How fat is too fat for outpatient colonscopy (no anesthesia machine available)

[aneftp]

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Gotta cover outpatient GI center next week.

Looking through the patient's charts today.

Notice that one patient is listed as 5 foot 5 and weighs 420 pounds. Typical sleep apena, DM, HTN etc. BMI has got to be close to 70 on this patient. I've been at this GI center before.

It's barebones facilitiy. No 12 lead EKG available. Just a craftsman cart with basic anesthesia drugs and they don't even stock sux (they don't want to stock it cause they don't want to pay for MH cart). This is a cheap ass facility.

All I have is an ambug bag there my basic airway equipment.

I always get in an argument with the GI guys on these types of patients.

What do you guys/gals think. The stretcher can hold up to 450 pounds.

One of the GI centers around town just had a patient death with routine colonscopy on a 400 plus pound patient.

I'm leading towards canceling the case and booting it back to the hospital. It's more of available resources available at the hospital in case it's needed.

 

[leaverus]

I think your second-to-last sentence says it all. The risks >>> benefits of doing this patient in the clinic.

 

[jwk]

This is a legitimate ASA IV patient, thus unsuitable for an ASC for just about anything except perhaps a topical cataract with no sedation.

 

[IlDestriero]

This is a legitimate ASA IV patient, thus unsuitable for an ASC for just about anything except perhaps a topical cataract with no sedation.

There are people that they can argue are borderline and therefore ok, in their minds, for an ASC. This person's BMI alone disqualifies them.
No Succs? I'm not sure how I feel about that. I guess they're believers in the "hypoxia breaks laryngospasm eventually" theory. I know that it will, but I think that ischemia, arrhythmia and anoxic brain injury might come first. BTW, I would think that hyperkalemic arrest would be more common than MH after administration of Succs. They should stock it. I'd be fine w/ no dantroline. I'm guessing that there's no insulin, bicarbonate, glucose or calcium either. Maybe you need to bring your own disaster box. When you assassinate someone because you don't have what you need to rescue them, all the liability will rest with you. They'll claim they had no idea that you needed X, Y, and Z and would have been happy to stock the stuff if only they understood why you wanted it. Sigh...

 

[Arch Guillotti]

What is the constant threat to life in this patient?

This is a legitimate ASA IV patient, thus unsuitable for an ASC for just about anything except perhaps a topical cataract with no sedation.

 

[aneftp]

There are people that they can argue are borderline and therefore ok, in their minds, for an ASC. This person's BMI alone disqualifies them.
No Succs? I'm not sure how I feel about that. I guess they're believers in the "hypoxia breaks laryngospasm eventually" theory. I know that it will, but I think that ischemia, arrhythmia and anoxic brain injury might come first. BTW, I would think that hyperkalemic arrest would be more common than MH after administration of Succs. They should stock it. I'd be fine w/ no dantroline. I'm guessing that there's no insulin, bicarbonate, glucose or calcium either. Maybe you need to bring your own disaster box. When you assassinate someone because you don't have what you need to rescue them, all the liability will rest with you. They'll claim they had no idea that you needed X, Y, and Z and would have been happy to stock the stuff if only they understood why you wanted it. Sigh...

I know. There's no consensus on obesity and stand a lone surgery centers. At the ASA meeting a few years ago, they had a topic on this (obesity at the stand alone surgery center). They beat around the bush and never issue and guidance. A multi-institutional study on obesity and outpatient procedures will only hurt the bottom line of physician owned surgery centers. You will basically fund a study (that you already know the answer: more mortality/morbidity with obese patients) that will potentially limit your income.

Yeah, the center is co-owned by a national corporation and they are cheap. I mean not only do we not have the 12 lead ekg, no machines, no sux etc, (think about the Las Vegas GI center fiasco that ended up in a 500 million dollar verdict). They aren't on that level YET, but you get my drift on the cost cutting on these centers.

I talked to the GI doc. We aren't going to do the case under MAC...but he's decided to sedate the patient himself with versed/fentanyl. He's an old timer (GI doc is in his late 50s) and he's been doing it for years.

 

[aneftp]

What is the constant threat to life in this patient?

I agree. It's very debatable on this ASA class.

To me, this patient is an ASA 3, but the issue is more ventilation. I don't have a anesthesia machine available. Just and ambug bag. So even if I needed to intubate the patient, I doubt I will be able to ventilate very well with an ambug bag just on the size of this patient. Can't give peep etc.

 

[drccw]

What is the constant threat to life in this patient?

BMI 69.9 That falls into the category of "malignant obesity" in my mind (something I came up with). I like to categorize anything over BMI 60 as malignant. It's going to catch on. Trust me...

drccw

Or maybe we can call it metastatic obesity...

