By Donnie Vinson, MD, Medical Director, CRH Anesthesia
The management of an EGD patient found to have esophageal and/or gastric contents presents a dilemma for both the GI doctor and the anesthesia provider. This is indeed a sticky situation, and not one to be taken lightly. It is important to reach a consensus on how to manage such cases in the future.
I encourage you to have discussions with your GI doctors about this patient care issue. I must emphasize that the subject below is not to be taken as a CRH Anesthesia “standard of care” to be applied across all CRH centers. As CRH Anesthesia providers, we work at our respective centers and develop plans of care that best benefit the patient. I, for example, offer guidance from previous management discussions that took place at Raleigh NC Endoscopy Center a couple of years ago. Dr. Naveen Narahari (Gastroenterologist, REX Digestive Healthcare) and I discussed ways our procedure teams could provide consistent and safe management practices when encountering patients with esophageal and/or gastric contents. We decided such a topic would be best discussed with the GI medical community that was present for the quarterly QAPI meeting (six GI MDs were present on the committee).
The discussions provided us with mutual respect, as each side became more aware of one another’s basis of action and concerns. As a result of the July 2018 meeting and a final approval of the guidelines at the CQI quarterly meeting in October, we reached a consensus.
Below are the guidelines shared with the CRNAs and GI doctors across the three centers that make up Raleigh Endoscopy.
I credit Dr. Narahari with providing the following guidelines (empirical/practical):
- Esophageal food content (liquid or solid) requires stopping the case.
- Semisolid mixed with liquid approaching the GE junction with a ‘food table’ noted at the fundus requires aborting the case.
- Liquid content (even if oily) should be expeditiously aspirated with EGD suction as the HOB is elevated and precautions are taken with suction devices readiness.
- If there is a small amount of solid material scattered around the body/fundus adherent to the wall, then EGD should be completed expeditiously, with little insufflation, to address the most immediate needs of the patient. This would include biopsies, with a high bar for dilation based on findings. If dilation is needed (EoE or Schatski ring), it would have to be a visualized, occlusion method (balloon), not a Maloney or Savary dilator method.
While we all agree that patient safety is of paramount importance, we should also be aware of its detriment as it would be related to delay of diagnosis (cancer) or delay of care or therapy (stricture). It is critical the CRNA, MDA, and the GI doctor come to a consensus and plan of treatment that addresses the needs of all the individuals and patients involved. The variables are plentiful, including patient safety, elective nature of the procedure, and documentation. This discussion aims to promote familiarity with guidelines to facilitate the recognition of the condition and subsequent plan of action by the GI doctor (procedural actions) and the CRNA or MDA (anesthesia delivery).
Many anesthesia providers feel that any contents noted should be an automatic stoppage of the case due to increased risk for aspiration on this elective, non-urgent case with an unprotected airway. I advised the REC GI doctors on the CQI Committee that a high percentage of anesthesia providers would still halt the delivery of anesthesia upon recognition of any of the four scenarios mentioned above., I wanted them to understand the prevalence of this stance and its basis. There are dangers of subsequently stopping Propofol administration unilaterally in some cases; as for instances #3 and #4, it would be less than ideal to have a gagging patient forcibly expelling gastric content. Anesthesia management, therefore, should be tailored accordingly.
Does the CRNA or MDA have any power in stopping the case or do they chart the facts as nonjudgmentally as possible and continue? The answer is that the GI doctor and anesthesia provider should come to an expedited categorization and do their best to keep the patient safe. Variance from the provided guidelines could be evaluated by peers at the CQI level. It is the hope and desire of these guidelines that an impasse is not met during such a case, but rather that the best team approach can be revealed expeditiously to promote patient safety.
As we move on to reporting some new Quality Metrics in 2021, there will be an evaluation of varying scenarios comprised of an Aspiration Focus Study. More information on the metrics for 2021 is forthcoming (look to the QA Corner in this issue). Remember: this article does not mandate these guidelines as “standards;” rather, my purpose is to encourage open dialogue with our GI colleagues about this most important medical management issue. I thank each of you for the outstanding job that you do in providing quality anesthesia care for the patients at your centers!