Morbidly Obese for TEE

[Sevo]

Here's a case from private practice.

What'dya do in this situation?

50 year old for "sedation" for a ten minute TEE. Nonspecific chest pains. 460lbs, MP IV airway, OSA, HTN. History of some sort of gastric procedure in the way distant past. Bigwig cardiologist wants to do it in a little lair that's equipped with a flat table, a bored respiratory therapist, a nurse that tries to be helpful, portable pulse oximetry, and an automated blood pressure cuff.

---

Members don't see this ad.

 

[pgy13]

They need to come to your house (the OR) for this one.

 

[Sevo]

"The OR? You've got to be kidding me - this isn't an OR case! We do fat people all the time here, assisted by people from YOUR department frequently!"

 

[UTSouthwestern]

Lots of topical anesthetic and a precedex infusion.

Or you could titrate in small amounts of versed or etomidate. I'm less worries about OSA because the TEE shaft will serve as your oral airway, along with the bite block.

 

[Planktonmd]

"The OR? You've got to be kidding me - this isn't an OR case! We do fat people all the time here, assisted by people from YOUR department frequently!"

This could be a disaster in the making:
You decide to accommodate the cardiologist, you sedate her with some stuff and spray her throat with topical, he inserts his TEE, the patient gags and vomits, now you have a partially sedated morbidly obese patient vomiting and about to fall off the table, and if the sedation is light will continue to gag and cough and the TEE will be impossible, if the sedation is deeper the patient will most likely aspirate and the SPO2 will drop to nothing in no time, and since the patient has sick coronaries this would be a perfect time for her to get ischemic and have an MI, you try to secure the airway at this point but you can't intubate and, guess what, you can't mask ventilate either!
Now if none of these horrible things happen and your "little sedation with topical" works then you are golden and you will keep doing this but sooner or later you will get burned.
So, I say let's secure the airway and anesthetize the patient so you don't stress her coronaries and yours!

 

[milrisome]

"The OR? You've got to be kidding me - this isn't an OR case! We do fat people all the time here, assisted by people from YOUR department frequently!"

This is beyond fat. No emergency here; no reason not to go to the safest location for difficult airway mangement. They can wheel their TEE to the OR.

 

[Noyac]

This is beyond fat. No emergency here; no reason not to go to the safest location for difficult airway mangement. They can wheel their TEE to the OR.

I agree.

 

[BLADEMDA]

"The OR? You've got to be kidding me - this isn't an OR case! We do fat people all the time here, assisted by people from YOUR department frequently!"

Plankton is correct here. When something goes wrong with the "sedation" and the patient aspirates or dies what are you going to tell the judge? How will you defend your actions to the legal system and "expert witnesses"?
Morally, what will you tell the family after the demise of their morbidly obese loved one? He/She was too fat anyway?

Every Medical student knows A...B...C... and A comes first. To the O.R. with airway cart in room as back-up or NO TEE. If you need to buy a pair of large Neuticles they are for sale.

Blade

 

[OB1🤙]

If you need to buy a pair of large Neuticles they are for sale.

 

[VentdependenT]

"The OR? You've got to be kidding me - this isn't an OR case! We do fat people all the time here, assisted by people from YOUR department frequently!"

ARGH!

This dude needs to know that you may have to tube this guy. He is too fat for even a rudimentary transthoracic so he is too fat for deep sedation required to have a giant probe shoved down his gullet.

I vote OR cause I want this big boy in my territory. The cardiologist can c'mon in on his DAY OFF to do it. I'll schedule it on labor day. If he cares soooooooooooooo much about getting this done, then dag nabbit, he should c'mon in on the weekend so he can DEDICATE his ENTIRE SELF to this procedure.

Could you do it awake? Sure. Go with UTSW's idea. Spray the hell out of his mouth. Have him guzzle Viscous 2% Lidocaine. No transtracheal needed so he should still have a cough reflex. Crank the precedex to the hilt (i'd start around 200 ucg/hr). Spank him with some mind scrambling scopolomine. Force that friggen lazy ass respiratory guy to set up one o them high flow nasal canulas that can apply peep (like 50 LPM flows on these bad boys..they rock).

 

[VentdependenT]

As an adjunct, do you guys do EGD's on people this size without intubating them in the OR?

 

[BLADEMDA]

As an adjunct, do you guys do EGD's on people this size without intubating them in the OR?

Yes.

Blade

 

[VentdependenT]

Yes.

