NPO and EGD for food bolus?

[Skot73]

So the debate has recently been made at my facility in regards to NPO status during removal of esophageal foreign body (food bolus).

Background Info: We are a small rural hospital with limited resources. We have 2 general surgeons who perform the majority of endoscopies. Anesthesia provides all sedation for endoscopy procedures, both scheduled and "emergency" cases. We have 1 endo suite that consist of wall O2, suction, ambu bag and an emergency airway box (NO anesthesia machine).

2 topics for discussion have came up recently....

1) These cases have historically always been done with propofol and NO ETT. However, anesthesia recently decided that all of these "EMERGENCY" cases be taken to the OR where we have all of our equipment, drugs, etc... available. More importantly, ALL of these cases get a RSI with ETT. There doesn't seem to be any kickback on these decisions other than the fact we don't have a portable endo cart and the surgeons are worried about the wear and tear on the cart. However, patient safety obviously comes first.

2) This one is not agreed upon between anesthesia and the surgeons (1 surgeon can "see our point" and the other is in disagreement and doesn't "understand the logic").....

If a esophageal food bolus walks in, is it ... 1) to be considered an EMERGENCY? 2) if possible, should an adequate NPO status be acheived?

Anesthesia POV:
Based on article reviews and personal experience at various facilities, it appears that as long as the esophageal object is not sharp or corrosive, it is within reason to wait. Within 24 hrs of occurence is reasonable to wait without causing any harm to the patient.

EMERGENCY OR NOT? It depends on the type of foreign body, IMO but that's not anesthesia's call

They think anesthesia is determing whether its an EMERGENCY OR NOT

So, if waiting 24 hours is acceptable (according to literature)... then why not wait until NPO requirments are met? I understand that there's a food bolus present but in order to OPTIMIZE the conditions and achieve MAXIMUM patient safety why not allow the stomach time to clear?

We were told by the surgeon that we are trying to "make it convenient" for us. How can putting off a scope at 4pm til 10pm be a convenience for us?

With all of that being said... It was told to the surgeon(s) that the "take home" message was... If the surgeons declare ANY CASE an EMERGENCY (Not anesthesia), That trumps NPO status. All I need to hear is that it's an EMERGENCY and can't wait and I'll do whatever I can do to safely provide anesthesia to the patient. However, if we can wait on an adequate NPO status to be achieved then I think it's wise to do so. It's much better to deal with a small food bolus and risk of aspiration vs a small food bolus and a stomach full of food.

Now, if the food bolus occured upon taking the first bite and prior to that the patient has been adequately NPO, then no need to wait, IMO. So each case needs to be evaluated and can vary.

AGAIN, tell me it's an EMERGENCY and nothing else matters. That's the surgeons call and not anesthesia.


Thoughts??

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[pgg]

100% get a tube. The esophagus is corked but it won't be as soon as they're done. And these cases can go very long, I don't want to play stupid MAC games for more than a few minutes. They go whenever the endoscopist wants. No point in waiting IMO because there will be food in the upper GI tract indefinitely, but it generally shouldn't bump other urgent cases.

 

[deleted875186]

I would think if there’s food stuck in the esophagus, there is risk of aspiration, either at the start of the case or when they are pulling the thing up or pushing it into the stomach. Many of these people will have esophagus pathology to being with. I would think an ETT for ever case.

 

[Noyac]

I have only done one of these in the past many hrs without an ETT.

But, that is up to the anesthesiologist’s discretion. Don’t let others veer into your lane.

Just thinking of a compromise, what if you were to take the pt to the OR for RSI and then move the pt to the end suite for the EGD? It’s a tremendous PITA but it addresses all concerns.

 

[anbuitachi]

RSI with ETT for all of them.

with regards to NPO, you already mentioned that if surgeon decides it's an emergency then it goes. so there's no controversy over there it seems. the part thats up for debate is the NPO status w food bolus. either way you are doing RSI ETT. it depends on how cautious you are i guess. i can see many anesthesiologists just proceeding with it. you have 2 lines of defense , 1 the LES and if the food passes the LES, then theres the food impaction blocking as well. but yea why take the risk, just let the surgeon make the call. if its E then go, cause if any of these goes to court, you know the surgeon will blame you in a heartbeat

 

[deleted162650]

NPO status?? The patient has a food bolus stuck in their esophagus! They’re never going to be NPO no matter how long you wait genius.

