The Dilemma of Gastric POCUS

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Ronin786 said:
There are much bigger factors that affect aspiration than the presence of something in the stomach on gastric ultrasound.
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If the stomach is empty on gastric US, then there is likely little to nothing within the stomach to regurgitate and aspirate. I'd encourage some further thought regarding this matter.
 
Guillemot said:
If the stomach is empty on gastric US, then there is likely little to nothing within the stomach to regurgitate and aspirate. I'd encourage some further thought regarding this matter.
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While your point is true I didn’t take that as his point, which is one I agree with. I could easily argue that you may have missed content on your US, and even if you saw some aspiration remains exceedingly unlikely.
 
Yesterday, I had 2 Ozempic patients with small ( <1.5cc/kg estimated on gastric pocus & a qualitatively non-distended gastric antrum) amounts of residual contents that were non-clear liquid. My concern for aspiration was still not high given the small volume and non-distended stomach. It's not like the stuff in their stomach would magically shoot up their esophagus after induction since there would not be a significant pressure differential. For example, these would not be patients I would do a MAC on in the Trendelenburg position, however as both the position as well as potential coughing (increased intra-abdominal pressure, shifting the gastric contents into the cardia) could increase the risk of regurgitation. Some procedures though I think would probably be fine under MAC. I am still developing my practice in regard to decision making though.


I also had a patient with poorly controlled DM1 with sequelae of end-organ failure and peripheral neuropathy. He had no documented gastroparesis. Gastric POCUS showed an estimated >1.5cc of non-clear liquid & a qualitatively moderately distended gastric antrum. We RSI'd this guy and the OGT returned liquified food mixed with gastric fluid.


The first two patient examples were technically not normal, but likely would not have had issues under many circumstances due to the minimal volume present. The third patient might have still been fine but also was at significant risk. Most people wouldn't have looked though, and this could have resulted in an emergency and significant morbidity.
 
Southpaw said:
While your point is true I didn’t take that as his point, which is one I agree with. I could easily argue that you may have missed content on your US, and even if you saw some aspiration remains exceedingly unlikely.
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Many of the posters in this thread are like yourself: they don't do gastric ultrasound and don't know what they are talking about.
 
Many factors contribute to aspiration risk.

The ER is sedating (with their hammy fists) full stomach patients for procedures every day, and they are not causing an epidemic of aspiration injuries. There is surely room for anesthesiologists to risk stratify individual patients with objective data from gastric ultrasound, and proceed/cancel based on what they find.

However, no one's really ever given me a reason why I should take on this task or assume even a little bit of extra risk, all for the sake of grinding one more elective procedure through the factory.
 
intubating a patient you wouldn’t have otherwise because you saw something that concerns you on a gastric US sounds fine. You intubate and do your best to empty their stomach with an OGT. On extubation you feel obligated to have the patient mostly awake with airway reflexes intact. They’re wretching on the tube, increasing every pressure known to god (including gastric), and unfortunately vomit/questionably aspirate.

The patient was npo and you’d otherwise planned an lma. There is a nonzero chance that had you just lma’d it, kept the patient deep, emerged smoothly, you’d escape unscathed.

One may argue i do my own cases and I am the greatest anesthesia evar. Maybe so. But many supervise CRNAs and work in not ideal circumstances.

I think gastric US can be utilized to benefit the patient. I can also envision scenarios where it leads to harm.
 
Guillemot said:
If the stomach is empty on gastric US, then there is likely little to nothing within the stomach to regurgitate and aspirate. I'd encourage some further thought regarding this matter.
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There's plenty of matter in the intestines that can find its way up into your lungs. In your supposition, nobody with an NGT should ever aspirate yet it happens on the floors all day long.
 
Ronin786 said:
There's plenty of matter in the intestines that can find its way up into your lungs. In your supposition, nobody with an NGT should ever aspirate yet it happens on the floors all day long.
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Are you being intentionally obtuse or does a straw man argument seem to you like a cogent way to convince someone?
 