 

[Trisomy13]

What is the constant threat to life in this patient?

gravity

 

[Arch Guillotti]

I agree - Based on how the guidelines are written I would make the patient an ASA 3. I can understand why some would want to make him a 4 though.

I have seen a few patients with SEVERE OSA for UPPP, etc. They haven't been superobese either and IIRC I made them an ASA 3.

I guess my point is that even though this guy is as big as a battleship and he could drop dead anytime due to a PE or something I really don't see the constant threat to life.

I wouldn't touch this guy at an ASC unless it was directly attached to a hospital and I certainly wouldn't want to do it without backup airway stuff etc.

I agree. It's very debatable on this ASA class.

To me, this patient is an ASA 3, but the issue is more ventilation. I don't have a anesthesia machine available. Just and ambug bag. So even if I needed to intubate the patient, I doubt I will be able to ventilate very well with an ambug bag just on the size of this patient. Can't give peep etc.

 

[aneftp]

gravity

That's so funny!

 

[Sergio99]

It's barebones facilitiy. No 12 lead EKG available. Just a craftsman cart with basic anesthesia drugs and they don't even stock sux (they don't want to stock it cause they don't want to pay for MH cart). This is a cheap ass facility.

All I have is an ambug bag there my basic airway equipment.

This is a perfect illustration of how is the job market in anesthesia. If there were enough jobs, these people wouldn't find an anesthesiologist to staff their facility in a million years.

Going to your question, yes, it is risky to take care of this patient in a place like that. Actually, it is risky to take care of any patient in a place like that, but much more so this particular case. I would send him to the hospital.

Remember that in the closed claims analyses and in the anesthesia oral boards the great majority of cardiac arrests occur in cases like this, where people think they can get away with minimal intervention and monitoring with IV sedation, and end up with irrecoverable disasters.

I would not work in a place like that. I know: the economy is bad, we live in tough times, but it is going to be much worse if on top of the Dow crashing you kill somebody, have a big lawsuit and possibly lose your license.

Greetings.

 

[sevoflurane]

It's barebones facilitiy. No 12 lead EKG available. Just a craftsman cart with basic anesthesia drugs and they don't even stock sux (they don't want to stock it cause they don't want to pay for MH cart). This is a cheap ass facility.

All I have is an ambug bag there my basic airway equipment.

I always get in an argument with the GI guys on these types of patients.

Yuck.

I wouldn't touch this guy at an ASC unless it was directly attached to a hospital and I certainly wouldn't want to do it without backup airway stuff etc.

Agree 100%

I know: the economy is bad, we live in tough times, but it is going to be much worse if on top of the Dow crashing you kill somebody, have a big lawsuit and possibly lose your license.

Rough couple of weeks. I maxed out my sep-IRA last year and I haven’t pulled the trigger.... yet. Wondering if I should do it sometime soon. If it falls much more, I think I’m jumping in. Of course, I don’t know shait about the stock market besides what "mad" krammer has to say and yet, I’m cautious about what my financial advisor thinks I need to do with my hard earned $$$.

 

[maceo]

the last few deaths that ive heard of that ive said (OMG) have been at GI centers doing the upper EGD.. what city do you work in OP?

 

[aneftp]

the last few deaths that ive heard of that ive said (OMG) have been at GI centers doing the upper EGD.. what city do you work in OP?

Down in the Orlando area.

I actually make very good money for outpatient anesthesia M-F (mid 400s with 6 weeks paid vacation). I'm contracted out so I get paid whether I do the case or not. While I also believe the job market is "tight" but not "super tight" unless you are in the NE or West Coast area.

I'm not that concerned about the anesthesia company breaking my contract; I've been with them for 3 plus years. They know how I work. I'm very safe. Some of the older anesthesiologist do guys up to 450 pounds because "it's what the stretchers fit mentality."

As I stated, you pick and choose your battles in private practice. In this case, I decided not to do the case. It's just the trend. More and more cases that routinely used to be done in the hospital are being pushed toward outpatient center (aka those not attached to the hospital...like next to Panera Bread)

At the other surgery center (mainly doing ENT, urology, minor general cases/plastics) I cover, we actually have a center imposed BMI limit of 40. Anything above that, requires a an automatic anesthesia review. So it varies by center.

 

[SexPanther]

How would you guys do this case? Assume it's in the proper location.

I haven't had a ton of exposure to EGDs, ERCPs, colonoscopies etc and when I have it has been difficult for me to find the balance in too much vs. too little anesthetic.

 

[jwk]

What is the constant threat to life in this patient?

Her obesity and OSA are a constant threat to her life, are they not?

 

[dhb]

Technically not you rarely suffer in the short term from those conditions. I agree that gravity is more dangerous.

 

[jwk]

Technically not you rarely suffer in the short term from those conditions. I agree that gravity is more dangerous.

Haha, gravity is definitely problematic, although if she's sitting up, gravity might be her friend.

