EBUS protocols

[B-Bone]

Anybody have a good anesthesia protocol for EBUS cases? Our hospital just started doing them. In residency we did awake fiber optics (mostly for resident/pulm cc fellow benefit) followed by remi/propofol drip. Where I'm at now, the pulmonologists want pts asleep but not paralyzed or bucking, and they demand that we leave the cuff down "to decrease the chance of tension ptx". We end up doing GETA with sux followed by TiVa with spontaneous ventilation. The thoracic surgeons want the pts paralyzed completely. I'm trying to find a happy medium for all. Also, I don't have access to remi currently. So how does your shop do these? Anybody doing LMAs? Appreciate any ideas. Thanks!

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[BuzzPhreed]

Pulmonologists are medicine doctors. Not surgeons. In my experience often long on theory and short on acumen. That's all I'm going to say about that. Your CT surgeons have a better grasp.

You can do these either way, even with a #5 LMA and vapors. PTX is rare. Run the propofol and remi if you like to piss money away. Alfentanil and sevo do just as well.

 

[urge]

Pulmonologists are medicine doctors. Not surgeons. In my experience often long on theory and short on acumen. That's all I'm going to say about that. Your CT surgeons have a better grasp.

You can do these either way, even with a #5 LMA and vapors. PTX is rare. Run the propofol and remi if you like to piss money away. Alfentanil and sevo do just as well.

Isn't Alfentanil more expensive than Remi?

 

[BuzzPhreed]

Isn't Alfentanil more expensive than Remi?

Not by a longshot.

 

[BuzzPhreed]

CONCLUSIONS: Both remifentanil and alfentanil provided a reasonably rapid and reliable recovery. The remifentanil-based TIVA was associated with high intraoperative cost and early postoperative pain, but it allowed a more rapid respiratory recovery.

http://www.ncbi.nlm.nih.gov/pubmed/12031745

 

[BuzzPhreed]

If I recall correctly from a P&T meeting sometime back a 2 ml vial of alfentanil was $4 wholesale whereas the powdered vial of remi wholesale was $47. Add to that you have to mix it and run it as an infusion. Pain in the rear. For an EBUS far easier to give small boluses of alfentanil. If you're doing a crani and need them super awake in the immediate post-op period then I agree remi is probably superior. Otherwise my opinion is that remi is pretty much an overpriced crap drug with limited clinical use. People who think it's superior or awesome or whatever have probably drank the drug-rep Koolaid.

 

[urge]

http://www.ncbi.nlm.nih.gov/pubmed/12031745

That's 12 years old. Prices are markedly different now.

 

[Sublimazing]

Where I train they do LMA and Tiva. Apparently the LMA is preferred because it allows them to visualize some of the superior nodes

At our dental surg center alfenta/prop is pretty normal (given our patient population)...at the med center though I see residents pull up remi then waste 85% of it after a 30-40min case and I just cringe

My attending made it seem that pneumo was a very real possibility.

 

[BuzzPhreed]

I don't think remi is off patent yet. And P&T info (from meeting I went to) was from like 2 years ago.

 

[BuzzPhreed]

http://www.drugs.com/availability/generic-ultiva.html

Has a generic version of Ultiva been approved?
No. There is currently no therapeutically equivalent version of Ultiva available in the United States.

 

[BuzzPhreed]

My attending made it seem that pneumo was a very real possibility.

Yeah they're good at needlessly scaring you. I've done probably at this point a few hundred of these and have yet to see a pneumo. Doesn't mean you shouldn't be prepared.

Our pulmonologists like to look at the cords on the way in so everyone gets a #5 LMA (even little old ladies) and a spray of lidocaine. No problems so far with sevo and a little alfentanil here and there when needed. Laryngospasm is also pretty rare too. Just get 'em deep fast and keep 'em deep for a short period of time. No need to get fancy.

 

[BuzzPhreed]

Remi is also more expensive because alfenta comes in much smaller packages (when normalized to potency). The 1000 mcg alfenta ampulla is the equivalent of about 50-100 mcg of remi, which is 2.5-5% of the remifentanil vial.

