Anesthesia for TEE’s

[urge]

This is quite possibly the dumbest thing I've ever read.

A new line of service that's quick turnover and minimal time required that gives you more business and you're bitching about it?

I am shocked at the level of stupidity by my highly educated colleagues.

They are offering you more money by needing your service.

We staff the 3D TEEs for mitral clips and tricuspid clips that take about an hour long. Those patients are mostly pretty old and sick and having them under MAC for an hour while someone shoves an echo probe, while complaining when the patients cough, is not fun.

Not a great new line of service as you portray.

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[Maverikk]

Had one dude who would do long full exams on a post watchman tee…literally had a full exam a few days prior, all he had to do was go in and make sure it was well seated. Would always ask the tech for advice, the few seasoned techs knew how to handle him the newer ones had no idea what to do. Got advice from a good colleague: let him desat a little, don’t jaw thrust, and tell him it’s getting iffy and may have to tube, how much time did he need.?He’d get the view of the watchman and then pull out.

 

[nimbus]

I don’t mind tee either since its 7 start up units but the annoying part is not the billing. It’s waiting around for the cardiologist. We never started on scheduled time and even with patient in room they would take forever to come in. Also turnover time was long for some reason. Also, they’re not as facile as sticking the probe in compared to Gi doctors.

Endoscope allows visualization as you advance. TEE is blind.

 

[Biochemist21]

We staff the 3D TEEs for mitral clips and tricuspid clips that take about an hour long. Those patients are mostly pretty old and sick and having them under MAC for an hour while someone shoves an echo probe, while complaining when the patients cough, is not fun.

Not a great new line of service as you portray.

I wish our docs could do these in an hour. When our Cards docs started doing these 4yr ago they were about 6hr each, sometimes longer. More than once I was on CV call relieving a colleague around 1800, only to wrap up the second clip at 2000-2100. Needless to say, they've gotten a lot better with a combination of experience and a little new blood on their team. Still finishing second case around 1600. However we continue to do these exclusively under GA. Anesthesia exclusively performs the TEEs b/c they can't hire a cardiologist capable of imaging adequately enough for their colleagues to perform the procedure. But hey, at least the cardiologists genuinely appreciate us, even if it's only for imaging quality and nothing to do with a safe anesthetic.

I've heard of places doing clips under MAC, is this common? Hard to keep somebody motionless under MAC for a 60min+ TEE. Also our patients skew "sick" even by Mitraclip standards (routinely EF <20%, concurrent severe AS, mod-severe pHTN...).

 

[PpfSuxTube]

I've never heard of clip under an hour, nor mac for them...
Do you guys get decent results with that? Our guys aren't bad usually 3 a day finishing by 4pm. They won't accept any movement whatsoever, and rarely will accept anything else mild residual

For some reason cards seem interested in doing the tee for them which must be a major lose financially for them for the day...

 

[arsene19]

In my old PP group, we would bunch them at lunchtime and have them call us when patient, TEE tech, cardiologist were ready to go and travel cart and capnography/O2 hooked up. Then we'd preop consent and propofol. Once airway fine, tech would bring to phase 2. They took about 15 min for one - call us back in 30-45 min and we will do the next.

 

[abolt18]

I wish our docs could do these in an hour. When our Cards docs started doing these 4yr ago they were about 6hr each, sometimes longer. More than once I was on CV call relieving a colleague around 1800, only to wrap up the second clip at 2000-2100. Needless to say, they've gotten a lot better with a combination of experience and a little new blood on their team. Still finishing second case around 1600. However we continue to do these exclusively under GA. Anesthesia exclusively performs the TEEs b/c they can't hire a cardiologist capable of imaging adequately enough for their colleagues to perform the procedure. But hey, at least the cardiologists genuinely appreciate us, even if it's only for imaging quality and nothing to do with a safe anesthetic.

