Anesthesia for dumb cases

[nimbus]

Disagree about GI. You do these cases with propofol, you most definitely need anesthesia

Seems to be a large regional variation with GI. The vast majority of endoscopy in our city is done with nurse sedation. Anesthesia care with propofol is the exception and requires a medical necessity note.

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[DocMcCoy]

Seems to be a large regional variation with GI. The vast majority of endoscopy in our city is done with nurse sedation. Anesthesia care with propofol is the exception and requires a medical necessity note

Curious. Where are you?

My experience in northeast mixed. With only difficult cases involving anesthesia.

In Texas we propofol everybody.

Wouldn’t mind finding a spot I didn’t have to do much GI. can become incredibly stressful very fast.

 

[nimbus]

Curious. Where are you?

My experience in northeast mixed. With only difficult cases involving anesthesia.

In Texas we propofol everybody.

Wouldn’t mind finding a spot I didn’t have to do much GI. can become incredibly stressful very fast.

Southern California. I need to clarify that anesthesia is used for ERCP and EUS cases. But not for the usual colonoscopies and upper endoscopies.

Understand what you say about things going south quickly. We are building a new hospital tower soon and one of our requests which will be honored is that at least 2 of the endoscopy rooms will have an anesthesia machine and a full anesthesia cart. All anesthesia cases will be done in those rooms which should significantly reduce the stress. We’ve been doing all our ERCPs with GA/ETT in the OR for years and those are not stressful at all.

 

[kidthor]

Southern California. I need to clarify that anesthesia is used for ERCP and EUS cases. But not for the usual colonoscopies and upper endoscopies.

Understand what you say about things going south quickly. We are building a new hospital tower soon and one our requests which will be honored is that at least 2 of the endoscopy rooms will have an anesthesia machine and a full anesthesia cart. All anesthesia cases will be done in those rooms which should significantly reduce the stress. We’ve been doing all our ERCPs with GA/ETT in the OR for years and those are not stressful at all.

Having an anesthesia machine definitely makes a difference. I hate having to go to an off site place and being expected to provide anesthesia with a suboptimal setup. Even if the machine is rarely used, it's an important back up to have.

Glad to hear also you do ETT for ERCPs. Our GI doctors often try to pressure for a natural airway and it induces some to comply with them. ETT absolutely reduces the stress level (and risk IMO).

 

[deleted875186]

Having an anesthesia machine definitely makes a difference. I hate having to go to an off site place and being expected to provide anesthesia with a suboptimal setup. Even if the machine is rarely used, it's an important back up to have.

Glad to hear also you do ETT for ERCPs. Our GI doctors often try to pressure for a natural airway and it induces some to comply with them. ETT absolutely reduces the stress level (and risk IMO).

Absolutely no reason to do an ERCP with a natural airway. Why a GI doc would push for this is also bizarre. GA makes everything easier and safer, and probably only adds 5 mins or so to the case.

 

[Iso4ane]

Our GI doctors often try to pressure for a natural airway and it induces some to comply with them. ETT absolutely reduces the stress level (and risk IMO).

Tell them you’ll do it without a tube, if they can do the ERCP without a scope.

 

[coffeebythelake]

Absolutely no reason to do an ERCP with a natural airway. Why a GI doc would push for this is also bizarre. GA makes everything easier and safer, and probably only adds 5 mins or so to the case.

There was a series on APSF recently about ERCPs with ETT vs IVGA. Our institution tends to do them without endotracheal intubation

 

[anesthesiadoc]

When I was in PP, had a GI doc try to tell me I shouldn’t intubate his food impaction patient because it would increase his procedural risk of esophageal perforation. It felt like a poorly written oral boards scenario.

 

[coffeebythelake]

When I was in PP, had a GI doc try to tell me I shouldn’t intubate his food impaction patient because it would increase his procedural risk of esophageal perforation. It felt like a poorly written oral boards scenario.

