Feb 27, 2010
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Input appreciated on following to residents and attendings.

Would you give sedation to patients for replacement of nonfunctioning PEG tube, followed by injection of 150-200cc of gastrografin to confirm proper placement? Surgeon seems to want this for patients who may be agitated. He actually simply pulls out the nonfunctioning PEG and replaces it by directly placing a G-tube.

Obviously my concern would be risk of aspiration.
 

sevoflurane

Ride
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Oral board answer = ETT. As soon as that 200cc's of gastrografin is in she has a full stomach.

If it's one of those ICU sicko patients with altered MS at baseline I would definately do a GA with ETT and suck out the stomach prior to extubation. If the patient is healthy I would consider consciuos sedation (light with plenty of local).

Why gastrograffin and not barium?

gastrograffin can kill: http://www.ncbi.nlm.nih.gov/pubmed/1470976
 
Feb 27, 2010
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I always like to hypothetically ask myself the worst case scenario of an option and ask if my choice is defensible in court.

If sedation is chosen, and the patient aspirates (which can occur in a PEG tube patient unsedated), can you defend sedating a full-stomach patient for a relatively non-painful and non-emergent procedure? I think it could be argued quite successfully that the procedure could be done with no sedation whatsoever.

Often surgeons are not cooperative in waiting for sedation to wear off prior to starting a procedure.

If GA ETT is selected, is it defensible to subject the patient who is likely to have significant co-morbidities to the risks of a general anesthetic for, as stated previously, a procedure that could be done with no sedation at all.

I am just playing devil's advocate, and do appreciate the input from others.
 

IlDestriero

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I'm at a large pediatric hospital. At our place, the IR guys had been doing these procedures in the IR suite with the sedation team, don't ask why. There were several "inadequate sedations" and several aspirations. They are now all done by us and they all get an ETT.
I know it is a different patient population, but that's our recent experience.