ERCP Question

[soccerboy2288]

Hi guys, I'm a resident and wanted to get advice from all the clinicians out there regarding ERCP. Its a little unclear to me which ERCP procedures are painful and need post-op narcotics? Ones with stent placements? location?

Also any guidelines to which ones you intubated vs mac? Obviously if they have severe vomiting from their pathology, I would know to intubate. But sometimes it is in the grey zone. For example, Patient has bloating/abd distention after they eat, and occasional nausea. coming in to get that worked up. Or known choledocholithiasis but no nausea or vomiting...

Thanks guys

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[dannyboy1]

You will never regret tubing them. Have seen too many ERCP’s taking an hour with lots of green coming up. Now that my institution got sugammadex it is even easier. Run them light on the gas and deep on the paralytic. Case over, reverse. They wake up quick.

 

[NICMAN]

Usually intubate, but at our place there are slick GI proceduralist who are able to do it with an endoscopy facemask. Usually safer to tube the patient.

 

[Arch Guillotti]

Intubate all of them.

 

[narcusprince]

It depends.... stent removal? Thin patient? Dont intubate, stent placement? Poor endoscopist, obese, osa intubate. All ercps are not the same.....

 

[facted]

Have you ever seen an ERCP where TONS of secretions and bile ISN'T coming out of the mouth?

Me neither. ETT for every one of them. You save maybe 2 or 3 minutes with a MAC vs ETT. Is that really worth it?

 

[GravelRider]

I’ve done ERCP both ways. Now I intubate all of them. My rule of thumb is that if I can’t relax during a routine case, like an ercp, then I’m doing something wrong. I’ve also had (cr@ppy) GI docs complain about things like a moving diaphragm. Why struggle? Put a tube in and put your feet up.

I use very little in the way of narcotics for an ERCP. The post-ercp pancreatitis that occasionally occurs is what is painful and by that time is no longer my problem.

 

[anbuitachi]

How do your GI positions your ERCPs? supine, lateral, or prone?

 

[pjl]

How do your GI positions your ERCPs? supine, lateral, or prone?

We do all ours with tubes. They are a lateral/prone/terrible position that I dislike.
I almost never give narcs or any pain meds, unless the patient is clearly hurting. They go down fast, wake up fast. Sadly, they frequently are sleeping a long time in between. Historically I would always use sux and no other paralytic. Now I use Roc if I expect to sit a long time.

 

[nimbus]

Prop roc tube sevo suga next

I never give narcs either.

 

[Noyac]

I have never “not” intubated an ERCP pt. And I have never regretted this.

Remember what narcotics do to the sphincter of oddi?

You should not be managing the pain post procedure. The GI specialist should. Mostly because s/he should be watching for pancreatitis. That is not your job or area of expertise. What if the pt c/p of pain, you give narcotics and pain doesn’t improve. Then you give more or stronger narcotics. Basically the issue is being worsened.

 

[Psai]

I’ve done ERCP both ways. Now I intubate all of them. My rule of thumb is that if I can’t relax during a routine case, like an ercp, then I’m doing something wrong. I’ve also had (cr@ppy) GI docs complain about things like a moving diaphragm. Why struggle? Put a tube in and put your feet up.

I use very little in the way of narcotics for an ERCP. The post-ercp pancreatitis that occasionally occurs is what is painful and by that time is no longer my problem.

I had a ******* gi fellow complain that the patient grimaced when they put the scope in. Im like thats because youre sticking a huge tube down their throat stfu

 

[Noyac]

I had a ******* gi fellow complain that the patient grimaced when they put the scope in. Im like thats because youre sticking a huge tube down their throat stfu

I had a GI guy tell me that the pt wasn’t sedated enough for the colonoscopy and that the last time he tried to scope this pt it was extremely difficult and they had to abort (it was attempted at his clinic with a crna). I usually take their word for it but this guy is a flipping tool. He is the worst GI (actually worst doc) I’ve dealt with in my career. I can be a hardass but I’m usually pretty easy going. This time I was the hardass. I told this GI tool that this was it for the sedation, make it work or reschedule it at your CRNA palace. He wouldn’t start and I wouldnt increase the sedation and we were at a standstill.
When it was all over the pt said it was the best nap he has had in a long time, didn’t remember anything and the GI Tool managed to get his procedure done without perforating the colon or rupturing the spleen like he has done on more than one occasion.
My point is that many of these GI docs don’t understand at all what we do. Nor do they appreciate it. If you get one that does, then be sure to thank that doc and do your best to keep them around.

 

[coffeebythelake]

I had a ******* gi fellow complain that the patient grimaced when they put the scope in. Im like thats because youre sticking a huge tube down their throat stfu

sounds like a huge tool

 

[dhb]

Sadly, they frequently are sleeping a long time in between.

