Ercps

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tube adds literally 5 minutes to the procedure top. often less. We actually reviewed this over 800 ercps

prop tube spontaneous extubate while/ after turning back. You lose time having to position post tube on top of intubating and extubating. This was a whopping 5 minutes on average. Maybe you can add another 45 seconds for having to change out the circuit between cases.


I’ve seen 500cc of biliary fluid come out during an ERCP.

Happy to hear thoughts from the anti tube sedation folks. I used to be in that group. Now only do sedation for stent removal in healthy pll
 
I only do it with certain GI docs I have done the procedures with personally over the years Mac cases
The rest of the GI docs I tube them.

So it’s GI doc dependent.
 
aneftp said:
I only do it with certain GI docs I have done the procedures with personally over the years Mac cases
The rest of the GI docs I tube them.

So it’s GI doc dependent.
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I’m not sure how a certain GI doc minimizes the risk for a prone high aspiration risk
 
Didn't we have a big thread on this recently?

Never tubed, probably won't ever.
 
Ours do them basically supine with a bump, not even truly lateral. I have no problem doing them as a MAC as long as there are no risk factors. I can count on one hand the number of times I’ve had to intubate, and it was never a big deal.

If they were done prone, I’d probably just tube them all, though.
 
ToKingdomCome said:
I’m not sure how a certain GI doc minimizes the risk for a prone high aspiration risk
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Some are more skilled than others. That’s why.

This is where AI and metrics fail and real clinical judgment and experience matters.

Everything matters patient selections clinical skills etc.
 
amyl said:
How many of you docs do ercps prone/pro ish swimming position without a tube? Never? Or decide based on gerd? OSA? Obesity?
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One of my shops, that was standard prone ish, no tube

Unless:
Confirmed obstructive stone —> tube automatic
Other BMI, N/V status.

Did not love doing these with unsecured airway. Felt it was an unnecessary risk.
 
BLADEMDA said:
I have seen countless low grade aspirations from MAC EGDs and ERCPs. If it was me getting the ERCP I prefer an ET tube placed by a McGrath (please).
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This

Not many requests I would have if I were a patient, or if a loved one needed an anesthetic: tube for an ercp (the second is that no one is intentionally puncturing the dura when placing an epidural)
 
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forums.studentdoctor.net

MAC vs GA for ERCP New Guidelines

Anyone see the recent clinical guidelines published in the British Journal of Anesthesia for ERCPs? They state rather pointedly that MAC is the favored anesthetic and should be done for the majority of ERCPs. Complex procedures or specific patient factors may favor GA...
forums.studentdoctor.net forums.studentdoctor.net

I guess no one here is on that panel of international experts.

BLADEMDA said:
I have seen countless low grade aspirations from MAC EGDs and ERCPs. If it was me getting the ERCP I prefer an ET tube placed by a McGrath (please).
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I wonder all the time how much silent aspiration I miss with my EGD, TEE, and other deep sedation cases.
 
I have personally performed and supervised countless anesthetics for ERCPs. Yes, they can be done under MAC/TIVA from our side of things. However, I have seen numerous low grade aspirations from an unprotected airway because all of us initiate deep, non responsive sedation. The so called experts rarely have decades of clinical experience in the field so I take their "recommendations" with a grain of salt. "First do no harm" means consider the consequences of your actions or inactions followed by actual experience in the field of those actions/inactions. If your patient population is such that your aspiration % is very low during or after an ERCP then by all means continue your MAC/TIVA; but, if your patient population is similar to mine I think you are ignorant of the actual aspiration % because you aren't actually physically present in the GI suite much or you think a little aspiration won't do much harm to the patient.
 
Worst is when they don't suction out the belly properly and pull out a bunch of bilious fluid when the scope comes out. Tube unless it's a 5 minute stent pull on a healthyish skinny patient as said above.
 
Previous places I’ve been tube always.

Current private practice standard is no tube. Granted its MD only so I’m doing it myself, they position lateral not prone and are very efficient (5-10 minutes).

Doesn’t bring me joy but sometimes you have to go with the flow. And I’ll tube if it’s obviously warranted.
 
ETT every time. Only complications from ERCPs I’ve attended to help or we reviewed as a group over past 3 years all were respiratory complications/aspirations in untubed patients. Adds what, extra 3-5 min total?

**only exception is very quick stent removal in healthy/skinny pts with 1 GI doc who is facile and can do them supine
 
BLADEMDA said:
I have personally performed and supervised countless anesthetics for ERCPs. Yes, they can be done under MAC/TIVA from our side of things. However, I have seen numerous low grade aspirations from an unprotected airway because all of us initiate deep, non responsive sedation. The so called experts rarely have decades of clinical experience in the field so I take their "recommendations" with a grain of salt. "First do no harm" means consider the consequences of your actions or inactions followed by actual experience in the field of those actions/inactions. If your patient population is such that your aspiration % is very low during or after an ERCP then by all means continue your MAC/TIVA; but, if your patient population is similar to mine I think you are ignorant of the actual aspiration % because you aren't actually physically present in the GI suite much or you think a little aspiration won't do much harm to the patient.
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Do you have any numbers to back that?
How many aspirate and how many of those develop complication?
 
