EGD for GI Bleed: Tube or not?

[C4C]

The title says it all.

If I am involved in the care of a GI bleed patient where the esophagus and stomach are considered possible bleeding sites (that is, in addition to a colonoscopy, the endoscopist wants to do an EGD), then I figure that the patient has a "presumed full stomach" and deserves to be intubated.

Yes, I could do the case as a MAC. In the event of an aspiration, I'm not sure I could defend the case.

Colleagues of mine at a single facility claim that I am out of step.

What is the standard at your shop??

Thanks.

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[deleted126335]

Behavioral economics of rare events- You diminish the risk in your mind until you have an event.
Most of us will have unnecessarily buckled our seatbelts tens of thousands of times over our life. Most of us will never collect on our life insurance or disability premiums.

You will get most likely get away with it for a very long time.
You are not out of step. They are gambling with someone else's life to save time and $$. It is a gamble that they will probably win.

 

[kidthor]

Yes, I could do the case as a MAC. In the event of an aspiration, I'm not sure I could defend the case.

I do some peds GI anesthesia at an ivory tower, and I'd intubate any possible/likely UGI bleed.

Also I'd personally call what you're referring to as TIVA-GA with an unprotected airway, not MAC.

 

[Twiggidy]

Protect the patient. I'd probably tube an UGI bleed but then again I don't do much endoscopy suite. I think the reasons you give (bleeding, possible full stomach, probably vomiting) are all good reasons to protect the airway. If your colleagues are criticizing you then have them do the case.

 

[Mman]

to me the question is are they bleeding right now or are we just looking after the fact to see where bleeding may have come from?

 

[drmwvr]

It's pretty appalling that anesthesiologists have appropriated their non anesthesia colleagues irrational equivalency of placing an ET tube with a big deal.

 

[Arch Guillotti]

Tube them most of the time. If you don’t tube them and the stomach is a mess just tell the gi guy that he needs to stop while the airway is secured.

 

[DM27]

My decisions vary on why they are doing the EGD. If this is a rule out GI bleed or the patient likely has a bleed but we don't know where I will rarely intubate. If this is someone who had hematemesis or has something like a variceal bleed then I will intubate in 99% of situations. For reference I don't do a ton of endoscopy, I likely average ~100 GI endoscopy cases a month.

The only near aspiration I have had so far in these scenarios was during an RSI for a concern for a gastric outlet obstruction.

 

[kidthor]

The only near aspiration I have had so far in these scenarios was during an RSI for a concern for a gastric outlet obstruction.

I gave a break to a colleague in GI a bit ago - they were doing TIVA-GA with an unprotected airway for an EGD for "gastritis". One minute after I was in there the patient spewed out bilious emesis mid-EGD and then went into laryngospasm. I gave sux and then couldn't intubate (really obese patient). Luckily I could ventilate s/p sux, but then I had concern about seeding bile into their airway. Eventually I intubated with a glidescope.

Bleh. GI anesthesia can be a minefield.

 

[Consigliere]

I gave sux and then couldn't intubate (really obese patient).

Thanks for having the nuts to admit that. No one else in this forum has ever been able to NOT intubate, can put in central lines in 14 seconds, and perform nerve blocks that work 100% of the time by smell alone.

 

[Arch Guillotti]

Thanks for having the nuts to admit that. No one else in this forum has ever been able to NOT intubate, can put in central lines in 14 seconds, and perform nerve blocks that work 100% of the time by smell alone.

Blade does it all and runs 4 rooms the entire time

 

[deleted162650]

I gave a break to a colleague in GI a bit ago - they were doing TIVA-GA with an unprotected airway for an EGD for "gastritis". One minute after I was in there the patient spewed out bilious emesis mid-EGD and then went into laryngospasm. I gave sux and then couldn't intubate (really obese patient). Luckily I could ventilate s/p sux, but then I had concern about seeding bile into their airway. Eventually I intubated with a glidescope.

Bleh. GI anesthesia can be a minefield.

Where was the scope when this started? Stomach, or not there yet?

And who the F needs a break mid EGD?? You can’t wait for 6 minutes dude???

 

[Mman]

Thanks for having the nuts to admit that. No one else in this forum has ever been able to NOT intubate, can put in central lines in 14 seconds, and perform nerve blocks that work 100% of the time by smell alone.

while we can all be super slick on things, there are always patients that can't be intubated or lines that can't be gotten. It's a patient anatomy issue, not a lack of skill. Anyone that hasn't seen it just hasn't done the job long enough.

