How would you do this case?

[deleted875186]

Short version.

Sick elderly lady for upper and lower GI before her TAVR for GI bleeding. Severe AS with SOB, Marlena with Hb that has now stabilized, no nausea, did a bowel prep last night, reassuring airway.

GETA? Anyone would try MAC?

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[Mikkel]

Propofol

 

[Twiggidy]

Short version.

Sick elderly lady for upper and lower GI before her TAVR for GI bleeding. Severe AS with SOB, Marlena with Hb that has now stabilized, no nausea, did a bowel prep last night, reassuring airway.

GETA? Anyone would try MAC?

A little propofol goes a long way. Maybe a touch of ketamine. Keep the phenylepherine flowing.

 

[Morzh]

500ml gentle bolus to fill the tank after bowel prep, low and slow phenylephrine infusion, titrated propofol... patience with propofol, it may take a little while to circulate to the brain.

 

[NICMAN]

Topical swish 4% viscous load fluids and start a small phenylephrine gtt. Then start with a little etomodate (2-6 mg in 1-2 mg boluses dilute in NS).

Or just put methohexital on a microdripper and dose lightly just like propofol.

 

[Arch Guillotti]

phenylephrine, slow propofol

 

[PainDrain]

One thing every, and I mean every, Anesthesiologist should be able to handle is AS. These patients are a dime a dozen and they come for every procedure under the sun. This case is simple, phenylephrine and propofol plus/minus ketamine. The only thing I may do differently compared to my other GI MAC cases is that perhaps I would do this in an OR so I have a vent, emergency monitors and a full Pyxis of drugs.


The question I have for the OP is WHY does she have a GI bleed?

 

[aneftp]

How about we take it up another level. More real life. Like only gi doc available is hospital employee who takes 20-25 minutes for egd and up to 1 hour for colonoscopy. Yes there are Gi docs like that.

Now how are u gonna to do the case.

All the legit Gi docs not available

 

[okayplayer]

I would love one of the folks who said ketamine to defend why that is preferred over propofol + neo here...

 

[deleted171991]

How about we take it up another level. More real life. Like only gi doc available is hospital employee who takes 20-25 minutes for egd and up to 1 hour for colonoscopy. Yes there are Gi docs like that.

Now how are u gonna to do the case.

All the legit Gi docs not available

The same way as for the genius GI guy: viscous lido gargle, slow propofol infusion (no or small rare boluses) with phenylephrine as needed, keep the vitals around resting parameters, management of expectations (on both sides), no promises (safety first, comfort second). I still have to see ONE patient with recall or serious hemodynamic instability, and I've done 0.5 cm2 critical AS including in the ICU. The alternative for really sick patients is fentanyl + versed + much less propofol.

If evidence of ongoing significant upper GI bleed, stop and intubate. Without an A-line. Yes, you can. Hint: first, you give phenylephrine, even for normotensives.

I don't bother adding ketamine unless the patient is morbidly obese.

What's etomidate?

P.S. It's called "the art of MAC" for a reason.

 

[Twiggidy]

I would love one of the folks who said ketamine to defend why that is preferred over propofol + neo here...

To defend myself I use a touch (TOUCH) of ketamine as an adjunct to the propofol so the patient tolerates tubes in the holes. Once in my it’s just propfol and neo

 

[Twiggidy]

How about we take it up another level. More real life. Like only gi doc available is hospital employee who takes 20-25 minutes for egd and up to 1 hour for colonoscopy. Yes there are Gi docs like that.

Now how are u gonna to do the case.

All the legit Gi docs not available

If it really takes this long I’m still doing my Mac but I might add an A-line whether others agree or not. I like the idea of doing it in an OR setting so I have home field advantage

 

[Mikkel]

Anything wrong with etomidate here? I’d bolus with that and use additional propofol if needed

Adrenal suppression, nausea, and not much cardiovascular benefit because they're already severely compromised.

Propofol would be better to focus on, as long as you don't give killer boluses.

 

[coffeebythelake]

Short version.

Sick elderly lady for upper and lower GI before her TAVR for GI bleeding. Severe AS with SOB, Marlena with Hb that has now stabilized, no nausea, did a bowel prep last night, reassuring airway.

GETA? Anyone would try MAC?

Lidocaine topicalization, propofol infusion, maybe some fentanyl to smooth things out a little. Phenylephrine available.

 

[OTCAwesome]

white stuff and neo on micro ggt

 

[woopedazz]

Midazolam ++, pinch of fentanyl, topical gargle, ultra-low propofol TCI.

 

[DrOwnage]

The question I have for the OP is WHY does she have a GI bleed?

