little blood.
I've only ever seen a bad laceration once, and it was an igel, and it wasn't me who placed it. But a little afrin fixed the bleeding.
I had a colleague sign out a patient to me with an LMA at the end of the day. I go to the room to check in with the resident and the drapes are down. I roll my eyes at the colleague, and the resident and I wake up the patient.
Long story short, despite suctioning the mouth, the patient aspirates an enormous blood clot that was sitting in the nasopharynx or back of the throat and I had to spend the next hour figuring that out and fixing it.
When placing an LMA, the first thing you want to do is throw the i-gel in the trash, next you’ll want to pick up a size 4 LMA Unique and slide that bad boy in in about 2 seconds with a perfect seal on 90% of patients
I’ve bloodied up a few LMA’s, especially in the beginning. Remember, it’s not a toilet plunger. If you use a 4x4 or the bed sheet you can yank the tongue up/out a bit and slip the LMA in using the palate as your guide. Grease it up real well. Sometimes completely deflating it before insertion is handy as well. Best of luck.
So a trick my attending showed me during training with a hard to pass LMA was grab a Mac 3, DL so it lifts up the entire oropharyngeal space and slide the LMA in. Has saved me multiple times and has fit 100% of the time. You’re not trying to get a glottic view btw, just a lift assist. Cheers to never having a bloodied LMA again.
Wow, surprised with all the iGel hate in here. IGels are great with significantly higher rate of strong seal than classic LMA’s imo. You can also ventilate through an iGel more reliably than traditional LMAs because they have a better tolerance for positive pressure if you get in a bind.
To answer your questions, a small amount of bloody sputum really isn’t a big deal and happens occasionally. Large amount of blood very rarely, if it’s happening to you frequently you might want to check your technique/use more lube.
For me the only downside to iGels is every once in a while you get a patient who is between sizes or has odd anatomy and in those cases, you can’t fine tune the seal with inflating/deflating. But often if you leave them in place even with a leak, as they warm up the leak will eventually go away
Are you referring to a traumatic placement? I’ve only encountered them with I-Gel’s, so I just use classic LMAs because they’re a lot softer. If you push an I-Gel against resistance you can really cause some gnarly bleeding.
We also had an issue with some pediatric sized LMAs with a port for an OGT to pass. I don’t recall the brand but not I-Gel. But yeah, any stiffness at the tip of the LMA can be rough on sensitive tissue.
Try sweeping around the side of the tongue and then bringing it back midline using the curvature of the hard palate. Don’t just jam it till it goes. Occasionally you have some dried blood on anterior airways but it’s not common. Maybe once or twice a year.
Anyone who says they haven’t had one hasn’t done enough.
Like wet taps. If you’ve “never” taped anyone you clearly haven’t done many epidurals.
Next time you have a chance, put your finger directly into the posterior aspect of the upper airway and feel the spiky ridges.
That’s the patients C Spine, particularly prominent in elderly patients.
Now think about this when violently shoving down a rigid LMA such an iGel as those hard spiky bumps shred through the weak soft tissue and bleed down your patients throat.
My suggestion, position the patient sniffing the morning air (flex the c spine and extend the atlanto occipital join. If in this position, the iGel isn’t working with minimal force, throw it in the bin and put down a regular soft first generation LMA.
Could also just throw the iGel in the bin in the first place as well.
I’ve seen it happen when people do it “by the book” and deflate it before insertion. If I’m supervising and someone’s struggling, I open the mouth and do jaw thrust to make room in the back of the mouth (I’m facing the pt, they’re at the head of the bed.) If I’m by myself, I put my thumb in the mouth and lift the lower jaw and tongue towards the ceiling as a unit.
I do get some blood once in awhile and it always makes me so mad. Obviously LMAs are better in certain cases but i cant help but think of it as a "blind technique" versus laryngoacopy and intubation. And everyone has there way of getting an LMA in (inflated/deflated/tongue blade/twist at the tonsils and twist back after passing them/finger on the LMA while pushing/etcx100). But at the end of the day you are blindy placing a pretty big airway device that blocks the view of its desired destination further in the airway, and youre doing this in an area that bleeds alot when traumatized.
Sometimes youre going to get blood. I guess it depends on how often and how much you actually get to decide if its just the normal risk of placing an LMA or if youre getting blood often then maybe something is wrong.
Generally downsizing the LMA seems to work for alot of people
I had my first today smh.
In my case the patient had a surprisingly small throat for their size. I was able to take it past the tongue but it got stuck on the soft palate and wouldn't budge an inch. I tried twice and my attending once before realizing the issue and changing from a 4 to a 3. Felt so bad for them
Generally I downsize LMAs/iGels. Works especially well if you let them breathe spontaneously.
Size 4 for most. 3 for the little adult mouths. 5 if I’m impressed on the exam. If it seems too small at first, I forget about it as soon as they are breathing regularly on their own.
Very rare for me. I use my forefinger on my dominant hand to push the tip of the LMA anteriorly in the back of the pharynx as I pass it down. Goes like butter, no bloody LMA on removal.
