"A Single EGD that will only take 10min"

[Arch Guillotti]

Posting for a long time member anonymously:

younger male, scheduled for EGD with GI doc. GI doc has never seen patient personally, as prior EGD done at childrens hospital.

PMH:
CHD - states history of TOF as child, that underwent Fontain Repair
OSA no CPAP
Obesity >40
Cirrhosis 2/2 suspected
suspected varices hence EGD
htn
gerd

GI doc says, even if i have to band, this will be simple and i will be out in 10min max.

what are you going to do?
what do you want to know?

***later details***
stable BP, pulse low 80s, but color in patient looks normal. On Room air, states no home o2 use. gets around using walker.

exam: no chin, MP III

labs:
art draw done shows pa02 <50

echo > 1yr ago done by adult cardiologist
EF >25-35%, ASD seen, limited quality. Fenestrations appreciated.

last follow up by transplant surgeon >1 year ago, questions of the stability of the cardiac repair at the time, no followup since.


what are you going to do? what do you want?

we we did. Called transplant surgeon/cardiologist Unhelpful, no new data except maybe something with repair off.

ordered CXR --> cardiomegaly
TTE bedside --> no fenestrations seen, ef 25-35%, (our limited intrep). In house cardiologist says you need the peds cardiologist to read this. we arent comfortable even giving a prelim.

Case Cancelled.

what we were prepared to do.

Pre induction aline
good oxygenation essential (tube in under 15s, glide scope at bed side).
Etomdate induction
run on low dose remi with volatile
avoid ketamine (inc HR, inc oxygen utilization potential)
avoid midoz/fent (together can get venodilation) which could effect preload and flow.
have to avoid phenyleph due to passive filling of repair, increased afterload effect CO.
titrate analgesic tightly with remi
patients like these ideally should be first starts so they arent NPO all day and volume deplete.

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[drmwvr]

A Fontan repair of TOF? Probably more to that story. I'd base the anesthetic on the assumption that there was some element of pulmonary hypertension and go from there. I think ketamine would be a good choice in that regard. A mg/kg over the course of the anesthetic wouldn't be a problem. No mention about the patient being on a beta blocker, but I wouldn't be surprised. I'd also not worry about using anxiolytic fentanyl/versed as long as oversedation didn't become a problem as anxiety will just drive the pulmonary pressure. If it were truly a Fontan, giving a little volume to treat hemodynamics would be a good thing to offset a fall in venous return from the anesthetic post induction. I'd have a little NE around too.

 

[btbam]

Fontan for TOF doesn't make any sense and a repaired Fontan should be satting normal upper 90s, not low 80s. Most likely he had a Tet repair then a RV-PA conduit at some point in childhood which has a big gradient now. There is something not adding up here.

 

[Psai]

If it's so simple, tell the gi doc to do it with conscious sedation by themselves

 

[OB1🤙]

I don't disagree with pausing until you can figure out the plumbing, but honestly my anesthetic for this case would be the same as it would for any other EGD. Titrate in some propofol and call it a day.

What were holding room vitals?

 

[Twiggidy]

Titrate ketafol. Start low to get the probe in and keep him breathing. Tell GI to get it done and you literally only have 10 mins.

 

[abolt18]

Titrate ketafol. Start low to get the probe in and keep him breathing. Tell GI to get it done and you literally only have 10 mins.

I'm sorry, I've run out of quarters for the anesthesia machine. As it turns out, I only brought enough for the ten minutes you promised the procedure would be.

 

[HalO'Thane]

Posting for a long time member anonymously:

Is this patient’s Fontan failing? Is that why he is in liver failure? I didn’t see any mention of coags. I would certainly try to get a pediatric cardiologist to get a read on his echo. A Fontan should not have saturations in the low 80s. If he does he could have a large fenestration, multiple AP collaterals, or be in CHF. I would also want to know the degree of tricuspid regurgitation, further indicating if his Fontan is failing. If there is severe TR then I would be very careful about interpreting his ejection fraction because his actual forward flow might be even crappier than the EF would indicate. I do think that the worst thing for this patient would be an intubation and positive pressure ventilation as Fontan hemodynamics are much better when spontaneously breathing, particularly if the repair is questionable. Therefore I think the ideal anesthetic would either be a MAC with your cocktail of choice (ketofol, remi, ketamine/dex etc) or if you can convince the G.I. doc to work around an LMA with the patient spontaneously breathing. I do this all the time at our children’s hospital. All you have to do is deflate the cuff and give a small jaw thrust and the endoscopist can pass the scope past the LMA pretty easily.