In some hospitals patients with MAC that has worn off avoid phase 1 recovery room and can go to ASU or phase 2. If this is the case a GA with ETT adds a lot more time to the process for ambulatory surgery patients.
 
Drwine said:
In some hospitals patients with MAC that has worn off avoid phase 1 recovery room and can go to ASU or phase 2. If this is the case a GA with ETT adds a lot more time to the process for ambulatory surgery patients.
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It doesn't have to.

A general done with propofol and no volatile, opioid, or benzo is ready for phase 2 just a few minutes after extubation.

I do 99% of my ERCPs with prop, succ[1], spontaneous ventilation, propofol infusion. They roll into a sloppy prone position, do the case, and I turn off the propofol when they're wrapping up. By the time they're supine on the gurney again, they're about ready to extubate. By the time all the EMR clicking is done, they're ready to go back to their endo holding room (phase 2). I am never ever the time limiting factor over there.

Where a GETA slows things down is if people do their usual polypharmacy thing with midazolam, propofol, fentanyl ...

A plain old colonoscopy or EGD done with single agent propofol is a general anesthetic without a secured airway. One can do essentially the same, albeit with a somewhat larger induction dose plus an endotracheal tube, for an ERCP. And the wakeup is the same.



[1] sometimes roc + sugammadex because I hate succ, and like stiggin' it to the hospital by spending more of their money
 
Drwine said:
In some hospitals patients with MAC that has worn off avoid phase 1 recovery room and can go to ASU or phase 2. If this is the case a GA with ETT adds a lot more time to the process for ambulatory surgery patients.
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most seem do “mac” aka ga without an airway for these cases with the same general anesthetic propofol they use for tube cases.


there is no rule against sending any post ga patient to phase 2. It’s up to the anesthesiologists discretion at my plaxe
 
Done countless ones under MAC. Hated every one. Much prefer GA but not always my call 🙂 .
 
aneftp said:
Some are more skilled than others. That’s why.

This is where AI and metrics fail and real clinical judgment and experience matters.

Everything matters patient selections clinical skills etc.
Click to expand...
so what youre saying is we all should've done gi
 
Southpaw said:
wish I could do them all geta. Culture here is ga w no airway. I often search hard for a reason for geta.
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Why can’t you decide Geta vs tiva/deep sedation/mac
 
Why does the input of a GI doc (meaningless) or culture of a group determine anyone’s practice? I just do what I feel is safest which when it comes to an ercp is an ETT
 
Southpaw said:
wish I could do them all geta. Culture here is ga w no airway. I often search hard for a reason for geta.
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I used to get a fair bit of pushback from the EP docs here because I put art lines in every single ablation. Most of my partners weren't routinely doing that.

I just shrugged and told them that's the way I do those cases. They eventually quit whining when they realized it wasn't costing them any time and that I was going to do them anyway.

It can be the same for you and ERCP GETAs. 🙂
 
amyl said:
How many of you docs do ercps prone/pro ish swimming position without a tube? Never? Or decide based on gerd? OSA? Obesity?
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The only time I do them MAC is when the patient is nonobese, young-ish, cooperative, with no neck hardware present and otherwise somewhat healthy. The proceduralist also has to be the fast (no fellows). I instruct them to go on their abdomen as they move to the table, place a pillow under their head and get comfortable. Anything else, these patients get a tube. I also have the bed right outside accessible in case we need to flip her right away (I notify C-arm and my nurse of this plan).
 
BLADEMDA said:
I have personally performed and supervised countless anesthetics for ERCPs. Yes, they can be done under MAC/TIVA from our side of things. However, I have seen numerous low grade aspirations from an unprotected airway because all of us initiate deep, non responsive sedation. The so called experts rarely have decades of clinical experience in the field so I take their "recommendations" with a grain of salt. "First do no harm" means consider the consequences of your actions or inactions followed by actual experience in the field of those actions/inactions. If your patient population is such that your aspiration % is very low during or after an ERCP then by all means continue your MAC/TIVA; but, if your patient population is similar to mine I think you are ignorant of the actual aspiration % because you aren't actually physically present in the GI suite much or you think a little aspiration won't do much harm to the patient.
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Agree 100%

Absolutely hated it, but it was locums job.
 
pgg said:
It doesn't have to.

A general done with propofol and no volatile, opioid, or benzo is ready for phase 2 just a few minutes after extubation.

I do 99% of my ERCPs with prop, succ[1], spontaneous ventilation, propofol infusion. They roll into a sloppy prone position, do the case, and I turn off the propofol when they're wrapping up. By the time they're supine on the gurney again, they're about ready to extubate. By the time all the EMR clicking is done, they're ready to go back to their endo holding room (phase 2). I am never ever the time limiting factor over there.