This GI doc sounds like a clown of the highest order

 

[vector2]

There was a series on APSF recently about ERCPs with ETT vs IVGA. Our institution tends to do them without endotracheal intubation

There is no worthwhile upside to forgoing the ETT in ERCPs, and it's crazy how much GI (in general) likes to argue about it.

I swear, there are so many surgeons who couldn't give two fcks if an ASA 1 undergoing a mildly or moderately painful procedure gets an ETT for whatever reason, yet GI thinks making a capital case about it in a 64 yo trainwreck with biliary obstruction and cholangitis is reasonable.

 

[JoelJoel84]

Why not just use one of those special Gastro LMAs?
They work great and I’ve used them at 3 jobs/hospitals in my career so far with no issues.

 

[pgg]

Why not just use one of those special Gastro LMAs?
They work great and I’ve used them at 3 jobs/hospitals in my career so far with no issues.

Why not do the whole case standing on one foot, too?

 

[MirrorTodd]

Why not do the whole case standing on one foot, too?

Agree. I don't really get why people are trying to avoid a tube. Like it's really NOT a big deal...with some exceptions of course.

 

[coffeebythelake]

There is no worthwhile upside to forgoing the ETT in ERCPs, and it's crazy how much GI (in general) likes to argue about it.

I swear, there are so many surgeons who couldn't give two fcks if an ASA 1 undergoing a mildly or moderately painful procedure gets an ETT for whatever reason, yet GI thinks making a capital case about it in a 64 yo trainwreck with biliary obstruction and cholangitis is reasonable.

I agree it is largely for convenience and workflow not to do ETT.

 

[patriot6]

The larger problem is the spineless anesthesiologists allowing a gastroenterologist to select an airway device.

 

[DonFL]

Disagree about GI. You do these cases with propofol, you most definitely need anesthesia

Don't disagree about propofol sedation being the sole purview of anesthesia. However, nurse-administered remimazolam is getting a serious look in a lot of places

 

[Mehd School]

When I was in PP, had a GI doc try to tell me I shouldn’t intubate his food impaction patient because it would increase his procedural risk of esophageal perforation. It felt like a poorly written oral boards scenario.

I had a food impaction on a Saturday morning where the GI guy couldn't get it, called 2 more of his partners to come in and try and they failed as well. They called the surgeon on call who happened to be bariatric trained, and he told them to pound sand because he isn't coming in for this. Guy very nearly aspirated on induction and the GI doc told me to extubate and they'd put him on the floor until Monday morning. Uh no way man. We've been constantly sucking **** out of this guy's basically blind esophageal pouch for hours and now it's bloody in there too. He decided he wanted to die on this hill but he eventually backed down. This patient got his steak sammich surgically removed that Monday, primarily because the last guy was too rough and caused an esophageal tear that apparently became very apparent by Sunday night.

 

[Beeftenderloin]

Absolutely no reason to do an ERCP with a natural airway. Why a GI doc would push for this is also bizarre. GA makes everything easier and safer, and probably only adds 5 mins or so to the case.

If the ERCP is getting done for anything acute/new they get a tube 100% of the time. Occasionally I’ll do these with a native airway if they are coming in from home after they’ve recovered just to get their stent pulled or something minor like that (plus normal body habitus, reassuring aiway, reliable proceduralist, etc).

 

[DesiredMemberName?]

Are you all doing ERCPs prone or left lateral/tilt?

 

[coffeebythelake]

Usually prone with head turned

 

[Luv2N2B8]

Yep, TTEs. "Patient does not tolerate pressure from probe." "Patient anxious about results and will not hold still with prior attempts."

This is the most ridiculous thing I've ever heard. Obviously you've ended up in a place where anesthesia is the hospital's water boy. Private practice, never would happen.

 

[Luv2N2B8]

I’m amazed that insurance will pay for that.

Academic practice, so even if insurance doesn't pay (likely doesn't), their workflows and everyday practice are completely divorced from that.