The ASA defines a status IV patient as "A patient with severe systemic disease that is a constant threat to life". I would argue that massively morbid (or malignant if you prefer) obesity on top of OSA, both of which are severe systemic disease processes in and of themselves, would elevate her into that "constant threat to life" stage.

 

[fakin' the funk]

BMI 69.9 That falls into the category of "malignant obesity" in my mind (something I came up with). I like to categorize anything over BMI 60 as malignant. It's going to catch on. Trust me...

drccw

Or maybe we can call it metastatic obesity...

overweight > obese > morbidly obese > mortally obese

 

[Arch Guillotti]

Maybe, but I don't consider it the same way I do severe unstable angina, bad CHF, ESRD etc

Her obesity and OSA are a constant threat to her life, are they not?

 

[IlDestriero]

If your pallbearers are actually going to be a motorized crane, you're too big for the ASC. That there policy will keep you out of trouble!

 

[2win]

I don't do ANY anesthesia without a machine available.
PURE BUSINESS.

 

[ProRealDoc]

How would you guys do this case? Assume it's in the proper location.

I haven't had a ton of exposure to EGDs, ERCPs, colonoscopies etc and when I have it has been difficult for me to find the balance in too much vs. too little anesthetic.

Done entire days of EGD/ERCPs/colonoscopies. The usual is propofol gtt 50-100mcg/kg/min with small ketamine boluses 10-20mg. Airway equipment and anesthesia machine are available. This simple approach has worked well for me and the patients seem to tolerate the procedure without much discomfort.

 

[IlDestriero]

How would you guys do this case? Assume it's in the proper location.

I don't harpoon many whales anymore, but here's my formula for Peds GI if you are interested:
Mask induction, IV, bolus 1mcg/kg Fentanyl in 2 aliquots a few minutes apart.
Start Propofol/ketamine infusion (1mg ketamine/cc propofol) at 250 mcg/kg/min. Consider giving glyco. I usually give it to the african american kids.
Continue 4-5% Sevo with 100% O2 until placing Nasal cannula with CO2 monitoring. Pt should be spontaneously breathing if you dosed the fentanyl as above. If the patient seems like a lightweight I might only give 0.5 mcg/kg.
Start.
Keep 5-10 cc of Prop in line.
If it is an upper lower, I may place an LMA if the patient has obstruction during or after the EGD. If only a colon, I place an LMA if the patient obstructs during the induction.
If the patient is under 10 or 12kg I usually intubate, unless they are older kids who have severe failure to thrive.
Our GI guys are really fast if they don't have a fellow, sometimes they are apneic at the start of the EGD, they're done before they desaturate if I give them a good preoxygenation.

 

[orangele]

Personally IMHO, I would CONSIDER doing this patient (although I would inform the GI doc that I need to evaluate the patient in person prior to making a decision). I WOULD NOT do this patient without a 12 Lead (Have seen 25 year olds with MI's), WOULD NOT do this case without emergency airway equipment (basic intubating equipment obviously oxygen and ambu bag, and back up method of intubating (fiberoptic, glidescope, etc), emergent cric kit available, defibrillator. Definitely would not do this case without succ present. I would not require an anesthesia machine present (not necessary to keep patient alive) .

I believe most people would not be surprised if a person like this died in their sleep overnight, and therefore would certainly consider them an ASA IV candidate since their obesity puts enough strain on their organ systems to be a constant risk to life.

Ultimately, as an anesthesiologist, you will be held to the standards expected of an anesthesiologist if the sh_t hits the fan (sorry for the pun).

 

[IlDestriero]

Just out of curiosity, what kinds of emergency drugs and equipment are available to you there in the GI suite? I know that you can send the tech to Panera Bread next door to borrow a knife for the surgical cricothyroidotomy, but you have some gear there, right?

 

[urge]

they don't even stock sux (they don't want to stock it cause they don't want to pay for MH cart).

You are ok with that?

Dantrolene is like 3k. I wouldn't work there.

 

[hoyden]

What is the constant threat to life in this patient?

He is clearly ASA 3.5- 3.75 - there are a lot of those who are further down the road than ASA 3 ( as this particular one) but do not strictly fit the death threat option of the ASA 4. However, one might take into consideration an everyday risk of his bed being broken and him buried underneath 😀

I hate those fatsos.

 

[Sergio99]

Hello,

...Have seen 25 year olds with MI's...

I have seen an extensive anterior MI in a 24 year old. Sorry for the anecdotal digression, but the guy was walking on the sidewalk across the hospital and felt a little twinge on his chest. He was going to continue walking and thinking it was "gas," as any of us would have done at that age, when, out of the blue, he had the idea of crossing the street to the ER and having himself examined. The residents at the ER thought it was gas, and were going to send him home, when, again, out of the blue, someone said, "lets do a 12 lead ECG before he leaves." Nobody could believe it: extensive anteroseptal MI. The guy spent almost two weeks in the ICU, with all kinds of complications, and I don't remember whether he was discharged alive or not.

