Aspiration during endoscopy

[Evenflow001]

Just putting this out there...anyone have a case of aspiration pneumonitis during a colonoscopy where the GI doc took a long time to get to the cecum, lots of air insufflation, or where the GI tech/nurse applies external abdominal pressure to reduce a "loop" or "straighten out" a flexure? Seems like the external abdominal pressure manuever is used quite routinely causing a significant amount of increased intrabdominal pressure and increased risk of aspiration in otherwise healthy patients. Would you terminate the case if the patient experiences an episode of laryngospasm, coughing/bucking or wretching without overt regurgitation/emesis or aspiration during the procedure? Any feedback and/or thoughts would be appreciated.

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[BLADEMDA]

Just putting this out there...anyone have a case of aspiration pneumonitis during a colonoscopy where the GI doc took a long time to get to the cecum, lots of air insufflation, or where the GI tech/nurse applies external abdominal pressure to reduce a "loop" or "straighten out" a flexure? Seems like the external abdominal pressure manuever is used quite routinely causing a significant amount of increased intrabdominal pressure and increased risk of aspiration in otherwise healthy patients. Would you terminate the case if the patient experiences an episode of laryngospasm, coughing/bucking or wretching without overt regurgitation/emesis or aspiration during the procedure? Any feedback and/or thoughts would be appreciated.

Aspiration during Colonoscopy is rare. It is more common (though still rare) in EGD cases.Fortunately. most aspirations due to Gi procedures are mild and the patient can usually be discharged home following the Mayo Clinic protocol.

As for terminating a case due to laryngospasm that is the provider's decision.
Again, though uncommon laryngospasm is more commonly seen with EGD than Colonoscopy. I've rarely needed to cancel a case due to mild laryngospasm. Severe Laryngospasm requiring Sux or intubation (I've done this twice in my career) may require cancellation or termination of the procedure. However, once the patient is intubated why cancel the case?

Overall, you sound very inexperienced in outpatient Gi as aspiration is extremely rare even with abdominal pressure.

I will conclude that my cancellation rate for Gi procedures is less than 0.1% due to any of the reasons you have mentioned on this thread.

 

[Evenflow001]

Actually, no I'm not inexperienced in out/inpatient GI procedures having done over 1650-1750 cases the past 6 years while supervising residents/nurse anesthetists for 2-3 x as many. The info I stated is a reflection of comments, concerns that were mentioned by various anesthesia and non-anesthesia providers during Grounds Rounds/QA. The scenario mentioned did actually occur with devastating consequences. While I agree that aspiration during endoscopy is rare (most often "micro-aspiration, rarely requiring treatment or resulting in long term sequalae or morbidity) our department has seen several in the past few months (EGD > colon) which is why I bring this up. The need/desire of ambulatory centers to do procedures, timing of preps, selection of patients, skill of endoscopist, patient positioning & alternative maneuvers (lat decub, supine, ext pressure) etc. have to be scrutinized and improved upon to reduce this rare but potentially catastrophic complication.

 

[BLADEMDA]

Actually, no I'm not inexperienced in out/inpatient GI procedures having done over 1650-1750 cases the past 6 years while supervising residents/nurse anesthetists for 2-3 x as many. The info I stated is a reflection of comments, concerns that were mentioned by various anesthesia and non-anesthesia providers during Grounds Rounds/QA. The scenario mentioned did actually occur with devastating consequences. While I agree that aspiration during endoscopy is rare (most often "micro-aspiration, rarely requiring treatment or resulting in long term sequalae or morbidity) our department has seen several in the past few months (EGD > colon) which is why I bring this up. The need/desire of ambulatory centers to do procedures, timing of preps, selection of patients, skill of endoscopist, patient positioning & alternative maneuvers (lat decub, supine, ext pressure) etc. have to be scrutinized and improved upon to reduce this rare but potentially catastrophic complication.

Perhaps your complications are related to lengthy Gi procedures and inexperienced endoscopists? During my career I've performed or supervised in excess of 20K Gi procedures without nearly the fanfare you have described in your original post.

Abdominal pressure is usually BRIEFLY applied, injection of air is limited, procedures usually lasting less than 30 minutes, etc. are all part of safe/skilled endoscopy in an outpatient setting.