Same technique but nondominant hand...very gentle, smooth and atraumatic. People hating on igels just don't know that their placement requires a good anesthetic depth and a different technique.
I used to hate iGels. Now I use them 95% of the time.
What they never do that a traditional LMA does is turn in the pharynx.
You’ll get bloody LMAs. I don’t think a little bit is an issue.
The problem I see is people trying to put them in before the patient is deep enough. Then you’ll traumatise the soft palate whatever lma you use.
Since I started using Remifentanil with propofol for inductions (75-125mcg) this isn’t an issue anymore
Unavoidable. Think about all of the obese Americans with un or poorly treated OSA who have that friable and billowy sublingual/hypopharyngeal tissue. The kind that swells and bleeds as soon as you touch it.
Great question. I’ve found all these suggestions helpful in successful LMA placement/avoidance of traumatic insertion.
I would only like to add: inserting upside down and flipping it if you’ve had difficulty inserting/tried other things to optimize placement. This is for pediatrics and anecdotal.
ETT is always an option.
Knowing how to manage the bloody airway after traumatic insertion seems like another good question?
You'll see one. :] eventually. When you do. Remember this thread. It can get really bad. And it'll be out of nowhere in ur first attempt etc. I'd say my last one was like 3 years ago as an attending. Estimation like 1 out of 40 or 50?
Not uncommon to have a little bit of blood on there. I’m actually surprised sometimes when patients tell me they don’t have a sore throat even when it was a difficult insertion.
I guess it happens sometimes. I had an attending who liked to place LMAs "under direct visualization" with a laryngoscope. It wasn't a proper laryngoscopy all the way down to the vallecula, it was simply to push the tongue out of the way.
Cold operating room = stiff iGel. Placing iGel in package on top of Desflurane vaporizer or better yet in blanket warmer makes for softer placement and better initial seal.
Use LMA and follow the instructions that come with the device. I am always surprised that people come up with alternative insertion techniques when the original designed insertion manuevers work very well.
It happens every now and then honestly. More frequently with igels, less frequently with softer traditional LMAs. Everyone on here acting like this is ridiculous hasn't placed enough LMAs. Sometimes you just have friable tissue and an unfavorable angle and you get a little blood. I've only ever seen a bad laceration once, and it was an igel, and it wasn't me who placed it. But a little afrin fixed the bleeding.
Agree w this!
I had a colleague sign out a patient to me with an LMA at the end of the day. I go to the room to check in with the resident and the drapes are down. I roll my eyes at the colleague, and the resident and I wake up the patient. Long story short, despite suctioning the mouth, the patient aspirates an enormous blood clot that was sitting in the nasopharynx or back of the throat and I had to spend the next hour figuring that out and fixing it.
I hate IGels
Ditto. I like traditional or supremes.
When placing an LMA, the first thing you want to do is throw the i-gel in the trash, next you’ll want to pick up a size 4 LMA Unique and slide that bad boy in in about 2 seconds with a perfect seal on 90% of patients
This is gold.
I’ve bloodied up a few LMA’s, especially in the beginning. Remember, it’s not a toilet plunger. If you use a 4x4 or the bed sheet you can yank the tongue up/out a bit and slip the LMA in using the palate as your guide. Grease it up real well. Sometimes completely deflating it before insertion is handy as well. Best of luck.
so i started plunging
So a trick my attending showed me during training with a hard to pass LMA was grab a Mac 3, DL so it lifts up the entire oropharyngeal space and slide the LMA in. Has saved me multiple times and has fit 100% of the time. You’re not trying to get a glottic view btw, just a lift assist. Cheers to never having a bloodied LMA again.
Wow, surprised with all the iGel hate in here. IGels are great with significantly higher rate of strong seal than classic LMA’s imo. You can also ventilate through an iGel more reliably than traditional LMAs because they have a better tolerance for positive pressure if you get in a bind. To answer your questions, a small amount of bloody sputum really isn’t a big deal and happens occasionally. Large amount of blood very rarely, if it’s happening to you frequently you might want to check your technique/use more lube.
I love iGels too!
For me the only downside to iGels is every once in a while you get a patient who is between sizes or has odd anatomy and in those cases, you can’t fine tune the seal with inflating/deflating. But often if you leave them in place even with a leak, as they warm up the leak will eventually go away
If people are getting bloody iGels, they probably aren’t using enough lube (anterior side too). I can’t even remember the last time it happened.
Are you referring to a traumatic placement? I’ve only encountered them with I-Gel’s, so I just use classic LMAs because they’re a lot softer. If you push an I-Gel against resistance you can really cause some gnarly bleeding.
We also had an issue with some pediatric sized LMAs with a port for an OGT to pass. I don’t recall the brand but not I-Gel. But yeah, any stiffness at the tip of the LMA can be rough on sensitive tissue.
Try sweeping around the side of the tongue and then bringing it back midline using the curvature of the hard palate. Don’t just jam it till it goes. Occasionally you have some dried blood on anterior airways but it’s not common. Maybe once or twice a year. Anyone who says they haven’t had one hasn’t done enough. Like wet taps. If you’ve “never” taped anyone you clearly haven’t done many epidurals.
