The Dilemma of Gastric POCUS

[Guillemot]

I have begun integrating gastric POCUS into my practice as part of the physical examination of patients with risk factors for non-empty stomachs such as taking GLP–1 agonists, opioids, having long-standing poorly controlled diabetes with autonomic neuropathy, etc.

It is not rare to find someone whose stomach has residual contents that are not clear liquid. IE an abnormal exam finding in a patient that is fasted per the ASA criteria.

The dilemma arises with what to do with this knowledge. I feel obligated to act on it. If I were to cancel patients, they could return in the same state in which they first presented i.e. NPO but without an empty stomach. I have generally therefore been tubing these patients and proceeding forward with the case. It becomes a real fvcking pain in the ass, though when their case is super short one. And realistically, even with a non-empty stomach, the odds of an adverse event such as aspiration, are probably elevated but still not high.

How do you guys proceed? Should I just stop looking on cases I don’t wanna deal with? Most anesthesiologists are not looking anyway. I’d have to get buy in from multiple parties to get these patients to come back after a longer NPO than ASA guidelines. Eg. only clears for 24 hours followed by strict NPO for 4 hours. (I’ve not seen significant residual gastric contents on those that have done colon preps for example.)

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[Arch Guillotti]

I have begun integrating gastric POCUS into my practice as part of the physical examination of patients with risk factors for non-empty stomachs such as taking GLP–1 agonists, opioids, having long-standing poorly controlled diabetes with autonomic neuropathy, etc.

It is not rare to find someone whose stomach has residual contents that are not clear liquid. IE an abnormal exam finding in a patient that is fasted per the ASA criteria.

The dilemma arises with what to do with this knowledge. I feel obligated to act on it. If I were to cancel patients, they could return in the same state in which they first presented i.e. NPO but without an empty stomach. I have generally therefore been tubing these patients and proceeding forward with the case. It becomes a real fvcking pain in the ass, though when their case is super short one. And realistically, even with a non-empty stomach, the odds of an adverse event such as aspiration, are probably elevated but still not high.

How do you guys proceed? Should I just stop looking on cases I don’t wanna deal with? Most anesthesiologists are not looking anyway. I’d have to get buy in from multiple parties to get these patients to come back after a longer NPO than ASA guidelines. Eg. only clears for 24 hours followed by strict NPO for 4 hours. (I’ve not seen significant residual gastric contents on those that have done colon preps for example.)

Take the approach found in the House of God:

X. If you don't take a temperature, you can't find a fever.

 

[coffeebythelake]

If it isn't going to change your management why bother doing it

 

[DrN2O]

Are you also confidently clearing patients that do not meet the NPO guideline if their stomachs look empty on POCUS?

 

[Guillemot]

Are you also confidently clearing patients that do not meet the NPO guideline if their stomachs look empty on POCUS?

I don’t look. Follow the guidelines in that case. Too much liability there.

Exceptions would be an equivocally light meal six hour time and conflicting reports about NPO status.

But I view the guidelines as a standard of care. Being more conservative is defensible or using pocus in the equivocal situations is acceptable IMO.

 

[AKMD_1984]

I don’t look. Follow the guidelines in that case. Too much liability there.

Exceptions would be an equivocally light meal six hour time and conflicting reports about NPO status.

But I view the guidelines as a standard of care. Being more conservative is defensible or using pocus in the equivocal situations is acceptable IMO.

Since when are guidelines ALWAYS considered standard of care?
We have to be careful about how to word things and be careful about language we use because many do not use a nuanced approach and they may equate the two.

Whether standard of care is met or not is highly factual and situation specific. For that particular situation, or resources of facility, guidelines may not be met. Not every place is a level 3 trauma center with 24/7 anesthesia coverage, 4 techs are 3 am for emergency surgery. Most places do not even have a POCUS for outpatient surgery.

Today for instance, I did OBA case for a SCS trial. Facility does not have ETCO2 nasal cannula, and have not had it for 6 months. Its too expensive. They have oxygen tanks. Last week I pushed Propofol at the same office for kyphoplasty for a 94 year old patient in office.