I've heard of places doing clips under MAC, is this common? Hard to keep somebody motionless under MAC for a 60min+ TEE. Also our patients skew "sick" even by Mitraclip standards (routinely EF QUOTE]

GA 100% of the time. We also do our watchman's with GA. Where I trained they usually did it he watchman's with nursing sedation. Anesthesia wasn't even involved.

 

[coffeebythelake]

How do you guys figure when a patient is ready to take the scope/probe? I usually load pts with iv lidocaine and a big slug of propofol until they are nearly apnea, do a jaw thrust to see if they respond, and if they don't all good to go

 

[markneil]

How do you guys figure when a patient is ready to take the scope/probe? I usually load pts with iv lidocaine and a big slug of propofol until they are nearly apnea, do a jaw thrust to see if they respond, and if they don't all good to go

Usually right after they start yawning. Another way I do it is have the cardiologist start out by talking to patient and having him swallow the probe until it's somewhat in and push some prop right after (usually after adequate local).

 

[urge]

I wish our docs could do these in an hour. When our Cards docs started doing these 4yr ago they were about 6hr each, sometimes longer. More than once I was on CV call relieving a colleague around 1800, only to wrap up the second clip at 2000-2100. Needless to say, they've gotten a lot better with a combination of experience and a little new blood on their team. Still finishing second case around 1600. However we continue to do these exclusively under GA. Anesthesia exclusively performs the TEEs b/c they can't hire a cardiologist capable of imaging adequately enough for their colleagues to perform the procedure. But hey, at least the cardiologists genuinely appreciate us, even if it's only for imaging quality and nothing to do with a safe anesthetic.

I've heard of places doing clips under MAC, is this common? Hard to keep somebody motionless under MAC for a 60min+ TEE. Also our patients skew "sick" even by Mitraclip standards (routinely EF <20%, concurrent severe AS, mod-severe pHTN...).

I’m talking about a 3D TEE preop for evaluation for candidacy. Takes an hour on average. Done under MAC.

The actual clip is done under GA and takes like 2 hours on average.

 

[Simba1711]

How do you guys figure when a patient is ready to take the scope/probe? I usually load pts with iv lidocaine and a big slug of propofol until they are nearly apnea, do a jaw thrust to see if they respond, and if they don't all good to go

I usually give 100 mg of iv lidocaine , 25 mcg of fentanyl , and then small boluses of propofol until they lose their lid reflex. I then check to make sure they are out with jaw thrust. With fentanyl it really limits their coughing and they will tolerate the probe without becoming apneic. After probe is in I start a propofol drip.

There is one cardiologist that wants the patient under conscious sedation. I do lidocaine spray and then versed, fentanyl , iv lidocaine and then propofol bolus and drip once probe is in.

 

[voxveritatisetlucis]

At my schools hospital CRNAs and AAs do these cases because the hospital is so cheap. I’m sure you could do it

 

[Twiggidy]

There is one cardiologist that wants the patient under conscious sedation. I do lidocaine spray and then versed, fentanyl , iv lidocaine and then propofol bolus and drip once probe is in.

Has that cardiologist given a reason for that request? I can’t imagine it improves image quality to have the patient more awake. Maybe some severity of valve lesions decrease with decreased BP but it’s probably not by that much for how much anesthetic we give for these particular cases.

 

[Arch Guillotti]

There is one cardiologist that wants the patient under conscious sedation. I do lidocaine spray and then versed, fentanyl , iv lidocaine and then propofol bolus and drip once probe is in.

Sounds about right.

 

[Simba1711]

Has that cardiologist given a reason for that request? I can’t imagine it improves image quality to have the patient more awake. Maybe some severity of valve lesions decrease with decreased BP but it’s probably not by that much for how much anesthetic we give for these particular cases.

He told me the probe goes down smoother and patient has less trauma when he tells the patient to swallow the probe. He is a really weird dude. To clarify he wants conscious sedation until the probe is in position. He wants general afterwards.