Guillemot said:
Are you being intentionally obtuse or does a straw man argument seem to you like a cogent way to convince someone?
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You literally argued that an empty stomach means no aspiration. I reillustrated my initial point about bigger factors affecting aspiration than stomach content on ultrasound.

literally no straw man but you do you.
 
Guillemot said:
If the stomach is empty on gastric US, then there is likely little to nothing within the stomach to regurgitate and aspirate. I'd encourage some further thought regarding this matter.
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I mean you should read and understand what he said before you adopt a holier than thou stance.

You're using a whole lot of big words there brother.

He's talking about its positive predictive value in this post you responded to and you are talking about its negative predictive value. Those two things can agree/disagree be irrelevant/high/low simultaneously.
 
Ronin786 said:
You literally argued that an empty stomach means no aspiration. I reillustrated my initial point about bigger factors affecting aspiration than stomach content on ultrasound.

literally no straw man but you do you.
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You are the one who implied that an NG tube ensures an empty stomach. I made no such claims.

If the NG tube is not performing optimally (position, clotted, etc), the stomach may not be empty. If the contents of the stomach are too viscous or too large, the NG tube will also not be able to empty the stomach. Even a functioning NG tube may not empty the stomach entirely.

People can look back at the responses and see what you've typed BTW.
 
Ronin786 said:
🤣
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Well, anyway, thanks for being annoying and contributing nothing of value to this thread. 👍

I'm still hopeful though that we can get some more people with experience using gastric POCUS to participate and share their experiences.
 
Guillemot said:
Well, anyway, thanks for being annoying and contributing nothing of value to this thread. 👍

I'm still hopeful though that we can get some more people with experience using gastric POCUS to participate and share their experiences
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Apparently you only get to decide what is and isn’t of value. Also quite ironic as I’ve actually taught gastric ultrasound at ASA just don’t find it to be of the utility you think it is.
 
Ronin786 said:
Apparently you only get to decide what is and isn’t of value. Also quite ironic as I’ve actually taught gastric ultrasound at ASA just don’t find it to be of the utility you think it is.
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Again, I would like to remind you that we can review your posts in this thread and read what you've typed.

You've made some claims in this thread that have not been substantiated:

1. NG tubes always empty the stomach entirely.

2. An NG tube in a patient is equivalent to an empty stomach on gastric POCUS.

3. GI contents distal to the stomach can be aspirated into the lungs without traversing the stomach.

You've also committed the logical fallacy of misattributing these claims to me. This type of fallacy is a "straw man" fallacy.

I'll grant you that deciding what is and is not of value is somewhat a matter of opinion. However, generally in a discussion, whether it be in an online forum or in person, the value of a person's contributions would be assessed based on the sharing of information of relevance to the topic being discussed. You have not shared any information of relevance, and have also made statements with fallacious reasoning. Committing these acts as well as not having the ability to reflect and recognize what you have done leads me to believe that you have a very disorganized mind.

It would be quite disappointing for most people if they took the time and money to attend a conference and the instructor to which they were assigned seemed to not know what they were doing. Were you invited back?
 
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sevo00 said:
As an anesthesiologist, I 100% agree with you.
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minion215 said:
Rad chiming in here. The fact that anyone is utilizing ultrasound to evaluate the stomach, let alone make a clinical decision based on it is insane to me.
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Many of the posters in this thread are like yourselves: they don't do gastric ultrasound and don't know what they are talking about. Either for or against gastric US, without experience, your opinion holds little value.
 
