EGD airways

[norski]

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Had a close to brown short incident today anesthetising a 90 yo old lady for an emergency EGD. This after a week of trippy airways and other little challenges leaving me hypertensive.

Pt: sweet old lady known to the dept. ASA3, mostly due to AF, htn and light valve insufficiencies, 10x sedations or lma GAs the previous year for ureter stent replacements. In the ED for GI obstruction. Thoracic abdominal CT revealed an enormous hiatus hernia, sphincter closed,ventricle was partially lodged above the diaphragm. ED were unable to pass the G-tube further than 30cm, SOL from removing any more gastric content than otherwise in the hernia,which was little. 1L estimated ventricular content.

My attending planned a relatively simple RSI. Glyco, Alfentanil, prop, sux, tube, positioned on her left side. No real airway concerns, MP2, nice neck movement and mouth opening.

We suctioned her existing G tube before removal, then put her to sleep. Had a CMAC with a plain mac blade for the onlookers' benefit (med student and paramedic), got a nice epiglottic view, tried to lift, and then nothing. BURP, AND scooping up the epiglottis unsuccesful, and instead of cracking teeth, I asked for the D-blade. First pass, A ok. 350 mg of prop, some phenylephrin later, the gastropedist found no way in hell to pass the sphincter, and gave up.

I guess the brown short proximity was related to the laryngoscopy part. Never had to switch blades before, always managed to force a grade 2b view, allowing for a blind bougie insertion, but no way were I going to try that in this view.

Anecdotal story aside, I truly hate elective EGDs. As a CRNA(sub 1 year after grad., even), I'm expected to do them solo, five minutes away from either an attending or crna. plan A is always glyco, propofol and no secure airway, and patients mostly end up with a hiatus hernia diagnosis of vsrious severity. They're either old, fat, sick or any combo therein. I'm wondering how you convince your gastropedist to go for an ETT-GA in the first place, instead of as the plan B, when laryngospasm shows its lovely face. I mean, it literally takes one extra minute, provides safety for the pt, and sanity for the person at the head, and also very likely better working conditions for the endoscopist.

How do you, respected anesthesiologists, AAs and CRNAs of SDN do EGDs? Prop, sux, tube and go?

Thanks.

 

[Planktonmd]

Have a second qualified person in he room with you when you are asked to do something you are not comfortable with... an anesthesiologist would have been a good choice.

 

[Arch Guillotti]

Have a second qualified person in he room with you when you are asked to do something you are not comfortable with... an anesthesiologist would have been a good choice.

What he said.

Before the peanut gallery gets all over this one, realize the OP is in another country from their posting history.

 

[norski]

Have a second qualified person in he room with you when you are asked to do something you are not comfortable with... an anesthesiologist would have been a good choice.

Oh, absolutely. No argument there. Rural hospital, three ORs and a gastro suite, typically one anesthesiologist supervising all, and one CRNA, if we're lucky, running loose/call. If we have two MDs and the extra CRNA, I'll take the one not doing anything useful with me in a heartbeat, but that's not always feasible, unfortunately.

As it is, I just pack a styleted tube, a mcgrath and ready drawn sux whenever I leave the OR, for sanity's sake. If the pt looks dodgy, I call the attending with my concerns, and either get the second person in the room, call it off, or prop sux tube.

 

[Southpaw]

Hard to tease this apart. Thanks for posting honestly. If you’re not comfortable with either the sedation you’re asked to provide or the physiology of the patient, seems in the interest of the patient to see if an anesthesiologist is willing to help you out.

Glad you made it out of that one ok. For you and your patient.

 

[norski]

What he said.

Before the peanut gallery gets all over this one, realize the OP is in another country from their posting history.

Thank you. It's not exactly central Africa, but we do have different medicolegal concerns than in the US.

 

[norski]

Hard to tease this apart. Thanks for posting honestly. If you’re not comfortable with either the sedation you’re asked to provide or the physiology of the patient, seems in the interest of the patient to see if an anesthesiologist is willing to help you out.

Glad you made it out of that one ok. For you and your patient.

thank you. In this case, my attending handed me the tube, so definitely in the room. It's the elective stuff that bugs me, and why in hell someone figured out unprotected airway upper GI endoscopy was a good idea.