 

[coffeebythelake]

He told me the probe goes down smoother and patient has less trauma when he tells the patient to swallow the probe. He is a really weird dude. To clarify he wants conscious sedation until the probe is in position. He wants general afterwards.

That's weird.

 

[abolt18]

I usually give 100 mg of iv lidocaine , 25 mcg of fentanyl , and then small boluses of propofol until they lose their lid reflex. I then check to make sure they are out with jaw thrust. With fentanyl it really limits their coughing and they will tolerate the probe without becoming apneic. After probe is in I start a propofol drip.

There is one cardiologist that wants the patient under conscious sedation. I do lidocaine spray and then versed, fentanyl , iv lidocaine and then propofol bolus and drip once probe is in.

Why so complicated? Straight propofol, titrated to effect, just like in EGDs. Nothing more, nothing less.

 

[coffeebythelake]

Why so complicated? Straight propofol, titrated to effect, just like in EGDs. Nothing more, nothing less.

I don't use fentanyl but I do like to use iv lidocaine to blunt oropharyngeal reactivity. I do the same thing for my egds

 

[abolt18]

I don't use fentanyl but I do like to use iv lidocaine to blunt oropharyngeal reactivity. I do the same thing for my egds

I am unconvinced that the IV lidocaine makes any difference. Have tried it with and without many times. I notice no difference other than that I had to draw up one less drug.

 

[Maz777]

You are the human embodiment of the Dunning-Kruger Effect.

Kid would make quite the militant CRNA.

 

[Twiggidy]

For both EGDs and TEEs I give a touch of fentanyl because it is still a probe in the esophagus and I think even the little bit of pain control helps, but you guys are right in that you can mostly lean on propofol with these

@Simba1711 yes….that cardiologist is weird

 

[dannyboy1]

If they are young I give Fentanyl. Much less reactivity and potential spasming. Older folks I don’t bother

 

[PpfSuxTube]

I don't use fentanyl but I do like to use iv lidocaine to blunt oropharyngeal reactivity. I do the same thing for my egds

Sprayed lido to oropharynx during egd with Propofol has been Proven to be a waste of time and possibly even dangerous. I would imagine iv isn't much better. Just a waste for no benefit. Propofol solo is the best drug for egd, tee...

Idk why ppl continue to complicate these things. I see so many mixes being used and all for no benefit, definitely slow down the procedure and recovery time, and possible harm.

Disclosure, I worked @ a high volume endo centre as anesthesia director, personally done 1000s of egd, and reviewed my partners many more 1000s. The days the "mixers" were on, the productivity ground to a halt. We always had to pay overtime, the patients had more complaints...

 

[coffeebythelake]

Sprayed lido to oropharynx during egd with Propofol has been Proven to be a waste of time and possibly even dangerous. I would imagine iv isn't much better. Just a waste for no benefit. Propofol solo is the best drug for egd, tee...

Idk why ppl continue to complicate these things. I see so many mixes being used and all for no benefit, definitely slow down the procedure and recovery time, and possible harm.

Disclosure, I worked @ a high volume endo centre as anesthesia director, personally done 1000s of egd, and reviewed my partners many more 1000s. The days the "mixers" were on, the productivity ground to a halt. We always had to pay overtime, the patients had more complaints...

Got some actual evidence aside from anecdote?

https://www.bjanaesthesia.org/article/S0007-0912(21)00641-3/fulltext

Effect of intravenous lidocaine on the ED50 of propofol for inserting gastroscope without body movement in adult patients: a randomized, controlled study - BMC Anesthesiology

Background Circulatory and respiratory depression are common  problems that occur in propofol alone sedation during gastroscopy. As a widely used analgesic adjuvant, intravenous lidocaine can reduce the consumption of propofol during Endoscopic retrograde cholangiopancreatography (ERCP) or...

bmcanesthesiol.biomedcentral.com

Effect of intravenous lidocaine on outcomes in patients receiving propofol for gastrointestinal endoscopic procedures: an updated systematic review and meta-analysis - European Journal of Clinical Pharmacology

Background Gastrointestinal endoscopic procedures (GEPs) are frequently employed for the diagnosis and treatment of various gastrointestinal ailments. While propofol sedation is widely used during these procedures, there is a concern regarding its potential negative effects. Intravenous (IV)...

link.springer.com

 

[GassYous]

I've also done many egds and tees, give like 100 of prop upfront for old people and 200 for young people and test to see how they do. I gave versed 2 for all people under about 50 for egds and fat people and it seems to smooth things out.

