ENDO for the moribidly obese/super obese

[acidbase1]

Hey gents, so many issues came about entering a facility that’s predominately been run by CRNAs for over a decade, one of which is endo. My program like many programs don’t place much emphasis on endo, rather higher complexity cases and ASA 4s. (I graduated before the mandatory endo month). That said I did a decent amount here and there.

When I got out here they were doing crazy stuff. For example, they had never put in a tube for upper GI bleeds or esophageal foreign bodies. It pissed the surgeons off bc I’d make them move all the endo equipment to the OR and do some under general. It’s shocking to me these guys got away without having major complications all the preceding years.

My next conundrum is the morbidly obese patients who reside out here. The general surgeon has a bariatric program whereupon we are doing screening EGDs on morbidly/super obese patients. (And sometimes just colonoscopies) Nothing bad has yet to happen, however, these poorly optimized patients obstruct and there’s no way to provide PPV if need be bc there isn’t an anesthesia machine in the endo room.

So my questions are for those of you who work at bariatric facilities, (or anyone in general) how do you handle these types of patients? It would cause a lot of problems, but do I demand these pts be done in the OR? Do you do a General on all of them and place OETT? Another thought is, should a small rural hospital even be handling such patients/cases?

I’ve thought about purchasing and implementing these:

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[BobLoblaw78]

We were the exact same way. We have made the transition to OR and ETT for foreign body/food bolus. We have had a handful of aspirations over the years, but be careful to accept blame. We had blamed on anesthesia that obviously were not and easily disproved. I think the best approach has been to discuss with the patient the level of sedation that will be given. I argue that less sedation is needed more than more sedation for these patients and accept that they have a legitimate chance of recall. It also is related to the endoscopists level of aggressiveness. Safer level of sedation and airway reflexes intact is better. There is obviously patients that get to GAWAC (general without airway control) but would trend lighter for the patients with these comorbidities. If the endoscopist insists on a deeper level (general) then that is a good argument for the OR or general in the endo suite.

I would buy an smaller anesthesia machine that is somewhat portable and can go from one endo suite to another as needed for these patients. I have not used that particular item, and can not speak for it.

I too am curious to hear others input.

 

[DrZzZz]

Always been fond of a generic nasal trumpet hooked up to the circuit via ETT connector for a little ppv as needed.

 

[somedumbDO]

Wait .. are you telling me there is no ambu in gi suite? Desate have gi guy stop and bag mask. Need a tube? Prop/sux/tube hand ventilate till they can spont with ambu plus your propofol. Don't over complicate this! We are a bariatric center and do this all the time. One a year we will turf a 500 plus pounder to or, however we still do all kids in the or...

 

[acidbase1]

Wait .. are you telling me there is no ambu in gi suite? Desate have gi guy stop and bag mask. Need a tube? Prop/sux/tube hand ventilate till they can spont with ambu plus your propofol. Don't over complicate this! We are a bariatric center and do this all the time. One a year we will turf a 500 plus pounder to or, however we still do all kids in the or...

Yes there’s an ambu bag. Just no anesthesia machine. I’ve intubated in there and ventilated with it before

 

[Noyac]

tell,the GI doc’s that you won’t need to go to the OR for cases if there is an anesthesia machine in the ENDO suite. If there isn’t one then go to the OR for the morbid obese, GI bleeds and food impaction.
I intubate all GI bleeds and food impactions. It’s just too easy to not do. Don’t be swayed away from common sense and safety by a few comments like, “the nurses never tubed these cases.” Our GI docs said this too me once, I said “so what”. They never brought it up again.

For the morbidly obese, I don’t intubate. I just don’t over sedate them. I really like some glyco to dry them up in pre-op and then some ketamine to enhance the propofol. Small doses, like 5-10mg at a time. I’m usually under 25mg for the entire procedure.

 

[Hoya11]

Hey gents, so many issues came about entering a facility that’s predominately been run by CRNAs for over a decade, one of which is endo. My program like many programs don’t place much emphasis on endo, rather higher complexity cases and ASA 4s. (I graduated before the mandatory endo month). That said I did a decent amount here and there.

When I got out here they were doing crazy stuff. For example, they had never put in a tube for upper GI bleeds or esophageal foreign bodies. It pissed the surgeons off bc I’d make them move all the endo equipment to the OR and do some under general. It’s shocking to me these guys got away without having major complications all the preceding years.

