pre-gastric bypass egds

[TheLoneWolf]

average patient in my city is around bmi of mid 30s. Patients coming in for pre-gastric bypass egds routinely encountered have BMIs in 50s and 60s. I think this may be the most dangerous elective procedure we do. No glidescope or anesthesia machine in room. No syringe or alaris pump, manual propofol pushes. Done in a small endo suite far away from the ORs. Despite preoxygenating and running them lighter, using POM NRB, rapid desats are common. Was told by a partner that there was a bad outcome a few years back but this did not change anything despite anesthesia asking for more equipment or a machine.

Surgeons take their time to do measurements for the coming surgeries and occasional biopsies.

Have considered using benzocaine spray but partners never do, most cite the concern for methemoglobinemia.

Some mix benzo or ketamine or both with prop for better conditions but all have their drawbacks. I give straight propofol and lidocaine.

Anyone care to share their management for the super morbidly obese EGDs?

---

Members don't see this ad.

 

[med2010]

We do these in rooms with machines, both at the hospital and ASC. These patients are high risk and should get moved to the OR until they equip your endo suite appropriately.

 

[Beeftenderloin]

Everyone wants to look slick and just do EGDs with prop, which works great for most patients, but that’s going to frequently lead to hard desats in this crowd.

I have good success doing these with a POM mask and multimodal analgesia. I’ll give 12-24mcg of precedex, 25-50mg ketamine, 60-100mg lido then supplement with a markedly reduced dose of propofol. They rarely obstruct or stop breathing and tolerate the scope quite well.

 

[GassYous]

preox, versed 2, spray the mouth, 50-100 of prop
need glide and machine in the room

 

[deleted875186]

Everyone wants to look slick and just do EGDs with prop, which works great for most patients, but that’s going to frequently lead to hard desats in this crowd.

I have good success doing these with a POM mask and multimodal analgesia. I’ll give 12-24mcg of precedex, 25-50mg ketamine, 60-100mg lido then supplement with a markedly reduced dose of propofol. They rarely obstruct or stop breathing and tolerate the scope quite well.

Agreed. Hard to do all propofol in this young population.

I typically avoid any fentanyl in the young super obese. Give glyco early outside the room. Head up, pom mask, bolus if lidocaine, bolus of propofol, bolus of ketamine, support airway, scope in, typically very little apnea from this. Secretions can be an issue.

If BMI 50 or more, I ask them to book in the OR and honestly would probably just put in an ETT. Not appropriate for endo suite if no machine. If going to try sedation, I typically tell these people they’re going to be sleepy but awake, and if any issues we simply wake up and abort.

 

[2Fast2Des]

preox, versed 2, spray the mouth, 50-100 of prop
need glide and machine in the room

This, except I skip the versed and give like 50mcg fent, and tell the pt the possibility of them being aware but comfortable. I hate these pre-op egds with a passion

 

[PpfSuxTube]

Prop remi, no spray works fine

Trick is get the nasal prongs o2 on first before u even start talking to them. Preox theabsolute bejesus out of them.

Put 20mcg of remi into 20ml syringe prop. So 1mcg remi per ml for us and our dilution.

Then they get 3mls of this at a time, sometimes 5 or 6 mls to start.

And jaw thrust them like there is no tomorrow, dont wait, start it the second after you push the propofol. Pull the mandible off them. Sometime im actually beside the endoscopist pulling their mandibles with both hands.

You must have etco2.
You must be hypervigilant.

After a while you get in the swing of it, and you can actually jaw thrust with 1 finger, type with the other hand, and do dj, buy shares at the same time.

I used to do 1000s of endoscopy procedures... not as much anymore. It takes 100s to get really slick at it.

Its safer in main or for sure, but endoscopist wont love you for that...

Never spray, useless and actually more dangerous when combined with Propofol. Just slows everything down and there is a risk for silent aspiration post op that I don't want anything to have to do with... never give midaz or fent? Why would you? Makes 0 sense. We have prop and remi. Much faster, cleaner, safer

 

[abolt18]

average patient in my city is around bmi of mid 30s. Patients coming in for pre-gastric bypass egds routinely encountered have BMIs in 50s and 60s. I think this may be the most dangerous elective procedure we do. No glidescope or anesthesia machine in room. No syringe or alaris pump, manual propofol pushes. Done in a small endo suite far away from the ORs. Despite preoxygenating and running them lighter, using POM NRB, rapid desats are common. Was told by a partner that there was a bad outcome a few years back but this did not change anything despite anesthesia asking for more equipment or a machine.

