Over the last few years I have become very comfortable with using muscle relaxants with LMAs.

Background: While in training I never paralyzed patients while using an LMA. The vast majority of sites I rotated at, preceptors wanted the patient back breathing spontaneously ASAP following induction. One rotation was different.... At that site we always did shoulders with an ISB and an LMA supreme. There I was taught to ventilate the patient the entire case with the LMA and pull it at the end following return of SV. (basically use it like and ett)

I found this approach to be an excellent way to deliver anesthesia. After training and starting to practice on my own I tended to use the proseal LMAs almost exclusively for my patients. I loved having the ability to ventilate with 30 cm H20 and having the option of placing a gastric tube.

As I became more comfortable with using LMAs to ventilate patients for the entire case I started to experiment with small doses of muscle relaxant. If I had a good seal and was worried about the patient moving or "getting tight" I would give 10 of roc to take the edge off. On multiple occasions I have given 50 of roc up front just like I would with an ett. Haven't had a problem.

I had a patient last week who has had multiple TURBTs for a recurrent bladder tumor. She has had both spinals and GA for her procedures in the past. She prefers GA but warns me that anesthesia providers in the past have told her they had to use an unusually large amount of medications to get her to relax for the procedure and that because of that she woke up very slowly and had to spend the night at the hospital.

I induced her with my usual prop, lido, fent, ketamine recipe and placed an LMA supreme. She was easy to ventilate so I switched on the vent, pressure control, peak of 15 pulling 500 cc TV. Tape the eyes get ready to move the patient south for lithotomy positioning. Now I hear a huge leak from the LMA. TV down to 50 -100. I check the LMA position, vent tubing, ect. No problem evident. Now she has become so tight that I cannot ventilate her at all. 20 mg IV succ fixed the problem. Easy to ventilate again. She needed to more doses of 20 mg succ during the case. Woke up beautifully and out the door within an hour.

I'm not saying I give all my LMAs muscle relaxant. I am saying that I can be a useful tool and as safe (safer?) than doing the case with an LMA and no relaxant.

Let the insults fly.....