So I did a bunch of LMA GAs this week and had a few less than perfect experiences that have been bugging me all week, including my first laryngospasm...sorry in advance for the following wall of text.

1. 50ish y.o. black male for TURP with laser vaporization. GA with LMA (4.5 AirQ), smooth induction and LMA placement, pt with SV throughout the case with RR 10-12ish on sevo at around 1 MAC, O2, and small doses of fentanyl titrated in...the usual...

Rock solid for 2 hours and nearing the end of the case, pt coughs once and then begins to have some noisy, labored respirations. I grab my propofol and give 50mg assuming he is somehow light on 2.2% of sevo wondering exactly how that could be and begin to attempt to assist ventilation with little success. I also notice suprasternal and supraclavicular retractions, negative deflection on inspiration on the bourdon gauge, and no tidal volumes or ETCO2 waveform = no air movement. uh-oh...

At this point I get hip checked by my CRNA who proceeds to also attempt to assist ventilation and gives another bolus of propofol saying the pt must be biting and occluding the LMA, although I had a soft bite block in place...At this point I'm thinking it must be laryngospasm, and my CRNA tells me to call our attending as she continues to attempt to ventilate via LMA ...sats quickly falling into low 80s...I have sux in my hand as she finally pulls the LMA and tells me to help 2 person mask ventilate in an attempt to move some air and break the laryngospasm...sats in upper 70s and falling...MDA comes in takes the sux out of my pocket, gives 40mg, and we finally start moving some air. LMA quickly replaced after sats recover...breath sounds clear bilaterally, RR back to low teens, SpO2 99% before emergence, LMA removed with no further issues. CXR in PACU showed clear lungs and a belly full of air, but no problems. Pt awake and fine.

Talking with my CRNA and MDA afterwards, she admitted that she spent way too much time trying to ventilate since she was convinced he was just biting down on the LMA instead of recognizing and treating laryngospasm. Lesson learned for me as well.
My MDA reminded me how the African-Am. population tends to have increased secretions and that he often will pretreat with glycopyrrolate for an LMA case to prevent secretions from making their way onto the cords and causing spasm, as was most likely the case here.

So that was my first laryngospasm...
Question for everyone: how many of you commonly pretreat pts with glyco before LMA case for this very reason? Any other comments or suggestions are welcome.

2. Friday afternoon...50ish y.o. F (~60kg) for a urethral bulking injection for urinary incontinence.
Pt has hx of asthma and current everyday smoker with audible wheezing in preop slightly improved after nebulizer tx. Still has marked expiratory obstruction when MDA asked pt to blow as hard as she could against his hand...Obviously a serious COPDer with chronic bronchitis even though not mentioned in the hx.

We decide to move forward and do a GA with LMA.

I premed with 2mg versed in preop then 50mcg fentanyl as we roll in the room. Then induce with 60mg lidocaine, 140mg propofol. LMA placed easily, but pt immediately starts coughing and breath holding. I turn on sevo as I am noticing no ETCO2 or TVs as she continues to cough, and I get hip checked before I have a chance to do anything else. My CRNA gives the rest of the propofol as the MDA assists with ventilation, and moments later the pt is ventilating comfortably, albeit with a wicked obstructive ETCO2 pattern. I then get the obvious lecture in front of everyone in the OR that you can't place an LMA when the pt is light, etc. Obviously I felt like crap and looked stupid as that was one of the worst LMA inductions I've had and on a pt that I really wanted a nice smooth induction...I hate looking like a novice...

In hindsight, I obviously should have ensured the pt was deeper before I placed the LMA. But I also feel like it's the classic catch 22 as student learning anesthesia...you give too little and the pt is not optimized for LMA or DL and ETT placement; you give more than your preceptor is comfortable with (a total moving target) and you've suddenly "overdosed" your pt and all hypotension for the rest of the case is blamed on your heavy-handed induction dosing. The saying "you can always give more, but you can't ever take it back" is usually sound advice, but isn't resonating well with me after my last terrible LMA induction. I essentially dosed the pt the same way I usually do for an LMA...versed, a touch of fentanyl, 1mg/kg-ish lidocaine, 2mg/kg-ish propofol. Obviously that just wasn't enough.

Again any suggestions or comments are welcome. These cases are really bugging the crap out of me, and I hate making the same mistake twice. Can't wait to get back in there and redeem myself. Freakin LMAs...