1 00:00:00,040 --> 00:00:02,080 Hello and welcome back to the Deep Dive. 2 00:00:02,840 --> 00:00:06,320 Today we have a very specific, very high stakes mission. 3 00:00:06,920 --> 00:00:10,720 We're stepping directly into the shoes of a resident, you know, 4 00:00:10,720 --> 00:00:14,240 someone preparing for their MD anesthesiology exams, and we're 5 00:00:14,240 --> 00:00:17,000 zeroing in on the Gujarat University curriculum. 6 00:00:17,000 --> 00:00:18,440 Which is now for being pretty rigorous. 7 00:00:18,520 --> 00:00:20,920 Exactly. And we're looking at a topic 8 00:00:20,920 --> 00:00:24,760 that is, I think, an absolute favorite of examiners because 9 00:00:25,680 --> 00:00:27,360 looks so deceptive on the surface. 10 00:00:27,360 --> 00:00:29,280 You know, it seems simple. It's just a Scoe, right? 11 00:00:30,440 --> 00:00:34,440 But it's a minefield, a complete minefield of physiological and 12 00:00:34,840 --> 00:00:37,920 logistical challenges. So today we are doing a 13 00:00:37,960 --> 00:00:41,760 definitive deep dive into the anesthetic management for ERCP 14 00:00:41,760 --> 00:00:44,680 or endoscopic retrograde Cholango pancreatography. 15 00:00:44,840 --> 00:00:46,080 It's a mouthful. It is. 16 00:00:46,400 --> 00:00:48,640 And to help me untack all of this, to really act as our 17 00:00:48,640 --> 00:00:51,240 virtual senior faculty member and guide us through the Viva 18 00:00:51,240 --> 00:00:54,360 traps and the theory, I'm joined by our expert welcome. 19 00:00:54,360 --> 00:00:55,680 Thank you. It's great to be here. 20 00:00:55,760 --> 00:00:58,400 And you're absolutely right to frame this as a mission, because 21 00:00:58,400 --> 00:01:01,480 when you look at ERCP from an exam perspective, especially for 22 00:01:01,480 --> 00:01:04,000 a board like Gudrat Universities, you have to look 23 00:01:04,000 --> 00:01:06,520 beyond just the rocedure. It's more than just the 24 00:01:06,520 --> 00:01:08,360 technical steps. O much more. 25 00:01:08,760 --> 00:01:11,000 You're not just learning how to push propofol, you're 26 00:01:11,000 --> 00:01:14,080 demonstrating that you understand not operating room 27 00:01:14,080 --> 00:01:17,040 anesthesia or orinara. You're showing you get the 28 00:01:17,040 --> 00:01:20,480 Physiology of the prone position, the pathology of liver 29 00:01:20,480 --> 00:01:25,120 failure, and the critical importance of airway safety in a 30 00:01:25,120 --> 00:01:28,560 dark radiation filled room. A dark radiation filled room. 31 00:01:28,680 --> 00:01:31,480 That's the image. It is this is a topic where they 32 00:01:31,480 --> 00:01:33,880 test your judgement, not just your book knowledge. 33 00:01:34,400 --> 00:01:36,720 They want to know if you can think on your feet when things 34 00:01:36,720 --> 00:01:39,200 go wrong. That sets the stage perfectly. 35 00:01:39,200 --> 00:01:42,160 I think we've all been there. You see ERCP on the list for the 36 00:01:42,160 --> 00:01:44,920 next day and you think, oh nice, an easy sedation case. 37 00:01:45,440 --> 00:01:49,160 But the literature and certainly the exam questions, they suggest 38 00:01:49,160 --> 00:01:50,640 the complete opposite. They do. 39 00:01:50,720 --> 00:01:53,120 It's one of the highest risk procedures we do outside the 40 00:01:53,120 --> 00:01:55,600 operating room. OK, so let's start where every 41 00:01:55,600 --> 00:01:58,280 good exam answer should start. I'm going to break this down 42 00:01:58,280 --> 00:02:01,680 really rigidly today into parts A through H to mimic the 43 00:02:01,680 --> 00:02:04,360 structure of a, you know, a gold standard exam answer. 44 00:02:04,520 --> 00:02:07,160 Let's begin with part A, introduction and exam framing. 45 00:02:07,200 --> 00:02:09,039 Let's do it. So if I'm sitting across from 46 00:02:09,039 --> 00:02:12,880 the examiner and they just ask what is the RCP, I can't just 47 00:02:12,880 --> 00:02:16,480 say it's a scope, I need that one mark precise definition. 48 00:02:16,480 --> 00:02:19,440 What are we looking for here? Precision is absolutely key. 49 00:02:19,800 --> 00:02:22,960 You want to sound like you've read the standard texts like 50 00:02:22,960 --> 00:02:27,240 Miller, so you should define ERCP as a specialized technique, 51 00:02:27,800 --> 00:02:32,080 one that combines both endoscopy and fluoroscopy to diagnose and 52 00:02:32,080 --> 00:02:35,360 treat conditions of the biliary or pancreatic ductal systems. 53 00:02:35,360 --> 00:02:37,560 OK, endoscopy plus fluoroscopy got. 54 00:02:37,560 --> 00:02:39,960 It But here's the key phrase, the one that really gets you the 55 00:02:39,960 --> 00:02:43,040 mark is that it involves the endoscopically guided injection 56 00:02:43,040 --> 00:02:46,560 of contrast media through the duodenal papilla, specifically 57 00:02:46,560 --> 00:02:49,360 the ample of a better to visualize these ducts. 58 00:02:49,480 --> 00:02:51,280 Right. So it's that hybrid nature, part 59 00:02:51,280 --> 00:02:53,080 scope, part X-ray that really defines it. 60 00:02:53,080 --> 00:02:54,840 Exactly. And you must mention the 61 00:02:54,840 --> 00:02:59,120 contrast injection. That's the CNP in ERCP Chilencio 62 00:02:59,120 --> 00:03:00,120 pancreatography. Right. 63 00:03:00,160 --> 00:03:02,160 Of course. So for the exam, we need to 64 00:03:02,160 --> 00:03:04,600 pivot quickly from the definition to the indications. 65 00:03:04,600 --> 00:03:06,560 We can't list every single one, but we need to show we 66 00:03:06,560 --> 00:03:09,040 understand the, you know, the scope of the procedure. 67 00:03:09,160 --> 00:03:11,440 How do we categorize these effectively for a written 68 00:03:11,440 --> 00:03:13,720 answer? The best way is to divide them 69 00:03:13,720 --> 00:03:18,160 into diagnostic and therapeutic. But, and this is a big but, you 70 00:03:18,160 --> 00:03:20,960 must emphasize the therapeutic side because that's where the 71 00:03:20,960 --> 00:03:23,840 real anaesthetic challenge lies. OK, so why is that? 72 00:03:24,320 --> 00:03:27,240 Well, on the diagnostic side, you're, you know, looking at 73 00:03:27,240 --> 00:03:30,480 biliary obstruction, maybe stones, maybe strictures or 74 00:03:30,480 --> 00:03:32,360 you're investigating A pancreatic mass. 75 00:03:32,440 --> 00:03:35,440 That's fairly straightforward. But the examiner's much more 76 00:03:35,440 --> 00:03:38,760 interested in the therapeutic maneuvers like what things like 77 00:03:38,880 --> 00:03:42,400 sphincterotomy where they're cutting the sphincteravati or 78 00:03:42,400 --> 00:03:47,600 placing A stent to relieve jaundice or stone extraction and 79 00:03:47,600 --> 00:03:50,160 even laser liltotripsy to break up a large stone. 80 00:03:50,560 --> 00:03:53,640 These are the things that turn a diagnostic look see into It is 81 00:03:53,640 --> 00:03:55,080 effectively A surgical procedure. 82 00:03:55,080 --> 00:03:58,520 With surgical risks, precisely. Risks of bleeding, perforation, 83 00:03:58,800 --> 00:04:01,280 pancreatitis. If a student only lists 84 00:04:01,280 --> 00:04:03,440 diagnosis of jaundice, they've missed the whole point. 85 00:04:03,760 --> 00:04:06,320 The point is that we're often actively intervening and that's 86 00:04:06,320 --> 00:04:08,920 why they need us there. Which leads us directly to the 87 00:04:08,920 --> 00:04:11,000 why? You know why is this such a high 88 00:04:11,000 --> 00:04:14,600 yield exam topic? Why do examiners seem to love 89 00:04:14,600 --> 00:04:17,959 asking about ERCP? Because it's the perfect storm. 90 00:04:18,360 --> 00:04:19,880 I mean think about it from their perspective. 91 00:04:19,880 --> 00:04:22,520 You've got 3 high risk components all rolled into one. 92 00:04:22,880 --> 00:04:24,560 First you have the patient factor. 93 00:04:24,640 --> 00:04:27,280 The patient is likely sick. They might have obstructive 94 00:04:27,280 --> 00:04:30,120 jaundice, cholangitis, maybe even full blown sepsis. 