EGD under MAC for bezoar?

[Timeoutofmind]

I am on my hospital quality committee. They gave me this case for review. What do you guys think about it?

86yo guy
Weight loss/eating intolerance/vomiting for a few months. Sees GI. They find anemia. Question of PUD versus malignancy. Do elective/fasted EGD.

Gets a MAC

They find a big beazor. Try and retrieve it a bunch but cant. When they pull the scope out he vomits/aspirates. Doesnt do well, ends up dying a week later.

My questions are basically
1. Although he didnt have bowel obstruction type symptoms, do you think MAC was the right choice up front (versus GA) given his presentation?
2. Do you think they should have halted the procedure/tubed once they saw the beazor?

Or basically, do you think care was appropriate?

Seems like a tough call to me.

Thanks!

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[anbuitachi]

I am on my hospital quality committee. They gave me this case for review. What do you guys think about it?

86yo guy
Weight loss/eating intolerance/vomiting for a few months. Sees GI. They find anemia. Question of PUD versus malignancy. Do elective/fasted EGD.

Gets a MAC

They find a big beazor. Try and retrieve it a bunch but cant. When they pull the scope out he vomits/aspirates. Doesnt do well, ends up dying a week later.

My questions are basically
1. Although he didnt have bowel obstruction type symptoms, do you think MAC was the right choice up front (versus GA) given his presentation?
2. Do you think they should have halted the procedure/tubed once they saw the beazor?

Or basically, do you think care was appropriate?

Seems like a tough call to me.

Thanks!

If they wanted to get the bezoar out from above , and from what you wrote, they found a 'big' bezoar, i wouldve tubed after they decide they will retrieve from above. if it's a bezoar near the distal end of GI tract, and they decide to retrieve from below, i would be fine with no tube

i can't think of any situation off the top of my head that involves retrieving a large xyz from above, and not tubing.

But obviously it also depends on what they saw in the room, patient comorbidities, how skilled is the proceduralist, how case was going etc

I can see how someone can argue that patient had no obstructive symptoms, the bezoar was not occlusive, and it wasn't much bigger than a polyp etc

 

[deleted162650]

It was ok to start as a MAC, but once they saw the bezoar and decided to remove it the dude gets a tube. Last I checked, a large foreign body in the stomach is pretty much the definition of “full stomach”.

 

[Psai]

We do egds under "mac" all the time.

Hindsight is 20/20 but dude was 86 with weight loss and anemia. Just because you found something doesn't mean there wasn't something else going on. Aspiration is a risk of anesthesia and so is dying.

 

[facted]

Saltydog is right. MAC to start. Once you see something big that you plan on bringing back up, stop, tube, and continue.

 

[narcusprince]

How big is big? A discussion with GI should be how many passes do we need to do to get the bezoar out? Sounds like anytime the scope comes completely out and back in greater then 3 times to remove a mass the patient should be intubated. Mac to start, GA after diagnosis made to remove bezoar. Btw what kind of bezoar was it?

 

[pjl]

This would be MAC initially (actually more of a general without a secured airway at my location), followed by switch to ETT when they saw bezoar and decided to remove it.

Seems like that would be clear best plan, however be careful with what standard of care is. There is a decent chance this plan would have changed the outcome.

Maybe use a root cause analysis setting (also legally protected) to change behavior in similar setting to that type of a plan. Less punitive that way. And it shows people that care can potentially be improved in the future which is what everyone wants.

 

[Timeoutofmind]

Thnx for the input all

To answer your question, I dont know what the bezoar type was, as he took it to the grave in his belly

Sounds like the consensus is MAC to start, should have tubed when they decided to retrieve the big bezoar

 

[WholeLottaGame7]

Thnx for the input all

To answer your question, I dont know what the bezoar type was, as he took it to the grave in his belly

Sounds like the consensus is MAC to start, should have tubed when they decided to retrieve the big bezoar

That's the anesthesia consensus, but 100% the GI doc was like "you don't need to do that, this'll take like 2 minutes, I promise..."

 

[lobelsteve]

Would have had the hospital quality committee send case for review with practicing anesthesia doc.