 

[BLADEMDA]

Risks

Perforation - Hole in bowel(1 in 1000; risk incresased if larger polyp removed, adhesions/hysterectomy or cancer present): if so will need surgery
Serious bleeding from bowel(or more rarely bleeding from spleen where colon is attached) (1 in 1000) : may need blood transfusion or an operation. Minor bleeding from trauma to haemorrhoids/bowel wall.
Sepsis/infection; anaesthetic reactions; aspiration/pneumonia; heart attack/stroke; death(1 in 10000)
Incomplete colonoscopy(<5%) because of looping/angulation of bowel- will then need another method of investigation to view the rest of the colon eg Contrast enema or CT colonscopy

 

[BLADEMDA]

http://www.anesthesia-analgesia.org/content/103/4/941.abstract


The current incidence of PPA is 1 of 7103, with morbidity 1 of 16,573 and mortality 1 of 99,441.

PPA=Perioperative Pulmonary Aspiration

 

[Gastrapathy]

If I could hazard a guess, this happened in a training environment where everyone was used to propofol MAC for endoscopy. The result of that is less focus on good endoscopy technique (minimize air, looping, etc) because you can just jack up the propofol until you've got a room-air general anesthetic and the patient doesn't feel/remember a thing.

Endoscopy should be performed under moderate sedation. Patients protect their own airways. Except for advanced procedures (ERCP/EUS), the surgical expectation of a near-apneic, practically paralyzed patient is unnecessary, risky and develops bad habits in trainee endoscopists.

You should back off the propofol and retrain your endoscopists to having patients a little less deep.

 

[pgg]

http://www.anesthesia-analgesia.org/content/103/4/941.abstract


The current incidence of PPA is 1 of 7103, with morbidity 1 of 16,573 and mortality 1 of 99,441.

PPA=Perioperative Pulmonary Aspiration

Those numbers are for all comers though, not just endoscopic cases. I didn't read the whole article but the abstract did say 50% of the aspirations occurred in GE procedures.

As for terminating a case due to laryngospasm that is the provider's decision.
Again, though uncommon laryngospasm is more commonly seen with EGD than Colonoscopy. I've rarely needed to cancel a case due to mild laryngospasm. Severe Laryngospasm requiring Sux or intubation (I've done this twice in my career) may require cancellation or termination of the procedure. However, once the patient is intubated why cancel the case?

Maybe a month ago I was doing an EGD with propofol/ketamine sedation. Patient abruptly went apneic, I tried the usual airway maneuvers in case it was just obstruction, it wasn't, surgeon pulled the scope, tried mask ventilating, obviously laryngospasm. I gave 80 mg of succ and intubated the patient. First time this has ever happened to me. Did not cancel the case.

 

[BLADEMDA]

EGD procedures can result in "low grade" aspirations. I've seen more than a dozen or so in my career. I've only had 2 from Colons and both of them went home. Out of the dozen or so mild aspirations from EGD procedures only 2 were admitted to the hospital while the other ten went home.

Despite all the obesity, sleep apnea, GERD, etc out there (it seems 70% or more suffer from one of those these days) I've only had one death (in hospital) during/after a Gi procedure. Of course, that patient was simply too ill and near death's door anyway to tolerate the procedure.

Even today when facing a 350-400 pounder with Sleep Apnea for an EGD/Colon I'm always prepared for the worst. Fortunately, most only need a jaw thrust then maybe an oral airway (after the EGD) to relieve their airway obstruction.

Anybody doing "MAC" on these types of patients for an ERCP? I much prefer an ET Tube for jaundiced or high risk patients.

 

[pgg]

Anybody doing "MAC" on these types of patients for an ERCP? I much prefer an ET Tube for jaundiced or high risk patients.

I intubate the OSA'ers, really obese patients, or anyone who looks off to me.

Most routine ERCPs I do with a nasal cannula + ETCO2, ketafol, prone, plus a little bit of Trendelenburg. I'm more worried about airway issues than aspiration. The endoscopist sucks out the stomach and duodenum on the way in, so I figure a) even if they did aspirate something, it's just going to be saliva (I know that sounds cavalier), and b) in that position gravity is my friend.