Do I cancel cases? Of course not. ETCO2 is not the only way to assess gas exchange and ventilation. You look at chest rise and keep them spontaneous, and on a lighter side and tell surgeon to use more local...that's it. Both patients walked out happy. The neurosurgeon I work with is completely on board with this because he knows its a waste of time to do these cases in the hospital. For everyone.

In our practice, which is high volume, mostly busy outpatient surgery - we proceed as usual and minimize cancellations and delays, not because we want to make $$$ but because there is no guarantee that next time the patient comes, they wont present the same and now we just wasted everyone's time. We manage risk, document briefly, obtain good consents and do the case. Our time is limited.

We take all steps to reduce aspiration and if it means intubate, then yes of course. But the way I look at it, you can take all preventive measures you want, but the patient may still aspirate, or lie about their NPO status. You still have to treat and correct it. POCUS is just a diagnostic tool. It is not therapeutic measure and I do not know anyone who's practice is modified or changed JUST because of gastric ultrasound.

 

[gunnershow]

Since when are guidelines ALWAYS considered standard of care?
We have to be careful about how to word things and be careful about language we use because many do not use a nuanced approach and they may equate the two.

Whether standard of care is met or not is highly factual and situation specific. For that particular situation, or resources of facility, guidelines may not be met. Not every place is a level 3 trauma center with 24/7 anesthesia coverage, 4 techs are 3 am for emergency surgery. Most places do not even have a POCUS for outpatient surgery.

Today for instance, I did OBA case for a SCS trial. Facility does not have ETCO2 nasal cannula, and have not had it for 6 months. Its too expensive. They have oxygen tanks. Last week I pushed Propofol at the same office for kyphoplasty for a 94 year old patient in office.

Do I cancel cases? Of course not. ETCO2 is not the only way to assess gas exchange and ventilation. You look at chest rise and keep them spontaneous, and on a lighter side and tell surgeon to use more local...that's it. Both patients walked out happy. The neurosurgeon I work with is completely on board with this because he knows its a waste of time to do these cases in the hospital. For everyone.

In our practice, which is high volume, mostly busy outpatient surgery - we proceed as usual and minimize cancellations and delays, not because we want to make $$$ but because there is no guarantee that next time the patient comes, they wont present the same and now we just wasted everyone's time. We manage risk, document briefly, obtain good consents and do the case. Our time is limited.

We take all steps to reduce aspiration and if it means intubate, then yes of course. But the way I look at it, you can take all preventive measures you want, but the patient may still aspirate, or lie about their NPO status. You still have to treat and correct it. POCUS is just a diagnostic tool. It is not therapeutic measure and I do not know anyone who's practice is modified or changed JUST because of gastric ultrasound.

EtCO2 is actually the standard of care for mod/deep sedation or GA, at least per the ASA

Now the legal term "standard of care" is defined as what a reasonable anesthesiologist would do in a given situation, but it's heavily influenced by professional standards, and pretty much any expert witness would testify that you violated the standard of care if you had a bad outcome and weren't using EtCO2 while pushing propofol

 

[AKMD_1984]

EtCO2 is actually the standard of care for mod/deep sedation or GA, at least per the ASA

Now the legal term "standard of care" is defined as what a reasonable anesthesiologist would do in a given situation, but it's heavily influenced by professional standards, and pretty much any expert witness would testify that you violated the standard of care if you had a bad outcome and weren't using EtCO2 while pushing propofol

So you’re saying that you need Etco2 only to determine ventilation?

lol

Ok.

 

[gunnershow]

So you’re saying that you need Etco2 only to determine ventilation?

lol

Ok.

No, I'm just saying that the ASA designates it as a basic monitor for sedation cases: "During moderate or deep sedation the adequacy of ventilation shall be evaluated by continual observation of qualitative clinical signs and monitoring for the presence of exhaled carbon dioxide unless precluded or invalidated by the nature of the patient, procedure, or equipment."

I don't believe "lack of equipment" would fly as a valid defense to this standard. It'd be an uphill battle in court trying to argue you didn't violate standards of care by skipping ETCO2.