95 00:04:30,120 --> 00:04:31,960 OK, so a sick patient. That's box 1. 96 00:04:31,960 --> 00:04:33,800 Box 2 is the environmental factor. 97 00:04:33,920 --> 00:04:35,840 You're placing them in a hazardous environment. 98 00:04:35,840 --> 00:04:39,480 The Nora setting, it's dark, there's radiation, so you're 99 00:04:39,480 --> 00:04:42,920 wearing lead, the machine is huge and you're crowded out by 100 00:04:42,920 --> 00:04:44,880 the gastroenterology team and their equipment. 101 00:04:45,160 --> 00:04:47,400 You're often literally pushed into a corner. 102 00:04:47,440 --> 00:04:50,200 You are. And finally, the third box, the 103 00:04:50,200 --> 00:04:54,760 rocedural factor, the position. The patient is almost always 104 00:04:54,760 --> 00:04:57,800 prone or semi prone. So you put it all together. 105 00:04:58,000 --> 00:05:01,320 You have a sick patient face down in the dark, sharing an 106 00:05:01,320 --> 00:05:04,440 airway with a gastroenterologist who is actively manipulating a 107 00:05:04,440 --> 00:05:07,320 large scope in their pharynx. When you put it like that, it 108 00:05:07,320 --> 00:05:09,960 sounds terrifying. It should be respected because 109 00:05:09,960 --> 00:05:12,920 if you lose that airway, you are in serious, serious trouble. 110 00:05:12,920 --> 00:05:14,480 That's why examiners ask about it. 111 00:05:14,480 --> 00:05:16,240 They want to know if you respect that risk. 112 00:05:16,480 --> 00:05:19,560 A sick patient face down in the dark. 113 00:05:20,120 --> 00:05:23,600 That's the mantra before we move on from the framing. 114 00:05:23,960 --> 00:05:26,000 How does this usually appear in the exam? 115 00:05:26,160 --> 00:05:29,040 What formats should you, the listener, be preparing for? 116 00:05:29,200 --> 00:05:31,200 You need to be ready for three main formats. 117 00:05:31,200 --> 00:05:34,400 First, the short note. This is usually titled something 118 00:05:34,400 --> 00:05:39,240 like Anesthetic challenges in ERCP or Nora for ERCP, pretty 119 00:05:39,560 --> 00:05:41,760 straightforward. Second, you can get a long 120 00:05:41,760 --> 00:05:45,520 question or a structured question for maybe 10 or 15 121 00:05:45,520 --> 00:05:47,080 marks. That will be a clinical 122 00:05:47,080 --> 00:05:49,520 scenario. Discuss the anesthetic 123 00:05:49,520 --> 00:05:53,280 management of a 60 year old male with obstructive jaundice posted 124 00:05:53,280 --> 00:05:56,000 for ERCP. Right, the classic case based 125 00:05:56,000 --> 00:06:00,160 question. And 3rd the Viva or the OK CE? 126 00:06:00,440 --> 00:06:03,160 And in the Viva it will almost always focus on your decision 127 00:06:03,160 --> 00:06:05,080 making. They'll ask why did you choose 128 00:06:05,080 --> 00:06:09,320 general anesthesia over sedation for this patient Or your patient 129 00:06:09,320 --> 00:06:11,560 saturation suddenly drops to 85%. 130 00:06:11,680 --> 00:06:13,480 What do you do? They want to see your thought 131 00:06:13,480 --> 00:06:15,720 process under pressure. So you need to be versatile, you 132 00:06:15,720 --> 00:06:17,800 need the book knowledge for the written and the clinical 133 00:06:17,800 --> 00:06:19,280 reasoning for the Viva. That's it exactly. 134 00:06:19,280 --> 00:06:21,120 Excellent. Let's move into Part B 135 00:06:21,120 --> 00:06:22,800 procedural and patient challenges. 136 00:06:22,800 --> 00:06:26,040 And this is the absolutely essential section according to 137 00:06:26,040 --> 00:06:28,000 our outline. Let's start with the position 138 00:06:28,000 --> 00:06:30,440 you mentioned prone. Why is the prone position such a 139 00:06:30,440 --> 00:06:34,040 specific physiological problem for us in this context? 140 00:06:34,120 --> 00:06:37,960 The prone position is it's technically demanding and it's 141 00:06:38,080 --> 00:06:41,200 physiologically altering. As you'll read in Morgan or 142 00:06:41,200 --> 00:06:44,920 Miller, ERCP is usually performed prone or in the 143 00:06:44,920 --> 00:06:48,960 swimmer's position which is semi prone to allow the endoscopist 144 00:06:48,960 --> 00:06:51,920 better orientation for cannulating the biliary duct. 145 00:06:52,040 --> 00:06:53,440 So it's for their benefit, not ours. 146 00:06:53,600 --> 00:06:56,800 Never for ours. Physiologically, this completely 147 00:06:56,800 --> 00:06:58,400 changes the mechanics of breathing. 148 00:06:59,200 --> 00:07:02,360 When a patient is prone, their chest wall and their anterior 149 00:07:02,360 --> 00:07:04,960 abdominal wall are bearing weight because it restricts 150 00:07:04,960 --> 00:07:06,680 their movement. So what happens to chest wall 151 00:07:06,680 --> 00:07:08,280 compliance? It has to decrease. 152 00:07:08,280 --> 00:07:11,080 It decreases significantly. So practically speaking, that 153 00:07:11,080 --> 00:07:13,720 means you need to push harder. You need higher pressures to get 154 00:07:13,720 --> 00:07:15,800 the same volume of air into the lungs. 155 00:07:16,040 --> 00:07:18,280 Exactly. You're going to see higher peak 156 00:07:18,360 --> 00:07:22,240 airway pressures to achieve the same tidal volume, but it goes 157 00:07:22,240 --> 00:07:24,000 deeper than that. Think about the abdomen. 158 00:07:24,560 --> 00:07:28,160 If the abdomen is compressed, it pushes the diaphragm cephalid up 159 00:07:28,160 --> 00:07:30,520 towards the head. Which compresses the bases of 160 00:07:30,520 --> 00:07:31,360 the lungs. Right. 161 00:07:31,560 --> 00:07:34,800 And that reduces your functional residual capacity, your FRC. 162 00:07:35,280 --> 00:07:38,760 This is the critical part. If your FRC drops below your 163 00:07:38,760 --> 00:07:42,240 closing capacity, the small Airways in the dependent parts 164 00:07:42,240 --> 00:07:46,160 of the lungs start to collapse. That creates atelectasis in 165 00:07:46,160 --> 00:07:48,760 shunting. And shunting means VQ mismatch 166 00:07:48,760 --> 00:07:51,160 and hypoxia. And that's why these patients 167 00:07:51,160 --> 00:07:53,720 can desaturate so quickly if they aren't being ventilated 168 00:07:53,720 --> 00:07:55,640 properly, it's a set up for failure. 169 00:07:55,640 --> 00:07:58,600 OK, that's the Physiology. What about the logistical issue? 170 00:07:58,600 --> 00:08:01,040 The practical problem. This is the examination core 171 00:08:01,040 --> 00:08:02,920 point. Limited access. 172 00:08:03,080 --> 00:08:06,240 Once that patient is turned over and draped, you cannot easily 173 00:08:06,240 --> 00:08:08,760 access the airway. You can't see the face, you 174 00:08:08,760 --> 00:08:11,720 can't see the eyes to check for pressure, and you certainly 175 00:08:11,720 --> 00:08:13,360 can't do effective chest compressions. 176 00:08:13,360 --> 00:08:15,480 It's a huge commitment turning them prone. 177 00:08:15,760 --> 00:08:20,160 It is if the endotracheal tube dislodges or if a patient under 178 00:08:20,160 --> 00:08:23,160 sedation obstructs. You can't just fix it quickly. 179 00:08:23,280 --> 00:08:26,280 You can't just pop in an LMA or do a jaw thrust easily. 180 00:08:26,520 --> 00:08:29,040 You have to stop the entire procedure, get everyone's help 181 00:08:29,360 --> 00:08:32,039 and turn them over in an exam answer. 182 00:08:32,200 --> 00:08:36,400 You have to use the words remote and inaccessible when describing 183 00:08:36,400 --> 00:08:38,320 the airway. Remote and inaccessible. 184 00:08:38,320 --> 00:08:40,799 Got it. Let's talk about the duration of 185 00:08:40,799 --> 00:08:42,880 the procedure. Is it predictable? 186 00:08:43,120 --> 00:08:45,400 Not at all, and that's another major challenge. 187 00:08:45,760 --> 00:08:49,440 A simple stent exchange might take 20 minutes, but a complex 188 00:08:49,440 --> 00:08:51,720 lithotripsy or a really difficult cannulation where they 189 00:08:51,720 --> 00:08:55,040 just can't find the duct, that can take 2, maybe 3 hours. 