Pre-op protocol for GI cases ?
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Follow the standards. With that being said, if they show up without certain tests I can usually get them through the procedure without much affair. GI and MAC sedation cases can be some of the more dangerous things we do.
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http://forums.studentdoctor.net/threads/anesthesia-outside-the-or.1097308/#post-15666243
Again, I don't think you fit the bill based on your previous posts. Just being careful. I would think you should know this stuff already too.
Again, I don't think you fit the bill based on your previous posts. Just being careful. I would think you should know this stuff already too.
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Why are you getting this stuff on healthy patients?
D
deleted171991
You shouldn't get these for any cases, not even for OR cases, if the patients are healthy.
D
deleted171991
You get what's pertinent. Most of the time H&P is enough. An EKG can be obtained in the admitting area, if you feel the need. Plus you don't go heavy on your sedation if you know there might be an underlying heart disease. Have a light hand on that propofol syringe; don't stress test your patients during the endoscopy (make the GI doc your partner in this), and you'll be fine most of the time, even with sick dudes. With GI, the main problem is the airway.
Don't postpone the procedure for tests that have a low pre-test probability to postpone the procedure. 😀
The enemy of good is better. Don't get stuff that has a low likelihood of changing your management, except when the consequences can be devastating. (E.g. don't give anesthesia to a patient with a AAA that was last checked 2 years ago.)
To answer you exact question: if a 65 y/o patient has only stable CAD, HTN and hyperlipidemia, he could probably have any low-risk surgery without any further testing, in my book (especially if he has good exercise tolerance).
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Just curious how you quantify having a propofol bolus "light hand" in mcg/kg numbers on a 60 yo with heart disease getting a scope. 100? 300? 500? 1000? Plus Fentanyl? Plus Versed? I usually go with 500 mcg/kg (3 mL bolus on a 60 kg pt to start) but I'm just curious about your technique.
D
deleted171991
I haven't done outpatient GI for the last few months, so this is all from long-term memory. Also, all my patients are non-intubated and in left lateral decubitus.
I mostly titrate propofol to effect. If the patient has low cardiac or respiratory reserve, the "effect" is the minimal level of sedation which keeps the patient comfortable while still being safe (I aim for vitals within 10-15% of what the patient had in admitting, before meeting me).
I don't have a magic number (I don't really think in mg/kg for GI or any MAC induction). In healthy young and middle-aged patients I go directly for ~100 mg to start with (around 1.5 mg/kg). But if I think the patient might be really sensitive to propofol, I can push as little as 1-2 cc's at a time, then wait for the effect; the older the patient, the more I wait (you know how it goes: half the dose, double the interval). I might push 1 cc while the patient is still being adjusted, just to get an idea of the patient's response. Once I see how the patient tolerates propofol, it's much easier; I might just leave them on an infusion pump.
If I am really concerned, I tell the patient pre-procedure that I cannot promise they will be completely asleep, that they might remember things, and that it's done for their safety. I also reassure them that the procedure is not really painful (for colonoscopies), but if they are uncomfortable at any time we will just stop (never happened, and 95+% of the time they still won't remember anything.)
I cycle that BP cuff every 3 minutes or more frequently, and watch the patient like a hawk. I involve the GI doc, explaining my concerns (and why), telling him/her that it might take a bit longer to induce and the patient might be lighter than usual, asking him/her to go slowly and gently, use local anesthetic for the pharynx etc.
The only patients I might give some Fentanyl and/or Versed to are the patients who are having painful procedures, such as dilation, or RFA (Halo). I also used more of those when we had a propofol shortage. For a relatively healthy patient who is having a double endoscopy, 50-100 mcg of Fentanyl + 1-2 mg of Versed can cut down nicely on the propofol requirements, without affecting wake-up.
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Keep it simply.
1) Set-up a syringe pump. Draw-up 50 mL of propofol into a 60mL syringe.
2) Push 5mL of 1% lidocaine and then 50 mg of propofol for otherwise healthy patients, then start the pump at 200 mcg/kg/min. Lower your bolus and/or give more time for low cardiac output state patients.
3) Tell the endoscopist to just stop and wait for a g'damn f'ing second or two before he starts shoving things in their ass. It takes a little time to work. It's not g'damn magic.
4) Keep the infusion at 200 mcg/kg/min until they get to the cecum, then turn it down to 100 mcg/kg/min.
5) Shut it off when they get to the sigmoid colon unless you saw disease on the way in and are going to have to biopsy. If there's a biopsy in the sigmoid colon or rectum, turn down to 50 mcg/kg/min then shut it off after the last one is done.
6) When they pull the scope out, turn the lights on, unhook the patient, and start rolling them to the recovery area. 50% of the patients will wake-up by the time you hook them up to the monitors in the recovery area, the other 50% will wake-up within 5 minutes. None of them will remember jack squat.
If you do this, you will have a smooth life in endoscopy. If you push little wimpy boluses here and there, you're going to be on a roller coaster between under and over sedation, and you will have a much higher chance your patient is going to remember. Of course airway precautions in the mega-fatties, watch for cardiac cripples, little tiny old lady copers, etc.... don't be stupid. It's not a perfect recipe for everyone. Although for 90% of the patients you'll see? Probably.
1) Set-up a syringe pump. Draw-up 50 mL of propofol into a 60mL syringe.
2) Push 5mL of 1% lidocaine and then 50 mg of propofol for otherwise healthy patients, then start the pump at 200 mcg/kg/min. Lower your bolus and/or give more time for low cardiac output state patients.
3) Tell the endoscopist to just stop and wait for a g'damn f'ing second or two before he starts shoving things in their ass. It takes a little time to work. It's not g'damn magic.
4) Keep the infusion at 200 mcg/kg/min until they get to the cecum, then turn it down to 100 mcg/kg/min.
5) Shut it off when they get to the sigmoid colon unless you saw disease on the way in and are going to have to biopsy. If there's a biopsy in the sigmoid colon or rectum, turn down to 50 mcg/kg/min then shut it off after the last one is done.
6) When they pull the scope out, turn the lights on, unhook the patient, and start rolling them to the recovery area. 50% of the patients will wake-up by the time you hook them up to the monitors in the recovery area, the other 50% will wake-up within 5 minutes. None of them will remember jack squat.
If you do this, you will have a smooth life in endoscopy. If you push little wimpy boluses here and there, you're going to be on a roller coaster between under and over sedation, and you will have a much higher chance your patient is going to remember. Of course airway precautions in the mega-fatties, watch for cardiac cripples, little tiny old lady copers, etc.... don't be stupid. It's not a perfect recipe for everyone. Although for 90% of the patients you'll see? Probably.
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I like how you keep it simple, i just fill a 20cc syringe and titrate to effect, a routine scope should be done with just one stick. Most patients wake up right at the end. We don't have a monitored recovery area patient goes back to his room.
