1 00:00:00,040 --> 00:00:03,320 Welcome back to the Deep Dive. Today we're doing something a 2 00:00:03,320 --> 00:00:06,440 little different. We are getting right into that 3 00:00:06,440 --> 00:00:10,160 specific headspace of a post grad student at like 3 in the 4 00:00:10,160 --> 00:00:13,120 morning. I know that feeling all too 5 00:00:13,120 --> 00:00:14,680 well. You know it, right? 6 00:00:15,080 --> 00:00:18,360 The coffee is stone cold, You've got Miller's anesthesia open on 7 00:00:18,360 --> 00:00:21,520 one side, the Oxford Handbook on the other, and you're staring at 8 00:00:21,520 --> 00:00:24,800 a topic that looks, I don't know, deceptively easy but is 9 00:00:24,800 --> 00:00:28,080 actually a total trap. The classic wolf in sheep's 10 00:00:28,080 --> 00:00:30,160 clothing topics. They look simple on the 11 00:00:30,160 --> 00:00:32,960 syllabus, but they are absolutely where exams are won 12 00:00:32,960 --> 00:00:34,480 and lost. Exactly. 13 00:00:34,760 --> 00:00:37,480 And the topic is anesthetic management for upper GI 14 00:00:37,480 --> 00:00:41,120 endoscopy and colonoscopy. And honestly my first thought 15 00:00:41,120 --> 00:00:43,200 was it's just a bit of sedation, right? 16 00:00:43,200 --> 00:00:45,360 How hard can it be? And that's the first mistake. 17 00:00:45,400 --> 00:00:47,600 But then I started digging into these notes you sent over, 18 00:00:47,600 --> 00:00:51,760 specifically the sections on RRA, you know, non operating 19 00:00:51,760 --> 00:00:55,160 room anesthesia, and I realized this is actually a minefield. 20 00:00:55,200 --> 00:00:57,720 It is, and that's exactly why examiners love it. 21 00:00:57,720 --> 00:01:01,480 If you walk into Aviva thinking it's just a bit of propofol, you 22 00:01:01,480 --> 00:01:03,280 will fail. I can guarantee it. 23 00:01:03,440 --> 00:01:06,400 The exam question isn't really about the endoscopy itself. 24 00:01:06,640 --> 00:01:09,760 It's about how you manage a compromised airway in a dark 25 00:01:09,760 --> 00:01:13,640 room with limited help on a patient who might be actively 26 00:01:13,640 --> 00:01:16,200 bleeding. It tests your crisis resource 27 00:01:16,200 --> 00:01:18,600 management just as much as your pharmacology. 28 00:01:18,760 --> 00:01:22,480 Yeah, Miller really emphasizes the the hostility of the 29 00:01:22,480 --> 00:01:24,400 environment. It's not the pristine or we're 30 00:01:24,400 --> 00:01:25,560 used to. Not even close. 31 00:01:25,640 --> 00:01:28,760 So the goal today, our mission is to synthesize these heavy 32 00:01:28,760 --> 00:01:32,360 texts into that perfect 15 mark answer for the Gujarat 33 00:01:32,360 --> 00:01:34,840 University MD Anesthesiology exams. 34 00:01:35,200 --> 00:01:39,040 We need to build the structure pre op, intra op, the specific 35 00:01:39,040 --> 00:01:41,720 pharmacology and of course the disaster management. 36 00:01:41,720 --> 00:01:43,080 Right. And there's a core tension. 37 00:01:43,080 --> 00:01:46,040 We need to keep coming back to a central theme, and that's the 38 00:01:46,040 --> 00:01:49,840 concept of the shared airway. In almost every other surgery, 39 00:01:50,000 --> 00:01:51,760 the anesthesiologist owns the airway. 40 00:01:51,760 --> 00:01:54,480 It's our domain. But in upper GI endoscopy, 41 00:01:54,480 --> 00:01:57,240 you're renting space. You're renting it from a 42 00:01:57,240 --> 00:02:00,240 gastroenterologist who is actively, if unintentionally, 43 00:02:00,240 --> 00:02:02,440 trying to obstruct it. That's a great way to put it. 44 00:02:02,880 --> 00:02:06,360 So let's kick this off. Part A introduction and exam 45 00:02:06,360 --> 00:02:08,639 framing. If I'm sitting in the exam hall, 46 00:02:08,639 --> 00:02:11,680 I turn over the paper and I find a long question on this. 47 00:02:12,840 --> 00:02:15,600 How do I even start? Do I just define the procedure? 48 00:02:15,800 --> 00:02:19,120 You start by defining the scope, yes, but you do it to show you 49 00:02:19,120 --> 00:02:22,440 understand the clinical context. So you'd write Upper GI. 50 00:02:22,440 --> 00:02:26,400 Endoscopy, often called EGD or OGD, involves the visual 51 00:02:26,400 --> 00:02:29,160 examination of the esophagus, stomach, and duodenum. 52 00:02:30,120 --> 00:02:33,280 Then colonoscopy is the examination of the lower GI 53 00:02:33,280 --> 00:02:36,920 tract from the rectum to the cecum and sometimes the terminal 54 00:02:36,920 --> 00:02:38,960 ileum. OK, simple definitions. 55 00:02:38,960 --> 00:02:41,320 But you must immediately pivot to the purpose. 56 00:02:41,360 --> 00:02:43,280 Don't just say what they are, say what they're for. 57 00:02:43,560 --> 00:02:45,720 These are diagnostic and therapeutic procedures. 58 00:02:45,720 --> 00:02:48,160 Therapeutic meaning that they might be clipping bleeds or 59 00:02:48,160 --> 00:02:49,560 removing polyps or something like. 60 00:02:49,560 --> 00:02:52,560 That exactly, and that single word therapeutic changes the 61 00:02:52,560 --> 00:02:54,920 entire anesthetic risk profile instantly. 62 00:02:55,400 --> 00:02:57,680 But the most critical part of your introduction, the part that 63 00:02:57,680 --> 00:03:01,680 gets you the marks is to classify this under ONORA, non 64 00:03:01,680 --> 00:03:04,560 operating room anesthesia. You need to write that acronym 65 00:03:04,560 --> 00:03:06,560 down and define it. OK N or R? 66 00:03:06,800 --> 00:03:08,800 Miller makes a very, very strong point here. 67 00:03:09,280 --> 00:03:12,960 Norara is a rapidly growing field and it often involves 68 00:03:12,960 --> 00:03:16,920 sicker patients ASA three and four in what it calls remote 69 00:03:16,920 --> 00:03:19,160 locations. Let's unpack that remote 70 00:03:19,160 --> 00:03:21,320 location aspect a bit in the exam. 71 00:03:21,320 --> 00:03:23,880 Why is that a point worth marks? It's still in the hospital, 72 00:03:23,880 --> 00:03:26,440 right? It is, but remote in this 73 00:03:26,440 --> 00:03:30,040 context means remote from the safety and resources of the main 74 00:03:30,040 --> 00:03:32,360 operating theater. It implies risk. 75 00:03:32,880 --> 00:03:35,200 You're working with limited space, for one. 76 00:03:36,080 --> 00:03:39,080 The room is designed for the gastroenterologist, not for us. 77 00:03:39,320 --> 00:03:41,280 The lighting is dimmed for their screens. 78 00:03:41,280 --> 00:03:43,240 Which means you lose visual cues. 79 00:03:43,240 --> 00:03:45,240 You can't see the patient's color properly. 80 00:03:45,280 --> 00:03:48,080 Precisely. You can't see cyanosis and the 81 00:03:48,080 --> 00:03:50,200 support staff are endoscopy nurses. 82 00:03:50,640 --> 00:03:53,560 They are brilliant what they do, but they are not trained in 83 00:03:53,560 --> 00:03:56,680 anesthetic emergencies in the same way an OR technician is. 84 00:03:56,840 --> 00:03:59,040 You're often physically isolated from backup. 85 00:03:59,080 --> 00:04:01,320 So things go South. You are basically on an island. 86 00:04:01,320 --> 00:04:03,800 You're on an island and you need to have brought all your 87 00:04:03,800 --> 00:04:07,120 equipment and plans with you. That directly leads back to the 88 00:04:07,120 --> 00:04:10,080 shared airway concept we mentioned in EGD. 89 00:04:10,080 --> 00:04:11,880 The endoscope itself is a foreign body. 90 00:04:11,880 --> 00:04:14,320 It's an airway obstruction. It's sitting right there in the 91 00:04:14,320 --> 00:04:16,320 pharynx it. Triggers the gag reflex. 92 00:04:16,399 --> 00:04:19,880 It can cause laryngospasm. You can't easily get a seal to 93 00:04:19,880 --> 00:04:21,440 mass ventilate with a scope in the mouth. 94 00:04:22,079 --> 00:04:25,440 This competition for space is the defining anesthetic 95 00:04:25,440 --> 00:04:27,840 challenge. If you don't mention shared 96 00:04:27,840 --> 00:04:30,960 airway in the first paragraph of your answer, you've missed the 97 00:04:30,960 --> 00:04:32,480 entire point of the question. Got it. 98 00:04:32,800 --> 00:04:34,760 OK, what about other exam patterns? 99 00:04:34,760 --> 00:04:37,800 Where else does this topic pop up besides the long question? 100 00:04:37,800 --> 00:04:40,200 Oh, it's everywhere. You'll see it in short notes, 101 00:04:40,200 --> 00:04:43,920 usually phrased as sedation challenges in colonoscopy, or 102 00:04:44,160 --> 00:04:47,280 maybe Neurala safety principles. But the Viva? 103 00:04:48,720 --> 00:04:50,440 The Viva is where they really get you. 104 00:04:50,600 --> 00:04:53,400 Of course, in a Viva they won't ask you to list facts. 