February FY23

[A Schutter]

This months Journal Club comes to you from Belinda Gardner, CRNA She chose an excellent article regarding Achalasia and anesthetic considerations.

As a group, we often care for patients with complex comorbidities like Achalasia, which puts these patients at high risk for aspiration. Aspiration pneumonia is the cause of more than 50% of the airway-related deaths in anesthesia, outweighing the cannot intubate, cannot ventilate scenario and commonly face substantial morbidity. 

Here is a link to the article.

Questions for discussion:

1. Have you ever cared for a patient with Severe Achalasia like the one described in the article, and if so what methods did you employ (RSI, GA, medications, special positioning, NGT placement, review of CT) to optimize patient safety?
2. What have you learned from this article or caring for these patients in the past that you would share with your colleagues to help them when caring for a patient with Severe Achalasia?

[Kels]

I have never cared for a patient with severe achalasia. This article highlights aspiration as a major risk for patients suffering from serve achalasia . When providing anethesia for patients with this diagnosis the following should be considered: awake intuabtion, GA with ett with RSI, awake extubation, appropriate fasting times .

[nanci]

1. Have you ever cared for a patient with Severe Achalasia like the one described in the article, and if so what methods did you employ (RSI, GA, medications, special positioning, NGT placement, review of CT) to optimize patient safety?
Have cared for many patients in Endoscopy with Severe Achalasia and have performed GA with RSI and positioning in a more head up inclined position instead of being flat to help avoid passive aspiration. I think that incorporating some POCUS (Pont of care Ultrasound) before taking the patient back to the operating room might give providers a better visualization (Trachea, esophagus, stomach) and understanding of peri-procedural aspiration risk prior to the induction of anesthesia.

2. What have you learned from this article or caring for these patients in the past that you would share with your colleagues to help them when caring for a patient with Severe Achalasia?
Communication with the surgical team essential so all are on the same page with plan of care, propping patient up to reduce risk of aspiration and most likely a good discussion with preoperative fasting and possibly extending the existing time frame if they deem that may be of help to reduce risks. Advocating for doing GA instead of a MAC also very important.

[sjsimmons]

1. During my training as an anesthesia student, I cared for a pediatric patient with severe achalasia, who was presenting for an esophageal dilation. Although the patient followed strict NPO guidelines, we proceeded with an RSI and GA. I had not considered special positioning or NGT placement but this may have been beneficial in providing the lowest risk for aspiration. I also like the suggestion of using POCUS before taking the patient back to the OR.

2. After reading this article, I have learned that the care of patients with severe achalasia should involve various methods to optimize patient safety (RSI, GA, special positioning, NGT, cola sips, POCUS, etc). Cola sips could be helpful in alleviating the severe presentation of achalasia as carbonated drinks can be effective in resolving a substantial portion of food bolus.

I also agree with the authors that anesthesia providers must remain strong patient advocates and not allow themselves to be influenced into doing a case using MAC for the sake of expediency when GA is indicated.

[Anne McNulty CRNA]

1. Having spent many years in Endoscopy, I have taken care of several patients with achalasia. Most memorable was a male, 30 year old that had a large piece of beef brisket stuck in his esophagus, Intubation was RSI with succinycholine. The case took several hours to complete as the food bolus was so large, I have had several JHU endoscopy procedures where the endoscopist looks into the esophagus and if he/she sees food , the scope is removed and RSI is done with glidescope. I now refuse to do this as I feel it is adding to the risk of aspiration. I have placed pre induction NGT at least twice that I recall. I have done the POEM procedures many times using the JHU Endoscopy protocol. (2) I enjoyed this article and found the cause, degeneration of ganglionic cells to be interesting. I have never used the cola sips method to relieve food impaction an interesting approach.

[Wai-Ling Lo]

1. Have you ever cared for a patient with Severe Achalasia like the one described in the article, and if so what methods did you employ (RSI, GA, medications, special positioning, NGT placement, review of CT) to optimize patient safety?
For this type of cases, we usually do GETA with RSI/cricoid pressure to reduce aspiration risk. 
2. What have you learned from this article or caring for these patients in the past that you would share with your colleagues to help them when caring for a patient with Severe Achalasia?
Anesthesia team should communicate with GI attending to make sure everyone is on the same page about the anesthesia plan and provide the safest care for pts. 

[Amy Swank CRNA]

1. I have cared for a number of patients with severe achalasia when I worked in outpatient endoscopy centers. Usually we employed techniques such as pneumatic dilation by the proceduralist. When seeing food boluses via endoscopy, we optimized the situation by positioning in a steeper sitting position, having suction nearby. Even the calmest GI doc seems to get very nervous with this patient.
2. I have not seen Botox injections utilized clinically. I thought using carbonated beverages as a therapy and meat tenderizer was quite interesting and may suggest that in non-clinical settings if suspected. I also see the correlation with this patient and the concomitant diagnosis of anxiety accurate and also very interesting.