Aspiration risk with EGD?

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RIGAS

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When do you intubate patients scheduled for EGD's? Wanted to intubate a patient with achalasia and another with food impaction scheduled by the gastroenterologist for EGD under MAC. His response "These patients seldom aspirate and intubation is not standard of care."

Is intubation overly conservative?

Any literature that you are aware of?
 
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RIGAS said:
When do you intubate patients scheduled for EGD's? Wanted to intubate a patient with achalasia and another with food impaction scheduled by the gastroenterologist for EGD under MAC. His response "These patients seldom intubate and intubation is not standard of care."

Is intubation overly conservative?

Any literature that you are aware of?
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I posted a case a couple of years ago about this same subject.
Got a call from a GI guy in the middle of the night...they had just transferred a young, skinny female prisoner from the ER to the ICU with suspected upper GI bleed...GI guy wasnt sure how bad it was but needed to take a quick look, said it wouldnt be but a few minutes.
I was home, came in, did a rapid dequence intubation and boy, was I glad I did.

Five minutes into the procedure (presumably from all the insufflation) a large amount of blood began running outta the girl's mouth.😀

Had we not intubated her I wouldda been hosed..more importantly the patient wouldda been REALLY hosed.
 
The situation you've described is the one I've seen at my place as well, even though I think intubation is clearly more safe. I'm a CA1, so my experience is limited, but if the proceduralist is doing a case on a pt BECAUSE there is some sort of GERD/regurgitation/dysphagia issue, I think it's ******ed not to intubate.

I did four EGDs a couple of Saturdays ago. The first guy vomits TONS of food seconds after they put the scope in. We suction/intubate/suction, and when they pass the scope, they see undigested food in the guys stomach. The next two patients have what look like full stomachs to my untrained eye. These are disasters waiting to happen.

All that said, I have no literature as backup for my opinions
 
RIGAS said:
When do you intubate patients scheduled for EGD's? Wanted to intubate a patient with achalasia and another with food impaction scheduled by the gastroenterologist for EGD under MAC. His response "These patients seldom aspirate and intubation is not standard of care."

Is intubation overly conservative?

Any literature that you are aware of?
Click to expand...

I will never, ever, ever NOT intubate a patient with achalasia. Well, maybe not never, but I'd need an awfully compelling reason not to.

I've personally witnessed two people get burned by passive regurgitation events after sedating or inducing patients with achalasia. Most recently, the anesthesiologist was inducing for surgery, NPO patient propofol in, seconds later, before any airway instrumentation, MASSIVE regurgitation and aspiration. Case cancelled, to the ICU. Patient did OK as it was probably just a huge amount of saliva backed up in the esophagus that he aspirated, not stomach contents (supported by pH testing the puddle around the patient's head).

I know anecdote isn't data, and I can't give you any literature. But just look at some of the barium swallow tests in these people. Marvel at the images. We're talking esophaguses (esophagi?) ballooned up to stomach size, full of rotting food bits and slobber.

JMHO. Others who are older and wiser than me may differ.
 
pgg said:
I will never, ever, ever NOT intubate a patient with achalasia. Well, maybe not never, but I'd need an awfully compelling reason not to.

I've personally witnessed two people get burned by passive regurgitation events after sedating or inducing patients with achalasia. Most recently, the anesthesiologist was inducing for surgery, NPO patient propofol in, seconds later, before any airway instrumentation, MASSIVE regurgitation and aspiration. Case cancelled, to the ICU. Patient did OK as it was probably just a huge amount of saliva backed up in the esophagus that he aspirated, not stomach contents (supported by pH testing the puddle around the patient's head).

I know anecdote isn't data, and I can't give you any literature. But just look at some of the barium swallow tests in these people. Marvel at the images. We're talking esophaguses (esophagi?) ballooned up to stomach size, full of rotting food bits and slobber.