Blade

What do you do?

 

[jetproppilot]

Plankton is correct here. When something goes wrong with the "sedation" and the patient aspirates or dies what are you going to tell the judge? How will you defend your actions to the legal system and "expert witnesses"?
Morally, what will you tell the family after the demise of their morbidly obese loved one? He/She was too fat anyway?

Every Medical student knows A...B...C... and A comes first. To the O.R. with airway cart in room as back-up or NO TEE. If you need to buy a pair of large Neuticles they are for sale.

Blade

I respectfully disagree.

"What are you gonna tell the judge?" is melodrama. Yes, there is an aspiration risk. But theres an aspiration risk if you intubate the guy too, regardless of how you choose to intubate him. Negative pressure pulmonary edema on extubation could also happen.

Point being, intubating someone like this presents its own set of problems, in addition to potential hemodynamic/myocardial stress, all for a TEE?

Additionally, youre opening up yourself to setting a precedence (sp?)...next thing you know many more TEEs will be coming to the OR...not an efficient use of OR time.

Risk benefit ratio doesnt fit IMHO.

Pt will be on their side. Use UT's sedation cocktail. Don't overly obtund him.

 

[Planktonmd]

If you are 460 pounds and need anything more than anxiolytic doses of drugs I will intubate you.
No exception!

 

[Fastrach]

Any takers for an a-line on this one, too?

 

[BLADEMDA]

If you are 460 pounds and need anything more than anxiolytic doses of drugs I will intubate you.
No exception!

Conservative. I respect that. But, I would give my usual Zantac and Reglan then attempt MAC. I would be ready to abort the MAC and/or procedure if needed. Airway cart in the O.R. and a high state of alert status during the case.

Blade

 

[BLADEMDA]

I respectfully disagree.

"What are you gonna tell the judge?" is melodrama. Yes, there is an aspiration risk. But theres an aspiration risk if you intubate the guy too, regardless of how you choose to intubate him. Negative pressure pulmonary edema on extubation could also happen.

Point being, intubating someone like this presents its own set of problems, in addition to potential hemodynamic/myocardial stress, all for a TEE?

Additionally, youre opening up yourself to setting a precedence (sp?)...next thing you know many more TEEs will be coming to the OR...not an efficient use of OR time.

Risk benefit ratio doesnt fit IMHO.

Pt will be on their side. Use UT's sedation cocktail. Don't overly obtund him.

We do about 3-4 HIGH RISK MAC's per week in the O.R. No big deal. Out of more than 500 cases per week three cases is NO BURDEN.

I like bringing them to the O.R. and will continue to do so. THis shows the GI docs and everyone else we take the airway seriously; in addition, the MD Anesthesiologist makes the call WHERE the case is done and NOT the requesting Physician.

So, if all the 450 pounders come to the O.R. then so be it.

Blade

 

[Gern Blansten]

Perhaps the bigger concern is the TEE probe. The esophagus of a person that big is not used to letting things go. He may eat the probe.

 

[VentdependenT]

Perhaps the bigger concern is the TEE probe. The esophagus of a person that big is not used to letting things go. He may eat the probe.

ZZZZZZZZZZZZZZZZZZZZZZZZZZZing!

 

[epidural man]

Lots of topical anesthetic and a precedex infusion.

Me too. A little ketamine (with robinol - assuming he is beta-blocked) will have a profound effect for analgesia making him tolerated the probe better.

The problem with precedex (which is "facilitated arousal") is that the probe will continue to facilitate him arousing and it may appear to have little effect. That is why I think the little touch of ketamine will add a lot to this MAC, as will 5% spearimint lidocaine jelly lolipop.

Why sedate the guy at all? If you topicalize him, will he still gag? I don't know the answer to this since I myself have never had a TEE (or something of that size down my throat ). It seems that many people are able to tolerate stuff of similar sizes without gagging.

Just a thought.

 

[VentdependenT]

Any takers for an a-line on this one, too?

Only if he/she is too fat to get a wrist/forearm NIBP.

 

[BLADEMDA]

Only if he/she is too fat to get a wrist/forearm NIBP.

Correct Again.

Blade

 

[BLADEMDA]

Look,

In my world topical is NOT well-received by the REQUESTING Physician asking for your services. Instead, I offer a choice for the HIGHEST RISK patients.
Topical in YOUR area (without us) or MAC (possible GA) in my area.
This way you appear cooperative when you would just as soon really say "get lost."

Blade