EGD sedation for slow endoscopist

[soorg]

Been doing the usual standard EGDs for a few years with no problems. Mainly just propofol, perhaps 50 ug of fentanyl for the younger patients to better blunt the gag reflex. Lately have been covering slow-ass endoscopists, or ones doing these BRAVO EGDs for GERD, both of whom require longer sedation. Tried using lidocaine with prop, fent with prop, but with varied success. Any ideas for better sedation on a longer EGD? Anybody throwing in some ketamine?

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[OB1🤙]

More propofol?

Edit: I don't use anything but propofol for all cases in endo. Uppers, lowers, long cases, short cases. Propofol gets it done.

Is the issue you're having that you achieve adequate sedation at first that then becomes inadequate after awhile?

 

[Foodie]

I slip in anywhere between 10-40mg ketamine for nearly all my MACS. Works great and patients are happy. Last week I had a CTR dude who laughed hysterically for 15 minutes and postop told me that he had the best trip of his life. Had a Bier block so he didn't move. Surgeon found it hilarious.

Also, more propofol.

Edit: You probably wouldn't want your patients laughing during EGD. It was a single incident out hundreds Of MAC cases. Also that dude got 50mg and he was ESRD and ESLD with a drug abuse history. Anyway, ketamine in small doses will work well. Propofol drip in syringe is nearly foolproof FWIW. I haven't used ketofol drip in a long time because I no longer have to work with slow as hell GI fellows; ketofol is perfect for long, uncomfortable cases such as your EGDs.

 

[risnwb]

More propofol. And lidocaine. I usually sim start with 100mg Bolus of lido followed by somewhere around150+ mg of prop (2mg/kg) and if it's gonna be longer than a peek I infuse at ~150mcg/kg/min. That is in healthy people of course. Optimal dose=just enough to make them obstruct - a little. If you don't start high they buck when the scope goes in and it slows things down ...


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[Noyac]

Why not just tube them if the endoscopist is that slow?

 

[aneftp]

Why not just tube them if the endoscopist is that slow?

Depends if it's private practice outpatient stand alone endo facility.

There is a lot of pressure in private practice not to intubate.

 

[Spinach Dip]

I slip in anywhere between 10-40mg ketamine for nearly all my MACS. Works great and patients are happy. Last week I had a CTR dude who laughed hysterically for 15 minutes and postop told me that he had the best trip of his life. Had a Bier block so he didn't move. Surgeon found it hilarious.

I'm gonna specifically ask for you next time I need procedural sedation for anything.

Why not just tube them if the endoscopist is that slow?

After a couple cases, the endoscopist might get the hint....

 

[Gastrapathy]

How slow can an egd be? I'm fascinated.


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[aneftp]

How slow can an egd be? I'm fascinated.


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Depends.

Some take multiple bx cause they own their own path lab(can you spell self referral). Ha ha. Stark law violations.

Seriously most shouldn't take more than 5-7 minutes long.

 

[Jay K]

Ketafol, remember the versed & glyco

or

Tube

 

[deleted171991]

Been doing the usual standard EGDs for a few years with no problems. Mainly just propofol, perhaps 50 ug of fentanyl for the younger patients to better blunt the gag reflex. Lately have been covering slow-ass endoscopists, or ones doing these BRAVO EGDs for GERD, both of whom require longer sedation. Tried using lidocaine with prop, fent with prop, but with varied success. Any ideas for better sedation on a longer EGD? Anybody throwing in some ketamine?

Throw in 2 mg of versed. It will significantly decrease propofol requirements, especially when coupled with 100 mcg of fentanyl in 25 mcg boluses.

 

[Planktonmd]

I use only Propofol and it is just a bolus for EGDs most of the time, but if the GI guy is slow then I just run an infusion.
I find that staying with Propofol alone makes apnea less likely and accelerates discharge.

 

[gasdoc77]

I always push a small bolus of ketamine with the first push propofol. That way they get max analgesic effect up front and its almost gone by the time they finish. About 20-30 mg. I don't mix it since I want it all from the get go. It literally feels like cheating. I don't give to larger African American patients who seem to salivate a LOT from it. All anecdotal.

 

[somedumbDO]

More propofol like love , that's all u need

 

[GhostTree]

Just a question, but does anybody topicalize for these? I'm an anesthesia resident graduating this June and I've done this a few times. When we do TEEs, the cardiologist have the pts gargle 2% lido, swallow some, and then spray with an atomizer. Most of the patients tolerate the probe pretty well with minimal propofol (~50 mcg/kg/min) and it doesn't take that long to topicalize. Granted TEEs take longer. It just seems that it goes so much smoother and essentially it's the same stimulus.

I do appreciate you're knocking out sensation and there could be issues with aspiration so you've got to choose wisely.

Just wondering if I'll be looked at funny if I try this when I start my PP gig in July.

