Egd case

[pd4emergence]

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I put this one forward more for the discussion value. My question is what would you do and does it differ from the board answer you would give and why?

40yr old 500lb 6 ft tall guy that "needs" an egd for abd pain, gerd, and dysphagia (yes dysphagia). He has OSA and htn on lisinopril. His airway looks bad and because of all of his posterior neck fat his neck doesn't extend well. How would you do this procedure that is most definitely essential to the health and well being of this patient?

 

[Planktonmd]

I put this one forward more for the discussion value. My question is what would you do and does it differ from the board answer you would give and why?

40yr old 500lb 6 ft tall guy that "needs" an egd for abd pain, gerd, and dysphagia (yes dysphagia). He has OSA and htn on lisinopril. His airway looks bad and because of all of his posterior neck fat his neck doesn't extend well. How would you do this procedure that is most definitely essential to the health and well being of this patient?

Simple,
Explain to him that he will not go to sleep for this procedure.
Good topical anesthesia to the mouth and pharynx a few minutes before we start then 1-2 mg versed and maybe a small dose of Fentanyl.
if he coughs or gags pull back and do a little more topical.
That's it.

 

[pd4emergence]

Simple,
Explain to him that he will not go to sleep for this procedure.
Good topical anesthesia to the mouth and pharynx a few minutes before we start then 1-2 mg versed and maybe a small dose of Fentanyl.
if he coughs or gags pull back and do a little more topical.
That's it.

This was my plan, glycopyrolate and 2 of versed in the holding area, some viscous lidocaine, and a few sprays of hurricane spray. Get to the procedure room, 2 more of versed and a cc of fentanyl. After multiple unsuccessful attempts and enough benzocaine to cause methemoglobinemia in 4 people, the need for a different plan became obvious.

 

[Idiopathic]

i think thats acceptable for the board answer, and i will say that ive done a similar case with propofol and with AFOI and with 1mg versed, and you never feel good about it.

 

[Idiopathic]

This was my plan, glycopyrolate and 2 of versed in the holding area, some viscous lidocaine, and a few sprays of hurricane spray. Get to the procedure room, 2 more of versed and a cc of fentanyl. After multiple unsuccessful attempts and enough benzocaine to cause methemoglobinemia in 4 people, the need for a different plan became obvious.

this is also when you document in your note that the surgeon deemed the procedure urgent, because I probably abort at this stage. (im assuming you induced general anesthesia, in a less-than-desirable fashion?)

 

[soorg]

Topical benzocaine spray, and mild, conscious sedation, consisting of small doses of midazolam and fent, or you can titrate in propofol CAREFULLY, i.e. 1-2 cc at a time until they can just tolerate the scope (again, after topicalization.) Once the scope is in, that's it. It's not worth it to kill someone just so the GI doc can diagnose "gastritis." I often wonder about the diagnostic yield of these EGDs. I figure 99% of the general population has gastritis from being stressed about life or from diet.

 

[Planktonmd]

This was my plan, glycopyrolate and 2 of versed in the holding area, some viscous lidocaine, and a few sprays of hurricane spray. Get to the procedure room, 2 more of versed and a cc of fentanyl. After multiple unsuccessful attempts and enough benzocaine to cause methemoglobinemia in 4 people, the need for a different plan became obvious.

Plan B would be awake FOI, but if your topical anesthesia is not good enough to insert a scope in the esophagus I doubt it will be enough for this big dude to let you insert a scope in his trachea.
When you do topical anesthesia for an EGD you need to keep the patient conscious and following command so he helps you swallowing the scope and it should not be that difficult, but if you give too much sedation this is when you get in a situation like the one described, he is not awake enough to help you but not asleep enough to not resist you and gag on you.
When they don't swallow the scope the solution is not to give more sedation but to do a better topical anesthetic and to talk to them and tell them to swallow slowly.
I do these frequently on our bariatric people and I use a lidocaine 4% atomizer for topical anesthesia of the pharynx, it works great.

 

[pd4emergence]

Plan B would be awake FOI, but if your topical anesthesia is not good enough to insert a scope in the esophagus I doubt it will be enough for this big dude to let you insert a scope in his trachea.
When you do topical anesthesia for an EGD you need to keep the patient conscious and following command so he helps you swallowing the scope and it should not be that difficult, but if you give too much sedation this is when you get in a situation like the one described, he is not awake enough to help you but not asleep enough to not resist you and gag on you.
When they don't swallow the scope the solution is not to give more sedation but to do a better topical anesthetic and to talk to them and tell them to swallow slowly.
I do these frequently on our bariatric people and I use a lidocaine 4% atomizer for topical anesthesia of the pharynx, it works great.