 

[deleted171991]

NPO status?? The patient has a food bolus stuck in their esophagus! They’re never going to be NPO no matter how long you wait genius.

Do not put off till tomorrow what you can do today... because, by tomorrow, it may not be needed anymore.

 

[AdmiralChz]

Ugh I've seen massive amounts of vomitus come up during these procedures, ESPECIALLY if the food bolus has been there a while and is distal "stenting" open the LES. I've done these cases a fair number of times, and often they have to pull out the food piece by piece up the esophagus. Often times it takes multiple attempts as the food is nasty and sticky, and I've seen pieces break apart in the oro/hypopharynx. If you aren't securing the airway for THAT... yikes.

I've seen these cases last 60 seconds where they can just push it into the stomach, or 90 minutes+ pulling out all the nasty chicken bones and crap. I'm always securing the airway for this, with an RSI. I've never regretted doing it that way, and the GI docs are usually just happy they don't have to do it under (bad) conscious sedation.

Whether the bolus is a true emergency or not, well I leave that up to GI. It should definitely get addressed urgently, but probably not crashing into the room shoving a scope down the mouth emergent (a la variceal bleed in a sicko)

Also, @FFP, bravo on the avatar! Will go great with the critical care pearls.

 

[DM27]

I have found that treating them as emergencies is proceduralist dependent unless the patients condition is on more of the extreme side.

I have always done RSI with ETT. As stated above, the logic behind NPO guidelines is mainly about the possibility of aspiration of foreign material/high volume of gastric contents. If they have a food impaction they will never be free of that risk (similar to someone with Zenkers but way more extreme).

 

[deleted50478]

Always tube them. RSI. I’ve had this talk multiple times:
GI Preop- “You are really going to tube him?”
Me - “Yep.”
GI Postop- “ Good thing you tubed that guy! That could have been a disaster!”

npo time is meaningless with food bolus IMO.

Just grab your blade and drugs and tube them in endo. You don’t need to be in the OR to intubate.

 

[Psai]

Sometimes it's nothing and the food passes spontaneously before they even hit the endo suite. But a lot of these patients have undiagnosed weirdo things like eosinophilic esophagitis or zenkers diverticulum and we tube them all. GI or general surgery decide when the case goes and need to document that it's an emergency but have zero say in what we do.

 

[Hork Bajir]

You don’t need to be in the OR to intubate.

But OP said he/she doesn't have an anesthesia machine in the endo suite, and as discussed these cases can go long. Sure you could bag the patient for 90 minutes while you run a TIVA, but eff that noise.

OP, do you have anesthesia techs who could help you bring an anesthesia machine into your endo suite? Because if no anesthesia machine is available out of the OR, and if you accept the premise that all of these patients should be intubated regardless of NPO status, then you need to be doing these in the OR or ICU where a ventilator is available.

Beyond this, I'm not sure I see the controversy here. Let the endoscopist dictate when they want to do the procedure. Whenever they want to do it --> prop, sux, tube. These patients will never be considered empty stomach, and I'm not convinced that waiting for the stomach to empty behind a food impaction will decrease the risk of harm to the patient should an aspiration event occur. However, letting an impaction sit in the esophagus for hours on end, potentially causing ischemia to the esophageal mucosa... That's probably not a great idea. If the endoscopist wants to delay the case for whatever reason, so be it- but it's not going to be because of me.

 

[Skot73]

Sometimes it's nothing and the food passes spontaneously before they even hit the endo suite. But a lot of these patients have undiagnosed weirdo things like eosinophilic esophagitis or zenkers diverticulum and we tube them all. GI or general surgery decide when the case goes and need to document that it's an emergency but have zero say in what we do.

