EGD for GI Bleed: Tube or not?

[vector2]

Attending GI. Its interesting how both the food impaction and UGI bleeding threads have taken off.

Unlike a food impaction where I agree that I would always like a secured airway, it is not nearly as straightforward in the setting of upper GI bleeding. In fact, this has been recently looked at and there were MORE complications in the group that was prophylactically intubated. These were ivory tower Cleveland Clinic patients:

Association of prophylactic endotracheal intubation in critically ill patients with upper GI bleeding and cardiopulmonary unplanned events. - PubMed - NCBI

"RESULTS:

Two hundred patients were included in the final analysis. The baseline characteristics, comorbidity scores, and prognostic scores were similar between the 2 groups. The overall cardiopulmonary unplanned event rates were significantly higher in the intubated group compared with the nonintubated group (20% vs 6%, P = .008), which remained significant (P = .012) after adjusting for the presence of esophageal varices."

This is a high quality journal from a high quality author.

We need to think more critically about these situations other than tube = good.

I posted this earlier. It may be a high quality journal and high quality author but it's a case-control study and we shouldn't be coming to definitive conclusions using observational data from one single-center study.

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[vector2]

motivated only by money, dangerous and worse.

Apologies if you meant earlier that you wish you could do conscious sedation for most of your own patients using versed and fentanyl, but if not, how can you seriously argue that allowing GIs to push propofol isn't about money, either personally or at a systems levels? It's certainly not intuitively safer for patients to have non-airway experts pushing non-reversible medications which can cause severe airway obstruction, apnea, hypoxia, and death.

 

[Neopolymath]

This thread is another great illustration of what one must put up with in becoming an anesthesiologist in America. There really should be a directory of such threads for prospective applicants. I enjoy this forum very much and feel like it has the best contributors of all the subforums.

 

[dhb]

Attending GI. Its interesting how both the food impaction and UGI bleeding threads have taken off.

Unlike a food impaction where I agree that I would always like a secured airway, it is not nearly as straightforward in the setting of upper GI bleeding. In fact, this has been recently looked at and there were MORE complications in the group that was prophylactically intubated. These were ivory tower Cleveland Clinic patients:

Association of prophylactic endotracheal intubation in critically ill patients with upper GI bleeding and cardiopulmonary unplanned events. - PubMed - NCBI

"RESULTS:

Two hundred patients were included in the final analysis. The baseline characteristics, comorbidity scores, and prognostic scores were similar between the 2 groups. The overall cardiopulmonary unplanned event rates were significantly higher in the intubated group compared with the nonintubated group (20% vs 6%, P = .008), which remained significant (P = .012) after adjusting for the presence of esophageal varices."

This is a high quality journal from a high quality author.

We need to think more critically about these situations other than tube = good.

Study doesn't address the point which is not "the ett will magically prevent the patient from any complication" but aspiration or not in relation to gastric content found upon gastroscopy.

 

[Southpaw]

Attending GI. Its interesting how both the food impaction and UGI bleeding threads have taken off.

Unlike a food impaction where I agree that I would always like a secured airway, it is not nearly as straightforward in the setting of upper GI bleeding. In fact, this has been recently looked at and there were MORE complications in the group that was prophylactically intubated. These were ivory tower Cleveland Clinic patients:

Association of prophylactic endotracheal intubation in critically ill patients with upper GI bleeding and cardiopulmonary unplanned events. - PubMed - NCBI

"RESULTS:

Two hundred patients were included in the final analysis. The baseline characteristics, comorbidity scores, and prognostic scores were similar between the 2 groups. The overall cardiopulmonary unplanned event rates were significantly higher in the intubated group compared with the nonintubated group (20% vs 6%, P = .008), which remained significant (P = .012) after adjusting for the presence of esophageal varices."

This is a high quality journal from a high quality author.

We need to think more critically about these situations other than tube = good.

Don’t have access to full article. I’ll read it tomorrow. Using your words and those in the study, why do you think we should intubate a food impaction but not a ‘brisk’ upper GI bleed ?

 

[Gastrapathy]

Apologies if you meant earlier that you wish you could do conscious sedation for most of your own patients using versed and fentanyl, but if not, how can you seriously argue that allowing GIs to push propofol isn't about money, either personally or at a systems levels? It's certainly not intuitively safer for patients to have non-airway experts pushing non-reversible medications which can cause severe airway obstruction, apnea, hypoxia, and death.

Once you are consulted, you do what you want. We control whether or not to ask for help. But you insult us in one breath and then demand respect in another. I respect the folks I work with but they at least seem to respect me too (although I’ve scoped too many of their spouses recently so maybe that’s bad).

I’ve written about the propofol thing here previously. There is no financial incentive for the GI personally. From a systems cost standpoint, versed plus opioid is basically the same. There are a few vocal proponents of GI administered propofol in the US (mostly at Indiana Univ) but it hasn’t taken hold because most of us think it’s a terrible idea. In fact, they’ve stopped banging the drum for the most part. I’ve never worked in a city where any GI has tried to give propofol to patients. We wouldn’t credential someone to do that. I declined to try that patient directed propofol machine before it disappeared either.

However, the primary thesis of that editorial is correct. Using anesthesia services for routine low risk endoscopy is not justifiable from a cost benefit perspective. It is the major reason a colonoscopy is 3x as expensive in the northeast as it is in the west.

 

[IM2GI]

Don’t have access to full article. I’ll read it tomorrow. Using your words and those in the study, why do you think we should intubate a food impaction but not a ‘brisk’ upper GI bleed ?