Guillemot said:
Many of the posters in this thread are like yourselves: they don't do gastric ultrasound and don't know what they are talking about. Either for or against gastric US, without experience, your opinion holds little value.
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lol so your opinion holds more value than an actual radiologist? You know the specialty that specializes in imaging? You’re an absolute clown bro
 
If you were my colleague and consistently saw your push around the ultrasound scanning every patient in preop’s stomach. I would snatch the probe from you and chew you out so every nurse, surgeon and patient could witness this public humiliation
 
Guillemot said:
Many of the posters in this thread are like yourselves: they don't do gastric ultrasound and don't know what they are talking about. Either for or against gastric US, without experience, your opinion holds little value.
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I can guarantee I’ve done more ultrasounds of the abdomen you my man. I’m not sure how you’re going to compare your experience with US as an anesthesiologist to a radiologist (interventional).
 
minion215 said:
I can guarantee I’ve done more ultrasounds of the abdomen you my man. I’m not sure how you’re going to compare your experience with US as an anesthesiologist to a radiologist (interventional).
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Hello, while I can appreciate that as an interventional radiologist you have general experience with procedural and diagnostic imaging, I also know that you definitely have much less experience and knowledge than me in this particular ultrasound scan. This is not a not a diagnostic scan that interventional radiologists usually perform. Additionally, you have no experience in applying the information from the images obtained to patient care as it pertains to anesthetic management.

So I'd like to reiterate that your opinion on this matter holds little value.
 
sevo00 said:
If you were my colleague and consistently saw your push around the ultrasound scanning every patient in preop’s stomach. I would snatch the probe from you and chew you out so every nurse, surgeon and patient could witness this public humiliation
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I'm sure that the nurses and surgeons would admire you for peeing and pooping your pants while crying/having a temper tantrum.

Again, I'd like to remind you that you have no experience in this matter, and your opinion is of little value.
 
We
Guillemot said:
Hello, while I can appreciate that as an interventional radiologist you have general experience with procedural and diagnostic imaging, I also know that you definitely have much less experience and knowledge than me in this particular ultrasound scan. This is not a not a diagnostic scan that interventional radiologists usually perform. Additionally, you have no experience in applying the information from the images obtained to patient care as it pertains to anesthetic management.

So I'd like to reiterate that your opinion on this matter holds little value.
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Have you heard of a percutaneous gastrostomy tube? Abdominal biopsies? You clearly have no idea what diagnostic scans an interventional radiologist does. Please stay in your lane when it comes to imaging interpretation.
 
minion215 said:
We

Have you heard of a percutaneous gastrostomy tube? Abdominal biopsies? You clearly have no idea what diagnostic scans an interventional radiologist does. Please stay in your lane when it comes to imaging interpretation.
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I'll reiterate my previous statement: While I can appreciate that as an interventional radiologist you have general experience with procedural and diagnostic imaging, I also know that you definitely have much less experience and knowledge than me in this particular ultrasound scan.

As you have just stated, while you do perform diagnostic and procedural imaging of the abdomen, you do not perform gastric US to assess the gastric contents. Gastric US to assess to contents of the stomach is not a diagnostic scan that interventional radiologists generally perform. So I wouldn't say you should feel insecure about not having experience in this particular scan. Additionally, you, just as most IR docs, do not any experience in applying information obtained from gastric US as it pertains to anesthetic management.

There is a word to describe someone such as yourself: dilettante.

I should also point out the irony of having an interventional radiologist coming to an anesthesiology forum to pontificate about something for which they have little knowledge or experience. Perhaps you should take some of your own advice and "stay in your lane."
 
Guillemot said:
I'll reiterate my previous statement: While I can appreciate that as an interventional radiologist you have general experience with procedural and diagnostic imaging, I also know that you definitely have much less experience and knowledge than me in this particular ultrasound scan.

As you have just stated, while you do perform diagnostic and procedural imaging of the abdomen, you do not perform gastric US to assess the gastric contents. Gastric US to assess to contents of the stomach is not a diagnostic scan that interventional radiologists generally perform. So I wouldn't say you should feel insecure about not having experience in this particular scan. Additionally, you, just as most IR docs, do not any experience in applying information obtained from gastric US as it pertains to anesthetic management.