Most people will respond nicely to a 250-500 mcg bolus of alfentanil. It is gone within an hour when you're finished. I use it for sheaths in the angio suite. I use it for short procedures where there's a lot of stimulation but they're going to go home. And it is 1/10th the cost of remi. I never run it as an infusion. If I'm going to run an infusion, I use regular old fentanyl especially for my TIVA spines.

Other clinicians don't often use alfentanil because they either aren't familiar with it, don't think about it, or it's not on formulary. That's why I went to that particular P&T meeting.

 

[urge]

We have 1mg vials of remi. It is my impression that they are about $10-11.

 

[BuzzPhreed]

From 2012

The current market cost for remifentanil is $49.00 for a 1-mg vial

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3468288/

 

[Sublimazing]

We have 1mg vials of remi. It is my impression that they are about $10-11.

No way, we pay over 40.

Albuterol and Methylene Blue are also shockers on price.

 

[urge]

From 2012



http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3468288/

That is outrageously expensive. I am firm on my $10-11 1mg price for my hosp.

the best I could find online is:
http://faculty.washington.edu/bramhall/lectures/opioids/remife~1.htm

Current costs of synthetic opioids as determined by the University of Washington pharmacies are listed below for general comparative purposes (US$):
FENTANYL (250 mg) 0.42
SUFENTANIL (250 mg) 23.77
ALFENTANIL (2,500 mg) 15.95
REMIFENTANIL (5,000 mg) 61.03

 

[urge]

Found some old 2010 price for Remi at my hosp. $25 per 1mg/vial

I concede that Alfentanil is cheaper.

 

[urge]

Found some old 2010 price for Remi at my hosp. $25 per 1mg/vial

I concede that Alfentanil is cheaper.

Interestingly, the 20ml propofol is $1.50

 

[BLADEMDA]

Figure 1: Olympus BF-UC160F-OL8 endobronchial ultrasound bronchoscope. Saline filled syringe attached to balloon inflation port
Mediastinoscopy is the ‘gold standard’ method for determining the presence of nodal metastases in the mediastinum. Generally performed as an outpatient surgical procedure, it is associated with a low rate of serious adverse effects (<1%) and the procedure is highly accurate, with false negative rates reported to be between 6% and 9%. Endobronchial ultrasound (EBUS) guided fine needle aspiration biopsy of mediastinal nodes offers a less invasive alternative for histologic sampling of the mediastinal nodes. The procedure has been widely adopted by pulmonologists and is poised to replace mediastinoscopy in the future. For thoracic surgeons, the technique can be easily learned and it may be important to do so if our specialty is to maintain its traditional and important role in the diagnosis and staging of thoracic malignancies

 

[BLADEMDA]

Figure 1: Olympus BF-UC160F-OL8 endobronchial ultrasound bronchoscope. Saline filled syringe attached to balloon inflation port
Mediastinoscopy is the ‘gold standard’ method for determining the presence of nodal metastases in the mediastinum. Generally performed as an outpatient surgical procedure, it is associated with a low rate of serious adverse effects (<1%) and the procedure is highly accurate, with false negative rates reported to be between 6% and 9%. Endobronchial ultrasound (EBUS) guided fine needle aspiration biopsy of mediastinal nodes offers a less invasive alternative for histologic sampling of the mediastinal nodes. The procedure has been widely adopted by pulmonologists and is poised to replace mediastinoscopy in the future. For thoracic surgeons, the technique can be easily learned and it may be important to do so if our specialty is to maintain its traditional and important role in the diagnosis and staging of thoracic malignancies

LMA works fine with Vapor. At most an ETT if the dude is super slow or not too slick. Fiberoptic Intubation? I'm guessiung you want the practice as these patients rarely have an issue with standard induction.

Even the really BAD cases can be masked down gently with SEVO while the patient maintains spontaneous respirations. A touch of Propofol (0.5-0.7 mg/kg) prior to intubation and lidocaine to the cords under direct visualization.