 

[kidthor]

Where was the scope when this started? Stomach, or not there yet?

And who the F needs a break mid EGD?? You can’t wait for 6 minutes dude???

The scope-timing was mid GI-Fellow trying to flummox into the esophagus. So definitely not yet to the stomach.

As for break timing, I don't know if there's per se a better convenient time in that room - at least there's no better time that I could have easily scheduled... so I don't hold it against them.

 

[kidthor]

while we can all be super slick on things, there are always patients that can't be intubated or lines that can't be gotten. It's a patient anatomy issue, not a lack of skill. Anyone that hasn't seen it just hasn't done the job long enough.

This patient definitely could not be intubated emergently by me with two blades (mac 3, miller 2)... and the patient was big. Maybe with better positioning or less emergent timing they'd be easier, but under my circumstances I couldn't intubate easily. Eventually it was easy with a glidescope though.

 

[deleted162650]

As for break timing, I don't know if there's per se a better convenient time in that room - at least there's no better time that I could have easily scheduled... so I don't hold it against them.

How ‘bout:

“Finish this one and I’ll do the next one so you can grab a break”

 

[Twiggidy]

I gave a break to a colleague in GI a bit ago - they were doing TIVA-GA with an unprotected airway for an EGD for "gastritis". One minute after I was in there the patient spewed out bilious emesis mid-EGD and then went into laryngospasm. I gave sux and then couldn't intubate (really obese patient). Luckily I could ventilate s/p sux, but then I had concern about seeding bile into their airway. Eventually I intubated with a glidescope.

Bleh. GI anesthesia can be a minefield.

Sorry if this makes none of you ever want to hire me as a colleague but if I walk in to give you a break and that’s the pre-disaster anesthetic you’ve chosen then you’re gonna have to hold it. Sorry not sorry.

 

[Twiggidy]

while we can all be super slick on things, there are always patients that can't be intubated or lines that can't be gotten. It's a patient anatomy issue, not a lack of skill. Anyone that hasn't seen it just hasn't done the job long enough.

I’ve botch many a line where I’ve had to phone a friend. No one’s perfect

 

[deleted171991]

I see 12 votes for intubation and one against (mine). Funny, since the question says that the bleed is of UNKNOWN origin, meaning, by definition, that it's not major (also the study is "emergent", not truly emergent, so I assume the patient is stable).

This is my approach (Mman's).

 

[deleted875186]

I see 12 votes for intubation and one against (mine). Funny, since the question says that the bleed is of UNKNOWN origin, meaning, by definition, that it's not major (also the study is "emergent", not truly emergent, so I assume the patient is stable).

If salt bae did anesthesia I’m sure he would vote for no tube as well. I also imagine him pushing propofol the way he salts meat.

 

[Consigliere]

while we can all be super slick on things, there are always patients that can't be intubated or lines that can't be gotten. It's a patient anatomy issue, not a lack of skill. Anyone that hasn't seen it just hasn't done the job long enough.

(Extends hand of gratitude to Captain Obvious)

 

[cchoukal]

As others have said, it depends on where they think the patient is bleeding, how much, and how recently. I do a fair number of these, and I intubate the ones who are borderline stable, who are thought to have ongoing bleeding, who have varices, and who are out of it. You usually know by history or exam whether the patient might have varices or not (and I work primarily in an integrated system, so the GI docs know if the patient has varices). Many of our scopes for bleeding are done after 12-24 hrs of IV PPI, which has been shown to downgrade the lesion (for stomach/duodenal stuff). Given all that, it's pretty rare that I intubate someone for EGD for bleeding. Certainly, I also get the ones who are requiring ongoing transfusion; they get intubated. The ones with any blood stains on their lips; intubated. The morbidly obese diabetics; intubated. The cirrhotics; intubated. The rest, mostly not.

 

[Hoya11]

The title says it all.

If I am involved in the care of a GI bleed patient where the esophagus and stomach are considered possible bleeding sites (that is, in addition to a colonoscopy, the endoscopist wants to do an EGD), then I figure that the patient has a "presumed full stomach" and deserves to be intubated.

