OG shortage?

[DoctwoB]

Talking about the tubes, not the gangsters. Have been told by admin at the VA that OGs are on national backorder and anyone not expecting to keep it for a prolonged period post op can’t get one (we’re told our very large referral center has 80 in the hospital and they need to last 3 months). Has anyone else encountered this?

I’m a surgeon and it seriously impacts our ability to do laparoscopy, both due to more dangerous entry and bowel distention. Can you think of any good alternative, even if not sumped, just to suction out the stomach at the start of the case? Feeding tubes maybe? Rectal tubes probably too stiff, foleys too short, egd too time consuming.

---

Members don't see this ad.

 

[deleted875186]

I’ve done anesthesia for many lap cases and never put in an OG tube unless specifically asked by the surgeon to decompress the stomach.

Why not do it on a case by case basis .... maybe ask the anesthesiologist not to bag after induction and just intubate, try to avoid putting air in the stomach.

 

[anbuitachi]

Talking about the tubes, not the gangsters. Have been told by admin at the VA that OGs are on national backorder and anyone not expecting to keep it for a prolonged period post op can’t get one (we’re told our very large referral center has 80 in the hospital and they need to last 3 months). Has anyone else encountered this?

I’m a surgeon and it seriously impacts our ability to do laparoscopy, both due to more dangerous entry and bowel distention. Can you think of any good alternative, even if not sumped, just to suction out the stomach at the start of the case? Feeding tubes maybe? Rectal tubes probably too stiff, foleys too short, egd too time consuming.

I’ve done anesthesia for many lap cases and never put in an OG tube unless specifically asked by the surgeon to decompress the stomach.

Why not do it on a case by case basis .... maybe ask the anesthesiologist not to bag after induction and just intubate, try to avoid putting air in the stomach.

Same as above. I dont often put in OG tubes in lap cases. i dont ventilate either, prop sux tube. The surgeons rarely say anything. if they want me to put in OG tube i will. but its not that often

 

[Velefunt]

We've not seen a backorder, but more importantly, do you require orogastric tubes to be inserted into the majority, if not every one, of your laparoscopic cases?

Editted: To be less inflammatory and condescending.

 

[deleted171991]

AFAIK, OGT are standard of care for laparoscopic cases. Otherwise, if the surgeon gets into a stomach vessel with one of the ports, he can argue that it was the anesthesiologist's fault.

 

[DoctwoB]

I’ve done anesthesia for many lap cases and never put in an OG tube unless specifically asked by the surgeon to decompress the stomach.

Why not do it on a case by case basis .... maybe ask the anesthesiologist not to bag after induction and just intubate, try to avoid putting air in the stomach.

Where I trained many attendings felt it would be borderline malpractice to stick a varress into a non decompressed belly. If you’re doing an open hassan it’s less of a big deal, but even then you definitely notice the difference in working space with a working OG vs one that is absent or not sumping. Would also think that a full stomach plus pneumo would affect respiratory mechanics. Given the struggle with peak pressures during our RALPs I’d think it would help.

Good thought on minimizing the masking though, thanks.

 

[deleted875186]

Where I trained many attendings felt it would be borderline malpractice to stick a varress into a non decompressed belly. If you’re doing an open hassan it’s less of a big deal, but even then you definitely notice the difference in working space with a working OG vs one that is absent or not sumping. Would also think that a full stomach plus pneumo would affect respiratory mechanics. Given the struggle with peak pressures during our RALPs I’d think it would help.

Good thought on minimizing the masking though, thanks.

No idea what an open Hassan is. Is that the large trocar they place near the umbilicus after dissecting?

For my own knowledge, how often is it reported to hit the stomach with the vares needle, they always seem to go in the lower abdomen from my experience.I thought the concern with the stomach was mostly just for exposure during the case.

 

[dmk5n]

Red rubber?

 

[nimbus]

No OG’s for most laparoscopic cases and no shortage either.

 

[okayplayer]

AFAIK, OGT are standard of care for laparoscopic cases. Otherwise, if the surgeon gets into a stomach vessel with one of the ports, he can argue that it was the anesthesiologist's fault.

What?!?

 

[deleted126335]

We have been informed that they are on backorder. They have a substitute product which is crap.


Sent from my iPhone using SDN mobile

 

[TexasDoc2388]

Talking about the tubes, not the gangsters. Have been told by admin at the VA that OGs are on national backorder and anyone not expecting to keep it for a prolonged period post op can’t get one (we’re told our very large referral center has 80 in the hospital and they need to last 3 months). Has anyone else encountered this?

I’m a surgeon and it seriously impacts our ability to do laparoscopy, both due to more dangerous entry and bowel distention. Can you think of any good alternative, even if not sumped, just to suction out the stomach at the start of the case? Feeding tubes maybe? Rectal tubes probably too stiff, foleys too short, egd too time consuming.

