Coughing during MAC

[deleted162650]

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Ketamine doesn’t blunt airway reflexes much. That’s one of its unique strengths. Unfortunately for an EGD with a big black scope down the throat you want those reflexes blunted to some degree. Just do what we do for damn near every EGD: straight propofol. Topical lido is good too. Now for an “emergent” EGD for a significant UGIB, I think many of us would tube that patient.

 

[fakin' the funk]

I am CCM, not anesthesia, but I do deep sedation for Cards (TTE and cardioversion) and GI (EGD) as I have privileges for this and sometimes anesthesia is not available. I had a lady last week, 135 lbs, 62 y/o, history of heavy opiate use but none for > 2 years, and no etoh or other drugs, who needed sedation for an emergent EGD. She had some vague "heart failure" history but no meds and my bedside echo showed good RV and LV function. She and gotten a total of 2 mg dilaudid over 3 hours for abd pain. Endoscopist was getting ready so I gave 2 mg versed and 30 mg ketamine. She goes completely out, but breathing fine. Over the course of a 15 minute egd where and ulcer was intervened upon, I gave a total of 8 mg versed, 100 mg ketamine and 100 mcg fentanyl and she coughed hard through the whole procedure (probably should have added some propofol) and as soon as it was over, she fell back asleep. Woke up 1 hour later with no recollection of the procedure.
Any pointers other than prop, and maybe she lied bout quitting opiates??

Your anesthetic was... not elegant.

 

[fakin' the funk]

Ketamine doesn’t blunt airway reflexes much. That’s one of its unique strengths. Unfortunately for an EGD with a big black scope down the throat you want those reflexes blunted to some degree. Just do what we do for damn near every EGD: straight propofol. Topical lido is good too. Now for an “emergent” EGD for a significant UGIB, I think many of us would tube that patient.

Agreed. I'm continually unimpressed with it during EGD. For a purely sedative/analgesic goal it's good. For airway/cough/gag, turrible.

 

[fakin' the funk]

You never have issues with secretions building up running MACs that deep?

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No.

Give glyco up front if you're worried.

 

[caligas]

Ketamine doesn’t blunt airway reflexes much. That’s one of its unique strengths. Unfortunately for an EGD with a big black scope down the throat you want those reflexes blunted to some degree. Just do what we do for damn near every EGD: straight propofol. Topical lido is good too. Now for an “emergent” EGD for a significant UGIB, I think many of us would tube that patient.

Agree, although with young patients starting with a cc or two of fentanyl goes a long way to smoothing things out.

 

[deleted162650]

Agree, although with young patients starting with a cc or two of fentanyl goes a long way to smoothing things out.

I’ll agree with that. Opioids get such a bad wrap these days, but a touch of narcotic makes for an infinitely smoother anesthetic.

 

[Mman]

Woke up 1 hour later with no recollection of the procedure.

most people under general anesthesia do not have recollection of the procedure and 8 mg of versed, 100 mg of ketamine, and 100 mcg of fentanyl given over the course of 15 minutes is quite likely considered general anesthesia. I mean just the versed and ketamine is enough to induce general anesthesia in just about anyone.

 

[nimbus]

I am CCM, not anesthesia, but I do deep sedation for Cards (TTE and cardioversion) and GI (EGD) as I have privileges for this and sometimes anesthesia is not available. I had a lady last week, 135 lbs, 62 y/o, history of heavy opiate use but none for > 2 years, and no etoh or other drugs, who needed sedation for an emergent EGD. She had some vague "heart failure" history but no meds and my bedside echo showed good RV and LV function. She and gotten a total of 2 mg dilaudid over 3 hours for abd pain. Endoscopist was getting ready so I gave 2 mg versed and 30 mg ketamine. She goes completely out, but breathing fine. Over the course of a 15 minute egd where and ulcer was intervened upon, I gave a total of 8 mg versed, 100 mg ketamine and 100 mcg fentanyl and she coughed hard through the whole procedure (probably should have added some propofol) and as soon as it was over, she fell back asleep. Woke up 1 hour later with no recollection of the procedure.
Any pointers other than prop, and maybe she lied bout quitting opiates??

If you had used propofol as sole agent she probably wouldn’t have coughed and been awake less than 5min after the procedure was done.

 

[caligas]

I am CCM, not anesthesia, but I do deep sedation for Cards (TTE and cardioversion) and GI (EGD) as I have privileges for this and sometimes anesthesia is not available. I had a lady last week, 135 lbs, 62 y/o, history of heavy opiate use but none for > 2 years, and no etoh or other drugs, who needed sedation for an emergent EGD. She had some vague "heart failure" history but no meds and my bedside echo showed good RV and LV function. She and gotten a total of 2 mg dilaudid over 3 hours for abd pain. Endoscopist was getting ready so I gave 2 mg versed and 30 mg ketamine. She goes completely out, but breathing fine. Over the course of a 15 minute egd where and ulcer was intervened upon, I gave a total of 8 mg versed, 100 mg ketamine and 100 mcg fentanyl and she coughed hard through the whole procedure (probably should have added some propofol) and as soon as it was over, she fell back asleep. Woke up 1 hour later with no recollection of the procedure.
Any pointers other than prop, and maybe she lied bout quitting opiates??

That coughing was blood from the ulcer going into her airway. Just intubate these patients for safety and ease.