JMHO. Others who are older and wiser than me may differ.
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As usual, you're right on the money PGG.👍
I intubate many GI scopes that my colleagues do not. End result, I never have aspiration problems, they have many (minor) aspirations. I don't understand why they don't see the problem. Eventually they will be badly burned. They get out a bit earlier and are more loved by the GI attendings. I sleep soundly and don't give a damn what those douches think about me.👍
:laugh:
 
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RIGAS said:
Wanted to intubate a patient with achalasia and another with food impaction scheduled by the gastroenterologist for EGD under MAC. His response "These patients seldom aspirate and intubation is not standard of care."
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For all comers, maybe it is that patients undergoing EGD seldom aspirate.

Then again, it is not the role of the gastroenterologist to tell anyone what the standard of care is for airway management. Especially in patients considered a "full stomach."

Hopefully your response was something along the lines of, "In the presence of achalasia, or KNOWN FOOD IN THE STOMACH OR ESOPHAGUS, I consider these patients 'full stomachs' and therefore at high aspiration risk." 😀

Isn't the gastroenterologist's underlying concern that RSI+ETT takes longer than MAC and therefore will delay case start/finish/next case?
 
this boils down to a fundamental misunderstanding/disconnect among our surgical colleagues regarding the difference between MAC and GETA. Agreed, you can do any case under MAC, because that should only be monitoring or the slightest bit of sedation, so that a patient is arousable or responsive, etc.

Our EGD/colonoscopies are ALL DONE UNDER GENERAL to borrow a trick...any propofol infusion where you can stick a 40 French scope down someones throat after banging around on the cords and they dont come off the table...well, you do the math...you are no longer administering a MAC

So, probably they associate MAC with no tube and general with a tube.

So, in closing, all EGD done by anesthesia are general anesthetics, and all achalasia patients get a tube, unless the endoscopist wishes to take them to the nursing sedation suite instead.
 
RIGAS said:
by the gastroenterologist for EGD under MAC. His response "These patients seldom aspirate and intubation is not standard of care."
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The gastroenterologist is not qualified to determine standard of care re: anesthesia for EGD's for any patient. Perhaps it's not the level of patient care he is accustomed to providing for his patients, but irrespective his statement and assessment is worth absolutely nothing.

If at the end of your decision process, you can say that you did the right thing, then that's all that matters. You'll be able to sleep well at night having done right by the patient. You'll certainly lose sleep if the patient did poorly as a result of short-cuts or unsafe practice. Unfortunately, you'll encounter these disagreements in the patient care plan throughout your years of practice.
 
pgg said:
I will never, ever, ever NOT intubate a patient with achalasia. Well, maybe not never, but I'd need an awfully compelling reason not to.
Click to expand...

Agree 100%.

I have seen nurses do EGD with achalasia with MAC. I am glad my name was not on the chart.

I think the CRNA thought achalasia was a casserole or a country in Africa or something.
 
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If they feel the pt does not need to be intubated, then I don't need to be there.They can sedate the pt just fine. Why would a GI doc need you, unless they require a GA. I do all upper GI cases with ETT, GA. They are all high risk and I don't want to share the airway in a lateral, sedated pt with a GI doc running a scope down the stomach.
 
Also, lets call this what it is. The GI docs for the most part, simply want us to propofol-ize their patients. They dont necessarily want our indight, evaluation, plan and assistance with the case. Thats really hard for me to rationalize and, as such, its one of the reasons why i so voraciously resist working in GI.
 
Idiopathic said:
Also, lets call this what it is. The GI docs for the most part, simply want us to propofol-ize their patients. They dont necessarily want our indight, evaluation, plan and assistance with the case. Thats really hard for me to rationalize and, as such, its one of the reasons why i so voraciously resist working in GI.
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I don't give the GI doc a say in what I'm going to do to the patient. If they have already tried and failed with their sedation and are requesting anesthesia care to facilitate their procedure, I'm going to do what I think is best. And the overwhelming majority of the time that involves an ETT.

From their point of view, the patient will rapidly be ready for them to complete their procedure with no concern of patient movement or pain. From my point of view, the patient will be less likely to aspirate and be safer. The extra few minutes until wakefulness for the patient are irrelevant to the discussion. It's not like the GI physician is going to be personally recovering the patient.
 
