Anesthesia for endoscopies.

[urge]

Those of you who have the 'pleasure" of doing these know how they go under "MAC". It's GA with a hypoxic, moving, coughing, hypertensive, puking.... etc, pt. It's a great time indeed. Every now and then we end up intubated after struggling(the anesthetist) for half an hour. My question is why do we do them under "mac"? I just cannot fathom any reason. Who came up with this anesthetic plan? Intubating somebody is so easy most of the time that I think it outweighs the risk of doing them under mac. Are we doing them so that the GI doc thinks his/her pts are only getting "sedation"? I'm leaning closer to intubating every single one of them.

Would you rather keep the status quo or move to intubation?

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[Planktonmd]

Those of you who have the 'pleasure" of doing these know how they go under "MAC". It's GA with a hypoxic, moving, coughing, hypertensive, puking.... etc, pt. It's a great time indeed. Every now and then we end up intubated after struggling(the anesthetist) for half an hour. My question is why do we do them under "mac"? I just cannot fathom any reason. Who came up with this anesthetic plan? Intubating somebody is so easy most of the time that I think it outweighs the risk of doing them under mac. Are we doing them so that the GI doc thinks his/her pts are only getting "sedation"? I'm leaning closer to intubating every single one of them.

Would you rather keep the status quo or move to intubation?

We do hundreds of endoscopic procedures every month and all of them are done under straight Propofol, nothing else.
They are done in endoscopy suites where there is no anesthesia machine and the average procedure takes 20-25 min from arriving to the room to leaving the room.
I don't see why we should intubate these people.
What we are doing is not MAC, it is GA with spontaneous ventilation and it works great as long as you don't start adding other agents (narcotics, bonzo...) and complicate the picture.

 

[huktonfonix]

while this would make life easier, it'll never happen unless you've got the ancillary staff and support capabilities to set up a machine in the GI suite, which the GI docs are never gonna go for if its at their expense. Good topicalization can make a big difference also.

 

[urge]

Have you placed a PEG or PEJ tube under "mac"? Great times indeed. I would much rather ambu the pt for an hour if I were the anesthetist and a machine is not available.

 

[Monty Python]

We do hundreds of endoscopic procedures every month and all of them are done under straight Propofol, nothing else.
They are done in endoscopy suites where there is no anesthesia machine and the average procedure takes 20-25 min from arriving to the room to leaving the room.
I don't see why we should intubate these people.
What we are doing is not MAC, it is GA with spontaneous ventilation and it works great as long as you don't start adding other agents (narcotics, bonzo...) and complicate the picture.

Quite right. On some colonoscopies also I'll give 0.2 mg glycopyrrolate up front if I get that 6th sense that a pt is gonna vagal way down.

Used to do it with versed and/or alfenta and/or propofol. Now just straight propofol 99% of the time. Faster discharge, less paperwork, no counting narcotics, etc.

 

[SleepIsGood]

We do hundreds of endoscopic procedures every month and all of them are done under straight Propofol, nothing else.
They are done in endoscopy suites where there is no anesthesia machine and the average procedure takes 20-25 min from arriving to the room to leaving the room.
I don't see why we should intubate these people.
What we are doing is not MAC, it is GA with spontaneous ventilation and it works great as long as you don't start adding other agents (narcotics, bonzo...) and complicate the picture.

Sufficient amnesia w/o the versed? How deep are you running the propofol?

I'd love to try this. But cranking up the propofol >125 mcg/kg/min on a guy w/ a huge scope in their mouth sounds tough w/o causing apnea.

Do you use a capnogram when you do these in the GI suites? Or just pulse ox and O2?

Obviously, in residency we use all the standard ASA monitors...just wondering how others are doing it.

 

[periopdoc]

I find it a bit ironic that, with all the concerns about aspiration risk that we have in the anesthesiology community, we continue to take individuals with some of the worst risks, active GERD etc, and perform general anesthesia without airway control while their esophageal sphincters are being somewhat stented open.

Are we over-concerned about the risk in the main OR or under-concerned in the GI lab? Or do we just hope that the endoscopist will get their suction in there quickly enough to prevent aspiration as a risk

Personally, I like to use either straight propofol or premixed propofol and alfentanil to accomplish this...

plus a bougie in the trachea before we start, just in case

- pod

 

[Planktonmd]

Sufficient amnesia w/o the versed? How deep are you running the propofol?