Definitely thought you were talking about the gangsters when I read the title lol.

 

[jwk]

Where I trained many attendings felt it would be borderline malpractice to stick a varress into a non decompressed belly. If you’re doing an open hassan it’s less of a big deal, but even then you definitely notice the difference in working space with a working OG vs one that is absent or not sumping. Would also think that a full stomach plus pneumo would affect respiratory mechanics. Given the struggle with peak pressures during our RALPs I’d think it would help.

Good thought on minimizing the masking though, thanks.

We rarely add an OG unless the surgeon requests it, and then, it's usually once they're already in and can see the distended stomach. Some of our GYN docs still do a fair number of veress needle techniques, but almost every other surgeon thankfully does an open technique with a Hassan. One of our GYN docs in particular whose name you would recognize does only laparoscopic surgery and exclusively open techniques, and lectures/presents worldwide on the dangers of the veress technique.

 

[Psai]

Preop colonoscopy and suction them all out from below

 

[DoctwoB]

We rarely add an OG unless the surgeon requests it, and then, it's usually once they're already in and can see the distended stomach. Some of our GYN docs still do a fair number of veress needle techniques, but almost every other surgeon thankfully does an open technique with a Hassan. One of our GYN docs in particular whose name you would recognize does only laparoscopic surgery and exclusively open techniques, and lectures/presents worldwide on the dangers of the veress technique.

This has been studied pretty extensively. The open entry (Hassan) does not reduce visceral or vascular injury, it takes longer, but is less likely to have a failed access attempt or preperitoneal insufflation. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD006583.pub3/abstract

Overall it’s very much a surgeons choice rather then a quality issue imo. I prefer Hassan in patients with prior belly surgery. I prefer veress in fat patients or patients when I’m using the da Vinci Xi as it’s hard as hell to do a hassan through an 8mm incision (size of xi camera port) meaning you have to extend the incision meaning you get pneumo leak around the port.

Call me old fashioned but I’d prefer an empty stomach when I enter the abdomen. I agree that the importance is probably overstated and on a quick look I found no evidence to support it, probably because it’s always been taught as SOC, and to prove that lack ofOG or NG doesn’t cause harm would require a massive study as the risk of visceral injury on entry is 1% or less. Anecdotally though the Bowels seem much less “poochy” for lack of better word when an OG is in and working. Either way, the whole idea seems ridiculous to me that we can’t get these things. I’m just waiting for them to tell us we’ll be operating without bovies.

 

[DoctwoB]

No OG’s for most laparoscopic cases and no shortage either.

Can we have yours?

 

[fittipaldi1of1]

How about just decompress with a soft suction catheter that we usually use to suck out ETT’s?

 

[Consigliere]

When I read the title I thought it meant there was an original gangster shortage which there definitely is.

 

[deleted875186]

This has been studied pretty extensively. The open entry (Hassan) does not reduce visceral or vascular injury, it takes longer, but is less likely to have a failed access attempt or preperitoneal insufflation. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD006583.pub3/abstract

Overall it’s very much a surgeons choice rather then a quality issue imo. I prefer Hassan in patients with prior belly surgery. I prefer veress in fat patients or patients when I’m using the da Vinci Xi as it’s hard as hell to do a hassan through an 8mm incision (size of xi camera port) meaning you have to extend the incision meaning you get pneumo leak around the port.

Call me old fashioned but I’d prefer an empty stomach when I enter the abdomen. I agree that the importance is probably overstated and on a quick look I found no evidence to support it, probably because it’s always been taught as SOC, and to prove that lack ofOG or NG doesn’t cause harm would require a massive study as the risk of visceral injury on entry is 1% or less. Anecdotally though the Bowels seem much less “poochy” for lack of better word when an OG is in and working. Either way, the whole idea seems ridiculous to me that we can’t get these things. I’m just waiting for them to tell us we’ll be operating without bovies.

It does seem ridicule to have a basic thing like an OG unavailable.

I think the soft tip ETT auction catheter is too soft to advance.

Next best thing I geuss would be a Dobhoff, although it may get clogged and not decompress well.

 

[nimbus]

Can we have yours?

No, we’ll be hoarding them now that you’ve warned us.

Gastric lavage tubes work very well to decompress the stomach. Our bariatric guys use them to size sleeves and G-J’s. If there’s any air in the stomach, it immediately deflates the moment the tube passes into the stomach.

 

[UscGhost]

I doubt there is actually that much air in a stomach so that a surgeon can "tell" if I have an OGT in or not. Unless we heavily mask ventilated the patient.

Also most enter through the umbilicus...so the stomach is pretty far away.