Definitely would not do this case without succ present.

I could not agree with you more.

Ultimately, as an anesthesiologist, you will be held to the standards expected of an anesthesiologist.

Absolutely! And guess what: the GI person who insists that you do it below standard practice will be the first one to accuse you of wrongdoing. He will say, "that's why we asked you to come and help us, to do it right, because he was high risk."

Greetings

P. S.: Let me add, I don't like to share the airway with GI guys, especially on a morbidly obese patient. I would definitely intubate this patient.

SB

P. S. #2: I am sorry, I thought it was an EGD; that is why I was talking about a shared airway. For a colonoscopy there is no issue with a shared airway. The patient will be lateral, so maybe I wouldn't intubate him after all. If he is breathing nicely without any help in the lateral position, he may do well without an airway, but if he has signs of obstruction, even mild, I would still want to intubate him. I get nervous when patients don't breathe well.

SB

 

[aneftp]

Just out of curiosity, what kinds of emergency drugs and equipment are available to you there in the GI suite? I know that you can send the tech to Panera Bread next door to borrow a knife for the surgical cricothyroidotomy, but you have some gear there, right?

This facility is a AAAHC accreditated outpatient center. There are three major accrediting groups recognized by CMS and this place is accreited. It's not a mom and pop office based procedure. It's as big as most surgery centers. They have 3 huge GI suites.

As for backup equipment. They have defribillators (the real one, not AED), the same crash cart you see in hospitals.

Same anesthesia cart stocked with every emergency drug (epi, lido, bicarbonate, amio, ca etc). For some stupid reason the corporation that co-owns the GI suites is too cheap to pay for MH cart (thus no sux). They have zemuron but that's obviously useless to me in a GI center.

They have LMAs, largyscopes, oral and nasal trumpets. While I don't have a anesthesia machine, they have a datascope monitoring machine with end-tidal co2 monitoring.

For those in private practice, there are facilities far worse than what I described. My friends from Washington DC, Dallas, Southern California have practiced in office based GI/Dental places with much less equipment. And they are in very successful large groups.

There's so many procedures being moved to the outpatient stand alone centers and sicker patients are being done there.

Until the ASA oases guidedance on obesity and the stand a lone center, it will be up to the anesthesiologists to make there own decisions. Because the surgeons and other providers (dentists/gi docs) are always asking me for data or studies available in the US. I know there's a study in the UK saying patients with BMI above 35 have more mobility. But BMIs above 35 are routine in many outpatient US facilities.

But no one wants to fund a study on obesity and stand alone centers. We all know the answer if such as study were to be done. I believe the real reason fr no such study has to do with the bottom line. Because if such study were to conclude massive obesity is dangerous (which it is in any setting outpatient or inpatient). If the ASA starts issue guidance not to do BMIs above 45-50, many physican owned facilities stand to lose 10-15% of potential revenue by doing these patients.

I bring my own own sux when I cover that GI center.

Private practice GI is very fast. These guys take 3-6 minutes for a EGD and around 10-15 minutes for colon.

 

[maceo]

Down in the Orlando area.

I actually make very good money for outpatient anesthesia M-F (mid 400s with 6 weeks paid vacation). I'm contracted out so I get paid whether I do the case or not. While I also believe the job market is "tight" but not "super tight" unless you are in the NE or West Coast area.

I'm not that concerned about the anesthesia company breaking my contract; I've been with them for 3 plus years. They know how I work. I'm very safe. Some of the older anesthesiologist do guys up to 450 pounds because "it's what the stretchers fit mentality."

As I stated, you pick and choose your battles in private practice. In this case, I decided not to do the case. It's just the trend. More and more cases that routinely used to be done in the hospital are being pushed toward outpatient center (aka those not attached to the hospital...like next to Panera Bread)

At the other surgery center (mainly doing ENT, urology, minor general cases/plastics) I cover, we actually have a center imposed BMI limit of 40. Anything above that, requires a an automatic anesthesia review. So it varies by center.

aaahhh ahp huh.... anyway they pay decent but totally not the norm.. I would do gi cases but they would have to be at a cool ass center and i would have to go to different ones every few days.. being in the same center constantly makes the politics with the nurse and the nurse manager and the other staff kinda thick.. annoying as hell.. but up in the pa area i heard of some deaths during egds..

 

[epidural man]

Can't you do a colonoscopy without sedation?

 

[Idiopathic]

abosolutely you can do this at an asc, with a little judicious propofol if you trust your GI guy to be quick.

and if you think this is an ASA 4 then you probably dont do enough ASA 4s