I agree they all should be RSI and tubed (No disagreement on that part)

I agree the endoscopist should be the one that decides when it goes (It's their call on the urgency... that's what was relayed to him but he didn't like the fact that the patients NPO status was a factor to consider. I simply explained that I'm just letting you know the NPO status and asked, are you declaring this an EMERGENCY? If so, then I document it as an EMERGENCY and do the case without question.

He felt as though I was questioning the urgency of the cases by addressing NPO status and I'm not. I do want to know the NPO status so I know what I'm dealing with.

I do think that if it's not an EMERGENCY and can wait for the stomach to clear then it would be beneficial to wait. This part becomes a volume issue. Would you rather deal with potential aspiration of what is lodged in the esophagus or deal with aspiration of a stomach full. Plus the patient does have to wake up and get extubated and now the food bolus is gone but you still have a full stomach. Just saying that if we can address it without harm to the patient in an effort to keep the patient as safe as possible then we should consider NPO status. If the patient does aspirate and they are NPO... we can easily defend that.

Again... tell me it's an EMERGENCY. Done deal... RSI with ETT. No questions.

Just food for thought and debate

 

[Impromptu]

It has taken some time, but we have transitioned all of my co-workers to do food bolus cases with an endotracheal tube. The PACU was not happy about this, as previously they did not have to come in in the middle of the night.

What we really need is a city wide education program about chewing your food before swallowing.

 

[acidbase1]

So the debate has recently been made at my facility in regards to NPO status during removal of esophageal foreign body (food bolus).

Background Info: We are a small rural hospital with limited resources. We have 2 general surgeons who perform the majority of endoscopies. Anesthesia provides all sedation for endoscopy procedures, both scheduled and "emergency" cases. We have 1 endo suite that consist of wall O2, suction, ambu bag and an emergency airway box (NO anesthesia machine).

2 topics for discussion have came up recently....

1) These cases have historically always been done with propofol and NO ETT. However, anesthesia recently decided that all of these "EMERGENCY" cases be taken to the OR where we have all of our equipment, drugs, etc... available. More importantly, ALL of these cases get a RSI with ETT. There doesn't seem to be any kickback on these decisions other than the fact we don't have a portable endo cart and the surgeons are worried about the wear and tear on the cart. However, patient safety obviously comes first.

2) This one is not agreed upon between anesthesia and the surgeons (1 surgeon can "see our point" and the other is in disagreement and doesn't "understand the logic").....

If a esophageal food bolus walks in, is it ... 1) to be considered an EMERGENCY? 2) if possible, should an adequate NPO status be acheived?

Anesthesia POV:
Based on article reviews and personal experience at various facilities, it appears that as long as the esophageal object is not sharp or corrosive, it is within reason to wait. Within 24 hrs of occurence is reasonable to wait without causing any harm to the patient.

EMERGENCY OR NOT? It depends on the type of foreign body, IMO but that's not anesthesia's call

They think anesthesia is determing whether its an EMERGENCY OR NOT

So, if waiting 24 hours is acceptable (according to literature)... then why not wait until NPO requirments are met? I understand that there's a food bolus present but in order to OPTIMIZE the conditions and achieve MAXIMUM patient safety why not allow the stomach time to clear?

We were told by the surgeon that we are trying to "make it convenient" for us. How can putting off a scope at 4pm til 10pm be a convenience for us?

With all of that being said... It was told to the surgeon(s) that the "take home" message was... If the surgeons declare ANY CASE an EMERGENCY (Not anesthesia), That trumps NPO status. All I need to hear is that it's an EMERGENCY and can't wait and I'll do whatever I can do to safely provide anesthesia to the patient. However, if we can wait on an adequate NPO status to be achieved then I think it's wise to do so. It's much better to deal with a small food bolus and risk of aspiration vs a small food bolus and a stomach full of food.

Now, if the food bolus occured upon taking the first bite and prior to that the patient has been adequately NPO, then no need to wait, IMO. So each case needs to be evaluated and can vary.

AGAIN, tell me it's an EMERGENCY and nothing else matters. That's the surgeons call and not anesthesia.


Thoughts??

Holy ****e it’s like I wrote this myself. I’m in the exact same situation.

