Ogilives pseudoobstruction

[coffeebythelake]

Distended abdomen and pain. Passing a little bit of gas. No nausea or vomiting. No NG tube. Here for colonoscopy and decompression. Do you intubate these cases by default?

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[Dr. Rude]

Judgement call…body habitus…clinical symptoms…skill of endoscopist….opinion of CRNA in room (if supervising)…etc.

 

[caligas]

Maintain ability to protect airway or RSI. Avoid the middle ground.

 

[Beeftenderloin]

Distended abdomen and pain. Passing a little bit of gas. No nausea or vomiting. No NG tube. Here for colonoscopy and decompression. Do you intubate these cases by default?

We very recently had a massive aspiration event requiring emergent intubation, near arrest, long ICU stay. They were doing this exact case under standard deep MAC w/ propofol. N=1.

 

[coffeebythelake]

My assessment was that patients risk of aspiration was relatively low. And certainly large bowel obstruction / or pseudoobstruction is felt to be lower risk of aspiration than small bowel obstruction. No nausea or vomiting. No burping. Pt has been passing more gas and some stools and bloating has improved somewhat pointing to resolving ogilives.

Case was booked for MAC which I felt reasonably comfortable with, then the GI doc said he actually wanted GA so the pt got tubed. Uneventful case. Before extubation, I dropped an OG tube with less than 50 cc output.

I didn't explicitly question the GI docs rationale for GA vs MAC, although I assume it was a combination of aspiration concern, getting optimal scoping conditions, plus possibility of bowel perforation (certainly a higher risk compared to usual colonoscopies) if the patient moved around /bucked / intraabd pressure much during the case.

 

[coffeebythelake]

I did read with interest some case studies about neuraxial anesthesia being used to treat ogilives. Never actually seen anyone do this in clinical practice

 

[MTGas2B]

Neostigmine

Neostigmine for acute colonic pseudo-obstruction: A meta-analysis

Acute colonic pseudo-obstruction (ACPO) is an uncommon condition that occasionally develops in hospitalized patients with serious underlying ailments. Its early recognition is essential to reduce life-threatening complications. Few low-powered randomized ...

www.ncbi.nlm.nih.gov

 

[caligas]

I mean why mess around for something you might see once in a career 🤷‍♂️

 

[Simba1711]

If I’m debating a tube I usually just intubate. I’ve never said to myself “i wish I didn’t intubate this guy.”

 

[T-burglar]

Personally I Don’t **** around with aspiration risk. I don’t care if it takes a little extra time and is a bit more expensive (roc sugammadex). I refuse to be the last person that a patient talks to before their string of disasters that leads to their death.

 

[makemoney2024]

Distended abdomen and pain. Passing a little bit of gas. No nausea or vomiting. No NG tube. Here for colonoscopy and decompression. Do you intubate these cases by default?

Why not just put an NGT in, suction and and keep to suction? The abdomen is distended for a reason. Why take that chance? No way if a massive aspiration happens you won’t be writing a check and feel guilty as hell.
And keep them lighter or intubate.

 

[makemoney2024]

I’m

My assessment was that patients risk of aspiration was relatively low. And certainly large bowel obstruction / or pseudoobstruction is felt to be lower risk of aspiration than small bowel obstruction. No nausea or vomiting. No burping. Pt has been passing more gas and some stools and bloating has improved somewhat pointing to resolving ogilives.

Case was booked for MAC which I felt reasonably comfortable with, then the GI doc said he actually wanted GA so the pt got tubed. Uneventful case. Before extubation, I dropped an OG tube with less than 50 cc output.

I didn't explicitly question the GI docs rationale for GA vs MAC, although I assume it was a combination of aspiration concern, getting optimal scoping conditions, plus possibility of bowel perforation (certainly a higher risk compared to usual colonoscopies) if the patient moved around /bucked / intraabd pressure much during the case.

The GI doc was being diligent and trying to do no harm to the patient and protect both your asses.
Why even question it? This should be a You thing. A You thought process. Not the GIs because we all know they like doing stupid stuff. I like this GI and you should be thankful he or she actually cares.

 

[makemoney2024]

Personally I Don’t **** around with aspiration risk. I don’t care if it takes a little extra time and is a bit more expensive (roc sugammadex). I refuse to be the last person that a patient talks to before their string of disasters that leads to their death.