 

[Planktonmd]

Just a question, but does anybody topicalize for these? I'm an anesthesia resident graduating this June and I've done this a few times. When we do TEEs, the cardiologist have the pts gargle 2% lido, swallow some, and then spray with an atomizer. Most of the patients tolerate the probe pretty well with minimal propofol (~50 mcg/kg/min) and it doesn't take that long to topicalize. Granted TEEs take longer. It just seems that it goes so much smoother and essentially it's the same stimulus.

I do appreciate you're knocking out sensation and there could be issues with aspiration so you've got to choose wisely.

Just wondering if I'll be looked at funny if I try this when I start my PP gig in July.

I do use topical anesthesia on obese patients or patients I am concerned they might not tolerate a deeper anesthetic, it allows you to get away with less IV anesthetic.

 

[Freak]

50 fent helps a lot to decrease your prop bolus needs and gag. Agreed prop infusion is way to go @150, decreased prn for gomers and increased for the IBD youngsters.

 

[painstop]

More propofol. And lidocaine. I usually sim start with 100mg Bolus of lido followed by somewhere around150+ mg of prop (2mg/kg) and if it's gonna be longer than a peek I infuse at ~150mcg/kg/min. That is in healthy people of course. Optimal dose=just enough to make them obstruct - a little. If you don't start high they buck when the scope goes in and it slows things down ...


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That's a pretty healthy bolus. I'm usually able to get by with a 500-1000 mcg/kg bolus depending on the patient's age and I usually reserve the 2000 mcg/kg dose for induction prior to intubation...do you pre-oxygenate these patients with a mask or through their nasal cannula?

 

[ghastly75]

I do primarily peds and the EGDs are painfully slow. I usually LMA/Tube kids if younger than 7-8. However, when an appropriate patient comes along I like the natural airway and use this mixture with nearly universal awesome results: Remifentanil 40 mcg/mixed with Propofol 2oml. Remi 2mcg/cc in propofol. I bolus with 1 mg/kg (based on Propofol) which is .2mcg/kg remifentanil. I do this right before scope is introduced and then run infusion at 200 mcg/kg/min (propofol) and assuming remi mixture is consistent then that is 0.04 mcg/kg/min. These are teenagers (need more MAC) but adjust for adults . Perhaps start at 100 mcg/kg/min and remi is .02mcg/kg/min. I can mix a 1 gram remi and use it all day. Patients wake up fast, no hangover and everyone is happy.

 

[GhostTree]

I do use topical anesthesia on obese patients or patients I am concerned they might not tolerate a deeper anesthetic, it allows you to get away with less IV anesthetic.

Thanks for the response. Your approach makes sense: probably overkill to topicalize everyone but for those that would benefit from less IV anesthetic, its a useful adjunct.

 

[Noyac]

Just a question, but does anybody topicalize for these? I'm an anesthesia resident graduating this June and I've done this a few times. When we do TEEs, the cardiologist have the pts gargle 2% lido, swallow some, and then spray with an atomizer. Most of the patients tolerate the probe pretty well with minimal propofol (~50 mcg/kg/min) and it doesn't take that long to topicalize. Granted TEEs take longer. It just seems that it goes so much smoother and essentially it's the same stimulus.

Absolutely. I have the pt gargle viscous lido for around a minute. That scope passes like jello.

As you can tell, there are many ways to sedate someone for these cases. Don't get caught up on any one particular way.

 

[imfrankie]

I do primarily peds and the EGDs are painfully slow. I usually LMA/Tube kids if younger than 7-8. However, when an appropriate patient comes along I like the natural airway and use this mixture with nearly universal awesome results: Remifentanil 40 mcg/mixed with Propofol 2oml. Remi 2mcg/cc in propofol. I bolus with 1 mg/kg (based on Propofol) which is .2mcg/kg remifentanil. I do this right before scope is introduced and then run infusion at 200 mcg/kg/min (propofol) and assuming remi mixture is consistent then that is 0.04 mcg/kg/min. These are teenagers (need more MAC) but adjust for adults . Perhaps start at 100 mcg/kg/min and remi is .02mcg/kg/min. I can mix a 1 gram remi and use it all day. Patients wake up fast, no hangover and everyone is happy.

this is a great "MAC" recipe I use all the time also

 

[Arch Guillotti]

Why not just tube them if the endoscopist is that slow?

Are you serious?

 

[soorg]

Will try throwing in some Versed. Any idea how much I should reduce my propofol if combining with Versed?

 

[Noyac]

Are you serious?

What do you think?

 

[Noyac]

Will try throwing in some Versed. Any idea how much I should reduce my propofol if combining with Versed?

None

Also, I don't understand using versed with propofol for this application. What are you trying to accomplish?

 

[deleted171991]

Will try throwing in some Versed. Any idea how much I should reduce my propofol if combining with Versed?

I usually run 250 mcg/kg/min without versed, and end up needing about 1/2-2/3 with.