The nurses did all of these under MAC, I get there and wanna do a GETA and surgeons freak out. I got the “we never had issues before”. Same thing for upper GI bleeds.

It’s tough working with surgeons in endo bc they weren’t trained in endo. I was use to doing 8 min scopes with endoscipists, surgeons take about 30 minutes.

It’s like the end of the world if you ask them to move the endo equipment.

Another massive issue is doing morbidly obese patients under MAC without an anesthesia machine in the instance of needing PPV. “You have an ambu bag”

And yet another issue, our surgeon doesn’t want the patient to move whatsoever. Wants them all snowed. Typically run them at 140-160 of propofol. Add in the fact they’re all fattys, it’s a ton of fun, pun intended.

I feel your pain bro

 

[Psai]

It's always the **** surgeons and proceduralists that can't deal with a tiny bit of moving. It's a mac, even an endotracheal tube doesn't guarantee paralysis.

 

[Iso4ane]

No one should be giving you trouble with RSI with ETT, because they will never clear NPO in time. Like others stated before it rather have the ETT in place in the off chance something happens.

In terms of not having a anesthesia machine, I hope you have at least monitors. There are products out there that are like Mapleson C circuits (a green soft bag connected to an apl valve), so TIVA, let them breath spontaneously, with you can see via the rise and fall of the soft bag. And there are portable etCO2 monitors as well. Not ideal, but no need for a full machine in dire situations.

Lastly, the surgeon should be documenting first that the case is urgent/emergent, then I just reference what they said.

 

[acidbase1]

It's always the **** surgeons and proceduralists that can't deal with a tiny bit of moving. It's a mac, even an endotracheal tube doesn't guarantee paralysis.

If these people flinch, he loses it. And then when the patients are obstructing and using accessory muscles to breathe, (bc they’re all fat and snowed) he freaks out again bc he “has difficulty taking biopsies” due to their rocking back and forth

Can’t win

 

[Psai]

If these people flinch, he loses it. And then when the patients are obstructing and using accessory muscles to breathe, (bc they’re all fat and snowed) he freaks out again bc he “has difficulty taking biopsies” due to their rocking back and forth

Can’t win

When you suggest general they look at you scandalized like "what? we always do mac for these! why do you need a tube?"

I don't need a tube asshat you do

 

[woopedazz]

We had a few "overnight emergency food boluses" go awry recently and our department has therefore made a few executive calls on what we are to do.

Firstly: Emergency status is to be decided by surgeons. We don't push back or attempt to delay for NPO/office hours. Most of the time they try to give them Coke to break down the bolus when they hit Emergency; apparently it has a very high success rate. So they're never going to be fasted for us.
Secondly: Department strongly recommends every patient be tubed. We have junior endoscopists at our teaching hospital who have dropped the bolus straight into the airway on the way out.
Thirdly: RSI for all.

I'm not sure if this is common, but I've found that giving the patient's sux, then tubing and then the endoscopist blowing air into the oesophagus while they set up --> lots of the time the food bolus is no longer there by the time they get the camera in position. Not sure if it's the sux or the insufflation they accidentally put down or a combination of both. They seem to just blow it all down into the stomach.

 

[lymphocyte]

We have junior endoscopists at our teaching hospital who have dropped the bolus straight into the airway on the way out.

This was the subject of a M&M last year. Chicken nugget in the right main. All of our food boluses now get RSI.

 

[acidbase1]

When you suggest general they look at you scandalized like "what? we always do mac for these! why do you need a tube?"

I don't need a tube asshat you do

I love our jobs

 

[anbuitachi]

so pretty much we all agree with RSI ETT

the part that has some debate is IF the GI doesn't say its emergent, where do you put this on your schedule. As soon as a spot opens? or do you wait for stomach to empty and just deal with the food bolus aspiration risk. like OP said, dealing with a big meal in the stomach in addition to food bolus is probably not the best. Many of you also said sometimes when Endoscopist goes in, the food bolus isn't even there, then in that case, it's just the full stomach. If that's the case, should you actually wait 8 hours?