100. This is ridiculous question and rationale to read from an anesthesiologist. They don’t bully me when I want to intubate. An extra five minutes is worth it.

 

[coffeebythelake]

I’m

The GI doc was being diligent and trying to do no harm to the patient and protect both your asses.
Why even question it? This should be a You thing. A You thought process. Not the GIs because we all know they like doing stupid stuff. I like this GI and you should be thankful he or she actually cares.

Eh I agree with you.

 

[NightyNight]

Distended abdomen makes me wanna tube. I’d rather go through the trouble of GA versus aspiration. Or at least have a Ng tube down and suction whatever. Don’t know if that’s gonna catch it all either if there’s a lot.

 

[pgg]

Neostigmine

Neostigmine for acute colonic pseudo-obstruction: A meta-analysis

Acute colonic pseudo-obstruction (ACPO) is an uncommon condition that occasionally develops in hospitalized patients with serious underlying ailments. Its early recognition is essential to reduce life-threatening complications. Few low-powered randomized ...

www.ncbi.nlm.nih.gov

It's the only thing that drug is good for these days.

Saw it work once when I was a resident in the ICU, and it was a sight to behold. From a safe distance. The patient sure hated it though.

 

[abolt18]

It's the only thing that drug is good for these days.

Saw it work once when I was a resident in the ICU, and it was a sight to behold. From a safe distance. The patient sure hated it though.

There was a legend shared at my training hospital about a patient coding in the ICU after a resident supposedly pushed a bunch of neostigmine to treat Ogilvie's.

 

[makemoney2024]

There was a legend shared at my training hospital about a patient coding in the ICU after a resident supposedly pushed a bunch of neostigmine to treat neostigmine.

Neostigmine to treat what? Probably not a legend. I am sure it happened.

 

[abolt18]

Neostigmine to treat what? Probably not a legend. I am sure it happened.

Corrected my post

 

[dozitgetchahi]

It's the only thing that drug is good for these days.

Saw it work once when I was a resident in the ICU, and it was a sight to behold. From a safe distance. The patient sure hated it though.

Gave it once at the tail end of IM residency for intestinal pseudo obstruction. Nurses drew it up, but refused to give it and treated the syringe as if it was full of plutonium. Whatever, I’ll do the 5 minute push.

What ensued about 3 minutes later was the longest fart that I have yet witnessed (about 45 seconds). It involved all three phases of matter. You could literally watch the patient’s abdominal distention decrease during that fart.

I considered it a sort of “grand finale” for residency.

 

[coffeebythelake]

There was a legend shared at my training hospital about a patient coding in the ICU after a resident supposedly pushed a bunch of neostigmine to treat Ogilvie's.

One of my colleagues responded to a cardiac arrest code on the floor after neostigmine was used for this indication. Atropine reportedly given without effect. Patient couldn't be resuscitated.

 

[BlueRug]

One of my colleagues responded to a cardiac arrest code on the floor after neostigmine was used for this indication. Atropine reportedly given without effect. Patient couldn't be resuscitated.

Epi on backorder?

 

[2buckchuck]

Saw it a few times in ICU fellowship. Make sure the patient is on a bedpan when you give it.

 

[makemoney2024]

Saw it a few times in ICU fellowship. Make sure the patient is on a bedpan when you give it.

It works that fast? Damn!! That’s a site to see.

 

[coffeebythelake]

Epi on backorder?

Got epi with acls

 

[2buckchuck]

It works that fast? Damn!! That’s a site to see.

It was within 5 minutes. The ICU nurse got the neostigmine bedside, wanted me to push it. I did, HR was fine. I walked down the hall to check other things, then walked back 5-10 min later and liquid shi-shi was collecting on the floor at the foot of the bed.

 

[D4C]

It works that fast? Damn!! That’s a site to see.

A coresident of mine used to bolus it if the urology resident was a dick.

 

[makemoney2024]

A coresident of mine used to bolus it if the urology resident was a dick.

With the proper chaser I hope? Because why would you risk a patients life to prove a point? This is childish and disgusting.

 

[GassYous]

One of my colleagues responded to a cardiac arrest code on the floor after neostigmine was used for this indication. Atropine reportedly given without effect. Patient couldn't be resuscitated.