This guy was following commands at this point. He just couldn't tolerate the scope. He was actually apologizing for being so difficult. He was not over sedated. 4 of versed in a 40 yr old is really not all that much even with the fentanyl. I like the nebulized lidocaine idea, I do that for my awake foi's but I think topicalization has failed here. I think you could go ahead and intubate this guy but would you really do that before you tried to titrate some propofol? I regularly see this same type of pt for endoscopies. I bet my average bmi on a given day when I am doing endoscopies is over 40. I usually see 3 to 4 pts a day with bmi's over 60. They all seem to have OSA and bad looking airways. I will be honest the only time I intubate someone for an endoscopy is when they have a full stomach or a really bad gi bleed.

 

[nap$ter]

This was my plan, glycopyrolate and 2 of versed in the holding area, some viscous lidocaine, and a few sprays of hurricane spray. Get to the procedure room, 2 more of versed and a cc of fentanyl. After multiple unsuccessful attempts and enough benzocaine to cause methemoglobinemia in 4 people, the need for a different plan became obvious.

abort.

if he and the Gi doc decide this scope is super important bring him back another day for awake intubation in the OR - glidescope peek vs fob. 4% lido via atomizer - minimal to zero sedation. maybe dexmed. GI doc is gonna need to document some crucial needs for this shenanigan.

 

[dhb]

Tell him the scope is licorice: he'll swallow it like a pornstar

 

[pd4emergence]

Tell him the scope is licorice: he'll swallow it like a pornstar

Awesome

 

[IlDestriero]

Tell him the scope is licorice: he'll swallow it like a pornstar

 

[pmichaelmd]

Tell him the scope is licorice: he'll swallow it like a pornstar

 

[Planktonmd]

This guy was following commands at this point. He just couldn't tolerate the scope. He was actually apologizing for being so difficult. He was not over sedated. 4 of versed in a 40 yr old is really not all that much even with the fentanyl. I like the nebulized lidocaine idea, I do that for my awake foi's but I think topicalization has failed here. I think you could go ahead and intubate this guy but would you really do that before you tried to titrate some propofol? I regularly see this same type of pt for endoscopies. I bet my average bmi on a given day when I am doing endoscopies is over 40. I usually see 3 to 4 pts a day with bmi's over 60. They all seem to have OSA and bad looking airways. I will be honest the only time I intubate someone for an endoscopy is when they have a full stomach or a really bad gi bleed.

I did not say "nebulized" Lidocaine, I said Atomizer which is a small bore catheter that produces a mist of the liquid injected that you can direct at the targets you want to anesthetize, namely the oropharunx, both sides of the tongue and the uvula in this particular case.
If you don't have these catheters order them, you will be pleased.

 

[saratoga733]

I have done more of these than I care to admit. Never done a 500 pounder but definitely a hand full of 400+ under 6' tall. In terms of topicalization I have tried them all: nebulizer, cetacaine spray, atomizer, etc... I find viscous lidocaine works best. Need to empathize to patient that they do a good job of gargling for no less than ten seconds and then SWALLOW-- coating the oral pharynx and esophagus. Add a couple of drops of cherry flavored infant simethacone if you have them handy up in the endo suite so that they don't give you a hard time from the foul taste. If done properly, most motivated/reasonable patients should tolerate an EGD with minimal sedation.

 

[pd4emergence]

I did not say "nebulized" Lidocaine, I said Atomizer which is a small bore catheter that produces a mist of the liquid injected that you can direct at the targets you want to anesthetize, namely the oropharunx, both sides of the tongue and the uvula in this particular case.
If you don't have these catheters order them, you will be pleased.

We tried those catheters for a while but they did not seem to catch on. I will have to take a look at them again.

 

[pd4emergence]

In the end I gave him 20 or 30 of propofol slipped a nasal airway in and let the gi guy do his thing, he ended up getting around 80 or 90 total. We have etco2 monitoring and he never went apneic. Unfortunately it looked like he has barrett's and will be back pretty often.

Doing lots of endos makes me feel like this guy...

http://www.youtube.com/watch?v=9VDvgL58h_Y&feature=youtube_gdata_player

 

[Oggg]

More local.
Lido atomizer definitely. maybe lido jelly/oint to back of tongue.
I like the gargle idea.
Glossopharyngeal blocks bilaterally?