105 00:04:53,600 --> 00:04:56,880 They'll present a scenario. You have a 70 year old male for 106 00:04:56,880 --> 00:05:01,000 an ERCP. 5 minutes in, his saturation drops to 85%. 107 00:05:01,160 --> 00:05:02,920 What do you do? They want to see your thought 108 00:05:02,920 --> 00:05:04,480 process. They want to know you were safe. 109 00:05:04,560 --> 00:05:06,400 Your crisis management algorithm. 110 00:05:06,400 --> 00:05:08,440 Exactly. They're testing your ability to 111 00:05:08,440 --> 00:05:11,400 think under pressure, far from your usual environment. 112 00:05:11,600 --> 00:05:15,200 OK, this is making a lot more sense now let's move to park B 113 00:05:15,200 --> 00:05:17,920 them procedural characteristics and challenges. 114 00:05:18,120 --> 00:05:20,720 So to write a good answer, I need to think like the 115 00:05:20,720 --> 00:05:23,640 gastroenterologist for a second. What are the key procedural 116 00:05:23,640 --> 00:05:25,280 characteristics I need to list out? 117 00:05:25,320 --> 00:05:27,560 First thing is duration and invasiveness. 118 00:05:28,320 --> 00:05:31,000 Usually these procedures are short, you know, 10 to 30 119 00:05:31,000 --> 00:05:34,160 minutes. But, and this is a big but, they 120 00:05:34,160 --> 00:05:37,360 are highly variable. A quick diagnostic look is one 121 00:05:37,360 --> 00:05:40,720 thing. A complex therapeutic ERCP can 122 00:05:40,720 --> 00:05:43,440 take hours. So the anesthetic plan has to be 123 00:05:43,440 --> 00:05:44,960 flexible. It has to be, Yeah. 124 00:05:45,280 --> 00:05:47,560 And generally, the surgical stress is minimal. 125 00:05:47,560 --> 00:05:49,000 It's not like a laparotomy. Yeah. 126 00:05:49,000 --> 00:05:51,000 And that's why we get lulled into this false sense of 127 00:05:51,000 --> 00:05:53,000 security. Right, and positioning is a big 128 00:05:53,000 --> 00:05:54,480 one. I see references to this 129 00:05:54,480 --> 00:05:56,920 everywhere in the Oxford Handbook and Histos. 130 00:05:56,960 --> 00:05:59,600 It's not supine usually. No, and you must know this. 131 00:05:59,720 --> 00:06:02,760 This is a key exam detail. The standard position for both 132 00:06:02,760 --> 00:06:05,560 EGD and colonoscopy is the left lateral position. 133 00:06:05,880 --> 00:06:07,360 It's also known as The Sims position. 134 00:06:07,360 --> 00:06:09,520 You have to write that down. OK, left lateral. 135 00:06:09,520 --> 00:06:12,240 Let's really visualize the setup here. 136 00:06:12,240 --> 00:06:15,880 We know the standard position is left lateral, and that obviously 137 00:06:15,880 --> 00:06:17,280 helps the endoscopist get access. 138 00:06:17,720 --> 00:06:21,480 But looking at the sources, there's a massive anesthetic 139 00:06:21,480 --> 00:06:24,720 safety angle here too, right? It's not just about their 140 00:06:24,720 --> 00:06:26,960 convenience. Crucially, no. 141 00:06:27,280 --> 00:06:28,920 It's not about convenience at all. 142 00:06:29,200 --> 00:06:32,040 It's about physics. It's about safety. 143 00:06:32,760 --> 00:06:34,880 Think about the physics of aspiration for a moment. 144 00:06:35,720 --> 00:06:38,840 In the supine position, gravity is working against you. 145 00:06:39,600 --> 00:06:43,960 Any regurgitated content, any fluid pools at the glottis and 146 00:06:43,960 --> 00:06:45,720 can just fall straight into the trachea. 147 00:06:46,160 --> 00:06:49,080 It's the worst possible position for an unprotected airway. 148 00:06:49,520 --> 00:06:51,120 But in the left lateral position. 149 00:06:51,120 --> 00:06:53,120 Your mouth is now lower than your larynx. 150 00:06:53,160 --> 00:06:55,880 The corner of the mouth becomes the lowest point, so you're 151 00:06:55,880 --> 00:06:58,360 essentially using gravity as a passive suction device. 152 00:06:58,760 --> 00:07:01,480 Anything that comes up will tend to drain out of the mouth rather 153 00:07:01,480 --> 00:07:04,320 than down into the lungs. Which is a huge safety buffer if 154 00:07:04,320 --> 00:07:06,920 you're doing deep sedation without an endotracheal tube. 155 00:07:06,960 --> 00:07:10,040 It's your single biggest safety buffer against aspiration in 156 00:07:10,040 --> 00:07:12,960 that scenario. But, and this is how you show 157 00:07:12,960 --> 00:07:14,800 the examiner, you're thinking at a higher level. 158 00:07:15,280 --> 00:07:18,000 There's a trade off. OK, what's the downside? 159 00:07:18,080 --> 00:07:21,720 While the airway is safer from aspiration, your monitoring 160 00:07:21,720 --> 00:07:24,680 becomes harder. You can't easily see chest 161 00:07:24,680 --> 00:07:27,280 excursion, can you? The patient is on their side, 162 00:07:27,280 --> 00:07:30,600 they're covered in drapes and physiologically you have to be 163 00:07:30,600 --> 00:07:34,080 very careful about VQ mismatch, especially in obese patients. 164 00:07:34,400 --> 00:07:37,560 VQ mismatch. That's ventilation perfusion. 165 00:07:37,560 --> 00:07:40,720 Why is that worse here? Because the dependent lung, the 166 00:07:40,720 --> 00:07:42,680 left lung in this case, is being compressed. 167 00:07:42,680 --> 00:07:45,320 Right by the weight of the other lung and the mediastinum. 168 00:07:45,480 --> 00:07:47,840 By the abdominal contents pushing up in the diaphragm, so 169 00:07:47,840 --> 00:07:51,600 your functional residual capacity, your FRC drops 170 00:07:51,600 --> 00:07:54,400 significantly in that lung. If you have an obese patient, 171 00:07:54,480 --> 00:07:57,680 their FRC is already low. That dependent lung might be 172 00:07:57,680 --> 00:08:00,400 adelectatic before you even start the procedure. 173 00:08:00,400 --> 00:08:02,560 Which means they have less oxygen reserve. 174 00:08:02,560 --> 00:08:05,840 They'll desaturate much faster if they become apnoic. 175 00:08:05,840 --> 00:08:08,240 Seconds if not minutes. So when you write the answer for 176 00:08:08,240 --> 00:08:10,240 positioning, don't just write left lateral. 177 00:08:10,400 --> 00:08:13,720 That's a pass you write. The left lateral position is 178 00:08:13,720 --> 00:08:17,240 utilized for both endoscopic access and to minimize 179 00:08:17,240 --> 00:08:20,360 aspiration risk via passive gravity drainage. 180 00:08:20,960 --> 00:08:24,200 However, it can compromise visual monitoring of respiration 181 00:08:24,360 --> 00:08:27,320 and may reduce FRC in the dependent lung, thereby 182 00:08:27,320 --> 00:08:30,360 accelerating the onset of hypoxia during apnea. 183 00:08:30,800 --> 00:08:33,200 That is the distinction between a pass and a distinction. 184 00:08:33,200 --> 00:08:35,760 Like a fantastic point. OK, now let's talk about 185 00:08:35,760 --> 00:08:38,360 stimulation levels. Is it actually painful? 186 00:08:38,720 --> 00:08:41,080 It depends on which end you're looking at, and this is a 187 00:08:41,080 --> 00:08:45,800 nuanced examiner's love. EGD, an upper GI endoscopy is 188 00:08:45,800 --> 00:08:47,720 not painful in the somatic sense. 189 00:08:47,720 --> 00:08:51,800 It's not like a skin incision, but it is intensely, intensely 190 00:08:51,800 --> 00:08:53,240 stimulating. How so? 191 00:08:53,400 --> 00:08:56,000 Insertion of the scope triggers the glossopharyngeal and vagal 192 00:08:56,000 --> 00:08:57,680 nerves. That's your gag reflex and your 193 00:08:57,680 --> 00:09:00,360 laryngeal reflexes. The body's primal response is to 194 00:09:00,360 --> 00:09:03,680 cough, gag and fight it. So for EGD, you need reflex 195 00:09:03,680 --> 00:09:05,320 suppression more than you need pain relief. 196 00:09:05,320 --> 00:09:07,040 Exactly. You need to Uptown the gag. 197 00:09:07,080 --> 00:09:09,160 You need to make the body tolerate this massive foreign 198 00:09:09,160 --> 00:09:11,360 object. Colonoscopy on the other hand, 199 00:09:11,360 --> 00:09:15,200 is a different beast entirely. Colonoscopy causes true visceral 200 00:09:15,200 --> 00:09:18,040 pain. This comes from 2 main sources, 201 00:09:18,360 --> 00:09:21,880 Gas insufflation, stretching the bowel wall, and traction or 202 00:09:21,880 --> 00:09:24,840 torque on the mesentery as the scope navigates the bends of the 203 00:09:24,840 --> 00:09:28,280 colon. It's a cramping, deep, poorly 204 00:09:28,280 --> 00:09:31,040 localized pain. So to summarize, for the exam, 205 00:09:31,640 --> 00:09:36,000 EGD requires reflex suppression. Colonoscopy requires analgesia 206 00:09:36,000 --> 00:09:38,600 and anxiolysis. That's a very clear distinction. 207 00:09:38,840 --> 00:09:41,520 That brings us to the big topic, anesthetic challenges. 208 00:09:41,520 --> 00:09:44,760 We've mentioned 4R and the shared airway. 