 

[Gastrapathy]

I have no opinion about the airway management but NPO? That’s pretty darn silly.

 

[drmwvr]

Why is there so much anxious hand wringing about putting in a stupid endotracheal tube? Why?

 

[Planktonmd]

If there is food stuck in the esophagus then NPO status is irrelevant and little bit silly to consider in my humble opinion.
Protecting the airway is ideal but sometimes an experienced anesthesiologist working with a trustworthy GI doc may decide to just give a little sedation and push the thing down...
Disclaimer: This is not the best answer on the oral boards

 

[deleted162650]

This was the subject of a M&M last year. Chicken nugget in the right main. All of our food boluses now get RSI.

Great, now you have to listen to the pulmonologist bitch “Why do you need a tube for this? Just give a little propofol. I’m just gonna go in, grab it, pull it out. 5 minutes.”

 

[pjl]

No one should be giving you trouble with RSI with ETT, because they will never clear NPO in time. Like others stated before it rather have the ETT in place in the off chance something happens.

In terms of not having a anesthesia machine, I hope you have at least monitors. There are products out there that are like Mapleson C circuits (a green soft bag connected to an apl valve), so TIVA, let them breath spontaneously, with you can see via the rise and fall of the soft bag. And there are portable etCO2 monitors as well. Not ideal, but no need for a full machine in dire situations.

Lastly, the surgeon should be documenting first that the case is urgent/emergent, then I just reference what they said.

This isn’t a dire situation, this is a common case. Either they move the endo stuff, you move a machine, or the hospital buys different equipment. Don’t handicap yourself on purpose for convenience.

I never wait for NPO on these, just do them when the GI doc calls it emergent. I let them decide which can sit safely until they are done with clinic to be emergent.

 

[Psai]

We had a few "overnight emergency food boluses" go awry recently and our department has therefore made a few executive calls on what we are to do.

Firstly: Emergency status is to be decided by surgeons. We don't push back or attempt to delay for NPO/office hours. Most of the time they try to give them Coke to break down the bolus when they hit Emergency; apparently it has a very high success rate. So they're never going to be fasted for us.
Secondly: Department strongly recommends every patient be tubed. We have junior endoscopists at our teaching hospital who have dropped the bolus straight into the airway on the way out.
Thirdly: RSI for all.

I'm not sure if this is common, but I've found that giving the patient's sux, then tubing and then the endoscopist blowing air into the oesophagus while they set up --> lots of the time the food bolus is no longer there by the time they get the camera in position. Not sure if it's the sux or the insufflation they accidentally put down or a combination of both. They seem to just blow it all down into the stomach.

I used to use diet coke to clear up clogged g tubes on the floor. It worked so well that I stopped drinking soda altogether. I swear I could hear part of the g tube dissolving along with the obstruction.

 

[anbuitachi]

I used to use diet coke to clear up clogged g tubes on the floor. It worked so well that I stopped drinking soda altogether. I swear I could hear part of the g tube dissolving along with the obstruction.

why diet? it tastes so bad

 

[Psai]

why diet? it tastes so bad

No taste buds in a g tube

 

[Skot73]

Patients who have no evidence of high-grade obstruction and who are in no acute distress can be handled less urgently because spontaneous passage of food boluses may occur and endoscopy can be postponed until a more convenient time (1–4). However, endoscopic intervention should not be postponed beyond 24 h from presentation because of the increased risk of complications (12,13). Early removal of the food bolus may minimize the amount of local pressure-induced mucosal damage in the esophagus. Smith and Wong (14) even suggested performing nonurgent endoscopy within the first 6 h to 12 h to increase the likelihood of removing a meat bolus in one piece, before it has a chance to soften. The actual timing of the endoscopy is often delayed a few hours in the early morning until a more convenient endoscopy time (usually 07:00) can be arranged. This seems to be a reasonable approach and, providing that the time for endoscopy fits into the above stated time period, is likely a safe approach.

Review of food bolus management

This is info that I copied from the above linked article. This is the patient population I'm referring to.

So should we wait? If it's declared an EMERGENCY then great... let's roll!