 

[jwk]

If I could hazard a guess, this happened in a training environment where everyone was used to propofol MAC for endoscopy. The result of that is less focus on good endoscopy technique (minimize air, looping, etc) because you can just jack up the propofol until you've got a room-air general anesthetic and the patient doesn't feel/remember a thing.

Endoscopy should be performed under moderate sedation. Patients protect their own airways. Except for advanced procedures (ERCP/EUS), the surgical expectation of a near-apneic, practically paralyzed patient is unnecessary, risky and develops bad habits in trainee endoscopists.

You should back off the propofol and retrain your endoscopists to having patients a little less deep.

Actually the preferred method is to let the anesthesia providers deal with the sedation and let the endoscopist do their thing.

If endoscopists want moderate sedation, there really is little need for anesthesia to be there. But that's not what they want. They want deep sedation, and the problem is that they've now gotten spoiled by having us there, and most that I deal with now refuse to do cases without anesthesia being present. No problem - as long as I get paid for these cases, we'll do them all day long. But if I'm there, the sedation is done my way, not your way, using drugs and techniques of my choosing. You have me there for my expertise - enjoy. 🙂

 

[Gastrapathy]

Actually the preferred method is to let the anesthesia providers deal with the sedation and let the endoscopist do their thing.

If endoscopists want moderate sedation, there really is little need for anesthesia to be there. But that's not what they want. They want deep sedation, and the problem is that they've now gotten spoiled by having us there, and most that I deal with now refuse to do cases without anesthesia being present. No problem - as long as I get paid for these cases, we'll do them all day long. But if I'm there, the sedation is done my way, not your way, using drugs and techniques of my choosing. You have me there for my expertise - enjoy. 🙂

My my, a little sensitive?

But, there isn't much reason for you to be there for most cases. I agree. Its too expensive and only marginally beneficial for patient flow and satisfaction.

If you read my post, the spoiled endoscopist was exactly my point and it starts with trainees who are used to working in anesthesia-only centers (mostly with CNRAs). My point was that endoscopist expectations need to be managed and keeping patients lighter is probably safer. I'm sorry if that was somehow deeply offensive to your extensive expertise.

For Blade, in my experience its about 50/50 GETA versus propofol MAC for ERCP and thats totally based on anesthesia preference. I don't really care. The only exception is that I don't want to do supine cases without an ET tube.

 

[dhb]

The only exception is that I don't want to do supine cases without an ET tube.

Why?

 

[PMPMD]

Why?

Think he meant 'prone'

 

[jwk]

My my, a little sensitive?

But, there isn't much reason for you to be there for most cases. I agree. Its too expensive and only marginally beneficial for patient flow and satisfaction.

If you read my post, the spoiled endoscopist was exactly my point and it starts with trainees who are used to working in anesthesia-only centers (mostly with CNRAs). My point was that endoscopist expectations need to be managed and keeping patients lighter is probably safer. I'm sorry if that was somehow deeply offensive to your extensive expertise.

For Blade, in my experience its about 50/50 GETA versus propofol MAC for ERCP and thats totally based on anesthesia preference. I don't really care. The only exception is that I don't want to do supine cases without an ET tube.

Not sensitive at all. We don't go seeking out these patients. Anesthesia is present at the request of the endoscopist. If you don't want us there, no problem. But if we are there, again, we'll do it our way. I'm sure you wouldn't expect me to dictate your endoscopy technique to you, right?

Just curious though - if I had to guess, I'll bet you're in favor of sedation with propofol and/or fospropofol WITHOUT an anesthesia provider.

 

[Gastrapathy]

Think he meant 'prone'

Nope. Prone or semi-prone patients tend to drool and can be suctioned easily. The supine patients aspirate their oral secretions and cough repeatedly during the case if they aren't intubated which is really annoying when trying to cannulate.

It really only comes up when working with a new anesthesia provider who thinks that we would prefer a patient not intubated and wants the patient on his back. My general preference is to do cases semi-prone, intubated or not but I don't mind supine intubated cases.