I didn't say you shouldn't. The OP asked the question of whether you should intubate for "EGD for work up of GI bleed of unknown origin."

I almost always intubate brisk bleeders. The difference with a bleeder and a food impaction is you can almost always pull out and intubate if its a hot mess when you get in. Food impactions can aspirate instantly.

 

[IM2GI]

Study doesn't address the point which is not "the ett will magically prevent the patient from any complication" but aspiration or not in relation to gastric content found upon gastroscopy.

here is the relevant table. Aspiration rates were essentially the same.

Again Im not saying this study is a slam dunk, but just pointing out that even in critically ill UGI bleed patients it is not cut and dry.

 

[vector2]

Once you are consulted, you do what you want. We control whether or not to ask for help. But you insult us in one breath and then demand respect in another. I respect the folks I work with but they at least seem to respect me too (although I’ve scoped too many of their spouses recently so maybe that’s bad).

I’ve written about the propofol thing here previously. There is no financial incentive for the GI personally. From a systems cost standpoint, versed plus opioid is basically the same. There are a few vocal proponents of GI administered propofol in the US (mostly at Indiana Univ) but it hasn’t taken hold because most of us think it’s a terrible idea. In fact, they’ve stopped banging the drum for the most part. I’ve never worked in a city where any GI has tried to give propofol to patients. We wouldn’t credential someone to do that. I declined to try that patient directed propofol machine before it disappeared either.

However, the primary thesis of that editorial is correct. Using anesthesia services for routine low risk endoscopy is not justifiable from a cost benefit perspective. It is the major reason a colonoscopy is 3x as expensive in the northeast as it is in the west.

I agree with you 100% that anesthesia for low-risk endoscopy is significantly more expensive. Whether improved patient satisfaction and earlier discharge makes propofol worth it is up for debate. And if we're talking about mild or moderate sedation with benzos and opioids in low risk pts, there's likely no difference in regard to outcomes or patient safety no matter who administers the meds.

In regard to whether propofol anesthesia is more profitable for a GI group, it depends on what model we're talking about. If it's just you and your RN, it's probably revenue neutral. But you can bet your ass that GI groups like this one who employ solo CRNAs and sign their charts are scooping some of the anesthesia professional fees.

The only thing I've said so far even remotely related to insults/respect is calling that editorial author a clown, so please leave me out of that discussion in regard to the string of replies to that GI fellow. Same as you, IRL, I get along with our GI guys and they get along with us- everyone is happy. The primary thesis of that author wasn't simply that anesthesia services for low risk isn't cost-effective, it's that GIs should be administering propofol themselves to save on that cost. That is a statement only a clown would make and I stand by that.

 

[Twiggidy]

@Southpaw
What I said to @Twiggidy is that I totally agree that GI (we) should sedate nearly all of the patients ourselves.

You want a GI fellow to be able to tell the difference between you and a CRNA? Good luck. They’re learning their craft. They know whether you are friendly and helpful. I was following this thread with bemusement until you guys started attacking a trainee.

I get along with all my anesthesiologists well. We trust each other. It’s all good. If you and your GIs mutually wish you weren’t there...well, they can’t leave.

If you think your tone in those posts was mutually respectful, I disagree. You require our acquiescence? In your 10 years on the forum, you’ve never even donated a dime. Not sure why you think you own the place.

I think you and your colleague missed my point when I said "you should sedate your own patient" in reference to your colleague pretty much saying that my colleagues and I know nothing about medicine and pathology and may as well be nurses. GI docs ask for our assistance because it makes their day easier and the patient gets better sedation, and thus and easier procedure to complete, when we use propofol. GI doc, ICU docs, cardiologists, and ER docs alike all observe us use propofol and pretty much assume, "Well that looks easy. I could just do that myself." Well that's like me saying, well, I can use a camcorder so I should direct the next Marvel movie. We make it look easy because we are WELL TRAINED with that drug and though it may look like we give it willy nilly, we know what to do with it, what to expect from a said dose, and already have an assortment of plans in our head if that said dose does something unexpected. Just because I watch someone do cardiac surgery everyday doesnt mean I'm ready to hold the scalpel. That's why we get uptight when we're told "we know nothing about medicine and pathology" because a certain patient rolls to the GI suite and may need a different plan than the usual "slug of propofol". The mutual respect comes when people realize, "hey. these guys actually know what they're doing. i've asked them to come to help me so maybe I should respect their decision as a consultant" It's no different than if you're consulted as a GI doc, give a recommendation that's safe for a patient, and the doc requesting your insight says you don't know what you're doing (basically).

So yeah. If you don't respect my decision as the anesthesia consultant, then do your own sedation and accept whatever consequence that may be while I go and work with people that do respect my decision.

 

[vector2]

Any time you have a study that uses the words "retrospective cohort," "propensity matched," and "logistic regression" this much, your (potential) BS alarms should be sounding loudly. But anyway, the intubated group had more varices (which the authors say doesn't matter in regard to worse cardiopulmonary outcome when the varices are adjusted for through stats magic). Additionally, the intubated group had significantly more "Treatment provided during EGD" and also received significantly more pRBCs within 48 hrs. If the patients in the intubated group had more procedural intervention and received more blood, don't you think their presentation pathology and the degree of intervention required might also have something to do with a worse outcome?

 

[abolt18]

here is the relevant table. Aspiration rates were essentially the same.

Again Im not saying this study is a slam dunk, but just pointing out that even in critically ill UGI bleed patients it is not cut and dry.