209 00:09:45,160 --> 00:09:47,000 What else is really high yield here? 210 00:09:47,040 --> 00:09:48,800 Hypoxia. You need to write that in 211 00:09:48,800 --> 00:09:51,160 capital letters. It is the number one adversary 212 00:09:51,160 --> 00:09:53,600 in the endoscopy suite. And remember what we said about 213 00:09:53,600 --> 00:09:56,000 the environment. You often working in a darkened 214 00:09:56,000 --> 00:09:57,160 room. Right, so they can see their 215 00:09:57,160 --> 00:09:59,160 monitor. Which means, as Miller 216 00:09:59,160 --> 00:10:02,120 emphasizes, clinical observation of cyanosis is almost 217 00:10:02,120 --> 00:10:04,280 impossible. You cannot rely on looking at 218 00:10:04,280 --> 00:10:05,880 the patient's lifts or nail beds. 219 00:10:06,160 --> 00:10:09,120 You rely strictly, and I mean strictly on your monitors, 220 00:10:09,560 --> 00:10:12,200 specifically the pulse oximeter and the cavanagraph. 221 00:10:12,200 --> 00:10:14,040 We'll come back to monitoring in detail. 222 00:10:14,120 --> 00:10:16,640 What about aspiration? This seems a bit controversial. 223 00:10:16,640 --> 00:10:19,360 These patients are technically fasting usually, so why do we 224 00:10:19,360 --> 00:10:22,440 treat them as high risk? Do not under any circumstances 225 00:10:22,440 --> 00:10:24,320 tell an examiner the risk is low. 226 00:10:24,520 --> 00:10:27,800 That's a major red flag. Miller's crystal clear on this. 227 00:10:27,800 --> 00:10:29,680 There are several reasons. First, you have gastric 228 00:10:29,680 --> 00:10:32,280 insufflation. The endoscopus is actively 229 00:10:32,280 --> 00:10:33,720 pumping air into the stomach to see. 230 00:10:34,080 --> 00:10:36,280 What does that do? It increases intragastric 231 00:10:36,280 --> 00:10:38,200 pressure. It blows the stomach up like a 232 00:10:38,200 --> 00:10:40,200 balloon, making regurgitation more likely. 233 00:10:40,560 --> 00:10:43,600 Second, many of these patients have underlying pathology. 234 00:10:43,760 --> 00:10:47,760 They're not healthy volunteers. They have GRDA, hiatus hernia, 235 00:10:47,760 --> 00:10:50,800 esophageal strictures. Their lower esophageal sphincter 236 00:10:50,800 --> 00:10:53,400 is already incompetent. And if they're actively 237 00:10:53,400 --> 00:10:55,120 bleeding? That's the trump card. 238 00:10:55,520 --> 00:10:58,920 That is the absolute indication. If a patient is having an upper 239 00:10:58,920 --> 00:11:01,680 GI bleed. That is a full stomach scenario 240 00:11:01,680 --> 00:11:04,120 by definition, regardless of when they last ate. 241 00:11:04,360 --> 00:11:07,280 Blood is a potent to medic. It irritates the stomach lining. 242 00:11:08,080 --> 00:11:11,520 So if you are doing an emergency scope for a bleed, you must 243 00:11:11,520 --> 00:11:14,200 assume they will vomit you treated as a rapid sequence 244 00:11:14,200 --> 00:11:14,880 induction. OK. 245 00:11:14,880 --> 00:11:17,200 That clarifies a lot. Moving on to Part C, 246 00:11:17,200 --> 00:11:19,560 preoperative assessment. This is listed in our notes as 247 00:11:19,600 --> 00:11:22,360 absolutely essential. So if I skip this in Aviva, I 248 00:11:22,360 --> 00:11:25,520 fail, right? You fail immediately without 249 00:11:25,520 --> 00:11:27,880 question. Safety begins before the patient 250 00:11:27,880 --> 00:11:30,640 even enters the room. You cannot fix a lack of 251 00:11:30,640 --> 00:11:33,520 preparation with agility and skill inside the room. 252 00:11:33,840 --> 00:11:36,640 It's too late by then. So what are we looking for in 253 00:11:36,640 --> 00:11:39,400 the pre procedure evaluation? Where's the focus? 254 00:11:39,840 --> 00:11:41,120 You start with the airway assessment. 255 00:11:41,440 --> 00:11:43,760 Always Morgan is insisting on this. 256 00:11:44,040 --> 00:11:47,880 You must document the Malampatti score, Thyro, mental distance, 257 00:11:48,040 --> 00:11:51,600 neck mobility and mouth opening the full assessment. 258 00:11:51,600 --> 00:11:53,400 But wait, here's a question I've always had. 259 00:11:53,760 --> 00:11:56,360 If we're not planning to intubate, if the plan is just 260 00:11:56,360 --> 00:11:59,640 sedation, why does the Malampatti score even matter? 261 00:11:59,640 --> 00:12:02,080 That is the trap. That is exactly the trap a 262 00:12:02,080 --> 00:12:04,240 junior resident falls into. You assess the airway not for 263 00:12:04,240 --> 00:12:06,560 your plan A, but for your plan BC and D. 264 00:12:07,040 --> 00:12:09,240 For the rescue. Always for the rescue if your 265 00:12:09,240 --> 00:12:12,280 sedation plan A fails, or if they obstruct and you suddenly 266 00:12:12,280 --> 00:12:15,000 can't ventilate them, you need to know immediately if this is 267 00:12:15,000 --> 00:12:16,200 going to be a difficult innovation. 268 00:12:16,400 --> 00:12:18,880 You do not want to be discovering A Mullampati 4 269 00:12:18,880 --> 00:12:21,600 airway with a receded chin after you've pushed a bolus of 270 00:12:21,600 --> 00:12:24,080 propofol and the saturation is plummeting to 60%. 271 00:12:24,160 --> 00:12:26,960 That makes perfect sense. Always prepare for the rescue, 272 00:12:27,680 --> 00:12:29,520 OK? What about comorbidities? 273 00:12:29,720 --> 00:12:32,240 What are the big red flags? Miller points out. 274 00:12:32,440 --> 00:12:35,200 The biggest one, and it's huge in all the Norway our 275 00:12:35,200 --> 00:12:38,880 literature, is obstructive sleep apnea, OSA. 276 00:12:39,560 --> 00:12:42,200 These patients have a collapsible pharyngeal airway. 277 00:12:42,200 --> 00:12:43,600 That's the definition of the disease. 278 00:12:43,840 --> 00:12:46,520 When they sleep at night, they obstruct when you give them even 279 00:12:46,520 --> 00:12:49,360 a whiff of a sedative like propofol or midazolam. 280 00:12:49,520 --> 00:12:51,680 What do you think happened? Instantly. 281 00:12:51,800 --> 00:12:55,080 Instantly and completely. Miller strongly suggests using a 282 00:12:55,080 --> 00:12:58,200 screening tool like Stop a Bang if they are high risk. 283 00:12:58,200 --> 00:13:01,600 For OSA, you need to be much, much more cautious with 284 00:13:01,600 --> 00:13:04,240 sedation. You might even decide Georgia 285 00:13:04,240 --> 00:13:06,760 with a secure airway is the only safe option. 286 00:13:06,920 --> 00:13:08,920 And cardiac disease. For cardiac disease, look at 287 00:13:08,920 --> 00:13:11,400 their functional status. Can they climb two flights of 288 00:13:11,400 --> 00:13:12,720 stairs without getting breathless? 289 00:13:13,120 --> 00:13:16,200 What's their met T score? Miller notes the risk of 290 00:13:16,200 --> 00:13:18,680 ischemia. The procedure itself can cause 291 00:13:18,680 --> 00:13:22,080 stress, tachycardia, hypertension, and a colonoscopy 292 00:13:22,280 --> 00:13:25,080 can cause profound vagal stimulation and bradycardia. 293 00:13:25,400 --> 00:13:27,360 You need to know their cardiac reserve is. 294 00:13:27,600 --> 00:13:30,760 Let's talk about fasting status, the NPO guidelines. 295 00:13:30,840 --> 00:13:33,920 I assume the standard ASA guidelines apply here. 296 00:13:33,920 --> 00:13:36,200 Yes, and you must state them in the exam. 297 00:13:36,760 --> 00:13:40,480 Two hours for clear fluids, 6 hours for a light meal or 298 00:13:40,480 --> 00:13:43,480 formula, 8 hours for a fatty or fried meal. 299 00:13:43,800 --> 00:13:46,960 The 268 rule. Here's the exam trap I've heard 300 00:13:46,960 --> 00:13:49,120 people discuss. Can I get away with being a bit 301 00:13:49,120 --> 00:13:52,800 LAX on this because it's just a minor procedure or just a camera 302 00:13:52,800 --> 00:13:54,680 test? Absolutely not, That's a huge 303 00:13:54,680 --> 00:13:57,400 trap. The exam answer is standard 304 00:13:57,400 --> 00:14:00,000 fasting guidelines must be strictly adhered to. 305 00:14:00,320 --> 00:14:03,040 In fact, you need to show your thinking even more deeply. 306 00:14:03,200 --> 00:14:06,040 Miller warned specifically about gastric emptying issues in 307 00:14:06,040 --> 00:14:09,680 patients with long standing diabetes, Castroparesis. 308 00:14:09,800 --> 00:14:12,800 Right, so a diabetic patient who says they fasted for 8 hours 309 00:14:12,800 --> 00:14:15,320 might still have a stomach full of food from the day before. 310 00:14:15,560 --> 00:14:17,880 Exactly, their autonomic neuropathy means the stomach 311 00:14:17,880 --> 00:14:21,520 doesn't empty properly, so for a long standing diabetic with poor 312 00:14:21,520 --> 00:14:23,480 control you treat them as a full stomach. 313 00:14:23,600 --> 00:14:25,520 Even if they follow the MPO guidelines. 