 

[Gastrapathy]

Not sensitive at all. We don't go seeking out these patients. Anesthesia is present at the request of the endoscopist. If you don't want us there, no problem. But if we are there, again, we'll do it our way. I'm sure you wouldn't expect me to dictate your endoscopy technique to you, right?

Just curious though - if I had to guess, I'll bet you're in favor of sedation with propofol and/or fospropofol WITHOUT an anesthesia provider.

This thread started as a discussion of endoscopy technique and aspiration and I listen to everyone in the room. All I did was raise the possibility that these new aspiration events were due to the only meaningful change in endoscopy in the last 10 years (the widespread use of propofol) and the tendency to expect deeper sedation. I blame endoscopists for expecting patients to be so deep for routine endoscopy. I think our expectations have definitely influenced anesthesia providers (particularly CRNAs) in the level of sedation that they provide.

If you disagree with my theory that the increase in aspiration this doc has seen could be due to routinely employing deeper sedation, thats fine. I'd love to hear why I'm wrong. But arguing that I should keep my head on the other side of the drapes is just being territorial. Trust me, during a case when you guys are there, I abdicate that part completely.

Finally, I am totally 100% opposed to endoscopist or nurse-administered propofol. Deep sedation is the province of dedicated anesthesia providers who are skilled at managing the inevitable dips into a deeper plane. That is not me and especially not when I'm otherwise occupied. I want your assistance with OSA patients, ASA 3 patients, ERCP cases and and EUS cases. The only difference between those is that I do want deep sedation for ERCP and EUS and I don't mind if you want to keep the patient lighter in the routine endoscopy but high-risk patient. Since that isn't always obvious to new providers, I'll explain that and they have always been appreciative of that conversation.

 

[pd4emergence]

This thread started as a discussion of endoscopy technique and aspiration and I listen to everyone in the room. All I did was raise the possibility that these new aspiration events were due to the only meaningful change in endoscopy in the last 10 years (the widespread use of propofol) and the tendency to expect deeper sedation. I blame endoscopists for expecting patients to be so deep for routine endoscopy. I think our expectations have definitely influenced anesthesia providers (particularly CRNAs) in the level of sedation that they provide.

If you disagree with my theory that the increase in aspiration this doc has seen could be due to routinely employing deeper sedation, thats fine. I'd love to hear why I'm wrong. But arguing that I should keep my head on the other side of the drapes is just being territorial. Trust me, during a case when you guys are there, I abdicate that part completely.

Finally, I am totally 100% opposed to endoscopist or nurse-administered propofol. Deep sedation is the province of dedicated anesthesia providers who are skilled at managing the inevitable dips into a deeper plane. That is not me and especially not when I'm otherwise occupied. I want your assistance with OSA patients, ASA 3 patients, ERCP cases and and EUS cases. The only difference between those is that I do want deep sedation for ERCP and EUS and I don't mind if you want to keep the patient lighter in the routine endoscopy but high-risk patient. Since that isn't always obvious to new providers, I'll explain that and they have always been appreciative of that conversation.

Over the last few years my group has drastically increased the number of endos that we do (I did around 60 endos yesterday). I have no real experience as to how many aspirated before we became so heavily involved. As for the last few years, the number of clinically relevant aspirations has been few and far between. I do think we are doing some good with our involvement. Some of the sickest pt's we do, we do in the hospital endoscopy lab. Our endoscopists are pretty demanding and most of our endos are IV general anesthetics. I think one of our saving graces is the fact that we are not a training facility. To our endoscopist's credit, the uppers are generally less than 10 minutes and the colons are generally less than 20 minutes. We tube all of our ercp's. So maybe its a time issue in addition to deeper sedation in your situation or maybe its my lack of experience in seeing endo's done with demerol/versed and the aspiration rates in that regard. It also could be the prep regimen. Any changes lately? I know when we first started doing these our colons would come in having just drunk a bunch of prep. Just a thought.

 

[jwk]

This thread started as a discussion of endoscopy technique and aspiration and I listen to everyone in the room. All I did was raise the possibility that these new aspiration events were due to the only meaningful change in endoscopy in the last 10 years (the widespread use of propofol) and the tendency to expect deeper sedation. I blame endoscopists for expecting patients to be so deep for routine endoscopy. I think our expectations have definitely influenced anesthesia providers (particularly CRNAs) in the level of sedation that they provide.