 

[Arch Guillotti]

I'm wondering how you convince your gastropedist to go for an ETT-GA in the first place, instead of as the plan B, when laryngospasm shows its lovely face. I mean, it literally takes one extra minute

Maybe to put them to sleep but it seems to add time to the wakeup and turnover.

 

[norski]

Maybe to put them to sleep but it seems to add time to the wakeup and turnover.

No doubts about it, and I'm guessing many or most here could do EGD sedations with 2mg of midazolam and the benefit of letting the drug actually work for all patients, the issues here would seem to be that I'm A) not work hardened yet and B) not wanting to call off or straight out tube every patient with a whiff of dodginess to them, and C) lacking additional anesthesia personnel resources.

 

[Southpaw]

It's the elective stuff that bugs me, and why in hell someone figured out unprotected airway upper GI endoscopy was a good idea.

Well GI is just awful, no way around it. You’re certainly correct. There’s nothing good about it aside when the day ends!

 

[Arch Guillotti]

No doubts about it, and I'm guessing many or most here could do EGD sedations with 2mg of midazolam and the benefit of letting the drug actually work for all patients

Would never work.

 

[Planktonmd]

I have been doing this business way longer than I wanted... but every time I am in a dodgy situation I try to have a second person with me who understands what I am trying to do... it can be a CRNA or another anesthesiologist , it really doesn't matter, the most important thing is to avoid hurting the patient.

 

[Southpaw]

No doubts about it, and I'm guessing many or most here could do EGD sedations with 2mg of midazolam and the benefit of letting the drug actually work for all patients, the issues here would seem to be that I'm A) not work hardened yet and B) not wanting to call off or straight out tube every patient with a whiff of dodginess to them, and C) lacking additional anesthesia personnel resources.

The skill of the endoscopist matters more than anything for an EGD. We do them all almost exclusively with propofol. Outlet obstructions or anything similar though deserves an ETT.

 

[IMGASMD]

No doubts about it, and I'm guessing many or most here could do EGD sedations with 2mg of midazolam and the benefit of letting the drug actually work for all patients, the issues here would seem to be that I'm A) not work hardened yet and B) not wanting to call off or straight out tube every patient with a whiff of dodginess to them, and C) lacking additional anesthesia personnel resources.

We use propofol mostly. Most places will call given 2mg of versed a sedation case, which we may not need to present for.

EGD for a fairly healthy patient you can probably get away with 2 of versed and lots of numbing spray. I would probably supplement with maybe a little fentanyl.

One of my partner’s standard dose is actually 20cc of prop for every EGD. Get them stop breathing then scope goes in. By the time it is done, they’re back to breathing and out of the room. But that certainly depends on what interventions is planned.

 

[Arch Guillotti]

One of my partner’s standard dose is actually 20cc of prop for every EGD.

That would never fly with the sick ones that routinely get added on where I work, this would cause half of them to arrest on induction.

 

[IMGASMD]

That would never fly with the sick ones that routinely get added on where I work, this would cause half of them to arrest on induction.

That’s for asc asa 1-2 patients. Which is where he is these days.

 

[FiO2@21]

I guess the brown short proximity was related to the laryngoscopy part. Never had to switch blades before, always managed to force a grade 2b view, allowing for a blind bougie insertion, but no way were I going to try that in this view.

This is interesting because I’ve definitely switched blades if what I was doing wasn’t working.

If I can’t see anything with a MAC 3, a Miller 2 seems to bail me out more often than not.

Or if I’m concerned I would use a hyperangulated blade from the get go.

My only other feedback would be if this was a frequent flier then you should have been able to see how the intubation was on prior anesthesia records. If it’s not part of your local culture to document the intubations then it should be.

 

[norski]

This is interesting because I’ve definitely switched blades if what I was doing wasn’t working.

If I can’t see anything with a MAC 3, a Miller 2 seems to bail me out more often than not.

Or if I’m concerned I would use a hyperangulated blade from the get go.

My only other feedback would be if this was a frequent flier then you should have been able to see how the intubation was on prior anesthesia records. If it’s not part of your local culture to document the intubations then it should be.

All airway manipulation will be documented. BVM ease, too. Thing is, we've never put in more than an LMA with this particular pt.

