When Endoscopy Cases aren’t Quick

It has been three months since I started working as a CRNA and “I m loving it!” However, good days, bad days, so-so days are there just like any other profession. Being able to practice independently has allowed me to finally use the drugs how I learned they were meant to be used. Going out of the box is a little unnerving even though I have been practicing in my scope of practice and using well researched techniques. General anesthesia is a little more forgiving in my attempts to ensure best use of anesthetic agents and adjunct pharmacology. On the other hand, Monitored-Anesthesia Care (MAC) doesn’t allow that luxury. I remember as a student I used to be think, pushing propofol for a five minute case is not bad at all.  That all changed during clinicals when I realized that my five minutes are not five minutes for the surgeons and their understanding of MAC is simply that it is a general anesthesia without the “tube”. So, now that I am in a place where endoscopy cases can last anywhere from 30 minutes to hour and a half long, I have been challenged more than once intraoperatively. Whenever a MAC anesthetic is used, it is important to acknowledge the fine line that exists between maintaining an unassisted airway and adequate sedation. So no surprise that for the first day I was re-introduced to endoscopy, either my patients were too awake and fighting or too sedated and apneic. And starting off with an embarrassing case where the patient gags, coughs, desaturate doesn’t help your reputation as the new guy. Luckily for me, I am at a place where anesthesia providers (I will leave it at that) are known to use physical restraints to hold patients during endoscopy cases. 

After trying out a few things, here are a few tips to bring back smooth, calm endoscopy day. (Like we all know every patient is different and there are thousands of ways to"skin a cat".)

       1)     To numb them or not? Entry of EGD scope can sometimes be traumatic and lead to the patient gagging and coughing. So I was always curious to see if numbing their oropharynx with hurricane sprays or lidocaine mists would make it less stimulating. I started off with using a 2% lidocaine gel in the back of their throat and asking them to gargle. That was too much or too thick to gargle so I soon converted to using a mist of 4% lido from the LTA kits. Now I haven’t personally tasted it but noticing patients’ facial expressions, I could tell that both tasted NASTY! And that taste would last a while making them cough as I rolled them to endoscopy suites. A bit counterproductive. Another issue with numbing was its timing. It was easy to administer it either too early or too late. Surgeon didn’t come in the room right away and it was gone! Using it also caused the patient to salivate more thus increasing their risk of aspiration. Now I don’t use numbing agents at all and just request the surgeons to go slow with the initial entry while I give the patient a jaw thrust. So far I have had positive outcomes with this technique.

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          2) How to induce. Being a new grad, it is easy to let yourself think that you are taking too long when the surgeon is waiting for you holding the scope. Truth it, it doesn’t matter. If I need time to do a safe anesthetic then I am taking that time. It is critical to take this time especially in endoscopy cases because a little too much and they go apneic and start desatting as the scope goes in. Slow induction is the key. I would give them just enough initially, for example, 50mg of propofol for a young healthy male, then continue in small squirts. Goal is to keep the patient anesthetized enough to tolerate the scope without going apneic.

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          3)Ketamine is awesome but…. I started using Ketamine for endoscopy solely because it does not depress respirations. However, one of its side effects includes excessive salvation. I thought using a small dose will limit its side effects but that is not true. I had a lot of patients laryngospasm on me as the saliva would collect in their oropharynx. Using 0.2 mg robinul about 3 minutes before the procedure starts greatly decreased this side effect resulting in a smoother anesthetic.

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           4)What I use now. In preop, I administer 1-2mg of Versed and 0.2 mg of Robinul if I am using ketamine or patient has a lot of secretions. Once in the room, I connect the monitors to get a baseline set of vitals and immediately give 25 mg of Ketamine. I follow it with propofol 200mg + 25mg of Ketamine at a slow rate. If it is a colonoscopy, I will also give 25-50mcg of fentanyl as insufflation generally causes pain and causes you to use more propofol. I will push a very small amount of propofol every other or third heartbeat (which I can hear from my monitor) for the remaining case. So far that has been working great for me. Let me know what works for you.

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