 

[AKMD_1984]

That would happen if there is a bad outcome. That would happen if you don’t pay attention to the patient or what’s happening or are distracted or texting. Poor outcome would happen if you don’t know how to titrate anesthetic (any medication, not just propofol) and keep the patient apneic. Lawsuit would happen if there’s a poor outcome.

So a lot has to go wrong for a poor outcome, and presence of etco2 is not going to make a difference in that situation. What will etco2 tell you in this situation? You really need etco2 to tell you that the patient is apneic? Now if you don’t know how to assess ventilation or keep patient knocked out plus you don’t have etco2 monitoring, of course that’s a problem.

My point is, there are many practice settings and each surgeon, facility, and case is different and sometimes adaptability is required and needed.

Situation changes if it’s an hour long case with slow surgeon and morbidly obese patient etc etc. Each situation and its associated risk is specific to that patient. That’s why they’re called guidelines and not law.

Deviations from guidelines must be rational and sound.

All this talk about aspiration prevention is certainly important but at the end of the day there are never any guarantees. I have not seen any studies showing me that aspiration risk becomes zero with any measure. Patients can still aspirate despite precautions - we just deal with it.

 

[nimbus]

We do formal site inspections before we start staffing any new sites. We refuse to staff sites with inadequate equipment. ETCO2 monitoring has been a requirement for over 25 years in our practice. If some eye center or plastic surgeons office doesn’t want to buy a capnograph, we just say no. We are self insured.

 

[AKMD_1984]

I do not disagree with you at all regarding monitoring. There’s nothing for me to disagree with nor am I endorsing doing cases without etco2.

I was giving a real and situation specific example and describing how logistics and facility play a role in practice and not everything is ideal 100% of the time.

What I was getting at is that in your 25 years of practice I’m sure if etco2 wasn’t available one day without fault of your own - and procedure time was less than 15 minutes (for kyphoplasty by a very experienced and fast neurosurgeon - on a 94 year old patient that required both of her daughters to take off work and bring her to the facility), you wouldn’t cancel the case. Or would you?

I wouldn’t.

JUST because of lack of etco2. I’d just tailor and modify my anesthetic so they’re more on the awake side and never get apneic.

I’d just get the case done because at the end of the day, etco2 is just a monitor - it’s not therapeutic.

Is that illegal? No.
Is that best practice? No.
Is that a deviation from standard? Probably yes.
Is it risky to do that patient in clinic? Yes.
But is the risk acceptable based on assessment and type of case and length of procedure and experience of physician and is there emergency airway, ett and ambu bag available? Yes.
So I did the case.

 

[pgg]

So you’re saying that you need Etco2 only to determine ventilation?

lol

Ok.

It's pretty clearly listed as a standard of care by the ASA and it's absolutely wild that you think it's optional.

During moderate or deep sedation the adequacy of ventilation shall be evaluated by continual observation of qualitative clinical signs and monitoring for the presence of exhaled carbon dioxide unless precluded or invalidated by the nature of the patient, procedure, or equipment.

 

[gunnershow]

I do not disagree with you at all regarding monitoring. There’s nothing for me to disagree with nor am I endorsing doing cases without etco2.

I was giving a real and situation specific example and describing how logistics and facility play a role in practice and not everything is ideal 100% of the time.

What I was getting at is that in your 25 years of practice I’m sure if etco2 wasn’t available one day without fault of your own - and procedure time was less than 15 minutes (for kyphoplasty by a very experienced and fast neurosurgeon - on a 94 year old patient that required both of her daughters to take off work and bring her to the facility), you wouldn’t cancel the case. Or would you?

I wouldn’t.

JUST because of lack of etco2. I’d just tailor and modify my anesthetic so they’re more on the awake side and never get apneic.

I’d just get the case done because at the end of the day, etco2 is just a monitor - it’s not therapeutic.

Is that illegal? No.
Is that best practice? No.
Is that a deviation from standard? Probably yes.
Is it risky to do that patient in clinic? Yes.
But is the risk acceptable based on assessment and type of case and length of procedure and experience of physician and is there emergency airway, ett and ambu bag available? Yes.
So I did the case.