Idiopathic said:
Also, lets call this what it is. The GI docs for the most part, simply want us to propofol-ize their patients. They dont necessarily want our indight, evaluation, plan and assistance with the case. Thats really hard for me to rationalize and, as such, its one of the reasons why i so voraciously resist working in GI.
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"the patient doesn't need anesthesia, just a little propofol"
 
imfrankie said:
"the patient doesn't need anesthesia, just a little propofol"
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The GI fellow called the workroom the other day because he needed someone for "sedation in the icu for an egd"

The part that really got me was the GI fellow explicitly said... "we don't need them intubated, just sedated so really we just need a CRNA to come up, not an Anesthesiologist."

I was so blown away by this fellow MD's uninformed response, i just didn't even know where to begin...
 
Idiopathic said:
this boils down to a fundamental misunderstanding/disconnect among our surgical colleagues regarding the difference between MAC and GETA. Agreed, you can do any case under MAC, because that should only be monitoring or the slightest bit of sedation, so that a patient is arousable or responsive, etc.

Our EGD/colonoscopies are ALL DONE UNDER GENERAL to borrow a trick...any propofol infusion where you can stick a 40 French scope down someones throat after banging around on the cords and they dont come off the table...well, you do the math...you are no longer administering a MAC

So, probably they associate MAC with no tube and general with a tube.

So, in closing, all EGD done by anesthesia are general anesthetics, and all achalasia patients get a tube, unless the endoscopist wishes to take them to the nursing sedation suite instead.
Click to expand...


That's what would be called "GANA" in my neck of the woods... General Anesthesia No Airway... lol... it seems to be what surgeons/GI peeps think how a "MAC" should be, and it's a crapshow...
 
mainly the issue here is that the GI guys like us handling the sedation for their ASA 3/4 patients rather then their nurses (with their supervision), and so they would really rather have all their patients done under anesthesia (oh but you dont need to evaluate them or consider intubating or worry about their unstable angina). They do 6 scope rooms and have actually tried to have us staff all of them. As it is we max out at 3 rooms, with occasionally doing 4.

Typical day for me is 4-8 acutely ill ERCPs, 10 EGD/EUS, 6 healthy screening colons, 6 sick colons for GI bleeds and then 5-10 grabbag cases of anything from nasal dobhoffs in hemiparetic stroke patients to motility studies to EGD for 400 pound pre-lap band patients. I intubate most of the ERCPs and about 10-15% of the EGDs, rarely a colon. The GI docs give us a lot of grief when we intubate the achalasia patients, because "they never aspirate". my response is "this patient vomits when he brushes his teeth...this morning he threw up hot dogs. he had hot dogs two days ago. he gets intubated" i have never regretted putting a tube in someone in GI. the reverse cannot be said.

I also have no problem with prescribing and executing a "fentanyl/versed" anesthetic rather than propofol, if the situation calls for it.
 
7 year bump.

GI I work with never wants me to intubate his patients, but he does a couple achalasia EGDs a day. Most have had prior uneventful propofol MAC and he points this out. I like to intubate. Too conservative?
 
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RIGAS said:
When do you intubate patients scheduled for EGD's? Wanted to intubate a patient with achalasia and another with food impaction scheduled by the gastroenterologist for EGD under MAC. His response "These patients seldom aspirate and intubation is not standard of care."

Is intubation overly conservative?

Any literature that you are aware of?
Click to expand...
Only standard of care I think everyone would agree on is that GI docs should not be making anesthesia decisions.
 
Idiopathic said:
mainly the issue here is that the GI guys like us handling the sedation for their ASA 3/4 patients rather then their nurses (with their supervision), and so they would really rather have all their patients done under anesthesia (oh but you dont need to evaluate them or consider intubating or worry about their unstable angina). They do 6 scope rooms and have actually tried to have us staff all of them. As it is we max out at 3 rooms, with occasionally doing 4.

Typical day for me is 4-8 acutely ill ERCPs, 10 EGD/EUS, 6 healthy screening colons, 6 sick colons for GI bleeds and then 5-10 grabbag cases of anything from nasal dobhoffs in hemiparetic stroke patients to motility studies to EGD for 400 pound pre-lap band patients. I intubate most of the ERCPs and about 10-15% of the EGDs, rarely a colon. The GI docs give us a lot of grief when we intubate the achalasia patients, because "they never aspirate". my response is "this patient vomits when he brushes his teeth...this morning he threw up hot dogs. he had hot dogs two days ago. he gets intubated" i have never regretted putting a tube in someone in GI. the reverse cannot be said.