I'd love to try this. But cranking up the propofol >125 mcg/kg/min on a guy w/ a huge scope in their mouth sounds tough w/o causing apnea.

Do you use a capnogram when you do these in the GI suites? Or just pulse ox and O2?

Obviously, in residency we use all the standard ASA monitors...just wondering how others are doing it.

You don't need Midazolam to achieve amnesia if you are giving high doses of Propofol (remember I said GA not MAC).
Apnea under straight Propofol is very commonly caused by airway obstruction which is greatly reduced in the lateral position and a little chin lift if needed.
We don't use capnograms in the Endo rooms but we keep an eye on chest movement etc...
By the way for periopdoc's question: The fear of aspiration is exaggerated in residency training.

 

[maceo]

upper endocopy can get hairy for sure. tough cases especially on patients who are obese and many co morbid conditions namely, sleep apnea and a smoking history. BUT one can get through that case. certainly the dose of propofol that is administered to blunt airway reflex for the insertion of the scope will cause apnea in MANY. However, with good preoxygnation the sat will not drop to scary levels. and the patient will resume breathing. and you are golden while the exam is done.. They are hairy cases sometimes. I also find a touch of narcotic helps greatly with blunting a/w reflexes and helps with coughing. Urge, while intubation would make us feel so much safer... totally not necessary for such a short case. But watch out for obese patients and the patients with co morbid conditions..

 

[Arch Guillotti]

We normally use a little bit of versed and a lot of propofol and it works pretty darn good the vast majority of the time.

 

[2ndyear]

My anesthetic of choice for endo is propofol boluses. 80-100 mg up front, scope in, supplement with 20-30 as needed. Our guys are usually in and out in 11 minutes. If they need to biopsy then start a drip. I agree that EGD's are a pain, but for whatever reason we only get called for the 'hard' ones. If someone has failed sedation, etc. I always find it funny that we make such a huge deal out of reflux, GERD, whatever and yet will do EGD's with active GERD and no airway.

 

[911_turbo]

All, please have a look at the thread entitled ACG Orlando in the members section. Thank you.

 

[dhb]

strait propofol; bucking is extremly rare if you start the milk soon enough to have the patient deep when the scope goes in: if you give a 100mg bolus and the GI rams the scope when eye closes it ain't gonna work.

periop: i agree with plank aspiration risks are exaggerated (i don't even bother to ask about gerd) patients are fasted and the scope has a suction port...

 

[jennyboo]

What we are doing is not MAC, it is GA with spontaneous ventilation

Yeah, I also think that whatever it is called on the anesthesia consent ("MAC") the reality is that most of the time what we're doing is a general anesthetic without a controlled airway.

We do have an anesthesia machine in the GI suite for those "special" cases (we are only asked to do the cases the sedation nurses failed, the ones they're afraid to sedate themselves, i.e. patients with high tolerance or patients who are really sick), or the kids (institutional bias).

Most of the time we don't intubate them anyway despite the presence of an anesthesia machine (longer turnover). For the appropriate candidate, a whiff of ketamine along with the propofol helps keep the respiratory rate up. For the young kids, propofol + narcotic (remi) is pretty standard, with the prop going around 200mcg/kg/min.

 

[sevo85288]

Endoscopies. 90% intubated. No risk of hypoxemia, aspiration, and movement.
I don't like to share. The airway that is.

 

[Planktonmd]

Endoscopies. 90% intubated. No risk of hypoxemia, aspiration, and movement.
I don't like to share. The airway that is.

Wow, really?
How many endo's do you do?
How long is your average procedure from induction to recovery?

 

[Frank Rizzo]

ketafol, 50 in 350 seems to work well.

 

[Laurel123]

Are you refering to just a routine endoscopy or more complicated endoscopic procedures like an ERCP or some of the dilating procedures?

For a routine endoscopy, most GI docs do them with just their nurse. Anesthesia is rarely involved, let alone are the patients intubated. My mother had an endoscopy for suspected ulcer just last month (she's OK!). I went in with her, but didn't do her anesthesia. It was just the routine case with the GO doc and the nurse. She gargled some lidocaine jelly stuff. The nurse gave her 2 mg of versed and 12.5 mg of demerol. She closed her eyes, the GI popped in the scope, looked all around, took a couple of biopsies and we went out to the recovery room. She barely coughed - and woke up in the recovery and asked if we had started yet.

