esophageal food impaction...tube or not

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Colba55o

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What are people's practices on adult patients who come in with esophageal food impactions? These patients are never NPO of course. Fortunately I trust the GI docs I work with and do propofol w/o a tube but I always dread these cases and feel like I'm not following standard of care for a patient who isn't appropriately NPO.
When do you decide to intubate?
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Colba55o said:
What are people's practices on adult patients who come in with esophageal food impactions? These patients are never NPO of course. Fortunately I trust the GI docs I work with and do propofol w/o a tube but I always dread these cases and feel like I'm not following standard of care for a patient who isn't appropriately NPO.
When do you decide to intubate?
Click to expand...

Every time.
They are actively pulling food out of a place much closer to the airway than the stomach, right past the airway. If you intubate for full stomach emergencies, why would this be different.
Exception would be a very light MAC where they are gagging the entire time on the scope and able to protect airway, which actually somehow seems more dangerous.
To me, these cases are not worth the risk to do as MAC, despite how frequently it works out just fine.


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Colba55o said:
What are people's practices on adult patients who come in with esophageal food impactions? These patients are never NPO of course. Fortunately I trust the GI docs I work with and do propofol w/o a tube but I always dread these cases and feel like I'm not following standard of care for a patient who isn't appropriately NPO.
When do you decide to intubate?
Click to expand...

i decided to intubate all of these patients about 5 years ago at the end of residency (and i do quite a bit of gi in sick patients without an ett)

we have great gi docs whom i trust in general, but i trust physiology more.

these cases sometimes take longer than advertised, full stomach, and a good old geta works great.

why risk propofol without a tube?
 
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nap$ter said:
these cases sometimes take longer than advertised, full stomach, and a good old geta works great.

why risk propofol without a tube?
Click to expand...

I had one take 7 hours in the middle of the night starting at 1AM (GI person was picking at the shrimp with biopsy forceps and refused to call ENT until we were 6 hours in when they couldn't push it into the stomach or pull it out). Glad the patient was intubated.
 
About 1/2 the time the GETA isn't necessary and a simple "MAC" would do. That said, the other 1/2 absolutely need an ETT. So, unless your crystal ball is working well that day I highly recommend you intubate all of them.
 
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I always do a tube. I had a guy with a piece of steak stuck for three hours. When the GI doc got it down he had about a liter of gastric fluid in his stomach that she sucked out. If he aspirated that stuff he would be toast and I would be in court. Nope, tube every time.
 
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Colba55o said:
What are people's practices on adult patients who come in with esophageal food impactions? These patients are never NPO of course. Fortunately I trust the GI docs I work with and do propofol w/o a tube but I always dread these cases and feel like I'm not following standard of care for a patient who isn't appropriately NPO.
When do you decide to intubate?
Click to expand...

You intubate people with "full stomachs" right?

Well, this is a full esophagus. That's closer to the trachea than the stomach. It's like a full stomach that goes to 11.
 
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Ashers said:
I had one take 7 hours in the middle of the night starting at 1AM (GI person was picking at the shrimp with biopsy forceps and refused to call ENT until we were 6 hours in when they couldn't push it into the stomach or pull it out). Glad the patient was intubated.
Click to expand...

What did the ENT do differently?
 
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I agree with all of the above. Especially the "takes longer than expected" part. It always seems like it should be simple to grab it and just pull it right on out. It rarely works out that way and it tends to come out piece meal. ETT is the safe way to go.
 
Ashers said:
She pushed it in the with scope when the GI person said it wasn't possible. The GI person has lost their privileges at the hospital for this among other reasons.
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I've seen them push too hard and the patient ended up in the OR for an esophageal perf.
 
Colba55o said:
What are people's practices on adult patients who come in with esophageal food impactions? These patients are never NPO of course. Fortunately I trust the GI docs I work with and do propofol w/o a tube but I always dread these cases and feel like I'm not following standard of care for a patient who isn't appropriately NPO.
When do you decide to intubate?
Click to expand...

