Out of OR case

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50 something male admitted 2 days prior for dizziness, melena, HCT 20, now scheduled for EGD in an in-hospital GI suite 3 floors away from OR. Still having melena, on PPI gtt and octreotide gtt. Has been pounding EtOH and NSAIDs to treat toe pain (chronic osteo). Does not walk. Does not take prescribed meds as outpatient, as inpatient on lasix and beta blocker

PMH: EtOH/HCV cirrhosis, cocaine/meth abuse, HTN, CAD, pulmonary HTN, COPD, current smoker, Afib, BMI 36

Labs: HCT 23 after tranfusion, INR 1.5, PLT 80, Albumin 2.2, Creatinine 1.9 (down from admission 2.3), K 4.6, HCO3 22 baseline 31

Exam: sat 93 2L NC, HR 110-150's Afib, BP 120s/70s, RR teens, alert, angry and grumpy, appears short of breath, generally hyperesthetic (screams upon placing pulse-ox probe), no JVD, +spiders, abdomen obese no frank ascites, airway MP3, TMD OK, no neck ROM, teeth poor, 20g PIV in forearm

Your plan, doctor?

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Tell him he has to cooperate if he does not want to die, good topical anesthesia to the airway, then transtracheal Lidocaine, do awake Glidscope or awake FOB which ever you prefer, once intubated the GI guy can go to work.
If he does not cooperate give some Ketamine and do the above.
 
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Secure the airway with AFOI. Also move the case to the main OR if possible.

Yep. He's sick enough that he qualifies to have his case NOT done out of OR. This may cause a severe case of grouchiness in the endoscopist, but it's worth it. If things go you-know-where in a handbasket, you will be grateful that you're not off in a corner of the hospital.
 
50 something male admitted 2 days prior for dizziness, melena, HCT 20, now scheduled for EGD in an in-hospital GI suite 3 floors away from OR. Still having melena, on PPI gtt and octreotide gtt. Has been pounding EtOH and NSAIDs to treat toe pain (chronic osteo). Does not walk. Does not take prescribed meds as outpatient, as inpatient on lasix and beta blocker

PMH: EtOH/HCV cirrhosis, cocaine/meth abuse, HTN, CAD, pulmonary HTN, COPD, current smoker, Afib, BMI 36

Labs: HCT 23 after tranfusion, INR 1.5, PLT 80, Albumin 2.2, Creatinine 1.9 (down from admission 2.3), K 4.6, HCO3 22 baseline 31

Exam: sat 93 2L NC, HR 110-150's Afib, BP 120s/70s, RR teens, alert, angry and grumpy, appears short of breath, generally hyperesthetic (screams upon placing pulse-ox probe), no JVD, +spiders, abdomen obese no frank ascites, airway MP3, TMD OK, no neck ROM, teeth poor, 20g PIV in forearm

Your plan, doctor?


CAD and HCT 20 is a problem. I would have endoscopist wait, start another IV (18 or 16), transfuse 2 more units rbc. Change him to NRB at 100% fio2. Recheck HCT. If > or = to 25 After transfusion and oxygenation, RSI with etomidate and sux. Glidescope intubation. Im not sure I would force the endoscopist to do it in the OR, I think I could do all these safely in the ICU. Then id just bag him with an ETCO2 equipped portable monitor throughout the case. Neo for hypotension/AF rate control. Beta blocker if pressure holds.

Overall seems like this guy is a mess and not a super urgent situation, so I would have them tune him up prior
 
I think I could do all these safely in the ICU.

I didn't get a sense that the pt is in the icu. I imagine he is one of those who pushes his IV pole to the cafeteria and steps out to smoke every now and then.
 
The guy's BMI is 36, he has no neck and possibly has a stomach full of blood!
I don't think that rules you out of a MAC.

The hardest part to deal with will be the low sats. I'll stick an LMA if he desats.

BTW, full stomach in the endo suite is like having CAD in the CABG room.
 
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50 something male admitted 2 days prior for dizziness, melena, HCT 20, now scheduled for EGD in an in-hospital GI suite 3 floors away from OR. Still having melena, on PPI gtt and octreotide gtt. Has been pounding EtOH and NSAIDs to treat toe pain (chronic osteo). Does not walk. Does not take prescribed meds as outpatient, as inpatient on lasix and beta blocker

PMH: EtOH/HCV cirrhosis, cocaine/meth abuse, HTN, CAD, pulmonary HTN, COPD, current smoker, Afib, BMI 36

Labs: HCT 23 after tranfusion, INR 1.5, PLT 80, Albumin 2.2, Creatinine 1.9 (down from admission 2.3), K 4.6, HCO3 22 baseline 31

Exam: sat 93 2L NC, HR 110-150's Afib, BP 120s/70s, RR teens, alert, angry and grumpy, appears short of breath, generally hyperesthetic (screams upon placing pulse-ox probe), no JVD, +spiders, abdomen obese no frank ascites, airway MP3, TMD OK, no neck ROM, teeth poor, 20g PIV in forearm

Your plan, doctor?