Yes, I could do the case as a MAC. In the event of an aspiration, I'm not sure I could defend the case.

Colleagues of mine at a single facility claim that I am out of step.

What is the standard at your shop??

Thanks.

I had a 22 year old guy in the MICU overnight for UGIB and HCT 20. The next morning they call me to do an EGD in the unit. GI Fellow says he doesnt need to be intubated, has not been coughing up much blood. GI attending is like you are describing, making a big deal out of tubing him. I talk to the guy he says he ate last at 5pm the night before, has been having very mild hemoptysis but not for a few hours. I do the case without an ETT, its going OK, the fellow is going to town, insufflating and moving around all up and down with the scope. After about 10 minutes he give s big puff of air and moves the scope into the stomach and blood starts pouring out of mouth and nose, like someone had set off a blood bomb inside the guys stomach.

I emergently intubate the guy. He remains intubated for a day or so and then extubated and does fine. This taught me that you have to consider not only giving anesthesia with blood in the stomach, that usually will be OK, but also to consider that whatever contents may be in the stomach can suddenly become under pressure and shoot out due to the scope insufflation and an unskilled endoscopist.

 

[rp218]

thresholds may change based on proceduralist. i'd have a low threshold to intubate if a fellow is doing it, as opposed to an experienced quick, no bs attending in pp.

 

[btbam]

I had a 22 year old guy in the MICU overnight for UGIB and HCT 20. The next morning they call me to do an EGD in the unit. GI Fellow says he doesnt need to be intubated, has not been coughing up much blood. GI attending is like you are describing, making a big deal out of tubing him. I talk to the guy he says he ate last at 5pm the night before, has been having very mild hemoptysis but not for a few hours. I do the case without an ETT, its going OK, the fellow is going to town, insufflating and moving around all up and down with the scope. After about 10 minutes he give s big puff of air and moves the scope into the stomach and blood starts pouring out of mouth and nose, like someone had set off a blood bomb inside the guys stomach.

I emergently intubate the guy. He remains intubated for a day or so and then extubated and does fine. This taught me that you have to consider not only giving anesthesia with blood in the stomach, that usually will be OK, but also to consider that whatever contents may be in the stomach can suddenly become under pressure and shoot out due to the scope insufflation and an unskilled endoscopist.

Hopefully you mic dropped the blade and stared down the GI fellow after intubating.

 

[sbhfl]

Anyone use straight Ketamine for these? Just enough until they look loopy but are still awake and coughing all over the place? Say for the guy on nasal CPAP who's DNR and doesn't want prolonged intubation.

 

[GastriqueGraffin]

Perspective from a GI fellow:

When it’s a severe enough upper GI bleed that they need to be intubated then they are usually in the ICU and usually intubated. If they are in GI endoscopy lab usually it’s a slow bleed or one that stopped. In those cases we can do conscious sedation but will ask for anesthesia help because of other comorbidities not related to the acute bleed.

There are exceptions to everything but that’s just been my experience and overall makes sense.

 

[sbhfl]

Perspective from a GI fellow:

When it’s a severe enough upper GI bleed that they need to be intubated then they are usually in the ICU and usually intubated. If they are in GI endoscopy lab usually it’s a slow bleed or one that stopped. In those cases we can do conscious sedation but will ask for anesthesia help because of other comorbidities not related to the acute bleed.

There are exceptions to everything but that’s just been my experience and overall makes sense.

Good to have input like this but you're missing the point. Even a "slow bleed" can mean a stomach full of blood and gastric juices just waiting to tear apart your patient's lungs. There's an enormous difference between usually (ie-- maybe you only kill 1% of your patients doing these cases without tubes) and always.

 

[abolt18]

Behavioral economics of rare events- You diminish the risk in your mind until you have an event.
Most of us will have unnecessarily buckled our seatbelts tens of thousands of times over our life. Most of us will never collect on our life insurance or disability premiums.

You will get most likely get away with it for a very long time.
You are not out of step. They are gambling with someone else's life to save time and $$. It is a gamble that they will probably win.

I appreciated this example the most. A great way of thinking about it.

 

[GastriqueGraffin]

Good to have input like this but you're missing the point. Even a "slow bleed" can mean a stomach full of blood and gastric juices just waiting to tear apart your patient's lungs. There's an enormous difference between usually (ie-- maybe you only kill 1% of your patients doing these cases without tubes) and always.

