Be prepared - make sure to have airways (oral/nasal) available, along with emergency medications (eg. phenylephrine, ephedrine, glycopyrrolate, etc). If the HOB will be rotated 180° away from the machine, have the suction, extension for EtCO2 tubing, and equipment needed to intubate and ventilate on hand. Preop preparation - additional evaluation of the patient's range of motion for the neck is helpful. The patient will be on their side and the head may be repositioned to allow advancement of the endoscope. Approach - MAC, usually a propofol push. Typically around 7-8 cc's of propofol is a good starting dose to get the patient initially sedated. However, this is very patient-specific. Most commonly, you'll maintain sedation with occasional pushes of propofol. Fast Turnover - Anticipate these surgeries to be very quick with a fast turnover. Active Bleeding Cases - If EGD is for active bleeding (varices/ulcers) be extra sure you have a great IV (for possible high blood loss) and are prepared to intubate. Know your coags. Obese/OSA/CPAP patients - Consider SuperNOVA/SuperNO2VA CPAP for obese OSA + CPAP patients. Tips to consider - 1-1.5mg/kg Lidocaine and/or 0.5mcg/kg Fentanyl prior to scope advancement helps to prevent coughing. A jaw thrust can aide the surgeon in passing their scope, which is also helpful for assessing the depth of anesthesia. If insufflation of the lumen is needed, CO2 rather than air will decrease the incidence of distension. Shared Airway - Airway is shared with surgeon. Make sure you can quickly get to the airway/intubate if you need to! Monitor - Complications are less that 0.15%, but involved aspiration pneumonia, PE, and MI. Monitor for desaturation, airway obstruction, laryngospasm, aspiration. Exercise more caution with advanced age, pulmonary disease, anemia, obesity, dementia, or emergency procedures. Perforation Risks - There is an increased risk of perforation with intubation with a Zenker’s diverticulum or esophageal stricture. EGD related perforation with esophageal diverticula is greatest for pneumatic dilation (less than 6%), followed by stricture dilation (less than 2.2%) and sclerotherapy (less than 1%), and diagonostic endoscopy (0.03%). Abort/Cancellation - If retained food is visualized in the stomach, it is a good reason to abort and intubate or wake up. GERD will be worsened by insufflation of stomach and bowel.
Absolute Contraindications - Known or anticipated perforation. Relative Contraindications - coagulopathy, neutropenia, hemodynamic instability, GI obstruction EGD Indications - dysphagia, vomiting, hematemesis or melena, abdominal pain, abnormal weight loss, GERD, dyspepsia, biopsy and diagnosis of disease or infection, tracheoesophageal fistula (pediatric). Therapeutic indications - esophageal dilation, foreign body removal, banding or sclerotherapy of varices, hemostasis by thermal or injection, GJ tube removal/exchange, PEG tube placement.