A miller blade is on my wish list, but they're more or less extinct except for 0 and 1. I guess I have to rephrase myself, got a bit late last night, beers and posting. This was a first where I had to switch blades during an RSI. Definitely had to switch blades during elective inductions, usually just mac3 to 4 or mac 2 to 3.

 

[nimbus]

Definitely had to switch blades during elective inductions, usually just mac3 to 4 or mac 2 to 3.

If you start with a Mac 4 you will never have to switch. Just don’t stick it in as far. Or better yet, start with a glidescope 3.

 

[Southpaw]

If you start with a Mac 4 you will never have to switch. Just don’t stick it in as far. Or better yet, start with a glidescope 3.

Fair. Mac 3>mac4 for small mouth openings. Only point I’d debate with you there.

 

[norski]

If you start with a Mac 4 you will never have to switch. Just don’t stick it in as far. Or better yet, start with a glidescope 3.

Since long before crna school, our attendings taught me to always go for the 4 blade if in doubt. Our blades are for the most part Kawe megalights, and with these, the 4 blade is actually slimmer at the mouth opening, with the tip lodged in the vallecula, than the same manufacture 3 blade. We also only keep a mac4 blade alongside the dBlade for the cmac, as most of us like the geometrics of the 4 vs the 3.

 

[teacher2md]

For older patients, especially women, I always go for a miller blade. The long floppy epiglottis isn’t a problem when you can lift it directly, and you don’t need a huge mouth opening to get the lift required for a Mac blade.

 

[nimbus]

Fair. Mac 3>mac4 for small mouth openings. Only point I’d debate with you there.

Ours have the same profile.

 

[coffeebythelake]

Ours have the same profile.

Same.

 

[jwk]

"My attending planned a relatively simple RSI. Glyco, Alfentanil, prop, sux, tube, positioned on her left side "

Not sure if you mean full lateral or rolled up 45deg for the EGD - but I don't induce ANY patient in any position other than supine, perhaps with a little reverse-T or ramp.

 

[norski]

"My attending planned a relatively simple RSI. Glyco, Alfentanil, prop, sux, tube, positioned on her left side "

Not sure if you mean full lateral or rolled up 45deg for the EGD - but I don't induce ANY patient in any position other than supine, perhaps with a little reverse-T or ramp.

Appreciate the question. 45 degrees, propped with pillows. Reverse T, yes. Forgot to mention I did a quick DL while supine before extubating;same crap view, all I saw was a floppy epiglottis folding around the tube (mostly for documenting the airway properly). We do full lateral (90deg) position inductions fairly often,btw, tubes and igels,rarely any issues, although DLing a right side positioned pt can be troublesome due to the tongue sliding.

If prone positioning is required, I tube and flip. If my attending for some reason insists on prone induction and iGel, that attending is "strongly encouraged" to stay close during the case.

 

[Beeftenderloin]

If prone positioning is required, I tube and flip. If my attending for some reason insists on prone induction and iGel, that attending is "strongly encouraged" to stay close during the case.

Prone induction. That’s a good one... You private practice folks can spare me the “bUt I’vE dOnE iT sAfEly BeFoRe“

Maybe in skinny patients with easy airways, bed in the room and good quality staff that knows how to move quickly if the patient starts desatting, spasms, etc. But even then, you’re begging for complications.

Flipping after induction takes 60 seconds.

 

[norski]

Prone induction. That’s a good one... You private practice folks can spare me the “bUt I’vE dOnE iT sAfEly BeFoRe“

Maybe in skinny patients with easy airways, bed in the room and good quality staff that knows how to move quickly if the patient starts desatting, spasms, etc. But even then, you’re begging for complications.

Flipping after induction takes 60 seconds.

Hah! You perfectly depicted my concerns.

 

[Arch Guillotti]

Flipping after induction takes 60 seconds.

The flip takes one second. Positioning, monitors, etc takes a bot longer based on the case.

 

[deleted59964]

I'm wondering how you convince your gastropedist to go for an ETT-GA in the first place, instead of as the plan B, when laryngospasm shows its lovely face.


Thanks.

Why on earth would I allow a non anaesthetist to have any input into the type of airway I insert at induction of anaesthesia?

How do I convince them ... I don't ... I choose.

 

[zizzer]

GI docs are so much worse than surgeons as far as trying to provide input about anesthetic management.

Also, some MAC 4 blades have a much thinner profile than others. See pearl 6 here.