I also have no problem with prescribing and executing a "fentanyl/versed" anesthetic rather than propofol, if the situation calls for it.
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Holy **** that is a long day. Hope they're paying you millions
 
Psai said:
Holy **** that is a long day. Hope they're paying you millions
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Doubtful. That units making way less than a colon factory.

We prefer MAC because it’s faster. More cases per day is better.

All achalsia EGDs aren’t the same. Acutely obstructed (usually with a 15 cm column of semi-liquid food), intubate away. Here for a 5 minute balloon dilation and on clears for a week in anticipation, please don’t. I need to get that latter patient off to rads to see if I perf’d (~5%). If they are really doing that many (seems impossible to me), it’s got to be the latter or maybe one of the biggest POEM centers in the country.
 
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Nothing gets my blood boiling faster than being sent to GI. Colons, whatever-I push the white stuff like the monkey I'm expected to be. But the EGDs always freak me out. I think it's sheer malpractice on our part knocking these patients out with propofol. I'm hereby calling on all our professional societies to come out with an advisory statement stating something like "The use of propofol sedation/MAC for upper endoscopy procedures can no longer be recommended as the benefits do not outweigh the risks." Some kind of crap like that. Just benzocaine and Versed/Fentanyl.

Funny thing about GI is that these docs can be the biggest anuses (pun may have been intended) to work with, yet we are there for them to make more money and do more cases than they used to back in the day when they were pushing Demerol + Versed, so give us some GD respect and don't tell us who we should/should not intubate.

P.S. Is it just me, or does everybody and their mother have friggin' gastritis?! Gastritis, gastritis, gastritis...
 
Gastrapathy said:
Doubtful. That units making way less than a colon factory.

We prefer MAC because it’s faster. More cases per day is better.

All achalsia EGDs aren’t the same. Acutely obstructed (usually with a 15 cm column of semi-liquid food), intubate away. Here for a 5 minute balloon dilation and on clears for a week in anticipation, please don’t. I need to get that latter patient off to rads to see if I perf’d (~5%). If they are really doing that many (seems impossible to me), it’s got to be the latter or maybe one of the biggest POEM centers in the country.
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Interesting, so elective case on clears for a week you are good with propofol Mac. Seems reasonable, but I don’t think GI here is having them do that.
 
caligas said:
Interesting, so elective case on clears for a week you are good with propofol Mac. Seems reasonable, but I don’t think GI here is having them do that.
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I looked at our instructions, it's actually 4 days. I thought it was longer but I can't say it's been a problem.

@soorg you shouldn't work with us. Find another job. I'm sure they don't look forward to having you there either.
 
Gastrapathy said:
Doubtful. That units making way less than a colon factory.

We prefer MAC because it’s faster. More cases per day is better.

All achalsia EGDs aren’t the same. Acutely obstructed (usually with a 15 cm column of semi-liquid food), intubate away. Here for a 5 minute balloon dilation and on clears for a week in anticipation, please don’t. I need to get that latter patient off to rads to see if I perf’d (~5%). If they are really doing that many (seems impossible to me), it’s got to be the latter or maybe one of the biggest POEM centers in the country.
Click to expand...

Interesting, I can see that scenario making me ok with a MAC for achalasia. I will say though that efficiency is not a medical indication for MAC, and that’s where our two specialties have the divide. We also don’t like being “told” how to do the case, it’s my decision who I tube and I couldn’t care less about your time utilization. But if our GI docs would explain or have dialogue about why they want MAC, using medical indications like you did above I certainly would listen and decide based on my assessment of risk/benefit just as I expect the GI doc to understand and respect my concerns.

As you seem quite reasonable, what say you on ERCPs? This is an issue becoming more and more common....
 