 

[narcusprince]

What about topicalization and 2mg of midazolam? Quick endoscopist? Sure lets go. I can keep ANYONE alive for 10 min. I know a few GI docs I would say yes to and a handful I would say no. Next case....

 

[anbuitachi]

Lido topicalization, low dose propofol infusion. It shouldn't be that stimulating with good topicalization.

Why do you guys want ketamine? Won't that raise pulmonary pressures....

 

[drmwvr]

Why do you guys want ketamine? Won't that raise pulmonary pressures....

That's a myth from the late 20th century that really needs to die. Ketamine dosed as we do for sedation/analgesia these days is good for patients with pulmonary HTN. The contrary idea got started in the 80's with kids whose CO2 was allowed to rise with sedation, causing their PA pressures to rise. Ketamine was blamed. Plenty to look at with a PubMed search.

 

[anbuitachi]

That's a myth from the late 20th century that really needs to die. Ketamine dosed as we do for sedation/analgesia these days is good for patients with pulmonary HTN. The contrary idea got started in the 80's with kids whose CO2 was allowed to rise with sedation, causing their PA pressures to rise. Ketamine was blamed. Plenty to look at with a PubMed search.

It seems like most recent papers say ketamine INCREASES pulmonary pressure in adults, but not in children and it seems like the current consensus does not recommend ketamine in phtn. And medical aspect aside, if some bad outcome does happen, the lawyers would probably Target the ketamine and I don't know how easy it'd be to defend that.

Which papers are you looking at that says Ketamine is good for patients with pHTN?

I don't usually use ketamine with a PA catheter but for sure the systemic pressure and HR often go up , not unexpectedly, after ketamine. Assuming this patient did have a Fontan.... I wouldn't risk it. Do we even understand why systemic pressures go up and not pulmonary with ketamine?

 

[HalO'Thane]

It seems like most recent papers say ketamine INCREASES pulmonary pressure in adults, but not in children and it seems like the current consensus does not recommend ketamine in phtn. And medical aspect aside, if some bad outcome does happen, the lawyers would probably Target the ketamine and I don't know how easy it'd be to defend that.

Which papers are you looking at that says Ketamine is good for patients with pHTN?

I don't usually use ketamine with a PA catheter but for sure the systemic pressure and HR often go up , not unexpectedly, after ketamine. Assuming this patient did have a Fontan.... I wouldn't risk it. Do we even understand why systemic pressures go up and not pulmonary with ketamine?

What “consensus” states that Ketamine should be avoided in pHTN? Care to provide any sources? Here is just one of many papers showing the safety of Ketamine in pHTN when taking hypoxia and hypercarbia out of the equation.

Hemodynamic response to ketamine in children with pulmonary hypertension. - PubMed - NCBI

 

[anbuitachi]

What “consensus” states that Ketamine should be avoided in pHTN? Care to provide any sources? Here is just one of many papers showing the safety of Ketamine in pHTN when taking hypoxia and hypercarbia out of the equation.

Hemodynamic response to ketamine in children with pulmonary hypertension. - PubMed - NCBI

If I'm not mistaken, this paper is in children. Like I said ketamine doesn't increase in children but does in adult.

I assumed the patient we are talking about is an adult since patient saw adult cardiology.

 

[WholeLottaGame7]

Is this patient’s Fontan failing? Is that why he is in liver failure? I didn’t see any mention of coags. I would certainly try to get a pediatric cardiologist to get a read on his echo. A Fontan should not have saturations in the low 80s. If he does he could have a large fenestration, multiple AP collaterals, or be in CHF. I would also want to know the degree of tricuspid regurgitation, further indicating if his Fontan is failing. If there is severe TR then I would be very careful about interpreting his ejection fraction because his actual forward flow might be even crappier than the EF would indicate. I do think that the worst thing for this patient would be an intubation and positive pressure ventilation as Fontan hemodynamics are much better when spontaneously breathing, particularly if the repair is questionable. Therefore I think the ideal anesthetic would either be a MAC with your cocktail of choice (ketofol, remi, ketamine/dex etc) or if you can convince the G.I. doc to work around an LMA with the patient spontaneously breathing. I do this all the time at our children’s hospital. All you have to do is deflate the cuff and give a small jaw thrust and the endoscopist can pass the scope past the LMA pretty easily.