190 00:08:55,080 --> 00:08:57,640 So you're stuck in this limbo. Total limbo, the 191 00:08:57,640 --> 00:08:59,240 gastroenterologist is always saying. 192 00:08:59,440 --> 00:09:01,600 Just five more minutes, and that can go on for hours. 193 00:09:01,840 --> 00:09:05,240 This unpredictability makes sedation titration incredibly 194 00:09:05,240 --> 00:09:07,440 difficult. If you give a large bolus of 195 00:09:07,440 --> 00:09:10,000 propofol thinking it's ending, and then they decide to do 196 00:09:10,000 --> 00:09:11,560 something else, you could have an apnea. 197 00:09:11,560 --> 00:09:15,160 Patient or the opposite you underdose the patient moves at a 198 00:09:15,160 --> 00:09:17,240 critical. And they cause a perforation. 199 00:09:17,520 --> 00:09:19,400 Exactly. It's a very fine line to walk. 200 00:09:19,760 --> 00:09:22,080 And we're doing all of this in the Nora environment. 201 00:09:22,080 --> 00:09:24,600 You know we aren't in our comfortable OT with bright 202 00:09:24,600 --> 00:09:27,520 lights and all our gear perfectly arranged on booms. 203 00:09:27,520 --> 00:09:31,160 No, this is non operating room anesthesia at its most 204 00:09:31,160 --> 00:09:33,640 challenging. The room is darkened for the 205 00:09:33,640 --> 00:09:36,080 fluoroscopy. You're wearing a heavy lead 206 00:09:36,080 --> 00:09:38,600 apron, which is fatiguing over a long case. 207 00:09:39,200 --> 00:09:41,680 Your anaesthetic machine is often pushed to the foot end of 208 00:09:41,680 --> 00:09:45,000 the bed or to the side to make room for the sea arm and the big 209 00:09:45,000 --> 00:09:47,640 endoscopy tower. So your own equipment is remote 210 00:09:47,640 --> 00:09:48,920 too. Your equipment is remote. 211 00:09:48,920 --> 00:09:51,080 Your patient is remote. Your airway is remote. 212 00:09:51,520 --> 00:09:55,000 Miller's chapter in Nora really emphasizes that close claims 213 00:09:55,000 --> 00:09:58,560 analysis, you know, lawsuits, shows a much higher proportion 214 00:09:58,560 --> 00:10:01,840 of death and permanent brain damage in Nora settings compared 215 00:10:01,840 --> 00:10:03,760 to the OR. Wow, why is that? 216 00:10:03,960 --> 00:10:06,640 It often comes down to inadequate oxygenation and 217 00:10:06,640 --> 00:10:08,600 ventilation that just wasn't caught in time. 218 00:10:09,240 --> 00:10:12,200 The dark room mentality, the noise, the distractions can lead 219 00:10:12,200 --> 00:10:14,880 to missed clinical signs you can't see, subtle chest 220 00:10:14,880 --> 00:10:16,720 movements. You rely entirely on your 221 00:10:16,720 --> 00:10:19,920 monitors. O we have a difficult position 222 00:10:19,920 --> 00:10:22,640 and a difficult room. Now let's add the third piece, 223 00:10:23,080 --> 00:10:25,000 the difficult patient we mentioned jaundice. 224 00:10:25,320 --> 00:10:28,640 What are the specific patient related risk factors we need to 225 00:10:28,640 --> 00:10:31,560 flag for the exam? The big one, the one you must 226 00:10:31,560 --> 00:10:35,120 discuss, is obstructive jaundice and the associated liver 227 00:10:35,120 --> 00:10:38,200 dysfunction, and the first thing that should come to mind is 228 00:10:38,200 --> 00:10:40,040 Coagulopathy. OK, bleeding risk. 229 00:10:40,080 --> 00:10:41,680 Right. Patients with biliary 230 00:10:41,680 --> 00:10:44,880 obstruction can't absorb fat soluble vitamins from their gut. 231 00:10:45,200 --> 00:10:49,040 Vitamin K is fat soluble, so they develop a deficiency in the 232 00:10:49,240 --> 00:10:53,000 vitamin K dependent clotting factors 27 I and X. 233 00:10:53,160 --> 00:10:56,120 So their INR goes up. Their INR goes up, but here is 234 00:10:56,120 --> 00:10:58,280 the nuance. For the high scoring candidate, 235 00:10:58,440 --> 00:11:01,720 you must mention the concept of rebalanced hemostasis. 236 00:11:01,720 --> 00:11:04,480 Rebalanced hemostasis, OK, unpack that for us because 237 00:11:04,600 --> 00:11:07,760 historically we just looked at the INR and you know, panicked. 238 00:11:08,080 --> 00:11:09,200 Right. And we still need to be 239 00:11:09,200 --> 00:11:12,040 cautious. But the historical view was, oh, 240 00:11:12,040 --> 00:11:15,400 the INR is high, they're anticoagulated, they will bleed. 241 00:11:15,720 --> 00:11:19,240 But newer evidence, which is discussed in text like Miller, 242 00:11:19,520 --> 00:11:22,440 suggests that while they're pro coagulant factors are low, 243 00:11:22,680 --> 00:11:25,600 They're anticoagulant. Proteins like Protein C and 244 00:11:25,600 --> 00:11:29,280 protein S are also low because they're made in the liver, too. 245 00:11:29,280 --> 00:11:32,440 So the whole system is down regulated, but it's balanced. 246 00:11:32,440 --> 00:11:35,080 It's rebalanced, yes, but it's a fragile balance. 247 00:11:35,480 --> 00:11:37,880 In the exam you must still acknowledge the clinical 248 00:11:37,880 --> 00:11:40,560 bleeding risk. If the INR significantly 249 00:11:40,560 --> 00:11:44,880 prolonged, say over 1.5, you still treat it with vitamin K, 250 00:11:45,760 --> 00:11:47,760 but you should mention this concept to show a deeper 251 00:11:47,760 --> 00:11:49,400 understanding. Very good point. 252 00:11:49,640 --> 00:11:52,440 We also see sepsis mentioned a lot in the sources, specifically 253 00:11:52,440 --> 00:11:55,080 cholingitis. Yes, and you should know Charcos 254 00:11:55,080 --> 00:11:56,720 triad. Can you name the components? 255 00:11:57,120 --> 00:12:00,560 Fever, jaundice, and right upper quadrant pain. 256 00:12:00,560 --> 00:12:02,280 Perfect. If your patient presents with 257 00:12:02,280 --> 00:12:04,880 that triad, they have ascending cholangitis, They are septic. 258 00:12:04,920 --> 00:12:07,000 And what does sepsis do to your hemodynamics? 259 00:12:07,080 --> 00:12:10,720 It causes massive vasodilation. They're peripherally shut down 260 00:12:10,720 --> 00:12:13,720 but centrally vasodilated, so they're SVRS in the boots. 261 00:12:14,040 --> 00:12:17,960 Exactly, they are vasodilated and hemodynamically unstable. 262 00:12:18,360 --> 00:12:21,240 Now imagine inducing anesthesia in that patient, especially when 263 00:12:21,240 --> 00:12:23,160 they're prone. It's a hemodynamic tightrope. 264 00:12:23,360 --> 00:12:25,800 You give a little bit of propofol, there are systemic 265 00:12:25,800 --> 00:12:28,000 vascular resistance drops off a Cliff, and because they're 266 00:12:28,000 --> 00:12:30,960 already volume depleted from this sepsis, they crash. 267 00:12:31,120 --> 00:12:34,160 It's a recipe for profound hypotension. 268 00:12:34,200 --> 00:12:38,000 It is, and if the examiner mentions Reynolds pentad that 269 00:12:38,000 --> 00:12:40,840 adds hypotension and altered mental status to the triad. 270 00:12:41,080 --> 00:12:43,160 That means the patient is in septic shock. 271 00:12:43,640 --> 00:12:46,960 That is a huge red flag that screams resuscitate before you 272 00:12:46,960 --> 00:12:49,240 sedate. Resuscitate before you sedate. 273 00:12:49,240 --> 00:12:52,360 I like that, and I imagine obesity plays a pretty big role 274 00:12:52,360 --> 00:12:53,000 here too. A. 275 00:12:53,000 --> 00:12:56,840 Huge role obesity and obstructive sleep apnea, or OSA. 276 00:12:57,200 --> 00:13:00,360 Miller flags these as high risk predictors for sedation failure. 277 00:13:00,720 --> 00:13:03,720 If you try to sedate an obese patient with OSA in the prone 278 00:13:03,720 --> 00:13:06,200 position, it's a disaster waiting to happen. 