Endo Fatties
Started by soorg
I think it all comes down to risk/benefit and clinical judgement.
Got a 350 pounder with obstructive sleep apnea and a thick neck who needs a colonoscopy? I think its reasonable to slap an O2 mask on, give a touch of propofol, put in a nasal airway, give some more propofol and see if he can fly on his own. You obviously will have the equipment to intubate if need be and the airway is very accessible to you because the endoscopist is working down below.
Got a 350 pounder with a thick neck, full beard and Mallampati class IV airway who needs an EGD? Maybe this is the time to consider an awake fiberoptic intubation (anticipation of difficult mask) and do the entire case under general anesthesia with a protected airway. Endoscopist wants to give you crap about taking too much time? Tell him to do the sedation himself if he thinks that would be quicker/easier. But your group can't afford to lose the hospital/endo contract? Better to lose a contract than to do something stupid and lose your a___ in court.
For ERCP's, they get a tube, no questions asked. An ERCP is a prone case where badness can and does occur. If intubation and GA is too much trouble for the endoscopist and his staff, then they can do the sedation themselves. Again, not worth risking a bad outcome when the whole reason for you being there is to provide safe care and keep the patient alive.
Got a 350 pounder with obstructive sleep apnea and a thick neck who needs a colonoscopy? I think its reasonable to slap an O2 mask on, give a touch of propofol, put in a nasal airway, give some more propofol and see if he can fly on his own. You obviously will have the equipment to intubate if need be and the airway is very accessible to you because the endoscopist is working down below.
Got a 350 pounder with a thick neck, full beard and Mallampati class IV airway who needs an EGD? Maybe this is the time to consider an awake fiberoptic intubation (anticipation of difficult mask) and do the entire case under general anesthesia with a protected airway. Endoscopist wants to give you crap about taking too much time? Tell him to do the sedation himself if he thinks that would be quicker/easier. But your group can't afford to lose the hospital/endo contract? Better to lose a contract than to do something stupid and lose your a___ in court.
For ERCP's, they get a tube, no questions asked. An ERCP is a prone case where badness can and does occur. If intubation and GA is too much trouble for the endoscopist and his staff, then they can do the sedation themselves. Again, not worth risking a bad outcome when the whole reason for you being there is to provide safe care and keep the patient alive.
Your approach is definitely the safest. I have yet to put a tube in someone coming in for an ERCP. Most I've used is a nasal trumpet.
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One of my good friends from medical school who is a GI fellow in another state thinks I'm crazy for insisting on ETT for all ERCP's. The way I look at it is that a patient has to be kind of sick to need an ERCP in the first place. Then you have the prone position, which is problematic for so many reasons (access to patient, altered physiology) and you have an endoscopist who is sticking a big, whopping hose down their esophagus. You can certainly get away with doing these cases without an ETT, but I think the benefits of having a secured airway in these cases/patients outweighs the risks/inconvenience of having to secure the airway and do a general anesthetic.
Given a fat & Mallampati-impaired patient, our endoscopists will offer to do their ERCPs supine. I've only taken them up on the offer once, and he did the procedure just as fast as usual.
I dislike endo fatties very much.
For egd, I definitely make them gargle the lido. Crank up the nasal cannula and do a little propofol and ketamine slowly. Usually about 50 propfol and 10 ketamine. Usually these fatties don't have much of a gag and their OSA is so bad they snooze easily. And at least they are laying on their side. Then just be ready to do some serious jaw lift. I avoid any narcs.
For egd, I definitely make them gargle the lido. Crank up the nasal cannula and do a little propofol and ketamine slowly. Usually about 50 propfol and 10 ketamine. Usually these fatties don't have much of a gag and their OSA is so bad they snooze easily. And at least they are laying on their side. Then just be ready to do some serious jaw lift. I avoid any narcs.
I've never seen a prone ERCP why the F**K do they need to flip the patient??? 😱 We do them in lateral decubitus and i've never had any problems. At one hospital i didn't intubate any at another the all eat pvc...
I'm with gasspasser 100%. Yellow patients with comorbid conditions, prone case, green stuff coming up after a big black endo sanke goes into the esophagus after bumping into the vocal cords a couple of times. Pent, sux, tube, 50 fentanyl, .5 Mac Sevo.
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you have good endoscopists. consider yourself lucky.
Often with the the ERCPs and EGDs the black snake improves the airway and when they go down below they require more suport to prevent obstruction. I dont routinely tube ercps, but when they think it'll go long, its just easier. The big fatties get a tube every time tho.
Well another option for there patients could just be a no anaesthetics at all. l know it may strike you as horrible, but here vast majority of endoscopies are done w/o anaesthesia, and it's not excruciating as some might think. Or touch of midazolam and nothing else.
l know it may not be SOC in US, but just saying it same as surgery, therefore sometimes maybe can be presented as possibility.
l know it may not be SOC in US, but just saying it same as surgery, therefore sometimes maybe can be presented as possibility.
