Caring for Potentially Difficult Patients

The Pulse | Thursday, September 19, 2019

Benjamin Sherman

SGNA’s 46th Annual Course had a number of interesting session topics from well-known, established speakers. If you missed out (or just want to re-live the fun), read on for a recap from the popular session, “Caring for the Nightmare Patient in the Endoscopy Suite: From an Anesthesiology Perspective.” Benjamin Sherman gives readers the low-down on his session from this year’s event.

I was honored to present at the 2019 SGNA Annual Course, held in Portland, Oregon. I've always found gastroenterology interesting and have several close friends that are gastroenterologists, so the opportunity to discuss difficult cases happens frequently. My wife is a nurse practitioner who also worked for several years in gastroenterology.

The field of gastroenterology is very fast paced and the endoscopy team frequently deals with some of the most ill patients in the hospital. During my session, I reviewed the management of difficult patients that could be found in the endoscopy suite, from both an anesthesiologist’s and gastroenterologist’s perspective.

The cases I presented during my session, although fictitious, represented situations where standard methods of sedation and treatment of endoscopy patients could trigger catastrophic side effects and acute patient decompensations. I tried to select disease states under two categories: ones that are common and difficult to manage (no IV access, alcohol abuse, etc.) and ones that are rare, yet could be triggered by the routine medications we give in common GI scenarios (glucagon, fentanyl, methylene blue, etc.). Given the production pressures in gastroenterology, I hope my talk helped attendees identify signs and symptoms of potentially difficult patients before they become a “nightmare patient,” requiring emergent lifesaving interventions.

Some of the newer tools and medications that are helpful for endoscopy team members to be aware of are as follows*:

1. Butterfly IQ ultrasound probe: The Butterfly IQ is a newer ultrasound probe which uses a completely different method of creating ultrasound waves. This newer method is revolutionary and will be a disruptive innovation, in that it is extremely cost effective to produce. As a result, the price point to purchase a high fidelity ultrasound machine (which plugs into your iPad or iPhone as the display) is down from $20,000 to approximately $2,000. This will give the endoscopy team access to ultrasound to help establish difficult IV access, as well as the ability to perform some point-of-care ultrasound (POCUS) techniques.

2. LMA Gastro: The LMA Gastro is a newer LMA that has a very large side port, allowing the gastroenterologist to perform upper endoscopy, while still having the ability to perform positive pressure ventilation and is a more secure airway to prevent aspiration. I would not say this is as secure as an endotracheal tube, but is an excellent option for patients that require airway protection and ventilatory assistance, but some contraindications for an endotracheal tube.

3. RYANODEX®: Ryanodex is a newer formulation of dantrolene, the lifesaving treatment for malignant hyperthermia. Ryanodex is an advanced nanosuspension technology that allows Ryanodex to be reconstituted with sterile water for injection and administered in significantly less time compared with other formulations of dantrolene sodium. Traditional dantrolene was difficult to reconstitute and administer requiring multiple vials. Ryanodex only requires one vial to administer. This significantly speeds up therapy and decreases the amount of help needed to treat malignant hyperthermia.

Thanks to Benjamin for a great session! For more great sessions, visit the SGNA eLearning Center at elearn.sgna.org. Search for recordings by price, contact hours, accreditation type, experience level and format.

*Resources shared in this article are solely from the author as part of his Annual Course presentation.

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