Have we not considered that PERHAPS the complication rate in those intubated was higher because they were sicker to begin with and therefore it was decided to intubate them because they looked like death to begin with?

 

[vector2]

Have we not considered that PERHAPS the complication rate in those intubated was higher because they were sicker to begin with and therefore it was decided to intubated them because they looked like death to begin with?

To be fair, the authors did consider that and that's why they propensity matched the groups. There were 221 pts in the non-ETT group and 144 in the ETT group, and they narrowed these groups down to 100 pts and 100 pts to get two groups which had relatively even baseline characteristics. Still, I don't think the final conclusion really holds.

 

[WholeLottaGame7]

I like the yellow line too.

I didn’t insult anyone. In the recent GI threads here in your forum, my profession has been called jockey, monkey, clown, unethical, motivated only by money, dangerous and worse.

Then you posted about mutual respect. There clearly isn’t any. But how can you act surprised that a fellow has figured that out and decided to go with your less capable replacements. If his practice is anything like the reception here, I understand that choice. Im lucky to practice with good anesthesiologists and if he has that experience, maybe it will overcome.

You may not have insulted anyone, but your boy/girl came in here mouthing off and insulting us, instead of listening and trying to learn from experts in the field.

Unless you follow the anesthesiologists around the OR, you likely have no idea which anesthesiologists are good and which ones are bad. Usually when proceduralists "like" someone or call them "good," it's because that person does what the proceduralist wants, not because of their critical thinking skills and decision-making. Thus why CRNAs are considered "good."

The reality is, if someone intubates everyone, they're probably a chicken, and if someone never intubates (until it's too late), then they have undoubtedly hurt someone (or not prevented them from being hurt).

Also, the reality is, proceduralists (whether it's GI, VIR, cards, etc) suck at sedation. Mostly because they don't understand what sedation is. And that hurts and/or kills people. The problem is, you can get away with it in reasonably healthy people. And when it happens to sick people, it's "eh, they were sick, it would have happened to anybody." Which may be true. Or it may not have happened to someone who knew what they were doing.

 

[Gastrapathy]

I don’t suck at sedation. Neither do my partners. But you’d have to follow me around the procedure room to know what I do. But hey, that’s just more mutual respect anesthesia forum style.

 

[WholeLottaGame7]

I don’t suck at sedation. Neither do my partners. But you’d have to follow me around the procedure room to know what I do. But hey, that’s just more mutual respect anesthesia forum style.

Why do you GI guys take everything so personally? There's nothing to be ashamed of. You weren't trained in sedation. You don't know what it is. If you did, you wouldn't keep titrating in fentanyl and midazolam until the patient stopped moving and call it "conscious sedation."

Your hubris is way more concerning than your lack of sedating skills. You would laugh if I said I was awesome at driving a colonoscope. Why is it so insulting to think you're not that good at something you weren't trained to do?

 

[Robotic Wis-Hipple]

Attending GI. Its interesting how both the food impaction and UGI bleeding threads have taken off.

Unlike a food impaction where I agree that I would always like a secured airway, it is not nearly as straightforward in the setting of upper GI bleeding. In fact, this has been recently looked at and there were MORE complications in the group that was prophylactically intubated. These were ivory tower Cleveland Clinic patients:

Association of prophylactic endotracheal intubation in critically ill patients with upper GI bleeding and cardiopulmonary unplanned events. - PubMed - NCBI

"RESULTS:

Two hundred patients were included in the final analysis. The baseline characteristics, comorbidity scores, and prognostic scores were similar between the 2 groups. The overall cardiopulmonary unplanned event rates were significantly higher in the intubated group compared with the nonintubated group (20% vs 6%, P = .008), which remained significant (P = .012) after adjusting for the presence of esophageal varices."

This is a high quality journal from a high quality author.

We need to think more critically about these situations other than tube = good.

As another poster has already said, this study should not dictate anyone’s practice. You’re telling me 20% of intubated patients had a cardiopulmonary event and that isn’t fishy to you? There’s no way the patient groups were similar I don’t care what the propensity score says. This study is basically like the PAC and worse outcomes in intubated neurointerventional pts studies, it’s likely a morbidity correlation.

All I think we are trying to get across (though snarkiness and bravado tends to derail these threads a bit) is that the GI doc (or any other proceduralists for that matter) does not dictate my anesthetic. Now I’m not saying a dialogue can not be had, it can, and I often do. If there’s a good reason to avoid intubation (severe pulmonary condition, likely delayed extubation, etc) then I’m open to weighing risk/benefit using all medical and social factors in play. But efficiency or your preference are not used in the equation. And if you’re adamant about it and I disagree, you’re welcome to do your own sedation.

My standard of care is clearly more stringent in all things sedation and airway management than yours regardless of what article in your journal you bring to the table. I do not intubate all UGIBs but when I decide to it is my decision, based on my expertise as it’s my risk and liability in that regard.

And while we are throwing around the “need to think critically about these patients” regarding intubation etc I think the same can be said about the decision to scope 1/4th of the patients that hit most of our GI labs in the first place.

 

[vector2]

I don’t suck at sedation. Neither do my partners. But you’d have to follow me around the procedure room to know what I do. But hey, that’s just more mutual respect anesthesia forum style.