I don't think anyone is saying they've never deviated from guidelines before, but you need a better reason than "the facility is too cheap to pay for basic monitoring".

For example, at a locums assignment, I had to do a stat section under GA for placental abruption at a secondary OR location that is normally out of service. The two usual c-section rooms were being cleaned. I realized the ETCO2 module was broken and I had no one to call to troubleshoot it.

Yes, I did the case. Yes, I broke standard of care. But a risk/benefit analysis would support my actions. In your case, a reasonable anesthesiologist would refuse to do sedations without the appropriate monitoring. It's an elective case and the facility needs to be up to par. I pride myself on solving problems instead of cancelling cases, but this is a slam-dunk cancel every time.

And to your other point, I'm not sure how you're assessing chest rise on a prone patient. Misting of the mask only goes so far... I would bet that we'd all catch developing obstruction far more quickly by observing the capnogram than by clinical signs alone.

 

[PpfSuxTube]

Gastric pocus for me is a nonsense. Liability waiting to happen. I mean what's the options here?

You suspect something, do pocus, find a full stomach then delay the case as you probably should have done anyways based on timing or whatever information tipped you off to even do pocus in the 1st place?

Or you find nothing on pocus and do a risky case that you are subsequently assuming all liability for if aspiration occurs?

I dont see any benefit.

Btw I echo every cardiac case. Their stomachs almost always have stuff in them.

 

[nimbus]

I do not disagree with you at all regarding monitoring. There’s nothing for me to disagree with nor am I endorsing doing cases without etco2.

I was giving a real and situation specific example and describing how logistics and facility play a role in practice and not everything is ideal 100% of the time.

What I was getting at is that in your 25 years of practice I’m sure if etco2 wasn’t available one day without fault of your own - and procedure time was less than 15 minutes (for kyphoplasty by a very experienced and fast neurosurgeon - on a 94 year old patient that required both of her daughters to take off work and bring her to the facility), you wouldn’t cancel the case. Or would you?

I wouldn’t.

JUST because of lack of etco2. I’d just tailor and modify my anesthetic so they’re more on the awake side and never get apneic.

I’d just get the case done because at the end of the day, etco2 is just a monitor - it’s not therapeutic.

Is that illegal? No.
Is that best practice? No.
Is that a deviation from standard? Probably yes.
Is it risky to do that patient in clinic? Yes.
But is the risk acceptable based on assessment and type of case and length of procedure and experience of physician and is there emergency airway, ett and ambu bag available? Yes.
So I did the case.

Today for instance, I did OBA case for a SCS trial. Facility does not have ETCO2 nasal cannula, and have not had it for 6 months. Its too expensive. They have oxygen tanks. Last week I pushed Propofol at the same office for kyphoplasty for a 94 year old patient in office.

We wouldn’t agree to staff this facility. At the facilities we do staff, a 94yo kyphoplasty likely wouldn’t even pass patient screening. We’d tell them they need to book the case at the hospital. Is there a medical director there?

 

[sevo00]

Why are you ultrasounding every patient? lol. You have that much free time in preop in between cases?

 

[Guillemot]

Gastric pocus for me is a nonsense. Liability waiting to happen. I mean what's the options here?

You suspect something, do pocus, find a full stomach then delay the case as you probably should have done anyways based on timing or whatever information tipped you off to even do pocus in the 1st place?

Or you find nothing on pocus and do a risky case that you are subsequently assuming all liability for if aspiration occurs?

I dont see any benefit.

Btw I echo every cardiac case. Their stomachs almost always have stuff in them.

Are you saying that you believe that gastric pocus is nonsense, but you do it routinely anyway? Then you chose to not modify your anesthetic technique based on the information obtained? That doesn't make any sense.

 

[PpfSuxTube]

Are you saying that you believe that gastric pocus is nonsense, but you do it routinely anyway? Then you chose to not modify your anesthetic technique based on the information obtained? That doesn't make any sense.

Tee brother. Everyone is diabetes **** show on glp1 etc. All get rsi 100 roc

 

[Guillemot]

Tee brother. Everyone is diabetes **** show on glp1 etc. All get rsi 100 roc

So if that’s always the plan in your practice, gastric pocus wouldn’t necessarily be useful.