 

[PpfSuxTube]

Got some actual evidence aside from anecdote?

https://www.bjanaesthesia.org/article/S0007-0912(21)00641-3/fulltext

Effect of intravenous lidocaine on the ED50 of propofol for inserting gastroscope without body movement in adult patients: a randomized, controlled study - BMC Anesthesiology

Background Circulatory and respiratory depression are common  problems that occur in propofol alone sedation during gastroscopy. As a widely used analgesic adjuvant, intravenous lidocaine can reduce the consumption of propofol during Endoscopic retrograde cholangiopancreatography (ERCP) or...

bmcanesthesiol.biomedcentral.com

Effect of intravenous lidocaine on outcomes in patients receiving propofol for gastrointestinal endoscopic procedures: an updated systematic review and meta-analysis - European Journal of Clinical Pharmacology

Background Gastrointestinal endoscopic procedures (GEPs) are frequently employed for the diagnosis and treatment of various gastrointestinal ailments. While propofol sedation is widely used during these procedures, there is a concern regarding its potential negative effects. Intravenous (IV)...

link.springer.com

No i don't, I guess I was wrong about IV. I had looked up the topical stuff a while back and just extrapolated badly from that...

Speeds up recovery by a fraction of a minute probably means nothing tho. I still think there's no benefit clinically just adding more complexity for no reason

 

[Maverikk]

Solo propofol works. If you’re at a busy endo center you’re high risk patients are bmis 40s

If you’re at a busy inpatient center that shovels all their trash to and gets all the complex endo referrals as well as their inpatient train wrecks it’s different. I do viscous lido swish and spit for the bmi>50, I think this has helped with apnea recovery time with people with no reserve and less bucking, and this was on same day patients. I order and have the preop nurse give it when the last one comes out, doesn’t slow down anything. If they’re inpatient and gigantic a whiff of ketamine goes a long way in someone who immediately starts desatting

 

[Bertelman]

He told me the probe goes down smoother and patient has less trauma when he tells the patient to swallow the probe. He is a really weird dude. To clarify he wants conscious sedation until the probe is in position. He wants general afterwards.

Sounds like the problem is the cardiologist. He just needs to get better placing the probe. It’s a little more difficult when they have esophageal tone, but shouldn’t be a struggle or traumatic. Just requires patience.

 

[sevoflurane]

Sounds like the problem is the cardiologist. He just needs to get better placing the probe. It’s a little more difficult when they have esophageal tone, but shouldn’t be a struggle or traumatic. Just requires patience.

Or if he's so dramatic, put it in yourself. I do this on occasion. Personally, I don't like the "swallow the probe while you are lightly sedated and still awake" approach.
Just seems cruel and also delays the procedure.
Good bump of propofol depending on co-morbidities and age and slide it in with a jaw thrust just like in the CT OR's.
I don't like giving fentanyl for these procedures. Sometimes I give a few mg of midaz to keep things smooth and spontaneous, but it needs to be the right patient. Many of these TEE's are 70+ year olds with severe comorbid conditions. Sometimes 50-70mg of prop gets me through these procedures w/o issue and they are awake and talking when I drop them off in recovery.

 

[Bertelman]

Good bump of propofol depending on co-morbidities and age and slide it in with a jaw thrust just like in the CT OR's.

This, exactly. We get called once a month to drop a probe.