 

[anbuitachi]

Thnx for the input all

To answer your question, I dont know what the bezoar type was, as he took it to the grave in his belly

Sounds like the consensus is MAC to start, should have tubed when they decided to retrieve the big bezoar

That's the anesthesia consensus, but 100% the GI doc was like "you don't need to do that, this'll take like 2 minutes, I promise..."

I think in these situations what the GI doc says also need to be taken into account. Since the job does involve a lot of communication.

 

[fakin' the funk]

You're constantly gonna be pushed by a GI doc to not do GETA. Especially for (expected) quick cases.

But you're the consultant. Whether they act like it or not, GI docs etc don't consult you to merely be a propofol machine, and they don't want their patients aspirating and dying.

It can be tough to assess symptomatology in these patients having EGDs with questionable "full stomach" symptoms. Early satiety, very-postprandial vomiting are big red flags for me. Sometimes it feels like you're jumping out of a plane with a ****ty parachute. Sometimes patients on full liquid diets for days and now asymptomatic have friggin intact broccoli in their stomach. But that's why you're there -- to change the plan if the circumstances change.

Based on just the info that you said, I probably won't have tubed. It's an 86yo that a whiff of propofol will be plenty for. But my spidey sense is tingling. If you'd known this dude had a bezoar up front, you woulda tubed. Once you gained that info, you shoulda tubed. Hindsight is 20/20.

GI lab is a good place to practice your gastric ultrasound. Yes, that's a thing.

**now realizes it's not the OP's case**

 

[deleted171991]

Hindsight is always 20/20. It's almost obvious that this patient should have been intubated (particulate matter/foreign bodies in the stomach). But that information should have come from the GI doc, so he is as liable as the anesthesiologist. Nobody does food boluses under MAC, so I don't see why it would be different with a bezoar.

Unfortunately, many GI docs are exceedingly cavalier about aspiration risks. They can be, because it's not their malpractice risk. This should be another lesson to everybody to just say NO to them, even in the middle of a case, and do what's prudent, even if it puts one's job at risk. I have never regretted being firm about a GI (or other NORA) case.

Like surgeons, GI docs simply lack the knowledge and judgment to decide the correct anesthesia plan (or step) and, like surgeons, they will throw you under the bus if anything bad happens.

 

[risnwb]

Hindsight is always 20/20. It's almost obvious that this patient should have been intubated (particulate matter/foreign bodies in the stomach). But that information should have come from the GI doc, so he is as liable as the anesthesiologist. Nobody does food boluses under MAC, so I don't see why it would be different with a bezoar.

Unfortunately, many GI docs are exceedingly cavalier about aspiration risks. They can be, because it's not their malpractice risk. This should be another lesson to everybody to just say NO to them, even in the middle of a case, and do what's prudent, even if it puts one's job at risk. I have never regretted being firm about a GI (or other NORA) case.

Like surgeons, GI docs simply lack the knowledge and judgment to decide the correct anesthesia plan (or step) and, like surgeons, they will throw you under the bus if anything bad happens.

I know a several docs who do food blouses under MAC - usually after the GI has failed with conscious sedation. I always tube, but just noting that outside of academics, practice varies widely. Not defending that practice, which I think is dangerous, but I’m pretty sure there are plenty of anesthesiologists out there who would not stop to tube before the GI doc messes with the bezoar...


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[facted]

Hindsight is always 20/20. It's almost obvious that this patient should have been intubated (particulate matter/foreign bodies in the stomach). But that information should have come from the GI doc, so he is as liable as the anesthesiologist. Nobody does food boluses under MAC, so I don't see why it would be different with a bezoar.

Unfortunately, many GI docs are exceedingly cavalier about aspiration risks. They can be, because it's not their malpractice risk. This should be another lesson to everybody to just say NO to them, even in the middle of a case, and do what's prudent, even if it puts one's job at risk. I have never regretted being firm about a GI (or other NORA) case.

Like surgeons, GI docs simply lack the knowledge and judgment to decide the correct anesthesia plan (or step) and, like surgeons, they will throw you under the bus if anything bad happens.

I do food boluses under topical with midaz/fent quite frequently. If it's not a 2 minute case, I adapt and tube. But frequently it's a one minute look and the food is pushed down or it's not.