279 00:13:06,240 --> 00:13:08,520 Why specifically? Their heavy chest wall 280 00:13:08,520 --> 00:13:11,880 compresses the lungs, they're already reduced FRC drops even 281 00:13:11,880 --> 00:13:14,800 further, their pharyngeal tissues collapse the moment they 282 00:13:14,800 --> 00:13:18,200 get sedated, and you can't get to their jaw to do a jaw thrust 283 00:13:18,200 --> 00:13:21,000 because they're face down. These are the patients where you 284 00:13:21,000 --> 00:13:23,760 should be thinking about securing the airway with an ETT 285 00:13:23,960 --> 00:13:27,480 from the very start. It sounds like for obese OSAGA 286 00:13:27,480 --> 00:13:30,320 is almost mandatory. In my opinion, for an exam 287 00:13:30,320 --> 00:13:33,400 answer, it absolutely is. The risk of sedation is just too 288 00:13:33,400 --> 00:13:35,320 high. OK, so we have framed the 289 00:13:35,320 --> 00:13:37,480 problem beautifully. Now let's move to the solution 290 00:13:37,640 --> 00:13:41,400 part C, preoperative assessment. The examiner asks, how do you 291 00:13:41,400 --> 00:13:43,720 evaluate this patient? We can't just say history and 292 00:13:43,720 --> 00:13:46,040 physical. We need to be specific and 293 00:13:46,040 --> 00:13:48,280 structured. Correct, you need an ERCP 294 00:13:48,280 --> 00:13:50,840 specific structured approach. You start with the airway, 295 00:13:51,160 --> 00:13:54,240 Morgan's text emphasizes this is absolutely mandatory. 296 00:13:54,520 --> 00:13:56,760 You're looking for the usual predictors of difficult 297 00:13:57,000 --> 00:14:00,040 laryngoscopy, Mamelopodi score, thyrimental sense, neck 298 00:14:00,040 --> 00:14:01,920 movement. But there's a twist. 299 00:14:02,080 --> 00:14:04,560 What's the twist? You're not just asking can I 300 00:14:04,560 --> 00:14:07,200 intubate this patient? You have to ask yourself if I 301 00:14:07,200 --> 00:14:10,000 lose this airway while they are prone, can I rescue it? 302 00:14:10,600 --> 00:14:14,440 If the answer is maybe not, then you have a very low threshold to 303 00:14:14,440 --> 00:14:16,480 intubate them electively at the beginning. 304 00:14:16,800 --> 00:14:19,320 So the rescue potential is the key factor. 305 00:14:19,360 --> 00:14:21,240 It is. You also need to check mouth 306 00:14:21,240 --> 00:14:23,160 opening. It needs to be greater than 3 307 00:14:23,160 --> 00:14:25,920 centimeters, not just for your laryngoscope, but for the 308 00:14:25,920 --> 00:14:27,600 endoscope itself to pass easily. Good. 309 00:14:27,720 --> 00:14:31,040 Point And what about the liver and coagulation assessment that 310 00:14:31,040 --> 00:14:33,640 we just touched on? What specific tests are we 311 00:14:33,640 --> 00:14:35,720 ordering? You want a full liver panel, 312 00:14:36,040 --> 00:14:39,280 bilirubin, obviously, to assess the degree of obstruction. 313 00:14:39,800 --> 00:14:42,400 Albumin is crucial because it tells you about the synthetic 314 00:14:42,400 --> 00:14:45,200 function of the liver. How well is it actually making 315 00:14:45,200 --> 00:14:47,800 proteins. A low albumin is a sign of 316 00:14:47,800 --> 00:14:49,720 chronic liver disease and malnutrition. 317 00:14:50,280 --> 00:14:52,960 And of course the INR. And what's our trigger point for 318 00:14:52,960 --> 00:14:54,360 the INR? When do we act? 319 00:14:54,680 --> 00:14:59,240 If the INR is prolonged, say greater than 1.5, the source 320 00:14:59,240 --> 00:15:02,080 material specifically attacks like long and short cases, 321 00:15:02,440 --> 00:15:06,400 advises administering vitamin K, usually 10 milligram, and you'd 322 00:15:06,400 --> 00:15:09,280 want to give it for one to three days preoperatively if you have 323 00:15:09,280 --> 00:15:11,120 the time. If it's an emergency, you might 324 00:15:11,120 --> 00:15:12,760 need fresh frozen plasma. OK. 325 00:15:12,960 --> 00:15:15,600 What about the renal side? You mentioned a specific renal 326 00:15:15,600 --> 00:15:18,400 risk with jaundice. Yes, hepatorenal syndrome. 327 00:15:18,960 --> 00:15:21,720 This is a fascinating bit of Physiology and a great thing to 328 00:15:21,720 --> 00:15:22,720 mention. In Aviva. 329 00:15:23,240 --> 00:15:26,640 These patients are very prone to acute kidney injury and it's 330 00:15:26,640 --> 00:15:29,120 driven by endotoxemia. Endotoxemia. 331 00:15:29,240 --> 00:15:33,400 Yes, normally bile salts in the gut blind endotoxins from gut 332 00:15:33,400 --> 00:15:36,520 bacteria. In obstructed jaundice, no bile 333 00:15:36,520 --> 00:15:39,520 reaches the gut, so these endotoxins are absorbed into the 334 00:15:39,520 --> 00:15:41,720 portal circulation. They trigger a massive 335 00:15:41,720 --> 00:15:44,160 inflammatory response which causes intense renal 336 00:15:44,160 --> 00:15:46,560 vasoconstriction. Combine that with a hypotension 337 00:15:46,560 --> 00:15:49,520 from sepsis or your induction agents and the kidneys just shut 338 00:15:49,520 --> 00:15:51,640 down. That's a deadly combination. 339 00:15:51,640 --> 00:15:54,080 Is there a preventative step we can mention to impress the 340 00:15:54,080 --> 00:15:55,480 examiner? Absolutely. 341 00:15:55,600 --> 00:15:58,720 First you check their baseline creatinine and electrolytes. 342 00:15:59,560 --> 00:16:01,840 But a high level detail mentioned in long and short 343 00:16:01,840 --> 00:16:05,160 cases is the preoperative administration of Lactulose or 344 00:16:05,160 --> 00:16:07,200 oral bile salts. And how does that help? 345 00:16:07,760 --> 00:16:10,760 It binds the endotoxins in the gut, preventing their 346 00:16:10,760 --> 00:16:14,040 absorption. It's a very specific, proactive 347 00:16:14,040 --> 00:16:17,440 measure that can reduce the risk of postoperative renal failure. 348 00:16:18,280 --> 00:16:21,120 It shows you're thinking about the pathophysiology, not just 349 00:16:21,120 --> 00:16:24,200 the anesthetic drugs. That is a fantastic clinical 350 00:16:24,200 --> 00:16:26,200 parole. Now here's a concept that comes 351 00:16:26,200 --> 00:16:27,680 up again and again in the sources. 352 00:16:27,680 --> 00:16:30,200 The full stomach. Even if these patients have 353 00:16:30,200 --> 00:16:32,200 followed fasting guidelines, are they really? 354 00:16:32,200 --> 00:16:34,040 Empty. No, and this is a major Viva 355 00:16:34,040 --> 00:16:35,680 trap. The examiner might say the 356 00:16:35,680 --> 00:16:38,040 patient has been nil by mouth for 8 hours. 357 00:16:38,280 --> 00:16:40,080 Is it safe to proceed with sedation? 358 00:16:40,840 --> 00:16:42,840 And the safe answer is to express caution. 359 00:16:42,920 --> 00:16:44,560 Why? For several reasons. 360 00:16:44,840 --> 00:16:48,160 As a text like Yowen Artuzio points out, these patients often 361 00:16:48,160 --> 00:16:51,440 have delayed gastric emptying or gastroparesis from their 362 00:16:51,440 --> 00:16:53,560 underlying illness, or they might have a functional bowel 363 00:16:53,560 --> 00:16:55,800 obstruction. Furthermore, during a procedure 364 00:16:55,800 --> 00:16:58,560 itself, the endoscopist insufflates the stomach with 365 00:16:58,560 --> 00:17:00,760 either air or CO2 to visualize it. 366 00:17:01,000 --> 00:17:03,880 So even if they were empty at the start, they become full of 367 00:17:03,880 --> 00:17:06,560 gas during the case. Exactly, they are functionally 368 00:17:06,560 --> 00:17:08,960 full. If that patient coughs or gags, 369 00:17:08,960 --> 00:17:12,119 they can regurgitate a large volume of gas and acidic fluid. 370 00:17:12,760 --> 00:17:15,960 So the safest exam answer, the one you should always give, is I 371 00:17:15,960 --> 00:17:19,359 would treat all ERCP patients as potentially having a full 372 00:17:19,359 --> 00:17:22,720 stomach. Aspiration is a leading cause of 373 00:17:22,720 --> 00:17:27,319 medical legal claims in NORAR. That's a clear, unambiguous 374 00:17:27,319 --> 00:17:29,480 directive. Treat as a full stomach. 375 00:17:30,520 --> 00:17:33,680 That brings us perfectly to Part D choice of anesthesia. 376 00:17:34,120 --> 00:17:36,400 This seems to be the biggest debate in clinical practice. 377 00:17:36,800 --> 00:17:40,200 Sedation versus general anesthesia for the exam. 378 00:17:40,200 --> 00:17:41,600 How do we structure this discussion? 