Most of us though do at least some cases where MAC/GAWA or LMA would be the default.

 

[ProPropofol]

Not that I'm advocating one way or the other but if you want it to be a little more scientific, you can measure the cross sectional area of the gastric antrum and estimate the gastric volume. If the volume is less than 1.5mL/kg, the aspiration risk is considered low. Greater than 1.5mL/kg, aspiration risk is high.

Here is a link for a website that can teach you how to do it if you're interested: Gastric Ultrasound | Show me the POCUS

 

[Guillemot]

Not that I'm advocating one way or the other but if you want it to be a little more scientific, you can measure the cross sectional area of the gastric antrum and estimate the gastric volume. If the volume is less than 1.5mL/kg, the aspiration risk is considered low. Greater than 1.5mL/kg, aspiration risk is high.

Here is a link for a website that can teach you how to do it if you're interested: Gastric Ultrasound | Show me the POCUS

I’m aware of this criteria as well as that any amount contents that are non-clear liquid is considered elevated risk. I’m not changing management for clear fluid that is 1.5 cc per kilogram or less.

How about partially digested food of 1.5 cc per kilogram or less? That is the most common elevated risk finding that I am observing.

 

[Maverikk]

What is feasible, perceived as safe does not mean defensible. You can do a case without etco2, you can say standard of care is open to interpretation, which I agree with, it’s your job as the physician to decide when NOT to apply, it’s the lowest threshold for care. I’ve rarely gone against the standard for elective cases, and when it happens I’m blunt and up front in a friendly way with the patient and document it. Instances would be where the patient has made significant life plans for a major surgery that couldn’t be easily rescheduled, which is rare. One case I can think of was a tka, surgeon had a flight to catch and was going for mission work for 6 weeks, patient had used vacation from work, set up PT, patient had coffee with cream. I think in this situation you have to be cognizant of all the factors involved. Did the case with a spinal with him completely awake. I had the preop nurse in the room with me for the preop talk and her write a little note beside my preop note. I think this was best for the patient, but I would also agree with someone who canceled. This was when I was first out of training, not sure I would do it again. I would compare this with a partner at that same site whose npo guidelines were 6 hours for full meals…for the same high volume boutique ortho practice (5-6 totals in one room, out by 5 usually)…the ortho guys eventually would tell their patients breakfast was ok for cases that were after noon. The group leaders had to have a little come to Jesus talk with the partner.
Doing cases with no etco2 may be perceived as safe, but the problem isn’t just an individual case it’s setting a new standard. So when your partner has the same case and says no the surgeon will go ‘Dr X says it’s ok’…violating the standard of care should be a rare and well documented exception, not the rule

 

[addoncase]

.

we proceed as usual and minimize cancellations and delays, not because we want to make $$$ next

sure….

 

[jthedestroyr]

So you’re saying that you need Etco2 only to determine ventilation?

lol

Ok.

You’re going to get destroyed in court with one event.

No end tidal monitoring, I am not doing the case unless it’s emergent and documented that it’s life or death that must proceed in the US system how it’s setup.

You think surgeon doesn’t turn on you the minute something that goes wrong that can be blamed on is. Playing with fire my friend.

 

[PpfSuxTube]

You’re going to get destroyed in court with one event.

There isn't really any monitor that prevents you not doing poorly in court if there's a bad outcome anesthesia related is there?

The best monitor is good oxygen, good BP and an an always on and present anesthesiologist.

 

[caligas]

If you’re in court you’ve already lost

 

[Guillemot]

In theory, malpractice awards are given for adverse outcomes resulting from substandard care as the proximate cause of harm. Using @PpfSuxTube 's example, suppose an anesthesiologist is not available for an emergency because they are found ****ing a nurse in the call room. In that case, it will be much worse medicolegally than if they showed up but the adverse outcome happened anyway. Similarly, if a patient suffers an injury due to hypoxia, its going to be a lot worse if standard ASA monitors were not applied.