There is a word to describe someone such as yourself: dilettante.

I should also point out the irony of having an interventional radiologist coming to an anesthesiology forum to pontificate about something for which they have little knowledge or experience. Perhaps you should take some of your own advice and "stay in your lane."
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The irony in your statement is laughable. Enjoy your gastric ultrasounds my friend.
 
abolt18 said:
I have yet to find a reason to perform gastric ultrasound...
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Clinical scenario:

Patient going for an elective TAVR but accidentally took his GLP-1 a few days ago. Surgeons are asking MAC vs. GETA vs. cancel. Moderately depressed LVEF from valvular disease. No GI symptoms. DM2 well-controlled. Plan?

I'm indifferent to gastric POCUS but have done it a few times to guide clinical decisions. It's been okay.
 
sevo00 said:
I’m not admitting defeat. I got all day. You’re a clown and this gastric ultrasound hill you’re dying on is ridiculous
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What is the gastric ultrasound hill I’m willing to die on exactly? Most of what I’ve been arguing is that you guys are a bunch of fvcking m0rons, not the greatness gastric ultrasound.

Again, I’d like to point out that everybody can review the posts in this thread and see what was typed by all parties.
 
Guillemot said:
What is the gastric ultrasound hill I’m willing to die on exactly? Most of what I’ve been arguing is that you guys are a bunch of fvcking m0rons, not the greatness gastric ultrasound.

Again, I’d like to point out that everybody can review the posts in this thread and see what was typed by all parties.
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And my argument is the only fvcuking m0oron here is you
 
sevo00 said:
And my argument is the only fvcuking m0oron here is you
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Again, I'd like to invite you to review the contents of the thread. It has been demonstrated that you and your cronies are unqualified to determine the utility of gastric US. In addition to a lack of knowledge and experience, you also lack insight about your limitations in these matters. It would therefore be fair to label you as a fvcking m0ron.( At work I'd probably say something more PC like "clinically weak.") Parroting the same insult back at me is just petulance.
 
Guillemot said:
Again, I'd like to invite you to review the contents of the thread. It has been demonstrated that you and your cronies are unqualified to determine the utility of gastric US. In addition to a lack of knowledge and experience, you also lack insight about your limitations in these matters. It would therefore be fair to label you as a fvcking m0ron.( At work I'd probably say something more PC like "clinically weak.") Parroting the same insult back at me is just petulance.
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Your hubris is a cloud that’s blinding you from seeing the obvious truth. Imagine a a radiologist coming here and saying they know more about airway management than you. That would be ridiculous. That’s exactly the same as you know claiming you know more about gastric ultrasound than them
 
sevo00 said:
Your hubris is a cloud that’s blinding you from seeing the obvious truth. Imagine a a radiologist coming here and saying they know more about airway management than you. That would be ridiculous. That’s exactly the same as you know claiming you know more about gastric ultrasound than them
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No. That is incorrect. I would rather not engage in circular arguments. This has already been hashed out. Please refer to earlier posts in this thread.
 
sevo00 said:
I referred to all them. You should like a broken record.
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You were trying to discuss the same thing over and over again. We've already discussed why the IR doc was not qualified in earlier posts. They are available for you to read.
 
Like most things, the truth lies somewhere in the middle. GUS has good accuracy. However I dont use it because I don’t know what to do with the findings. If you’re looking for a reason to go ahead, an empty stomach is probably reassuring enough and passive regurgitation is unlikely, although if a vomiting reflex occurs the pylorus relaxes and there will be retrograde propulsion of contents from the small intestine. I’m not sure what to do with finding something in the stomach; we have no idea what volumes correlate with risk of regurgitation and it doesn’t take into account things like gaseous distension. In the ICU where there is probably a lot of passive regurgitation happening we accept GRVs well in excess of 1.5ml/kg and the GRV appears to have no correlation to aspiration risk.
 
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