379 00:17:42,120 --> 00:17:45,080 You need to present a balanced view, but you must lean heavily 380 00:17:45,080 --> 00:17:47,120 towards safety, especially for the exam. 381 00:17:47,440 --> 00:17:50,160 Let's look at sedation first. This is usually moderate or deep 382 00:17:50,160 --> 00:17:51,840 sedation, almost always with propofol. 383 00:17:52,240 --> 00:17:54,960 The pros are obvious, it's faster, turnover for the unit is 384 00:17:54,960 --> 00:17:57,840 less invasive, and patients tend to recover and go home quicker. 385 00:17:58,000 --> 00:18:01,800 But the cons are significant and you need to quote this Miller 386 00:18:01,800 --> 00:18:04,320 sites data showing that procedural failure rates for 387 00:18:04,320 --> 00:18:08,640 ERCP are twice as high for patients under sedation compared 388 00:18:08,640 --> 00:18:10,520 to those under general anesthesia. 389 00:18:10,600 --> 00:18:12,840 Twice as high. That's a massive difference. 390 00:18:12,840 --> 00:18:14,920 What's the reason for that? The patient moves. 391 00:18:15,200 --> 00:18:18,960 It's as simple as that. If the patient coughs, gags, or 392 00:18:18,960 --> 00:18:22,960 moves while the endoscopist is trying to cannulate a tiny 2mm 393 00:18:22,960 --> 00:18:26,240 duct, they fail. Or worse, they cause a 394 00:18:26,240 --> 00:18:29,480 perforation or pancreatitis. And then there's the respiratory 395 00:18:29,480 --> 00:18:31,240 risk. If you deepen the sedation to 396 00:18:31,240 --> 00:18:32,840 stop them from moving, what happens? 397 00:18:32,840 --> 00:18:35,000 They stop breathing, They stop breathing, and they're prone. 398 00:18:35,080 --> 00:18:37,840 So you're caught in this very narrow, very dangerous 399 00:18:37,840 --> 00:18:39,280 therapeutic window. OK. 400 00:18:39,280 --> 00:18:42,720 So that's a strong case against sedation in complex cases. 401 00:18:43,160 --> 00:18:46,400 Let's talk about the alternative general anesthesia with 402 00:18:46,400 --> 00:18:48,240 endotracheal intubation. Right. 403 00:18:48,640 --> 00:18:52,080 The primary advantage of GA is a secure, protected airway. 404 00:18:52,360 --> 00:18:55,120 You have absolutely control of their ventilation, which is 405 00:18:55,120 --> 00:18:57,320 crucial because the CO2 insufflation can cause 406 00:18:57,320 --> 00:18:59,280 significant hypercarbia if it's not managed. 407 00:18:59,960 --> 00:19:03,160 You provide total immobility, which makes the endoscopist job 408 00:19:03,200 --> 00:19:05,720 easier and dramatically increases success rates. 409 00:19:05,720 --> 00:19:08,080 And the downsides? The downside is it takes more 410 00:19:08,080 --> 00:19:10,400 time. You got an extra 10 to 15 411 00:19:10,400 --> 00:19:14,040 minutes for induction and wake up, and you do risk hemodynamic 412 00:19:14,040 --> 00:19:16,320 instability on induction, which we've already discussed. 413 00:19:16,840 --> 00:19:19,440 However, for the exam, the most important thing you need to know 414 00:19:19,440 --> 00:19:22,320 is the indications. For GA, if the examiner asks 415 00:19:22,320 --> 00:19:25,760 when do you intubate, you need a clear, concise list. 416 00:19:25,760 --> 00:19:27,880 OK, let's have that list. This is an exam favorite 417 00:19:27,880 --> 00:19:30,480 section. What are the absolute triggers 418 00:19:30,480 --> 00:19:33,120 for GA and ERCP? According to a source like 419 00:19:33,120 --> 00:19:37,800 Miller, you should plan for and strongly recommend GA if #1 the 420 00:19:37,800 --> 00:19:39,520 patient has a high aspiration risk. 421 00:19:40,000 --> 00:19:42,200 This includes known gastroparesis, bowel 422 00:19:42,200 --> 00:19:44,720 obstruction, active GI bleeding, you name it. 423 00:19:44,960 --> 00:19:46,280 OK. Aspiration risk. 424 00:19:46,600 --> 00:19:51,280 Two uncooperative patients or those with extreme anxiety. 425 00:19:51,880 --> 00:19:55,520 You simply cannot sedate A combative or agitated patient 426 00:19:55,520 --> 00:19:57,800 safely in the prone position. It's impossible. 427 00:19:57,800 --> 00:20:01,720 That makes sense. 3 prolonged or complex therapeutic procedures. 428 00:20:02,160 --> 00:20:03,800 If they tell you they're planning a pancreatic 429 00:20:03,800 --> 00:20:06,560 necrospectomy, a difficult stone extraction, or treating a 430 00:20:06,560 --> 00:20:09,000 pseudocyst, don't even think about sedation. 431 00:20:09,400 --> 00:20:12,720 If it's likely to take more than, say, 90 minutes, just plan 432 00:20:12,720 --> 00:20:16,400 for Aga, right? Be proactive. 4 Human dynamic 433 00:20:16,400 --> 00:20:19,360 instability, like an aseptic patient securing the airway, 434 00:20:19,360 --> 00:20:21,520 allows you to focus all your attention on managing their 435 00:20:21,520 --> 00:20:23,880 circulation without also worrying about respiratory 436 00:20:23,880 --> 00:20:27,440 depression. And five, A history of failed 437 00:20:27,440 --> 00:20:30,240 sedation in previous attempts. OK, that's a solid list of five. 438 00:20:30,320 --> 00:20:32,880 And I would add a 6th which we've discussed significant 439 00:20:32,880 --> 00:20:36,680 obesity and OSA for me in exam setting that's an absolute 440 00:20:36,680 --> 00:20:40,160 indication airway protection in that group is non negotiable. 441 00:20:40,240 --> 00:20:42,360 Airway protection is non negotiable. 442 00:20:42,920 --> 00:20:45,200 I like that phrase. OK, so we've decided on our 443 00:20:45,200 --> 00:20:47,320 technique. Let's say we're doing Aga for a 444 00:20:47,320 --> 00:20:50,280 complex case. We moved to part E 445 00:20:50,280 --> 00:20:52,160 intraoperative anesthetic management. 446 00:20:52,560 --> 00:20:54,720 Walk us through the airway strategy from the top. 447 00:20:55,320 --> 00:21:00,280 The Golden Rule, the absolute unbreakable rule, is secure the 448 00:21:00,280 --> 00:21:03,640 airway supine. Never let anyone, the surgeon, 449 00:21:03,640 --> 00:21:07,760 the nurse, anyone talk you into turning the patient prone before 450 00:21:07,760 --> 00:21:10,120 you have definitive control of that airway. 451 00:21:10,280 --> 00:21:13,080 So on the stretcher or the table, but flat on their back. 452 00:21:13,080 --> 00:21:15,880 Flat on their back. You induce, you intubate, you 453 00:21:15,880 --> 00:21:18,760 confirm tube placement with bilateral air entry and, 454 00:21:18,760 --> 00:21:20,600 crucially, A capnograph waveform. 455 00:21:20,640 --> 00:21:22,960 Then you tape that tube like your life depends on it, because 456 00:21:22,960 --> 00:21:25,240 the patient's does. Then, and only then, do you 457 00:21:25,240 --> 00:21:28,160 coordinate a slow, careful turn to the prone position with the 458 00:21:28,160 --> 00:21:30,440 entire team. What about superglottic Airways? 459 00:21:30,440 --> 00:21:32,680 I see Lmas use sometimes. Where do they fit in? 460 00:21:32,760 --> 00:21:35,480 The sources like Morgan and other review articles are very 461 00:21:35,480 --> 00:21:37,520 cautious here. Can you use an LMA? 462 00:21:37,920 --> 00:21:41,640 Technically yes, in highly selected low risk cases, a short 463 00:21:41,640 --> 00:21:43,920 simple procedure and a slim fasted patient. 464 00:21:44,400 --> 00:21:46,280 But you have to tell the examiner the risks, which are 465 00:21:46,360 --> 00:21:50,080 the patient is prone. The LMA can easily be dislodged 466 00:21:50,080 --> 00:21:53,080 or rotated during the turn or by the pressure of the endoscoe 467 00:21:53,120 --> 00:21:55,240 itself. If that happens, you can't fix 468 00:21:55,240 --> 00:21:58,240 it easily. Also, and this is critical, a 469 00:21:58,240 --> 00:22:01,440 standard LMA does not offer full protection against aspiration 470 00:22:01,680 --> 00:22:04,120 and we've already established that these patients are at high 471 00:22:04,120 --> 00:22:05,960 risk from the gastric distention. 472 00:22:06,360 --> 00:22:08,320 So for a high stakes exam answer. 473 00:22:08,320 --> 00:22:11,000 For a high stakes exam answer, endotracheal intubation is the 474 00:22:11,000 --> 00:22:13,600 gold standard. For any complex or high risk, 475 00:22:13,600 --> 00:22:16,440 ERCP is a safe, defensible answer. 