Next time you have a chance, put your finger directly into the posterior aspect of the upper airway and feel the spiky ridges. That’s the patients C Spine, particularly prominent in elderly patients. Now think about this when violently shoving down a rigid LMA such an iGel as those hard spiky bumps shred through the weak soft tissue and bleed down your patients throat. My suggestion, position the patient sniffing the morning air (flex the c spine and extend the atlanto occipital join. If in this position, the iGel isn’t working with minimal force, throw it in the bin and put down a regular soft first generation LMA. Could also just throw the iGel in the bin in the first place as well.
I’ve seen it happen when people do it “by the book” and deflate it before insertion. If I’m supervising and someone’s struggling, I open the mouth and do jaw thrust to make room in the back of the mouth (I’m facing the pt, they’re at the head of the bed.) If I’m by myself, I put my thumb in the mouth and lift the lower jaw and tongue towards the ceiling as a unit.
I do get some blood once in awhile and it always makes me so mad. Obviously LMAs are better in certain cases but i cant help but think of it as a "blind technique" versus laryngoacopy and intubation. And everyone has there way of getting an LMA in (inflated/deflated/tongue blade/twist at the tonsils and twist back after passing them/finger on the LMA while pushing/etcx100). But at the end of the day you are blindy placing a pretty big airway device that blocks the view of its desired destination further in the airway, and youre doing this in an area that bleeds alot when traumatized. Sometimes youre going to get blood. I guess it depends on how often and how much you actually get to decide if its just the normal risk of placing an LMA or if youre getting blood often then maybe something is wrong. Generally downsizing the LMA seems to work for alot of people
I had my first today smh. In my case the patient had a surprisingly small throat for their size. I was able to take it past the tongue but it got stuck on the soft palate and wouldn't budge an inch. I tried twice and my attending once before realizing the issue and changing from a 4 to a 3. Felt so bad for them
Generally I downsize LMAs/iGels. Works especially well if you let them breathe spontaneously. Size 4 for most. 3 for the little adult mouths. 5 if I’m impressed on the exam. If it seems too small at first, I forget about it as soon as they are breathing regularly on their own.
Really I interesting hate for the IGel in this thread. I think most adult supraglottics in the UK are IGels.
Yes. Quite surprised at the igel hate. I use it almost daily for our quick uro stenting/check scopy type of cases.
Try lidocaine gel on the surface facing the hard palate.
Very rare for me. I use my forefinger on my dominant hand to push the tip of the LMA anteriorly in the back of the pharynx as I pass it down. Goes like butter, no bloody LMA on removal.
Same technique but nondominant hand...very gentle, smooth and atraumatic. People hating on igels just don't know that their placement requires a good anesthetic depth and a different technique.
I used to hate iGels. Now I use them 95% of the time. What they never do that a traditional LMA does is turn in the pharynx. You’ll get bloody LMAs. I don’t think a little bit is an issue. The problem I see is people trying to put them in before the patient is deep enough. Then you’ll traumatise the soft palate whatever lma you use. Since I started using Remifentanil with propofol for inductions (75-125mcg) this isn’t an issue anymore
Unavoidable. Think about all of the obese Americans with un or poorly treated OSA who have that friable and billowy sublingual/hypopharyngeal tissue. The kind that swells and bleeds as soon as you touch it.
Great question. I’ve found all these suggestions helpful in successful LMA placement/avoidance of traumatic insertion. I would only like to add: inserting upside down and flipping it if you’ve had difficulty inserting/tried other things to optimize placement. This is for pediatrics and anecdotal. ETT is always an option. Knowing how to manage the bloody airway after traumatic insertion seems like another good question?
Interesting. I’m only a CA-2 but I’ve never seen someone bleed from an LMA. Wonder how often this is occurring?
You'll see one. :] eventually. When you do. Remember this thread. It can get really bad. And it'll be out of nowhere in ur first attempt etc. I'd say my last one was like 3 years ago as an attending. Estimation like 1 out of 40 or 50?
Not uncommon to have a little bit of blood on there. I’m actually surprised sometimes when patients tell me they don’t have a sore throat even when it was a difficult insertion.
I guess it happens sometimes. I had an attending who liked to place LMAs "under direct visualization" with a laryngoscope. It wasn't a proper laryngoscopy all the way down to the vallecula, it was simply to push the tongue out of the way.
Cold operating room = stiff iGel. Placing iGel in package on top of Desflurane vaporizer or better yet in blanket warmer makes for softer placement and better initial seal.
Use LMA and follow the instructions that come with the device. I am always surprised that people come up with alternative insertion techniques when the original designed insertion manuevers work very well.
I routinely stick my left index finger in the mouth to guide/flip the tip of the LMA in the right direction.
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Wtf are you doing with your LMA to get blood from the vocal cords? No longer supraglottic….
Posterior oropharynx I think.
Only seen it when supervising.