I use the bronchoscope a fair amount when I staff ICU to get BALs and do toileting. I use the bronchoscope a fair amount in the OR to place double lumen endotracheal tubes and occasionally do fiberoptic intubations. The pulmonologists at my hospital don't need to follow me around to know that I barely scratch the surface of what is possible in the field of diagnostic and interventional pulmonology, just like I don't need to follow you or any other proceduralist around to know that you guys have essentially the most superficial understanding of the continuum of sedation and anesthesia.

 

[Southpaw]

Once you are consulted, you do what you want. We control whether or not to ask for help. But you insult us in one breath and then demand respect in another. I respect the folks I work with but they at least seem to respect me too (although I’ve scoped too many of their spouses recently so maybe that’s bad).

I’ve written about the propofol thing here previously. There is no financial incentive for the GI personally. From a systems cost standpoint, versed plus opioid is basically the same. There are a few vocal proponents of GI administered propofol in the US (mostly at Indiana Univ) but it hasn’t taken hold because most of us think it’s a terrible idea. In fact, they’ve stopped banging the drum for the most part. I’ve never worked in a city where any GI has tried to give propofol to patients. We wouldn’t credential someone to do that. I declined to try that patient directed propofol machine before it disappeared either.

However, the primary thesis of that editorial is correct. Using anesthesia services for routine low risk endoscopy is not justifiable from a cost benefit perspective. It is the major reason a colonoscopy is 3x as expensive in the northeast as it is in the west.

GI seems to profit big time when they hire their own CRNAs and bill for their services.

I’m all for GI doing their own sedation but propofol has gained favor with everyone, patients included, everywhere I’ve been.

 

[Southpaw]

I don’t suck at sedation. Neither do my partners. But you’d have to follow me around the procedure room to know what I do. But hey, that’s just more mutual respect anesthesia forum style.

You’re no less sensitive on this than I am. Take note though - nowhere in this thread have I told you that I’m the king of scoping nor have I told you what to biopsy or how long you should take to do your job.

 

[Robotic Wis-Hipple]

here is the relevant table. Aspiration rates were essentially the same.

Again Im not saying this study is a slam dunk, but just pointing out that even in critically ill UGI bleed patients it is not cut and dry.

Ok, so the only independent outcome even approaching a p value of 0.05 was ICU mortality, which was more than double in the non-intubated patients. Plus, the aspiration numbers show 20% of those intubated aspirated. So that tells me; a.) they had aspirated already due to the briskness of the bleed or B.) they aspirated between induction and a secured airway which is definitely possible but if that is the case and you think that argues for a “MAC” anesthetic you’re wrong. Basically nothing about that chart makes any sense, the act of intubation alone doesn’t increase rates of ARDS, pneumonia, pulmonary edema etc unless they remained intubated for a prolonged time in which case I’d say they were pretty sick.

 

[Hoya11]

I don’t suck at sedation. Neither do my partners. But you’d have to follow me around the procedure room to know what I do. But hey, that’s just more mutual respect anesthesia forum style.

You're not capable of assessing whether or not you suck at sedation. That's the whole gist of what everyone is trying to tell you. You probably all suck ..

 

[IM2GI]

As another poster has already said, this study should not dictate anyone’s practice. You’re telling me 20% of intubated patients had a cardiopulmonary event and that isn’t fishy to you? There’s no way the patient groups were similar I don’t care what the propensity score says. This study is basically like the PAC and worse outcomes in intubated neurointerventional pts studies, it’s likely a morbidity correlation.

All I think we are trying to get across (though snarkiness and bravado tends to derail these threads a bit) is that the GI doc (or any other proceduralists for that matter) does not dictate my anesthetic. Now I’m not saying a dialogue can not be had, it can, and I often do. If there’s a good reason to avoid intubation (severe pulmonary condition, likely delayed extubation, etc) then I’m open to weighing risk/benefit using all medical and social factors in play. But efficiency or your preference are not used in the equation. And if you’re adamant about it and I disagree, you’re welcome to do your own sedation.

My standard of care is clearly more stringent in all things sedation and airway management than yours regardless of what article in your journal you bring to the table. I do not intubate all UGIBs but when I decide to it is my decision, based on my expertise as it’s my risk and liability in that regard.

And while we are throwing around the “need to think critically about these patients” regarding intubation etc I think the same can be said about the decision to scope 1/4th of the patients that hit most of our GI labs in the first place.

Im not sure why this is getting so contentious. I have never once told an anesthesiologist they could not intubate a patient nor dictated their anesthetic plan. I stay in my lane.

All I was pointing out, is that the OP asked the question as to if you should insist on intubating for GI bleeding of unknown origin. I think that most of the time that seems like overkill to me. Clinical context and anesthesiologist clinical judgement certainly impact that. I am lucky to have 24/7 coverage by excellent anesthesiologists so I guess I am not used to as many confrontational situations as some of you.

 

[WholeLottaGame7]

Im not sure why this is getting so contentious. I have never once told an anesthesiologist they could not intubate a patient nor dictated their anesthetic plan. I stay in my lane.

All I was pointing out, is that the OP asked the question as to if you should insist on intubating for GI bleeding of unknown origin. I think that most of the time that seems like overkill to me. Clinical context and anesthesiologist clinical judgement certainly impact that. I am lucky to have 24/7 coverage by excellent anesthesiologists so I guess I am not used to as many confrontational situations as some of you.

I appreciate your viewpoint, and just wish that others would have the same. All anyone (GI, surgeon, whatever) has to say is, "You take care of the patient safely and let me know when you're ready." All the peds GI people I work with are like that. Some of the adult ones are like that.

