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GassYous said:
EGDs can be 3 minutes for a diagnostic scope with a biopsy if they find nothing. But this is a lateral case and usually not more than 30 minutes max. This one ended up just under 30 minutes of procedure time and less than 40 minutes in the OR.
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Maybe I can trade you my EUS guy for yours? Pretty please?
 
GassYous said:
Ha
So I started with a prop drip for "mac" and the egd went okay, didn't see anything. Only issue was that one time the patient's head was a little flexed and she obstructed. Repositioned head and ventilation resumed.

Gastroenterologist couldn't pass the EUS scope. So decided to paralyze with roc and intubate. He brought out the small scope and we passed the tube in fiberoptically. No issues with the vocal cords, trachea and main bronchi looked fine as we got the tube in. EUS finished, no lymph nodes or anything of note.

Turned off gas, gave sugammadex and extubated. Tidal volumes around 200. Took her out to pacu and saw the next patient.

Returned to pacu, sat is 70.
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thanks for presenting this interesting case, but personally i prefer when all the details and events are laid out, and then discussion ensues, instead of intermittently revealing pieces of the story. its hard to comment when your not sure which direction the discussion is going to go.. just my 0.02

my first thoughts based on whats posted so far:

strange decision to intubate to facilitate passing a scope, not sure why the surgeon not passing the scope meant you needed to paralyze and intubate. sometimes i take the laryngoscope and pass the scope into the right orifice for them if its a struggle. also, not sure why you would use a fiberoptic intubation and examine the airway on this routine case. i would not have intubated, and if i intubated i would have used the standard mac 3.

sat of 70: maybe the GI doc perforated a lung or the airway on his attempts to intubate the esophagus, and/or maybe the reversal was not adequate since it was a mid-case paralysis and quick case so maybe need more sugga. since you stuck a scope in the airway im sure some fingers will be pointed at you without basis

i would think a chest xray would be my next move in addition to more reversal and increasing oxygenation support in PACU. would probably give an albuterol nebulzier if the situation is stable enough. may need emergent intubation in PACU if NRB not sufficient.
 
GassYous said:
Ha
So I started with a prop drip for "mac" and the egd went okay, didn't see anything. Only issue was that one time the patient's head was a little flexed and she obstructed. Repositioned head and ventilation resumed.

Gastroenterologist couldn't pass the EUS scope. So decided to paralyze with roc and intubate. He brought out the small scope and we passed the tube in fiberoptically. No issues with the vocal cords, trachea and main bronchi looked fine as we got the tube in. EUS finished, no lymph nodes or anything of note.

Turned off gas, gave sugammadex and extubated. Tidal volumes around 200. Took her out to pacu and saw the next patient.

Returned to pacu, sat is 70.
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Lol so the GI doc couldn’t get his scope in, requested muscle relaxation to help, and then offered to show you how to place an ETT fiberoptically? What a clown.

I also would prefer all information up front. Did she have radiation to her neck? Obviously not most likely on differential but Sugammadex anaphylaxis?
 
GassYous said:
I am trying to gear my cases towards students and residents reading this forum. I don't want to give them the whole thing upfront so that we can at least pretend to think about the preop, intraop and postop. I am sorry that you don't like my presentation style.

The ultrasound scope was getting caught around 15 or so and the gastroenterologist was wondering if there's some aberrant anatomy. He didn't notice anything on the EGD. He wanted to see if there was anything affecting the airway as well so he wanted to take a look and also thought that paralysis would help with passing the scope.

Have you ever perforated the lung during an egd? I've never heard of that happening although I have heard of colonic perfs during lower scopes.

It definitely can be inadequate reversal. I used roc 50 and gave sugammadex 200 maybe 10 minutes later. I didn't check postreversal twitches but I thought that with a good tidal volume patient would be okay.
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Did you get called to pacu or just happen to be checking on them?
 
This is a 10 minute case in my place unless they find stuff they want to biopsy… then all bets are off. I have never been asked to intubate and paralyze to be able to get the scope down- sounds like a proceduralist that should stay in his or her lane.
 
amyl said:
This is a 10 minute case in my place unless they find stuff they want to biopsy… then all bets are off. I have never been asked to intubate and paralyze to be able to get the scope down- sounds like a proceduralist that should stay in his or her lane.
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Every EUS I have ever staffed takes longer than this.

Never paralyzed just to get the scope down. If anything they complain about the ET tube impeding the scope from passing down.
 
Arch Guillotti said:
Every EUS I have ever staffed takes longer than this.

Never paralyzed just to get the scope down. If anything they complain about the ET tube impeding the scope from passing down.
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EUS = ETT
ERCP = ETT

Hasn’t failed me yet. Never done one that’s less than 30 mins. We also have a couple of thoracic surgeons who would do esophageal dilation in the endo suite. I tube those too, since they’re so much more comfortable with ETT than GI.
 
Agree with Hoya. Maybe some underlying reason she would be sensitive to neuromuscular blockade. Otherwise some one poked a hole somewhere. Aspiration,NPPE in differential too. Agree with above treatment. Review meds and history, support ventilation, reverse anything possible, CXR. be prepared to reintubate.
Arch Guillotti said:
Every EUS I have ever staffed takes longer than this.

Never paralyzed just to get the scope down. If anything they complain about the ET tube impeding the scope from passing down.
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it does keep them from trying to dilate the vocal cords though.
 
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