Anesthetic for EGD/Colonoscopy - low EF and/or severe AS?

[deleted899865]

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What is your go to anesthetic for these sick GI patients? For these patients that have any of the above- severe pulm HTN, RV strain, severe AS, NSTEMi needing clearance for DAPT, 15% EF etc.

A line vs NIBP? Topicalize and minimal anesthesia? Precedex versed? Doses?

My go to has been A line then prop + ephedrine/phenylephrine. My colleagues never put in A lines for any GI pts and will use ketamine, precedex. For pts with severe pulm HTN I usually have A line + epi pushes available and use prop. Partners will tell CRNA to assist ventilation to avoid hypercapnia and otherwise no change in anesthetic.

Am I too conservative? Would love some input

 

[Arch Guillotti]

What is GICU?

 

[deleted899865]

What is GICU

Gi*

 

[dhb]

Topicalize and minimal anesthesia?

This

 

[Arch Guillotti]

Nickname for sick GI pts.

I like it!

 

[Arch Guillotti]

This

Only if they are really on death’s door.

 

[dhb]

Only if they are really on death’s door.

They still sleep pretty good with < 50mg of propofol

 

[Arch Guillotti]

No aline. Ketamine, versed, numb them up if truly horrendous. These are rare thankfully and require 100% micromanagement.

 

[Southpaw]

Propofol. Or versed ketamine. FYI I hate the GI world.

 

[okayplayer]

Less propofol. Given slowly.

 

[linkin06]

Ketafol

 

[chocomorsel]

What is the reason for a scope? How recent is this NSTEMI? Is it related to this GI bleed?

 

[GassYous]

"NSTEMi needing clearance for DAPT"
this is such total bs

 

[chocomorsel]

"NSTEMi needing clearance for DAPT"
this is such total bs

I am sorry. This cannot be the entire reason for the GI Workup can it? OP needs to tell us why the GI workup is needed. It could be a simple hemorrhoid +Cologuard or +guiac.

 

[DrOwnage]

Please tell me how you "assist" ventilation during an EGD for a patient with PHTN. If its severe PHTN, succ and intubate, no volatile, run propofol infusion. Doesn't add much to the time.

 

[deleted899865]

No aline. Ketamine, versed, numb them up if truly horrendous. These are rare thankfully and require 100% micromanagement.

What doses do you use for ketamine versed?

 

[coffeebythelake]

What is your go to anesthetic for these sick GI patients? For these patients that have any of the above- severe pulm HTN, RV strain, severe AS, NSTEMi needing clearance for DAPT, 15% EF etc.

A line vs NIBP? Topicalize and minimal anesthesia? Precedex versed? Doses?

My go to has been A line then prop + ephedrine/phenylephrine. My colleagues never put in A lines for any GI pts and will use ketamine, precedex. For pts with severe pulm HTN I usually have A line + epi pushes available and use prop. Partners will tell CRNA to assist ventilation to avoid hypercapnia and otherwise no change in anesthetic.

Am I too conservative? Would love some input

How significant is the RV dysfunction.

 

[secretasianman]

The best anesthesia is always no anesthesia. But a little versed fent plus the lidocaine sticky stuff that comes in a tube and uroject or 4% gargle goes a long way.

 

[GassYous]

Please tell me how you "assist" ventilation during an EGD for a patient with PHTN. If its severe PHTN, succ and intubate, no volatile, run propofol infusion. Doesn't add much to the time.

grab em by the shoulders and yell "breathe!"

 

[deleted162650]

Please tell me how you "assist" ventilation during an EGD for a patient with PHTN. If its severe PHTN, succ and intubate, no volatile, run propofol infusion. Doesn't add much to the time.

Trach first, then EGD.

 

[deleted126335]

The best anesthesia is always no anesthesia. But a little versed fent plus the lidocaine sticky stuff that comes in a tube and uroject or 4% gargle goes a long way.

AKA OK Anesthesia. "It's OK.....It's OK"

 

[sevo00]

A-line seems kind of extreme for a 5 minute colo

 

[MoMoGesiologist]

A-line seems kind of extreme for a 5 minute colo

Congrats you figured out you overdosed the patient two minutes earlier. What ya gonna do about it?

 

[2Fast2Des]

Congrats you figured out you overdosed the patient two minutes earlier. What ya gonna do about it?

Trach, ecmo, open chest

 

[dannyboy1]

In GI your complications are invariably airway, airway, and airway. I’ll take that 60 kg LOL with the stenotic aortic valve any day over the 35 year old with a neck like a fire hydrant.