476 00:22:16,440 --> 00:22:18,440 Got it. ETT is the safe answer. 477 00:22:18,640 --> 00:22:21,880 Now monitoring, we're in that dark room, we can't see the 478 00:22:21,880 --> 00:22:24,120 patient's chest rise and fall very well. 479 00:22:24,200 --> 00:22:26,880 Which is precisely why capttography is mandatory. 480 00:22:27,280 --> 00:22:29,280 Miller's absolutely emphatic on this. 481 00:22:29,280 --> 00:22:32,520 In the Nora section, in a dark room with a patient covered in 482 00:22:32,520 --> 00:22:35,840 lead aprons and surgical drapes, the captagraph is your lifeline. 483 00:22:36,040 --> 00:22:38,920 It is your earliest indicator of apnea, obstruction or 484 00:22:38,920 --> 00:22:40,720 disconnection. And it tells you about more than 485 00:22:40,720 --> 00:22:42,480 just ventilation, right? It does. 486 00:22:42,960 --> 00:22:44,360 It also tells you about perfusion. 487 00:22:44,760 --> 00:22:47,960 If your cardiac output suddenly drops, like from an air embolism 488 00:22:47,960 --> 00:22:51,080 or severe hypotension, your entitle CO2 will drop 489 00:22:51,080 --> 00:22:53,400 precipitously. It's an invaluable tool. 490 00:22:53,680 --> 00:22:56,280 And of course you need all the other standard ASA monitors, 491 00:22:56,280 --> 00:22:59,480 ECG, noninvasive blood pressure, and a pulse oximeter. 492 00:23:00,080 --> 00:23:02,880 But do not start the case without a clear continuous 493 00:23:02,880 --> 00:23:05,520 waveform captor graph. OK, let's talk drugs. 494 00:23:05,560 --> 00:23:08,160 We've got a sick patient with potential liver and kidney 495 00:23:08,160 --> 00:23:11,120 issues. What is our anesthetic cocktail 496 00:23:11,120 --> 00:23:13,160 of choice? For induction and maintenance, 497 00:23:13,160 --> 00:23:15,960 propofol is actually an excellent choice, even 498 00:23:15,960 --> 00:23:18,840 insignificant liver dysfunction. As noted, in long and short 499 00:23:18,840 --> 00:23:20,680 cases, propofol is generally safe. 500 00:23:21,240 --> 00:23:24,120 It has a high hepatic extraction ratio, but it also has 501 00:23:24,120 --> 00:23:26,480 significant extra hepatic metabolism, so it doesn't 502 00:23:26,480 --> 00:23:28,520 accumulate easily. OK, so protocol is fine. 503 00:23:28,520 --> 00:23:30,760 What about? Pain relief for analgesia. 504 00:23:31,000 --> 00:23:33,560 The wonder drug for this particular scenario is REMA 505 00:23:33,560 --> 00:23:36,000 fentanyl. And why specifically REMA 506 00:23:36,000 --> 00:23:39,800 fentanyl over say, fentanyl? It's all about the metabolism. 507 00:23:40,400 --> 00:23:43,840 REMA fentanyl is broken down by nonspecific plasma in tissue 508 00:23:43,840 --> 00:23:46,440 esterases. It's clearance is completely 509 00:23:46,440 --> 00:23:48,640 independent of liver and renal function. 510 00:23:49,400 --> 00:23:53,200 It also has an incredibly rapid on off profile which is perfect 511 00:23:53,200 --> 00:23:55,720 for a Nora setting where you want a fast, predictable wake 512 00:23:55,720 --> 00:23:57,000 up. And fentanyl. 513 00:23:57,040 --> 00:24:00,680 Fentanyl is also safe, but its metabolism is liver dependent so 514 00:24:00,680 --> 00:24:03,080 its effects might be prolonged. In a patient with severe 515 00:24:03,080 --> 00:24:05,840 cirrhosis, you'd certainly need to reduce the dose. 516 00:24:06,320 --> 00:24:09,400 The one to avoid if possible is morphine because it's active 517 00:24:09,400 --> 00:24:11,960 metabolites can accumulate, especially if there's any degree 518 00:24:11,960 --> 00:24:14,320 of renal impairment. Good to know and muscle 519 00:24:14,320 --> 00:24:16,960 relaxants for the GA. If you're doing Aga, you need 520 00:24:16,960 --> 00:24:20,320 profound immobility. The drugs of choice here are 521 00:24:20,320 --> 00:24:23,960 cisaturium or atrocurium. Because of Hoffman degradation. 522 00:24:23,960 --> 00:24:26,800 Exactly. Organ independent elimination. 523 00:24:27,400 --> 00:24:30,920 It breaks down spontaneously in the plasma based on pH and 524 00:24:30,920 --> 00:24:33,160 temperature, so it doesn't care what the liver or kidneys are 525 00:24:33,160 --> 00:24:36,000 doing. If you have to use rocuronium, a 526 00:24:36,000 --> 00:24:39,240 source like long and short cases suggests reducing the dose by up 527 00:24:39,240 --> 00:24:42,480 to 40% in significant liver disease because it relies 528 00:24:42,480 --> 00:24:44,440 heavily on hepato biliary excretion. 529 00:24:44,680 --> 00:24:47,720 You definitely don't want a patient who is paralyzed for two 530 00:24:47,720 --> 00:24:49,520 hours after a 30 minute procedure. 531 00:24:49,560 --> 00:24:52,080 That's a scenario to avoid at all costs. 532 00:24:52,080 --> 00:24:53,960 OK. We have the patient intubated. 533 00:24:54,000 --> 00:24:57,320 We've got our drug plan now we are positioning them prone. 534 00:24:57,680 --> 00:25:00,520 What is on your mental safety checklist for the turn in 535 00:25:00,520 --> 00:25:03,000 positioning? The DNB question source provides 536 00:25:03,000 --> 00:25:05,720 a great checklist here. You should be to recite this one 537 00:25:06,200 --> 00:25:08,920 Eyes. Corneal abrasions are a common 538 00:25:08,920 --> 00:25:13,000 and entirely preventable injury. Tape them shut securely after 539 00:25:13,000 --> 00:25:14,760 turning. Physically checked that there's 540 00:25:14,760 --> 00:25:17,280 no pressure on the globes. OK, eyes first. 541 00:25:17,600 --> 00:25:20,680 Two neck Keep the neck in a neutral position. 542 00:25:21,000 --> 00:25:23,080 Avoid excessive rotation or extension. 543 00:25:23,320 --> 00:25:25,800 You don't want to compress the carotid arteries or the jugular 544 00:25:25,800 --> 00:25:28,960 veins, which could impede cerebral blood flow or increase 545 00:25:28,960 --> 00:25:32,080 intracranial pressure. Makes sense. 3 and this is 546 00:25:32,080 --> 00:25:34,680 physiologically critical, the chest and abdomen. 547 00:25:35,200 --> 00:25:38,720 You must use supports like chest rolls or pelvic bolsters so that 548 00:25:38,720 --> 00:25:41,840 the abdomen hangs free. This is an absolute must do. 549 00:25:41,920 --> 00:25:44,680 And why is the abdomen hanging free so important? 550 00:25:44,680 --> 00:25:47,320 I want to make sure our listener really gets this mechanism down 551 00:25:47,320 --> 00:25:49,160 cold. It's crucial for two reasons, 552 00:25:49,760 --> 00:25:53,520 respiratory and hemodynamic. From a respiratory standpoint, 553 00:25:53,560 --> 00:25:56,680 if the abdomen is compressed, it pushes all the viscera up into 554 00:25:56,680 --> 00:25:59,480 the diaphragm. This splints the diaphragm 555 00:25:59,840 --> 00:26:02,360 dramatically, reduces lung compliance, and makes 556 00:26:02,360 --> 00:26:05,160 ventilation very difficult. And hemodynamically? 557 00:26:05,200 --> 00:26:08,200 Hemodynamically, compression of the abdomen compresses the 558 00:26:08,200 --> 00:26:11,440 inferior vena cava. If you compress the IVC, you 559 00:26:11,440 --> 00:26:14,480 decrease venous return to the right side of the heart, preload 560 00:26:14,480 --> 00:26:17,760 drops, cardiac output drops, and blood pressure drops. 561 00:26:18,040 --> 00:26:20,560 You might see a persistent hypotension that doesn't seem to 562 00:26:20,560 --> 00:26:24,040 respond to fluids. The fix isn't more vasopressors, 563 00:26:24,160 --> 00:26:26,200 the fix is getting the pressure off the belly. 564 00:26:26,200 --> 00:26:28,680 So it's a mechanical problem with a mechanical solution. 565 00:26:28,680 --> 00:26:30,800 Precisely and 4th on the checklist. 566 00:26:31,120 --> 00:26:33,680 Nerves protect the ulnar nerve at the elbow. 567 00:26:34,000 --> 00:26:36,720 It's very vulnerable to pressure injury in the prone or swimmers 568 00:26:36,720 --> 00:26:38,880 position. That abdomen hanging free point 569 00:26:38,880 --> 00:26:41,120 is pure Physiology gold for Aviva. 