Ercp

[dabears505]

Hey, what are you guys doing for ercps? General for all? Sedation?

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[caligas]

Good question but this has been covered. The correct answer is ETT.

7 people will say that. 2 people will say MAC, but they work with slick GI docs and patients that aren’t mostly dead.

 

[Mikkel]

ERCP is a glorified EGD. Like I wouldn't intubate an EGD regularly, I wouldn't intubate an ERCP.

But the endoscopists disagree, and they call the shots on this.

 

[Arch Guillotti]

been discussed, tube 100% is what most folks do.

 

[dhb]

Depends on the person doing the procedure and the patient population.
If it's less than 30min in a "healthy" patient no tube if not then tube.
I like to give propofol topicalize the airway intubate and leave them in SV with sevo. Very easy, stable and you can wake them up quickly when they decide they've finished mucking around.

 

[nimbus]

been discussed, tube 100% is what most folks do.

Here it is.

ERCP Question

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...

forums.studentdoctor.net

 

[dannyboy1]

Intubate and paralyze them all. Run 0.5 mac + nitrous. Suggamadex is your friend at the end.

 

[facted]

At the end of the case, look at the pillow and the massive amount of saliva and other sections in the pillow. Then imagine those sections working themselves down into the larynx.

If you still want to do "mac", go for it. The rest of us do ETT. Btw, I work with two very swift endoscopists, but it's not even a question for them, or us, on putting in an ETT. It's the right thing to do.

 

[dhb]

It's the right thing to do.

So why is the right thing to do not done by many people to many patient with no proof of worse outcomes?

 

[Dexmetaketapropofol]

It is the right thing to do, their own GI association agrees. It's not the most robust study, but if their society has looked into it, and it's easier for us to do, then why fight it

https://www.giejournal.org/article/S0016-5107(18)33012-8/fulltext

 

[Mikkel]

At the end of the case, look at the pillow and the massive amount of saliva and other sections in the pillow. Then imagine those sections working themselves down into the larynx.

The patient coughs. Throat gets suctioned. Patient stops coughing.

How is this any different than an EGD? They still have a ton of secretions, but you don't tube all those now, do you?

In fact, going prone makes it even easier for the secretions to drip out on their own.

Just my past experience. I tube now because I work with a different GI group that expects tubes for ERCPs.

But, I miss MAC ERCPs... Patients position themselves and they make sure they're comfortable before sedating. They wake up very quickly and go straight back to their hospital room.

 

[caligas]

It is the right thing to do, their own GI association agrees. It's not the most robust study, but if their society has looked into it, and it's easier for us to do, then why fight it

https://www.giejournal.org/article/S0016-5107(18)33012-8/fulltext

Better study than you usually get when trying to answer these kind of questions.

 

[facted]

So why is the right thing to do not done by many people to many patient with no proof of worse outcomes?

Because poor outcomes are rare, but definitely more common than ETT. My job is to minimize risk as much as possible, not to almost always get away with it.

 

[facted]

The patient coughs. Throat gets suctioned. Patient stops coughing.

How is this any different than an EGD? They still have a ton of secretions, but you don't tube all those now, do you?

In fact, going prone makes it even easier for the secretions to drip out on their own.

Just my past experience. I tube now because I work with a different GI group that expects tubes for ERCPs.

But, I miss MAC ERCPs... Patients position themselves and they make sure they're comfortable before sedating. They wake up very quickly and go straight back to their hospital room.

There's a lot of cases that go fine even though it wasn't the right thing to do. In fact, vast majority of them. Doesn't make it a good decision.

Losing an airway prone with tons of sections is something I would like to avoid 100% of the time even if I could get away with it 99% of the time.

 

[Ezekiel2517]

I've done MAC for >90% of these in PP. Our GI's must be slick compared to others I guess.

 

[nimbus]

Tube is less work.

 

[IMGASMD]

Mostly tube. Once in a long while, GI May say this is a patient (whatever reason) may be a good candidate for MAC.

 

[Mikkel]

Because poor outcomes are rare, but definitely more common than ETT. My job is to minimize risk as much as possible, not to almost always get away with it.

You have no evidence of that.

My guess is there are more complications with intubated patients than non-intubated patients. I never had any issue with MAC.

 

[Mikkel]

Losing an airway prone with tons of sections

What does that even mean?

Sounds like residency faculty mumbo jumbo.

 

[facted]

What does that even mean?

Sounds like residency faculty mumbo jumbo.

I've been in private practice for 7 years.

You do whatever you want to do. Trust me, no one here cares what you do for your cases. But if the question is which is safer, it's not even a question.

Here's just one paper showing it:

https://www.qxmd.com/r/30217726

 

[facted]

You have no evidence of that.

My guess is there are more complications with intubated patients than non-intubated patients. I never had any issue with MAC.

First of all, you're probably not then doing MAC. Is your patient fighting the endoscopist throughout the case? If not, you're doing GA without an airway, not "MAC". Read the ASA sedation guidelines.

Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists

Developed by the American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists: Jeffrey B. Gross, M.D. (Chair), Farmington, CT; Peter L. Bailey, M.D., Rochester, NY; Richard T. Connis, Ph.D., Woodinville, WA; Charles J. Coté, M.D., Chicago, IL; Fred G...

anesthesiology.pubs.asahq.org

 

[Mikkel]

First of all, you're probably not then doing MAC. Is your patient fighting the endoscopist throughout the case? If not, you're doing GA without an airway, not "MAC". Read the ASA sedation guidelines.

Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists

Developed by the American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists: Jeffrey B. Gross, M.D. (Chair), Farmington, CT; Peter L. Bailey, M.D., Rochester, NY; Richard T. Connis, Ph.D., Woodinville, WA; Charles J. Coté, M.D., Chicago, IL; Fred G...

anesthesiology.pubs.asahq.org

Are your EGDs and colonoscopies general anesthesia then? Or is your MAC just rubbish, with patients fighting the endoscopist the whole case?

 

[Ezekiel2517]

Tube is less work.

Lol not even close. Hopefully you can find some slicker GI's

 

[facted]

Are your EGDs and colonoscopies general anesthesia then? Or is your MAC just rubbish, with patients fighting the endoscopist the whole case?

You push propofol and it's GA. That my groups definition, my billing company definition, and the ASA definition. Therefore, it's also mine.

Per ASA guidelines: GA - "unarousable even after painful stimuli".

That includes colonoscopy and EGD. We do very few "MAC" cases.

 

[deleted697127]

Lol not even close. Hopefully you can find some slicker GI's

Slick GIs are seasonal in academics.

 

[dhb]

Slick GIs are seasonal in academics.

What's your record?
I've done a stone extraction in 11min.

 

[nimbus]

What's your record?
I've done a stone extraction in 11min.

We used to have a guy like that. Stones/stents mostly 10-15min and did them all supine. He was born in Egypt and spoke 5 languages too (English/Arabic//French/Spanish/Mandarin). Sadly he’s stopped coming to our hospital.

 

[deleted162650]

What's your record?
I've done a stone extraction in 11min.

Must be nice. I’m used to 30mins of:

“Bow, Un-bow. . bow, un-bow. . . bow 1/2 way, ok now un-bow, bow . . . un-bow then bow again real quick, un-bow . . . . . . “

 

[Mikkel]

Must be nice. I’m used to 30mins of:

“Bow, Un-bow. . bow, un-bow. . . bow 1/2 way, ok now un-bow, bow . . . un-bow then bow again real quick, un-bow . . . . . . “

[Two hours later]...

"Let's flip the patient to supine."

 

[DM27]

Overall I don’t find this study to be the best piece of evidence to be used in this argument. For one, among people who determine the anesthetic based on the case and patient rather than “MAC for all” or “tube for all”, they likely would’ve tubed most of their inclusion group. The inclusion criteria included OSA, Mallampati 4, BMI over 35, Ascites, COPD, and heavy alcohol use. Also to qualify as having an adverse event you needed to have had a single airway maneuver performed (chin lift = serious event), have a pulse ox reading <90% for any period of time (poor waveform = serious event?), low blood pressure needing any pressor administration.

The main airway event reported was an airway maneuver such a chin lift, which would ONLY be occurring a MAC patient to begin with and in my opinion does not represent a serious maneuver at all. I will chin lift someone who is sedated who isn't obstructing to simply make any likelihood of obstruction less likely, and in this study chin lifting was at the provider's discretion, so I would've been 100% event prone.

Also, one of the study's main sources (citation 9) actually found nearly the opposite outcome and suggests MAC as a reasonable and safe option for most comers.

I am not even sure what the purpose was of performing this study as any practicing anesthesiologist could have told them with those criteria they will definitely have a significant increase in “sedation related adverse events” in the MAC group.

For ERCPs I personally base it on the patient, the CRNA I am working with, and the endoscopic. I personally prefer general with a tube for these because I just find prone MAC to be a pain in the ass. I probably do MAC at most 30-40% of the time for these.

 

[nimbus]

Lol not even close. Hopefully you can find some slicker GI's

I never have to get up from my chair if I have a tube in

 

[rakotomazoto]

Did vast majority as MAC during residency, never got burned. Every now and then, tubed a particularly sick one. Joined a group where everyone does GETA, apparently some partners have been burned in the past. Our GI docs vary widely, some are super-slick, others not so much... best to have the safest anesthesia plan to protect patients from the lowest common denominator.

 

[2Fast2Des]

I agree propofol for GI cases is general, whole mac classification is ridiculous just because no tube. Pt having light propofol for a Ortho spinal case is mac, pt is easily arousable. I prefer a tube unless the GI is reliable and quick for ERCP. Why spend time watching the pt closely with GA no airway than GA with a real airway?

 

[deleted697127]

What's your record?
I've done a stone extraction in 11min.

Ha. I wasn’t even referring to the actual procedure. I’ve just noticed it takes less propofol to get the probe in smoothly for a GI or cards fellow that’s about to graduate.

 

[T-burglar]

Lmao @ “tube is more work”

In what world ...

 

[narcotics999]

We used to have a guy like that. Stones/stents mostly 10-15min and did them all supine. He was born in Egypt and spoke 5 languages too (English/Arabic//French/Spanish/Mandarin). Sadly he’s stopped coming to our hospital.

Not related to ERCP. Your logo pic is disgusting.

 

[Noyac]

I have never done one under sedation. Every single one was GETA. AND I DOUBT I WILL EVER CHANGE, unless they want to do these supine.

 

[jeesapeesa]

Hey, what are you guys doing for ercps? General for all? Sedation?

my group varies...50% ETT, 25% sedation, 25% depends. our GI guy is pretty quick so i don't have a problem with either unless it's a behemoth with airway issues.

 

[NoodleIncident]

About 90% of mine are TIVA with Propofol/Fent and nasal cannula. I agree with the above poster that the secretions just follow gravity and come out of the mouth. I prefer that they get into a position of comfort before induction. I don't want to find out after an ETT case that we had them positioned in a way that their body can't naturally do and now they have a positional injury. Even OSA patients do well because the tongue is no longer falling back into the pharynx, but rather forward and out of the way. The 10% that get tubed are those with dementia and can't get themselves positioned or have such poor neck mobility that I don't think that I'd be able to mask them prone with their head rotated.