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Published by Suresh Kumar

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Published by: Suresh Kumar on Sep 16, 2012
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Dr. Jaya Susan Jacob, Lakeshore Hospital & Research Centre, Kochi 
Anesthesiologists are often called upon to provide care to patients undergoing diagnosticand therapeutic procedures outside the operating room. One of the common locations isthe gastrointestinal endoscopy suite. It is vital that we strive to maintain the same highstandards of anaesthesia care as in the operating room despite the physical and logisticconstraints imposed by the environment.Ideal requirements for providing safe anaesthesia care include the availability of piped andcylinder oxygen, suction, anaesthesia machine and components, good illumination,monitoring equipment, emergency cart and defibrillator
to name a few. But the verynature of many procedures demand that some of these requirements are not available athand. Familiarity with the layout, the procedure and the patient will go a long way in
making the anesthesiologist’s work less stressful.
 Procedures commonly done in the GI endoscopy suite includeUpper GI endoscopy Flexible sigmoidoscopyEndoscopic retrograde cholangiopancreatography Liver biopsyEndoscopic ultrasonography EnterescopyPercutaneous transhepatic biliary drainage Stent placements, removalColonoscopy Transjugular intrahepaticportosystemic shuntThe indications for endoscopy may be diagnostic (upper and lower GI bleed, infection,malignancy or postsurgical evaluation) and/or therapeutic (variceal bleed, angiodysplasia,foreign body removal, stricture dilatation, stent placement). GI endoscopy though mostlysafe can have some complications. Among the more common of these are cardiopulmonarycomplications such as hypotension, hypoventilation, airway obstruction. Complications dueto instrumentation such as bleeding, perforation and infection are less frequent. Still rarerare life threatening complications such as aspiration, myocardial infarction and pulmonaryembolism.According to guidelines laid down by ASA task forceAnesthesiologist assistance may be considered for
Prolonged/ therapeutic endoscopic procedure requiring deep sedation
Anticipated intolerance to standard sedatives
Increased risk of complications because of severe comorbidity (ASA III or greater)
Increased risk for airway obstruction because of anatomic variant (Difficult airway)Techniques of anaesthesia employed areMonitored anaesthesia careConscious sedationDeep sedationGeneral anaesthesiaThe anaesthetic management starts with the mandatory preanaesthetic evaluation of thepatient focussing on medical history, medication history, physical examination, relevantlaboratory investigations, fasting status.Medications that are commonly used in the endoscopy suite include benzodiazepines(midazolam), opiates (fentanyl, remifentanil, pethidine, butorphanol), intravenousanaesthetics (propofol, ketamine), topical anaesthetics (lignocaine, benzocaine),inhalational agents (sevoflurane, desflurane, nitrous oxide), dexmedetomidine. Short actingfast emerging agents are preferred. As no single drug has all the properties required tomake it the ideal agent combinations or cocktails using 2 or more agents are used.Worldover, the use of propofol for endoscopic sedation has increased markedly duringthe last 10 years. While the American Society of Anesthesiologists recommends thatpropofol should be administered by someone trained in administering general anaesthesia;the American College of Gastroenterology, American Gastroenterology Association and theAmerican Society for Gastrointestinal Endoscopy have opined that adequately trainednurses supervised by a physician can safely administer propofol. Target controlled infusion(TCI), patient controlled sedation or analgesia (PCS or PCA), computer assisted personalisedsedation (CAPS) facilitate titration of propofol to obtain the desired effect.Miscellaneous medications administered in the endoscopy suite include antihistaminics,neuroleptics (droperidol, haloperidol), parasympatholytics (glycopyrrolate, hyoscinebromide), antiemetics, antisecretory (somatostatin, octreotide), anti-inflammatory(diclofenac).Airway management is complicated by need to share the airway with the endoscopist andpatient positioning (lateral or prone). Nasal cannulae and face masks may be sufficient forconscious sedation, nasal airway may be required for deep sedation while generalanaesthesia necessitates endotracheal intubation. Following the procedure the patientshould be cared for in a recovery area with facilities for supplemental oxygen andmonitoring by dedicated personnel.

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