Check out Heyde's Syndrome

 

[deleted171991]

Check out Heyde's Syndrome

And yet the world is full of GI geniuses who don't look for vWD, or coagulopathy in general. They don't even mention the possibility to their patients (first do no harm... to my pocketses). Heck, they even scope bleeding that stops abruptly once the patient discontinues the anticoagulation. Really? It's called a therapeutic trial.

 

[PainDrain]

Check out Heyde's Syndrome

Exactly. Some AS patients have frequent GI bleeds as a result of Heyde’s syndrome.

 

[dchz]

Exactly. Some AS patients have frequent GI bleeds as a result of Heyde’s syndrome.

Check out Heyde's Syndrome

So give some Cryo or DDAVP while you're pushing the propofol?

 

[PainDrain]

So give some Cryo or DDAVP while you're pushing the propofol?

No, the GI bleeds are due to angiodysplasia in the GI tract. If it was a general case you could consider DDAVP if bleeding was a major concern.

 

[ethilo]

My go-to is 5 mL 4% lidocaine liquid and have the patient gargle for 2 minutes by the clock, then swallow. If they truly will do it for a full 2 minutes they're very numb on scoping. If they're super sick then do the UGI with hand-holding and they'll be fine, else just lido 1 mg/kg IV and a whiff of propofol should be enough (up to 0.5 mg/kg bolus). Neo prn.

For the colonoscopy, they will be in recovery position which will help prevent aspiration. Most stimulating part is not anal intubation, it's advancing around the flexures (splenic flexure especially). Just give propofol for movement.

If you had to intubate at any point the really good gargling will greatly reduce stimulation from laryngoscopy.

 

[Arch Guillotti]

My go-to is 5 mL 4% lidocaine liquid and have the patient gargle for 2 minutes by the clock, then swallow.

Do you use a viscous preparation or just stuff out of an ampule?

 

[ethilo]

Do you use a viscous preparation or just stuff out of an ampule?

we do, but not in a 4% formulation, it's 2%. I personally think the thin liquid form would be easier to gargle, it's also higher concentration.

 

[zizzer]

we do, but not in a 4% formulation, it's 2%. I personally think the thin liquid form would be easier to gargle, it's also higher concentration.

I'm confused. Viscuous or plain liquid? And your previous post said 4% but this one here you say 2%.

 

[Arch Guillotti]

I'm confused. Viscuous or plain liquid? And your previous post said 4% but this one here you say 2%.

yeah which one is it?

 

[deleted875186]

How about we take it up another level. More real life. Like only gi doc available is hospital employee who takes 20-25 minutes for egd and up to 1 hour for colonoscopy. Yes there are Gi docs like that.

Now how are u gonna to do the case.

All the legit Gi docs not available

My attending wanted to do MAC. I really wanted to go GETA, and in the end it ended up taking 1.5-2 hours for the EGD and colonoscopy. Wish I had put a tube in.

 

[Mikkel]

My attending wanted to do MAC. I really wanted to go GETA, and in the end it ended up taking 1.5-2 hours for the EGD and colonoscopy. Wish I had put a tube in.

What if you put the tube in and the positive pressure was enough to drop his preload and kill the guy?

 

[ethilo]

yeah which one is it?

Sorry, you guys got lost in a back alley in my brain. Don't go there alone.

We have viscous 2%, liquid 4%. I chose the liquid 4% bc I think the higher concentration works quicker and denser (personal experience. Yay residency!). Also easier to gargle IMHO, which makes it more likely the patient will actually do it right.

 

[Echo33]

Same as every other. Prop and Neo. Go slow, watch like a hawk. Key factor is knowing who your CRNA is. If it’s someone weak, or even just average, I’m in the room.

That being said, 1.5-2 hours for EGD/colon? I do not miss academics

 

[coffeebythelake]

I

I'm confused. Viscuous or plain liquid? And your previous post said 4% but this one here you say 2%.

Personally I like the viscous 2%. Anecdotally it works better than 4% liquid

 

[deleted697535]

What if you put the tube in and the positive pressure was enough to drop his preload and kill the guy?

Just 25 to50 fent, 1 to 2 of midaz, wait ages Slip a cobalt glide 3 in spray lido and slide a 7et home with psv and 100 phenyl. 1% sevo on psv for ever. Not possible to kill anyone ever with that.

 

[fakin' the funk]

The question I have for the OP is WHY does she have a GI bleed?

What if there was a procedure where a doctor could look inside the bowel to find out WHY she has a GI bleed?

 

[deleted875186]

Just 25 to50 fent, 1 to 2 of midaz, wait ages Slip a cobalt glide 3 in spray lido and slide a 7et home with psv and 100 phenyl. 1% sevo on psv for ever. Not possible to kill anyone ever with that.