I guess it’s technically never wrong to intubate everyone. Just keep in mind in many county, rural, and VA hospitals where we don’t have anesthesia readily available 24/7 we do most of these cases under sedation. I’ve been in these situations. We have large caliber suction channels in therapeutic scopes and just try to suction as much and as quickly as possible. It’s not ideal and you guys should do whatever you feel is necessary.

 

[nimbus]

I guess it’s technically never wrong to intubate everyone. Just keep in mind in many county, rural, and VA hospitals where we don’t have anesthesia readily available 24/7 we do most of these cases under sedation. I’ve been in these situations. We have large caliber suction channels in therapeutic scopes and just try to suction as much and as quickly as possible. It’s not ideal and you guys should do whatever you feel is necessary.

Different standards when we get involved. Doesn’t matter at all what happens when anesthesia is not present. We have to do what a plaintiff’s anesthesia expert witness would testify is standard.

 

[Twiggidy]

Anyone use straight Ketamine for these? Just enough until they look loopy but are still awake and coughing all over the place? Say for the guy on nasal CPAP who's DNR and doesn't want prolonged intubation.

Personal experience, I dont like the laryngospasm that tends to happen with low dose Ketamine. I used to love it but then found myself fighting spasms for what should've been otherwise simple sedations.

 

[WholeLottaGame7]

I guess it’s technically never wrong to intubate everyone. Just keep in mind in many county, rural, and VA hospitals where we don’t have anesthesia readily available 24/7 we do most of these cases under sedation. I’ve been in these situations. We have large caliber suction channels in therapeutic scopes and just try to suction as much and as quickly as possible. It’s not ideal and you guys should do whatever you feel is necessary.

Yessss, my favorite line from proceduralists asking for our help, wanting us to do it "their" way, and not-so-secretly judging us when we disagree with them.

Was talking about tubing an EGD in our main GI suite because the indication was hematemesis. GI doc tried to talk to me out of it "he hasn't vomited any blood in a few hours" and "most of your colleagues wouldn't tube this guy" and followed it up with a "but do whatever you want."

Yeah, what I want is for this guy to not aspirate blood and end up in the ICU or dead.

Prop-sux-tube. GI doc "man, that's a lot of blood in there."

Sooo, did you think he was bleeding or were just trying to pad your RVUs?

 

[GastriqueGraffin]

Yessss, my favorite line from proceduralists asking for our help, wanting us to do it "their" way, and not-so-secretly judging us when we disagree with them.

Was talking about tubing an EGD in our main GI suite because the indication was hematemesis. GI doc tried to talk to me out of it "he hasn't vomited any blood in a few hours" and "most of your colleagues wouldn't tube this guy" and followed it up with a "but do whatever you want."

Yeah, what I want is for this guy to not aspirate blood and end up in the ICU or dead.

Prop-sux-tube. GI doc "man, that's a lot of blood in there."

Sooo, did you think he was bleeding or were just trying to pad your RVUs?

You do you buddy. If you’re worried then you should tube. From GI standpoint we don’t care at all as long as you don’t postpone or delay cases.

 

[sbhfl]

You do you buddy. If you’re worried then you should tube. From GI standpoint we don’t care at all as long as you don’t postpone or delay cases.

Put yourself in an anesthesiolgist's shoes here. You're an expert in sedation, and a GI doc consults you, and says "you do you as long as you don't postpone or delay my case."

Seems disrespectful, even a bit insulting. As an anesthesiolgist, I'll do what's safest for the patient. That will take more time then say, always giving a punch of propofol and just hoping we don't get into a bad situation that would have been avoidable.

Most anesthesiologists aren't these bad guys who get their thrills by dragging their feet and delaying cases. They are physicians with expertise in sedating patients. Consulting them takes more time then just telling a nurse to give some fentanyl/versed. Keep in mind, we're there to help.

 

[DocVapor]

Put yourself in an anesthesiolgist's shoes here. You're an expert in sedation, and a GI doc consults you, and says "you do you as long as you don't postpone or delay my case."

Seems disrespectful, even a bit insulting. As an anesthesiolgist, I'll do what's safest for the patient. That will take more time then say, always giving a punch of propofol and just hoping we don't get into a bad situation that would have been avoidable.