The reason most GI docs want to do the cases prone is to decrease the risk of bowel perforation. When they pass that scope down and turn on the gas to insufflate the bowel, the pressure exerted on the abdomen in the prone position decreases the amount of gas that passes through the GI tract distally...in the prone position, the gas will exit via the path of least resistance (the esophagus). When the patient is supine or lateral, that gas will track through the GI tract like crazy. If the procedure is short, it probably won't be an issue...but eventually you will get a longer ERCP and the bowel will perforate. And that will suck. The good GI docs (and you, if you are good) should always palpate the abdomen post procedure to ensure the abdomen is soft.
I'm at a very well know hospital when it comes to GI scopes doing endoscopic gastroplasties etc...
Some of the ERCPs can run more than 2h, i've never heard of a perforation occurring due to insufflation it's got to be some lame excuse from the GI doc and i have a hard time believing this could happen.
Some of the ERCPs can run more than 2h, i've never heard of a perforation occurring due to insufflation it's got to be some lame excuse from the GI doc and i have a hard time believing this could happen.
its supposed to be easier to access the duct in the prone position, this is why they want it
According to the literature, the incidence of perforation during an ERCP is around 1% with a close to 20% mortality rate...look it up & get educated...glad you've been so lucky doing ERCPs for upwards of 2hrs...ours usually only take 20-30min. I haven't ever seen a bowel perf from an ERCP, but I know the risk is there and I'm always looking for it!
well perforations are usually related to sphincterotomy or guidewires and not to insufflation, so if you are seeing lots of insufflation related injuries then maybe you have other issues.
1% due to insufflation in the literature...can even happen during EGDs...I've been fortunate to never have seen a perf during any of these procedures, but they do happen...I suggest you read a book or journal with the word "anesthesia" in the title a little more often...it may save a life.
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since you are choosing to be so cavalier about this why dont you show me your data that says that insufflation is responsible for 1 in 100 patients having intestinal perforation after ERCP. i doubt you will be able to as I suspect it doesnt exist.
Wait, are you saying that 1% of cases have perfs due to insufflation, or that 1% of all perfs are due to insufflation? The latter is a lot more plausible.
We never see the colonoscopy patients. We almost never see the EGD patients. We see some of the ERCP patients. If we see the EGD and ERCP patients, it is because they have been unable to tolerate the attempted procedure under sedation or have major medical issues. Either way they are getting an ETT from me when I'm off in the middle of nowhere and away from help (aka radiology or gi land).
🙄 dude i've sedated probably more than 200 patients for endoscopic procedures and i've never had a perfoation does that mean anything to you? are you seeing a 1% rate??
What kind of litterature are you reading? here's a 10sec pubmed search for you:
Only one case of perforation was found in the non-anesthetized group (n = 2460) compared with two cases in the anesthetized group (n = 7041).
Perforations in 72 of 217,507 EGD procedures were identified (incidence, 0.033%); 124,844 EGDs included an interventional procedure and 92,663 were examination only. The incidence of perforation was similar whether an interventional procedure was performed or not (0.040% vs 0.029%; P = .181)
7,804 colonoscopies were performed. Five colonoscopic perforations were identified (0.06%)
yeah its a ridiculous claim, probably 0.7% of ERCPs get perfs and over 80% of those are from direct trauma, so the rate of insufflation related perf is very low and the poster admits hes never seen one, so that also doesnt quite fit with the claim...and he also got awfully quiet after all the snarky comments attacking knowledge bases and safety, etc.
If fatty and concerned about airway I would only use propafol in a very small infusion about 25 mcg/kg/min make sure patient is talking to me and holding his airway this will be anxiolytic and hopefully amnestic.. for EDG I will use lidocaine swish to suppress gag...I wont do awake intubation it is more traumatic than doing awake EGD, unless it is a GI bleeding...
late to the discussion, but i intubate all ERCP's. Our gi docs do them prone, and we dont have great access to the head, so they get a tube
I'm so glad you did a 10sec Pubmed search...at least your getting started somewhere...I'll give you some more tips on looking for good literature on ERCPs...1. Don't limit yourself to articles written in Taiwan, Brazil, or single center studies in the US...2. Search not only the Anesthesia journals, but also major, respected GI journals...3. Find a prospective multicenter study from the US published in the last 5 years...This should give you some good clues to find a good article...I'll give you a week to find it...After that I'll post a link if you fail to find the article I'm referring to...I'm so excited I got the ball rolling on you looking up some stuff...Also, as I have stated before for the other posters, I have never seen a perf due to insufflation during an ERCP...I've also never had a patient with MH...that doesn't mean it doesn't exist...I've just been lucky for the last decade...Also, the reason I got "quiet" was I had to roll to the OR yesterday...but I'm now back in the game!🙄 dude i've sedated probably more than 200 patients for endoscopic procedures and i've never had a perfoation does that mean anything to you? are you seeing a 1% rate??