 

[TrustMe]

I love the atomizer as well. Not many peeps at my place use it, but I love it. I like it for oral or nasal intubations. Once the anterior portion of the nose or mouth are numb with whatever you like, you can bend the extension on the atomizer and keep advancing it until you have it all the way in their mouth/nose. This will get you almost right at the cords and you can give them 1-2 cc's. Pt. won't cough or buck at all. I have been using these in the ICU lately for awake/nasal bronchoscopy. Ten minutes of prep and some Precedex and pt.'s tolerate just about anything. The bronch techs that work with the pulm. guys can't believe how smooth this is.

For some of the residents out there, good topicalization takes TIME. 5-10 extra minutes of prep will save you tons of hassle and annoyance when you are trying to get the scope/ETT in place.

 

[DrN2O]

I put this one forward more for the discussion value. My question is what would you do and does it differ from the board answer you would give and why?

40yr old 500lb 6 ft tall guy that "needs" an egd for abd pain, gerd, and dysphagia (yes dysphagia). He has OSA and htn on lisinopril. His airway looks bad and because of all of his posterior neck fat his neck doesn't extend well. How would you do this procedure that is most definitely essential to the health and well being of this patient?

Call me conservative, but I don't get it. The plan A seems to be that for a suspected and likely bad airway, let's hit him with sedation to get right up to the edge of trouble then back off. What's plan B, an urgent intubation in a 500# guy in prone position in the endo suite? I think local is all he get, or else he gets tubed from the get go.

 

[cchoukal]

I find the first thing the scope hits on the way in is the hard and soft palate, and patients gag on this. I like some stiff (ointment or jelly) lidocaine on the tongue, and have them hold their tongue to their palate and swirl it around for several seconds. I do that in addition to either a gargle or atomizer.

 

[cincincyreds]

Board answer : Sedate patient with a precedex infusion and topicalize the airway for an awake fiberoptic intubation. If you induce this patient or only use topicalization on the boards, you will be sending them another check for 2 grand next year.

Real world : If I actually took the 45 minutes to do that properly for a 3 minute egd, I would promptly be fired from my job, so what I would really do is just use one drug, propofol, avoid polypharmacy, and give it in increments of 1-2cc's and titrate to effect. I would also use cetacaine spray. I had something similar a few weeks ago and what I just described worked perfectly fine.

 

[G0S2]

Tell him the scope is licorice: he'll swallow it like a pornstar

Haven't laughed out loud in a while. Thank you.

 

[pd4emergence]

Call me conservative, but I don't get it. The plan A seems to be that for a suspected and likely bad airway, let's hit him with sedation to get right up to the edge of trouble then back off. What's plan B, an urgent intubation in a 500# guy in prone position in the endo suite? I think local is all he get, or else he gets tubed from the get go.

Pt was not prone, this was a egd not ercp (thanks to the diety of your choice). I would be run out of town if I intubated every scary looking airway for a colonoscopy or egd. Here plan A didn't work (versed, fentanyl, topicalization). At this point I felt like I had a few options, more topicalization, more sedation, move to the or and intubate, or abort. I felt like at the time I had given topicalization every chance and plenty of time to work. I also felt like cancelling it was a better option than intubation. That leaves the option of more sedation and this is the route I went. This gets back to the much debated topic of possible difficult airways and sedation/Mac/iv general cases. Do you stick to the party line of controlling the airway first no matter what or do you proceed carefully and maintain spontaneous respiration?

 

[Planktonmd]

Pt was not prone, this was a egd not ercp (thanks to the diety of your choice). I would be run out of town if I intubated every scary looking airway for a colonoscopy or egd. Here plan A didn't work (versed, fentanyl, topicalization). At this point I felt like I had a few options, more topicalization, more sedation, move to the or and intubate, or abort. I felt like at the time I had given topicalization every chance and plenty of time to work. I also felt like cancelling it was a better option than intubation. That leaves the option of more sedation and this is the route I went. This gets back to the much debated topic of possible difficult airways and sedation/Mac/iv general cases. Do you stick to the party line of controlling the airway first no matter what or do you proceed carefully and maintain spontaneous respiration?