314 00:14:25,680 --> 00:14:28,160 That might be an indication to intubate them rather than just 315 00:14:28,160 --> 00:14:29,800 sedate them. Great point. 316 00:14:29,800 --> 00:14:31,640 Let's touch on some special patient groups. 317 00:14:31,640 --> 00:14:33,720 The elderly, what's the key concern? 318 00:14:34,040 --> 00:14:37,360 Reduced physiological reserve is the umbrella term, but be 319 00:14:37,360 --> 00:14:39,600 specific. Their circulation time is 320 00:14:39,600 --> 00:14:42,640 slower. Miller notes that drugs take 321 00:14:42,640 --> 00:14:46,080 longer to reach the brain. Slower arm to brain time. 322 00:14:46,120 --> 00:14:49,320 So if I push a dose of propofol and nothing happens in 20 323 00:14:49,320 --> 00:14:51,640 seconds and I get impatient and push another ghost. 324 00:14:51,640 --> 00:14:54,040 You've just overdosed them. The first dose hasn't even 325 00:14:54,040 --> 00:14:56,600 arrived at the brain yet. By the time the second dose hits 326 00:14:56,600 --> 00:14:59,840 on top of the first, they are profoundly apnoic and 327 00:14:59,840 --> 00:15:02,480 hypotensive. The mantra for the elderly is 328 00:15:02,520 --> 00:15:07,000 start low, go slow, and wait. They're also much more sensitive 329 00:15:07,000 --> 00:15:10,200 to the cognitive side effects of metazolem, leading to post 330 00:15:10,200 --> 00:15:11,600 operative delirium. OK. 331 00:15:11,640 --> 00:15:14,280 And the obese patient? We touched on the VQ mismatch in 332 00:15:14,280 --> 00:15:16,600 FRC. Yes, but also remember the pure 333 00:15:16,600 --> 00:15:19,440 mechanics of their airway. They have a heavy, thick neck. 334 00:15:20,080 --> 00:15:22,800 When they lose consciousness, that redundant soft tissue 335 00:15:22,800 --> 00:15:25,600 collapses inwards immediately, and because of the weight of the 336 00:15:25,600 --> 00:15:28,720 chest and abdomen, they have that severely reduced FRC. 337 00:15:28,920 --> 00:15:32,280 Their oxygen tank is tiny. They desaturate in seconds, not 338 00:15:32,280 --> 00:15:34,240 minutes. They are the definition of a 339 00:15:34,240 --> 00:15:35,640 high risk airway in this setting. 340 00:15:35,880 --> 00:15:37,960 And finally, patients with liver disease. 341 00:15:38,000 --> 00:15:39,880 Long cases has a whole section on this. 342 00:15:40,120 --> 00:15:43,160 And for good reason. Liver patients are frequent 343 00:15:43,160 --> 00:15:46,640 Flyers in the endoscopy suite for Ferris wheel screening, 344 00:15:46,640 --> 00:15:49,560 banding, things like that. You have three main problems to 345 00:15:49,560 --> 00:15:52,760 worry about. 1 Altered drug metabolism. 346 00:15:53,160 --> 00:15:56,720 Drugs, especially those metabolized by the liver, last 347 00:15:56,720 --> 00:15:59,160 much longer. Two must be Coagulopathy. 348 00:15:59,280 --> 00:16:02,040 Correct bleeding risk during biopsies is high. 349 00:16:02,160 --> 00:16:05,400 You need to know their INR and platelet count and three, 350 00:16:05,680 --> 00:16:08,840 encephalopathy. They are extremely sensitive to 351 00:16:08,840 --> 00:16:11,000 sedatives, particularly benzodiazepines. 352 00:16:11,160 --> 00:16:14,080 Why benzodiazepine specifically? I've heard this before. 353 00:16:14,120 --> 00:16:17,160 They can precipitate or worsen hepatic encephalopathy. 354 00:16:17,640 --> 00:16:21,080 The mechanism is complex, but it involves the GABA receptors in 355 00:16:21,080 --> 00:16:23,960 the brain, which are already up regulated in liver failure. 356 00:16:24,520 --> 00:16:27,000 So Miller advises avoiding midazolam in patients with 357 00:16:27,000 --> 00:16:29,800 severe liver disease if possible, or using tiny, 358 00:16:29,800 --> 00:16:32,800 carefully titrated doses. Propofol is often a better 359 00:16:32,800 --> 00:16:35,600 choice as its metabolism is less dependent on liver function, 360 00:16:35,720 --> 00:16:37,800 right? OK, let's move into Part D, 361 00:16:37,800 --> 00:16:40,400 choice of anesthesia. This is marked in our outline as 362 00:16:40,400 --> 00:16:43,160 Exam gold. So how do I describe the 363 00:16:43,160 --> 00:16:44,840 different options available to me? 364 00:16:45,080 --> 00:16:47,680 You must start by describing the continuum of sedation. 365 00:16:48,200 --> 00:16:51,000 The American Society of Anesthesiologist, the ASA 366 00:16:51,400 --> 00:16:54,960 defined 4 distinct levels. You need to know these 367 00:16:54,960 --> 00:16:56,680 definitions by heart for the exam. 368 00:16:56,800 --> 00:17:00,640 OK, let's go through them. Level 1 is minimal sedation or 369 00:17:00,680 --> 00:17:03,800 anxiolysis. Here the patient responds 370 00:17:03,800 --> 00:17:06,920 normally to verbal commands. Cognitive function might be a 371 00:17:06,920 --> 00:17:09,280 little impaired, but their airway and breathing are 372 00:17:09,280 --> 00:17:10,520 unaffected. Level 2. 373 00:17:10,680 --> 00:17:13,240 Moderate sedation, which used to be called conscious sedation. 374 00:17:13,240 --> 00:17:15,800 This is the key one. The patient responds 375 00:17:15,800 --> 00:17:19,200 purposefully to verbal commands, either alone or accompanied by 376 00:17:19,200 --> 00:17:21,960 light tactile stimulation. The crucial part of the 377 00:17:21,960 --> 00:17:25,000 definition is no interventions are required to maintain a 378 00:17:25,000 --> 00:17:27,800 patent airway. So they're still breathing on 379 00:17:27,800 --> 00:17:29,360 their own just fine. Correct. 380 00:17:29,440 --> 00:17:33,440 Now Level 3 is deep sedation. Here the patient cannot be 381 00:17:33,440 --> 00:17:36,240 easily aroused, but will respond purposefully following a 382 00:17:36,240 --> 00:17:39,440 repeated or painful stimulation. And here's the Cliff edge. 383 00:17:39,760 --> 00:17:42,800 The definition includes the phrase The ability to 384 00:17:42,800 --> 00:17:45,880 independently maintain ventilatory function may be 385 00:17:45,880 --> 00:17:47,520 impaired. So that's the danger zone, the 386 00:17:47,520 --> 00:17:49,040 transition from moderate to deep. 387 00:17:49,200 --> 00:17:52,080 That is the precipice. As soon as you cross from 388 00:17:52,080 --> 00:17:55,320 moderate to deep, which can happen in a matter of seconds 389 00:17:55,320 --> 00:17:59,160 with a drug like propofol, you are effectively inducing general 390 00:17:59,160 --> 00:18:01,640 anesthesia, but without a protected airway. 391 00:18:02,280 --> 00:18:06,120 And the final level, of course, is general anesthesia GA, a loss 392 00:18:06,120 --> 00:18:09,240 of consciousness where the patient is not arousable even by 393 00:18:09,240 --> 00:18:11,840 painful stimulation. And Miller notes, there's been a 394 00:18:11,840 --> 00:18:13,760 real shift in the field here, hasn't there? 395 00:18:13,760 --> 00:18:16,240 Away from the traditional moderate sedation. 396 00:18:16,240 --> 00:18:19,440 A massive shift. Historically conscious sedation 397 00:18:19,640 --> 00:18:23,040 with a combination of midazolam and opioid like fentanyl was the 398 00:18:23,040 --> 00:18:26,720 standard, but there has been a huge move toward propofol based 399 00:18:26,720 --> 00:18:28,320 deep sedation. And why is that? 400 00:18:28,320 --> 00:18:31,160 Three reasons. Better patient satisfaction. 401 00:18:31,200 --> 00:18:33,200 They remember nothing and feel better afterwards. 402 00:18:33,720 --> 00:18:36,640 Faster recovery and discharge times and frankly better 403 00:18:36,640 --> 00:18:38,400 operating conditions for the endoscopist. 404 00:18:38,680 --> 00:18:41,920 The patient is completely still, but it comes to the cost of that 405 00:18:41,920 --> 00:18:44,200 Higher risk of airway compromise in apnea. 406 00:18:44,360 --> 00:18:46,480 Is there a controversy here about who gets to give the 407 00:18:46,480 --> 00:18:48,520 propofol A? Huge controversy. 408 00:18:48,520 --> 00:18:50,440 This is the whole N double AAP debate. 409 00:18:50,600 --> 00:18:53,440 Non anesthesiologist administer propofol. 410 00:18:54,120 --> 00:18:55,800 Stolting discusses this at length. 411 00:18:56,280 --> 00:18:59,440 Can a specially trained nurse or the gastroenterologist 412 00:18:59,440 --> 00:19:03,680 themselves give propofol safely? The FDA label for propofol is 413 00:19:03,680 --> 00:19:06,400 very clear. It says it's for use only by 414 00:19:06,400 --> 00:19:08,680 persons trained in the administration of general 415 00:19:08,680 --> 00:19:11,760 anesthesia. So anesthesiologists would argue 416 00:19:11,760 --> 00:19:14,120 it's unsafe for others to be using it. 417 00:19:14,200 --> 00:19:17,320 The argument is that you need someone whose sole job, whose 418 00:19:17,320 --> 00:19:19,640 entire focus is monitoring the patient's level of 419 00:19:19,640 --> 00:19:22,560 consciousness, their airway, and their hemodynamics. 