This case is an average afternoon add-on for endoscopy.

Does the patient have a history of esophageal varices that may need banding? If so, then probably intubate. If not, maybe still intubate. Would not bring to the OR and would not do an awake fiberoptic intubation. If a tube is necessary use the glidescope.
 
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Did it the other day :p What i usually agree to is to sedate the patient once the GI guy has checked that the stomach is empty, or else we'll do it in the OR which they hate even more
 
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This is not a MAC case.

My plan RSI and secure the airway with whatever our best first attempt may be. Probably glidescope.
 
Mac versus GA ETT after RSI and glidescope. Most times its MAC. Do this stuff all the time, usually at the beside in the ICU. Biggest decider for me is how easily the patient gets sedated, sometimes these patients require a ton to get sedated and then they are apnea.

Without actually seeing the patient and getting an understanding of the airway risk or full stomach risk, hard to say over the internet. Also depends on how the endoscopist is, some will shove the scope in quick and start suctioning.
 
Mac versus GA ETT after RSI and glidescope. Most times its MAC. Do this stuff all the time, usually at the beside in the ICU. Biggest decider for me is how easily the patient gets sedated, sometimes these patients require a ton to get sedated and then they are apnea.

Without actually seeing the patient and getting an understanding of the airway risk or full stomach risk, hard to say over the internet. Also depends on how the endoscopist is, some will shove the scope in quick and start suctioning.

Gargle lidocaine.

Usual MaC plan.

No need to intubate as long as airway supplies are available.
 
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Only thing about using the Glide on this is that a little bit of blood in the oropharynx will red-out your image instantly. In the past I'd have used a Glide on it, nowadays I'd lean towards awake FOB.
 
Mac versus GA ETT after RSI and glidescope. Most times its MAC. Do this stuff all the time, usually at the beside in the ICU. Biggest decider for me is how easily the patient gets sedated, sometimes these patients require a ton to get sedated and then they are apnea.

Without actually seeing the patient and getting an understanding of the airway risk or full stomach risk, hard to say over the internet. Also depends on how the endoscopist is, some will shove the scope in quick and start suctioning.

Known or suspected full stomach = NG tube placement prior to start of case. Nurses place NG tubes on the floor all the time. I've never gotten why most anesthesiologists seem allergic to this. Give them some sedation and lidocaine jelly, small NG tube, and get that stomach empty. Beats a goat rodeo going on with the fiber optic in the endo suite. And before anyone says "but I do the best FOIs", I've heard that time and time again only to walk into an absolute circus. Superior laryngeal nerve blocks, nebulizer lidocaine, transtracheal blocks, etc. still sometimes don't save you.
 
Known or suspected full stomach = NG tube placement prior to start of case. Nurses place NG tubes on the floor all the time. I've never gotten why most anesthesiologists seem allergic to this. Give them some sedation and lidocaine jelly, small NG tube, and get that stomach empty. Beats a goat rodeo going on with the fiber optic in the endo suite. And before anyone says "but I do the best FOIs", I've heard that time and time again only to walk into an absolute circus. Superior laryngeal nerve blocks, nebulizer lidocaine, transtracheal blocks, etc. still sometimes don't save you.

I don't get why people would attempt an awake FOI on a full stomach. Aren't you purposely blunting their airway protection reflexes? The truth is most of the airway blocks/topical are incomplete. So you end up with the worst of both worlds: a patient who reacts to stimulation but cannot fully protect his airway.
 
I don't get why people would attempt an awake FOI on a full stomach. Aren't you purposely blunting their airway protection reflexes? The truth is most of the airway blocks/topical are incomplete. So you end up with the worst of both worlds: a patient who reacts to stimulation but cannot fully protect his airway.
When you have a full stomach + likely difficult intubation anything but awake intubation is gambling your patient's life, you might get lucky but what if you don't?
And it does not have to be FOB, it can be any method of intubation just do it AWAKE and without turning a semi urgent controlled situation into a disaster.
As for the argument against airway blocks because the stomach is full and you don't want to suppress the airway reflexes, it's much better to vomit while you are still breathing spontaneously and some one is right there with suction than to vomit after someone gave you a muscle relaxant and foolishly took away your ability to breath.
 
, it's much better to vomit while you are still breathing spontaneously
So you can take a breath and aspirate?
to vomit after someone gave you a muscle relaxant and foolishly took away your ability to breath
So you cannot take a breath and cannot aspirate?
 
Interesting that everyone above who mentions indirect laryngoscope names the Glidescope. In anesthesia circles, is this favored over the C-MAC? I'm an EM resident and definitely prefer the Storz. Thoughts?
 