But unfortunately, as you can tell from the replies in this thread, there are plenty of GI docs (like the fellow in this thread) saying "Do whatever you want, but so-and-so wouldn't do this" or "Do whatever you want, just don't delay or postpone my case," which is not at all the same thing.

Are there lazy or inexperienced anesthesiologists who delay unnecessarily? Sure. Are there MDGs who scope unnecessarily? Sure. But most of us on both sides just want to take care of patients safely (first) and efficiently (second).

And there's been lots of accusations about lack of trust, but I have to say it starts with the side asking for help. When you boil it down, we are a consult service, and you are asking for our help (or the hospital is making you ask us). You have to trust our expertise. Think of what it feels like when GI surgery, or the hospitalist service, asks you to help manage their patient, then proceeds to ignore your recommendations or makes disparaging comments about your suggestions. You probably have some choice words for them when you're out of earshot. Here you just get to say it out loud.

 

[GastriqueGraffin]

I like the yellow line too.

I didn’t insult anyone. In the recent GI threads here in your forum, my profession has been called jockey, monkey, clown, unethical, motivated only by money, dangerous and worse.

Then you posted about mutual respect. There clearly isn’t any. But how can you act surprised that a fellow has figured that out and decided to go with your less capable replacements. If his practice is anything like the reception here, I understand that choice. Im lucky to practice with good anesthesiologists and if he has that experience, maybe it will overcome.

Thank you. I have good anesthesiologists who make the difficult cases go smooth and bad ones that will try to cancel or push cases all the time based on standards that don’t make sense and lack any evidence (often too late in the day to correct it in time). I believe they are able to get away with that behavior because I’m a trainee and it’s an academic institution but tell myself that it cannot be like that in the real world. I got fed up with being attacked in this forum for nothing and told that we went from being good thinking physicians to money hungry “proceduralists”. I did nothing IMO to get that response so I responded in kind.

 

[Twiggidy]

Thank you. I have good anesthesiologists who make the difficult cases go smooth and bad ones that will try to cancel or push cases all the time based on standards that don’t make sense and lack any evidence (often too late in the day to correct it in time). I believe they are able to get away with that behavior because I’m a trainee and it’s an academic institution but tell myself that it cannot be like that in the real world. I got fed up with being attacked in this forum for nothing and told that we went from being good thinking physicians to money hungry “proceduralists”. I did nothing IMO to get that response so I responded in kind.

I will say a lot of what you probably put up with IS because you’re and trainee and BECAUSE you’re at an academic facility. You’re dealing with a forum of mostly private practice anesthesiologists who work with private practice GI docs. We “get away” with things (ie sicker patients) because we are seasoned anesthesiologists and work with fast GI docs. It’s a lot different when you’re an academic anesthesia attending covering a resident or CRNA in 2 or more rooms (who are also probably learning the trade) dealing with a sick patient being scoped by someone who also in the learning process. Yes there are bad apples on both sides in PP but the end goal with everyone is usually patient safety first and while the standards and evidence may not make sense to you, these are the same attendings will still get questioned by peers as to why they did a procedure without the patient OPTIMIZED. That’s a big key word in our field.

 

[vector2]

I got fed up with being attacked in this forum for nothing and told that we went from being good thinking physicians to money hungry “proceduralists”. I did nothing IMO to get that response so I responded in kind.

I'm just gonna put the highlights of your 2nd post onward here. Maybe when all lumped together you'll perhaps get an idea of how condescending you initially sounded (esp. for someone who is still a fellow and likely the most inefficient, slowest link in the GI suite) and how ridiculously defensive you got when people were very patiently trying to explain that our clinical judgement and safety standards may be a bit different than you perceive them to be.

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"you guys should do whatever you feel is necessary."

"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."

"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."

"I have never met anyone more sensitive than MDAs. You went to medical school but have no concept of the medicine to understand an evidence based approach or reasonable thinking to the pathology of what you’re taking care of. Might as well be a nurse with that reasoning, which is why I don’t mind more CRNAs running independently in GI labs unless there is more to the case than a GI bleed. I am telling you do whatever you want if it makes you feel better or more secure... like a PCP that orders every test they can think of because they may theoretically catch that random cancer in an asymptomatic patient not thinking of the evidence behind this approach."
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My favorite is really your last post waxing poetic about how we have no concept of EBM, considering the authors of the one retrospective study that's been posted in this thread pointed out in their discussion that "it is highly unlikely that a randomized controlled trial will be performed addressing the benefits and risks of PEI in this population..." -The implication is that the patient characteristics are too varied and the stakes are too high with many UGI bleeders to ever be able to effectively (or perhaps even ethically) randomize intubation vs making an on-the-spot clinical judgement about its need. This kind of acute care judgement is light-years away from your analogy about PCPs and shotgunning screening tests, and I can only assume you'd make this sort of category error because you haven't seen how quickly a high-risk anesthetic can go very bad.

 

[Mman]

Attending GI. Its interesting how both the food impaction and UGI bleeding threads have taken off.

Unlike a food impaction where I agree that I would always like a secured airway, it is not nearly as straightforward in the setting of upper GI bleeding. In fact, this has been recently looked at and there were MORE complications in the group that was prophylactically intubated. These were ivory tower Cleveland Clinic patients:

Association of prophylactic endotracheal intubation in critically ill patients with upper GI bleeding and cardiopulmonary unplanned events. - PubMed - NCBI

"RESULTS:

Two hundred patients were included in the final analysis. The baseline characteristics, comorbidity scores, and prognostic scores were similar between the 2 groups. The overall cardiopulmonary unplanned event rates were significantly higher in the intubated group compared with the nonintubated group (20% vs 6%, P = .008), which remained significant (P = .012) after adjusting for the presence of esophageal varices."