The problem is that 1 general surgeon agrees to wait to achieve an adequate NPO status and the other doesn't "see the logic" in it BUT also doesn't seem to want to take the liability of DECLARING the case an EMERGENCY due to NPO status and claims that we are trying to say his case isn't an EMERGENCY bc we are addressing NPO status. I've told him that I'm always going to ask about NPO status regardless of the situation/case. Emergency or not? That's your call. He even called me and quoted Wikipedia that said it was a medical emergency. Lol. Fine. Declare it an Emergency and let's go


Sent from my iPhone using SDN mobile

 

[caligas]

I think the OPs problem is less about knowing the right thing to do and more about how to communicate the right thing with surgical or GI colleagues.

I have found that putting it in the following terms will help end debate, even if they still don’t agree:

“I understand your concerns but the standard of care for an Anesthesiologist involved in the care of this patient requires me to secure the airway.”

 

[Ronin786]

Waiting for NPO is idiotic. You're never going to achieve it.

If your plan is RSI w/ETT whenever they show up, NPO status is moot. If you're trying to do these with sedation then you're basically just looking for a loophole to justify your shady plan in the first place.

 

[Aether2000]

It IS an emergency. The patient discomfort is profound with a food bolus stuck in the esophagus, and hospitalizing them and giving them sedatives or narcotics so they can tolerate this discomfort while waiting 8 hours for ???? is ridiculous. We do these cases in the ER with RSI+ETT and propofol TIVA.

 

[drmwvr]

point of order...it's ETT + RSI

 

[facted]

Def no need for NPO. It's an emergency case.

As for technique, to each their own. Many people RSI/ETT all of them.

I usually do a little midaz and topical. Endoscopist takes quick look and if there's something they can't pass into the stomach right away, they come out and I tube. I've tubed one of the past 100 or so with this technique and haven't had an aspiration. Procedure is usually very quick. Granted, our endoscopists are very good and I trust their skills...

 

[Gastrapathy]

@facted
That's our approach too. The vast majority can be passed to the stomach with gentle pressure. The 20cm food column with the esophageal overtube and 2 hours of misery...tube away.

 

[jwk]

I have only done one of these in the past many hrs without an ETT.

But, that is up to the anesthesiologist’s discretion. Don’t let others veer into your lane.

Just thinking of a compromise, what if you were to take the pt to the OR for RSI and then move the pt to the end suite for the EGD? It’s a tremendous PITA but it addresses all concerns.

Why does that need to be done in the OR? You can do an RSI in the GI unit with an ambu bag. We have a GI room with a machine, but it's often tied up with ERCP or EBUS. Do an RSI and TIVA with O2 via an ambu bag.

 

[okayplayer]

Why does that need to be done in the OR? You can do an RSI in the GI unit with an ambu bag. We have a GI room with a machine, but it's often tied up with ERCP or EBUS. Do an RSI and TIVA with O2 via an ambu bag.

I’ve sat through 2 hours of the GI doc picking at a piece of roast beef with tiny forceps at 2AM. No thanks. In the OR with an actual anesthesia machine.

 

[pgg]

Why does that need to be done in the OR? You can do an RSI in the GI unit with an ambu bag. We have a GI room with a machine, but it's often tied up with ERCP or EBUS. Do an RSI and TIVA with O2 via an ambu bag.

Life's too short to torture yourself like this.

 

[Noyac]

Why does that need to be done in the OR? You can do an RSI in the GI unit with an ambu bag. We have a GI room with a machine, but it's often tied up with ERCP or EBUS. Do an RSI and TIVA with O2 via an ambu bag.

No need indeed. But the OP’s group seems to want to induce in the OR. I was just think8ng outside the box some.

 

[HLxDrummer]

ED resident here... just wanted to say I’m surprised you guys intubate all these folks. I’ve done quite a few of these in the ED and never intubated, just procedural sedation. My last one I honestly should have refused as he was chronically ill with sats of 95% on 3L NC prior to sedation, however, the others went without issues luckily. Some are super fast... my last two were 90 mins. Maybe I should stop doing some of these semi elective cases in the ED!