420 00:19:22,920 --> 00:19:25,760 You cannot safely perform the endoscopy and manage a deep 421 00:19:25,760 --> 00:19:29,000 sedation simultaneously. For the exam and for any high 422 00:19:29,000 --> 00:19:30,680 risk patient, the answer is clear. 423 00:19:30,920 --> 00:19:33,520 Propofol sedation should be administered by a dedicated 424 00:19:33,520 --> 00:19:35,840 anesthesia provider. OK, so sticking with that safety 425 00:19:35,840 --> 00:19:38,960 principle, when do I as the anesthesiologist decided to skip 426 00:19:38,960 --> 00:19:41,200 sedation and go straight to general anesthesthesia? 427 00:19:41,400 --> 00:19:43,280 What are the hard indications for GA? 428 00:19:43,360 --> 00:19:45,240 This feels like a classic exam question. 429 00:19:45,400 --> 00:19:48,400 It's an absolute exam favorite. You need to have a must intubate 430 00:19:48,520 --> 00:19:50,560 list in your head. It's about identifying 431 00:19:50,560 --> 00:19:52,200 unacceptable risks. OK, what's on the list? 432 00:19:52,360 --> 00:19:55,240 Number one, high aspiration risk. 433 00:19:55,600 --> 00:19:58,080 We've already covered this. Active GI bleeding is the 434 00:19:58,080 --> 00:20:00,680 classic example. Blood in the stomach equals a 435 00:20:00,680 --> 00:20:03,920 full stomach. Also known bowel obstruction, 436 00:20:04,040 --> 00:20:08,400 severe GERD or conditions like achalasia. #2. 437 00:20:08,560 --> 00:20:11,440 Uncooperative patients. This could be a child, an adult 438 00:20:11,440 --> 00:20:14,600 with severe anxiety or claustrophobia, or a patient 439 00:20:14,600 --> 00:20:18,120 with cognitive impairment or developmental delay who cannot 440 00:20:18,120 --> 00:20:20,520 follow commands or stay still. That makes sense. 441 00:20:20,520 --> 00:20:22,840 What's #3. Complex or prolonged therapy, 442 00:20:23,040 --> 00:20:26,120 the procedures. Think of ERCP which requires the 443 00:20:26,120 --> 00:20:29,160 patient to be prone or semi prone for a long time, or a 444 00:20:29,160 --> 00:20:32,480 procedure like POEM, paroral, endoscopic myotomy. 445 00:20:33,040 --> 00:20:35,720 Anything where you anticipate it will take a long time and the 446 00:20:35,720 --> 00:20:38,320 patient simply won't tolerate staying in one position under 447 00:20:38,320 --> 00:20:40,440 sedation and the last one failed sedation. 448 00:20:40,720 --> 00:20:42,920 This is a judgment call. If you have given what you 449 00:20:42,920 --> 00:20:45,240 consider to be safe and appropriate doses of sedation 450 00:20:45,240 --> 00:20:47,160 and the patient is still fighting, agitated or 451 00:20:47,160 --> 00:20:49,480 uncomfortable, you don't just keep pushing more drugs. 452 00:20:49,480 --> 00:20:52,880 That's how disasters happen. You stop, you reassess, and you 453 00:20:52,880 --> 00:20:54,960 convert to a controlled general anesthetic. 454 00:20:55,200 --> 00:20:57,440 Excellent. That's a really solid safe list 455 00:20:57,440 --> 00:21:00,440 for an exam answer. Now let's move into the room 456 00:21:00,640 --> 00:21:03,160 part E, intraoperative anesthetic management. 457 00:21:03,640 --> 00:21:06,120 Let's talk about our airway management strategies. 458 00:21:06,160 --> 00:21:08,720 OK, we're in the room for a standard EGD. 459 00:21:08,720 --> 00:21:11,080 Under sedation, you have a shared airway. 460 00:21:11,320 --> 00:21:13,440 You almost always start with topicalization. 461 00:21:13,480 --> 00:21:15,600 You mean like a lidocaine spray? Exactly. 462 00:21:15,600 --> 00:21:18,640 A lidocaine spray to the back of the throat or a viscous gargle. 463 00:21:19,040 --> 00:21:21,840 Morgan highlights this. Why do we do it? 464 00:21:22,160 --> 00:21:24,560 It tons. That gag reflex we talked about? 465 00:21:24,960 --> 00:21:28,200 This makes scope insertion more tolerable and often lowers the 466 00:21:28,200 --> 00:21:30,760 total dose of intravenous sedation you need to give. 467 00:21:30,760 --> 00:21:32,400 And what about oxygen delivery it? 468 00:21:32,400 --> 00:21:34,320 Is mandatory. You never do sedation without 469 00:21:34,320 --> 00:21:36,960 supplemental oxygen. Standard nasal cannula are the 470 00:21:36,960 --> 00:21:38,920 minimum. You can also get specialized 471 00:21:38,920 --> 00:21:41,360 bite blocks now that have a little oxygen port built right 472 00:21:41,360 --> 00:21:42,840 into them, which is quite clever. 473 00:21:43,000 --> 00:21:45,520 I see a high yield note here from Miller about something 474 00:21:45,520 --> 00:21:49,120 else, high flow nasal oxygen HFNO. 475 00:21:49,120 --> 00:21:52,000 Yes, this is a real game changer especially for high risk 476 00:21:52,000 --> 00:21:54,720 patients. You might also hear it called TH 477 00:21:54,720 --> 00:21:58,760 rive Transnasal Humidified rapid insufflation Ventilatory 478 00:21:58,760 --> 00:22:00,640 exchange. OK, that's a mouthful. 479 00:22:00,640 --> 00:22:02,520 How does it actually help in this situation? 480 00:22:02,720 --> 00:22:06,800 It provides very high flows of warm humidified oxygen, up to 60 481 00:22:06,800 --> 00:22:10,760 or 70 liters per minute. This is 2 very important things. 482 00:22:11,040 --> 00:22:15,080 One, it creates a massive reservoir of 100% oxygen in the 483 00:22:15,080 --> 00:22:19,360 pharynx and fills the lungs. This dramatically extends the 484 00:22:19,360 --> 00:22:22,360 safe apnoea time. If the patient stops breathing, 485 00:22:22,360 --> 00:22:25,280 their saturation stays up for many minutes longer give you 486 00:22:25,280 --> 00:22:27,040 more time to intervene. And the second thing. 487 00:22:27,640 --> 00:22:30,760 The high flow generates a small amount of PEEP, or positive end 488 00:22:30,760 --> 00:22:33,080 expiratory pressure. It's only about 5 to 7 489 00:22:33,080 --> 00:22:36,040 centimeters of water, but it's often enough to splint the 490 00:22:36,040 --> 00:22:39,080 pharyngeal airway open, preventing it from collapsing. 491 00:22:39,360 --> 00:22:43,040 Especially in an obese patient with OSA, it's a fantastic tool. 492 00:22:43,040 --> 00:22:46,760 So if we decide to go to GA, the debate is LMA versus 493 00:22:46,800 --> 00:22:50,360 endotracheal tube or ETT. And for an EGD and upper GI 494 00:22:50,360 --> 00:22:53,880 endoscopy, the endotracheal tube ETT is almost always the 495 00:22:53,880 --> 00:22:55,600 preferred device. Why not an LMA? 496 00:22:55,600 --> 00:22:57,800 It's less stimulating, easier to put in. 497 00:22:58,000 --> 00:23:01,760 Because the LMA, by its very design, occupies the pharyngeal 498 00:23:01,760 --> 00:23:05,120 space, it sits right in the hypopharynx, which is exactly 499 00:23:05,120 --> 00:23:06,520 where the endoscopist needs to go. 500 00:23:06,880 --> 00:23:10,360 If you put an LMA in, the scope has to be squeezed past the LMA 501 00:23:10,360 --> 00:23:12,560 cuff. You are literally fighting for 502 00:23:12,560 --> 00:23:15,640 space Lus. The LMA does not fully rotect 503 00:23:15,640 --> 00:23:18,200 against aspiration if the stomach is full of blood or air 504 00:23:18,200 --> 00:23:20,200 from insufflation. But for a colonoscopy. 505 00:23:20,280 --> 00:23:24,480 For a colonoscopy the airway is free O an LMA or even just mask 506 00:23:24,480 --> 00:23:27,280 ventilation is perfectly acceptable if you're doing a 507 00:23:27,280 --> 00:23:30,360 Georgia. But for EGD, YouTube them. 508 00:23:30,680 --> 00:23:33,880 Secure the airway, get it out of the way, and let the endoscopist 509 00:23:33,880 --> 00:23:35,840 do their job. OK, let's talk about the drugs, 510 00:23:35,880 --> 00:23:38,040 sedation and drug consideration. Right. 511 00:23:38,040 --> 00:23:40,840 The pharmacology, as we said, the text describe a massive 512 00:23:40,840 --> 00:23:43,040 shift over the last decade. It used to be all 513 00:23:43,040 --> 00:23:45,720 benzodiazepines and opioids. Now if you read Stolting, it's 514 00:23:45,720 --> 00:23:47,400 practically a love letter to propofol. 515 00:23:47,560 --> 00:23:49,880 But for the exam you can't just, say, use propofol. 516 00:23:49,880 --> 00:23:53,440 You have to be more nuanced. You do you say that Propofol is 517 00:23:53,440 --> 00:23:55,520 often considered the gold standard for outcomes. 518 00:23:56,080 --> 00:23:59,640 It has a rapid onset, a very rapid offset and valuable anti 519 00:23:59,640 --> 00:24:02,240 emetic properties. It is perfect for a high 520 00:24:02,240 --> 00:24:05,280 turnover endoscopy list where efficiency is key. 521 00:24:05,320 --> 00:24:08,680 I see a note here in Sculpting about something called sadasis. 