 

[deleted697127]

First of all, remember most of these procedures can be done awake. (Obviously not full stomach or active UGI bleeding requiring transfusion) Sedation is not 100% necessary. Second, GI routinely does these with minimal sedation with patients that are somewhat awake and responsive. They do not need to be at a GA no airway level of sedation just because we are involved.

Numb them up and tell them the most stimulating part is the scope going in and it helps if you can follow command to swallow. I usually start with minimal doses of midaz 0.5-1 and fentanyl 25mcg at a time and then propofol 10mg at a time. Just go slow. If their BP shoots up with putting the bite block i they usually end up doing fine and tolerating a decent amount of propofol.

Slamming in 70mg of prop all at once in these patients is where you run into trouble. Or not giving your cocktail enough time to circulate.

 

[Urzuz]

Please tell me how you "assist" ventilation during an EGD for a patient with PHTN. If its severe PHTN, succ and intubate, no volatile, run propofol infusion. Doesn't add much to the time.

Maybe I’m not understanding, but what sense does this make? Volatile is more cardiac stable than propofol is if you’re giving them in doses to achieve similar anesthetic effects. If you’re concerned enough to intubate them, run volatile, just run a low concentration.

 

[GassYous]

Maybe I’m not understanding, but what sense does this make? Volatile is more cardiac stable than propofol is if you’re giving them in doses to achieve similar anesthetic effects. If you’re concerned enough to intubate them, run volatile, just run a low concentration.

Agreed. Short case so it's not even that much volatile. No need for anything else, keep it simple.

 

[secretasianman]

Am I the only one that “assists” ventilation by gradually applying pressure to the spasm notch? When I was a resident I was told it was inhumane lol.

 

[deleted697127]

Please tell me how you "assist" ventilation during an EGD for a patient with PHTN. If its severe PHTN, succ and intubate, no volatile, run propofol infusion. Doesn't add much to the time.

Depends on the endoscopist and anticipated duration of the procedure. If this is look around really quick to see if there are any ulcers so they can restart DAPT, often times we can get away with very minimal sedation and doing the procedure supine rather than lateral in under 2 minutes.

Particularly in severe pulmonary hypertension, this approach is preferable to inducing the depth of anesthesia required to intubate and switching from negative to positive pressure ventilation. You can always have your backup plan be GA and ETT if for whatever reason this doesn’t work. However, usually if minimal sedation isn’t working it turns out to be because your patient can tolerate higher doses of sedation. Just go slow and don’t burn bridges. Production pressure for sick patients is in your head.

If your justification for propofol is that the cause of severe pHTN is uncontrolled sleep apnea, sure maybe I’ll buy that propofol could be beneficial to volatile because it doesn’t rely on ventilation to decrease its depth on wake up but as others have said volatile is usually more stable than propofol. A lot of ICU cases end up on midaz over propofol due to hypotension and do fine in the OR with iso...

I am less worried about sleep apnea as cause of pHTN compared to more acute causes like MI, PE or valve issues because sleep apnea is more chronic and the patient likely deals with high CO2 and low sat every night.

 

[chocomorsel]

Agreed. Short case so it's not even that much volatile. No need for anything else, keep it simple.

Still waiting on your NEJM Hispanics and Blacks and Covid agenda article. I already know you are full of it and are putting a spin on what was really written and calling it a conspiracy or agenda when it was just facts that you twisted in your head.

 

[BloodySurgeon]

All my sick EGD pt get viscous lidocaine. Gargle and swallow. If not contraindicated ketamine/precedex. Otherwise 20-40mg IV lidocaine followed by 10mg propofol pushes l +/- neo/ephedrine. Wait in between (slow circulation). A little time consuming but works well for me. When the pt eyes are half open/half closed and i can tap on their forehead without response then its time for Endoscopy. I have 3inch tape across the side rails. Usually pt move hands a little but go back to sleep once in the esophagus/stomach.

Just prefer prop over etomidate, but use both successfully. Have a nasal trumpet connected to a 7.0 ETT tip, lubed and ready to go if necessary. Never needed to use fortunately. POM NRB O2 or cut side hole on a NRB for probe entry

 

[anbuitachi]

depends on the patient and surgeon. EGD plus colonoscopy will take at least 1 hr of procedure time here..
Plus our patients are terrible at following instructions. having them gargle lidocaine is pretty ineffective in many of my patients, i dont know if its due to language barriers or they are just bad at gargling..

i hate etomidate for sedation cases. the worst. i would place arterial line, and do propofol and ketamine. if it's just colonoscopy, then no arterial line.

