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Jaya Susan Jacob, Lakeshore Hospital & Research Centre, Kochi

Anesthesiologists are often called upon to provide care to patients undergoing diagnostic and therapeutic procedures outside the operating room. One of the common locations is the gastrointestinal endoscopy suite. It is vital that we strive to maintain the same high standards of anaesthesia care as in the operating room despite the physical and logistic constraints imposed by the environment. Ideal requirements for providing safe anaesthesia care include the availability of piped and cylinder oxygen, suction, anaesthesia machine and components, good illumination, monitoring equipment, emergency cart and defibrillator to name a few. But the very nature of many procedures demand that some of these requirements are not available at hand. Familiarity with the layout, the procedure and the patient will go a long way in making the anesthesiologists work less stressful. Procedures commonly done in the GI endoscopy suite include Upper GI endoscopy Endoscopic retrograde cholangiopancreatography Endoscopic ultrasonography Percutaneous transhepatic biliary drainage Colonoscopy Flexible sigmoidoscopy Liver biopsy Enterescopy Stent placements, removal Transjugular intrahepatic portosystemic shunt The 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 mostly safe can have some complications. Among the more common of these are cardiopulmonary complications such as hypotension, hypoventilation, airway obstruction. Complications due to instrumentation such as bleeding, perforation and infection are less frequent. Still rarer are life threatening complications such as aspiration, myocardial infarction and pulmonary embolism. According to guidelines laid down by ASA task force Anesthesiologist 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 are Monitored anaesthesia care Conscious sedation Deep sedation General anaesthesia The anaesthetic management starts with the mandatory preanaesthetic evaluation of the patient focussing on medical history, medication history, physical examination, relevant laboratory investigations, fasting status. Medications that are commonly used in the endoscopy suite include benzodiazepines (midazolam), opiates (fentanyl, remifentanil, pethidine, butorphanol), intravenous anaesthetics (propofol, ketamine), topical anaesthetics (lignocaine, benzocaine), inhalational agents (sevoflurane, desflurane, nitrous oxide), dexmedetomidine. Short acting fast emerging agents are preferred. As no single drug has all the properties required to make 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 during the last 10 years. While the American Society of Anesthesiologists recommends that propofol should be administered by someone trained in administering general anaesthesia; the American College of Gastroenterology, American Gastroenterology Association and the American Society for Gastrointestinal Endoscopy have opined that adequately trained nurses supervised by a physician can safely administer propofol. Target controlled infusion (TCI), patient controlled sedation or analgesia (PCS or PCA), computer assisted personalised sedation (CAPS) facilitate titration of propofol to obtain the desired effect. Miscellaneous medications administered in the endoscopy suite include antihistaminics, neuroleptics (droperidol, haloperidol), parasympatholytics (glycopyrrolate, hyoscine bromide), antiemetics, antisecretory (somatostatin, octreotide), anti-inflammatory (diclofenac). Airway management is complicated by need to share the airway with the endoscopist and patient positioning (lateral or prone). Nasal cannulae and face masks may be sufficient for conscious sedation, nasal airway may be required for deep sedation while general anaesthesia necessitates endotracheal intubation. Following the procedure the patient should be cared for in a recovery area with facilities for supplemental oxygen and monitoring by dedicated personnel.

To conclude, anaesthesia for GI endoscopy is necessary and safe. The anesthesiologist is an integral member of the team. Short acting fast emerging medications are preferred and eternal vigilance is the key to safe conduct of anaesthesia outside the OR.