Its not about trusting the GI doc as much as it is about trusting that the pt wont gag/cough/bring contents up/obstruct..etc. After all that, yes its then about making sure the GI guy is going to be quick an not drop the content into the pharynx accidentally as they are taking it out. Since I didn't go to fortune telling school, theres no way any of that can be predicted consistently and S*** can hit the fan very quickly. For this reason, the pt and I have a LOT to lose and NOTHING to gain from doing the case without a tube. Is there a time when you can do it w/o a tube? OF COURSE. You've been doing it all along so there's your answer. BUT that ONE DAY will come, maybe not today, tomorrow, next year.. but it will. And there will be no way to justify why you did it without a tube. The point is it's a GAMBLE and I only do that when the benefits>risks OR when I go to Vegas..
 
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Thanks for all the replies! I have been with my practice for almost 3 years and my 5 colleagues all do unprotected airway/MACs for these cases..so I just went along with the flow as the newbie. My chief at a former locum gig that I did straight out of residency also did them this way so I'm surprised to hear how uncommon this is in the rest of the world. Definitely something to think about
 
Colba55o said:
Thanks for all the replies! I have been with my practice for almost 3 years and my 5 colleagues all do unprotected airway/MACs for these cases..so I just went along with the flow as the newbie. My chief at a former locum gig that I did straight out of residency also did them this way so I'm surprised to hear how uncommon this is in the rest of the world. Definitely something to think about
Click to expand...

I did that too when I first started, and then I started thinking about how it's a full stomach. I know where you're coming from. I get a lot pressure in my group to do things the same way as everyone else, but I stopped listening to it when I think it's for patient safety.
 
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Colba55o said:
but I always dread these cases and feel like I'm not following standard of care
Click to expand...

This is why you should tube every time. I tube every time and the cases are no stress no brainers. If I'm doing something that causes "dread", I stop it.
 
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I was told as a resident that your anesthetic plan should not start with: I think I can get away with . . .
 
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Talked myself into doing a native airway for a 6 yo with a coin in the esophagus. NPO >8hrs, fast GI doc (figured it would literally take about 10 seconds), healthy kid, no chance of the foreign body breaking up into pieces. Of course this was the case where they dropped the coin in the pharynx and there were a couple dicey moments before I grabbed the Magills and the CRNA fished it out.

Never again. Figured this was a good warning sign early in my attending-hood. Tube every time for crap in the esophagus.
 
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When I arrived at my current job, the standard seemed to be to do these as MAC. I did one that way, as the new guy going with the flow. It went great, but by week 2 when I had a bit more attending self confidence, I switched. Now a few years later the standard has changed to ETT. No bad events, just a few discussions in our group meetings about risk vs benefit.


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Wow this thread has been eye opening

I'm a new attending and remember my first call for a food bolus. I'm thinking ett and the CRNA and GI team all looks at me like I've got three eyes. They insist MAC

GI doc assures me he will suck any residual gunk out while he pushes the bolus through... 2 min max.

I've done a couple cases this way, with MAC. No problems.

I think I'll be switching to GETA from now on. Our GI suite doesn't have an anesthesia machine so I guess we'll have to do tiva with an ambu bag.
 
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I recall a few times when on call, a kiddo swallowed something, I told my attendings my plan for an intubation. They told me MAC. Worked out fine but I'd still intubate if it was just me.
 
I can't remember if I read it here or if one of my attendings said it to me, but "I have never regretted 'tubing someone. I have regretted not 'tubing someone."
 
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So yesterday I had an esophageal foreign body. A healthy lady with a piece of wire in the esophagus. I RSI the lady and as I was incubating I saw the wire sticking out of the goose. Had magills and tube. Decision time pull the wire or place the tube. I placed the tube and the wire was pushed further in. Surgeon did his rigid DL and pulled the wire. Pt did fine but always place the tube: )
 
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WholeLottaGame7 said:
Talked myself into doing a native airway for a 6 yo with a coin in the esophagus. NPO >8hrs, fast GI doc (figured it would literally take about 10 seconds), healthy kid, no chance of the foreign body breaking up into pieces. Of course this was the case where they dropped the coin in the pharynx and there were a couple dicey moments before I grabbed the Magills and the CRNA fished it out.

Never again. Figured this was a good warning sign early in my attending-hood. Tube every time for crap in the esophagus.
Click to expand...