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Robotic Wis-Hipple said:
what say you on ERCPs
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My issue with ERCPs is that sometimes it's a quick 20min case, and sometimes it's damn near an hour to cannulate the ampulla: "Bow, unbow, ok now 1/2 bow, no a little less bow, now bow, unbow then bow again real quick. . .":bang::boom:

Not to mention the pt is essentially prone with minimal airway access and they tend not to be healthy 30 year olds. It's also not that uncommon to see bile in the mouth at the end. I've always tubed them. All my partners tube them. At my last gig a few of the guys would go propofol MAC, and they all had stories of having to stop in the middle - go supine - etc. Talk about killing efficiency.
 
coffeebythelake said:
for achalasia = GA RSI (preferred) or topical lidocaine + versed/fentanyl (if patient does not want GA and understands risks)
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I don’t mean to hijack this thread, but I always wondered: how protected are you in doing something which may be (relatively) contraindicated or risky, be it MACing someone that probably should be tubed (and they aspirate yada yada) or blocking someone who probably shouldn’t (and they develop nerve injury etc), given that you have a detailed discussion and explain the risks to the pt and document them? If there is a negative outcome, are you protected because you discussed/documented the risks? I can’t imagine that you are that protected, but does anyone have any real life examples?
 
caligas said:
7 year bump.

GI I work with never wants me to intubate his patients, but he does a couple achalasia EGDs a day. Most have had prior uneventful propofol MAC and he points this out. I like to intubate. Too conservative?
Click to expand...

Can you look at the endoscopic images from previous anesthetics?

Also, what do you do with a food impaction or ERCP? I intubate 100% of them.
 
i understand that these cases are among the highest risk for aspiration --
when i do achalasia cases with this technique, there is patient selection involved.
1. no solid food for at least 4-5 days, no liquids for at least 12 hours
2. patient with no active sensation of stuff in throat / fullness in esophagus and able to lay flat or even t-berg without regurgitation
3. occasionally i also have a patient who is adamant they would only want GA if it was an "emergency" because they've had it done with conscious sedation before.

i think this comes down to your assessment of risk: would you consider fentanyl/versed is an acceptable option for a patient with achalasia? because in real life people with achalasia get conscious sedation for EGD's. in this setting would you consider gagging and coughing with the placement of the endoscope more likely to cause significant aspiration vs light topicalization above the vocal cords?

also i aim to blunt the gag reflex not ablate it outright. this usually means 2-3cc of 4% lidocaine by atomizer directed to base of tongue.
 
Do you call a propofol gtt with airway manipulation for an unprotected EGD "MAC" or "GA"? I'm in the GA camp... My colleagues seem mixed on this issue.

I do get irritated when GI or cardiology calls it "conscious sedation"... when the patient's unconscious.
 
kidthor said:
Do you call a propofol gtt with airway manipulation for an unprotected EGD "MAC" or "GA"? I'm in the GA camp... My colleagues seem mixed on this issue.

I do get irritated when GI or cardiology calls it "conscious sedation"... when the patient's unconscious.
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Well it's not like they're neurologists
 
This thread is gold!

My only issues with patient reported 'clears for a week' is that the fecking lie to you. The first time they might do clears for a week and all is good. The next time they cut it to 5 days. Then next time the gi doc seems em in clinic and laughs and winks about 'a week' and then they do 3 days...

I've seen it way too often.

Went up the wards the other day and a patient had a big empty Mac d bag in front of him. You could see the grease on his fingers as he was lying to me about his fasting time
 
Newtwo said:
My only issues with patient reported 'clears for a week' is that the fecking lie to you.
Click to expand...

Yep.

During my general surgery month we were doing an upper to check on a previous balloon dilation for a patient that had botched wt loss surgery in mexico. Anesthesiologist wanted to tube due to altered anatomy basically creating a surgical distal achalasia. Surgeon convinced the anesthesiologist after explaining she'd been on clears for 4 days.

Apparently the patient considered an egg mcmuffin to be a clear liquid. She didn't aspirate but everyone in the room was pissed and the anesthesiologist said "never again" as he wheeled the patient out.
 
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Gastrapathy said:
Doubtful. That units making way less than a colon factory.

We prefer MAC because it’s faster. More cases per day is better.