This is the best answer so far. The only thing I'd add is that his original anatomy might have been more like a DORV with a hypoplastic LV which would explain the need for Fontan instead of RV-PA conduit.

Wouldn't place a pre-induction a-line for this. Given the multiple cardiac surgeries, it might take longer than the EGD itself. And what's it going to tell you? You know the PaO2 is in the ****ter. If you're worried about tight BP control just cycle the cuff q1min. Also intubating regardless of what agent you use will be tolerated poorly. As mentioned, it's not the anesthetic agent that's the problem, it's the PPV.

 

[drmwvr]

It seems like most recent papers say ketamine INCREASES pulmonary pressure in adults, but not in children and it seems like the current consensus does not recommend ketamine in phtn. And medical aspect aside, if some bad outcome does happen, the lawyers would probably Target the ketamine and I don't know how easy it'd be to defend that.

Which papers are you looking at that says Ketamine is good for patients with pHTN?

I don't usually use ketamine with a PA catheter but for sure the systemic pressure and HR often go up , not unexpectedly, after ketamine. Assuming this patient did have a Fontan.... I wouldn't risk it. Do we even understand why systemic pressures go up and not pulmonary with ketamine?

Putting medical aspects aside isn't what we do and I can't control or predict what a lawyer would probably do, nor do I really care. That will not be part of my decision making.

That said, the bias against ketamine is primarily based on non-mechanically ventilated pediatric patients and has since been revisited and found to be without merit. Yet the bias persists. And when I say ketamine is "good" for patients with PHTN, I mean it is "OK to use" for achieving the desired objectives of the anesthetic. I'm sure you didn't take that to mean that it improves the condition as, say, NO or epoprostenol do. The main idea is to avoid significant rises in CO2 and falls in PO2. I might ask what doses you're using.

As to the use in adults, try this:

Anesthesia for pulmonary endarterectomy. - PubMed - NCBI

If that isn't convincing, simply do not use ketamine. I will.

 

[T-burglar]

This is the natural progression of the palliated single ventricle pathway. PPV will probably be a worse insult than modest hypercarbia, but if he’s not close to shock at rest then it would be very unlikely that either would kill him.

In any case it’s an EGD so there’s no need to investigate extensively for things you can optimize. Just do what you usually do for these. I would probably insist on a reliable Etco2 method like a mask with a sampling line.

 

[anbuitachi]

Putting medical aspects aside isn't what we do and I can't control or predict what a lawyer would probably do, nor do I really care. That will not be part of my decision making.

That said, the bias against ketamine is primarily based on non-mechanically ventilated pediatric patients and has since been revisited and found to be without merit. Yet the bias persists. And when I say ketamine is "good" for patients with PHTN, I mean it is "OK to use" for achieving the desired objectives of the anesthetic. I'm sure you didn't take that to mean that it improves the condition as, say, NO or epoprostenol do. The main idea is to avoid significant rises in CO2 and falls in PO2. I might ask what doses you're using.

As to the use in adults, try this:

Anesthesia for pulmonary endarterectomy. - PubMed - NCBI

If that isn't convincing, simply do not use ketamine. I will.

Dont have access to full article, only abstract, which doesn't even mention the word ketamine

 

[drmwvr]

Dont have access to full article, only abstract, which doesn't even mention the word ketamine

Right...you'll need to utilize your affiliation with your institution's medical library or equivalent. I was just providing the citation for you.

 

[psychbender]

I have given ketamine to patients with PHTN and with PACs. If the PA pressure goes up at all, it's by very little, at low doses of ketamine (0.1-0.5mg/kg). The fears of this drug in cardiac patients is greatly overblown.

Sent from my SM-G930V using SDN mobile

 

[anbuitachi]

Right...you'll need to utilize your affiliation with your institution's medical library or equivalent. I was just providing the citation for you.

Yea i get that. Just saying can't read it right now since im not at work

 

[urge]

Hope we are not talking about doing the case at a stand alone endo center.