Have you actually done this successful? Versed and fentanyl was enough to have them tolerate laryngoscopy?

 

[deleted162650]

Not possible to kill anyone ever with that.

Challenge accepted!

 

[deleted697535]

Have you actually done this successful? Versed and fentanyl was enough to have them tolerate laryngoscopy?

Yes many times. I'm a little bit surprised you ask even as I thought this was a fairly standard approach to a semi crashing ICU type patient. I'm not quite sure how close to semi crashing this patient is however.

Obviously it's done as a staged approach, start with a vigorous jaw thrust and move on slowly.

 

[vector2]

Yes many times. I'm a little bit surprised you ask even as I thought this was a fairly standard approach to a semi crashing ICU type patient. I'm not quite sure how close to semi crashing this patient is however.

Obviously it's done as a staged approach, start with a vigorous jaw thrust and move on slowly.

It's not. Anyone who tolerated your approach well likely didn't need sedation at all. A fairly standard ICU approach is [pressor] + [versed or whiff of ketamine or couple mg of etomidate or super slow prop] + [sux].

Speaking as someone who had deep sedated a bunch of sick TAVRs, there's no patient who would tolerate awake insertion of a cobalt glide without either 1. Healthy doses of ketamine and/or 2. Topicalization sufficient for an AFOI

These patients have sick hearts; it's not like their pharynges and larynges are insensate

 

[Twiggidy]

Yes many times. I'm a little bit surprised you ask even as I thought this was a fairly standard approach to a semi crashing ICU type patient. I'm not quite sure how close to semi crashing this patient is however.

Obviously it's done as a staged approach, start with a vigorous jaw thrust and move on slowly.

Exactly. I think people really gloss over the up front versed-fentanyl we give prior to the other drugs. If anything it’s a great test dose especially in older frail populations. In the wrong old person 1 of versed will knock them out,. Better yet, just titrate fentanyl and when they’re asleep give a small amount of propofol and slip the tube in with topicals

 

[Arch Guillotti]

Yes many times. I'm a little bit surprised you ask even as I thought this was a fairly standard approach to a semi crashing ICU type patient. I'm not quite sure how close to semi crashing this patient is however.

Obviously it's done as a staged approach, start with a vigorous jaw thrust and move on slowly.

Uh no, especially since many of them are full stomachs.

 

[deleted875186]

Yes many times. I'm a little bit surprised you ask even as I thought this was a fairly standard approach to a semi crashing ICU type patient. I'm not quite sure how close to semi crashing this patient is however.

Obviously it's done as a staged approach, start with a vigorous jaw thrust and move on slowly.

I will have to try this, although in my opinion any airway manipulation in a sick patient should always have muscle relaxation.

If it were me, I would do fentanyl/versed, plus whatever else titrated tk effect until asleep, than blast them with roc or sux.

Not sure what the non paralyzed topical lidocaine approach achieves for you. Seems like a lot of risk.

 

[shepardsun]

Another thread where I learn more than a week's worth of teaching in the OR. Heyde's syndrome. Totally badass stuff, thanks guys.

 

[MoMoGesiologist]

If we’re talking about ICU intubations, I’m starting to think a lot of the crashing/sick ones don’t need any induction drug, just paralytic and go. Maybe one CC propofol so you don’t feel like a monster...

 

[deleted697535]

it works quite well thank you very much with almost no downside. I think we've had this conversation before on another thread.

It's one of my approaches, it's not my exam answer. I switch it up every now and again.

It's the same sedative every bronchoscopy gets, and they do fine. A cobalt glide is smaller than many oral airway and they do fine too. It's no big deal

But there's loads of ways to do it. Except the wrong way lol

 

[sanityonleave]

If we’re talking about ICU intubations, I’m starting to think a lot of the crashing/sick ones don’t need any induction drug, just paralytic and go. Maybe one CC propofol so you don’t feel like a monster...

One of our ICU staff is fond of making this point to new residents:

Q: "What's the appropriate anesthetic for an emergent airway in a crashing patient?"
A: "100 of roc and an apology..."

As far as the original case, I would have gone with some good oral topicalization (pick your poison), some fent and then a whiff of propofol. Agreed with another poster who said severe AS should be pretty well within your skillset; that said, I think you could have done this patient safely as a GA as well. The one thing that wouldn't be appropriate is the GI-favorite natural airway general, where you give enough propofol to anesthetize the Rock and then fail to instrument the airway.