There is ideally a distinction between adverse outcomes despite adherence to standard of care, and medical malpractice. In reality, juries are made up of salt of the earth folks that may award a plaintiff out of sympathy rather than a preponderance of evidence.

I agree with @caligas on his point though that if you're in court, you've already lost. Even if the law sides with you, you've still lost dozens to hundreds of hours of time, lost thousands in lost income from not being at work, and suffered emotional turmoil.

 

[Bertelman]

Btw I echo every cardiac case. Their stomachs almost always have stuff in them.

You should try emptying that stomach before you drop the probe. Better images.

 

[PpfSuxTube]

You should try emptying that stomach before you drop the probe. Better images.

do you do much echo? The stuff in the stomach never really interferes with TG views. Air from BVM can or hiatus hernia does for sure but for some reason never the crud in the stomach. It's always deeper or off to the side for some reason idk.

the tg views offer little info anyways. If I can't get em there usually an alternate ME view but thats very rare

 

[DrN2O]

I don’t look. Follow the guidelines in that case. Too much liability there.

Exceptions would be an equivocally light meal six hour time and conflicting reports about NPO status.

But I view the guidelines as a standard of care. Being more conservative is defensible or using pocus in the equivocal situations is acceptable IMO.

If I'm understanding you correctly, you are essentially adding another huddle on top of the NPO guideline in populations that have risk factors. I personally think it is commendable that you are applying a skill to objectively assess that risk. However, the application feels one sided, namely you are only using this modality to delay cases or escalate care. If you can tell full stomach on POCUS, why couldn't you clear someone with empty stomach that falls short of the NPO guideline? Or do you believe that this is the exact purpose of gastric POCUS--confirm your suspicion of full stomach? Am I misinterpreting you?

 

[Guillemot]

If I'm understanding you correctly, you are essentially adding another huddle on top of the NPO guideline in populations that have risk factors. I personally think it is commendable that you are applying a skill to objectively assess that risk. However, the application feels one sided, namely you are only using this modality to delay cases or escalate care. If you can tell full stomach on POCUS, why couldn't you clear someone with empty stomach that falls short of the NPO guideline? Or do you believe that this is the exact purpose of gastric POCUS--confirm your suspicion of full stomach? Am I misinterpreting you?

The purpose is to limit my liability and provide safer care. Not following NPO guidelines would do the opposite. Small amounts of particulate matter could go undetected on gastric POCUS. Additionally, although up to 1.5cc/kg of clear fluid is normal, the lower the volume, the lower the risk. So the ASA guidelines serve as a baseline and I do additional risk assessment based on patient history.

 

[Bertelman]

do you do much echo? The stuff in the stomach never really interferes with TG views. Air from BVM can or hiatus hernia does for sure but for some reason never the crud in the stomach. It's always deeper or off to the side for some reason idk.

the tg views offer little info anyways. If I can't get em there usually an alternate ME view but thats very rare

Anywhere from 150-400 exams per year, for over a decade

1) I drop an OG before the TEE to identify the esophagus and clear the contents. For me, the OG is less traumatic than jabbing that probe around.
2) you getter better images when tissue is closer to the probe. That’s a foundation of ultrasound. With obese patients, I’m already often scanning through the liver in TG views. Last thing I want is air and gastric contents as well
3) “tg offers little info”- you can’t be serious. How are you measuring gradients? Quantifying EF? Identifying RWMAs? I’ve never seen an aortic gradient measured in an ME view. Try assessing for aortic PVLs after an AVR/MVR. You can’t, unless you’re in the stomach.

I started this practice in fellowship. I had a few episodes where I believed air in the stomach made it very difficult to image the AV in the Deep TG view. Poor resolution, poor envelopes with CW Doppler. Since I began clearing the stomach, I very rarely have issues.

 

[pgg]

the tg views offer little info anyways. If I can't get em there usually an alternate ME view but thats very rare

I don't understand - what cases are you doing TEE for that TG views aren't important? Are you not doing cardiac surgery?

 

[AKMD_1984]

You’re going to get destroyed in court with one event.

No end tidal monitoring, I am not doing the case unless it’s emergent and documented that it’s life or death that must proceed in the US system how it’s setup.