This is a high quality journal from a high quality author.

We need to think more critically about these situations other than tube = good.

Fortunately we have evidence from other situations (such as the millions of general anesthetics every year in the US) that intubating the patients does not cause them to have worse outcomes in any real way. I mean how many hundreds of thousands of hip fracture patients do we have every year and we have dozens and dozens of studies comparing GA vs spinal and we have to get really deep in the numbers to try to find a difference here or there.

Anybody attempting to show that the GI patient will have a worse outcome BECAUSE they were intubated is simply wrong. I mean 100% wrong. Now maybe they are slightly more likely to get a sore throat with an ETT in addition to the large black snake down their throat, but that's literally it.

On a related note, I always find it funny when surgeons/proceduralists/whoever think we are intubating the patient and using GA because we get paid more. Nope, we get the same reimbursement to sit in the room and chart vitals and give no medication as we do to intubate them and use general anesthesia. If we are doing GA, it probably makes more work for ourselves for no financial benefit. The only reason we do it is because we feel it is safer.

 

[Robotic Wis-Hipple]

@GastriqueGraffin

Don’t sweat it. Just pick a practice where you have control and can work with folks whose interests are aligned with yours. There are lots of good anesthesiologists who will work with you happily. The “in the name of patient safety” stall tactic shift workers aren’t actually that prevalent in the real world.

Now this is likely true, in the private world mutual respect and both sides having the same goal of getting the cases done likely makes the environment less contentious. And I’m curious, if an anesthesiologist informs you (our in the real world) that they’re going to intubate what is your initial thought/response? Is it your practice to fight that, why or why not? Actually, one step further, if you guys think most patients should be scoped without anesthesia (which I tend to agree with), why do you have us at all? I ask this question because your Fellow colleague here said we were only requested for other comorbidities (which is interesting as it was also stated later that we don’t know any medicine so not sure what non-medical comorbidities we are requested for).

So basically, if you all just want us to play ball your way, most patients should be scoped without us, you guys do perfectly adequate “conscious sedation”, and you guys are the ones with the pertinent medical knowledge required to take care of the patient, what exactly do you want us for? Put another way, what do you want our MACs for (we’ll exclude the obvious emergency cases and obvious intubation scenarios for this question)?

My concern with these conversations comes from statements like your; “the ‘in the name of patient safety’ stall tactic shift workers” comment. Do you hear how that sounds? Can you name another area of medicine, anywhere, where patient safety concerns or discussions would be likened to stalling? Seems to be only used when discussing anesthesia. I just think referring to concern for patient safety as a stall tactic is a bit much and is quite disrespectful to both the patient and consultant anesthesiologist.

I’ll also reiterate what I mentioned before, I don’t know of an anesthesiologist who works GI shift work but we do have a limit to our guaranteed staffing of your particular “offsite”. So it’s not me “clocking out” at 4 or 5pm, it’s a reshuffle of resources between all the sites we cover similar to how particular surgeons/services are allotted OR block times and as such ORs close down at certain times throughout the day to reduce the number of ORs (or sites) being staffed without cases to do.

 

[deleted171991]

Attending GI. Its interesting how both the food impaction and UGI bleeding threads have taken off.

Unlike a food impaction where I agree that I would always like a secured airway, it is not nearly as straightforward in the setting of upper GI bleeding. In fact, this has been recently looked at and there were MORE complications in the group that was prophylactically intubated. These were ivory tower Cleveland Clinic patients:

Association of prophylactic endotracheal intubation in critically ill patients with upper GI bleeding and cardiopulmonary unplanned events. - PubMed - NCBI

"RESULTS:

Two hundred patients were included in the final analysis. The baseline characteristics, comorbidity scores, and prognostic scores were similar between the 2 groups. The overall cardiopulmonary unplanned event rates were significantly higher in the intubated group compared with the nonintubated group (20% vs 6%, P = .008), which remained significant (P = .012) after adjusting for the presence of esophageal varices."

This is a high quality journal from a high quality author.

We need to think more critically about these situations other than tube = good.

There is a problem that you and your GI friends are missing: these are not aspiration-related outcomes. These are cardiopulmonary complications that come either from inducing the critical patient for intubation, from positive-pressure ventilation, or from poor post-intubation ICU care (e.g. sedating a hemodynamically-sensitive patient with propofol).

What this single-center retrospective study (I assume because I can't read it) has proven is that, at Cleveland Clinic, the ICU care sucks enough that it's better to not intubate a bleeding critical patient for an EGD.

FYI, I am an anesthesiologist-intensivist. As an intensivist, I only intubate when I have no choice, always thinking about what that will do to my patient's physiology (e.g. it can crash a bad RV). As an anesthesiologist, I do it when I am concerned about a significant risk of aspiration. Do you know how much you need for aspiration pneumonia? About 0.2 ml/kg of body weight. That's 15 cc for the average adult, not much. And, let me tell you, aspiration pneumonia in a critical patient can be a killer, the tombstone, exactly because there is no reserve.

Few gastroenterologists realize that an EGD can be almost as stimulating as a videolaryngoscope intubation. I can do either with just midazolam (and some fast/short-acting muscle relaxant for the latter), with a semi-awake patient who won't remember crap, despite having an EF of 10%. That's the magic of anesthesia and anesthesiologists.