Interesting that everyone above who mentions indirect laryngoscope names the Glidescope. In anesthesia circles, is this favored over the C-MAC? I'm an EM resident and definitely prefer the Storz. Thoughts?
The Glidescope has a pronounced curvature that makes it more suitable for anterior airways, which are the difficult ones.

The Storz C-mac is just a Mac blade with a video camera on it. It was designed to help teach intubation, so that the instructor could see what the trainee saw. Whatever you see with the C-Mac you ought to be able to visualize directly.

Storz does make a blade with a more pronounced curve ( the "D blade" I believe it's called), but the Glidescope curvature is optimal IMO.
 
patient is in Afib with rvr. I never take these guys lightly. I would first see what i could do (blood, fluid, beta-blockers) to get HR down over the next few hours before doing the EGD. Once HR is under control, rsi in the GI suite.
 
So which one is better: Not breath and die.... or breath and aspirate but someone with a suction makes sure you don't aspirate too much???
1 The palliative care folks will tell you that many people prefer the first scenario rather than ending up trached in an icu.

2 Why do you assume that you cannot intubate? In this age anybody who has a decent mouth opening (without anything blocking your access) can be intubated relatively safely with an RSI.
 
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1 The palliative care folks will tell you that many people prefer the first scenario rather than ending up trached in an icu.

2 Why do you assume that you cannot intubate? In this age anybody who has a decent mouth opening (without anything blocking your access) can be intubated relatively safely with an RSI.
You know... I hate to say it... but I cringe when I think that you are out there teaching new residents what to do!
 
50 something male admitted 2 days prior for dizziness, melena, HCT 20, now scheduled for EGD in an in-hospital GI suite 3 floors away from OR. Still having melena, on PPI gtt and octreotide gtt. Has been pounding EtOH and NSAIDs to treat toe pain (chronic osteo). Does not walk. Does not take prescribed meds as outpatient, as inpatient on lasix and beta blocker

PMH: EtOH/HCV cirrhosis, cocaine/meth abuse, HTN, CAD, pulmonary HTN, COPD, current smoker, Afib, BMI 36

Labs: HCT 23 after tranfusion, INR 1.5, PLT 80, Albumin 2.2, Creatinine 1.9 (down from admission 2.3), K 4.6, HCO3 22 baseline 31

Exam: sat 93 2L NC, HR 110-150's Afib, BP 120s/70s, RR teens, alert, angry and grumpy, appears short of breath, generally hyperesthetic (screams upon placing pulse-ox probe), no JVD, +spiders, abdomen obese no frank ascites, airway MP3, TMD OK, no neck ROM, teeth poor, 20g PIV in forearm

Your plan, doctor?
The first question I would ask is if this is level 1 emergent or can it wait a few hours? I think this can wait a little longer to get a few of his comorbidities under better control, such as his AF with RVR, check the tox screen, check chest x-ray and ABG. Why is he short of breath? Is it COPD exacerbation? Is it fluid overload, heart failure? If I could tone him up a little, I would.

Next, do you want to empty his stomach prior to the procedure? Because this is melena and not hematemesis there is less of a risk, but I would inquire about his history of varices. Depending on the answers, if I suctioned his stomach, I would use an OG rather than an NG because of his coagulopathies.

The next question is what kind of anesthetic will I give him? I would intubate the patient because of the potential for a full stomach as well as unseen ascites requiring more GI precautions. If the airway looked otherwise normal I would perform a rapid sequence induction with several options for emergency airway near by, such as my fiberoptic video laryngoscope of choice (C-Mac, Glidescope, McGrath) as well as my fiberoptic bronchoscope. Most obese patients can be successfully intubated if their airway looks otherwise normal. My goals would be to provide as much cardiovascular stability as possible with an RSI, so I would use fentanyl, etomidate, and succinylcholine. I would have pressors and vasodilators available.
 
You know... I hate to say it... but I cringe when I think that you are out there teaching new residents what to do!
Checkmate. Ad hominem attack.
Description: Attacking the person making the argument, rather than the argument itself, when the attack on the person is completely irrelevant to the argument the person is making.

Ad hominem attacks are usually made out of desperation when one cannot find a decent counter argument.


:)
 
Urge, the OP said that the patient has a MPT 3 and no Neck ROM. That plus possibility of a full stomach makes people want to do an AFAI.
BTW people can aspirate when apneic due to simple gravity. Head is usually elevated on intubation. So unless the bed is TBerged there is always that possibility. It has happened to me.
 