Surgeons take their time to do measurements for the coming surgeries and occasional biopsies.

Have considered using benzocaine spray but partners never do, most cite the concern for methemoglobinemia.

Some mix benzo or ketamine or both with prop for better conditions but all have their drawbacks. I give straight propofol and lidocaine.

Anyone care to share their management for the super morbidly obese EGDs?

A little benzocaine spray goes a long way! Methemoglobinemia doesn't just pop up from a couple little sprays in the throat. Also, in a relatively healthy outpatient without anemia, the morbidity associated with methemoglobinemia is small.

Benzocaine-Induced Methemoglobinemia Based on the Mayo Clinic Experience From 28 478 Transesophageal Echocardiograms

Background The potentially life-threatening condition of methemoglobinemia is characterized by cyanosis, low pulse oximetric readings, and normal arterial PO2 values. Acquired methemoglobinemia has been linked to the use of the topical anesthetic benzocaine in endoscopic procedures...

jamanetwork.com

Of over 28K patients, less than 0.1% of patients developed it. (0.06% I think it said)

"A typical 1-second spray provides 150 to 200 mg of drug. Investigations in healthy volunteers indicate that a 2-second spray marginally affects systemic methemoglobin levels (0.8%-0.9%)."

"For example, in a patient with a hemoglobin level of 14.0 g/dL, a methemoglobin level of 30% results in functional anemia of 9.8 g/dL, potentially of little symptomatic consequence; in contrast, in an anemic patient with a baseline hemoglobin level of 9.0 g/dL, a methemoglobin level of 30% results in functional anemia of 6.3 g/dL, likely highly symptomatic."

 

[Simba1711]

I had to do a bmi 92 first year out of residency. I asked one of the partners for help and he walked away what a pos. I moved on from that job. Yeah these cases are very dangerous. We also did not have Pom masks and just nasal cannula.

For the above patient and others I use lidocaine spray, versed, ketamine (up to 0.5 mg/kg), and a few ccs of propofol.

 

[agammaglobulin]

Add Ketamine (30-50mg) and reduce propofol dose for high BMI EGDs. For super Obese I'd skip propofol and just do versed/ket/lido.

I feel for you not having an anesthesia machine or a Video Laryngoscope available, that's dangerous. Maybe buy a McGrath for yourself?

 

[Arch Guillotti]

Everyone wants to look slick and just do EGDs with prop, which works great for most patients, but that’s going to frequently lead to hard desats in this crowd.

I have good success doing these with a POM mask and multimodal analgesia. I’ll give 12-24mcg of precedex, 25-50mg ketamine, 60-100mg lido then supplement with a markedly reduced dose of propofol. They rarely obstruct or stop breathing and tolerate the scope quite well.

Too much junk. Would never get everyone discharged in a timely manner.

 

[DocMcCoy]

We have an open ercp room in GI with a machine you could move to if needed otherwise same set up as yours.

I like the spray but tell them it will taste like cherry gasoline. The methemoglobin is academic BS.

POM mask cranked to 15L O2 ensure EtCO2 then lidocaine and propofol and send it.

Maybe a little versed. Group frowns upon other adjuncts and they aren’t readily available in GI anesthesia carts.

All hands ready to hold them down. Don’t mind a wrestling match if it helps keeps the patient safe.


These suck. All the time. Every time.

 

[nimbus]

Some of these responses are shocking. We have surgeons who insist on using the Davinci for their weekend lap choles. Why are anesthesiologists doing dangerous nonsense in endo suite and testing their luck? Just do it in the OR with your usual cart, a VL, and an anesthesia machine. It is a patient safety issue. These events will happen again.

Starkman: Beaumont Hospital Staffers Horrified After Patient Dies During Routine Colonoscopy

www.deadlinedetroit.com

Cardiac Arrests in Patients Undergoing Gastrointestinal Endoscopy: A Retrospective Analysis of 73,029 Procedures

Airway difficulties leading to cardiac arrest are frequently encountered during propofol sedation in patients undergoing gastrointestinal (GI) endoscopy. With a noticeable increase in the use of propofol for endoscopic sedation, we decided to examine ...

www.ncbi.nlm.nih.gov

 

[shepardsun]

We're starting to do more and more of these at our ASC and I'm pretty sure we'll have a terrible outcome within the next year or two. Surgeons have no idea how badly things can go and no respect for the airway.

 

[jwk]

Too much junk. Would never get everyone discharged in a timely manner.