My next conundrum is the morbidly obese patients who reside out here. The general surgeon has a bariatric program whereupon we are doing screening EGDs on morbidly/super obese patients. (And sometimes just colonoscopies) Nothing bad has yet to happen, however, these poorly optimized patients obstruct and there’s no way to provide PPV if need be bc there isn’t an anesthesia machine in the endo room.

So my questions are for those of you who work at bariatric facilities, (or anyone in general) how do you handle these types of patients? It would cause a lot of problems, but do I demand these pts be done in the OR? Do you do a General on all of them and place OETT? Another thought is, should a small rural hospital even be handling such patients/cases?

I’ve thought about purchasing and implementing these:

View attachment 235083

In General:

BMI <40 - mac
BMI 40-50 probably mac
BMI 50+ ETT with prop gtt and ambu bag

I would not demand they be done in the OR and just do a clean propofol anesthetic and let them be wide awake with nasal trumpet upon extubation.

Having a machine in the room seems like not a lot to ask for these cases to be done safely. Especially for a BMI >50 case. If these cases are being done with some frequency then I would think you can get an anesthesia machine in the room at least part of the day and schedule them then.

 

[anbuitachi]

Man thats rough. we do a lot of endos here but we have an old anesthesia machine in every endo room. The food impactions go to the OR for general anesthesia. GI bleeds usually go to endo suite unless middle of the night, then OR.
Because we do so many endos on sick people (obese, Bleed, bad heart, LVADs, etc), we've had a number of issues, mostly aspiration and occasional arrests.

Really obese patients it depends on where the fat is. if it's in the neck, then just a touch of ketamine, spray the crap out of the back of mouth, and use low dose prop infusion

 

[acidbase1]

Another issue is one of the endoscopists doesn’t want the patients to move at all during EGDs/Colonoscopies. Is this the norm?

 

[BobLoblaw78]

That is somewhat the norm. But for a patient that is higher risk, I allow for a lighter level of sedation. Not moving with stimulus is a general anesthetic level. And yes, we often get to that level for endoscopy. It is risk versus benefit. It sounds like a discussion needs to be had stating as much. I think it is grossly unreasonable to expect the patient to never move. Just address it when it affects the procedure versus the risk of airway obstruction and blunting of airway reflexes.

 

[anbuitachi]

Another issue is one of the endoscopists doesn’t want the patients to move at all during EGDs/Colonoscopies. Is this the norm?

Here they are usually ok with some movement with just EGD/Colons.. sometimes we hold the patient down while they are doing it

 

[acidbase1]

So would you guys demand an anesthesia machine in the room to do these bariatric patients?

 

[Psai]

Another issue is one of the endoscopists doesn’t want the patients to move at all during EGDs/Colonoscopies. Is this the norm?

Yes, they want general anesthesia but don't want to wait for a tube. I felt like punching one of the fellows when they kept complaining that the patient was grimacing. We should make them rotate in endoscopic anesthesia and let them get a taste of what it's like to deal with them.

 

[acidbase1]

Yes, they want general anesthesia but don't want to wait for a tube. I felt like punching one of the fellows when they kept complaining that the patient was grimacing. We should make them rotate in endoscopic anesthesia and let them get a taste of what it's like to deal with them.

What do you think about the Anesthesia machine being in the room for the super obese patients?

 

[Psai]

What do you think about the Anesthesia machine being in the room for the super obese patients?

You should have an anesthesia machine anytime they want your services anywhere in the hospital.

 

[POW16]

You should have an anesthesia machine anytime they want your services anywhere in the hospital.

I agree completely. By definition any MAC case can become GA. Definitely not appropriate to cut corners on that.

 

[acidbase1]

You should have an anesthesia machine anytime they want your services anywhere in the hospital.

Floor intubations?

 

[Arch Guillotti]

You should have an anesthesia machine anytime they want your services anywhere in the hospital.

Too dogmatic and not practical.

 

[fakin' the funk]

Not having an anesthesia machine doing MAC or GETA on the morbidly obese is extremely outside of the standard of care.

The only place I've done anesthesia without a machine is cardioversions. I suppose ECT would be a similar deal.