50 something male admitted 2 days prior for dizziness, melena, HCT 20, now scheduled for EGD in an in-hospital GI suite 3 floors away from OR. Still having melena, on PPI gtt and octreotide gtt. Has been pounding EtOH and NSAIDs to treat toe pain (chronic osteo). Does not walk. Does not take prescribed meds as outpatient, as inpatient on lasix and beta blocker

PMH: EtOH/HCV cirrhosis, cocaine/meth abuse, HTN, CAD, pulmonary HTN, COPD, current smoker, Afib, BMI 36

Labs: HCT 23 after tranfusion, INR 1.5, PLT 80, Albumin 2.2, Creatinine 1.9 (down from admission 2.3), K 4.6, HCO3 22 baseline 31

Exam: sat 93 2L NC, HR 110-150's Afib, BP 120s/70s, RR teens, alert, angry and grumpy, appears short of breath, generally hyperesthetic (screams upon placing pulse-ox probe), no JVD, +spiders, abdomen obese no frank ascites, airway MP3, TMD OK, no neck ROM, teeth poor, 20g PIV in forearm

Your plan, doctor?
Ok I'll attempt a plan.
I would first get better access. Then transfuse a couple units PRBCS along with some FFP. Hopefully, this will stabilize him some AND NOT WORSEN HIS CHF. If it does then we know how to treat this as well. But we need to get on with this case because he is bleeding and it isn't going to improve without controlling the bleeders.
Next, assuming this helped, I would proceed with RSI for a couple reasons. First, he is what I consider uncooperative and I don't want to be fighting him. Im not gonna sedate this guy the way he will need in order to perform AFOI because he is a full stomach just wait to spew HCV blood all over the place. I'm also not sending an OG tube down cuz I assume he has bleeding varies and I don't want more bleeding. If this bleeds more then it won't stop and we are in trouble
Also, I'm not doing this under MAC because these cases can last longer than usual when trying to get control of bleeding varies. I'm not gonna sit there and watch the GI guy struggle all while trying to sedate this nightmare pt. if he has spider veins then I assume he has varies. I guess I could be wrong tho. I'm not gonna wait to find out. This is varies until proven otherwise.
 
This case goes to OR no matter what. Anytime you have a cirrhotic patient you have to think portal HTN and you have to think varices. Tube the guy. Also, he has cirrhosis and pulm HTN so you have to think he has hepato-pulm syn. Depending on how bad his pulm HTN is he may desat very quickly, especially considering his other issues and that may be particularly problematic and worsen his pulm HTN. Also, if he has varices then you want him immobile for the procedure. He bucks on the scope and tears one of those it can be game over and bleed out by the time you tube him.
 
EGD without sedation i'll go have a coffee
I was debating who to agree with but, if I think better about this, dhb is right. If a consentable patient is disrespectful/uncooperative, you should walk away. Nothing emergent here.
 
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50 something male admitted 2 days prior for dizziness, melena, HCT 20, now scheduled for EGD in an in-hospital GI suite 3 floors away from OR. Still having melena, on PPI gtt and octreotide gtt. Has been pounding EtOH and NSAIDs to treat toe pain (chronic osteo). Does not walk. Does not take prescribed meds as outpatient, as inpatient on lasix and beta blocker

PMH: EtOH/HCV cirrhosis, cocaine/meth abuse, HTN, CAD, pulmonary HTN, COPD, current smoker, Afib, BMI 36

Labs: HCT 23 after tranfusion, INR 1.5, PLT 80, Albumin 2.2, Creatinine 1.9 (down from admission 2.3), K 4.6, HCO3 22 baseline 31

Exam: sat 93 2L NC, HR 110-150's Afib, BP 120s/70s, RR teens, alert, angry and grumpy, appears short of breath, generally hyperesthetic (screams upon placing pulse-ox probe), no JVD, +spiders, abdomen obese no frank ascites, airway MP3, TMD OK, no neck ROM, teeth poor, 20g PIV in forearm.

Thanks for the responses everyone, and sorry for the long wait for more info.

Case discussed with GI docs. They are expecting to find no smoking gun to intervene on, planning to NOT do any interventions, and actually they are of the opinion he's done bleeding and is just clearing old blood with the current melena. They think it's NSAID/EtOH gastritis; not expecting to find fat varices. HCT has been metastable since transfusion (at admission). Teaching point: choosing the plan for this case depends heavily on the intended procedure (intervention vs no, what type of pathology expected).

Previous anesthesia record, from a similar admission for similar problems. RSI'd, Grade 3, ETT able to be passed.

Current TTE (done day of case): LV fxn OK, LV small, RV pressure overload with IV septum and IA septum bowed toward left, RV FAC ok, mod-severe TR, est RVSP 40+CVP (keep in mind Afib). Cardiology fellow says "TTE consistent with volume overload," keep in mind, no JVD no peripheral edema, i.e., no clinical signs of decompensated R/L heart failure or volume overload. I take all this to mean, this patient has pulm HTN but not RV failure, volume status is OK. Nonetheless, probably minimal RV reserve and the TTE looked pretty unhealthy. I was in no mood to let this dude hypoventilate/desat with a MAC given all of the above plus obesity etc. Teaching point: correlate your test results with the patient in front of you.

This is in an in-hospital GI suite like I said. You have an anesthesia machine, pressure transducers for art line etc, and an anesthesia tech with you the whole case.