522 00:24:08,880 --> 00:24:09,440 What was that? Oh. 523 00:24:09,520 --> 00:24:12,720 Yes, Sadasis. That was a computer assisted 524 00:24:12,720 --> 00:24:15,760 sedation delivery system. It was a machine designed to 525 00:24:15,760 --> 00:24:19,720 allow non anesthesiologist to administer propofol for 526 00:24:19,720 --> 00:24:22,480 endoscopy. It had built in monitors and 527 00:24:22,480 --> 00:24:25,120 would titrate the drug based on the patient's response. 528 00:24:25,160 --> 00:24:27,640 And what happened to it? Stolting mentions it is an 529 00:24:27,640 --> 00:24:29,680 interesting technological development, but it was 530 00:24:29,680 --> 00:24:32,520 withdrawn from the market. It's a good historical point to 531 00:24:32,520 --> 00:24:35,440 mention in an essay to show you've read the text deeply, but 532 00:24:35,440 --> 00:24:37,360 the principle it highlights remains. 533 00:24:37,880 --> 00:24:40,760 Propofol is a powerful drug that needs very careful continuous 534 00:24:40,760 --> 00:24:42,440 monitoring. What about the traditional 535 00:24:42,440 --> 00:24:45,840 cocktail, the midazolam and fentanyl combination? 536 00:24:46,120 --> 00:24:48,120 It's still used. It's the classic conscious 537 00:24:48,120 --> 00:24:51,320 sedation mix. Midazolam provides excellent 538 00:24:51,320 --> 00:24:55,160 amnesia and anxiolysis. Fentanyl provides that visceral 539 00:24:55,160 --> 00:24:57,360 analgesia needed for colonoscopy. 540 00:24:57,840 --> 00:25:01,160 But here is the massive, enormous trap. 541 00:25:01,680 --> 00:25:05,240 Miller warns in no uncertain terms about synergistic 542 00:25:05,240 --> 00:25:08,000 respiratory depression. This concept blew my mind when I 543 00:25:08,000 --> 00:25:09,360 first read it. I always just thought, oh, 544 00:25:09,360 --> 00:25:11,920 little midazolam, a little fentanyl, perfectly safe. 545 00:25:12,200 --> 00:25:15,160 And that is the trap. It is not an additive effect. 546 00:25:15,160 --> 00:25:19,720 It's not 1 + 1 = 2 with these drugs, it's more like 1 + 1 = 10 547 00:25:19,720 --> 00:25:21,360 when it comes to respiratory depression. 548 00:25:21,720 --> 00:25:24,440 The dose response curve for respiratory Dr. shifts 549 00:25:24,440 --> 00:25:26,120 dramatically to the left. Why? 550 00:25:26,320 --> 00:25:28,960 Is it because they hit different receptors but ultimately depress 551 00:25:28,960 --> 00:25:30,920 the same respiratory center in the brain stem? 552 00:25:31,000 --> 00:25:33,560 That's exactly it. So the exam tip here is crucial. 553 00:25:33,720 --> 00:25:36,600 If you were describing the balance sedation technique, you 554 00:25:36,600 --> 00:25:39,520 must explicitly state that the doses of each drug must be 555 00:25:39,520 --> 00:25:42,920 significantly reduced by at least 50% when used in 556 00:25:42,920 --> 00:25:45,240 combination. If you write down the standard 557 00:25:45,240 --> 00:25:47,960 doses for both drugs given individually, the examiner will 558 00:25:47,960 --> 00:25:50,400 assume you have just rendered the patient APNOEC in the dark 559 00:25:50,400 --> 00:25:51,960 room. That's a vital point. 560 00:25:51,960 --> 00:25:55,600 And what about dexametomidine? Dexametomidine is an interesting 561 00:25:55,600 --> 00:25:58,640 1 long cases mentions it. It's an A2 agonist. 562 00:25:59,080 --> 00:26:01,920 It provides what's called cooperative sedation and some 563 00:26:01,920 --> 00:26:05,200 analgesia, but crucially, without significant respiratory 564 00:26:05,200 --> 00:26:07,760 depression. Patients are sedated but can 565 00:26:07,760 --> 00:26:10,520 often maintain their own airway and breathe spontaneously. 566 00:26:10,520 --> 00:26:12,240 Sounds perfect. Why don't we use it all the 567 00:26:12,240 --> 00:26:14,680 time? The downsides are it's slow on 568 00:26:14,680 --> 00:26:18,960 set and it's long recovery time. It's not ideal for a quick 10 569 00:26:18,960 --> 00:26:21,720 minute diagnostic scope where rapid turnover is needed. 570 00:26:22,080 --> 00:26:25,640 It's much better suited for longer, more complex cases like 571 00:26:25,640 --> 00:26:28,600 an ERCP, where you want the patient to be calm and breathing 572 00:26:28,600 --> 00:26:30,200 spontaneously for an hour or more. 573 00:26:30,280 --> 00:26:32,120 Monitoring. We've touched on this, but let's 574 00:26:32,120 --> 00:26:34,080 drive it home for the exam. What do I need to list? 575 00:26:34,120 --> 00:26:38,080 You list the standard ASA monitors as non negotiable ECG, 576 00:26:38,200 --> 00:26:42,800 non invasive blood pressure, NIPP and pulse oximetry, but for 577 00:26:42,800 --> 00:26:45,840 the exam you must emphasize and maybe even underline 578 00:26:45,880 --> 00:26:48,560 capnography. Miller states that it is now 579 00:26:48,560 --> 00:26:51,600 considered mandatory for any deep sedation in an RR 580 00:26:51,600 --> 00:26:53,480 environment. And why is it so critical? 581 00:26:53,480 --> 00:26:56,920 Why isn't the pulse oximeter this PO2 enough? 582 00:26:57,160 --> 00:26:59,360 Because pulse oximetry is a lag indicator. 583 00:26:59,520 --> 00:27:02,080 It tells you about oxygenation, not ventilation. 584 00:27:02,960 --> 00:27:05,880 If a patient who is receiving supplemental oxygen stops 585 00:27:05,880 --> 00:27:09,800 breathing, becomes apnoic, their oxygen saturation might stay at 586 00:27:09,800 --> 00:27:13,760 98% for a minute or two. The oxygen in their lungs acts 587 00:27:13,760 --> 00:27:18,600 as a buffer, but the capnograph which measures N title CO2 will 588 00:27:18,600 --> 00:27:20,080 show you a flat line immediately. 589 00:27:20,480 --> 00:27:23,920 So capnography measures breathing, while pulse oximetry 590 00:27:23,920 --> 00:27:25,640 measures the consequence of not breathing. 591 00:27:25,640 --> 00:27:27,200 Beautifully put. Exactly. 592 00:27:27,520 --> 00:27:30,200 In that dark room where you can't see the chest moving? 593 00:27:30,200 --> 00:27:33,000 Well, that little waveform on the monitor is your lifeline. 594 00:27:33,200 --> 00:27:36,280 It detects apnoea before desaturation occurs, giving you 595 00:27:36,280 --> 00:27:39,160 a critical head start. And a practical tip, how do you 596 00:27:39,160 --> 00:27:41,800 even measure CO2 if they aren't intubated? 597 00:27:41,920 --> 00:27:45,040 You use specialized nasal prongs that have a CO2 sampling line 598 00:27:45,200 --> 00:27:47,920 built into them alongside the oxygen delivery ports. 599 00:27:48,080 --> 00:27:51,560 It's simple and very effective. Long cases also mentions A 600 00:27:51,560 --> 00:27:53,840 precordial stethoscope. Is that still relevant? 601 00:27:54,040 --> 00:27:56,320 I think it is especially for Pediatrics or even just for your 602 00:27:56,320 --> 00:27:58,560 own Peace of Mind. You tape it to the Super sternal 603 00:27:58,560 --> 00:28:01,360 notch. Having that continuous audible 604 00:28:01,360 --> 00:28:04,800 breath sound is a very reassuring thing in a dark, 605 00:28:04,880 --> 00:28:07,680 quiet room. It's a low tech backup that 606 00:28:07,680 --> 00:28:09,720 connects you physically to the patient's breathing. 607 00:28:09,840 --> 00:28:12,400 OK, we are deep into the procedure now, Part F 608 00:28:12,400 --> 00:28:15,240 Complications and emergencies, the outline says. 609 00:28:15,240 --> 00:28:18,560 This is absolutely essential. It is. 610 00:28:18,920 --> 00:28:21,160 This is where you prove you're a safe anesthetist. 611 00:28:21,520 --> 00:28:24,320 You need to categorize these in your mind and in your exam 612 00:28:24,320 --> 00:28:26,040 answer. There are anesthetic 613 00:28:26,040 --> 00:28:29,240 complications and there are procedure related complications. 614 00:28:29,360 --> 00:28:31,120 Let's start with the big anesthetic 1. 615 00:28:31,240 --> 00:28:34,600 Hypoxia caused, as we've said, by airway obstruction from the 616 00:28:34,600 --> 00:28:37,920 tongue or the scope, or by central hypoventilation from too 617 00:28:37,920 --> 00:28:40,280 much drug. Or you can have laryngospasm. 618 00:28:40,360 --> 00:28:43,560 This is a nightmare scenario. The scope or secretions touch 619 00:28:43,560 --> 00:28:46,560 the vocal cords under light anesthesia and the cords just 620 00:28:46,560 --> 00:28:49,320 snapshot reflexively. You can't ventilate in or out. 621 00:28:49,520 --> 00:28:51,840 And hypotension. Very common, especially with 622 00:28:51,840 --> 00:28:55,320 propofol. And remember why many of these 623 00:28:55,320 --> 00:28:57,520 patients are significantly volume depleted. 