Agree - simple is easier and safer. POM masks are great if you have them, then judicious lidocaine and propofol, just like every other EGD. We don't use benzocaine except for TEEs where the cardiologist can't seem to figure out how to easily get their probe down.

 

[Beeftenderloin]

Too much junk. Would never get everyone discharged in a timely manner.

I’ll have maybe 1-2 of this type of patient out of 12-15 scopes in a day. I’m at a hospital, not a surgicenter, so I’ll happily let them eat up a PACU bed for an extra hour if it means getting them safely through their procedure.

 

[Arch Guillotti]

I’ll have maybe 1-2 of this type of patient out of 12-15 scopes in a day. I’m at a hospital, not a surgicenter, so I’ll happily let them eat up a PACU bed for an extra hour if it means getting them safely through their procedure.

Why are they going to pacu to begin with? Straight back to outpatient area.

 

[Beeftenderloin]

Why are they going to pacu to begin with? Straight back to outpatient area.

That’s how our GI unit/workflow is set up. Pre-op bay > endo suite > PACU. Totally separate unit from main OR/PACU but basically the same. Majority of patient’s are out in 15-20mins.

 

[coffeebythelake]

A little benzocaine spray goes a long way! Methemoglobinemia doesn't just pop up from a couple little sprays in the throat. Also, in a relatively healthy outpatient without anemia, the morbidity associated with methemoglobinemia is small.

not to mention we're talking about absolutely massive patients here.
a couple sprays of benzocaine isn't going to be a problem.
nice topicalization can help a ton if you don't want to run them deep on propofol
blunt those reflexes, sit them up, slap on a POM mask,

 

[anaesthetic]

Prop, nasal CPAP, occasional jaw thrust, call it a day. I do a ton of these for our busy bariatric surgeons. Haven’t had an issue pretty much ever. I keep the anesthetic clean to minimize respiratory depression post-procedure. There’s no way I can run to PACU if the patients are oversedated/overnarcotized, and most of the stimulation ends once the scope goes in (with the occasional hyperreactive gag reflex). K.I.S.S., personally.

 

[Southpaw]

Too much junk. Would never get everyone discharged in a timely manner.

Agree - simple is easier and safer. POM masks are great if you have them, then judicious lidocaine and propofol, just like every other EGD. We don't use benzocaine except for TEEs where the cardiologist can't seem to figure out how to easily get their probe down.

whatever is best for the airway here is best for the patient. I'm not going to judge the EGD anesthetic in the super morbidly obese. If someone wants to use a propofol sparing anesthetic (which honestly makes a lot of sense here) then god bless them. I really doubt it'll slow things down significantly.

 

[coffeebythelake]

A modified nasal trumpet with an ETT attachment on it,
This works quite well as an alternative, and you can set some CPAP on it
Did it a few times including a BMI 60+ patient for a TEE..
(not my pics)

 

[coffeebythelake]

again probably needlessly complex for most situations, but such tools have been described

combo oral airway with endoscopy mouth piece,
haven't seen this used but seems like a great idea!

 

[dannyboy1]

Our guy does the scope in literally 3 seconds. My understanding is it’s legally/or required by insurance prior to gastric sleeve. I don’t think he actually sees anything but I’m not complaining. This is done by the actual surgeon, not the GI guy, if that makes a difference.

 

[abolt18]

Our guy does the scope in literally 3 seconds. My understanding is it’s legally/or required by insurance prior to gastric sleeve. I don’t think he actually sees anything but I’m not complaining. This is done by the actual surgeon, not the GI guy, if that makes a difference.

Same here. Our bariatric surgeon brings terribly large patients for EGDs (like they all do) but he's in and out in usually 30 seconds. It's literally a single slug of propofol with some chin lift/jaw thrust.

 

[amyl]

We have nasal cpaps and a Jackson Rees circuit to the oxygen from the wall. Get it on and fitting well. Let them breath like that while you’re getting the monitors and doing time out. Propofol pushes. Works great.
If you want have them gargle the lidocaine 4% before. I did 4 the other day - not one sat below 92. Key is get it on and let them get some positive pressure up front before sedation

 

[amyl]

View attachment 367772

View attachment 367773

A modified nasal trumpet with an ETT attachment on it,
This works quite well as an alternative, and you can set some CPAP on it
Did it a few times including a BMI 60+ patient for a TEE..
(not my pics)

We do something similar but buy commercially available nasal cpaps with straps

 

[Arch Guillotti]

2 of versed and 2 of fentanyl. Conscious sedation. Tell the patient exactly what to expect. Let the surgeon know it isn’t safe to do it any other way and they need to talk the pt theough the procedure. Tell them id they want it any other way you need a better place to do the case. Problem solved.

