I highly recommend that residents push where it hurts and seek out cases that scare and frustrate them until they are able to do them smoothly and confidently. Obviously, not all ASA4s are created equally.
Doing TEEs for sick hearts (IE pre TAVR with multiple comorbidities) and interventional pulmonology is a great way to learn how to handle EGDs. Pay attention to functional status. TEEs are quick. There is a ton of variation in bronchs from both IP side and anesthesia side giving you a lot to pick up from different cases.
Bleeding EGDs are a separate beast. Do NOT get bullied into doing a procedure before a patient is adequately resuscitated because the primary team, GI, and the floor/ED couldn’t get their act together to give the patient the blood they needed a few hours ago. Also don’t let yourself get bullied into doing something you do not think is safe. If you think the patient needs a tube, tube them. For instance, dropping Hct out of proportion to transfusion, nausea, hematemesis on admission, BUN elevated, a1c 12 and gastroparesis, previous EGD during admission saw arterial spurting and the best they could do was temporize with epi and some magic powder while they wait out anticoagulation wearing off. Your gut is right a surprising amount of times because that’s the what you’ve been training for. Be weary of advice from GI docs you don’t know and trust. Assume all they care about is getting their cases done the fastest.
Make a mental note of the wins when you tube them and there is blood or food in their stomach as justification for your future decision making. Where I’m at GI will acknowledge and say thank you if you made the right call. If you tube, and they have an ugly bleed, ask the GI doc if they think they have adequate control of bleeding before you extubate. Assessment of control of bleeding is their specialty, not ours.
As Southpaw already stated, sedative dose is definitely correlated to the skill of proceduralist. Realize that if a new fellow looks at you like your sedation is the issue, it is at least partially their technique. Ideally they don’t buck but but if they do, they have an empty stomach and you have to give more sedative, that’s not the end of the world. I have witnessed far more M+Ms in GI than than any other room.
It is very easy for a patient with the combination of a sick heart, acute bleed, and undergoal hct to bottom out with even a little bit of sedation. Have blood ready. If someone has a normal heart and/or functional status before their EGD and they are hypotensive, get them blood and send of labs.
Just propofol +\- lido +/- spray is great for most endoscopies. A little bit of low dose glyco, fentanyl, midaz, ketamine can be very helpful. Fentanyl reduces response to stim. Midaz if you’re worried about amnesia. Glyco to dry out anyone who looks like theyre going to drool. Doing more TEEs will make you more comfortable with giving glyco if you’re worried about raising their HR. 10 or 20 of Ketamine can help out sedating obese, chronic marijuana, chronic opiate users, or drinkers.