624 00:28:58,240 --> 00:29:01,040 They've been fasting, but more importantly, they've taken a 625 00:29:01,040 --> 00:29:04,040 powerful bowel prep, strong laxatives that have dehydrated 626 00:29:04,040 --> 00:29:06,840 them. You then give propofol, A potent 627 00:29:06,840 --> 00:29:09,600 vasodilator, and their blood pressure can just fall like a 628 00:29:09,600 --> 00:29:12,320 Cliff. Fluid resuscitation is part of 629 00:29:12,320 --> 00:29:15,080 the anesthetic plant. Now, what about the procedure 630 00:29:15,080 --> 00:29:17,560 related complications? This is where S dos is a good 631 00:29:17,560 --> 00:29:19,520 reference. The big one is perforation. 632 00:29:20,360 --> 00:29:22,480 The endoscope can literally punch a hole through the 633 00:29:22,480 --> 00:29:24,840 esophageal, gastric, or colonic wall. 634 00:29:25,240 --> 00:29:28,640 S Dos and Miller both warn you to look for the sign of free gas 635 00:29:28,640 --> 00:29:31,160 under the diaphragm on a subsequent X-ray. 636 00:29:31,720 --> 00:29:34,400 But how would you spot that during the case itself? 637 00:29:34,400 --> 00:29:36,840 If the patient suddenly becomes tachycardic, their abdomen 638 00:29:36,840 --> 00:29:39,200 becomes rigid and distended, and they become difficult to 639 00:29:39,200 --> 00:29:41,560 ventilate. But the classic sign mentioned 640 00:29:41,560 --> 00:29:44,680 in S Dos that you might pick up is of cutaneous emphysema. 641 00:29:45,480 --> 00:29:48,120 The air from the gut escapes into the peritoneum, tracks up 642 00:29:48,120 --> 00:29:50,800 the mediastinum, and you can feel this crackling like Rice 643 00:29:50,800 --> 00:29:53,160 Krispies under the skin of the neck and chest. 644 00:29:53,640 --> 00:29:55,760 And if you find that, it's a surgical emergency? 645 00:29:55,960 --> 00:29:57,840 It's an immediate stop. Call the surgeons. 646 00:29:58,080 --> 00:29:59,720 This is a life threatening complication. 647 00:29:59,720 --> 00:30:01,920 And what about vasovagal episodes? 648 00:30:02,000 --> 00:30:03,920 These are very common during colonoscopy. 649 00:30:04,240 --> 00:30:07,000 As the scope stretches the mesentery, it stimulates the 650 00:30:07,000 --> 00:30:09,240 vagus nerve. This can lead to profound 651 00:30:09,240 --> 00:30:11,800 bradycardia and in some cases even a systol. 652 00:30:12,320 --> 00:30:15,160 The anesthesia OSCE books highlight this risk. 653 00:30:15,360 --> 00:30:18,680 You absolutely must have atropine or glycopyrrolate drawn 654 00:30:18,680 --> 00:30:21,000 up and ready before any colonoscopy starts. 655 00:30:21,000 --> 00:30:24,040 OK, so let's go into that war room scenario you mentioned 656 00:30:24,040 --> 00:30:26,440 earlier. You're 5 minutes into an EGD. 657 00:30:26,440 --> 00:30:29,040 The patient is obese. ASA three, you've given some 658 00:30:29,040 --> 00:30:31,920 propofol. Suddenly the pulse oximeter tone 659 00:30:31,920 --> 00:30:34,320 drops. It's not that polite high 660 00:30:34,320 --> 00:30:37,760 pitched beeping anymore. It's that low ominous falling 661 00:30:37,760 --> 00:30:40,240 tone. The screen says saturation is 662 00:30:40,240 --> 00:30:44,000 88% and dropping fast. What is the cognitive flow 663 00:30:44,000 --> 00:30:44,840 chart? What do you do? 664 00:30:45,160 --> 00:30:46,880 The first rule is that panic is the enemy. 665 00:30:47,240 --> 00:30:49,360 You have to rely on your training on the algorithm, and 666 00:30:49,360 --> 00:30:52,360 step one is counterintuitive for the gastroenterologist who is 667 00:30:52,360 --> 00:30:55,760 focused on the procedure. Step one is the procedure stops. 668 00:30:55,760 --> 00:30:57,680 They must hate that, don't they? They're so close. 669 00:30:57,680 --> 00:30:59,160 They just want to finish up real quick. 670 00:30:59,320 --> 00:31:01,800 They do, but you have to be the authority in the room. 671 00:31:02,040 --> 00:31:03,880 Your voice must be calm but firm. 672 00:31:04,760 --> 00:31:08,040 Scope out now, please. You cannot diagnose or fix an 673 00:31:08,040 --> 00:31:10,800 airway problem with a garden hose in the patient's esophagus. 674 00:31:11,120 --> 00:31:13,880 OK, the scope is out. The patient's saturation is 675 00:31:13,880 --> 00:31:17,280 still 85% and falling. Now you assess the mechanism. 676 00:31:17,640 --> 00:31:21,040 Is it central apnea from the drug or is it obstruction? 677 00:31:21,520 --> 00:31:24,080 In Nora? With sedation it is almost 678 00:31:24,080 --> 00:31:26,600 always obstruction. The tongue has fallen back and 679 00:31:26,600 --> 00:31:30,120 is blocking the pharynx. So first maneuver is a jaw 680 00:31:30,120 --> 00:31:32,440 thrust. An aggressive 2 handed jaw 681 00:31:32,440 --> 00:31:35,560 thrust. This serves 2 vital purposes. 1 682 00:31:35,560 --> 00:31:38,200 It physically opens the airway by lifting the tongue off the 683 00:31:38,200 --> 00:31:42,480 posterior pharyngeal wall. Two, it is an intensely painful 684 00:31:42,480 --> 00:31:44,320 stimulus. That pain is often the best 685 00:31:44,320 --> 00:31:47,640 respiratory stimulant you have. Sometimes just that action will 686 00:31:47,640 --> 00:31:49,400 cause the patient to gasp and take a breath. 687 00:31:50,080 --> 00:31:52,720 You can also apply pressure at Larson's Point just behind the 688 00:31:52,720 --> 00:31:55,280 earlobe, which is also very stimulating and can help break a 689 00:31:55,280 --> 00:31:57,200 laryngal spasm. And suction. 690 00:31:57,200 --> 00:31:59,480 Yes, tab suction ready. Clear any secretions from the 691 00:31:59,480 --> 00:32:01,360 mouth, but be gentle. Don't go too deep and trigger 692 00:32:01,360 --> 00:32:03,240 more spasm. And if the jaw thrust doesn't 693 00:32:03,240 --> 00:32:07,160 work, saturation is now 75%. Positive pressure ventilation. 694 00:32:07,800 --> 00:32:12,440 Get a good seal with a face mask and bagging with 100% oxygen if 695 00:32:12,440 --> 00:32:15,360 you still can't ventilate. If the chest isn't rising and 696 00:32:15,360 --> 00:32:19,000 you feel resistance, you are now in a can't ventilate emergency. 697 00:32:19,840 --> 00:32:22,600 You must call for help immediately, and your next step 698 00:32:22,720 --> 00:32:25,960 is likely a muscle relaxant like sucxomathonium to break the 699 00:32:25,960 --> 00:32:28,840 laryngospasm followed by immediate intubation. 700 00:32:29,200 --> 00:32:32,920 And for the exam, the key is showing that stepwise escalating 701 00:32:32,920 --> 00:32:35,120 response. Exactly, but you also add that 702 00:32:35,120 --> 00:32:37,440 early recognition via capnography prevents you from 703 00:32:37,440 --> 00:32:39,280 ever getting to the sucxathonium stage. 704 00:32:39,880 --> 00:32:43,000 If you wait for the pulse oximeter to drop to 85%, you're 705 00:32:43,000 --> 00:32:44,880 already a minute or two behind the event. 706 00:32:45,080 --> 00:32:47,160 The capita graph tells you the second they stop breathing. 707 00:32:47,240 --> 00:32:49,320 Clear and decisive. That's what they want to hear, 708 00:32:49,320 --> 00:32:51,480 right? OK, let's move to part G post 709 00:32:51,480 --> 00:32:53,160 procedure care. The procedure is done. 710 00:32:53,160 --> 00:32:54,880 Can we just send the work to the ward or home? 711 00:32:55,080 --> 00:32:57,160 Not yet. They must go to a dedicated 712 00:32:57,160 --> 00:32:59,560 recovery area. We use a scoring system like the 713 00:32:59,560 --> 00:33:03,200 Aldridge score or a modified PAS that's a post anesthetic 714 00:33:03,360 --> 00:33:05,840 discharge scoring system to assess their readiness for 715 00:33:05,840 --> 00:33:09,480 discharge and in recovery. We are specifically monitoring 716 00:33:09,480 --> 00:33:12,120 for sedation. What exactly is reservation? 717 00:33:12,360 --> 00:33:14,760 It's particularly a problem with drugs that have a longer half 718 00:33:14,760 --> 00:33:18,320 life, like midazolam. The drug circulates, it can be 719 00:33:18,320 --> 00:33:20,840 stored in fat tissue, and then leach back out into the 720 00:33:20,840 --> 00:33:23,120 bloodstream later. So a patient might look 721 00:33:23,120 --> 00:33:25,800 perfectly awake and alert in the procedure room, you wheel them 722 00:33:25,800 --> 00:33:28,680 to recovery, and 20 minutes later they're fast asleep and 723 00:33:28,680 --> 00:33:31,760 obstructing their airway again. This is why a mandatory 724 00:33:31,760 --> 00:33:34,080 monitored recovery period is so important. 725 00:33:34,120 --> 00:33:36,760 Makes sense. OK, the final step Discharge 726 00:33:36,760 --> 00:33:39,320 criteria. This is another exam core topic. 