We only get called in to do endoscopies for 'complicated' cases like if a patient is on narcotics or has OSA. For those cases, 40 mg of ketamine in 200mg of propofol works great. 50-70mg bolus, with 10 mg increments of propofol throughout the case. No versed, no narcs. Sometimes they cough, usually they don't. They never remember.

 

[Jeff05]

100% straight prop.
no nausea and vomiting as with narcs.
no increased pacu d/c times because of nystagmus as with ketamine.

i bolus about 1.5mg/kg up front, much more for kids. they will start breathing as the scope goes in. run infusion at 125-200mcg/kg/min.

there is absolutely NO need for midaz. not sure why some people insist on giving it. again, increased pacu d/c times. propofol by itself is an amnestic.

 

[Consigliere]

100% straight prop.
no nausea and vomiting as with narcs.
no increased pacu d/c times because of nystagmus as with ketamine.

i bolus about 1.5mg/kg up front, much more for kids. they will start breathing as the scope goes in. run infusion at 125-200mcg/kg/min.

there is absolutely NO need for midaz. not sure why some people insist on giving it. again, increased pacu d/c times. propofol by itself is an amnestic.

Pharmacologically, no. That being said, I have done thousands of EGDs and colonoscopies with nothing but propofol and almost all patients remember nada.

Remember, there are ENTIRE anesthesia groups who do nothing but GI sedation (ie Somnia). On parts of the East Coast (NJ, NY, MD) the presence of either an anesthesiologist or a CRNA is the NORM. Very geographically specific.

 

[numbmd]

I'm in NJ, and we have some rooms with 18 to 20 endos in a day. All with anesthesia coverage. The GI docs all want slabs of meat on the stretcher. They all do well. no intubations, ever. Could you do 18 cases in a day if they all are intubated? Without starting at 1 am, of course.

 

[jwk]

Endoscopies. 90% intubated. No risk of hypoxemia, aspiration, and movement.
I don't like to share. The airway that is.

Totally unrealistic.

 

[urge]

I'm in NJ, and we have some rooms with 18 to 20 endos in a day. All with anesthesia coverage. The GI docs all want slabs of meat on the stretcher. They all do well. no intubations, ever. Could you do 18 cases in a day if they all are intubated? Without starting at 1 am, of course.

I do pediatric endoscopies every once in a while. I intubate all of them. The GI doc says it is faster. Deep extubations on all of them.

 

[Planktonmd]

Pharmacologically, no.

Why not?
What would a pharmacologically amnestic drug be?

 

[Jeff05]

i beg to differ.


Titre du document / Document title
The comparative amnestic effects of midazolam, propofol, thiopental, and fentanyl at equisedative concentrations
Auteur(s) / Author(s)
VESELIS R. A. (1) ; REINSEL R. A. (1) ; FESHCHENKO V. A. (1) ; WRONSKI M. (1) ;
Affiliation(s) du ou des auteurs / Author(s) Affiliation(s)
(1) Department of Anesthesiology and Critical Care Medicine, Memorial Sloan-Kettering Cancer Center, New York, New York, ETATS-UNIS
Résumé / Abstract
Background: The authors evaluated the effects of midazolam, propofol, thiopental, and fentanyl on volunteer participants' memory for words and pictures at equisedative concentrations. Methods: Sixty-seven healthy volunteers were randomized to receive intravenous infusions of midazolam (n = 11), propofol (n = 11), thiopental (n = 10), fentanyl with ondansetron pretreatment (n = 11), ondansetron alone (n = 8), or placebo (n = 16) in a double-blind design. Three increasing and then two decreasing sedative concentrations were achieved by computer-controlled infusion in each volunteer. Measures of sedation, memory, and drug concentration were obtained at each target concentration. Drug concentrations were normalized to equisedative effects using both Emax and logistic regression methods of pharmacodynamic modeling. The serum concentrations at 50% memory effect (Cp50s) were determined using four different memory end points. The relative potencies compared with midazolam for memory impairment were determined. Results: Equisedative concentrations were midazolam, 64.5 ± 9.4 ng/ml; propofol, 0.7 ± 0.2 μg/ml; thiopental, 2.9 ± 1.0 μg/ml; and fentanyl, 0.9 ± 0.2 ng/ml. The Cp50s for 50% loss of memory for words were midazolam, 56 ± 4 ng/ml; propofol, 0.62 ± 0.04 μg/ml; thiopental, 4.5 ± 0.3 μg/ml; and fentanyl, 3.2 ± 0.4 ng/ml. Compared with midazolam, relative potencies (with 95% confidence intervals) were propofol, 0.96 (0.44-1.78); thiopental, 0.76 (0.52-0.94); and fentanyl, 0.34 (0.05-0.76). Large effects on memory were only produced by propofol and midazolam. Conclusions: At equal sedation, propofol produces the same degree of memory impairment as midazolam. Thiopental has mild memory effects whereas fentanyl has none. Ondansetron alone has no sedative or amnesic effects.
Revue / Journal Title
Anesthesiology ISSN 0003-3022 CODEN ANESAV
Source / Source
1997, vol. 87, no4, pp. 749-764 (68 ref.)