I've seen that very scenario play out several times over. The tube-every-time people get a lot of push back from the I'll-only-be-a-second procedure docs, who cheer when they get assigned one of the (generally newer) attendings who will go along with them. But the list of tube-every-time people grows every time they run into something like this.
 
ZzzPlz said:
I think I'll be switching to GETA from now on. Our GI suite doesn't have an anesthesia machine so I guess we'll have to do tiva with an ambu bag.
Click to expand...

Our GI suite has state of the art endoscopy equipment hanging on ceiling-mounted swivel arms; however it doesn't have an anesthesia machine. Any unscheduled / unfasted case goes to an OR and gets ETT. The circulator fetches the portable cart with the pre-swivel arm GI equipment and monitor, and rolls it to the OR.
 
MAC every time, unless there are other reasons to use the ETT. That is what everyone does around here. Maybe I'll start bending the trend toward ETTs.
 
I did way too many food bolus cases in my last job. I felt I was in the Mecca for food bolus impactions. I always ended up doing an RSI with ETT. There patient almost always had tons of secretions secondary to impaction and were often found to have emesis bags just spitting secretions. I have seen way too many going down to pulls pieces after pieces of food in esophagus out. It's smart to protect the airway and save the stress of a MAC with these patients. I beg you to save your sphincter and tube them.


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Why on Earth would you NOT tube them? Am I missing something?

Do you skip this important step just to save 60 seconds?
 
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Had to bump this up...

So was on call Saturday at my pediatric hospital, and we get an otherwise healthy 14yo male with food impaction (chicken from like 2 days ago...)
So my plan (like usual) is oxygenate, and then RSI with prop, sux, tube and then twiddle thumb.

My attending (10 days away from finishing this fellowship...) takes one look at the sux syringe and is like... whoa whoa whoa... I'm not so sure about that. Um... OK. So now the plan is prop, +/-roc, tube... Granted this is a 14yo 5'5" that weighs 61kg (134lbs.) Banana for scale, I'm a 31 year old who is 5'8, 140lbs...

So we get back to the room. Preoxygenate, place some cricoid (yea yea whatever..) and he pushes like 60mg lidocaine, 100mg of propofol and the kid drifts off. He then starts bagging the kid... and then using my magical powers of propofol knowledge decide to attempt to intubate. Yea... that's not happening. Mouth barely opens. He pushes 20mg(?!?!?!) of roc (WTF?!?!?!?!?!) and continues to bag.

I wait another 30 seconds and just go for it. Grade 1 view. ETT in. +ETCO2. On vent. Thumb twiddling commences. LOTS of thumb twiddling. Endo scope not working. Endo attending has no clue how to fix. On phone with endo tech for 30 minutes... (How come surgeons are allowed to waste time, yet if my equipment malfunctions thy get all pissy?) Then she lets the fellow do the scope and it appears the fellow has no clue how to use the scope nor have any idea the anatomy of the airway/esophagus... Here's a hint, the trachea is IN FRONT of the easophagus. So when you keep seeing my ETT, you should probably back out and readjust. They then proceed to take over an hour to pick apart this chicken, and then after that end up just shoving most of it into the stomach... (Couldn't they have attempted that from the start..?!)

Then my attending questions my judgment of reversing the patient with glyco/neo, since it had been over an hour and the costs. Not only did I have to mention the APSF recs that pretty much everyone should be reversed, but the fact is the kid didn't get a twitch back until about 30-35 minutes despite the mini-dose of roc given. (was about to call for a new set of batteries thinking the twitch monitor wasn't working) And he didn't have 4/4 twitches until about 5-10 minutes before they finished. (All of this wouldn't have been necessary with sux... although I always check twitches at least once after sux dosing)

What a frustrating case... Can't wait to be done training. Although in August when I'm supervising I won't be in the rom the whole time to see some of this stuff...

And to top off the call, I got a 530AM wake up page for 17 month old with likely (and fiberoptic confirmed) epiglottitis. Get down to ED to see resp therapy suctioning the kid... FCOL!!! Went up to OR, masked him down (although he did have two IVs which is another debate...) scoped the patient, and then DL'ed and tubed him.. Got a fist bump from the gen surg and ENT attendings just as the CRNA walked in to relieve me of my duties at 7am. Fun times...
 