Anyone have any change of plans or new thoughts now? (I'm drawing this out a little bit for the sake of discussion and for my own education btw...not necessarily because an EGD on a polysubstance abuser is that rare or novel ;))
 
Funsies, portopulmonary hypertension (note: distinct entity from hepatopulmonary syndrome).

Not terrible though, sounds a little less than half systemic (CVP of 15 is a reasonable assumption, so PASP sounds like it's 55 mmHg-ish and systemic pressure is 120).

The only change in my management then is to make vasopressin my first line pressor. As everyone undoubtedly knows, vaso will increase the SVR without increasing PVR, making it a useful tool in the setting of pulm htn. Annoyingly, vaso is one of those drugs (along with neostigmine) that went from generic to brand name, making it go from pennies to multiple dollars. Yay, supply and demand.

Before that as other posters have mentioned I would probably start a better IV and get some hemoglobin circulating. The bicarb 22 from 31 is concerning. Homeboy has an oxygen delivery issue.

The RVR and question of whether to RSI and whether to a-line is a tough one. For me this would come down to looking at the guy and the echo myself. With just the data presented, my plan would probably involve:

No a-line (if cuff pressures are shady for any reason, or if I get a spidey-sense tingle, this changes), and an alfentanil (for the HR more than anything else)/low dose ketamine/low dose propofol/sux RSI after good preoxygenation in the head-up position, and I'd use a Glidescope with a documented previous grade 3 view.

All that said, if this dude is a cokehead/tweaker, you can do whatever the hell you want to him, you're not gonna hurt him. Those dudes are indestructible.
 
Thanks for the responses everyone, and sorry for the long wait for more info.

Case discussed with GI docs. They are expecting to find no smoking gun to intervene on, planning to NOT do any interventions, and actually they are of the opinion he's done bleeding and is just clearing old blood with the current melena. They think it's NSAID/EtOH gastritis; not expecting to find fat varices. HCT has been metastable since transfusion (at admission). Teaching point: choosing the plan for this case depends heavily on the intended procedure (intervention vs no, what type of pathology expected).

Previous anesthesia record, from a similar admission for similar problems. RSI'd, Grade 3, ETT able to be passed.

Current TTE (done day of case): LV fxn OK, LV small, RV pressure overload with IV septum and IA septum bowed toward left, RV FAC ok, mod-severe TR, est RVSP 40+CVP (keep in mind Afib). Cardiology fellow says "TTE consistent with volume overload," keep in mind, no JVD no peripheral edema, i.e., no clinical signs of decompensated R/L heart failure or volume overload. I take all this to mean, this patient has pulm HTN but not RV failure, volume status is OK. Nonetheless, probably minimal RV reserve and the TTE looked pretty unhealthy. I was in no mood to let this dude hypoventilate/desat with a MAC given all of the above plus obesity etc. Teaching point: correlate your test results with the patient in front of you.

This is in an in-hospital GI suite like I said. You have an anesthesia machine, pressure transducers for art line etc, and an anesthesia tech with you the whole case.

Anyone have any change of plans or new thoughts now? (I'm drawing this out a little bit for the sake of discussion and for my own education btw...not necessarily because an EGD on a polysubstance abuser is that rare or novel ;))
MAC
 
I don't get why people would attempt an awake FOI on a full stomach. Aren't you purposely blunting their airway protection reflexes? The truth is most of the airway blocks/topical are incomplete. So you end up with the worst of both worlds: a patient who reacts to stimulation but cannot fully protect his airway.

Me either. If we are truly worried about aspiration that would preclude a MAC. I see remi or ketamine titrated in generously with these cases all the time. The ol' "playing it safe" by gorking a patient out to unresponsiveness and/or blunted airway reflexes for the FOI....to prevent aspiration. Always good to see.

I would do MAC here or if worried about aspiration, RSI with a VL and slam the tube in. Not need to be a hero with the fiber optic.
 
Funsies, portopulmonary hypertension (note: distinct entity from hepatopulmonary syndrome).

Not terrible though, sounds a little less than half systemic (CVP of 15 is a reasonable assumption, so PASP sounds like it's 55 mmHg-ish and systemic pressure is 120).

The only change in my management then is to make vasopressin my first line pressor. As everyone undoubtedly knows, vaso will increase the SVR without increasing PVR, making it a useful tool in the setting of pulm htn. Annoyingly, vaso is one of those drugs (along with neostigmine) that went from generic to brand name, making it go from pennies to multiple dollars. Yay, supply and demand.

Before that as other posters have mentioned I would probably start a better IV and get some hemoglobin circulating. The bicarb 22 from 31 is concerning. Homeboy has an oxygen delivery issue.