 

[coffeebythelake]

Same here. Our bariatric surgeon brings terribly large patients for EGDs (like they all do) but he's in and out in usually 30 seconds. It's literally a single slug of propofol with some chin lift/jaw thrust.

do you work at an academic place?
our surgeons are slow and they let the residents muck around,
it can be tough

 

[Blockit]

Too much junk. Would never get everyone discharged in a timely manner.

Word. I’m scheduled to do 18 of these tomorrow, one every half hour from 7 am to 5.

 

[vector2]

Word. I’m scheduled to do 18 of these tomorrow, one every half hour from 7 am to 5.

 

[GassYous]

View attachment 367783

Not if it's pay for play
Private insurance $$$

 

[nimbus]

Our guy does the scope in literally 3 seconds. My understanding is it’s legally/or required by insurance prior to gastric sleeve. I don’t think he actually sees anything but I’m not complaining. This is done by the actual surgeon, not the GI guy, if that makes a difference.

Must be regional. We have a busy bariatric program and never do them.

 

[jwk]

View attachment 367774

again probably needlessly complex for most situations, but such tools have been described




combo oral airway with endoscopy mouth piece,
haven't seen this used but seems like a great idea!

OMG - a friend of mine did this exact thing more than 30 years ago. Crazy but it works.

 

[coffeebythelake]

There’s a million ways to do this, but the only way I would say is unequivocally dangerous is to not have an anesthesia machine and airway equipment available.

Honestly that’s a non starter for me. I’d tell them to get some other stooge to risk killing patients. If they fire you just spread the word about how unsafe their practices are and see how many people they can get to replace you

An anesthesia machine is great, but if you have backup available you don't absolutely need it.
That means not doing the procedure in the far corners of your hospital away from help.
For instance, we've done them (BMI 60+) in an empty bay in our PACU before,
What you really need is suction, oxygen source, ability to deliver positive pressure, and drugs/tools to intubate if necessary.

 

[AKMD_1984]

Yes many places don’t have an anesthesia machine. Atleast not in every room.

I mean it would be nice to have it but we have two rooms - one with machine and one without.

The GI scheduler don’t really pay attention to bmi etc - it’d be nice if they did but…

There’s a glidescope outside

Suction/ ambu bag/ sux ready in the non- machine room

 

[AKMD_1984]

2 of versed and 2 of fentanyl. Conscious sedation. Tell the patient exactly what to expect. Let the surgeon know it isn’t safe to do it any other way and they need to talk the pt theough the procedure. Tell them id they want it any other way you need a better place to do the case. Problem solved.

This is what I do

 

[Simba1711]

Bmi 40 + I give 25 mcg of fentanyl early and give a little bit of propofol and 100mg of lido. Just enough prop that they don’t respond to verbal stimuli or have an eyelid reflex. Plus or minus 50 mg of propofol not much. I then give a jaw thrust to make sure they are deep enough. Majority of the time. They will be breathing unobstructed without any airway manipulation and wont cough. The fentanyl helps with the gag and cough reflex and the propofol for the amnesia and sedation.

Bmi 50 + i do the lidocaine spray before or. Then give glyco versed lidocaine and ketamine up to 0.5 mg/kg in the room. I make sure to give the ketamine in small doses. I then give a few cc of propofol. I also have a nasal airway lubed up and hooked up to ett circuit in case they obstruct or I have to give positive pressure.

These cases suck for sure. It also helps to have a doctor who is doing the procedure who is fast and understands that some movement is okay.

 

[26B]

Have had great luck using the SuperNova Nasal CPAP device for BMI > 50 EGDs.

SuperNO2VA™ Nasal PAP Ventilation System

Delivers positive airway pressure to stent open the upper airway, allowing for the preoperative delivery of positive pressure ventilation and oxygen for patients with a decreased level of consciousness. The SuperNO2VA™ nasal PAP ventilation device is available in medium and large sizes and is...

www.vyaire.com

 

[Maverikk]

I was at a hospital with a busy bariatric/foregut program, it always depends on the patient and surgeon and really makes you appreciate how to do endo well. Most of our surgeons were fast, 10 minute egd and biopsies. Usually a slug of prop, I mostly used viscous lido, gargle as long as possible and spit. These patients are selected for their procedure and aren’t elderly/pulmonary cripples, I tell them to go easy with the sips to prevent aspiration but they don’t need to drink a gallon for discharge. Nasal airway right before egd to know depth of anesthesia, then a big healthy jaw thrust throughout.