 

[GassYous]

depends on the patient and surgeon. EGD plus colonoscopy will take at least 1 hr of procedure time here..
Plus our patients are terrible at following instructions. having them gargle lidocaine is pretty ineffective in many of my patients, i dont know if its due to language barriers or they are just bad at gargling..

i hate etomidate for sedation cases. the worst. i would place arterial line, and do propofol and ketamine. if it's just colonoscopy, then no arterial line.

EGDs are usually <10 minute from scope in to scope out. If they have to take a lot of biopsies or they can't find what they are looking for, could be longer. Colons are maybe 20-30 minutes. Together definitely under an hour.

 

[DocMcCoy]

Topical with wiff of versed and small etomidate boluses has worked well for my quick egds.

Low and slow and just about anything will work.

I love ketamine but my GI cases always seem a little more sloppy when I augment with it. patient moving, secretions, obstruction, etc. I like it for PEGs.

 

[GassYous]

I think the problem with ketamine is that you have to either give not enough or too much. Etomidate is a crappy drug. Low dose propofol all the way baby. I don't even use the pump anymore for most of my gi cases. One syringe of the white stuff, to go! Pacu discharges are great too.

 

[caligas]

Maybe old school, but here’s a good habit for any case with these kind of folks: feel/find a pulse before induction.

Then when cuff is cycling over and over post induction you can go back and compare pulse to baseline. if it’s threadier (or gone) then you know pretty well what’s happening.

 

[Arch Guillotti]

Please tell me how you "assist" ventilation during an EGD for a patient with PHTN.

Have a nasal trumpet connected to a 7.0 ETT tip, lubed and ready to go if necessary.

What he said. Can be connected to circuit. Works great for certain cases.

 

[Arch Guillotti]

no volatile

Why not?

 

[Arch Guillotti]

having them gargle lidocaine is pretty ineffective in many of my patients

Numb them up with a needle then. Gets them numb and maybe gives some incentive to learn how to gargle.

 

[anbuitachi]

Numb them up with a needle then. Gets them numb and maybe gives some incentive to learn how to gargle.

You mean blocks?

 

[Arch Guillotti]

You mean blocks?

Yes.

 

[anbuitachi]

Yes.

which blocks do you like the best for EGDs... glosspharyngeal? suprerior laryngeal?

 

[Arch Guillotti]

What doses do you use for ketamine versed?

10-20 mg ketamine.
1-2 mg versed.

 

[Arch Guillotti]

which blocks do you like the best for EGDs... glosspharyngeal? suprerior laryngeal?

Glossopharyngeal.

 

[OB1🤙]

Less propofol. Given slowly.

This is the correct answer.

 

[Drwine]

Less propofol. Given slowly.

No "Jackson Pollock Club" anesthesia in a patient like this. A line overkill.

 

[Velefunt]

Propofol like I do BBQ - low and slow

In that once in a decade special occasion I'll give ketamine 250mg IVP and let it ride.

 

[Katheudontas parateroumen]

We get called quite a few times for EGD on LVAD patients or super sick hearts low EFs. Half attendings just do low and slow propofol + pressor, or drug of choice (ketamine, etomidate, etc), other half will intubate to control ventilation. Even if it's just a "5 minute" case. Reasoning for LVADs/horrible RVs is it's usually easy enough to keep up the BP but the main thing we can mess up is their ventilation and thus RV failure leading to all the badness. As a current trainee, I can see both sides but i'm leaning towards if it doesn't add much to my time/they are in the ICU with all the monitors already, I'm gonna tube them. Honestly, GI is the worst!

 

[IMGASMD]

We get called quite a few times for EGD on LVAD patients or super sick hearts low EFs. Half attendings just do low and slow propofol + pressor, or drug of choice (ketamine, etomidate, etc), other half will intubate to control ventilation. Even if it's just a "5 minute" case. Reasoning for LVADs/horrible RVs is it's usually easy enough to keep up the BP but the main thing we can mess up is their ventilation and thus RV failure leading to all the badness. As a current trainee, I can see both sides but i'm leaning towards if it doesn't add much to my time/they are in the ICU with all the monitors already, I'm gonna tube them. Honestly, GI is the worst!

Would advise to do as many procedures outside of OR as possible. And try it both ways, as much as possible. Both has its values.

We don’t like to talk about it, but when you’re in private practice, there are days the surgeon/proceduralist who are set in their ways. If it’s safe, it’s not the hill to die on.