 

[somedumbDO]

Ect, gi, Mri/ct, tee/cv, picc lines almost always done without a anesthesia machine. We have a portable one but it doesn't get a whole lotta mileage...

 

[somedumbDO]

Not having an anesthesia machine doing MAC or GETA on the morbidly obese is extremely outside of the standard of care.

The only place I've done anesthesia without a machine is cardioversions. I suppose ECT would be a similar deal.

I always get squeamish when someone says STANDARD OF CARE....

 

[Psai]

Floor intubations?

There's a difference between doing a case on your patient vs intubating some random that you saw for the first time 2 minutes ago before you head back to the OR.

 

[narcusprince]

First the Bariatric EGDs are much quicker then diagnostic egds. I joke with my Bariatric surgeon here that he just puts the tip of the scope in. Second all my Bariatric patients get a petroleum jelly lidocaine lollipop. Let them suck on it after the pre eval. Then benzocaine in the room. Then light propofol 30-40 flush 40 flush tell the surgeon to drop the scope. Smooth as butter 99% of the time. Disassociate the stimulus from the patient is the game. Usually the surgeon takes one biopsy to test for H pylori and looks at relevant surgical anatomy to determine sleeve or roux and y. Easy money.

 

[caligas]

First the Bariatric EGDs are much quicker then diagnostic egds. I joke with my Bariatric surgeon here that he just puts the tip of the scope in. Second all my Bariatric patients get a petroleum jelly lidocaine lollipop. Let them suck on it after the pre eval. Then benzocaine in the room. Then light propofol 30-40 flush 40 flush tell the surgeon to drop the scope. Smooth as butter 99% of the time. Disassociate the stimulus from the patient is the game. Usually the surgeon takes one biopsy to test for H pylori and looks at relevant surgical anatomy to determine sleeve or roux and y. Easy money.

How do you make the lido lollipop?

 

[anbuitachi]

How do you make the lido lollipop?

i imagine dump some viscous lidocaine in the freezer and hope it freezes

 

[Psai]

How do you make the lido lollipop?

Anything can be a lollipop if you're fat enough

 

[Libertas]

You take a big glob of lidocaine (usually I've seen 5% whiteish lido 'mint' flavor) and put it on a tongue depressor and have patient put it as far back on their tongue as they can tolerate and then let them close their mouth. Melts over a couple minutes.

 

[narcusprince]

Thats the lollipop. Usually about as much as the tip of my finger. I have uuuge hands though. Bigger and larger then most lol probably the biggest hands you have ever seen on someone my size(see if you can refrence that). Once the patients cant tell you how nasty the jelly tastes they are good. Bring them back one benzocaine spray and prop them down. Good indicator is tell them to hold their thumb up. Once it goes down the scope goes down.

 

[sigrhoillusion]

Thats the lollipop. Usually about as much as the tip of my finger. I have uuuge hands though. Bigger and larger then most lol probably the biggest hands you have ever seen on someone my size(see if you can refrence that). Once the patients cant tell you how nasty the jelly tastes they are good. Bring them back one benzocaine spray and prop them down. Good indicator is tell them to hold their thumb up. Once it goes down the scope goes down.

So you have bigly yuuuuuge hands?

 

[caligas]

 

[acidbase1]

First the Bariatric EGDs are much quicker then diagnostic egds. I joke with my Bariatric surgeon here that he just puts the tip of the scope in. Second all my Bariatric patients get a petroleum jelly lidocaine lollipop. Let them suck on it after the pre eval. Then benzocaine in the room. Then light propofol 30-40 flush 40 flush tell the surgeon to drop the scope. Smooth as butter 99% of the time. Disassociate the stimulus from the patient is the game. Usually the surgeon takes one biopsy to test for H pylori and looks at relevant surgical anatomy to determine sleeve or roux and y. Easy money.

So you think an anesthesia machine in the room is necessary?

 

[narcusprince]

So you think an anesthesia machine in the room is necessary?

For the morbidly obese bmi greater then 40 or 35 plus with severe OSA yes. Even if you secure the airway you need a way to reliably do ppv. Jackson Reese is great but its not great if you have to share the airway with the surgeon.

 

[fakin' the funk]

Ect, gi, Mri/ct, tee/cv, picc lines almost always done without a anesthesia machine. We have a portable one but it doesn't get a whole lotta mileage...

PICC lines?