I would do it in house and I'm not ruling out an icu bed until the case is finished and doing well.

 

[deleted697535]

I don't disagree with pausing until you can figure out the plumbing, but honestly my anesthetic for this case would be the same as it would for any other EGD. Titrate in some propofol and call it a day.

What were holding room vitals?

And what if something goes wrong?

Amazing case. Equally amazing that gi don't comprehend the enormity of the situation

 

[deleted697535]

This is the best answer so far. The only thing I'd add is that his original anatomy might have been more like a DORV with a hypoplastic LV which would explain the need for Fontan instead of RV-PA conduit.

Wouldn't place a pre-induction a-line for this. Given the multiple cardiac surgeries, it might take longer than the EGD itself. And what's it going to tell you? You know the PaO2 is in the ****ter. If you're worried about tight BP control just cycle the cuff q1min. Also intubating regardless of what agent you use will be tolerated poorly. As mentioned, it's not the anesthetic agent that's the problem, it's the PPV.

How about keeping him breathing? Or very short acting agents remi/sux? Cord spray. Pressure support?

 

[Twiggidy]

this young lad is more an airway issue than a cardiac issue. give enough Propofol (mixed with some ketamine) to get the probe in and have your propofol handy for if he moves move. the insertion of the probe will stimulate him to breath. at that point it's airway management. put a mask over the nose and mouth (yes, with the probe in) and you'll probably need a chin lift. he'll start to snore while they're doing the EGD. Hopefully the band is as easy as he says and you'll probably barely use one stick of propofol to keep him sedate. If things are taking to long, tell the GI doc he probably needs to stop or if he's taking too long and things are ok, stick to the plan. hopefully the GI doc is experienced and can probably be in and out. if it's a fellow or someone early in PP, just have a discussion on the amount of time they can waste. this case sounds worse then it probably is

 

[OB1🤙]

This patient is an interesting patient.

This case is an easy case.

If this was some awful big long bloody surgery the case might be interesting too, but dude, it's an EGD.

Give some propofol. I give people ketamine not infrequently but an EGD doesn't need it TBH. Sure you can, but you don't have to. Prop. Probe. Make sure the pt breathes. Case done. Move on.

If there's any academic point to be made here, it's that with these fenestrated Fontans, if that's what this even really is, patients don't have the risk of crumping from low CO from increased PVR that non-fenestrated Fontans do.

Yeah they can have crappy sats, but they invariably have compensatory polycythemia. Their oxygen delivery- which is the point of the whole enterprise- is therefore normal. At least, it is in someone who walks into the hospital for a non cardiac procedure and is normotensive and not clinically in CHF.

This patient will do fine with a little propofol and a little oxygen.

 

[OB1🤙]

I set the over/under on this patient's hematocrit at 52.

Smart money is probably on the over.

 

[somedumbDO]

Posting for a long time member anonymously:

Are we kidding ourselves? At my shop (and I asssume most of yours) we don't have pedi perfusionists or cardiac surgeons, if this goes south your screwed quick! Transfer to tertiary hospital and call it a day.

 

[btbam]

I set the over/under on this patient's hematocrit at 52.

Smart money is probably on the over.

We get some adopted unrepaired cardiac kids from China in Cath lab sometimes. Highest crit I’ve seen was 80!

 

[dchz]

Also interesting aside:

TOF + ASD = PENTOLOGY of fallot

 

[Twiggidy]

Are we kidding ourselves? At my shop (and I asssume most of yours) we don't have pedi perfusionists or cardiac surgeons, if this goes south your screwed quick! Transfer to tertiary hospital and call it a day.

what are you expecting to happen where the answer is " I need a pedi perfusionist and cardiac surgeon?" i'm asking seriously. You give 100 mg of Propofol, they stick the probe in, he breathes and maybe fights a bit so you give a touch more and then what happens to where your next thought is "Bypass". If you do anything in this particular case and the next step is "Bypass" you've done too much and done it wrong. Again, given the description this is more an airway issue than anything a like Hawaiian Bruin stated, "It's an EGD".

It's a complex patient, but it's an easy case.