If you disagree with my theory that the increase in aspiration this doc has seen could be due to routinely employing deeper sedation, thats fine. I'd love to hear why I'm wrong. But arguing that I should keep my head on the other side of the drapes is just being territorial. Trust me, during a case when you guys are there, I abdicate that part completely.

Finally, I am totally 100% opposed to endoscopist or nurse-administered propofol. Deep sedation is the province of dedicated anesthesia providers who are skilled at managing the inevitable dips into a deeper plane. That is not me and especially not when I'm otherwise occupied. I want your assistance with OSA patients, ASA 3 patients, ERCP cases and and EUS cases. The only difference between those is that I do want deep sedation for ERCP and EUS and I don't mind if you want to keep the patient lighter in the routine endoscopy but high-risk patient. Since that isn't always obvious to new providers, I'll explain that and they have always been appreciative of that conversation.

As far as the OP - we've had very few patients aspirate during colonoscopy. I've had one in the thousands that I've done, and that was when the patient was turned supine and abdominal pressure applied. That patient went home the same day after a few extra hours of observation. A larger issue for most of us - we have significant concerns about those patients who do all or part of their prep a few hours prior to their colonoscopy as opposed to the night before - clear fluid or not, that's an accident waiting to happen.

Most of our endoscopy procedures are done with deep sedation - our endoscopists prefer it (most have many years of experience) because they can do a better exam, our patients prefer it, and we would much rather be involved from the start than coming in for a "rescue" in the middle of the case (quite common in the pre-propofol days). I use propofol-only on 99% of my endoscopies, avoiding the prolonged and discharge-delaying effects of narcotics and midazolam combinations. My patients are talking before they leave the procedure room and gone by the time I get to the PACU with the following patient.

Our ERCP's are split between GA and MAC, usually according to the endoscopists preference (although we make the final choice). Each has it's plusses and minuses. I can do a great ketamine-propofol-midaz MAC combination, but I do think the aspiration risks are inherently higher. GA is not automatically easier, especially with the poor logistics and layout of our GI lab or tiny x-ray suite. Intubating, turning prone, then turning the stretcher, being isolated from the head of the patient, etc., all make it a royal pain. Adding EtCO2 monitoring to the mix probably will push us towards more MAC cases, since it wil be easier to monitor the patient from the other end of the bed. Unfortunately, nobody consults us about room layouts during the construction phase.

 

[Hamhock]

A bit of a change of topic, if folks don't mind.

I think this was briefly discussed in years past, but I can't find the thread and the topic has resurfaced for me as I have since been exposed to a few new practice environments.

How do you guys handle UGIB endoscopy? ...in the ICU or, if you also cover it, the ED?

The background to my question: (I am EM-trained and only work in the ED currently)

UGIBs were frequently scoped in the ED in my previous two EDs. In the first ED, the GI docs would handle their own "sedation" and rarely involve the ED docs (a few times I have "involved myself"). In the second ED, the GI docs frequently asked the EM docs for help with "sedation". I was only involved in a few of these requests and each time expressed my desire to intubate the UGIB before "sedation". The GI docs balked and acted like I was overly conservative.

So, when you guys are called for help with UGIB in the ICU (or ED) and the patient has vomited blood within, let's say, the past two to three hours, would you guys not intubate?

All I envision is a belly of blood and I so I won't "help" without an ETT and I shake thinking about the GI docs going at it alone with fentanyl and versed.

Opinions? How do you guys handle these situations?

Rarely are folks scoped in the ED at my current shops, but I think I will still go for the ETT and am considering discussing it with my new group to make it policy.

HH

 

[cchoukal]

A bit of a change of topic, if folks don't mind.

I think this was briefly discussed in years past, but I can't find the thread and the topic has resurfaced for me as I have since been exposed to a few new practice environments.

How do you guys handle UGIB endoscopy? ...in the ICU or, if you also cover it, the ED?