All achalsia EGDs aren’t the same. Acutely obstructed (usually with a 15 cm column of semi-liquid food), intubate away. Here for a 5 minute balloon dilation and on clears for a week in anticipation, please don’t. I need to get that latter patient off to rads to see if I perf’d (~5%). If they are really doing that many (seems impossible to me), it’s got to be the latter or maybe one of the biggest POEM centers in the country.
Click to expand...

A deftly done GA with a tube really shouldn't add more than 5-10 minutes extra. I can't imagine that these cases crop up so often that they'd really disturb overall workflow.

It would just be hard to defend any kind of aspiration event in these patients if you don't RSI them. Granted, someone who's been on clears for a few days is likely to have an esophagus full of oral secretions as opposed to food and gastric fluid, with a better risk profile, but they can still have a relatively large volume of fluid there.

In a way this discussion is like the ones we have with the ER about their sedation practices and NPO looseness. They do things that just would not fly in our world. In fairness, they're not bumping people off when they do shoulder reductions with etomidate "sedation" in people with full stomachs; I don't mean to imply they're committing malpractice. 🙂 But despite the apparent safety of what they're doing, on the occasions when they ask us to come to the ER to help out, the only answer we can give is one grounded in our own standard of care.

Likewise - however low risk you as a gastroenterologist feel selected achalasia patients are, the answer I feel I have to give is RSI and a tube. And again, a brief GA with a tube doesn't have to be a lengthy logistical ordeal. They should emerge quickly and be extubated within a few minutes.
 
Busy GI center I used to be at, ERCPs were done in left "lazy" lateral. Only tubed for patient factors, not procedure.

I would intubate any case being done for an obstructive process, and many of the cases for functional slowing.

EGDs for routine stuff like Barrett's or gastritis only require a tube if the patient is truly massive.
 
kidthor said:
Do you call a propofol gtt with airway manipulation for an unprotected EGD "MAC" or "GA"? I'm in the GA camp... My colleagues seem mixed on this issue.

I do get irritated when GI or cardiology calls it "conscious sedation"... when the patient's unconscious.
Click to expand...

It's MAC but borders GA and probably crosses back n forthl.
 
I think here GIs used to get annoyed but when i'm there at least i dont get that feeling anymore when i want to tube. probably because the hospital/departments involved are more aware of how dangerous Endo rooms are. get a string of aspirations requiring ICU stays or codes and that gets peoples attention. especially since we are a large hospital with many sick people needing scopes/ercps/
 
My hospital has told me that we can not bring a portable anesthesia machine to endo suite because it is designated as a procedure room not a OR. This forces me to bring the pt to the main OR when I want to intubate. Has anyone ever heard of this policy? I laugh when they tell me general is not allowed in endo when every EGD/colon we do is really a general.
 
turnupthevapor said:
My hospital has told me that we can not bring a portable anesthesia machine to endo suite because it is designated as a procedure room not a OR. This forces me to bring the pt to the main OR when I want to intubate. Has anyone ever heard of this policy? I laugh when they tell me general is not allowed in endo when every EGD/colon we do is really a general.
Click to expand...

It makes me ill thinking about the idiots that run health care/hospitals these days.

So, your hospital has never heard of MRI’s under GA etc? Certainly an MRI room isn’t designated as an OR.
 
turnupthevapor said:
My hospital has told me that we can not bring a portable anesthesia machine to endo suite because it is designated as a procedure room not a OR. This forces me to bring the pt to the main OR when I want to intubate. Has anyone ever heard of this policy? I laugh when they tell me general is not allowed in endo when every EGD/colon we do is really a general.
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As much as I dislike our procedure rooms, we have anesthesia machines sitting there 24/7. It is way more dangerous to not have an anesthesia machine handy when you're running a crapton of prop with a giant tube down the throat of someone with significant upper gi pathology.
 
turnupthevapor said:
My hospital has told me that we can not bring a portable anesthesia machine to endo suite because it is designated as a procedure room not a OR. This forces me to bring the pt to the main OR when I want to intubate. Has anyone ever heard of this policy? I laugh when they tell me general is not allowed in endo when every EGD/colon we do is really a general.
Click to expand...

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