 

[ZA_Gasman]

On my private list day I do 5-7 endoscopies - short cases usually 15-30min. No one buys a tube unless my hand is really forced. I use a combo of Alfentanil titration, 1.5-2.5mg midaz up front and titrate boluses of Propofol. Minimal/no recall, pt street ready in 45-60min, and no bucking/coughing on the g-scopes. I sometimes put the g-scope down myself - then can be sure it isn't going anywhere it shouldn't.... I do insist and my surgeon is very happy with intubating the ERCPs. I don't like sedating prone patients. Call me a chicken if you will.

 

[Consigliere]

Why not?
What would a pharmacologically amnestic drug be?

Midazolam for one.

 

[Consigliere]

On my private list day I do 5-7 endoscopies - short cases usually 15-30min. No one buys a tube unless my hand is really forced. I use a combo of Alfentanil titration, 1.5-2.5mg midaz up front and titrate boluses of Propofol. Minimal/no recall, pt street ready in 45-60min, and no bucking/coughing on the g-scopes. I sometimes put the g-scope down myself - then can be sure it isn't going anywhere it shouldn't.... I do insist and my surgeon is very happy with intubating the ERCPs. I don't like sedating prone patients. Call me a chicken if you will.

Chicken. Too many drugs and too labor intensive. Use propofol +/- lidocaine only and pt will be street ready in 30 minutes.

 

[Consigliere]

i beg to differ.


Titre du document / Document title
The comparative amnestic effects of midazolam, propofol, thiopental, and fentanyl at equisedative concentrations
Auteur(s) / Author(s)
VESELIS R. A. (1) ; REINSEL R. A. (1) ; FESHCHENKO V. A. (1) ; WRONSKI M. (1) ;
Affiliation(s) du ou des auteurs / Author(s) Affiliation(s)
(1) Department of Anesthesiology and Critical Care Medicine, Memorial Sloan-Kettering Cancer Center, New York, New York, ETATS-UNIS
Résumé / Abstract
Background: The authors evaluated the effects of midazolam, propofol, thiopental, and fentanyl on volunteer participants' memory for words and pictures at equisedative concentrations. Methods: Sixty-seven healthy volunteers were randomized to receive intravenous infusions of midazolam (n = 11), propofol (n = 11), thiopental (n = 10), fentanyl with ondansetron pretreatment (n = 11), ondansetron alone (n = 8), or placebo (n = 16) in a double-blind design. Three increasing and then two decreasing sedative concentrations were achieved by computer-controlled infusion in each volunteer. Measures of sedation, memory, and drug concentration were obtained at each target concentration. Drug concentrations were normalized to equisedative effects using both Emax and logistic regression methods of pharmacodynamic modeling. The serum concentrations at 50% memory effect (Cp50s) were determined using four different memory end points. The relative potencies compared with midazolam for memory impairment were determined. Results: Equisedative concentrations were midazolam, 64.5 ± 9.4 ng/ml; propofol, 0.7 ± 0.2 μg/ml; thiopental, 2.9 ± 1.0 μg/ml; and fentanyl, 0.9 ± 0.2 ng/ml. The Cp50s for 50% loss of memory for words were midazolam, 56 ± 4 ng/ml; propofol, 0.62 ± 0.04 μg/ml; thiopental, 4.5 ± 0.3 μg/ml; and fentanyl, 3.2 ± 0.4 ng/ml. Compared with midazolam, relative potencies (with 95% confidence intervals) were propofol, 0.96 (0.44-1.78); thiopental, 0.76 (0.52-0.94); and fentanyl, 0.34 (0.05-0.76). Large effects on memory were only produced by propofol and midazolam. Conclusions: At equal sedation, propofol produces the same degree of memory impairment as midazolam. Thiopental has mild memory effects whereas fentanyl has none. Ondansetron alone has no sedative or amnesic effects.
Revue / Journal Title
Anesthesiology ISSN 0003-3022 CODEN ANESAV
Source / Source
1997, vol. 87, no4, pp. 749-764 (68 ref.)