570 00:26:41,680 --> 00:26:43,320 OK, now we have to go to the dark side. 571 00:26:43,520 --> 00:26:46,160 Part F Complications and crisis management. 572 00:26:46,520 --> 00:26:49,200 This is the absolutely essential section on what to do when 573 00:26:49,200 --> 00:26:51,200 things go wrong. What are the common 574 00:26:51,200 --> 00:26:54,080 complications in ERCP? Well, you have to divide them 575 00:26:54,080 --> 00:26:56,960 into anesthetic complications and procedure related ones. 576 00:26:57,680 --> 00:27:00,560 Anesthetically, the big ones are hypoxia and hypoventilation. 577 00:27:01,320 --> 00:27:05,040 This is most common with over sedation in a prone patient or 578 00:27:05,040 --> 00:27:07,240 an obstructed airway that you can't easily manage. 579 00:27:07,720 --> 00:27:10,160 Aspiration is the other major threat we've discussed. 580 00:27:10,160 --> 00:27:13,440 Hemodynamic instability, specifically hypotension, is 581 00:27:13,440 --> 00:27:15,720 very common because these patients are often septic or 582 00:27:15,720 --> 00:27:19,000 dehydrated and propofol is a potent vasodilator. 583 00:27:19,360 --> 00:27:22,560 And finally, arrhythmias, usually bradycardia, can occur 584 00:27:22,560 --> 00:27:25,400 from vagal stimulation when the scope stretches the duodenum or 585 00:27:25,400 --> 00:27:26,560 esophagus. OK. 586 00:27:26,600 --> 00:27:28,760 And the procedure related complications, the big. 587 00:27:28,760 --> 00:27:34,800 Three you must know are post ERCP, pancreatitis, PPP bleeding 588 00:27:34,800 --> 00:27:37,360 especially after sphincterotomy and perforation. 589 00:27:37,840 --> 00:27:40,640 A retroperitoneal perforation is a surgical emergency. 590 00:27:40,920 --> 00:27:43,440 OK, let's talk about that nightmare scenario we teased in 591 00:27:43,440 --> 00:27:45,520 the intro. You're providing deep sedation. 592 00:27:45,520 --> 00:27:48,280 The patient is prone. Suddenly the sats dropped to 593 00:27:48,280 --> 00:27:50,400 80%. The Captain graph waveform, if 594 00:27:50,400 --> 00:27:52,760 you have one, goes flat or shows a clear obstruction. 595 00:27:52,920 --> 00:27:54,880 What do you do? This is the airway loss and 596 00:27:54,880 --> 00:27:57,360 prone drill. You must have a pre rehearsed 597 00:27:57,360 --> 00:28:00,800 mental algorithm. Step one, recognition and 598 00:28:00,800 --> 00:28:04,160 communication to immediately identify the problem and call 599 00:28:04,160 --> 00:28:06,200 out loud and clear. Stop the procedure. 600 00:28:06,320 --> 00:28:09,720 I have an airway emergency. The endoscopist must pull the 601 00:28:09,720 --> 00:28:11,920 scope out immediately. Stop the stimulus. 602 00:28:12,040 --> 00:28:15,200 Stop the stimulus. Step two, attempt in situ 603 00:28:15,200 --> 00:28:17,560 rescue. While still prone, you try 604 00:28:17,560 --> 00:28:20,360 simple maneuvers. A jaw thrust if you can get your 605 00:28:20,360 --> 00:28:24,280 hands in, suction the pharynx apply 100% oxygen with positive 606 00:28:24,280 --> 00:28:26,000 pressure. If you can ventilate them, 607 00:28:26,000 --> 00:28:28,560 great, you might be able to insert a nasal airway. 608 00:28:28,560 --> 00:28:31,040 Well, what if you can't? What if you're getting no air 609 00:28:31,040 --> 00:28:33,040 entry? Then you move to Step 3, and you 610 00:28:33,040 --> 00:28:34,960 do it without hesitation. The turn. 611 00:28:35,400 --> 00:28:37,320 If you cannot ventilate the patient, you do not waste 612 00:28:37,320 --> 00:28:39,440 precious seconds trying to intubate them prone. 613 00:28:39,800 --> 00:28:42,440 Unless you are an expert with a flexible bronchoscope ready to 614 00:28:42,440 --> 00:28:44,440 go, you must turn the patient supine. 615 00:28:45,080 --> 00:28:47,200 This is the critical life saving decision. 616 00:28:47,520 --> 00:28:50,240 You call for all hands on deck, you flip the patient safely onto 617 00:28:50,240 --> 00:28:52,800 a stretcher or the bed, and you manage the airway in the 618 00:28:52,800 --> 00:28:55,480 familiar supine position where you have access and control. 619 00:28:55,680 --> 00:28:59,040 Turn the patient supine. It sounds so drastic, but in a 620 00:28:59,040 --> 00:29:02,800 crisis, it's the only safe move. It is the only defensible action 621 00:29:02,920 --> 00:29:06,400 if ventilation fails. You cannot effectively 622 00:29:06,520 --> 00:29:10,080 resuscitate or reintubate A prone patient in a crisis. 623 00:29:10,480 --> 00:29:13,040 Time is brain and time is myocardium. 624 00:29:13,320 --> 00:29:15,280 Let's talk about pancreatitis. Is there anything the 625 00:29:15,280 --> 00:29:17,440 anesthetist does to actively prevent that? 626 00:29:17,800 --> 00:29:20,960 Surprisingly, yes, and this is another great fact to drop in an 627 00:29:20,960 --> 00:29:24,440 exam to show you're up to date. Miller sites a major randomized 628 00:29:24,440 --> 00:29:27,840 trial showing that a single dose of rectal indomethacin, a 629 00:29:27,840 --> 00:29:31,920 specific NSEID administered either before or immediately 630 00:29:31,920 --> 00:29:34,640 after the procedure, significantly reduces the risk 631 00:29:34,640 --> 00:29:37,520 and severity of post ERCP pancreatitis. 632 00:29:37,520 --> 00:29:39,800 And the mechanism there. It's thought to inhibit the 633 00:29:39,800 --> 00:29:42,560 inflammatory cascade involving prostaglandins within the 634 00:29:42,560 --> 00:29:45,240 pancreas that gets triggered by the trauma of the procedure. 635 00:29:45,680 --> 00:29:47,600 Fascinating. And perforation. 636 00:29:47,600 --> 00:29:49,640 How would we know that has happened intraoperatively? 637 00:29:49,880 --> 00:29:53,200 It can be subtle. A retroperitoneal perforation 638 00:29:53,200 --> 00:29:56,200 might just present as surgical emphysema, you might feel 639 00:29:56,200 --> 00:29:59,880 crepitus or air under the skin of the neck or chest, or it 640 00:29:59,880 --> 00:30:02,920 could be a sudden unexplained tachycardia and hypotension. 641 00:30:03,600 --> 00:30:07,000 If an air embolus occurs, which is where now that they use CO2 642 00:30:07,000 --> 00:30:10,480 for insufflation, but still possible, you might see a sudden 643 00:30:10,480 --> 00:30:14,600 catastrophic drop in end title CO2 and cardiovascular collapse. 644 00:30:14,600 --> 00:30:18,520 OK, a lot to watch for. Moving on to part G post 645 00:30:18,520 --> 00:30:20,800 procedure care. The procedure is done. 646 00:30:21,080 --> 00:30:23,920 We survive the dark room. What are we watching for in the 647 00:30:23,920 --> 00:30:26,640 recovery area? In recovery, we're watching for 648 00:30:26,640 --> 00:30:29,280 a few key things. First, delayed respiratory 649 00:30:29,280 --> 00:30:31,880 depression. This is especially a risk if we 650 00:30:31,880 --> 00:30:34,960 use sedation with longer acting opioids in a patient with liver 651 00:30:34,960 --> 00:30:37,720 dysfunction who can't metabolize the drugs properly, right? 652 00:30:37,720 --> 00:30:40,080 Second, we are on high alert for signs of perforation. 653 00:30:40,200 --> 00:30:43,840 This would be severe abdominal pain, a rigid abdomen, fever or 654 00:30:43,840 --> 00:30:46,240 tachycardia. The pain of perforation is very 655 00:30:46,240 --> 00:30:48,520 different from the usual visceral ache of the procedure. 656 00:30:48,520 --> 00:30:51,240 It's severe, constant and a surgical emergency. 657 00:30:51,320 --> 00:30:53,120 And bleeding. And pancreatitis, yes, I'd 658 00:30:53,120 --> 00:30:55,680 assume. Yes, watching for hypotension or 659 00:30:55,680 --> 00:30:58,920 Melena for bleeding and rising, amylase or lipase for 660 00:30:58,920 --> 00:31:01,560 pancreatitis, although that usually presents a few hours 661 00:31:01,560 --> 00:31:03,720 later. What about discharge criteria? 662 00:31:03,720 --> 00:31:05,360 When is it safe for them to go home? 663 00:31:05,720 --> 00:31:08,960 For discharge you use standard criteria like the Aldridge score 664 00:31:08,960 --> 00:31:12,360 or the post anesthesia discharge scoring system PADSS. 