727 00:33:39,480 --> 00:33:43,160 Miller has specific guidelines. Yes, and you must know them. 728 00:33:43,400 --> 00:33:46,760 They must have stable vital signs back to their baseline. 729 00:33:47,000 --> 00:33:50,480 They must be alert and oriented to time, place and person. 730 00:33:50,800 --> 00:33:54,280 They should have no significant pain and minimal to no nausea or 731 00:33:54,280 --> 00:33:57,200 vomiting. But the two big non medical ones 732 00:33:57,200 --> 00:33:59,880 are absolutely critical for the exam and for real life. 733 00:33:59,880 --> 00:34:02,440 What are they? One, they must have a 734 00:34:02,440 --> 00:34:05,960 responsible adult escort. They cannot go home alone, no 735 00:34:05,960 --> 00:34:09,440 Uber, no taxi by themselves. Someone has to be there to take 736 00:34:09,440 --> 00:34:12,600 them home and look after them. And two, they're given explicit 737 00:34:12,600 --> 00:34:17,360 instructions of no driving, operating machinery, or signing 738 00:34:17,360 --> 00:34:20,280 legal documents for 24 hours if sedatives were used. 739 00:34:20,719 --> 00:34:22,120 This is a medical legal absolute. 740 00:34:22,280 --> 00:34:24,679 If they drive home and have an accident and you didn't document 741 00:34:24,679 --> 00:34:27,400 that you gave this specific instruction, you are liable. 742 00:34:27,560 --> 00:34:29,440 Excellent. Now let's wrap all this 743 00:34:29,440 --> 00:34:32,120 knowledge up with Part H comparison and exam integration. 744 00:34:32,120 --> 00:34:35,760 I love a good table. Let's compare endoscopy EGD 745 00:34:35,760 --> 00:34:37,880 versus colonoscopy for the exam paper. 746 00:34:38,199 --> 00:34:40,920 How would we structure that? This is a fantastic way to 747 00:34:40,920 --> 00:34:42,960 present your answer. It shows you can synthesize 748 00:34:42,960 --> 00:34:44,960 information. You draw a simple table with two 749 00:34:44,960 --> 00:34:47,239 columns. For EGD you write Shared 750 00:34:47,239 --> 00:34:50,600 restricted airway, high risk. For colonoscopy, you write 751 00:34:50,880 --> 00:34:54,280 airway is free and accessible. For EGD it's Gaggler and Jill 752 00:34:54,280 --> 00:34:57,000 reflexes. For colonoscopy is visceral pain 753 00:34:57,000 --> 00:34:59,520 from distention. For EGD you write aspiration, 754 00:34:59,560 --> 00:35:02,640 for colonoscopy you write dehydration from prep and vagal 755 00:35:02,640 --> 00:35:04,640 tone stimulation. That's perfect. 756 00:35:04,640 --> 00:35:07,040 And the same for sedation versus general anesthesia. 757 00:35:07,240 --> 00:35:10,360 Another great table. Under pros you write faster 758 00:35:10,360 --> 00:35:13,440 turnover, less invasive, fewer side effects like sore throat. 759 00:35:14,120 --> 00:35:18,040 Under cons you write unprotected airway, variable, depth of 760 00:35:18,040 --> 00:35:22,480 sedation, risk of obstruction. Under pros you write secure 761 00:35:22,480 --> 00:35:25,680 protected airway with an ETT motionless field for the 762 00:35:25,680 --> 00:35:28,600 endoscopist. Under cons you write more 763 00:35:28,600 --> 00:35:32,440 hemodynamic instability, longer recovery, risk of post op nausea 764 00:35:32,440 --> 00:35:34,760 and sore throat. Before we close out, let's hit 765 00:35:34,760 --> 00:35:36,880 some of those common exam questions and Viva traps. 766 00:35:36,880 --> 00:35:40,480 You mentioned trap number one. Can I just do this under local 767 00:35:40,480 --> 00:35:42,520 anaesthesia? The trap is to say yes, of 768 00:35:42,520 --> 00:35:46,120 course the safe and correct answer is only for a very 769 00:35:46,120 --> 00:35:49,200 specific, highly cooperative patient for a brief diagnostic 770 00:35:49,200 --> 00:35:51,600 procedure, and even then you would usually want an 771 00:35:51,600 --> 00:35:55,080 anesthesiologist on standby ready to provide sedation if 772 00:35:55,080 --> 00:35:57,880 needed. You cannot do a complex EGD on 773 00:35:57,880 --> 00:36:00,160 an anxious patient with just a bit of throat spray. 774 00:36:00,360 --> 00:36:02,080 Chap 2. Ignoring the bowel prep. 775 00:36:02,280 --> 00:36:04,640 We mentioned this, but it's a common Viva question. 776 00:36:04,640 --> 00:36:08,160 The examiner says your patient's blood pressure is 90 / 60 on 777 00:36:08,160 --> 00:36:09,120 induction. Why? 778 00:36:09,480 --> 00:36:13,440 You must mention the patient is likely significantly dehydrated 779 00:36:13,440 --> 00:36:16,680 from the bowel preparation. If you just blame the propofol 780 00:36:16,680 --> 00:36:19,840 and miss that key piece of Physiology, you lose marks. 781 00:36:19,840 --> 00:36:23,600 And trap 3 How do you monitor respiration in a darkened room? 782 00:36:24,080 --> 00:36:26,840 If you say I watched the chest rise and fall, you fail. 783 00:36:27,040 --> 00:36:30,160 The answer is primarily with capnography, which directly 784 00:36:30,160 --> 00:36:33,000 measures ventilation, and secondarily with the audible 785 00:36:33,000 --> 00:36:35,720 pulse oximetry tone, which reflects oxygenation. 786 00:36:35,880 --> 00:36:38,240 Miller is very specific on this. Finally, let's talk about 787 00:36:38,240 --> 00:36:40,360 presentation. You mentioned diagrams, yes. 788 00:36:41,120 --> 00:36:43,960 If you have time in a written exam, a simple diagram gets you 789 00:36:43,960 --> 00:36:47,560 extra marks. Draw the Norar airway setup a 790 00:36:47,560 --> 00:36:50,280 simple line drawing of a patient's head in the lateral 791 00:36:50,280 --> 00:36:53,680 position showing the nasal cannula providing oxygen, the 792 00:36:53,680 --> 00:36:56,480 bite block in the mouth and the endoscope going in clearly 793 00:36:56,480 --> 00:36:59,680 separate from the trachea. You can also draw the flow chart 794 00:36:59,680 --> 00:37:04,680 for desaturation, A box saying PO2 falls with arrows leading to 795 00:37:04,680 --> 00:37:08,560 start procedure than to stimulate and jaw thrust, then 796 00:37:08,560 --> 00:37:11,160 to bag mass ventilate and finally to intubate. 797 00:37:11,520 --> 00:37:13,600 Visuals are powerful. Fantastic. 798 00:37:13,600 --> 00:37:16,360 OK, let's summarize this whole session for that final 15 mark 799 00:37:16,360 --> 00:37:17,800 answer. What's the checklist? 800 00:37:17,880 --> 00:37:20,880 Here is your summary checklist. Your concluding paragraph should 801 00:37:20,880 --> 00:37:22,600 hit these. Points safety standards. 802 00:37:22,840 --> 00:37:25,200 Nor are our safety standards, are identical to or are 803 00:37:25,200 --> 00:37:26,920 standards. No shortcuts are permissible. 804 00:37:26,920 --> 00:37:29,840 Pre op assessment is paramount with a specific focus on the 805 00:37:29,840 --> 00:37:33,360 airway and high risk comorbidities like OSA, cardiac 806 00:37:33,360 --> 00:37:36,080 and liver disease. The shared airway is the primary 807 00:37:36,240 --> 00:37:39,080 anesthetic challenge in EGD. Monitoring continuous 808 00:37:39,080 --> 00:37:42,000 capnography is mandatory for detecting apnea early. 809 00:37:42,200 --> 00:37:45,080 Technique. Propofol is the modern workhorse 810 00:37:45,080 --> 00:37:49,280 agent, but you must understand the entire sedation continuum 811 00:37:49,440 --> 00:37:52,960 and the synergetic respiratory depression trap with benzos and 812 00:37:52,960 --> 00:37:54,880 opioids. Complications. 813 00:37:55,280 --> 00:37:58,560 You must be prepared to manage hypoxia decisively and be ready 814 00:37:58,560 --> 00:38:01,920 to convert to a general anesthetic if patient safety is 815 00:38:01,920 --> 00:38:04,760 ever compromised. And to leave our listeners with 816 00:38:04,760 --> 00:38:07,160 something to think about. A final provocative thought. 817 00:38:07,320 --> 00:38:09,960 The debate continues and you'll see it in Stolting and Miller 818 00:38:09,960 --> 00:38:13,160 regarding non anesthesiologist administering propofol. 819 00:38:13,560 --> 00:38:17,880 Is it safe in young healthy ASA one patients? 820 00:38:17,960 --> 00:38:21,680 Maybe the data supports it, but in the sick, elderly, obese, 821 00:38:21,680 --> 00:38:25,160 complex and Nora population that we see more and more of today, 822 00:38:25,480 --> 00:38:27,800 does it compromise the fundamental safety first 823 00:38:27,800 --> 00:38:30,880 principle of our specialty? It's something to think about as 824 00:38:30,880 --> 00:38:33,000 you study and form your own professional opinion. 825 00:38:33,000 --> 00:38:35,440 That's a wrap on this deep dive. You have the notes, you have the 826 00:38:35,440 --> 00:38:36,920 strategy, and you have the mindset. 827 00:38:37,040 --> 00:38:39,920 Now go ace that exam. Safety, preparation, vigilance. 828 00:38:40,040 --> 00:38:40,600 Good luck.