K_Z, I was hoping you'd chime in!
The profile of Yorkville Endoscopy states that all of their anesthesia providers are board certified MDs and are present during every procedure. They have also publicly stated that a)general anesthesia is never used there, b)there has never been a vocal cord biopsy done there, and c)no outside physician has performed a procedure there.
The first surprised me, as propofol is a general anesthetic and used WIDELY in endoscopy centers. b) and c) are assertions being disputed in the press, so it will indeed be interesting to see where the truth lies. I agree with you that if the "sources" are accurate, this center is in for a whole lot of grief.
Right after this happened, I spoke with one of our CRNAs about it, and he theorized something almost identical to what you surmised and told me that is why we do NOT do procedures on vocal cords at our center. What didn't occur to me was the flash pulmonary edema scenario. Thanks so much for your posts; they are always something to learn from.
Well, a word about General Anesthesia. All levels of anesthesia are along a continuum. There is no hard and fast line that separates "deep sedation" and "general anesthesia", unless you have an EEG going on. This is a question I frequently ask students-- how do you know when you have passed deep sedation into General Anesthesia? Some answer, "I know if the patient stops breathing and needs support from bagging, or an ETT, or an LMA." That's a really artificial threshold, because lots of times we conduct GA's with patients breathing spontaneously and no muscle relaxants or heavy opioids-- AND, we "allow" patients to regain spontaneous respirations during GA as we near the end of the case (sometimes considerably sooner). So the presence, or absence, of respiratory effort in and of itself is not a reliable indicator of depth of anesthesia.
Propofol is an incredibly useful anesthetic agent. In tiny doses, it can obliterate the intense itching induced from centrally (spinal) placed opioids. In medium doses, it is an effective light anesthetic, and in heavy doses, it is used to rapidly induce general anesthesia, or even used as a stand alone TIVA (total intravenous general anesthetic.) So, Propofol is a drug that is dosed and monitored in a continuum-- often combined with benzodiazepines (like versed) and opioids (like fentanyl) which potentiate each other, as well as volatile agents ("anesthetic gasses"-- but these are seldom used in endoscopy suites). It is really easy to "tip over" a patient who is spontaneously breathing on a deep sedation case, into apnea (no breathing). And all this is separate and apart from the laryngospasm event that I mentioned in my other post. The drastic difference is in how the 2 situations are managed-- they are vastly different.
If the patient has simply been tipped over into apnea (no breathing) or weak-effort breathing, it is a simple matter to augment or assist the breathing efforts of the patient until return of spontaneous effective respirations. (Bag/mask, or simple to complex airways, with positive pressure ventilation.)
If the patient has a severe laryngospasm, generally the first thing to try is sustained positive pressure ventilation, via mask and bag (anesthesia machine, if present, or Ambu if not), which may or may not break the spasm. Failing that, one has to do a rapid induction of general anesthesia with paralytics in order to break the vocal cord spasm, intubate the patient, and establish an airway with positive pressure. Or, if intubation is not possible in 1-2 tries, establish an airway thru surgical means. For the love of God, JR had at least 2 docs (one an ENT!!) with substantial experience placing surgical airways, as well as possibly an anesthesiologist. What the he!! happened in there??!!
JMO, but I think this is almost certainly a situation where they kept trying the same thing over and over (intubating with a laryngoscope and blade), and
failed, without knowing when to go to Plan B, or Plan C. It sure sounds like that is exactly what happened, IMO.