 

[narcusprince]

what are you expecting to happen where the answer is " I need a pedi perfusionist and cardiac surgeon?" i'm asking seriously. You give 100 mg of Propofol, they stick the probe in, he breathes and maybe fights a bit so you give a touch more and then what happens to where your next thought is "Bypass". If you do anything in this particular case and the next step is "Bypass" you've done too much and done it wrong. Again, given the description this is more an airway issue than anything a like Hawaiian Bruin stated, "It's an EGD".

It's a complex patient, but it's an easy case.

Twigs
Do you do your own cases? I can get this guy breathing but not conscious with 50mg of propofol 50mg of iv lido and topical benzocaine. With good flushes and having the endoscopists standing by... and i dont mean at a computer. I mean scope in hand lubed and waiting to go in. And once in flush 30mg/30mg prop to keep them down. If you want to lower their conscious threshold without hemodynamic impairment give 2mg of versed to start. I may have some vaso in the room and neo drawm up. Im not pulling any darn ketamine......

 

[T-burglar]

Echoing previous posters that there is no reasonable expectation of needing freaking bypass or Ecmo or a cardiac surgeon. There’s also no reasonable expectation of possibly needing an ICU bed.

Some of these comments are strange to me

 

[Twiggidy]

Twigs
Do you do your own cases? I can get this guy breathing but not conscious with 50mg of propofol 50mg of iv lido and topical benzocaine. With good flushes and having the endoscopists standing by... and i dont mean at a computer. I mean scope in hand lubed and waiting to go in. And once in flush 30mg/30mg prop to keep them down. If you want to lower their conscious threshold without hemodynamic impairment give 2mg of versed to start. I may have some vaso in the room and neo drawm up. Im not pulling any darn ketamine......

I do 100% of my cases including cases. The ketamine in reality is plus/minus. True you don't really need it. We're both pretty much doing the same thing. My point is there's no need for A-lines, remi drips, ICU, CV surgeons, bypass, etc for something that probably will only take 10 maybe 15 mins. It's overkill.

Now if CRNA's and residents are handling the GI suite while you're quadruple covering, that's another story.

 

[nimbus]

If he has been compensating for years for a BMI >40 and OSA, seems like a little propofol won't likely knock him off. His circulation couldn’t be that tenuous. I’d say it’s gotta be pretty robust.

 

[urge]

Echoing previous posters that there is no reasonable expectation of needing freaking bypass or Ecmo or a cardiac surgeon. There’s also no reasonable expectation of possibly needing an ICU bed.

Some of these comments are strange to me

I don't think you and some others realize how sick this patient is.

I'll summarize it for you:

He's got one foot on the grave and the other on a banana peel.

This patient is going to die soon and while getting anesthesia is a great time to do it. That little propofol might give him just a little push needed to end up in heaven.

 

[coffeebythelake]

this is a freaking EGD

if you are so worried...
topical lidocaine, versed
tell patient they are high risk and doing it like this is probably the safest thing. most patients get it.
tell GI doc no messing around, no trainees

i've done it to BMI 50 patients with horrible airways
i've done it to cardiac cripples (EF 10%, severe MR and pulmonary HTN who PA pressures close to systemic pressures)

most patients (even the incredibly sick ones) can take a little propofol gtt or precedex

 

[T-burglar]

I don't think you and some others realize how sick this patient is.

I'll summarize it for you:

He's got one foot on the grave and the other on a banana peel.

This patient is going to die soon and while getting anesthesia is a great time to do it. That little propofol might give him just a little push needed to end up in heaven.

Without a good quality echo and RHC by specialists, i don't know how you can make this statement. Clinically he doesn't seem like hes about to croak. Again - this is the natural history of a palliated single ventricle (cardiac cirrhosis and enteropathies). Hes ambulating and urinating at home, and not experiencing episodes of sudden death at night, right?

Much of my practice is cardiac, including structural heart procedures for prohibitive risk cardiac cripples. We do all kinds of anesthetics for TAVRs, Clips, CAVI, melody TF PVR. I would be embarassed if I administered an anesthetic to a patient like this that was such a physiologic insult that it landed them in the ICU.

 

[somedumbDO]

Done more pedi hearts than I care to remember, some of you seem pretty cavalier about how sick or how fast these cases can turn south. I am curious out of the people who have replied how many have done more than 10 fontains in their career? Understanding the physiology is one thing, but having a group of dedicated physicians/surgeons/intensivists that do this every day is another. We can all agree this case should be done at a tertiary care hospital? This isnt an emergency. I have had this happen to me, just a simple dental rehab on this hypoplast w central shunt.... glad there was bypass available

 

[deleted697535]

This is a great thread!!!

