"A Single EGD that will only take 10min"

[dchz]

Lidocaine spray and versed. My plan never changed.

I' m not a pediatric cardiac anesthesiologist but I've dealt with more than a fair share of sick ass, tettering on death patients in the GI suite.

I’m more worried about a little hypoxia or hypercarbia increasing his PVR, worsening his Rt to Lt shunt through is already in use pop off valve fenestration, decreased cardiac output, etc. Then you’re in the profound hypoxia, hypotension, arrhythmia death spiral. I’ve been there, you don’t want to be there. This guy’s 2/3 of the way there already.


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Il Destriero

With enough topical, and very judicious sedation (I’d use midazolam) I think he’ll do fine.

Since aspiration is disastrous for him, and I’m going to carefully topicalise anyway I might as well do an afoi as well. Once the ett is in, if the case drags on he can have a little sevo

why aren't you guys using propofol?

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[WheezyBaby]

why aren't you guys using propofol?

Venodilation and myocardial depression would be my assumption since those are suboptimal in failing fontan phys, but I'm not a gas doc

 

[Arch Guillotti]

why aren't you guys using propofol?

Why is anybody talking about intubating this guy?

 

[coffeebythelake]

why aren't you guys using propofol?

multiple reasons.

depending on the depth of anesthesia you could potentially cause laryngospasm, hypoventilation, upper airway obstruction with accompanying hypoxemia, vasodilation/changes in preload/afterload. also more likely for aspiration to occur with an obtunded sedated patient than a conscious one. and because it is a freaking EGD.

GI docs love when you use propofol because it keeps the patient still. you don't need propofol. set expectations from the beginning.

 

[coffeebythelake]

Oh is that all...with or without acute hypoxemia? And how does that bode for an already hypoxemic patient with a Fontan?

Yes this risk exists whether you do it in a surgicenter or in a tertiary care center.
Yes this risk exists for most everyone getting an EGD (no specific mention that this patient is high risk for aspiration aside from the fact he is huge).

instead of your snarky tone, please explain how this would affect your actual plan?? and no, punting a high risk patient to someone else isn't a plan.

 

[deleted59964]

Why is anybody talking about intubating this guy?

huh? i did
he’s at risk of aspirating and if he does he’ll probably die

 

[Twiggidy]

Cmon guys. Seriously? Intubation?

 

[shepardsun]

PPV decreasing PBF and CO wouldn't help him out.

 

[deleted59964]

PPV decreasing PBF and CO wouldn't help him out.

he aspirates, he probably dies.

you think the increased intrathoracic pressure from say 8cm H2O pressure support ventilation is going to be an issue?

i'd be more worried about increased PVR from hypoventilation and from decreased FRC due to sedation.

 

[dchz]

The more I think about this, the more i agree with @Hawaiian Bruin , Like @pgg said about the epidural. The best way to do this happens to be just the way we most commonly do it.

For those of you that think propofol with timely phenylephrine is going to knock him into a death spiral. It just feels a bit

 

[dhb]

This is a lido spray, 1mg midaz and hold someone's hand but not mine case.
Why you would want to give propofol, intubate and all the other stuff is beyond me.

 

[drmwvr]

Yes this risk exists whether you do it in a surgicenter or in a tertiary care center.
Yes this risk exists for most everyone getting an EGD (no specific mention that this patient is high risk for aspiration aside from the fact he is huge).

instead of your snarky tone, please explain how this would affect your actual plan?? and no, punting a high risk patient to someone else isn't a plan.

You said:
"...usually the complication is aspiration. Not decompensated heart failure."

Which I took to you mean that the two were mutually exclusive in this patient, when in fact the former would likely lead directly to the latter. If you didn't mean that, it wasn't apparent. My plan wouldn't change at all. Like I said in my first post, I'd treat him on the presumption of severe PHTN and go from there. Any amount of distress, hypoxia or fall in venous return risks catastrophe in this particular patient. So, no, this patient aspirating in an ASC is not the same risk as when he does in my tertiary center.

 

[Twiggidy]

So for the people intubating......you guys intubating people who need sedation for TEE exams or nah?

 

[dchz]

Why is anybody talking about intubating this guy?

You don't have to intubate just because you used propofol.

 

[narcusprince]

What’s required here is topicalization midazolam and micro titration of propofol. 30mg flush 30 more flush scope in. Keep down with 20-30 mg flush its 10 minutes. Some of you cats must have never used microdosages of propofol. 20mg with 10mg of lidocaine provides the same anxiolysis that 2mg of versed. Zu ze case.

 

[deleted59964]

What’s required here is topicalization midazolam and micro titration of propofol. 30mg flush 30 more flush scope in. Keep down with 20-30 mg flush its 10 minutes. Some of you cats must have never used microdosages of propofol. 20mg with 10mg of lidocaine provides the same anxiolysis that 2mg of versed. Zu ze case.

Hmm ... for some people I anaesthetise that is a generous full induction dose.

 

[deleted59964]

You don't have to intubate just because you used propofol.

And you don’t have to use propofol, or even PPV to intubate

 

[pgg]

What’s required here is topicalization midazolam and micro titration of propofol. 30mg flush 30 more flush scope in. Keep down with 20-30 mg flush its 10 minutes. Some of you cats must have never used microdosages of propofol. 20mg with 10mg of lidocaine provides the same anxiolysis that 2mg of versed. Zu ze case.

I'm not sure I'd call 30+30 a "microdose" of propofol.

 

[narcusprince]

I'm not sure I'd call 30+30 a "microdose" of propofol.

30mg flush wait for effect..... 30mg flush wait..... zu ze case

 

[pgg]

I'd rather zu ze case and not have to zu ze M&M.

 

[DocVapor]

While I do like the slow titration strategy, I'm not sure I'd admit to doing anything "micro."

 

[narcusprince]

I'd rather zu ze case and not have to zu ze M&M.

Haha PGG! I never had to present one at your gig.....

 

[pgg]

Haha PGG! I never had to present one at your gig.....

I get to present one next month. (By which I mean, the resident who did the case with me is going to present it, and I'll watch. )

When are you coming back?

 

[narcusprince]

I get to present one next month. (By which I mean, the resident who did the case with me is going to present it, and I'll watch. )

When are you coming back?

Not sure when or if I will be back. The med board process has thrown some curveballs. Staffing shortages too. Needs of the navy.

 

[Gastrapathy]

Wandered here with the link from the other thread. My only input is that you want adult GI doing this scope. Peds doesn’t do anything like the banding that we do. Also the comment that banding isn’t effective because it doesn’t treat the underlying problem...that’s always true and as long as you do serial procedures to band to eradication, you’ll buy some time.