 

[Iso4ane]

Prop roc tube sevo suga next

Unfortunately, where I am it would prop roc tube sevo ‘twiddle thumbs’ ‘twiddle thumbs some more’ ‘Almost done’ ‘Twiddle thumbs’ suga next.

 

[DocVapor]

I'm a resident too and we intubate every single one. Often no narcotic whatsoever. I do usually have a little bit of fentanyl available if they need it though. Variety of slick GI's that get things done quick to GI's that utilize the time as social hours to try and mask their ineptness, to ones that consistently seem to try and chastise/impress me about how many scopes they do at their endoscopy centers on ASA 1's and 2's and how I need to be more "efficient."

Prop-roc (suxx if indicated)-tube-sevo-roll to either full prone or some sloppy tilted proneish position that I hate-let breathing come back-twiddle thumbs-roll back-reverse-next

 

[Southpaw]

Almost every good, solid surgeon or proceduralist I've worked with who's both good and fast, never discusses how efficient they are. It never comes up, ever, unless staff brings it up. On the other hand, every slow or 'not-that-great' surgeon or proceduralist I've worked with, at some point in the day will bring up whether directly or not, how good they are.

And I like to intubate for ERCPs.

 

[Psai]

Almost every good, solid surgeon or proceduralist I've worked with who's both good and fast, never discusses how efficient they are. It never comes up, ever, unless staff brings it up. On the other hand, every slow or 'not-that-great' surgeon or proceduralist I've worked with, at some point in the day will bring up whether directly or not, how good they are.

And I like to intubate for ERCPs.

Never thought about this before but it is so true.

 

[deleted162650]

Almost every good, solid surgeon or proceduralist I've worked with who's both good and fast, never discusses how efficient they are. It never comes up, ever, unless staff brings it up. On the other hand, every slow or 'not-that-great' surgeon or proceduralist I've worked with, at some point in the day will bring up whether directly or not, how good they are.

And I like to intubate for ERCPs.

The Dunning-Kruger on display.

 

[coffeebythelake]

i'm going to be a dissenter.
we usually do our ERCP's under MAC (around 95%). Occasionally GA if I felt pt has increased risk (nausea, fresh surgery, bad airway, gerd, HH, etc...) or if anatomy was complicated (e.g. post whipple or liver txp).
Large academic center. Over the last few years I've done about 100 of them. No aspiration events. Other colleagues in my group also favor MAC.

 

[pgg]

I've done many with ketofol, sloppy prone position, O2 face mask, and a good endoscopist I knew well. These days I intubate everyone. Sugammadex makes intubation with roc and prompt complete reversal so easy. The cases really aren't appreciably more efficient without a tube.

 

[ranvier]

I guess I am in the minority but estimate 25 percent Mac, 25 percent gastro lma and 50 percent ett. Lots of factors as described above. We do advanced gi with spyglass etc so lots of return patients with old records to review and see how they did.

 

[Ezekiel2517]

Your GI's must be trash. Can't even remember the last time I had to tube one of these. Been st least a year. And we do a lot. We don't even go to the OR for these.

 

[Southpaw]

Can't even remember the last time I had to tube one of these.

Probably the last time they desat’d to 40 and/or aspirated with your sedation.

 

[Plead the Fifth]

For GI I always intubate ERCPs, food boluses, and any upper GI bleed (Mallory-Weiss, bleeding ulcer, variceal bleeds, etc.). Don’t compromise on these.

In this same vein I have been getting quite a few pre-cath EGDs in people with suspected acute coronary syndromes. I had a recent pre-cath EGD patient just under sedation go into asystole when she desaturated briefly prompting resuscitation (she did ok). Would any of you intubate these? I can see both sides of the coin.

 

[Arch Guillotti]

For GI I always intubate ERCPs, food boluses, and any upper GI bleed (Mallory-Weiss, bleeding ulcer, variceal bleeds, etc.). Don’t compromise on these.

In this same vein I have been getting quite a few pre-cath EGDs in people with suspected acute coronary syndromes. I had a recent pre-cath EGD patient just under sedation go into asystole when she desaturated briefly prompting resuscitation (she did ok). Would any of you intubate these? I can see both sides of the coin.

Pre-cath egd?

🙁😡😕

 

[Arch Guillotti]

Your GI's must be trash. Can't even remember the last time I had to tube one of these. Been st least a year. And we do a lot. We don't even go to the OR for these.

It’s more the patient than the gi doc. Your patient population must be very dofferent than most of us.

 

[chocomorsel]

Pre-cath egd?

🙁😡😕

Yeah, is this a thing?

 

[narcotics999]

Institution and GI Doc specific. I did 100+ ERCP prone MAC at one hospital with 2 GI dudes (>90%). All good, usually within 30mins. GA for fatty, bad OSA, N/V, or anything I don't feel right.