Ok

 

[Planktonmd]

Midazolam for one.

So, If Midazolam causes amnesia does that mean that other medications don't?
What is the pharmacological property you were referring to when you said that Propofol can not "pharmacologically" produce amnesia?
We don't even know the exact mechanism by which medications can alter memories, all we have is theories, and I can venture to say that any medication that alters the level of consciousness can have amnestic properties that vary according to individual patient characteristics, dosage, concomitant use of other drugs, environmental factors and many other variables.

 

[Planktonmd]

Chicken. Too many drugs and too labor intensive. Use propofol +/- lidocaine only and pt will be street ready in 30 minutes.

Yes.
👍

 

[m32b]

for both egds and colonoscopies: propofol ~1mg/kg prior to scope insertion, then infusion @ 100 to 200 mcg/kg/min.

for ercps: the above recipe plus 25 to 50 mcg fentanyl prior to ampula cannulation.

 

[radslooking]

We do hundreds of endoscopic procedures every month and all of them are done under straight Propofol, nothing else.
They are done in endoscopy suites where there is no anesthesia machine and the average procedure takes 20-25 min from arriving to the room to leaving the room.
I don't see why we should intubate these people.
What we are doing is not MAC, it is GA with spontaneous ventilation and it works great as long as you don't start adding other agents (narcotics, bonzo...) and complicate the picture.

certainly adding bonzo will complicate the picture. nobody wants a damn hairy ape running around the Gi suite

 

[ncdoc1974]

Totally unrealistic.

I have to agree (with sevo dude) I intubate 90% of these cases as well...but it is rather specific to my pracitce...I only end up doing a handful of these cases a month, and it is usually because the patients have significant comorbidities, or it is for a longer, often prone ERCP (we do have one guy doing ERCP's supine)...More often than not in these cases I prefer a secured airway...As far as how much time this adds to the case, I would argue that for these cases I can put the patient to sleep and have them intubated faster than I can set up a propofol infuson and I can get the Des or Sevo off fast enough at the end of the case that I can have the patient awake in PACU just as fast as a MAC case...I am sure my incidence of nausea probably a little higher, but at least the aspiration risk is lower

 

[Consigliere]

So, If Midazolam causes amnesia does that mean that other medications don't?
What is the pharmacological property you were referring to when you said that Propofol can not "pharmacologically" produce amnesia?
We don't even know the exact mechanism by which medications can alter memories, all we have is theories, and I can venture to say that any medication that alters the level of consciousness can have amnestic properties that vary according to individual patient characteristics, dosage, concomitant use of other drugs, environmental factors and many other variables.

Can't argue with that.

 

[Laurel123]

certainly adding bonzo will complicate the picture. nobody wants a damn hairy ape running around the Gi suite

Bad joke! Yet I still laughed out the loud.

Well, regarding those that intubate most of their endoscopies, are you guys refering to ERCP's or just routine endoscopies? It is pretty excessive to intubate most routine endoscopies. They can be done routinely with some lidocaine swish and versed and narcotic. ERCP is a different story because some of those cases can last a long time, patients are prone, and the ampulla manipulation can be painful.

 

[ncdoc1974]

Bad joke! Yet I still laughed out the loud.

Well, regarding those that intubate most of their endoscopies, are you guys refering to ERCP's or just routine endoscopies? It is pretty excessive to intubate most routine endoscopies. They can be done routinely with some lidocaine swish and versed and narcotic. ERCP is a different story because some of those cases can last a long time, patients are prone, and the ampulla manipulation can be painful.

We rarely do routine endoscopy anesthesia due to billing issues with most of the payors in our state...so we are basically only doing ERCPs and endoscopies on patients with significant comorbidities, substance abuse issues, morbid obesity etc.

 

[LethalInjection]

MAC with propofol boluses, nothing else. In private practice, EGD's take less than 10 minutes, colonoscopies less than 20 minutes.