Thus..most surgeons don't request them for these regular lap cases

 

[dannyboy1]

The CRNA’s that I work with place them in every intubated patient. Seriously, you could be doing a hip replacement and the patient will get an OGT. I have no idea what the thought process is...

 

[pgg]

How about just decompress with a soft suction catheter that we usually use to suck out ETT’s?

I was just going to post this. I often use them to suck out the oropharynx prior to extubation, instead of using a hard Yankauer. They're usually easy to pass into the stomach too.

 

[anbuitachi]

This has been studied pretty extensively. The open entry (Hassan) does not reduce visceral or vascular injury, it takes longer, but is less likely to have a failed access attempt or preperitoneal insufflation. https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD006583.pub3/abstract

Overall it’s very much a surgeons choice rather then a quality issue imo. I prefer Hassan in patients with prior belly surgery. I prefer veress in fat patients or patients when I’m using the da Vinci Xi as it’s hard as hell to do a hassan through an 8mm incision (size of xi camera port) meaning you have to extend the incision meaning you get pneumo leak around the port.

Call me old fashioned but I’d prefer an empty stomach when I enter the abdomen. I agree that the importance is probably overstated and on a quick look I found no evidence to support it, probably because it’s always been taught as SOC, and to prove that lack ofOG or NG doesn’t cause harm would require a massive study as the risk of visceral injury on entry is 1% or less. Anecdotally though the Bowels seem much less “poochy” for lack of better word when an OG is in and working. Either way, the whole idea seems ridiculous to me that we can’t get these things. I’m just waiting for them to tell us we’ll be operating without bovies.

Yea i imagine the benefit is minuscule. 1) is it worth the cost of placing hundreds/thousands of NG/OGs to even maybe have a benefit. 2) NG/OGs are not procedures without complications. There are many documented complications with insertion (trauma, bleed, spinal cord injury, pulmonary injury etc)

AFAIK, OGT are standard of care for laparoscopic cases. Otherwise, if the surgeon gets into a stomach vessel with one of the ports, he can argue that it was the anesthesiologist's fault.

where is this from? the surgeon can argue its the anesthesiologists fault for anything. last time there was a lap case the surgeon requested more paralysis because he saw peristalsis. the question is is there actually data to support NGT/OGT use to decrease injury

 

[Psai]

The CRNA’s that I work with place them in every intubated patient. Seriously, you could be doing a hip replacement and the patient will get an OGT. I have no idea what the thought process is...

No wonder we have a shortage

 

[dannyboy1]

Yea i imagine the benefit is minuscule. 1) is it worth the cost of placing hundreds/thousands of NG/OGs to even maybe have a benefit. 2) NG/OGs are not procedures without complications. There are many documented complications with insertion (trauma, bleed, spinal cord injury, pulmonary injury etc)



where is this from? the surgeon can argue its the anesthesiologists fault for anything. last time there was a lap case the surgeon requested more paralysis because he saw peristalsis. the question is is there actually data to support NGT/OGT use to decrease injury

It can also go both ways. I remember a case from residency. Repeat ACDF. Surgeon starts operating and suddenly “notices” a perf in the esophagus. He quickly and loudly blames anesthesia and says it must have been from the OGT....
Ever since then I never place an OGT for neck surgery unless specificly requested by surgeon.

 

[Psai]

It can also go both ways. I remember a case from residency. Repeat ACDF. Surgeon starts operating and suddenly “notices” a perf in the esophagus. He quickly and loudly blames anesthesia and says it must have been from the OGT....
Ever since then I never place an OGT for neck surgery unless specificly requested by surgeon.

"Oh you want an OG now? Here's the tube and lube"

 

[deleted171991]

.

where is this from? the surgeon can argue its the anesthesiologists fault for anything. last time there was a lap case the surgeon requested more paralysis because he saw peristalsis. the question is is there actually data to support NGT/OGT use to decrease injury

It may be old school, but I have seen surgeons complain vocally if the stomach was not decompressed. And I am usually careful not to put air in any stomach, lap case or not.

 

[deleted171991]

The CRNA’s that I work with place them in every intubated patient. Seriously, you could be doing a hip replacement and the patient will get an OGT. I have no idea what the thought process is...

The thought process is that the stomach is not always empty at the end of case, and sucking out the bile and acid decreases the chances of aspiration, if the patient has GERD, or vomits during emergence. I used to do a lot of cases with Supreme LMAs (which have a suction port), and I can confirm that many stomachs I probed were not empty at the end of the case.

One only needs 0.2 ml/kg of gastric goodness for aspiration pneumonitis, which can be a killer in the elderly. I will never fault somebody who is cautious, unless the risks exceed the benefits (e.g. insisting on the OGT when it's difficult to place).