I used to think the fears of neostigmine were overblown but now I have a healthy respect for the drug

I have used it once in residency for this indication but only 2 mg which worked well

 

[dozitgetchahi]

With the proper chaser I hope? Because why would you risk a patients life to prove a point? This is childish and disgusting.

From the “when I was an IM resident” files…

When I was a 2nd year resident, our team had an attending who was very old-timey (he was well into his 80s). One morning during rounds (I was post call), he says “you know, you guys don’t get to have much fun as residents anymore. See, when we were on call, we used to have “DKA races”. You tried to beat your co residents to close the gap as soon as possible. Of course, once or twice we had someone go hypokalemic, and code”.

We all looked at him horrified.

“But they were quickly resuscitated.”

 

[GassYous]

From the “when I was an IM resident” files…

When I was a 2nd year resident, our team had an attending who was very old-timey (he was well into his 80s). One morning during rounds (I was post call), he says “you know, you guys don’t get to have much fun as residents anymore. See, when we were on call, we used to have “DKA races”. You tried to beat your co residents to close the gap as soon as possible. Of course, once or twice we had someone go hypokalemic, and code”.

We all looked at him horrified.

“But they were quickly resuscitated.”

Eh I once saw a person get 100 of insulin and they were fine

 

[PpfSuxTube]

So when I was a med student in Europe in a small hospital the surgical team I was attached to had this case and they actually took him to the OR to give him the neostigmine... I had absolutely no clue what was going on so can't remember the specifics... I think they made the anesthesiologist tube him idk

All I remember was this big fat dude in lithotomy stirrups blowing chunks all over the chief of surgery and his staff, and they celebrated high fives all round

It was weird as **** at the time
Still isn't much better

 

[Ronin786]

Maybe I just haven't seen the bad stuff, but we push 1mg of Neostigmine at a time in our ICU routinely. I'd say I've used it 5 times in the past 18 months personally.

No problems, just a lot of satisfied customers (not really because the cramping is a bitch). And this is a cardiac ICU so much more prone to rhythm issues.

Asystole and cardiac collapse is really a very rare complication (Neostigmine for acute colonic pseudo-obstruction: A meta-analysis)

FWIW I would venture colonic decompression is as risky if not more than neostigmine. Especially if you're going to roc them and push neostigmine at the end of the case anyways...

 

[makemoney2024]

From the “when I was an IM resident” files…

When I was a 2nd year resident, our team had an attending who was very old-timey (he was well into his 80s). One morning during rounds (I was post call), he says “you know, you guys don’t get to have much fun as residents anymore. See, when we were on call, we used to have “DKA races”. You tried to beat your co residents to close the gap as soon as possible. Of course, once or twice we had someone go hypokalemic, and code”.

We all looked at him horrified.

“But they were quickly resuscitated.”

I bet they offed a few patients back in the day with the attendings all supervising from home. And now the pendulum may have swung to the opposite extreme of constantly babying residents.
This is still happening as one of my attending friends who is ICU in academics tells me. He has complained that some of the residents are very egotistical won’t call at night and he arrives in the morning to find patients dead. Culture problem.

 

[Simba1711]

I was a med student when I saw it for the first time too. Patient was awake and they gave neostigmine guy shat his pants immediately. They had atropine bedside in case **** hit the fan.

 

[pgg]

I was a med student when I saw it for the first time too. Patient was awake and they gave neostigmine guy shat his pants immediately. They had atropine bedside in case **** hit the fan.

Back in ye not-so-olden days before sugammadex, I think every residency program in the country had at least one CA1 every year who thought he'd try not giving the glycopyrrolate with the neostigmine in order to fix tachycardia he should've fixed with opioids or beta blockers ...

After the predictably juicy arrival in PACU, the story gets told and everybody goes "duh you idiot" and then it doesn't happen again until the next year when a new batch of CA1s show up all bright eyed and enthusiastic about using pharmacology side effects to their advantage.

 

[psychbender]

Back in ye not-so-olden days before sugammadex, I think every residency program in the country had at least one CA1 every year who thought he'd try not giving the glycopyrrolate with the neostigmine in order to fix tachycardia he should've fixed with opioids or beta blockers ...

After the predictably juicy arrival in PACU, the story gets told and everybody goes "duh you idiot" and then it doesn't happen again until the next year when a new batch of CA1s show up all bright eyed and enthusiastic about using pharmacology side effects to their advantage.