The background to my question: (I am EM-trained and only work in the ED currently)

UGIBs were frequently scoped in the ED in my previous two EDs. In the first ED, the GI docs would handle their own "sedation" and rarely involve the ED docs (a few times I have "involved myself"). In the second ED, the GI docs frequently asked the EM docs for help with "sedation". I was only involved in a few of these requests and each time expressed my desire to intubate the UGIB before "sedation". The GI docs balked and acted like I was overly conservative.

So, when you guys are called for help with UGIB in the ICU (or ED) and the patient has vomited blood within, let's say, the past two to three hours, would you guys not intubate?

All I envision is a belly of blood and I so I won't "help" without an ETT and I shake thinking about the GI docs going at it alone with fentanyl and versed.

Opinions? How do you guys handle these situations?

Rarely are folks scoped in the ED at my current shops, but I think I will still go for the ETT and am considering discussing it with my new group to make it policy.

HH

As an intensivist, I deal with this issue a lot, as many of our GIB patients are scoped in the units where I work. I base the decision primarily on what I think the source of bleeding is. If there's a high likelihood it's an esophageal varix, I generally intubate. If it is unlikely to be esophageal, I generally don't. Much of this comes from the history and exam. There are shades of grey here, and there are other patient factors (mental status, current vomiting, likelihood of difficult intubation, ability to tolerate an aspiration event, etc.) that might sway me one way or another.

I marvel at the fact that anyone cares how we choose to anesthetize patients for their procedures. We just had an M/M session filled with cases that turned to $hit because, at the root of it, the surgeon didn't agree with our judgment and pushed us to do something we didn't really agree with. I just don't get why the endoscopist would care whether we intubate or not (or whether the ENT would care if we did an awake fiber, or why the vascular surgeon would care if I put in a central line), assuming scoping conditions were adequate in either case. Is it the "time" it takes?

 

[pgg]

A bit of a change of topic, if folks don't mind.

I think this was briefly discussed in years past, but I can't find the thread and the topic has resurfaced for me as I have since been exposed to a few new practice environments.

This the one you're looking for? An oldie but a goodie.

 

[jwk]

As an intensivist, I deal with this issue a lot, as many of our GIB patients are scoped in the units where I work. I base the decision primarily on what I think the source of bleeding is. If there's a high likelihood it's an esophageal varix, I generally intubate. If it is unlikely to be esophageal, I generally don't. Much of this comes from the history and exam. There are shades of grey here, and there are other patient factors (mental status, current vomiting, likelihood of difficult intubation, ability to tolerate an aspiration event, etc.) that might sway me one way or another.

I marvel at the fact that anyone cares how we choose to anesthetize patients for their procedures. We just had an M/M session filled with cases that turned to $hit because, at the root of it, the surgeon didn't agree with our judgment and pushed us to do something we didn't really agree with. I just don't get why the endoscopist would care whether we intubate or not (or whether the ENT would care if we did an awake fiber, or why the vascular surgeon would care if I put in a central line), assuming scoping conditions were adequate in either case. Is it the "time" it takes?

👍 As I tried to indicate a few posts above, it's not about a turf battle. It's about what is best for the patient.

What Hamhock describes, sedating/anesthetizing/intubating for a GI bleed at the request of the endoscopist in the ICU, would be induction of anesthesia by most people's definitions. I'm really surprised an ER doc would leave the ER to go do this. It's one thing to emergently handle a deteriorating airway, but that's not what happened. This is routine stuff for most anesthesia departments. Is this a small-town hospital with no anesthesia available in a reasonable time frame?

 

[Hamhock]

This the one you're looking for? An oldie but a goodie.

That might be it...I am not sure, as I don't remember clearly what I am looking for.

However, there is some good anecdote in there to consider...and some not-so-good EM-bashing.

I think those anecdotes further supports my conservative approach.

Thanks for finding that thread.

HH

 

[Hamhock]

👍 As I tried to indicate a few posts above, it's not about a turf battle. It's about what is best for the patient.

What Hamhock describes, sedating/anesthetizing/intubating for a GI bleed at the request of the endoscopist in the ICU, would be induction of anesthesia by most people's definitions. I'm really surprised an ER doc would leave the ER to go do this. It's one thing to emergently handle a deteriorating airway, but that's not what happened. This is routine stuff for most anesthesia departments. Is this a small-town hospital with no anesthesia available in a reasonable time frame?

jwk - I agree with you too much. Essentially what GI and the admitting IM team was requesting of us was - by everyone's definition - anesthesia. However, at those shops anesthesiology was not interested in helping in the ED and certainly was not interested in taking these folks to the OR or endoscopy suite.

