Colonoscopy death. 25 Million Jury verdict
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cittykat
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Suit yourself. Keep doing 40-50 BMIs without an airway because you are afraid somebody might laugh at you.
cittykat
Full Member
How often are your high BMI OSA patients coughing and sputtering and limping along with sats in the 80s and you just tolerate it hoping the case is over fast?
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Literally never.
Its a colon not open heart. They dont need to be deep except for when the scope is looped. You just gotta watch the patient and the endoscopist. They'll tell ya when they're looped. Withdrawal needs no sedation.
The reason they're coughing is poor positioning not bmi or osa. You need to tip them forward so the secretions fall forward out of their mouth not back into their glottis
Most ppl should be doing it sedation free. Plenty countries and population do that and its not too bad.
I did
Until recently our ERCP suite had no anesthesia machine. We did those cases (intubated) with a mapleson circuit.
It was a pain in the ass, but not unsafe. The worst of it was the really obese ones who'd derecruit during the case from spontaneously breathing through a straw, but a little recruitment work at the end and they'd do fine. For the real pulmonary cripples I'd insist on moving one of our mobile machines in there.
Now there's a machine in that room and everyone is happier.
I could list the reasons I hate doing GI, but since this is the internet, so there isn't near enough room.
It was a pain in the ass, but not unsafe. The worst of it was the really obese ones who'd derecruit during the case from spontaneously breathing through a straw, but a little recruitment work at the end and they'd do fine. For the real pulmonary cripples I'd insist on moving one of our mobile machines in there.
Now there's a machine in that room and everyone is happier.
I could list the reasons I hate doing GI, but since this is the internet, so there isn't near enough room.
... no?
I mean, some of these guys will briefly desaturate initially but that's not a problem that can be solved with an induction dose of propofol and a LMA. Touch the patient, lift the chin and be done with it.
I have never in my life put a LMA in a colonoscopy.
cittykat
Full Member
So your 400lb colonoscopies cruise for the rest of the case with a native airway after you tug on their chin? Do you use that induction strategy for any non-GI cases? AV fistulas under MAC? Egg retrievals?
In high risk patients, I position lateral, induce, place the LMA , and turn on PSV from the get go. I don’t wait for them to desaturate. In my hands, I get far fewer instances of desaturation, however transient, than with native airway.
Low risk patients, I’m happy to do 50-100mg prop bolus and prop infusion @100mcg/kg/min. That’s my std recipe and it works well most of the time.
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I would never consider putting a LMA in a colonoscopy patient unless it is part of the difficult airway algorithm or a rescue situation.
Seeing a patient puke from the abdominal pressure of the scope / looping is enough for me to say not gonna happen. I’m not gifting a plaintiff’s attorney a reason to sue on a silver platter.
I dislike GI for the above reasons. I always will put on a non rebreather. Much less desaturation than with NC. not sure why the hate for the guy who wants to put in an LMA for the fatties. Personally I don’t (though I’m very quick to put in nasal trumpets, love em) but nothing wrong with being extra cautious with airway management.
+1 on the rare LMA for the heavy, bearded, sweating colos. Maybe they get 100 of propofol up front instead of the 50 someone above mentioned, but who cares? Put it in, re-bolus as necessary, take it out when done. Could you do it with an OPA instead? Probably, but if upper airway obstruction in the problem, it's hard to argue the LMA isn't a superior device, and if the anesthetic is basically the same, why not? I get the optics of having something sticking out of the mouth, especially at an closet-based endo center, but I should think a competent anesthesiologist who's passed their oral boards could handle the slings and arrows of the odd endo nurse and their side-eye.
There are other airway devices. Sometimes I slip in a nasal trumpet. We also use SuperNova for large BMI patients with OSA. It is like Nasal CPAP and it works quite well.
I agree I would not intentionally deepen the patient so much to put in a SGA. If anything they get less rather than more.