 

[vector2]

Check out Heyde's Syndrome

This case is an excellent example of where being a physician first is just an important as being an anesthesiologist. An anesthesia nurse might set up some propofol and a neo drip. An anesthesiologist should realize the following prolonging, mitigating factors and set up for GETA: 1. It's already a double scope and GI may have to d*ick around for awhile looking for angiodysplasias, 2. They're probably going to find 1 or more and then d*ck around with coagulating or injecting the lesion(s), 3. There's a high chance that deep push through enteroscopy is going to happen and no one including the GI, anesthesiologist, or pt likes doing those without GETA.

 

[Mikkel]

This case is an excellent example of where being a physician first is just an important as being an anesthesiologist. An anesthesia nurse might set up some propofol and a neo drip. An anesthesiologist should realize the following prolonging, mitigating factors and set up for GETA: 1. It's already a double scope and GI may have to d*ick around for awhile looking for angiodysplasias, 2. They're probably going to find 1 or more and then d*ck around with coagulating or injecting the lesion(s), 3. There's a high chance that deep push through enteroscopy is going to happen and no one including the GI, anesthesiologist, or pt likes doing those without GETA.

I think IR is a better option to treat distal angiodysplasias than push enteroscopy which could stress a critical aortic stenosis patient to the point of complete heart failure.

Not saying it would. But, I think the easiest anesthetic to tolerate is slow propofol with no other sedatives.

Why are people here freaking out about full stomach and sedation? They're not deep enough to have no cough reflex, and their mouth is easily accessible for large bore suction.

 

[MoMoGesiologist]

Why are people here freaking out about full stomach and sedation? They're not deep enough to have no cough reflex, and their mouth is easily accessible for large bore suction.

You do this? Is anyone else here pushing sedation on full stomachs? I’ve never done it but curious if others do it and how they prevent adverse events

 

[vector2]

I think IR is a better option to treat distal angiodysplasias than push enteroscopy which could stress a critical aortic stenosis patient to the point of complete heart failure.

Not saying it would. But, I think the easiest anesthetic to tolerate is slow propofol with no other sedatives.

Why are people here freaking out about full stomach and sedation? They're not deep enough to have no cough reflex, and their mouth is easily accessible for large bore suction.

IR is obviously a better option if the lesion is well past the duodenum/proximal jejunum. But the patient still needs an upper and lower GI for the initial screening and they very well may find angiodysplasias in the visualized colon or duodenum. Only once that's negative will they get a pill cam and/or tagged RBC scan/multiphase CT with contrast if a GI bleed is still the presumed diagnosis. Even then, identifying a tiny bleeder in the IR suite with fluoro is a huge pain.

In CCM fellowship, I had a pt s/p old AVR now with prosthetic stenosis (not eligible for ViV tavr) that was in the SICU for 9 months out of my 12. He would receive 1u of blood every 4-5 days d/t GI bleed. An area that was probably identified as the culprit on RBC scan couldnt be reached with scope or identified with fluoro. Surgery wouldnt operate and the pt's son wouldnt agree to surgery anyway. They were extremely catholic and would not deal with palliative either. So he would bleed, we would give blood, and such was life. He ended up dying of pneumonia right before I left.

As far as the case in question, I don't think slow propofol is the worst idea if this was just a screening colonoscopy. Slow propofol is a bad idea when you know the case is minimum going to be a double plus possible push plus possible multiple coags or epi injections. I honestly don't care that I might looks like a dunce if it's a quick in and out both top and bottom and I did geta for a nothing case. But its certainly going to be the safest thing for the patient if the case turns into a 1hr+ odyssey of the GI tract.

 

[deleted162650]

They were extremely catholic and would not deal with palliative either.

Catholic doctrine is fully compatible with palliative care.

 

[vector2]

Catholic doctrine is fully compatible with palliative care.

That may be so given the range of services palliative medicine provides. However, strict catholic doctrine is not compatible with withdrawing care or having a real-deal goals of care discussion if literally anything and everything can be done to prolong life. When I say the patient I was talking about ‘died of pneumonia,’ I mean that this 83yo coded from pulmonary sepsis, I intubated and lined him up, he started to make a bit of a recovery but was essentially GCS 8-9 and mostly non-communicative. Couldn’t wean him off the vent. Explained prognosis to the son but he insisted on trach and peg which we did. The guy gets infected again but this time goes into multi system organ failure and starts crumping but, you guessed it, he’s still full code so we code him again. But thank sweet merciful buddha he doesn’t make it that time and we can finally stop torturing his shell of a human being.

I finished CCM fellowship in a diverse (racially, religious, socioeconomically and ethnically) major metro area and have had more end of life discussions than I would like, but feel free to tell me more about various religious beliefs and the scope of palliative care.