What I cannot do, as an anesthesiologist, is teach proper ICU care to the arsehole ICU attendings who are not around to take care of their critical patients and prevent post-intubation problems (if the patient cannot be extubated at the end of the procedure). That's not something to leave to trainees or nurses. I also cannot eliminate intubation-related crashes because of stupid (mostly unsupervised) anesthesia trainees who, for example, push a ****ton of medication for intubation (yes, people can crash even with etomidate), which is another problem one would clearly notice in a big academic place such as Cleveland Clinic, and much less likely to happen in a community hospital.

And before one starts spewing around "evidence-based medicine", one should be so kind to learn to actually interpret the value of the "evidence", and learn to separate the truly good science from the resume-padding pseudoscience (hint: most of the retrospective studies). Otherwise, one will harm more patients than help. What some gastroenterologists call "evidence" is downright laughable: I remember being an intern and a GI protocol in widespread use in the US was based on a joke of a Chinese study.

ONE CANNOT EXTRAPOLATE A SINGLE-CENTER RETROSPECTIVE STUDY DONE IN AN ACADEMIC PLACE TO MOST HOSPITALS IN AMERICA, BECAUSE THEN ONE IS LIKE THE IDIOTS WHO SAY THAT MEDICAL ERRORS KILL 100,000 PATIENTS EVERY YEAR. Before drawing conclusions from a sample, one has to prove that the sample is truly representative for the large population.

P.S. My best friend is a gastroenterologist. And, as I said, I am also an intensivist, which makes me approach every study with a healthy dose of skepticism. (Just look up the Surviving Sepsis Crap Campaign controversy.)

 

[DM27]

Thank you. I have good anesthesiologists who make the difficult cases go smooth and bad ones that will try to cancel or push cases all the time based on standards that don’t make sense and lack any evidence (often too late in the day to correct it in time). I believe they are able to get away with that behavior because I’m a trainee and it’s an academic institution but tell myself that it cannot be like that in the real world. I got fed up with being attacked in this forum for nothing and told that we went from being good thinking physicians to money hungry “proceduralists”. I did nothing IMO to get that response so I responded in kind.

Do you have some examples you can give of the reasons for cancellations or delays? This is not some ploy on my end to then attack your response. I am just curious. My practice has a good working relationship with the GI attendings and cancellations or delays are a rarity and the cancellations I have been a part of can basically be boiled down to "snorted cocaine in the car on the way here" or "just finished eating a Denny's Grand Slam", so we aren't party to many, if any, questionable cancellations. The people on this forum tend to represent your upper 1% of Anesthesiologists as they actually have enough interest in their field to spend time typing into the aether instead of doing something more enjoyable, so I don't get much exposure to BS cancellation reasons here either.

I am curious as to the reasons you've been given because 1) It's interesting to get some context of how bad some other people can be, or 2) Maybe some of the reasons actually have some thought process behind them and we can share our own insights with you since this is a more controlled environment (previous comments above mine non-withstanding) than some face-to-face confrontation.

 

[Southpaw]

In the name of patient safety - GI not doing doubles (EGD/colon) because the second procedure gets reduced reimbursement.

Of course you can’t tell the patient that so you say ‘the anesthesia is too high risk’ for two procedures so the patient has to come back a second time for another anesthetic. I benefit from the startup units of another case also, but let’s just do right by the patient.

I’d love it if GI did their own sedation. Unfortunately everywhere I’ve been everyone (GI, nursing, patients) has requested propofol.

 

[Consigliere]

Jeez....you all are spending WAY too much time with this '****. Just ignore it.

 

[IMGASMD]

I’d love it if GI did their own sedation. Unfortunately everywhere I’ve been everyone (GI, nursing, patients) has requested propofol.

GI nurse: “it’s so wonderful to have you here. I remember the days we did this without propofol...”

 

[Pluto201]

I tube, this will free my hand in case if I need to start iv infuse blood.

 

[2Fast2Des]

GI nurse: “it’s so wonderful to have you here. I remember the days we did this without propofol...”

In residency, during my SICU month, GI came up to do a bedside scope on a bleeder, she was stable overall, not Intubated. They took care of the "sedation." After the procedure Pt wanted the name of the MDG to complain against since she wasn't sedated well, remembered and felt everything. Nurses had the wtf look during the procedure because of this guys sedation or lack thereof skills. This was an anesthesia-ccm ICU, all he had to do was ask the anesthesia resident managing her and we would have gladly gave her an actual anesthetic lol

 

[deleted162650]

Pt wanted the name of the MDG

What you did there . . . I see it.

 

[WholeLottaGame7]

In residency, during my SICU month, GI came up to do a bedside scope on a bleeder, she was stable overall, not Intubated. They took care of the "sedation." After the procedure Pt wanted the name of the MDG to complain against since she wasn't sedated well, remembered and felt everything. Nurses had the wtf look during the procedure because of this guys sedation or lack thereof skills. This was an anesthesia-ccm ICU, all he had to do was ask the anesthesia resident managing her and we would have gladly gave her an actual anesthetic lol

Honestly this was probably better than getting a sloppy GA from too much midaz/fent without an airway. She probably was at least protecting her airway.

 

[DM27]

The amount of fentanyl and midazolam that is given during some of these directed conscious sedation cases can be fairly impressive.

 

[Twiggidy]

What you did there . . . I see it.

i think i see it

 

[IMGASMD]

i think i see it

What do you see? I don’t see it.