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Problem is placing an LMA in a morbidly obese patient, when morbid obesity is a relative contraindication for using an LMA.
Its a big medicolegal risk.
First thing they will say is that if you determined this patient was such a risk, why didn't you do it under light sedation (the safest strategy by default)... especially for colons that are routinely done under light sed.
Then they will ask, why did you place an airway thats contraindicated in this population, and not intubate
Then they will ask what the community standard is (placing LMAs for colons is not)
It would not play well for a jury AT All.
Arch Guillotti
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Maybe. An LMA is just a glorified oral airway and those are used all the time in obese patients. Ours are not done under light sedation either.
Oral airway is fine.
A planned GA with LMA is going to be framed very differently, compared to an OA placed after patient obstructs during sedation. You can also suction with an OA in place, not so with an LMA
Placing an OA as needed will fit with the community standard. LMA does not.
Placing an LMA in obese is a relative contraindication, for a case that can be done under sedation (if patient is determined to be a high airway risk), and not the community standard for colons. Recipe for a lawsuit IF something goes wrong
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Arch Guillotti
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We put LMA’s in obese people all the time.
Certainly.
But you need something to justify it...such as the community standard practice. Still some degree of risk there if patient aspirates..but more defensible since its routine practice
Placing an LMA in a 400lb patient for a knee scope is one thing. Some would intubate, some would LMA. Both common practices.
Placing an LMA in a colon, is electively exposing a high risk patient to increased risk (at least on paper, in front of a jury). Think about it this way, if this patient popped up on oral boards, "400lb patient for screening colonoscopy". Lma would likely be a failing response.
Intubate, or light sedation would be the passing answers
This has been an odd thread.
Let’s be honest. When bad things happen to patients who were relatively healthy and expected to leave the hospital in the conditions that they arrive in you are likely looking at a lawsuit and large settlement. If you have a large aspiration under an LMA the lawyer will find SOMETHING, maybe they had diabetes, mild obesity maybe a history of GERD. Maybe you used a size that’s different than the package recommends given the patients weight. There are a million “relative” contraindications that are routinely ignored in actual practice. Lawsuits happen when unexpected bad things happen. The only way you can avoid this is tubing everyone but good luck with that in a busy surgicenter. I personally know of 2 aspiration cases. Both bowel obstruction where proper RSI was attempted but the patient aspirated and later died. Both patients were relatively young and in both cases insurance settled even though everything was done correctly. Nobody wants these cases to come before a jury.
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Mainly it's the department itself, and the way it's run, and an atmosphere so thick with entitlement and obliviousness that it's hard to breathe.
Its an odd world. We gripe about surgeons, but at least in the OR even the most difficult surgeons are at least vaguely aware that there are other surgeons and maybe even other humans working there. Not so in GI - they have scopes, and a conveyor belt of meat, and there's this apparatus of things and other meat-like entities that don't get scoped but still for some reason have to be present and breathing their air.
As one of those meat-like entities I hate that ****ing place.
A lateral LMA and PSV on a morbidly obese patient getting abdominal pressure?…now I’ve heard everything.
Yeah I wouldn't be touching that. I dont mind ruffling a few feathers for a safe plan but that sounds like ruffling the mane of a hungry lion
Certainly is easier in the thumbs than manually pushing propofol though!!
True...to an extent.
Doesn't mean you should routinely do something out of the ordinary simply because lawsuits can happen even when everything is done right.
Most docs win most cases. But that's usually because they cant prove that something was done outside of the standard. Using a contraindicated airway..for a case that doesnt usually need an airway..is virtually guaranteeing a losing case if something were to go wrong
If a regular colonoscopy aspirates and gets a postop pna. If you do a usual prop tiva..there is no case. They may settle to avoid expensive litigation, but its the difference between 30-50k and 1 million
If the patient had glaring risk factors for aspiration and you proceeded with GA natural airway, you are most certainly on the hook even if you did the "usual practice" for an Endo case. You didn't have a usual patient.
