NPO and EGD for food bolus?

[dhb]

Dude, you need to push back on this

That's what he said?

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[IMGASMD]

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.

How are they ever going to learn how to use propofol correctly without standing there pinching their butt, hoping the patient will eventually start to breath? Or hoping that the hypotension and apnea is transient until it is permanent.......

 

[IM2GI]

@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.

I get the sense from this thread that most of the anesthesia folks unfortunately are dealing with poorly trained general surgeons who have minimal endoscopy skills.

I agree with most of the sentiments in this thread. I am always happy with a secured airway. I also am comfortable taking a quick look and if its an easy 60 second push through we are done, or if its gonna be a flog pulling out and intubating.

In my experience though you never regret intubating the patient.

 

[drmwvr]

If extubation were emphasized as much as intubation in em residencies, this wouldn't be a conversation here.

 

[GassmanMD]

+1 for RSI + ETT. We have heard a lot of stories on here about close calls and near misses with an unprotected airway. But at my facility, we recently had a death that was a direct result of aspiration during removal of a food bolus under propofol sedation. No matter how challenging the logistics may be, I have and will always insist on a tube. If they disagree, they are free to proceed without my assistance. Surprisingly, the recent bad outcome has not changed culture amongst the GI docs, and one of them just the other day told me: "but we always do these under MAC."

 

[deleted547339]

If extubation were emphasized as much as intubation in em residencies, this wouldn't be a conversation here.

Ummmmmm.....what?

 

[Arch Guillotti]

+1 for RSI + ETT. We have heard a lot of stories on here about close calls and near misses with an unprotected airway. But at my facility, we recently had a death that was a direct result of aspiration during removal of a food bolus under propofol sedation. No matter how challenging the logistics may be, I have and will always insist on a tube. If they disagree, they are free to proceed without my assistance. Surprisingly, the recent bad outcome has not changed culture amongst the GI docs, and one of them just the other day told me: "but we always do these under MAC."

So who was the rokkstar that chose this anesthetic?

 

[GassmanMD]

So who was the rokkstar that chose this anesthetic?

A dear colleague whose years in practice exceed my years on Earth and who felt absolutely devastated afterwards....

Reminds me how much our own mental health is tied to the outcomes of our cases. Sometimes doing whats best for the patient is also what's best for your ability to sleep at night.

 

[ranvier]

We don’t push propofol in the emergency room (or ICU) for anything including food bolus (or closed reductions). We insist the patient come to endo and we typically intubate. We do have an anesthesia machine available and it’s a familiar environment. The previous GI group really gave us some push back and we held firm and even had our malpractice carrier write a letter. Administration supported us and that group has since been replaced with a new GI group (for many reasons). Now it’s not even an issue.

These are usually add-on cases at the end of a lineup or so there really shouldn’t be any production pressure. As discussed, they are at risk of aspiration no matter how long you wait so I just do them when convenient for our schedule. We have all had the multi-hour bolus. If its quick, great....there is always bridion if you used roc, As far as surgeons and endoscopists declaring an emergency so the case must go asap....I guess we are fortunate to have a more collegial relationship. They know I don’t cancel or delay without good reason. We are fast and efficient but if something gives us pause they respect our judgement and a tantrum doesn’t get the case performed any quicker.

I have rarely moved endo cases to the main if I’m really worried about the airway. They bring a tower and do it there....no traveling with the anesthetized patient. Sometimes these forums make me appreciate my practice environment even more even though the payer mix sucks.

 

[Hamhock]

I am EM-trained.
In training we mostly left these case to anesthesiologists and these cases mostly left the ED.
When we did do these cases (mostly at the county hospital), we always RSI. There was no question about it from any of the attendings; who in other circumstances would induce semi-urgent deep sedation/general anesthesia with recent enteral intake without a second thought (cases that would make most anesthesiologists in academics apoplectic).
Although I agree with TimesNewRoman's point above (EM residents shouldn't be learning to extubate), we mostly did these cases in the county hospital because we also extubated in our ED-ICU once or twice a week. This sounds infrequent to non-EM folks, but it is extremely rare I have found since finishing residency.
HH