What kind of litterature are you reading? here's a 10sec pubmed search for you:
Only one case of perforation was found in the non-anesthetized group (n = 2460) compared with two cases in the anesthetized group (n = 7041).
Perforations in 72 of 217,507 EGD procedures were identified (incidence, 0.033%); 124,844 EGDs included an interventional procedure and 92,663 were examination only. The incidence of perforation was similar whether an interventional procedure was performed or not (0.040% vs 0.029%; P = .181)
7,804 colonoscopies were performed. Five colonoscopic perforations were identified (0.06%)
I'm with you Frank...In residency we did them with an unprotected airway and a propofol infusion...in an MD only private practice with limited back-up available at a remote site doing a GA with an ETT is the safest and easiest option in my opinion.
look you are still wrong. endoscopic sphincterotomy is by far the biggest risk factor for perforation. keep trying to dig yourself out
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I don't want to hi-jack this thread and I apologize ahead of time.
I also will say that I, like most middle-aged American males, weigh more than I should, but don't qualify for the catagory of pt being discussed.
All of that said...
Am I the only one here who feels that referring to our pts with such a derogatory term as "fatty" makes us look unprofessional and brings dishonor to us. I cringe whenever one of my colleagues regales us with stories about the "fatty" that they just took care of.
I will also add that I doubt that demeaning the patient was the intent of the OP, but couldn't this thread, and the medical discussion that followed, have been better served with a more professional thread title?
I also will say that I, like most middle-aged American males, weigh more than I should, but don't qualify for the catagory of pt being discussed.
All of that said...
Am I the only one here who feels that referring to our pts with such a derogatory term as "fatty" makes us look unprofessional and brings dishonor to us. I cringe whenever one of my colleagues regales us with stories about the "fatty" that they just took care of.
I will also add that I doubt that demeaning the patient was the intent of the OP, but couldn't this thread, and the medical discussion that followed, have been better served with a more professional thread title?
If you want to get into the technical definition of "fatties" Should we just call patients with BMI's over 35 "obese" in front of them and those of 40 BMI morbidly obese? I believe over 45-50, you need to call them super morbidly obese.
There's no easy way around what you call some of these patients. Look I am 5 foot 8 and weigh 175-180. I consider myself "overweight" for a male. That's because my normal college weight was around 150 pounds.
But these days, you routinely see women who are 5 foot 4 and weigh 240 and don't even blink. Or males who are 5 foot 10 and weigh 280. What do you want to call these patient.
Obesity is a huge problem in the US. Should be call people obese? fat? What should be call these patients?
hmm, i thought anesthesiology was the right wing gun club forum not the left wing PC forum.
If you are lumping in with the PC/left wing crowd, you don't know how wrong you are.
I wasn't trying to start something. I just thought to myself that I doubt a physician would call a patient a "fatty" to their face, at least I hope not, so is it professional to use that term in a discussion amongst ourselves.
However, if this is going to lead to name calling and such, forget I even asked the question. Life is too short for more rancor than there has to be.
while my post was tongue in cheek, and i never am anything but totally professional with my patients, i will admit to using a colloquialism or to when referring to patients. im not necessarily proud of it, but its a very concise way to refer to a patient who meets a certain description...and it is easily understood in our profession.
I can see your point.
When talking to other people in healthcare, the terms I use depend on the context. I wouldn't write 'fat dude' in a chart, or formally present a consult with the words '47 yo fat dude with ...' but if I'm telling a story for the sake of the story, it might be a 'fat dude' ... or if I'm describing a patient to a colleague who may later take care of him I might use some nonflattering verbal shortcuts, sure.
Is it disrespectful to speak of the patient so? Maybe a little bit.
I'm excessively polite in front of patients or family. I won't even use the word 'obese' in front of them. If somehow the situation requires me to convey that information, I'll say 'BMI 45' because I always feel bad reminding fat people that they're fat.
Not long ago I took care of a patient having an elective ACL repair who was absolutely obnoxious. The only time he could be bothered to open his eyes and look at either me or the OR nurse during our preop interviews was during repeated gripes that 'that first dude already asked me that' ... all of his other answers were 'yeah' or 'no' even when the question wasn't a yes/no question. Later, when discussing this jerk with others, I referred to him as a 'jerk' ... maybe that makes me a bad person?
There's no shortage of black humor and verbalized disgust for certain patients in any hospital. In the right context I don't think it's inappropriate. You could argue that a sort-of-public forum like this isn't the right context, I don't know, maybe a gray area.
Idiopathic said:
Is this an invitation for me to post pics of my new(ish) AR10? 🙂
I'm not right wing though.
tick tock...