665 00:31:12,880 --> 00:31:17,000 They need to be awake, alert, hemodynamically stable with pain 666 00:31:17,000 --> 00:31:20,720 and nausea under control. But Miller has a specific note 667 00:31:20,720 --> 00:31:24,120 for our high risk OSA or obesity hypoventilation syndrome 668 00:31:24,120 --> 00:31:25,360 patients. What's the special 669 00:31:25,360 --> 00:31:27,560 consideration? For those patients, you should 670 00:31:27,560 --> 00:31:30,200 specifically check for hypercapnia before you discharge 671 00:31:30,200 --> 00:31:32,320 them. They are prone to retaining CO2 672 00:31:32,320 --> 00:31:35,120 after sedation. If they are still hypercapnic or 673 00:31:35,120 --> 00:31:38,240 excessively somnolent, they need to be admitted for observation 674 00:31:38,440 --> 00:31:40,960 and may even require non invasive ventilation. 675 00:31:41,040 --> 00:31:43,760 Great point. OK, now for Part H comparison 676 00:31:43,760 --> 00:31:46,360 and exam integration. This is where we tie it all 677 00:31:46,360 --> 00:31:49,400 together For the written exam or the Viva, let's build a quick 678 00:31:49,400 --> 00:31:52,200 mental sedation versus GA comparison table. 679 00:31:52,280 --> 00:31:54,320 How would you visualize this for the listener? 680 00:31:54,480 --> 00:31:57,000 OK, imagine a simple table with four key rows. 681 00:31:57,480 --> 00:32:01,040 Row one, airway safety. For GA you write secured and 682 00:32:01,040 --> 00:32:04,200 protected. For sedation, you write at risk 683 00:32:04,200 --> 00:32:06,040 and shared. Clear distinction. 684 00:32:06,240 --> 00:32:09,400 Row 2 hemodynamics. For GA the key issue is 685 00:32:09,400 --> 00:32:13,800 induction hypotension. For sedation it's more variable 686 00:32:13,880 --> 00:32:16,440 but generally more stable unless you have an overdose event. 687 00:32:17,080 --> 00:32:23,160 Row 3 Operating Conditions GA provides complete immobility, 688 00:32:23,280 --> 00:32:25,960 which, as Miller says, leads to higher technical success. 689 00:32:26,240 --> 00:32:30,000 Sedation is plagued by potential patient movement and Row 4 The 690 00:32:30,000 --> 00:32:33,280 bottom line success rate. The literature supports that GA 691 00:32:33,280 --> 00:32:35,920 has a higher procedural success rate, especially for difficult 692 00:32:35,920 --> 00:32:39,240 or therapeutic interventions. That's a perfect concise table 693 00:32:39,240 --> 00:32:41,280 for exam answer. Now the Viva traps. 694 00:32:41,280 --> 00:32:43,720 We've mentioned the INR trap and the full stomach trap. 695 00:32:43,840 --> 00:32:46,720 What are the other common ways a student can fail this question? 696 00:32:46,720 --> 00:32:49,320 Trap number one is under estimating aspiration. 697 00:32:49,560 --> 00:32:51,480 If a student says something like like I'll just use light 698 00:32:51,480 --> 00:32:53,920 sedation for a patient with a bowel obstruction because it's 699 00:32:53,920 --> 00:32:56,120 only a scope, they will fail that station. 700 00:32:56,400 --> 00:32:59,400 You must recognize and verbalize the full stomach risk and have a 701 00:32:59,400 --> 00:33:01,920 plan for it. Trap number 2 is having a casual 702 00:33:01,920 --> 00:33:05,040 attitude. The Nora is easy trap if you 703 00:33:05,040 --> 00:33:07,800 sound dismissive. Oh it's just the GI suite, I 704 00:33:07,800 --> 00:33:09,960 don't need full monitoring or an IV line. 705 00:33:10,400 --> 00:33:13,600 You sound dangerous. The Examiner wants to see more 706 00:33:13,600 --> 00:33:16,440 vigilance in Nora, not less. It's a hostile environment. 707 00:33:16,440 --> 00:33:17,680 You have to be more. Careful exactly. 708 00:33:17,680 --> 00:33:20,600 And trap #3 is forgetting the basics. 709 00:33:21,280 --> 00:33:24,920 If you have a jaundice patient with a high INR and you don't 710 00:33:24,920 --> 00:33:27,640 mention checking their clotting and considering vitamin K, 711 00:33:28,040 --> 00:33:30,760 you've missed a fundamental physiological step of 712 00:33:30,760 --> 00:33:33,760 preoperative preparation. Simple but crucial. 713 00:33:34,280 --> 00:33:37,000 And finally, diagrams. If this is a long written 714 00:33:37,000 --> 00:33:40,040 question, what are we drawing to get those extra marks? 715 00:33:40,040 --> 00:33:42,000 Two simple diagrams will get you a long way. 716 00:33:42,000 --> 00:33:45,880 First draw the prone position schematic, a simple stick figure 717 00:33:45,880 --> 00:33:49,240 prone with rectangles onto the chest and pelvis and label it 718 00:33:49,240 --> 00:33:52,520 chest pelvic bolsters and draw an arrow to the abdomen and 719 00:33:52,520 --> 00:33:55,360 label it abdomen hanging free. It shows you understand the 720 00:33:55,360 --> 00:33:56,080 mechanics. Right. 721 00:33:56,120 --> 00:33:58,520 And the second one. The second is a flow chart for 722 00:33:58,520 --> 00:34:01,000 your crisis plan. Draw a box that says airway 723 00:34:01,000 --> 00:34:04,280 obstruction in prone been an arrow to stop procedure, then 724 00:34:04,280 --> 00:34:07,080 arrow to attempt jaw thrust suction, then a diamond shape 725 00:34:07,080 --> 00:34:08,560 that asks ventilation successful. 726 00:34:08,719 --> 00:34:12,280 If yes, continue with caution. If no a big arrow to a box that 727 00:34:12,280 --> 00:34:16,040 says turn supine immediately and then to intubator rescue airway. 728 00:34:16,159 --> 00:34:17,840 That fully chart shows you have a Plan B. 729 00:34:17,880 --> 00:34:20,480 That is fantastic advice. OK, so let's summarize. 730 00:34:20,480 --> 00:34:21,880 We've covered a huge amount of ground. 731 00:34:22,199 --> 00:34:25,360 What is the high yield? Recap the take home message for 732 00:34:25,360 --> 00:34:27,520 that Gujarat University exam candidate. 733 00:34:27,639 --> 00:34:29,800 You're a 5 golden points. I mean nothing else. 734 00:34:29,800 --> 00:34:33,199 Remember these one ERCP is Eric's to Nora. 735 00:34:33,440 --> 00:34:36,880 Treat it with the respect it deserves. 2 The prone position 736 00:34:36,880 --> 00:34:40,560 dictates your airway management have a very low threshold for GA 737 00:34:40,560 --> 00:34:44,400 and intubation, especially in obese, sick or complex cases. 738 00:34:44,400 --> 00:34:48,639 Got it. 3 Obstructive jaundice means Coagulopathy and renal 739 00:34:48,639 --> 00:34:51,600 risk. Think vitamin K think hydration, 740 00:34:51,760 --> 00:34:56,239 think Lactulose. 4 Capnography is mandatory in the dark. 741 00:34:56,239 --> 00:34:57,800 You cannot see so you must monitor. 742 00:34:57,960 --> 00:35:02,200 It is your sixth sense. And. 5 Have a prices plan. 743 00:35:02,440 --> 00:35:05,360 No when to stop and no when to turn the patient supine. 744 00:35:06,400 --> 00:35:09,000 And the overarching theme for all of this, for your exam 745 00:35:09,000 --> 00:35:13,120 answer and for your career, is to prioritize safety over speed. 746 00:35:13,600 --> 00:35:16,520 The examiner does not care if you are fast, they care if you 747 00:35:16,520 --> 00:35:18,480 are. Safe safety over speed. 748 00:35:18,480 --> 00:35:22,360 A motto for anaesthesia and really for life expert. 749 00:35:22,360 --> 00:35:24,480 Thank you so much. This has been a true deep dive 750 00:35:24,480 --> 00:35:26,200 into the darkroom. It's been my pleasure. 751 00:35:26,200 --> 00:35:27,760 Good luck to everyone sitting the exams. 752 00:35:27,840 --> 00:35:30,160 Go in there with confidence, quote the guidelines and just 753 00:35:30,160 --> 00:35:33,520 remember airway is king. You heard it here first. 754 00:35:33,640 --> 00:35:36,120 Airway is king. Thanks for listening to the deep 755 00:35:36,120 --> 00:35:38,480 dive. Visualize that darkroom, prepare 756 00:35:38,480 --> 00:35:40,360 your crisis plan, and ace that exam. 757 00:35:40,440 --> 00:35:41,200 We'll see you next time.