The RVR and question of whether to RSI and whether to a-line is a tough one. For me this would come down to looking at the guy and the echo myself. With just the data presented, my plan would probably involve:

No a-line (if cuff pressures are shady for any reason, or if I get a spidey-sense tingle, this changes), and an alfentanil (for the HR more than anything else)/low dose ketamine/low dose propofol/sux RSI after good preoxygenation in the head-up position, and I'd use a Glidescope with a documented previous grade 3 view.

All that said, if this dude is a cokehead/tweaker, you can do whatever the hell you want to him, you're not gonna hurt him. Those dudes are indestructible.
Thanks for the responses everyone, and sorry for the long wait for more info.

Case discussed with GI docs. They are expecting to find no smoking gun to intervene on, planning to NOT do any interventions, and actually they are of the opinion he's done bleeding and is just clearing old blood with the current melena. They think it's NSAID/EtOH gastritis; not expecting to find fat varices. HCT has been metastable since transfusion (at admission). Teaching point: choosing the plan for this case depends heavily on the intended procedure (intervention vs no, what type of pathology expected).

Previous anesthesia record, from a similar admission for similar problems. RSI'd, Grade 3, ETT able to be passed.

Current TTE (done day of case): LV fxn OK, LV small, RV pressure overload with IV septum and IA septum bowed toward left, RV FAC ok, mod-severe TR, est RVSP 40+CVP (keep in mind Afib). Cardiology fellow says "TTE consistent with volume overload," keep in mind, no JVD no peripheral edema, i.e., no clinical signs of decompensated R/L heart failure or volume overload. I take all this to mean, this patient has pulm HTN but not RV failure, volume status is OK. Nonetheless, probably minimal RV reserve and the TTE looked pretty unhealthy. I was in no mood to let this dude hypoventilate/desat with a MAC given all of the above plus obesity etc. Teaching point: correlate your test results with the patient in front of you.

This is in an in-hospital GI suite like I said. You have an anesthesia machine, pressure transducers for art line etc, and an anesthesia tech with you the whole case.

Anyone have any change of plans or new thoughts now? (I'm drawing this out a little bit for the sake of discussion and for my own education btw...not necessarily because an EGD on a polysubstance abuser is that rare or novel ;))

I think you went for all the head fakes. I would do a MAC. After the scope is down, it isn't very stimulating if they've gargled even a little bit of lidocaine.
 

I think you went for all the head fakes. I would do a MAC. After the scope is down, it isn't very stimulating if they've gargled even a little bit of lidocaine.

I'm confused. I'm a huge believer in there being a thousand different ways to accomplish the same goal, each with their own unique risk/benefit profiles, each defensible in their own right. I followed your guys' line of thinking (don't want to do an awake FOI on a potential full stomach, don't want to blunt airway reflexes, etc) up until we got more information regarding the patient. We have info saying that he's able to be intubated with DL. Here is my biggest question for you two: what are you gaining by doing a MAC? Less anesthesia to not drop his pressure? Quicker wakeup? Are you going to titrate just enough sedation to make him comfortable but keep his airway reflexes intact (which you guys agreed is important...since topicalizing for an AFOI seemed dangerous to you guys)? I would again see your reasoning if this scenario was the exact same but the guy was 50 kg. But as we all know, sedating fat people with COPD who are satting 93% on 2L NC is a nightmare. How do you envision this thing playing out? I can just see someone giving this guy a bit of propofol, and then getting into this situation where they are jaw thrusting him, trying to stop him from obstructing, etc, having the gastroentereologist pull his scope out so they can try bag masking him. Or, you give him just enough propofol to make him disinhibited, and he's wiggling around throughout the entire case, and everyone (gastroenterologist, you, AND the patient) is collectively pissed off. Sure, you may strike just the right balance of anesthesia and not blunting airway reflexes...but then again you might not? It seems like dhb's suggestion of having coffee and having them just deal with him awake seems to make more sense than MAC. With MAC you get the worst of all worlds, the best of none.

And maybe I am letting my laziness get the better of me, but putting a tube in this guy, letting him ride the vent, and titrating in vasopressors/blood as needed to keep his pressure up seems SO much easier with less variables. Sure he may get hypotensive, but we know how to treat that, and we anesthetize much sicker patients every single day. What's the downside to doing him under general with a tube?

Teaching point: choosing the plan for this case depends heavily on the intended procedure (intervention vs no, what type of pathology expected).

While I agree in theory, how many times have we all heard "this will take 5 minutes"....and then 1 hour later....
 