Most anesthesiologists aren't these bad guys who get their thrills by dragging their feet and delaying cases. They are physicians with expertise in sedating patients. Consulting them takes more time then just telling a nurse to give some fentanyl/versed. Keep in mind, we're there to help.

I always think it's funny - we should be the surgeon's/proceduralist's best friends. Our job is specifically to protect the surgeon by avoiding complications. We're the surgeon's (and patient's, of course) last line of defense against themselves.

 

[Consigliere]

You do you buddy. If you’re worried then you should tube. From GI standpoint we don’t care at all as long as you don’t postpone or delay cases.

If I "delay" a case for a few minutes in the name of patient safety I don't care one iota......buddy.

 

[T-burglar]

Don’t mess around with aspiration risk.

A major aspiration event will be scrutinized very carefully by your department/colleagues. As well it should be.

 

[drmwvr]

You do you buddy. If you’re worried then you should tube. From GI standpoint we don’t care at all as long as you don’t postpone or delay cases.

Putting the tube in would be the beginning of the case and taking it out would be the end.

 

[GastriqueGraffin]

My point to all of this was my perspective as “a proceduralist”. If we are looking for a slow occult GI bleed or history of minor recent bleed that the odds of finding a significant amount of blood is very low. If you want to intubate everyone as a rule I don’t think anyone would ever blame you from a safety standpoint. But if you do shift work and are done at 4pm on the dot as a service, for a particularly busy day, I’ve had situations where these little things add up and I’ve pushed cases to the next day or even the next week if it’s a Friday because we have run out of time with anesthesia. Just something to keep in mind.

 

[Arch Guillotti]

My point to all of this was my perspective as “a proceduralist”. If we are looking for a slow occult GI bleed or history of minor recent bleed that the odds of finding a significant amount of blood is very low. If you want to intubate everyone as a rule I don’t think anyone would ever blame you from a safety standpoint. But if you do shift work and are done at 4pm on the dot as a service, for a particularly busy day, I’ve had situations where these little things add up and I’ve pushed cases to the next day or even the next week if it’s a Friday because we have run out of time with anesthesia. Just something to keep in mind.

lol most of us just keep pumping the cases out as long as guys like you keep posting them, day and night

 

[nimbus]

You do you buddy. If you’re worried then you should tube. From GI standpoint we don’t care at all as long as you don’t postpone or delay cases.

How about, “you do you as long as you finish on schedule so I can get to my next case.” From an anesthesia standpoint, we don’t care as long as you don’t make us late for our next case. An aspiration in endo suite is gonna make me really late. I don’t like that.

 

[ProRealDoc]

I had a 22 year old guy in the MICU overnight for UGIB and HCT 20. The next morning they call me to do an EGD in the unit. GI Fellow says he doesnt need to be intubated, has not been coughing up much blood. GI attending is like you are describing, making a big deal out of tubing him. I talk to the guy he says he ate last at 5pm the night before, has been having very mild hemoptysis but not for a few hours. I do the case without an ETT, its going OK, the fellow is going to town, insufflating and moving around all up and down with the scope. After about 10 minutes he give s big puff of air and moves the scope into the stomach and blood starts pouring out of mouth and nose, like someone had set off a blood bomb inside the guys stomach.

I emergently intubate the guy. He remains intubated for a day or so and then extubated and does fine. This taught me that you have to consider not only giving anesthesia with blood in the stomach, that usually will be OK, but also to consider that whatever contents may be in the stomach can suddenly become under pressure and shoot out due to the scope insufflation and an unskilled endoscopist.

So you let a trainee from another specialty dictate how you did your job?

 

[ProRealDoc]

Perspective from a GI fellow:

When it’s a severe enough upper GI bleed that they need to be intubated then they are usually in the ICU and usually intubated. If they are in GI endoscopy lab usually it’s a slow bleed or one that stopped. In those cases we can do conscious sedation but will ask for anesthesia help because of other comorbidities not related to the acute bleed.

There are exceptions to everything but that’s just been my experience and overall makes sense.

do you think the ambulance chasers will make a distinction on whether the anesthesiologist was there because of the other comorbidities and will overlook the fact that the patient died from aspiration pneumonia 2/2 an unprotected airway?