Where a GETA slows things down is if people do their usual polypharmacy thing with midazolam, propofol, fentanyl ...

A plain old colonoscopy or EGD done with single agent propofol is a general anesthetic without a secured airway. One can do essentially the same, albeit with a somewhat larger induction dose plus an endotracheal tube, for an ERCP. And the wakeup is the same.



[1] sometimes roc + sugammadex because I hate succ, and like stiggin' it to the hospital by spending more of their money
Click to expand...
++
 
My (air)way or the highway buddy

I say it to the GI docs to their face when this debate comes up. Like it’s not my decision to tell what scope goes into which anus it’s not their decision how I manage airway.

Day goes longer in your opinion with ett? Ok. Np. Let’s start at 5 am. 6 am. Let’s save time that way. But I know they’ll roll in at 815 and bitch anyways.

They used to not like it until one of their ercps took 3 hours. Then I made it a point to say “aren’t you glad we intubated”.

I didnt get any pushback after.
 
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pgg said:
I used to get a fair bit of pushback from the EP docs here because I put art lines in every single ablation. Most of my partners weren't routinely doing that.

I just shrugged and told them that's the way I do those cases. They eventually quit whining when they realized it wasn't costing them any time and that I was going to do them anyway.

It can be the same for you and ERCP GETAs. 🙂
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a-line for every flutter line or SVT ablations? Any estimate of how frequently it made a difference?
 
AKMD_1984 said:
My (air)way or the highway buddy

I say it to the GI docs on their face when this debate comes up. Like it’s not my decision to tell what scope goes into which anus it’s not their decision how I manage airway.

Day goes longer in your opinion with ett? Ok. Np. Let’s start at 5 am. 6 am. Let’s save time that way. But I know they’ll roll in at 815 and bitch anyways.

They used to not like it until one of their ercps took 3 hours. Then I made it a point to say “aren’t you glad we intubated”.

I didnt get any pushback after.
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It's easier to push back when you've been at a place longer than the proceduralists. For new people, it helps to have an open mind, learn the culture and take notes, before writing off people/techniques.
 
DrN2O said:
It's easier to push back when you've been at a place longer than the proceduralists. For new people, it helps to have an open mind, learn the culture and take notes, before writing off people/techniques.
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You bring up a fair point generally.

However this particular procedure (prone, high aspiration risk, shared airway) means that risk vs benefit for GA without airway is not an option.

I’m yet to be convinced why one should not intubate here. Pggs technique is what I use.

GI docs’ opinion on anesthesia delivery is irrelevant here.

Many places do these cases in IR and fluoro suite away from main OR. My first job was like this. You should be even more careful in doing these cases without extra hands or equipment.
 
DrN2O said:
a-line for every flutter line or SVT ablations? Any estimate of how frequently it made a difference?
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I don't keep stats, but in the last two years here I've had two routine ablations go south after the heart got perf'd and instant detection with the art line probably improved the outcomes.

Would I have detected the perforations 3 - 5 minutes later with a NIBP and done mostly the same things, probably.

But the last one got a pericardial pigtail placed quickly, crumped anyway, got CPR in the hallway to a cardiac OR where an emergency sternotomy saved the patient's life. Neurologically intact and discharged a few days or a week later. I was glad to have the art line from the start.

They're easy to do. Patient goes to sleep, ETT goes in, I walk over to the arm which the RN has put on an armboard for me, ultrasound-guided a-line in (2? 3 minutes?), and then we still usually wait 10-20 more for prep and the cardiologist to arrive.

(I'm also exceptionally unsympathetic to this particular EP department's occasional efficiency chattering, because they routinely stroll in after 8 or 8:30 for cases posted to start at 7:30 with some song and dance about a meeting that ran late or a scheduling mistake.)

I just figure any time someone's jabbing wires around the inside of the heart and cooking or freezing things, there's potential for abrupt and significant hemodynamic changes. The gold standard for monitoring there is an art line. Fast, cheap, low risk, solid benefit.
 
Lets be clear about something here: these cases are all done under general anesthesia, regardless of the medication used to achieve that level. I would argue that all endo procedures we're involved in are done under general, +/- an airway.

There was a study done in 2013 out of Boston. Published in a GI journal. GA with ett vs "deep sedation" without an ETT. I think they claimed that the two techniques were the same but 1. they didn't monitor the depth of sedation in the "deep sedation" arm and 2. they had a 4% conversion rate to an ett in the "deep sedation" arm. (Barnett SR, Berzin T, Sankara S et al. Deep Sedation without intubation for ERCP is appropriate in healthy, non-obese patients. Dig Dis Sci (Epub ahead of print).) (I read the study a year ago after an endoscopist gave me a hard time for intubating someone.)

There is no benefit to the patient by not intubating them, but there is clear harm. And a 4% chance that you're rushing to flip supine and secure an airway.
 
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