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I'm confused. I'm a huge believer in there being a thousand different ways to accomplish the same goal, each with their own unique risk/benefit profiles, each defensible in their own right. I followed your guys' line of thinking (don't want to do an awake FOI on a potential full stomach, don't want to blunt airway reflexes, etc) up until we got more information regarding the patient. We have info saying that he's able to be intubated with DL. Here is my biggest question for you two: what are you gaining by doing a MAC? Less anesthesia to not drop his pressure? Quicker wakeup? Are you going to titrate just enough sedation to make him comfortable but keep his airway reflexes intact (which you guys agreed is important...since topicalizing for an AFOI seemed dangerous to you guys)? I would again see your reasoning if this scenario was the exact same but the guy was 50 kg. But as we all know, sedating fat people with COPD who are satting 93% on 2L NC is a nightmare. How do you envision this thing playing out? I can just see someone giving this guy a bit of propofol, and then getting into this situation where they are jaw thrusting him, trying to stop him from obstructing, etc, having the gastroentereologist pull his scope out so they can try bag masking him. Or, you give him just enough propofol to make him disinhibited, and he's wiggling around throughout the entire case, and everyone (gastroenterologist, you, AND the patient) is collectively pissed off. Sure, you may strike just the right balance of anesthesia and not blunting airway reflexes...but then again you might not? It seems like dhb's suggestion of having coffee and having them just deal with him awake seems to make more sense than MAC. With MAC you get the worst of all worlds, the best of none.

And maybe I am letting my laziness get the better of me, but putting a tube in this guy, letting him ride the vent, and titrating in vasopressors/blood as needed to keep his pressure up seems SO much easier with less variables. Sure he may get hypotensive, but we know how to treat that, and we anesthetize much sicker patients every single day. What's the downside to doing him under general with a tube?



While I agree in theory, how many times have we all heard "this will take 5 minutes"....and then 1 hour later....
I'm opposed to the concept of awake foi for full stomachs. This pts are probably best served with an RSI, unless the airway looks extremely difficult. In that case you have to pick the lesser evil. I would do an awake foi if I thought I couldn't intubate. But the idea that I can suction all the stuff coming out with a yankauer as the pt keeps breathing is not very appealing.

In the endo suite they can suction your stomach with a giant hose as they go in. So, I'm more lax about doing a MAC.

You would never go wrong with a tube. Pent Sux Tube forever.


It's a challenging MAC, but I don't think it is impossible.
 
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I'm confused. I'm a huge believer in there being a thousand different ways to accomplish the same goal, each with their own unique risk/benefit profiles, each defensible in their own right. I followed your guys' line of thinking (don't want to do an awake FOI on a potential full stomach, don't want to blunt airway reflexes, etc) up until we got more information regarding the patient. We have info saying that he's able to be intubated with DL. Here is my biggest question for you two: what are you gaining by doing a MAC? Less anesthesia to not drop his pressure? Quicker wakeup? Are you going to titrate just enough sedation to make him comfortable but keep his airway reflexes intact (which you guys agreed is important...since topicalizing for an AFOI seemed dangerous to you guys)? I would again see your reasoning if this scenario was the exact same but the guy was 50 kg. But as we all know, sedating fat people with COPD who are satting 93% on 2L NC is a nightmare. How do you envision this thing playing out? I can just see someone giving this guy a bit of propofol, and then getting into this situation where they are jaw thrusting him, trying to stop him from obstructing, etc, having the gastroentereologist pull his scope out so they can try bag masking him. Or, you give him just enough propofol to make him disinhibited, and he's wiggling around throughout the entire case, and everyone (gastroenterologist, you, AND the patient) is collectively pissed off. Sure, you may strike just the right balance of anesthesia and not blunting airway reflexes...but then again you might not? It seems like dhb's suggestion of having coffee and having them just deal with him awake seems to make more sense than MAC. With MAC you get the worst of all worlds, the best of none.

And maybe I am letting my laziness get the better of me, but putting a tube in this guy, letting him ride the vent, and titrating in vasopressors/blood as needed to keep his pressure up seems SO much easier with less variables. Sure he may get hypotensive, but we know how to treat that, and we anesthetize much sicker patients every single day. What's the downside to doing him under general with a tube?



While I agree in theory, how many times have we all heard "this will take 5 minutes"....and then 1 hour later....

As urge said, you can never go wrong with a tube, and yes, I'm opposed to doing an awake FOI in a guy that history says is able to be intubated with a blade.

With that said, I would do a MAC for the same reason I would do a MAC on a sick as heck phaco patient. I think it can be done with less hullabaloo than the alternative. As someone mentioned, this is your standard 3pm add-on endo. I don't see anything in this case that is above what I've handled in endo MAC cases before.

I have a plan B, C, and D with LMAs, a nearby ambu-bag, and a blade ready to go.

I think way to often we think going down a path in one road means it is doom if it doesn't work out. I disagree. I've done MACs before where, in a controlled fashion, I transitioned to GA after it was apparent MAC wasn't going to work. MAC is the easier and just as safe alternative at this point, IMO. It doesn't hurt to gargle and just see if he can swallow the scope. They did it without us for a long time.
 
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To everyone that wants to do MAC, do you think this guy will cooperate? Or are you gonna sedate him enough that he does cooperate?

I Prefer GETA in this scenario as I've mentioned. And the fact that this GI guy thinks he won't find anything means nothing to me. If I had a dime for every time I heard this and we found something then I'd have a lot of dimes.
 