Now I do GETA only. One thing I dislike about GETA is flipping the pt. The head is awfully heavy.

 

[Noyac]

For GI I always intubate ERCPs, food boluses, and any upper GI bleed (Mallory-Weiss, bleeding ulcer, variceal bleeds, etc.). Don’t compromise on these.

In this same vein I have been getting quite a few pre-cath EGDs in people with suspected acute coronary syndromes. I had a recent pre-cath EGD patient just under sedation go into asystole when she desaturated briefly prompting resuscitation (she did ok). Would any of you intubate these? I can see both sides of the coin.

My approach exactly. It’s just too damn easy to intubate these pts and in the last 10 yrs when we have started to do so many more GI procedures across the country, I have seen a tremendous amount of complications in the GI suite when compared to the main OR. And airway/aspiration has been a huge portion of this. I just don’t mess.

I had a 90+ yo guy with an upper GI bleed for an EGD the other day. His HR was in the 30’s. He was DNR and refusing a pacemaker. But he wanted his presumed ulcer treated if we could do it quickly. I premeditated him with glyco to a HR of 52. Then told GI guy, let’s do this. Well of course he went asystolic as the stomach was insuflated. It took me about 1 min to get him back. And we got the procedure done. We found a legit bleeder and everyone was high fiving because we actually saved his life for at least another week.

 

[pgg]

In this same vein I have been getting quite a few pre-cath EGDs in people with suspected acute coronary syndromes.

Please elaborate, what's going on here?

 

[Psai]

Please elaborate, what's going on here?

Time is stomach

 

[T-burglar]

My approach exactly. It’s just too damn easy to intubate these pts and in the last 10 yrs when we have started to do so many more GI procedures across the country, I have seen a tremendous amount of complications in the GI suite when compared to the main OR. And airway/aspiration has been a huge portion of this. I just don’t mess.

I had a 90+ yo guy with an upper GI bleed for an EGD the other day. His HR was in the 30’s. He was DNR and refusing a pacemaker. But he wanted his presumed ulcer treated if we could do it quickly. I premeditated him with glyco to a HR of 52. Then told GI guy, let’s do this. Well of course he went asystolic as the stomach was insuflated. It took me about 1 min to get him back. And we got the procedure done. We found a legit bleeder and everyone was high fiving because we actually saved his life for at least another week.

Was he in heart block , out of curiosity? And did you have pads on to pace?

 

[Plead the Fifth]

Please elaborate, what's going on here?

I’ve only had a couple of these but typically it’s an NSTEMI type patient from the ER, some bumps in troponins but usually trending down when they come to OR. Cards wants to cath the patient but their HGB has dipped a few points and/or they have a hemoccult positive stool or an episode of “hematemesis” or whatever. Cards is too scared to heparinize or put in a DES/DAP therapy without ruling out GI pathology. This is the usual story.

 

[Noyac]

Was he in heart block , out of curiosity? And did you have pads on to pace?

Yes. Yes.

 

[Velefunt]

ETT.

As an aside, everyone who's mentioning the use of sugammadex - are y'all getting this on the cheap, cause last I was told it's $150 a vial. I've only ever used it once, and only because it was mandated as part of an (overly complex) anesthetic regimen for a particular ECT patient.

 

[deleted171991]

ETT.

As an aside, everyone who's mentioning the use of sugammadex - are y'all getting this on the cheap, cause last I was told it's $150 a vial. I've only ever used it once, and only because it was mandated as part of an (overly complex) anesthetic regimen for a particular ECT patient.

It's more like $50-70 per 200 mg/2 ml vial.

 

[Velefunt]

It's more like $50-70 per 200 mg/2ml vial.

Just re-checked our departmental email that came out this week - $165/5ml vial.

 

[OB1🤙]

It's more like $50-70 per 200 mg/2 ml vial.

Yep. Same as neostigmine/glyco pretty much.

 

[ProtonPump]

$165/5ml vial.

for standard reversal of ROC 200mg (2ml) vial seems to be enough for almost all the cases I've used it for. Maybe your department should get the smaller vials. Especially if you will continue to have that patient booked for ECT.

 

[Southpaw]

Just re-checked our departmental email that came out this week - $165/5ml vial.

Get the 2 ml vials. I almost NEVER need more than 200mg. Suggamadex is a beautiful reversal agent and relative to neo/glyco, I believe the patient benefits big time (shorter PACU times, less PONV).

 

[coffeebythelake]

Get the 2 ml vials. I almost NEVER need more than 200mg. Suggamadex is a beautiful reversal agent and relative to neo/glyco, I believe the patient benefits big time (shorter PACU times, less PONV).

Agree. If not for supply issues and price (both becoming less significant issues nowadays) I would use it for all my cases that I normally glyco/neo