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sigrhoillusion said:
Had to bump this up...

So was on call Saturday at my pediatric hospital, and we get an otherwise healthy 14yo male with food impaction (chicken from like 2 days ago...)
So my plan (like usual) is oxygenate, and then RSI with prop, sux, tube and then twiddle thumb.

My attending (10 days away from finishing this fellowship...) takes one look at the sux syringe and is like... whoa whoa whoa... I'm not so sure about that. Um... OK. So now the plan is prop, +/-roc, tube... Granted this is a 14yo 5'5" that weighs 61kg (134lbs.) Banana for scale, I'm a 31 year old who is 5'8, 140lbs...

So we get back to the room. Preoxygenate, place some cricoid (yea yea whatever..) and he pushes like 60mg lidocaine, 100mg of propofol and the kid drifts off. He then starts bagging the kid... and then using my magical powers of propofol knowledge decide to attempt to intubate. Yea... that's not happening. Mouth barely opens. He pushes 20mg(?!?!?!) of roc (WTF?!?!?!?!?!) and continues to bag.

I wait another 30 seconds and just go for it. Grade 1 view. ETT in. +ETCO2. On vent. Thumb twiddling commences. LOTS of thumb twiddling. Endo scope not working. Endo attending has no clue how to fix. On phone with endo tech for 30 minutes... (How come surgeons are allowed to waste time, yet if my equipment malfunctions thy get all pissy?) Then she lets the fellow do the scope and it appears the fellow has no clue how to use the scope nor have any idea the anatomy of the airway/esophagus... Here's a hint, the trachea is IN FRONT of the easophagus. So when you keep seeing my ETT, you should probably back out and readjust. They then proceed to take over an hour to pick apart this chicken, and then after that end up just shoving most of it into the stomach... (Couldn't they have attempted that from the start..?!)

Then my attending questions my judgment of reversing the patient with glyco/neo, since it had been over an hour and the costs. Not only did I have to mention the APSF recs that pretty much everyone should be reversed, but the fact is the kid didn't get a twitch back until about 30-35 minutes despite the mini-dose of roc given. (was about to call for a new set of batteries thinking the twitch monitor wasn't working) And he didn't have 4/4 twitches until about 5-10 minutes before they finished. (All of this wouldn't have been necessary with sux... although I always check twitches at least once after sux dosing)

What a frustrating case... Can't wait to be done training. Although in August when I'm supervising I won't be in the rom the whole time to see some of this stuff...

And to top off the call, I got a 530AM wake up page for 17 month old with likely (and fiberoptic confirmed) epiglottitis. Get down to ED to see resp therapy suctioning the kid... FCOL!!! Went up to OR, masked him down (although he did have two IVs which is another debate...) scoped the patient, and then DL'ed and tubed him.. Got a fist bump from the gen surg and ENT attendings just as the CRNA walked in to relieve me of my duties at 7am. Fun times...
Click to expand...
Why did your attending not want to use sux? Risk of undiagnosed myopathy is virtually nonexistent in an asymptomatic 14 year old and the use of succinylcholine is not contraindicated in an emergency with aspiration risk.
 
Chloroform4Life said:
Why did your attending not want to use sux? Risk of undiagnosed myopathy is virtually nonexistent in an asymptomatic 14 year old and the use of succinylcholine is not contraindicated in an emergency with aspiration risk.
Click to expand...
This is why fellowships sometimes make people more stupid... this "attending" is at the end of his pediatric fellowship and that means they filled his head up with all the crap he can handle, now it's going to take him years of practice on unlearn all that useless dogma!
 
Planktonmd said:
This is why fellowships sometimes make people more stupid... this "attending" is at the end of his pediatric fellowship and that means they filled his head up with all the crap he can handle, now it's going to take him years of practice on unlearn all that useless dogma!
Click to expand...
Heh, he knows it's crap already.

Sometimes bad role models are useful warnings ...
 
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Pretty much sux paranoia...

"Undiagnosed" myopathies, plus myalfias, plus supposedly he had a kid go asystolic with sux like 20-30 years ago...