It's a question of judgement and experience, if the topical anesthetic is not sufficient as you stated then you should ask yourself the following question:
How confident am I that I will be able to ventilate this guy if I lose the airway?
The answer based on your experience and clinical judgement should determine your plan of action.
If you feel that more likely than not you will not be able to ventilate him then giving deeper sedation is not a great idea.
And you have to keep in mind that in the event you lose the airway and you have a bad outcome you will have a hard time defending what you did.
As for intubating a patient for an endoscopy, if you feel it is the safest plan for a particular patient you should not hesitate to do it regardless of what anyone might say or think. At the end of the day you are the expert and you are expected to do what's right for the patient.

 

[rsgillmd]

Real world : If I actually took the 45 minutes to do that properly for a 3 minute egd, I would promptly be fired from my job, so what I would really do is just use one drug, propofol, avoid polypharmacy, and give it in increments of 1-2cc's and titrate to effect. I would also use cetacaine spray. I had something similar a few weeks ago and what I just described worked perfectly fine.

Not necessarily disagreeing with you. However, I could make the argument that if you sincerely felt awake intubation was the best route, you could move other patients in the queue up while you prep this patient with the aid of the preop nurses (if you have reliable help). Ex: let a lidocaine nebulizer treatment run while you do the next EGD in line.

 

[Mac4]

This guy's BMI is close to 70 and people are OK with "sedating" him without a protected airway? I agree with the plan of good topicaliztion and/or AFOI. If you are good at AFOI, it should not take that long anyway. GI doctors would also appreciate that they do not have to stop in the middle of procedure so that you could "sedate" the patient more.

 

[pd4emergence]

This guy's BMI is close to 70 and people are OK with "sedating" him without a protected airway? I agree with the plan of good topicaliztion and/or AFOI. If you are good at AFOI, it should not take that long anyway. GI doctors would also appreciate that they do not have to stop in the middle of procedure so that you could "sedate" the patient more.

This is the future. As you go forward, you will see higher and higher bmi's. That's kinda why I posted this. I did zero endoscopies in residency. But as anesthesiology has evolved we are getting asked more and more to do things out of the or. Endos, radiology, mri's, cath lab. In the case of endos, I have asked the gi guys what they were doing before we started giving the white stuff. Their answer was eye opening. Yeah, this guy's got a bmi over 70 and yeah his airway doesn't look the best, but when they get that fat they never do. In the days before we got involved, the gi guys would have given this dude 10 of versed and 150 of demerol and went to town. They would not have even looked at his airway and chances are he would have done fine. I personally think there is some middle ground. I think my mistake here was bothering with the versed, I should have topicalized and went straight for propofol.

 

[DrN2O]

In the days before we got involved, the gi guys would have given this dude 10 of versed and 150 of demerol and went to town. They would not have even looked at his airway and chances are he would have done fine.

Then I would say to the GI guy, "Go ahead, take your chances." Of course, in the real world you are probably stuck with doing these EGDs for your group, so I'm not envious.

On the other hand, have people done EGDs with LMAs in place? I once did a tracheal stent with a LMA. The first stent got lost in the goose, and we had to fish it out with the scope. I didn't even fully deflate the cuff. I kind of liked that idea.

 

[Planktonmd]

I think my mistake here was bothering with the versed, I should have topicalized and went straight for propofol.

If you have to sedate this kind of patient Propofol alone is a good choice.
We do "sedation" for endoscopy everyday at 3 different locations and we all use only Propofol with nothing else.

 

[Monty Python]

If you have to sedate this kind of patient Propofol alone is a good choice.
We do "sedation" for endoscopy everyday at 3 different locations and we all use only Propofol with nothing else.

On this particular patient would a molecule or two of ketamine mixed in the propofol help? Especially in places without precedex?

 

[Planktonmd]

On this particular patient would a molecule or two of ketamine mixed in the propofol help? Especially in places without precedex?

You can but why use 2 drugs to do what can be achieved perfectly with one?
I am assuming that you are still going to use topical anesthesia here.

 

[Monty Python]

You can but why use 2 drugs to do what can be achieved perfectly with one?
I am assuming that you are still going to use topical anesthesia here.

The vast vast majority of the EGDs I've done are with glyco, topical, and diprivan.

C/scopes I do with straight propofol 99% of the time. I think once in the past decade we added a few mg of ketamine to make ketafol on a well-known pt who was (for whatever physiological/biochemical reason) very resistant to propofol. Did quite well and later thanked me for what had been the least-unpleasant scope of his life.

Was just curious if ketafol might have helped the OP's pt here get over the rough spots easier than straight propofol?

 

[pd4emergence]

The vast vast majority of the EGDs I've done are with glyco, topical, and diprivan.