You think surgeon doesn’t turn on you the minute something that goes wrong that can be blamed on is. Playing with fire my friend.

Ok. First of all, if I thought it was risky, I’d never proceed.

If you’re not an attorney, I do not think you can make that determination.

Patient walked out fine.

 

[AKMD_1984]

We wouldn’t agree to staff this facility. At the facilities we do staff, a 94yo kyphoplasty likely wouldn’t even pass patient screening. We’d tell them they need to book the case at the hospital. Is there a medical director there?

They do
They do plenty of cases
It’s a proper place with OBA certification etc

I’ve done anesthetic there before

It was just a one off incident because the surgeon I worked for scheduled the case there due to patients and family’s convenience

 

[AKMD_1984]

sure….

Yes sure.
It was within my specified shift. Made no difference to do the case or not. I earn the same. I don’t bill.

 

[AKMD_1984]

We wouldn’t agree to staff this facility. At the facilities we do staff, a 94yo kyphoplasty likely wouldn’t even pass patient screening. We’d tell them they need to book the case at the hospital. Is there a medical director there?

Not every insurance allows you to do cases at every facility, especially commercially manager Medicare plans.

 

[PpfSuxTube]

I don't understand - what cases are you doing TEE for that TG views aren't important? Are you not doing cardiac surgery?

relax guys, read what I actually said. Given I do as much cardiac as you don't go on the attack so easily.

I didnt say they weren't important. I said ive almost never had a problem finding the tg views. So it's a hypothetical problem youre trying to attack me over... and I've almost never had to empty a stomach definitely never for the particulate matter in there. Rarely for air but since I stopped bagging them I don't need it anymore

Peace

 

[pgg]

relax guys, read what I actually said. Given I do as much cardiac as you don't go on the attack so easily.

I didnt say they weren't important. I said ive almost never had a problem finding the tg views. So it's a hypothetical problem youre trying to attack me over... and I've almost never had to empty a stomach definitely never for the particulate matter in there. Rarely for air but since I stopped bagging them I don't need it anymore

Peace

🙂

Not attacking

Thought maybe you only did Watchmans or Mitraclips, or just did sedation for cardiologist-driven TEEs or something.

You said "the tg views offer little info anyways" which struck me as odd. It's tough to get an aortic or LVOT gradient from any other position, and that's a common enough and essential enough requirement in cardiac surgery that I was confused.

 

[nimbus]

They do
They do plenty of cases
It’s a proper place with OBA certification etc

I’ve done anesthetic there before

It was just a one off incident because the surgeon I worked for scheduled the case there due to patients and family’s convenience

You said they didn’t have capnometry for 6mos because they are too cheap to buy cannulas with sampling ports. How is that a one off?

 

[jthedestroyr]

Ok. First of all, if I thought it was risky, I’d never proceed.

If you’re not an attorney, I do not think you can make that determination.

Patient walked out fine.

I do expert witness.

You’d get absolutely destroyed without end tidal monitoring, absolutely indefensible in court.

Yes, if you’re in court you’ve already lost, but no use in making it easy for the lawyers.

 

[repititionition]

Ok. First of all, if I thought it was risky, I’d never proceed.

If you’re not an attorney, I do not think you can make that determination.

Patient walked out fine.

You’ve heard of confirmation bias?

 

[Bertelman]

relax guys, read what I actually said. Given I do as much cardiac as you don't go on the attack so easily.

Peace

Lol, didn't mean to attack. To be fair, you did ask me if I did much echo.

I can come off as pretty pedantic on here, but honestly most of the time I respond it's to educate the forum, not to attack a person. I post on here to foster discussions and encourage people to evaluate their practice. I hope that's why we are all here. I don't feel strongly about what I do, other than to say it works for me. But there are countless discussions here on what you can get away with versus best practices.

Intraoperative TEE for cardiac surgery is a different beast. You are the source of truth that guides intervention, then evaluates the viability and success of that intervention. You do not want to go through the circus of a pump run just to implant a valve with a significant leak, or a leaflet that isn't properly functioning. If a cardiologist can't image a structure, they abort the procedure and order another imaging modality. We don't have that luxury. Decisions are made based on your images.