 

[coffeebythelake]

The CRNA’s that I work with place them in every intubated patient. Seriously, you could be doing a hip replacement and the patient will get an OGT. I have no idea what the thought process is...

not to mention that placing OGT isn't without risk. i'd like to do as little as possible.

 

[anbuitachi]

.
It may be old school, but I have seen surgeons complain vocally if the stomach was not decompressed. And I am usually careful not to put air in any stomach, lap case or not.

does it change if you put an OGT? there are surgeons who complain about everything. some will say its not decompressed despite there being OGT on suction sucking out gastric contents. the most obvious example that i see all the time is surgeon complaining patient isn't paralyzed, despite 0 twitch. then you give like 1ml of propofol and the surgeon says much better.

 

[abolt18]

We now only have the 14g ones so they clog pretty easily. As useful as not having one at all.

 

[deleted50478]

Are you saying one day we might use

?

 

[deleted171991]

does it change if you put an OGT? there are surgeons who complain about everything. some will say its not decompressed despite there being OGT on suction sucking out gastric contents. the most obvious example that i see all the time is surgeon complaining patient isn't paralyzed, despite 0 twitch. then you give like 1ml of propofol and the surgeon says much better.

Because propofol is a muscle relaxant.

 

[narcusprince]

Egd errbody. And suck them out. Probably do a study on the gastric residual volume.

 

[drmwvr]

Since when does and OGT guarantee an empty stomach anyway?

 

[abolt18]

Since when does and OGT guarantee an empty stomach anyway?

A good point.

Just last week on call I took over a case from a crna. He gave me a story about "this patient was retching and vomiting a bunch in pre-op so we did an RSI and I put down this OG with only a couple hundred CC's out. I gave zofran and was planning to deep extubated this guy"

I manipulated the OG to try to get more out with little success. Woke him up all the way before extubation. Then less than 30 seconds after extubating he sat up and threw up approximately 300cc. He then vomited or retched 10 more times before getting to PACU, producing a few hundred more cc.

 

[DM27]

Yeah I heard something about the OG shortage too. I view the need for an OG for cases as being just more relevant than the need for paralysis for the surgeon to pull the appy/gallbladder bag out.

 

[deleted162650]

He gave me a story about "this patient was retching and vomiting a bunch in pre-op so we did an RSI and I put down this OG with only a couple hundred CC's out. I gave zofran and was planning to deep extubated this guy"

And we worry about these people taking our jobs. . .

 

[abolt18]

And we worry about these people taking our jobs. . .

I was just glad he was awake enough to protect his own airway...when he told me he was going to deep extubate I about laughed in his face.

 

[Consigliere]

And we worry about these people taking our jobs. . .

We should because they are. How many people do you think were told about this CRNA's "mistake?" How many more egregious errors do you think are swept under the rug?

Answers: Zero and a lot.

 

[deleted162650]

We should because they are.

Only they're not really the ones taking our jobs. We are taking each others' jobs and giving them to CRNA's by selling out to AMC's. AMC corpo buys out a practice and then wants to maximize profits. They do this in part by stretching ratio's. CRNA's are just the lucky bystanders in this situation. *Off topic side note*: We've talked ad nauseam how AMC's take good MD jobs and turn them into crap jobs. Does the working environment get worse for the CRNA's too, or do they escape with basically the same package??

How many more egregious errors do you think are swept under the rug?

You can only sweep so much under the rug until you start to trip over it.

 

[anbuitachi]

Can anyone find any studies on og use in lap cases to decrease stomach/bowel injury? Tried searching myself and unable to find anything..

 

[drmwvr]

Can anyone find any studies on og use in lap cases to decrease stomach/bowel injury? Tried searching myself and unable to find anything..

there's the answer....

 

[deleted697535]

Isnt part of ERAS to not place OG's? Very rare to see OG/NG in any elective case (laparoscopic or no)...

 

[2Fast2Des]

Isnt part of ERAS to not place OG's? Very rare to see OG/NG in any elective case (laparoscopic or no)...

I think it's post op use to avoid gastric tube and that intraop is ok

 

[zizzer]

I thought somebody just forgot to order them where I work lol

 

[hununuh]

Our hospital started stocking OGT from different brand recently, but we have plenty. No shortage here.

 

[abolt18]

Our hospital started stocking OGT from different brand recently, but we have plenty. No shortage here.

Ours started buying them off Amazon while searching for a new vendor hahahaha

 

[Airlife91]

If I find it necessary to RSI somebody, I put in an OGT or NGT. Otherwise if it’s a standard laparoscopy, I ask the surgeon if they’d like one. It’s about 50/50 on their responses. I document and typically do what they request (unless I have strong opposing feelings).