To everyone that wants to do MAC, do you think this guy will cooperate? Or are you gonna sedate him enough that he does cooperate?

I Prefer GETA in this scenario as I've mentioned. And the fact that this GI guy thinks he won't find anything means nothing to me. If I had a dime for every time I heard this and we found something then I'd have a lot of dimes.

Whether he will cooperate is ascertained before we enter the endo suite. Uncooperative patients always preclude MAC cases, of course.
 
For me, if I hear an endoscopist say "Ah, I don't really expect to find much blood in the stomach," I take that to mean there's gonna be blood everywhere.

If the people you work with have superior clinical judgment, good for you, do what works.
 
And maybe I am letting my laziness get the better of me, but putting a tube in this guy, letting him ride the vent, and titrating in vasopressors/blood as needed to keep his pressure up seems SO much easier with less variables. Sure he may get hypotensive, but we know how to treat that, and we anesthetize much sicker patients every single day. What's the downside to doing him under general with a tube?

Urzuz, your thinking was very similar to mine. I probably could do a propofol MAC on this dude, with the its attendant desatting / patient moving / hypoventilation, but was never strongly considering doing so in this out of OR setting, with some-to-no help, a sick patient, and an unknown procedure.

Here's what happened.

Attempts at radial art line x4 failed. Pt hyperesthetic, wouldn't hold still, and I simply had no mojo. So I bailed.

Preox'ed in 30 degrees head of bed up position (lowest pt would tolerate), started induction with 1 unit vasopressin then 0.1 mg/kg etomidate then 0.5 mg/kg propofol then 1 mg/kg sux. Easy glidescope, no sign of blood or aspiration in hypopharynx. Desatted a tiny bit (95%) despite the preox. Controlled ventilation with etCO2 in mid 30s. Maintained with 1% sevo in oxygen (no air available) and a little propofol gtt. BP stays stable.

GI pops scope in and VOILA! ... there's just some erosive gastritis, mild portal HTN gastropathy, one small varix. Pretty unexciting. They poke around for 10-15 minutes just to make sure. Gave another unit of vasopressin to keep BP stone cold normal. Still A-fibbing away at 130's.

At some point he went into a rapid SVT at 195. Cycled BP but it had self terminated by the time the BP finished. I reached for my drawn-up esmolol, and called for adenosine while the cuff was running...on this floor adenosine is only in the crash cart :confused: .

Pt emerged thrashing and dysphoric...big surprise. Fairly juicy but easily suctioned. Extubated to a nonrebreather. Barely maintaining sats in high 80's, sitting up. Held 10cm CPAP on him for a minute or so, figuring he was very atelectatic, that got sats up to high 90's until he was awake enough to cough and deep breathe.

Had a nice chat with the hospitalist about procedure and dispo.
 
50 something male admitted 2 days prior for dizziness, melena, HCT 20, now scheduled for EGD in an in-hospital GI suite 3 floors away from OR. Still having melena, on PPI gtt and octreotide gtt. Has been pounding EtOH and NSAIDs to treat toe pain (chronic osteo). Does not walk. Does not take prescribed meds as outpatient, as inpatient on lasix and beta blocker

PMH: EtOH/HCV cirrhosis, cocaine/meth abuse, HTN, CAD, pulmonary HTN, COPD, current smoker, Afib, BMI 36

Labs: HCT 23 after tranfusion, INR 1.5, PLT 80, Albumin 2.2, Creatinine 1.9 (down from admission 2.3), K 4.6, HCO3 22 baseline 31

Exam: sat 93 2L NC, HR 110-150's Afib, BP 120s/70s, RR teens, alert, angry and grumpy, appears short of breath, generally hyperesthetic (screams upon placing pulse-ox probe), no JVD, +spiders, abdomen obese no frank ascites, airway MP3, TMD OK, no neck ROM, teeth poor, 20g PIV in forearm

Your plan, doctor?

don't really get why this thread has gone so far.

we get called about patients like this fairly infrequently - the answer is recommend optimization prior to EGD (most of our GI guys wouldn't even call us until this had happened). next case.

primary team needs to: transfuse more red cells and ffp, more access, control afib rate (ie volume/red cells/electrolytes). call me when crit>25, INR <1.5, attempt at afib rate control has been made, better access, etc etc... do not accept him on the schedule until this has been done.

this is an urgent case, not emergent. i can do all of the above in the OR, but i don't have time to do floor/ICU rescuscitations.

if you are silly enough to take this guy straight to the OR you will unleash the kraken with your induction - you think his afib is bad now wait until you drop his SVR and contractility and enter the pHTN circle of death...

oh, just read that he was admitted 2 d ago, so call the primary service and ask them what the hell they have been doing for him for 2 days - he still looks under-rescuscitated and sub-par to me (even if he looks full on tte he's full of the wrong mixture - his carburetor wants more red and protein - not helping his afib)...
 
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