 

[Southpaw]

Much of my practice is cardiac, including structural heart procedures for prohibitive risk cardiac cripples. We do all kinds of anesthetics for TAVRs, Clips, CAVI, melody TF PVR. I would be embarassed if I administered an anesthetic to a patient like this that was such a physiologic insult that it landed them in the ICU.

Not at hospitals do your level of cardiac, and have the resources that come with that level of care. I could be wrong, but I got the vibe the OP works in a place that doesn’t routinely care for this type of patient (the cardiologist wouldn’t give a prelim, and no mention of peds cards in house). Before you start doing procedures and giving anesthetics to patients, it’s worthwhile considering what’s best for the long term interest of the patient. Seems reasonable to me that his cirrhosis and varices are cardiac-related, so he should go to a place that can fix his heart along w his varices, not provide piecemeal care.

 

[Twiggidy]

This is a great thread!!!

It really is. I wonder if some of the difference in opinion comes from salary vs. unit-based people too. Some are like, "get this guy away from me" vs "give me those 10 units for 10 min of work".

 

[HalO'Thane]

I have no doubt that a competent anesthesiologist can get this patient through the case provided they don’t do anything too cavalier. However, for his long-term management he has no business being in an adult hospital. All signs indicate that he has a failing Fontan physiology. His 5 year mortality is extremely high; potential culprits being sudden cardiac death, thromboembolism, or decompensated heart failure. He not only needs to be managed by a pediatric cardiologist specializing in adults with congenital heart disease, but other pediatric specialists who can coordinate his entire care, including cardiac transplant and GI services. He very well could have Protein Losing Enteropathy, for which I doubt an adult GI physician will have much experience in managing. You may get away with getting him through a 10 minute procedure now but do you really want him back here later if he develops hemorrhage from his varices or is in septic shock?

 

[urge]

It really is. I wonder if some of the difference in opinion comes from salary vs. unit-based people too. Some are like, "get this guy away from me" vs "give me those 10 units for 10 min of work".

People are not reading between the lines. The guy got turned down for a heart transplant after his Fontan failed. Otherwise he would be listed. Basically his primary team sent him on palliative care. He might be having hematemesis and some random physician thought it would be good to have an egd to rule out varices and possibly treat them. Even if you manage to ligate a few a few other will pop up. And it doesn't address his underlying issue.

 

[Man o War]

Done more pedi hearts than I care to remember, some of you seem pretty cavalier about how sick or how fast these cases can turn south. I am curious out of the people who have replied how many have done more than 10 fontains in their career? Understanding the physiology is one thing, but having a group of dedicated physicians/surgeons/intensivists that do this every day is another. We can all agree this case should be done at a tertiary care hospital? This isnt an emergency. I have had this happen to me, just a simple dental rehab on this hypoplast w central shunt.... glad there was bypass available

Agree, agree, agree. Elective case. No reason to tempt fate without proper infrastructure in place.

 

[drmwvr]

....it's just an EGD...famous last words...

 

[urge]

Without a good quality echo and RHC by specialists, i don't know how you can make this statement. Clinically he doesn't seem like hes about to croak. Again - this is the natural history of a palliated single ventricle (cardiac cirrhosis and enteropathies). Hes ambulating and urinating at home, and not experiencing episodes of sudden death at night, right?

Much of my practice is cardiac, including structural heart procedures for prohibitive risk cardiac cripples. We do all kinds of anesthetics for TAVRs, Clips, CAVI, melody TF PVR. I would be embarassed if I administered an anesthetic to a patient like this that was such a physiologic insult that it landed them in the ICU.

His PaO2 is less than 50. Do you know how much it should be normally? And he has bad cirrhosis.

You don't need much more info to know this patient is on the way out.

 

[Twiggidy]

I'm curious what the poll would look like on this one......how many people on here would do the case vs canceling?

 

[Man o War]

I'm curious what the poll would look like on this one......how many people on here would do the case vs canceling?

Cancelled for me.

 

[drmwvr]

Do the case where I am.