 

[fakin' the funk]

ED resident here... just wanted to say I’m surprised you guys intubate all these folks. I’ve done quite a few of these in the ED and never intubated, just procedural sedation. My last one I honestly should have refused as he was chronically ill with sats of 95% on 3L NC prior to sedation, however, the others went without issues luckily. Some are super fast... my last two were 90 mins. Maybe I should stop doing some of these semi elective cases in the ED!

A) if you're doing it in the ED, it's not elective
B) tube or no tube does not define the depth of sedation, though 99% of nonanesthesiologists feel otherwise
C) placing an ETT and using volatile anesthetic is superior in nearly every way, including speed of wakeup, for cases like this longer than ~45mins

 

[Laryngophed]

100% get a tube. The esophagus is corked but it won't be as soon as they're done. And these cases can go very long, I don't want to play stupid MAC games for more than a few minutes. They go whenever the endoscopist wants. No point in waiting IMO because there will be food in the upper GI tract indefinitely, but it generally shouldn't bump other urgent cases.

*ding*ding*ding*

Let me tell you, I've never been happier to have a 'tube than I was watching GI pull corned beef out of someone's goose for two hours. It just shredded. And shredded. And shredded.

All the patients should get intubated via RSI. The proceduralist determines acuity, but I get the final vote on tube and method of induction.

 

[Psai]

ED resident here... just wanted to say I’m surprised you guys intubate all these folks. I’ve done quite a few of these in the ED and never intubated, just procedural sedation. My last one I honestly should have refused as he was chronically ill with sats of 95% on 3L NC prior to sedation, however, the others went without issues luckily. Some are super fast... my last two were 90 mins. Maybe I should stop doing some of these semi elective cases in the ED!

Most of the time you will probably get away with it but all you need to do is see one patient aspirate and end up in the icu for weeks with horrible ards.

 

[San Marzano]

ED resident here... just wanted to say I’m surprised you guys intubate all these folks. I’ve done quite a few of these in the ED and never intubated, just procedural sedation. My last one I honestly should have refused as he was chronically ill with sats of 95% on 3L NC prior to sedation, however, the others went without issues luckily. Some are super fast... my last two were 90 mins. Maybe I should stop doing some of these semi elective cases in the ED!

We can get away with a lot of shady practices and things will go just fine... until they don’t. That one time it goes bad, you telling the attorney “well I did it a bunch of times before and nothin bad ever happened so I kept doin it!” isn’t going to get you very far.

 

[coffeebythelake]

ED resident here... just wanted to say I’m surprised you guys intubate all these folks. I’ve done quite a few of these in the ED and never intubated, just procedural sedation. My last one I honestly should have refused as he was chronically ill with sats of 95% on 3L NC prior to sedation, however, the others went without issues luckily. Some are super fast... my last two were 90 mins. Maybe I should stop doing some of these semi elective cases in the ED!

if GI doc want to do procedural sedation then don't involve us
you know what's worse than a chronically ill guy with 95% on 3L? that plus aspiration.

 

[HLxDrummer]

if GI doc want to do procedural sedation then don't involve us
you know what's worse than a chronically ill guy with 95% on 3L? that plus aspiration.

Yep... I had a little hesitation right before we started but didn't say anything. Got a few mins in and it was a constant battle keeping sats up, airway positioned properly, secretions suctioned, etc. It was also one of those cases like mentioned previously where the meat was pulling apart in chunks. Lesson definitely learned on that patient!

 

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ED resident here... just wanted to say I’m surprised you guys intubate all these folks. I’ve done quite a few of these in the ED and never intubated, just procedural sedation. My last one I honestly should have refused as he was chronically ill with sats of 95% on 3L NC prior to sedation, however, the others went without issues luckily. Some are super fast... my last two were 90 mins. Maybe I should stop doing some of these semi elective cases in the ED!

Dude, you need to push back on this. Why are you taking on an elective sedation that could last a while when you’re an ER doc???? If things go south, you’re writing a check. There actually is a whole medical specialty who spends years learning how to do that safely. Plus, you have other patients to see.