 

[narcusprince]

Always tube a food impaction. Just not worth the risk of aspiration and lawsuit.

 

[facted]

Always tube a food impaction. Just not worth the risk of aspiration and lawsuit.

Definitely no prop, but topical and midaz/fent go a long way. Patient is awake and can protect the airway. No aspiration risk. Also clearly depends on how severe you think the impaction is.

 

[deleted162650]

Definitely no prop, but topical and midaz/fent go a long way. Patient is awake and can protect the airway. No aspiration risk. Also clearly depends on how severe you think the impaction is.

Can a topicalized patient protect their airway? Honest question. If they are numb enough to tolerate a scope down the throat with light sedation, will they notice lil bits o food bolus in their trachea??

 

[facted]

Can a topicalized patient protect their airway? Honest question. If they are numb enough to tolerate a scope down the throat with light sedation, will they notice lil bits o food bolus in their trachea??

You're not topicalizing their cords and certainly not their trachea. Viscous lido gargle and one benzocaine spray to their throat. They sometimes gag a bit on the scope but often not, and once the scope is in, they're totally fine.

I have done tons of TEE in similar fashion on sick or morbidly obese.

 

[fakin' the funk]

Can a topicalized patient protect their airway? Honest question. If they are numb enough to tolerate a scope down the throat with light sedation, will they notice lil bits o food bolus in their trachea??

Yes. I would argue that lil bits o food in the trachea don't matter. The size of regurgitated/aspirated stuff that matters to be clinically significant would also be readily sensed and coughed up in someone who did lido gargle.

It's amazing how we think about aspiration on 100% of cases and yet it is incredibly rare.

 

[deleted162650]

You're not topicalizing their cords and certainly not their trachea. Viscous lido gargle and one benzocaine spray to their throat. They sometimes gag a bit on the scope but often not, and once the scope is in, they're totally fine.

I have done tons of TEE in similar fashion on sick or morbidly obese.

I realize you're not aiming to numb the cords, but I think it's a little foolish to think that none of your lido gargle or especially the benzocaine spray aren't getting the upper larynx. Of course it's not AFOI level numbness, but I wouldn't count on it being enough to prevent small particles or the copious secretions many of these patients have (since they can't swallow) from sneaking their way into the lungs. TEE does not involve a chunk of food in the esophagus - apples and oranges.

Yes. I would argue that lil bits o food in the trachea don't matter. The size of regurgitated/aspirated stuff that matters to be clinically significant would also be readily sensed and coughed up in someone who did lido gargle.

It's amazing how we think about aspiration on 100% of cases and yet it is incredibly rare.

Maybe lil bits o food wouldn't matter to you or me, but it might in someone older/frailer. A little morsel of food or bacteria laden saliva can be a nice little nidus for a pneumonia - doesn't have to be full blown aspiration pneumonitis/ARDS to get the right patient in trouble.

I tend to be on the more cavalier side of things, but doing food bolus cases with an open airway is unreasonable in my opinion. A chunk of food sitting above the LES pretty much defines "not NPO." I'm not sure how you could argue otherwise. NPO guidelines are the shining example of "standard of care" for our specialty. Why is it ok to violate them for food bolus cases but not anything else?

And we let "rare" events dictate our practice all the time. Neuraxial in thrombocytopenic patients for example. The risk of hematoma is stupid low - like 1 in 6 figures low, but we still won't do it. I bet the risk of aspiration is higher than that for these cases.

It should also be noted that pushing the bolus down into the stomach is also not a totally benign procedure. Esophageal trauma/laceration is not unheard of.

 

[fakin' the funk]

I think we're mostly talking past each other on this topic and mostly agree.

I'll just point out that GETA for this type of case in the old/frail patient is not benign. It carries all sorts of risk, including risk of aspiration, especially in the scenario you evoke with copious secretions etc. I think it's reasonable to advocate for either plan; in the old/frail I favor a minimalist approach, which often means topical/local/regional depending on what the case is.

I agree that extremely rare events guide the standard of care in our practice; I don't necessarily agree with them, but I usually abide.