We were faced with either letting the GI docs go at it alone or stepping in and helping as best as we could...which, at least in a few cases, bought patients an ETT that an anesthesiologist may not have required.

In response to an ER doc leaving the ER to do this: We never left the ED to help in the ICU, if we were assigned to the ED. When we were assigned to the ED, we were only responsible for the ED and for responding to codes on the first two floors (shockingly!, including the ORs).

However, as a resident, I was asked twice by GI - one case was asked by the MICU director - to basically provide deep sedation with brief periods of general anesthesia (as it worked out) using propofol and fentanyl for endoscopy in the MICU.

Not my choice, but...that's the way it worked there. I was certainly not going to tell the MICU director "no"...and we all knew anesthesiology was not going to show up to help.

However, I am now at a different center (where anesthesiology is very strong and always available!)...but I remain interested in opinions regarding how you folks would handle cases like I presented...given my relative lack of experience, I think I will still reach for the ETT, at this point.

HH

 

[Gastrapathy]

jwk - I agree with you too much. Essentially what GI and the admitting IM team was requesting of us was - by everyone's definition - anesthesia. However, at those shops anesthesiology was not interested in helping in the ED and certainly was not interested in taking these folks to the OR or endoscopy suite.

We were faced with either letting the GI docs go at it alone or stepping in and helping as best as we could...which, at least in a few cases, bought patients an ETT that an anesthesiologist may not have required.

In response to an ER doc leaving the ER to do this: We never left the ED to help in the ICU, if we were assigned to the ED. When we were assigned to the ED, we were only responsible for the ED and for responding to codes on the first two floors (shockingly!, including the ORs).

However, as a resident, I was asked twice by GI - one case was asked by the MICU director - to basically provide deep sedation with brief periods of general anesthesia (as it worked out) using propofol and fentanyl for endoscopy in the MICU.

Not my choice, but...that's the way it worked there. I was certainly not going to tell the MICU director "no"...and we all knew anesthesiology was not going to show up to help.

However, I am now at a different center (where anesthesiology is very strong and always available!)...but I remain interested in opinions regarding how you folks would handle cases like I presented...given my relative lack of experience, I think I will still reach for the ETT, at this point.

HH

Lots of small mediocre studies on the issue of intubating GIBs. They seem to favor not intubating patients with suspected variceal hemorrhage. People aspirate during induction or aspirate during endoscopy. For most UGIB, the key is using the right scope with a big channel and getting the stomach clear quickly.

I've never asked an ED physician for help with endoscopy sedation. In fact, I recently had to tell one to go away on a meat impaction. I'm credentialed to do sedation, so if I'm asking for help, its got to be a case that needs an expert. Its either something I can do or I want an anesthesiologist to decide how he/she wants to manage the airway/sedation. In patients that are already tubed in the unit, I might ask the intensivist to standy-by to see if they need to up the propofol gtt.

In general, I hate doing bleeders in the ER. Its always chaotic, loud and cramped. Much rather take them to our unit or scope in the ICU/step-down.

 

[Gastrapathy]

It also could be the prep regimen. Any changes lately? I know when we first started doing these our colons would come in having just drunk a bunch of prep. Just a thought.

Interesting thought. I haven't seen any upswing in aspiration either (was just speculating about why the OP might have).

WRT bowel preps, the prep hasn't changed but the instructions may have. Doug Rex and his cohort have started to strongly advocate for "split preps" with Golyte or whatever you are using. Usually this means taking the last liter of prep ~4 hours before the procedure instead of the night before.

 

[Arch Guillotti]

However, there is some good anecdote in there to consider...and some not-so-good EM-bashing.

Yeah but you clowns are such easy targets........😀

Kidding of course - in all seriousness of you are called on to bring your particular skill then you should be the one deciding how you want to handle things. I never understood why surgeons/gi get all up in our grill so much either when it comes to intubating, lines, etc.