Upper GI Bleed (GETA)

[acidbase1]

I have surgeons who refuse to do these under GETA, anyone have literalture I can provide? They’re accustomed to careless CRNAs in the past and “never had any issues before”.

Patients Hb dropped from 8 ==> 6 over night and had received 2 PRBCs.

Surgeon, “if they had a stomach full of blood they’d be vomiting”. Smh

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[jwk]

Simple - you do the anesthesia, they do the EGD. You can certainly refuse to do a MAC EGD if you think it's unsafe. They can then decide if they want to do the sedation themselves without anesthesia, or agree with our common-sense approach.

We're doing an ever-increasing number of GETA for EGDs, and we have an anesthesia machine in our GI unit so it's pretty easy to do, and pretty indefensible if you have one and don't use it and there's a problem.

That being said - I'd guess maybe 90% or more of our "urgent" EGDs for "GI bleeding" have zero pathology in the upper GI tract when they're scoped. Could be why they've "never had any issues before".

 

[caligas]

Agree YOU decide on anesthesia plan. That said, for good GI doc and patient is NPO and no nausea or vomiting, I am generally ok with propofol MAC for an EGD to r/o bleeding.

 

[Comptongasman]

Yes - you determine the airway and they determine the scope. If they want your input on which scope to use and where to put it, then that's pretty similar to them telling you airway management


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[Noyac]

I tube every single one of them.
I don’t know why Scope jockeys think a general with a tube is so bad. It shows their lack of understanding.

 

[caligas]

I tube every single one of them.
I don’t know why Scope jockeys think a general with a tube is so bad. It shows their lack of understanding.

Even if the only symptom/sign is anemia?

 

[facted]

You do whatever you feel comfortable with. End of story.

With that being said, unless they're puking blood, I do propofol for these all the time. If they go in and see anything messy (VERY RARE), I have them come out and tube the patient.

 

[deleted126335]

I tube every single one of them.
I don’t know why Scope jockeys think a general with a tube is so bad. It shows their lack of understanding.

It shows their concern about an extra 10 minutes for turnover.


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[vector2]

Uptodate article about UGI bleed quotes one study where those who were intubated for the EGD had a slightly higher rate of pneumonia. Of course every GI in the country took the results of that one study as gospel and requests MAC. If I suspect a belly full of blood (significant ongoing hematemesis or melena with acute hgb drop), I tell them that they're free to provide their own sedation if they don't like my anesthetic plan.

 

[Noyac]

Even if the only symptom/sign is anemia?

If the case warrants an emergent add-on then, yes. I would say, possibly 10% of the egd’s for bleeding that I’ve done have surprised us with how much blood was in the stomach.

 

[Noyac]

It shows their concern about an extra 10 minutes for turnover.


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Exactly.
I think some of my partners used to say “let’s take a look and if there is blood then pull out and I will intubate”. But I’d rather not waste the time or take the risk. Plus, I think my group has shown that it doesn’t any more time to do a GETA.

 

[PainDrain]

One situation where I will always tube/GETA for an EGD is in anyone where the source is suspected to be varices. I have seen variceal bleeds where there is a ton of blood coming out of the mouth and the patients acutely decompensate, the last thing I need to worry about at that point is securing the airway (which can be extremely difficult in brisk bleeds).

I tube anyone who is obese or I suspect may take me longer than a few seconds to intimate.

 

[Hamhock]

... or I suspect may take me longer than a few seconds to intimate.

I've always heard anesthesiologists are the quickest.

HH

 

[PainDrain]

I've always heard anesthesiologists are the quickest.

HH

F-ing autocorrect.

 

[Hoya11]

I have surgeons who refuse to do these under GETA, anyone have literalture I can provide? They’re accustomed to careless CRNAs in the past and “never had any issues before”.

Patients Hb dropped from 8 ==> 6 over night and had received 2 PRBCs.

Surgeon, “if they had a stomach full of blood they’d be vomiting”. Smh

things that push me towards intubation:

admitted to hospital less than 24hrs
pt tells me they had blood come out of their mouth within 24 hrs
pt is known drinker/cirrhotic whose last drink was less than 24hrs ago
a fellow is doing the scope

things that push me to not intubate:
young well looking patient with mild anemia
no alcohol history
gives a clear history and is npo
fast endoscopist who uses minimal insufflation
an anemia that has been going on for many days - weeks


you have to decide where your individual patient falls on the spectrum...

 

[WholeLottaGame7]

As a mostly peds person, I hate adult GI with a passion. Most peds GI cases are IBD, foreign bodies, vague abd complaints. Adult GI at the ambulatory center is fine. Adult GI at the big house is a f*ing disaster, least favorite place in the hospital.

Had this exact case a few months ago. GI: "we have this semi-urgent add-on, had been throwing up blood and Hct dropped." OK we're tubing him. GI: "But he hasn't thrown up in a few hours, we always do these under 'MAC'." Don't care, you can find someone else to do it if you want. GI, 15min later: "Holy **** that's a lot of blood." Nos***, Sherlock.

I'm constantly amazed when people are surprised to find the thing they are subjecting a patient to urgent/emergent anesthesia to specifically look for. Like, if you didn't think there was blood coming out of his stomach, why were you putting a scope down there?

 

[Planktonmd]

If you think there might be blood in the stomach you need to intubate the patient and just ignore what these *****s are saying. If they called you to do the anesthesia that means they don't know how to do it themselves!

 

[acidbase1]

So this thread has proven there’s no definitive answer.

Just bc they’re not actively vomiting or nauseous doesn’t mean there isn’t blood in the stomach

 

[anbuitachi]

So this thread has proven there’s no definitive answer.

Just bc they’re not actively vomiting or nauseous doesn’t mean there isn’t blood in the stomach

i think the definitive answer is if something goes wrong, you can be 1000% sure the Gi will blame you regardless of what they told you.
it feels like once people start doing procedures, they start getting *****ic. whether its cards doing their cases, GI doing scopes, pulm doing bronchs, they say some of the most *****ic things. but i guess its cause they dont understand.