C/scopes I do with straight propofol 99% of the time. I think once in the past decade we added a few mg of ketamine to make ketafol on a well-known pt who was (for whatever physiological/biochemical reason) very resistant to propofol. Did quite well and later thanked me for what had been the least-unpleasant scope of his life.

Was just curious if ketafol might have helped the OP's pt here get over the rough spots easier than straight propofol?

I haven't used ketamine much for endoscopies. I do use it a lot for av fistula declots, and other longer sedation cases. It might have helped here but I had already gone down the road of giving more versed than usual and I was trying to keep it from getting too complicated. My plan was to try some propofol and have a low threshold for aborting the procedure. H ended up doing fine with just a little bit. I think ketamine is something to keep in mind and honestly not something I think of much when I am in endo hell.

 

[Monty Python]

... not something I think of much when I am in endo hell.

Just like any other day going to work ... just another day at the orifice.

 

[urge]

Just lube the scope with some Big Mac sauce. It will be fine.

 

[Idiopathic]

On this particular patient would a molecule or two of ketamine mixed in the propofol help? Especially in places without precedex?

you will pay for it ultimately, id leave it out

 

[NotAMD]

attempt awake foi off the bat, back up is asleep with sevo inh induction then go for another fo attempt vs glidescope look while spont breathing sevo, third option would be the brutal awake method proposed here but i think there is little chance this guy will tolerate an awake endoscopy - that scope is much bigger than our fo scopes and must be jammed in the esophagus, by the time ours touches anything it should be trachea and the tube is on its way in as is propofol

 

[pd4emergence]

I am surprised at the number of people who would go straight to foi. I know this is an anonymous forum, in real life do you really foi every bad looking airway no matter what the case? How about specifically in endoscopies? To me endoscopies pose special circumstances. They are generally short, predictable, the stimulus can be removed immediately, and the procedure can be usually be aborted quickly. That being said some of the sickest people I see, I see for endoscopy. I have seen somebody die with just 30 of propofol. For those younger attendings and residents, keep in mind that a fast gi guy can do upwards of 20 or more scopes a day. In my case, I would predict to have three or four super morbidly obese patients in a typical day (bmi's over 55). My group has done this day in and day out for a few years. At all of our endoscopy sites we probably do 80-100 scopes a day. We have had very few bad outcomes and none because of lost airways. So from our experience, I disagree with the straight to foi answer.

 

[Planktonmd]

I have a low threshold to do an awake fiber optic intubation on a patient I truly think would be difficult to intubate and difficult to ventilate in my hands.
This is not any "difficult looking airway" we are talking about here and it happens probably once every 2-3 months.
And you are right, in Endo I have done awake FOI once in my whole career.

 

[Arch Guillotti]

attempt awake foi off the bat, back up is asleep with sevo inh induction then go for another fo attempt vs glidescope look while spont breathing sevo, third option would be the brutal awake method proposed here but i think there is little chance this guy will tolerate an awake endoscopy - that scope is much bigger than our fo scopes and must be jammed in the esophagus, by the time ours touches anything it should be trachea and the tube is on its way in as is propofol

Asleep sevoflurane induction in a 500 pounder? Sounds like a recipe for disaster to me.

 

[NotAMD]

sevo doesnt suppress respiration and will allow them to tolerate FOI, if you think this sounds like a disaster you should do more of them, if you stop breathing the sevo stops, but that never happens everyone breathes right through to 1mac, sometime i wonder why we bother with awake foi when we have inhalational inductions

 

[Planktonmd]

sevo doesnt suppress respiration and will allow them to tolerate FOI, if you think this sounds like a disaster you should do more of them, if you stop breathing the sevo stops, but that never happens everyone breathes right through to 1mac, sometime i wonder why we bother with awake foi when we have inhalational inductions

You are not serious are you?
Inhaled induction in a morbidly obese patient is a guaranteed disaster!
Vapors are excellent muscle relaxants and as soon as you reach a deep level of anesthesia all the soft tissue around the airway will collapse on you and you will have a patient who is obstructed and unable to eliminate the vapor because he is not breathing!
An awake fiberoptic intubation in the experienced hands of an anesthesiologist who knows how to anesthetize the airway properly is a very simple and straight forward process that takes 2 minutes.

 

[dhb]

attempt awake foi off the bat, back up is asleep with sevo inh induction

😱 I'm not a fan of malpractice guided practice but how will you defend this: you decide his airway is bad enough to mandate a afoi then because it didn't work you're putting him to sleep? doesn't make any sense.