 

[BLADEMDA]

In the United States EBUS is usually performed under general anesthesia with use of a laryngeal mask airway and intravenous anesthesia [1] (Figure 3). This permits evaluation of the upper paratracheal nodes which may not be accessible if an endotracheal tube is used. A standard fiber optic bronchoscope is first used to determine anatomy, clear secretions and ensure absence of endobrochial disease that might make EBUS superfluous. The EBUS scope is then advanced into the trachea. When manipulating the bronchoscope through the vocal cords it is important to note that the visualized image is at 30 degrees to the long axis of the bronchoscope. The balloon is then inflated so that a small crescent of it may be seen at the bottom of the fiber optic image (Figure 4). The image is inferior to that of a standard bronchoscope because of the smaller diameter of the fiber optic system required to accommodate the biopsy channel and ultrasound. The [US-EXT] button on the ultrasound processor (EU-C60; Olympus America Inc., Center Valley, PA) toggles between the fiber optic and ultrasound views (Figure 5). Use of 2 monitors or a single monitor with picture-in-picture display is useful

 

[urge]

To answer the OP,

I do them with an LMA with spontaneous ventilation of high dose Iso or Sevo, ~2 MAC on the dial, and phenylephrine drip for hypotension. You have to keep them very deep or they keep bucking. Tiva is also fine but a lot of time you end up ventilating them.

 

[chmd]

A pulmonologist at my hospital wants to place igel supraglottic airway devices with local and sedation and do the cases without anesthesiology helping out. He states that this is a very common practice. I'm not sure how I feel about that. I fear he'll end up doing heavy sedation and putting patients in danger. Thoughts?

 

[deleted171991]

A pulmonologist at my hospital wants to place igel supraglottic airway devices with local and sedation and do the cases without anesthesiology helping out. He states that this is a very common practice. I'm not sure how I feel about that. I fear he'll end up doing heavy sedation and putting patients in danger. Thoughts?

The i-gel is an excellent LMA in the right hands (and possibly the easiest to place). I personally have no experience with EBUS.

Try the Igel brand lma, we do thousands per year with these. Scope passes ez.

http://forums.studentdoctor.net/threads/bronchoscopy.977215/#post-13545725

 

[Arch Guillotti]

A pulmonologist at my hospital wants to place igel supraglottic airway devices with local and sedation and do the cases without anesthesiology helping out. He states that this is a very common practice. I'm not sure how I feel about that. I fear he'll end up doing heavy sedation and putting patients in danger. Thoughts?

Let him do it. Don't see the patient or put your name on the chart or have anything else to do with it.

 

[chmd]

Should we encourage the EDs interpretation of fasting requirements too? I kid of course. You're probably right about not caring what they do. I just can't imagine it working with light to moderate sedation.

 

[Impromptu]

Bump of a 2 year old thread. I am doing an EBUS later this week. I have been told that our pulmonologists prefer general anesthesia with an LMA. I like the idea of >1 MAC Sevo, phenylephrine, and possibly some topical lidocaine by the bronchoscopist.

Anyone have any updated ideas on how to do it?

 

[Laryngophed]

A pulmonologist at my hospital wants to place igel supraglottic airway devices with local and sedation and do the cases without anesthesiology helping out. He states that this is a very common practice. I'm not sure how I feel about that. I fear he'll end up doing heavy sedation and putting patients in danger. Thoughts?

I know your post is 2 year old, but at my place the pulm docs just do fiberoptic intubations on the patients and give boluses of propofol to keep the patients down while doing the procedure. The one I've seen do it the most has a pretty open bias against anesthesiologists and is pretty cowboy.


I was less than impressed.

 

[deleted171991]

Bump of a 2 year old thread. I am doing an EBUS later this week. I have been told that our pulmonologists prefer general anesthesia with an LMA. I like the idea of >1 MAC Sevo, phenylephrine, and possibly some topical lidocaine by the bronchoscopist.

Anyone have any updated ideas on how to do it?

i-gel is your friend. I haven't done any, by the way, but I've heard it from 2 places already.

 

[Scotty_G]

Yes I used to do them with an LMA or just a modified facemask.

 

[fakin' the funk]

In residency we usually did these with CookGas "Air-Q" LMAs, a bronch elbow, sevo, and spontaneous ventilation. These LMAs have a larger caliber breathing tube than a regular LMA. So you can use an appropriately sized LMA but still accommodate a FOB and exchange gas.

You can do just fine with propofol, lido, fentanyl or make it a tad more elegant with alfentanil or remifentanil.