We have all had cases where our images either led to an intervention that's not planned, or prevented a procedure that was unnecessary. As far as I'm concerned, better imaging allows me to provide better information. I get that by emptying the stomach. I see dropping an OG as a relatively harmless procedure that has proven to provide better images for me, and a less traumatic probe insertion. I use those images to guide my surgeons. If you aren't doing easy things like this to optimize the imaging that the team relies on to evaluate outcomes, then you may not be providing the best care. Maybe your images are optimized, maybe they are not. But for everyone else around here looking to get better at TEE, maybe dropping an OG will help.

 

[Gaseous Clay]

They do
They do plenty of cases
It’s a proper place with OBA certification etc

I’ve done anesthetic there before

It was just a one off incident because the surgeon I worked for scheduled the case there due to patients and family’s convenience

Dude you just need to stop. You’re walking an extremely fine line between trying to appease the patient and surgeon and downright being unsafe and committing malpractice.

 

[dchz]

I had this happen to me yesterday. Pt did not stop GLP-1 for an elective procedure (cardioversion). I decided that a Gastric POCUS was a good idea. Clearly see air fluid levels in the stomach. Pt was on GLP-1 and had a cardioversion done in Nov and it was uneventful.

Pt wanted to proceed and is willing to sign anything that absolves me of liability (I know this is non binding and won't stand up in court).

- I made sure cardiologist was on board, he's gonna be sued with me even if it's my decision.
- I made patient and MPOA understand the risk of prolonged intubation and even possible death.
- I made it clear this is a relatively low probability event but the effects are detrimental.

Pt agreed and I proceeded. It was a ridiculous amount of work/documenting for a 4 min sedation...

I'm not sure I'd do the same if I had to do it over again.

 

[DrN2O]

I'm not sure I'd do the same if I had to do it over again.

Do you mean you would forego the POCUS and cancel? Or consent the patient and cards for higher risk based on GLP-1 history alone and go ahead with sedation? I assume finding solid food vs. liquid in the stomach would have affected your decision making.

 

[nimbus]

I had this happen to me yesterday. Pt did not stop GLP-1 for an elective procedure (cardioversion). I decided that a Gastric POCUS was a good idea. Clearly see air fluid levels in the stomach. Pt was on GLP-1 and had a cardioversion done in Nov and it was uneventful.

Pt wanted to proceed and is willing to sign anything that absolves me of liability (I know this is non binding and won't stand up in court).

- I made sure cardiologist was on board, he's gonna be sued with me even if it's my decision.
- I made patient and MPOA understand the risk of prolonged intubation and even possible death.
- I made it clear this is a relatively low probability event but the effects are detrimental.

Pt agreed and I proceeded. It was a ridiculous amount of work/documenting for a 4 min sedation...

I'm not sure I'd do the same if I had to do it over again.

Why bother with the gastric ultrasound if you’re going to proceed after it shows a full stomach? Maybe your point is “don’t do gastric ultrasound for a cardioversion.”

 

[dchz]

Do you mean you would forego the POCUS and cancel? Or consent the patient and cards for higher risk based on GLP-1 history alone and go ahead with sedation? I assume finding solid food vs. liquid in the stomach would have affected your decision making.

Having liquid in stomach isn't a huge deal, clear liquids are liquids too. I do think air fluid and the reflections are solid food until proven otherwise.
I think I would just say. Stuff in stomach. Cancel.

Why bother with the gastric ultrasound if you’re going to proceed after it shows a full stomach? Maybe your point is “don’t do gastric ultrasound for a cardioversion.”

I don't think each decision should automatically necessitate the next.

I think no food in stomach is automatic proceed, assuming right lateral decubitus and sensitive scan.

Tbh I was helping out a partner that would have gone and done it anyways, so I was looking for an excuse to do it.

So yeah, may be I I'm saying don't do a gastric ultrasound if you're gonna do it anyways. 🤷‍♂️

 

[Bertelman]

If I'm gonna scan one population for gastric contents, I'd feel compelled to scan them all. No sense in limiting your caution to that population.