Did it as a CA2 to a teen who was a heart transplant recipient, in for some minor-ish procedure. Went, "hey, the heart is chemically denervated, he won't get bradycardic..." *whistles innocently away from the PACU*

 

[Gasmd98]

Eh I once saw a person get 100 of insulin and they were fine

I am old enough to have used succinylcholine infusions for short cases requiring relaxation. Amazingly no one died. Now, doing hearts and giving versed/high dose fentanyl/vecuronium? That was sometimes exciting.

 

[PpfSuxTube]

I am old enough to have used succinylcholine infusions for short cases requiring relaxation. Amazingly no one died.

We did it too a bit. Worked great

 

[pgg]

I am old enough to have used succinylcholine infusions for short cases requiring relaxation. Amazingly no one died. Now, doing hearts and giving versed/high dose fentanyl/vecuronium? That was sometimes exciting.

I am also old enough, barely, and remember the occasional attending using them. They'd add a bit of methylene blue to the bag of succ to be a visual marker.

Mivacurium was available too, but they did the succ infusions anyway. Seemed like a lot of effort for not much point.

 

[IMGASMD]

I read through the thread. I am also under the impression that the GI doc probably saved you in the situation.

Since it is a pseudo obstruction; you’re worrying the possible aspiration…. why wouldn’t you intubate? To save 30 seconds of RSI? To make everyone else (nurses and the proceduralist) more “comfortable”? At the expanse of what? I’m sure especially with Bridion, you can get them to PACU as fast as GA without airway.

“If this was your mom/dad on the table, wouldn’t you just intubate?” Said the lawyer.

 

[makemoney2024]

I am also old enough, barely, and remember the occasional attending using them. They'd add a bit of methylene blue to the bag of succ to be a visual marker.

Mivacurium was available too, but they did the succ infusions anyway. Seemed like a lot of effort for not much point.

So…you were studying for Step 1 in 2008 and people were using the above after that year? Where? I thought this was a thing of the 90s.

 

[pgg]

So…you were studying for Step 1 in 2008 and people were using the above after that year? Where? I thought this was a thing of the 90s.

I was an intern in 2002. Still had mivacurium and halothane vaporizers. Spent 3 years as a GMO in the military after that and then started residency in 2006.

 

[nimbus]

We used to say mivacurium cost 10 times as much as saline and worked two times better.

 

[pgg]

We used to say mivacurium cost 10 times as much as saline and worked two times better.

Sometimes I think the generic rocuronium in our carts might fit that description.

 

[makemoney2024]

Sometimes I think the generic rocuronium in our carts might fit that description.

I sure hope it is cheap considering how poorly it seems to work.

 

[GassYous]

I sure hope it is cheap considering how poorly it seems to work.

I gave 100 yesterday and the patient started moving less than an hour in and I was like uh...

 

[psychbender]

As an aside regarding poorly functioning rocuronium, I am convinced that it is a function of how long its left out of the fridge here. From what I recall reading through the product insert many years ago during a long flap case as a resident, the effectiveness decreases measurably when left out of the fridge for more than 14 days. Our pharmacy does not date when the rocuronium comes out of the fridge, and is put it in the pyxis, just when it expires.

 

[coffeebythelake]

As an aside regarding poorly functioning rocuronium, I am convinced that it is a function of how long its left out of the fridge here. From what I recall reading through the product insert many years ago during a long flap case as a resident, the effectiveness decreases measurably when left out of the fridge for more than 14 days. Our pharmacy does not date when the rocuronium comes out of the fridge, and is put it in the pyxis, just when it expires.

I like to think it is because they don't refrigerate it when it goes on the big container ship from India

 

[pgg]

As an aside regarding poorly functioning rocuronium, I am convinced that it is a function of how long its left out of the fridge here. From what I recall reading through the product insert many years ago during a long flap case as a resident, the effectiveness decreases measurably when left out of the fridge for more than 14 days. Our pharmacy does not date when the rocuronium comes out of the fridge, and is put it in the pyxis, just when it expires.

I suspect you're right.

In Afghanistan we had a batch of succinylchole that didn't work at all. We eventually pulled and replaced all of it, and it worked again. I've always wondered if it sat in a pallet on an asphalt taxiway getting cooked to 180 degrees for a few hours.