 

[ProRealDoc]

I guess it’s technically never wrong to intubate everyone. Just keep in mind in many county, rural, and VA hospitals where we don’t have anesthesia readily available 24/7 we do most of these cases under sedation. I’ve been in these situations. We have large caliber suction channels in therapeutic scopes and just try to suction as much and as quickly as possible. It’s not ideal and you guys should do whatever you feel is necessary.

The voice of reason.

 

[ProRealDoc]

My point to all of this was my perspective as “a proceduralist”. If we are looking for a slow occult GI bleed or history of minor recent bleed that the odds of finding a significant amount of blood is very low. If you want to intubate everyone as a rule I don’t think anyone would ever blame you from a safety standpoint. But if you do shift work and are done at 4pm on the dot as a service, for a particularly busy day, I’ve had situations where these little things add up and I’ve pushed cases to the next day or even the next week if it’s a Friday because we have run out of time with anesthesia. Just something to keep in mind.

Just write a bigger check and you"ll get all the coverage you need even past 4pm

 

[Robotic Wis-Hipple]

Perspective from a GI fellow:

When it’s a severe enough upper GI bleed that they need to be intubated then they are usually in the ICU and usually intubated. If they are in GI endoscopy lab usually it’s a slow bleed or one that stopped. In those cases we can do conscious sedation but will ask for anesthesia help because of other comorbidities not related to the acute bleed.

There are exceptions to everything but that’s just been my experience and overall makes sense.

I understand what you’re saying and appreciate the perspective you’re trying to provide. But the difference is many GI docs equate “MAC” with “better sedation” with an Anesthesiologist involved for “other comorbidities” and this is mostly false. These propofol “MACs” are GAs with an unprotected airway that by definition we are calling full stomach. A bleed that stopped is not equal to no blood in the stomach. If you want to do “conscious sedation” by all means go ahead, don’t ablate protectives and you’re good, but when you guys expect them to be asleep and I’m involved then my standard of care trumps your efficiency.

And in regards to the done at 4pm comment, many anesthesia departments are pulled in 3-5 different directions with the multiple offsites in addition to the main OR and quite simply can’t staff an offsite till late evening. If your case is emergent and it’s late we can try to accommodate or you can come to the main. Again, patient safety trumps all of our scheduling, efficiency, and priority logistical considerations.

 

[2Fast2Des]

My point to all of this was my perspective as “a proceduralist”. If we are looking for a slow occult GI bleed or history of minor recent bleed that the odds of finding a significant amount of blood is very low. If you want to intubate everyone as a rule I don’t think anyone would ever blame you from a safety standpoint. But if you do shift work and are done at 4pm on the dot as a service, for a particularly busy day, I’ve had situations where these little things add up and I’ve pushed cases to the next day or even the next week if it’s a Friday because we have run out of time with anesthesia. Just something to keep in mind.

Usually the delay I've always noted has nothing to do with providing anesthesia. It takes me the same time to make sure patient is safely sedated as it would be to get a tube in... ok maybe 30 more seconds. But the usual GI hee hawing and going on a scenic tour taking way longer than one should is the delay. In our community hospital, we don't have anesthesia machines in the GI suite so we need slick GI guys. Most are in and out in 3-5 minutes or less, maybe a couple of more to clip a bleeder with "MAC" or tube with hand ventilation. In the academic hospital when it's fellows, we have anesthesia machines thankfully, and dear lord, time to start the roc drip . So yes the rare delay is usually emerging because y'all take so damn long looking for nothing and give zero warning on how long you need more.

Lesson: let us do what is best in our view and skills, if you want it done your way, don't call us, just take the risk and liability you want us to inherit instead.

 

[2Fast2Des]

And from billing standpoint, what's the difference between circling MAC or GA for the usual GI case? MAC means there is some level of patient ability to respond, and we are always doing GA without an airway. I would like to think MAC should get reimbursed more since it's a bit more challenging to keep a patient in the right plane and constant reassurance or hey stop grabbing the surgeon lol. GA with tube is so much easier

 

[deleted162650]

And from billing standpoint, what's the difference between circling MAC or GA for the usual GI case? MAC means there is some level of patient ability to respond, and we are always doing GA without an airway. I would like to think MAC should get reimbursed more since it's a bit more challenging to keep a patient in the right plane and constant reassurance or hey stop grabbing the surgeon lol. GA with tube is so much easier

No difference. Type of anesthesia has zero affect on billing. Billing is strictly the CPT code for the procedure plus time (and modifiers).