Anesthesia for EGD

Started by hoopstaahh22
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hoopstaahh22

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10+ Year Member
I would like to know what others do for EGD to prevent the patient from bucking/coughing/gaging when the probe is initially inserted. I’ve been using just straight propofol (bonus to induce and infusion to maintain) but I have to give panic doses in order to prevent the patient from gaging. I want to try some fentanyl with the propofol but have concerns about apnea. What doses do people use? Any suggestions would be appreciated. Thanks.
 
Just prop the cat majority of the time. If you don't think they'll tolerate enough of a bolus to take the hose, then try having themselves swallow viscous lidocaine before taking them back to the room. Rarely, I'll add 5-20mg ketamine for these people. I virtually never give opioids.

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I like a touch of fentanyl for young patients having EGD, but adds to the complexity of perfecting your bolus dosing.

aim for the initial bolus to cause a few seconds of apnea, that’s the sweet spot. Don’t under-dose so they are coughing and obstructing and puking, don’t over dose so that they are apneic for 2 minutes. Takes practice. I find a robust young person often needs over 100 mg initial bolus. Get in there with a jaw thrust too, you do it better than anyone in regards to helping the scope pass AND it helps the airway.
 
Tell the GI to slip the scope in on the propofol yawn. Super slick if you can pull that off with an LMA.
 
50 mcg fent...50mg lidocaine IV...60-120mg propofol. Should be briefly apneic at time of scope placement to avoid coughing. Scope placement will stimulate.

You can go lighter if you have more time before GI doc places scope or GI doc is gentle. Some GIs want to jam it in 2 seconds after you start pushing prop
 
I get those 5 mL 4% lido ampules in a syringe ready before seeing patient. When I'm done talking to them I squirt the lido in their mouth and instruct them to either gargle it for the next 2 mins BY THE CLOCK (we have a clock in view at our gig), then swallow, or if they start to wheel back pre-emptively to gargle then swallow on arrival to GI suite. Propofol only in the room. I really emphasize to them to not swallow pre-emptively. Works pretty well!
 
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I use the Hurricane spray as soon as they hit the door, then straight Propofol. Midazolam only if they are on lots of benzos, or have some deathly fear of recall.

I can give tons of propofol before making most folks truly apneic. Don’t get me wrong, they’ll obstruct, but it takes quite a bit for true apnea. Once you go adding narcs to the propofol, all bets are off, and they WILL go apneic.

Ketamine works great for keeping people still during “sedation” cases. Young folks will move their arms and legs and grab at stuff when doing a biopsy/excision/foot under propofol, but add 50-75mg of ketamine (always after some versed) and it’s hardly ever an issue. (And they, and the old folks, won’t go apneic on the ketamine).
 
100mg lido, 1mg/kg prop and then redose prop prn. That's been working well so far. Young dudes or the alcoholic have to redose a bit more.
 
Ketamine requires dilution and checking and wasting. No time for that ish. Bad airways benzocaine spray. If they are particularly difficult i will test the airway with a tongue depressor. Propofol bolus FLUSH recheck Propofol flush. Thumbs down scope goes down.
 
Straight propofol bolus + IV Lido, gets them home sooner. Never use narcotics, ketamine extremely rarely. Benzocaine spray helps, don't really need it though, much more common when only benzos+midaz were used.
 
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