 

[Mman]

In residency, during my SICU month, GI came up to do a bedside scope on a bleeder, she was stable overall, not Intubated. They took care of the "sedation." After the procedure Pt wanted the name of the MDG to complain against since she wasn't sedated well, remembered and felt everything. Nurses had the wtf look during the procedure because of this guys sedation or lack thereof skills. This was an anesthesia-ccm ICU, all he had to do was ask the anesthesia resident managing her and we would have gladly gave her an actual anesthetic lol

a pet peeve of mine is when the surgeon or GI doc or whoever tells the patient not to worry that they will be asleep and won't feel anything when talking to a patient they want a MAC on instead of GA. I tell 100% of my MAC patients that they may remember some of the procedure (although probably not).

 

[anbuitachi]

a pet peeve of mine is when the surgeon or GI doc or whoever tells the patient not to worry that they will be asleep and won't feel anything when talking to a patient they want a MAC on instead of GA. I tell 100% of my MAC patients that they may remember some of the procedure (although probably not).

i do the same

 

[getdown]

The amount of fentanyl and midazolam that is given during some of these directed conscious sedation cases can be fairly impressive.

There was one time I was on call and got an "emergency" call from IR to help sedate the patient. I get down the IR suite and walk in. There's the patient with an ETT and on one of those portable ventilators that the RT was managing. Now, I have no idea whether the patient came down intubated or the RT or someone else intubated him. But the patient was already "sedated" by the time I got there. Guess what kind of "sedation" he was on? He was on a versed drip, fentanyl drip and phenyelphrine drip. I think the IR attending had directed the nurse to give dilaudid as well cause the patient kept moving. It was insane. I basically just stood there for a bit gave a couple cc's of propofol when the pt kind of moved again. They were basically doing a GA down there with how much sedation they were giving this patient.

*Runs away before MDIR comes in and trashes Anesthesia as always delaying and never available to do cases they need to do*

 

[2Fast2Des]

i do the same

The problem is patients demand that they don't want to remember any portion. It turns into more explaining and talking to explain the difference between ga and sedation level than I'd like so I'll just tell them they'll be fine and have a nice nap. Unless they're super sick then I'll have a real chat to tell em yeah you might remember stuff since I'm going to run you on fumes but you'll be comfy anyway

 

[vector2]

ASA posted a procedural guideline for moderate sedation (Practice Guidelines for Moderate Procedural Sedation and Analgesia 2018:A Report by the American Society of Anesthesiologists Task Force on Moderate Procedural Sedation and Analgesia, the American Association of Oral and Maxillofacial Surgeons, American College of Radiology, American Dental Association, American Society of Dentist Anesthesiologists, and Society of Interventional Radiology* | Anesthesiology | ASA Publications) and were nice enough to include the survey responses from proceduralists about a number of a questions related to moderate sedation. Some strikingly low "strongly agree" percentages for some things which easily should be over 90%....

 

[anbuitachi]

The problem is patients demand that they don't want to remember any portion. It turns into more explaining and talking to explain the difference between ga and sedation level than I'd like so I'll just tell them they'll be fine and have a nice nap. Unless they're super sick then I'll have a real chat to tell em yeah you might remember stuff since I'm going to run you on fumes but you'll be comfy anyway

it's true its often not the best idea if you want to save time. less talking is more time saved. but i think its worth spending couple minutes to explain the differences, at least to me

 

[Impromptu]

There are many conclusions that I could take away from that study. One possibility is that anesthesiologists are able to predict the patients that are going to have worse outcomes, despite similar boxes checked on the EMR. MDGreat, "Dr. MDAwesome, would you prefer General or MAC on this patient?" MDAwesome, "after reviewing his chart, I would definitely prefer general with an ETT." MDGreat, "Case cancelled. Order a consult to palliative care".

As to the original question, I think if the hematemesis has not occurred for over 24-36 hours (and no other mitigating factors), you are much safe to forgo the ETT. "He hasn't vomited blood since last night" will get an ETT. "He hasn't vomited blood since 2 nights ago" will get MAC.

I do not find much difference between in-the-room and procedure start times for general verses MAC. The sick patients take longer either way. Hospital GI is practically all sick patients. Emergence is a little longer for general compared to MAC, but this may be counterbalanced with the faster procedure time and better procedural conditions due to general.

MDAwesome and MDGreat were written with humor intended. ​

 

[deleted171991]

People underestimate how much stuff there can be in a stomach, and also how little is needed for an aspiration.

I still remember a case from residency. The young guy had a SBO, had an NG tube with no output and had not thrown up in more than 24 hours. So we intubated him without RSI (thankfully it was uneventful). Then I replaced his NG, and suddenly got 1L of ugly stuff out. We got so lucky.

Just because somebody stopped vomiting, it doesn't mean that their stomach is empty. It takes a good amount of bleeding for patients to vomit. I do realize this was a SBO, but one should think twice before not intubating a hematemesis.

 

[WholeLottaGame7]

There are many conclusions that I could take away from that study. One possibility is that anesthesiologists are able to predict the patients that are going to have worse outcomes, despite similar boxes checked on the EMR.

Absolutely. It's a retrospective study. I seriously doubt 50% of the anesthesiologists there just like intubating for funsies while the other 50% avoid intubating at all costs. These were trained professionals looking at patients and deciding that some patients warranted intubating, and some didn't. I don't think it's much of a stretch to argue that the ones that were intubated were at higher risk for aspiration (or had already aspirated). Not sure APACHE score is a great surrogate for "this guy has a stomach full of blood and looks like a$$."