 

[NotAMD]

well what do you do when despite adequate topicalization they wont tolerate tube passing touching the chords and you cant get in with your scope but its an otherwise easy view (which is often the case) , give IV sedatives? wake up and cancel? i think sevo is a nice option for this case scenario - theres asleep with sevo, and then theres asleep with IV agents and apnea, not the same - kids with difficult airways who wont tolerate awake foi get sevo off the bat all thetime - i didnt mean it was my backup plan in case i couldnt see anything with the scope that would not make sense, but i do give sevo if ive given the guy 2 rounds of 4% lido nebs, transtracheal block, lido lollipop with 5% ointment, adequate time to set in, dexmedetomine 0.6 for 40 mins, and glyco - and i can see the chords but he just coughs when the scope goes to enter and blocks me out - in this case i know that i can do the procedure, just need to get him to tolerate it - this is the scneario i meant, which i have done >50 times with good succcess - but i did misspeak it was not my backup plan for failed awake foi for other reaons just inability to tolerate - in this case i would just cancel if i couldnt do it truly awake easily since its not super important procedure and hes really fat

 

[Planktonmd]

Kids who get sevo for induction are not 500 pounds with sleep apnea and horrible airway.
I routinely do asleep fiberoptic intubations on patients who appear difficult to intubate but I feel I can ventilate them easily, but I don't induce anesthesia on a patient that appears difficult to intubate and difficult to ventilate as the one mentioned in this case.
Also there is no such thing as: "they will not tolerate the tube passing through the cords" if you know how to anesthetize the airway.

 

[Planktonmd]

i can see the chords but he just coughs when the scope goes to enter and blocks me out -

when this happens to you pull your scope back, wait until he stops coughing, then inject a little Lido 4% through the scope directly on top of the cords, wait a few seconds then pass the scope.
This should be a rare situation if your transtracheal block is good enough because when they cough after you inject your lido in the trachea they spray their own cords with local anesthetic.
You still have to properly anesthetize the area above the cords though.

 

[Arch Guillotti]

Give some more lidocaine and wait for the ensuing seizure so they are not coughing and gagging anymore...........🙂 Just kidding.

Seriously though, a 500 pounder difficult airway is completely different than a little kid. If it is a big fat kid with a difficult airway then that is a whole different thread.

I am surprised that you have done this >50 times, that sounds like a lot.

I agree with Plank in that inhalation induction is great for keeping patients breathing (until their soft tissue is relaxed and they start to obstruct). I have seen a couple of inhalation inductions in this sort of patient and it never went well. It was just too difficult to get them deep enough for intubation via DL. Maybe this would have been better with fiberscope but maybe it would have been worse. If the patient is in an inadequate plane of anesthesia for intubation you run the risk of laryngospasm if you muck around too much.

I don't do too many awake FOI's anymore but I have always been able to intubate even when tube tolerance in not perfect.

Rather than inhalational induction, I would try a few other things in your situation - squirting the cords like plank described (under direct vision), squirting the cords with a MAD syringe (not under direct vision) in lieu of a transtracheal block prior to scope insertion - a small dose of ketamine to stun the patient.

well what do you do when despite adequate topicalization they wont tolerate tube passing touching the chords and you cant get in with your scope but its an otherwise easy view (which is often the case) , give IV sedatives? wake up and cancel? i think sevo is a nice option for this case scenario - theres asleep with sevo, and then theres asleep with IV agents and apnea, not the same - kids with difficult airways who wont tolerate awake foi get sevo off the bat all thetime - i didnt mean it was my backup plan in case i couldnt see anything with the scope that would not make sense, but i do give sevo if ive given the guy 2 rounds of 4% lido nebs, transtracheal block, lido lollipop with 5% ointment, adequate time to set in, dexmedetomine 0.6 for 40 mins, and glyco - and i can see the chords but he just coughs when the scope goes to enter and blocks me out - in this case i know that i can do the procedure, just need to get him to tolerate it - this is the scneario i meant, which i have done >50 times with good succcess - but i did misspeak it was not my backup plan for failed awake foi for other reaons just inability to tolerate - in this case i would just cancel if i couldnt do it truly awake easily since its not super important procedure and hes really fat

 

[birchswing]

I'm doing research on ultra-thin endoscopes (2-6 mm). Based on this discussion, is it safe to assume they're not used commonly in practice and are relegated to research? I've found they cost around 30,000, not sure how much that is compared to a regularly sized endoscope.