Fine you don't want to use sux... But what's with the wimpy roc dose and manually ventilating?? Give the RSI dose and do the true RSI. Granted nothing went wrong... This time...

It's actually lucky we used a small dose and the GI docs were slow or else he might have give to pacu intubated if it only took them 10 minutes.
 
sigrhoillusion said:
Pretty much sux paranoia...

"Undiagnosed" myopathies, plus myalfias, plus supposedly he had a kid go asystolic with sux like 20-30 years ago...

Fine you don't want to use sux... But what's with the wimpy roc dose and manually ventilating?? Give the RSI dose and do the true RSI. Granted nothing went wrong... This time...

It's actually lucky we used a small dose and the GI docs were slow or else he might have give to pacu intubated if it only took them 10 minutes.
Click to expand...

Once sugammadex is readily available you are going to see a lot more sux paranoia unearthed, which is unfortunate.
 
Timely topic for our group as we are getting pressure from GI to push propofol in the ED for these cases because "everybody else does it." We drafted a policy with some claims data and went straight to admin. These patients will come to endo where we have our equipment or GI is welcome to leave us out of it.
 
You Don't understand how many Times I'm on call and the attending refuses to use sux. One gen surgeon here does lap appy in 15-20 minutes. It's like they push the roc and i pray...
 
On a side note, what are everyone's opinions on academic teaching on overnight/weekend coverage?

Look we've all been through medical school and training, and not all of us were born rockstars (well not all of us...) but aren't there 5 weekdays from 6am to 6pm that provide at least SOME adequate teaching for these trainees? I shouldn't be doing a food impaction case at 6pm on a Saturday that the attending is teaching the fellow how to scroll the wheel on the endoscope... It's just inappropriate. This is an urgent/emergent case. You get in and get out... You don't want to be spending 2 hours in the OR mucking around when an actual emergency rolls through the ER. The bigger question is when did this fellow start? It's May! Even if it's her first year, that still gives you 10 months prior to practice and learn. That would be like me not having intubated at this point... the orthopods did the same thing earlier that day letting the resident do the pinning. See one, teach one, do one perhaps...? Shouldn't be holding his hand through a pinning when you have 3 other cases booked that day.

Same thing on OB when you've just sat through a 2+hour "urgent" C-section and then they let the medical student close. Don't they have at least 3 other weeks on their rotation where they can close skin? That way they can take their sweet time and at least you have other coverage around incase other things need to get done.


Grrr... The bitterness is strong in me right now. 10 days... 10 days... 10 days... And I know! It only gets worse from here. haha
 
Succinylcholine myalgias suck. I speak from personal myalgic experience. I avoid it when there's no indication for it.

But when it's the right drug, it's the right drug.
 
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GravelRider said:
Once sugammadex is readily available you are going to see a lot more sux paranoia unearthed, which is unfortunate.
Click to expand...
No what we are seeing is a trend of "deep mucle relaxation is (suddenly) so much better for surgery" and how convenient it is to just reverse with sugammadex...
 
Chloroform4Life said:
Why did your attending not want to use sux? Risk of undiagnosed myopathy is virtually nonexistent in an asymptomatic 14 year old and the use of succinylcholine is not contraindicated in an emergency with aspiration risk.
Click to expand...

He sounds ******ed, some people during residency serve as examples of what not to do.
First mistake no rapid sequence. Second mistake being afraid of succinylcholine, especially in this patient. Third mistake ventilating patient who should have ample oxygen reserve. Fourth mistake using poorly thought out dose of roc. Fifth mistake is not wanting to reverse the patient. Which ones did I miss? It's frightening that this person is an attending at a Children's Hospital.

--
Il Destriero
 
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dhb said:
No what we are seeing is a trend of "deep mucle relaxation is (suddenly) so much better for surgery" and how convenient it is to just reverse with sugammadex...
Click to expand...

I had a surgeon mention to me the other day how we can keep the patient at zero twitches until they are done closing because we now have sugammadex available at our hospital.
 
partydoc said:
I had a surgeon mention to me the other day how we can keep the patient at zero twitches until they are done closing because we now have sugammadex available at our hospital.
Click to expand...
Sure. And because we have blood at the hospital, we don't need to carefully cauterize all bleeding sites.
 
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