They’d also do complex hiatal hernias and egds with bravos that were longer but bmis >50. A little (20-30) of ketamine goes a long way and probably doesn’t extend discharge too much, secretions can be an issue in smokers/AA so have to think it through. Needed it rarely in the bmi>60, chronic pain patients. I have colleagues who use precedex, I don’t think it hurts but the only thing it does is delay discharge imho.

The nasal trumpet attached to vent is interesting. Are you doing this with pressure support? I suppose you could do it with pressure control considering they’re npo and insufflating the abdomen. My thoughts would be it would work with pressure support, the negative intrathoracic pressure would draw oxygen in, but with pressure control if they were truly apneic it would just go to the stomach as it’s an open passageway due to the scope. I’ve had a few bmis 60-70s (hiatal hernias, not sleeves) but everything was in their abdomen and their chin was resting on a few pillows of tissues that I struggled through the case with a nasal airway and vigorously jaw thrusting the whole time

The only thing worse was the head and neck cancer patients for feeding tubes in the hospital for months. Tongues the size of crocs from edema, some part of their jaw missing…you were lucky if they hadn’t taken out their trach

 

[Simba1711]

I think the above is a good technique but preemptively putting in a nasal airway would make me nervous. It is rare but I’ve seen some terrible nose bleeds from the npa. A bloody obstructing airway on a difficult to bag patient would be a disaster. If they don’t respond to an aggressive jaw thrust they will usually not respond to egd but for these patients I keep them a little bit lighter. I give ketamine versed glyco and prop slowly after a lidocaine bolous and lidocaine gargle. I tirate slowly until they lose their lid reflex or they stop responding to verbal stimuli. I try to put a npa only as a last resort. I have not had to put it in for these cases.

 

[okayplayer]

I’m surprised to read the variety of techniques employed but obviously there are many ways to get it done.

I keep the HOB way up and use only propofol - given slowly and titrated to effect. Maybe my endoscopists are better than yours. These are 5 minute cases.

Of course I have a glidescope nearby and sux at the ready. Thankfully very rarely would need either.

 

[amyl]

Nasal cpap on while I’m putting monitors on. Pre oxygenate and insure good fit. Propfol. Have used this up to bmi 60… had a bmi 85 the other day… just tubed that one

 

[pocafx]

I had bmi 80s. Egd. 1 versed, 25 fent , 25 ketamine and told him to swallow!

 

[PpfSuxTube]

Unrelated but 4 ercp yesterday. 3 fine with prop remi. Last one bmi 40, severe osa. For 90 mins... omfg, the worst. Nigh on periarrest @ the end. Saliva and goop everywhere, obstructed.

 

[gunnershow]

Unrelated but 4 ercp yesterday. 3 fine with prop remi. Last one bmi 40, severe osa. For 90 mins... omfg, the worst. Nigh on periarrest @ the end. Saliva and goop everywhere, obstructed.

If only there were signs that this patient was a poor candidate for deep sedation...

 

[Onefellswoop87]

Unrelated but 4 ercp yesterday. 3 fine with prop remi. Last one bmi 40, severe osa. For 90 mins... omfg, the worst. Nigh on periarrest @ the end. Saliva and goop everywhere, obstructed.

I despise ERCPs. My longest during residency was 3 hrs. This one GI doc always warranted general anesthesia. And then all of a sudden after 3, if not 3.5 hrs, she declares stent is in and it’s done, so i can wake up the patient. Ugh

 

[PpfSuxTube]

If only there were signs that this patient was a poor candidate for deep sedation...

Dude, do you practice? Have you read the title of this thread? Everyones a poor candidate for sedation

 

[gunnershow]

Dude, do you practice? Have you read the title of this thread? Everyones a poor candidate for sedation

There's a difference between a 5 minute EGD and a 90min ERCP. If you end up in an avoidable situation that is "nigh periarrest", then it's worth reevaluating your practice.

 

[deleted875186]

There's a difference between a 5 minute EGD and a 90min ERCP. If you end up in an avoidable situation that is "nigh periarrest", then it's worth reevaluating your practice.

Seriously, if I think patient is tenuous and long procedure with no end in sight, just tell them you need to stop, flip supine, and if they want to continue do GETA.