I don't mind Endo but it has this expectation that you must do natural airway on patients that you would otherwise be doing an RSI for if they were in the OR.
He was a top notch guy that worked in a high acuity tertiary care center for 20-25 years, but quit hospital work and was nearing retirement. Is it easy to know when it's time to quit? Hope I do!
An obese patient is a routine patient these days.
A sponv vent colonoscopy patient still maintains a cough reflex and can be suctioned. A colonoscopy with lma doesnt and cant be easily suctioned.
If a patient is a glaring aspiration risk then its ETT or light sedation. LMA is STILL not the correct choice
I never said PSV.
Citykat did.
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The level of sedation for a typical colonoscopy or upper does not reliably maintain airway reflexes throughout the entirety of the procedure and we all know that.
I never said anything about using an LMA, just that an aspiration event is still indefensible if patient had GI tract or other pathology that obviously puts them at risk for aspiration and we chose not to secure their airway
I think all the NORA sites are like this. But GI and IR are definitely the worst. Our IR has two sites were we can do anesthesia at different ends of the hospital, they once coordinated with MRI to do a case to follow, they could’ve scheduled it in the IR suite closer to the MRI, but no, it had to be scheduled at the other end of the hospital.
Interesting. There is a big difference between high acuity guy and high volume guy obviously. I know top cardiac guys that avoid ob, gi, kids anything high turn over because they cant keep the pace or feel safe or something.
And ageing obviously exacerbated thes issue. I guess he wanted the money but lost the touch.
Instincts and touch/feel is so much in these cases
Do you explain all of that to your patients? They're happy with the anesthesia they're paying for?
You explain that they will be asleep and comfortable. That general anesthesia requires a breathing tube and sedation will be as deep as they tolerate.
But otherwise, its as he said. Goal is that patient should be close to or waking up right as the scope comes out.
I'm similar.
I say I'll be with you keeping you comfortable and safe. Sometimes people open their eyes on the descent down from the cecum; 3-5cc prop fixes that, no one remembers or cares. They walk out 20-30 minutes later
No anesthesia machine so I error on the side of less is more, everyone goes home safe and happy
Explain what? Haven't had a complaint yet. And had tonnes of compliments so good luck with your quest there.
You seem to think theres a specific dose required or something? The result is all that matters, the dose is irrelevant. And if you havent learned the proper timings and cues, when the endoscopist is looped, when theyre stuck and need pressure etc etc... already then im not your teacher.
Some take 50 some take 500... but they're all safe and most happy with the sedation.
You seem to think theres a specific dose required or something? The result is all that matters, the dose is irrelevant. And if you havent learned the proper timings and cues, when the endoscopist is looped, when theyre stuck and need pressure etc etc... already then im not your teacher.
Some take 50 some take 500... but they're all safe and most happy with the sedation.
Wouldn’t routinely place or plan lma for colonoscopy but certainly wouldn’t judge someone if patient desat’d routinely in a case and they decided LMA. Nothing else would change - except patient would do better. Oxygenate better. Ventilate better. Less saliva around the cords. Likely less coughing/sputtering.
Nothing needs to change w the sedation. If you think they need to be deeper for lma placement give them a couple more cc’s of prop and move on. Patients tolerate LMAs perfectly fine once in. They fight oral airways more. Rig up something to provide oxygen and measure co2. Not hard. Doesn’t have to be an anesthesia machine if you don’t have one close, but if you do, great. Hook the lma up to that.
Case done, patient wakes up, remove lma. Move on. I don’t see the big deal.
All the discussion of pushing on the belly w lma etc etc. well they’re pushing on the belly wout the lma. Why does putting an lma in and improving oxygenation/ventilation affect belly pushing/intra abd pressure? They were doing it before lma (with oral airway) so the risk of aspiration isn’t changing or worsening w lma.