 

[Impromptu]

Did a few of them today. From my perspective it was nearly identical to doing a super dimensional bronchoscopy, except using an LMA instead of an ETT. The first one was picture perfect. Starting with greater than 3% Sevo, then 25 mcg fentanyl and an infusion of phenylephrine. We also had the pulmonologist spray some 2% lidocaine on the vocal cords before passing. The patient maintained spontaneous breathing and woke up a minute or two afterward. It was picture perfect.

I think the second one would have benefited from an i-gel LMA had we had one. It took a little finagling to get our LMA to seat well. With the initial bronchoscope pass we saw that his glottic opening was quite deep with some excess mucosa covering most things. He didn't maintain breathing too well with the bronchoscope in (any slight dislocation of the LMA caused it to not work well). As the target lymph node was subcarinal (zone 7) we intubated with a 9.0 ETT and paralyzed. I could have struggled through and hand masked with the LMA, but this option worked better.

For either the Super D's or EBUS's I recommend using one of the ICU tube holders, rather than the typical tape They hold it in place pretty well.

 

[Fajardo04]

Propofol, place LMA, turn on gas. If you have LMA issues then propofol, sux, tube. Nothing fancy about these cases.

 

[vector2]

Abdelmalak from Cleveland gave us this presentation for a grand rounds not too long ago http://www.stahq.org/index.php/download_file/view/349/184/

The most interesting part was this Ramsay et al paper he cited where the guy used Precedex running anywhere from 7-10 mcg/kg/hr with sevo 1% for some spontaneous respiration airway procedures. I've come close to doses like this letting a large amount of precedex run in on a microdipper for AFOI's and I gotta say...the anesthesia is impressive.


Dexmedetomidine for anesthetic management of anterior mediastinal mass
http://link.springer.com/article/10.1007/s00540-010-0946-x

 

[Scotty_G]

Dam 7-10mcg/kg/hr!?!?!

 

[cchoukal]

Dopey academic comment: If you're planning to do these with an ETT, gas, and the cuff down, as someone reported above, consider the potential consequences of occupational exposure to anesthetic gases. This is a particular concern in the bronch suite, where room air turnover rates are generally not up to the same standard as proper ORs and where, in some cases, waste gas scavenge is into a filter, not wall suction. The consequences of occupational exposure are controversial, but it certainly won't make you smarter or MORE fertile to be breathing that stuff all day.

 

[kidthor]

I've done a number of these and generally I just do an asleep DL with an 8.0 or 8.5 ETT and then run Propofol, and Remi (no or minimal gas), with a little Fentanyl on induction and then right before waking up. I do muscle relax them with Rocuronium on induction (and maintain them to 2 twitches if I feel like it) then reverse them at the end. I've done it with an LMA but I don't really trust the pulm people enough to get things done quickly enough to ward off airway bad spirits. If I thought they'd be efficient it's a reasonable thing to do tough.

Running Precedex at 7-10mcg/kg/hr seems VERY high...

 

[subtle1epiphany]

I realize that many programs routinely have airways placed for EBUS, but where I was trained we tended to do the procedure following an airway examination with a P-180/190. After the airway exam, which was generally one with just normal variations, we go back down with the EBUS scope after additional lidocaine at the cords and midazolam/fentanyl. Rarely would we exceed 6-8 mg midazolam and 200 mcg fentanyl for the two bronchs together over the course of ~90 minutes from intake to recovery (procedure ~20-45 min, including on-site cytology).

I can recall one patient (out of >40-50 EBUS cases from my three years) where s/he was admitted, and that one was a woman with recurrent breast cancer encircling the Right mainstem bronchus that we got a little angry/bloody. I admitted her overnight, but discharged uneventfully the next AM.

Again, I know that many places routinely have anesthesia present and the patients are under MAC/general +/- muscle relaxation but not sure it's really necessary for this type of procedure. That said, we would in specific cases of either past high BZD/opioid requirements or anticipated difficulty (obstructing tumors, poor physiological reserve, etc) request anesthesia to provide assistance, but this was the exception rather than the common situation.

Just a couple thoughts, although reading the different approaches in anesthesia is always enjoyable and fascinating. It's a great specialty!

 

[Ignatius J]

LMA w/ the dilly cut out and a Propofol TIVA. May give them a little pressure support.