I’m not a believer your options are either oral airway or ett. Not sure I’d routinely place lma. In fact I’m sure I wouldn’t. But I do see a place for it during a colon.
Nothing needs to change w the sedation. If you think they need to be deeper for lma placement give them a couple more cc’s of prop and move on. Patients tolerate LMAs perfectly fine once in. They fight oral airways more. Rig up something to provide oxygen and measure co2. Not hard. Doesn’t have to be an anesthesia machine if you don’t have one close, but if you do, great. Hook the lma up to that.
Case done, patient wakes up, remove lma. Move on. I don’t see the big deal.
All the discussion of pushing on the belly w lma etc etc. well they’re pushing on the belly wout the lma. Why does putting an lma in and improving oxygenation/ventilation affect belly pushing/intra abd pressure? They were doing it before lma (with oral airway) so the risk of aspiration isn’t changing or worsening w lma.
I’m not a believer your options are either oral airway or ett. Not sure I’d routinely place lma. In fact I’m sure I wouldn’t. But I do see a place for it during a colon.
Placing an LMA on a patient thats struggling is part of the rescue algorithm. So no medicolegal issue with that.
Electively placing an LMA on a obese patient for colonoscopy, simply because they are ovese, as the planned anesthetic is a medicolegal liability.
Its not routine in the community. I would imagine most of us have never done it.
If patient is considered an airway risk (as suggested by planning to do an LMA) then the correct answer for airway management would be intubation or awake (light sed)
If that patient has a complication, saying your plan was to electively place an LMA on an obese patient in lateral position....it is game over.
If the plan was routine sedation as we do for all patients, and patient has an issue, your attempt OA then LMA and patient has same complications...then you have followed the community as standard and its defensible.
Risk of aspiration is certainly higher with LMA than OA. LMA requires deeper sedation, and very limited ability to suction.
I don’t agree here. It’s not consistent with what I’ve found. I’ve seen more gagging on oral airway than LMA or nasal airway. Do agree with most of the rest of your post. I don’t know how long you’ve been doing this or where you practice. I’ve been at this over a decade and I work in the South, the Fatbelt of this country. People are so freaking unhealthy here. Placing an lma as rescue is part of the job where I am. Did it yesterday in fact.
Not my teacher? Well, this forum used to be about teaching each other. ShalI i assume you're here to neither learn nor teach?
Yes, placing an LMA as a rescue is perfectly fine and reasonable. Better than struggling with an OA that patient isnt tolerating...for regular cases that require GA levels of sedation that is.
For colonoscopy? They dont need GA. Its a 20 min case and only the first 5-7 mins are painful. Patients do fine. So starting a case by placing an LMA simply because its "easier" as another poster put it...is going to result in ALOT more patients getting LMAs than need it. LMAs have complications (airway trauma, dental, etc). If the rest of the community can perform tens of thousands of colons without needing one...then its not needed.
Not to mention the logistics. If this patient is 300lb, we keeping the patient supine to place lma and then rotate? Calling in lots of help to do that? Or we just inducing and placing it lateral (if lma doesn't seat, this wont go over well in court, unless its an unplanned rescue). Cancel the case if no vent? Take all obese colons to the OR? Hopefully patient doesnt need to go prone..
Even an OA for a colon is quite rare. I think i have done that maybe 3-5 times in my career. But certainly feasible.
You tryna accuse me of substandard care now ask for teaching? Everything ok with you?
I dont need to learn how to do a colon without killing someone buddy. No book for turnips
Honestly some of your posts come across like you’re just not comfortable with LMAs or patients having them. I’ll give you the benefit of the doubt and think that’s just how online posting goes.
OA 3-5 times in your career? Where is this utopia? Just not realistic for any place in the south.
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Also I’ve never said start w lma for colon. It’s a rescue airway for that procedure imo.
Yes, the discussion was in regards to Cittykat...he said he places LMAs for routine colons if patients are obese.
FINALLY someone talks some sense here.
