ANESTHESIA FOR

ENDOSCOPIC PROCEDURES
What goes in, must come out (or call a surgeon)

© 2016 Mark S Weiss, MD

Department of Anesthesiology and Critical Care
HUP GI
 Sick, ASA III and IV, patients undergoing endoscopic GI
procedures
• Or ASA II patients with acute GI symptoms
 “Minimally invasive,” but room must be set up for full
spectrum of emergencies/resuscitation/airway
management
• Set up the same as in any OR:
– MSMAIDS! (machine, suction (flexible sucker), medications,
airway, IV, special)
– Double check supplemental O2, emergency cardiac drugs
– Remember help may be far away
 Rapid turnover
• Never fast, just efficient
Common Procedures
 BASIC PROCEDURES
• Esophagogastroduodenoscopy (EGD)
• Colonoscopy
• Flexible Sigmoidoscopy
 COMPLEX PROCEDURES (technically challenging, long
duration, etc.)
• Endoscopic retrograde cholangiopancreatography (ERCP)
• Sphincterotomy, bile duct stone removal, biliary stents
• Esophageal varices banding
• Endoscopic Ultrasound (EUS)
• Esophageal stent / dilation
• Double balloon enteroscopy
EGD
 Gastroscope (100 cm
length, 8-11 mm diameter)
 Exam scope may go as far
as duodenum
 Quick procedure
• 5-30min depending on diagnostic or
therapeutic maneuvers
EGD Airway
 Shared airway with bite
block in place
 Watch for
hypoventilation,
obstruction, apnea,
hypoxia
• Essential to have
surrogate for ventilation
– CAPNOGRAPH
– ECG respiratory leads
• Rescue Procedures
• Jaw thrust, chin lift
• Nasal Trumpet with attach
to mapelson circuit (next
slide)
• Mask ventilate, two hand
seal
• Advanced airway (LMA,
ETT)
• succinylcholine
Nasal Airway Circuit
• Nasal airway with circuit adapter-
– Special adapters for nasal trumpets vs 7.0 ETT
adapter (fits best, less cost effective)
– Attached to Mapleson circuit with flex tubing
– Allows for some positive pressure
EGD Stimulus

Gag/pharyngeal
reflex:
• Afferent limb
-Glossopharyngeal
(CN IX)
• Efferent limb- Vagus
nerve (CN X)
EGD Sedation Tips
 Blunt gag reflex
• Start with a safe and effective upfront bolus
• Use Fentanyl as an adjunct to propofol
 Keep patient immobile while in fragile areas-
esophagus/stomach
• Stable maintenance propofol infusion
• Depth of sedation influenced by procedure complexity (variceal ligation
vs. routine diagnostic screen)
• Potential for multiple scope passes (wider lumen scopes for EUS)
EGD Complications

Perforation
Bleeding
Infection
Rare (each
1:1000)
Variceal bleeding
in liver disease
 Once at cecum the scope is removed
slowly-- average time 7 minutes, but longer
depending on number of biopsies
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 Colonoscopy Stimulus
 Proceduralist technique greatly
impacts the amount of pain
stimulation
• “Looping” the scope
• Luminal distention through gas insufflation
• External abdominal pressure to help
direct scope
• Retroflex at the sigmoid colon (end of the
procedure)
 Pain mechanism
• Visceral pain, mechanoreceptors
transmitted via rectal/pelvic spinal
afferents, cell bodies in the lumbosacral
region of the spinal cord
• Autonomic vasovagal reactions
Looping Scope
 A perforation can occurs due to a transverse bowing of
the side of the scope creates an outward distention of
the bowel
• most perforations are NOT due to direct scope tip
pressure

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Colonoscopy Pain
Patient conditions can alter acute pain processing
• Inflammatory Bowel disease
• Irritable Bowel Syndrome
• Functional abdominal pain from chronic disease
• Cancer pain

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Colonoscopy Sedation Tips
 Scope insertion is not the most stimulating (unlike EGD)
 Propofol (small bolus plus infusion) provides optimal
procedural conditions in most patients
 Pain stimulus is not predictable (i/e when the scope loops),
but typically occurs in sigmoid and transverse colon
• Fentanyl may be given if the patient moves
 Propofol infusion can be discontinued while 20-30 cm of
scope remains
 Retroflexion at rectum may arouse the patient, but do NOT
give a reactionary bolus

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Colonoscopy Complications
 Bleeding (polypectomy)
 Perforations (mechanical trauma from colonoscope,
barotrauma, electrocautery during polypectomy)
 Postpolypectomy syndrome- electrocoagulation injury to
bowel wall

 ~2 per 1000 examinations, 85% during polypectomy

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 ERCP
 Upper endoscopy with fluoroscopically
assisted guidance to cannulate the
biliary tract
 **Prone position
 Can be performed as deep sedation
with nasal airway
• when in doubt GA with ETT
 Radiation safety (lead apron, thyroid
shield, etc)
 Small Room and difficult to get rescue
equipment in case of emergency

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 Glucagon Administration
Inhibit GI/biliary tract during a
fluoroscopic evaluation.
Peak GI effect in 1 min, Peak
glucose effect 5-20 min
Dose 0.2 - 0.5 mg IV
Common side effects
• hypertension, hyperglycemia,
nausea/vomiting, secondary
hypoglycemia
Contraindications
• hypersensitivity, pheochromocytoma,
insulinoma

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Common Endoscopy Related Complications
Attributed to sedation
• Hypoxia, hypotension, consequences of
hypercarbia, prolonged PACU stay
• 50-85% complications attributed to
cardiopulmonary events in setting of sedation
What is our value?
• Safe administration of deep sedation during
complex procedures
• Reduction complications in low risk
procedures
• Rescue during sedation care

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Hypotension
 Sympathetic blunting of response to hypovolemia by
anesthetics
 Vasovagal reaction
 Procedural complication
 Rare:
• Decreased LV contractility (from anesthetics),
• Hypercapnia/hypoxia
• Increased PVR (decreased RV function)
• anaphylaxis

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Procedure Specific Level Of Sedation/Anesthesia
 Review lecture 1 on Sedation levels (minimal, moderate,
deep)
 Healthy patients undergoing basic procedures can often
tolerate moderate sedation
 Complex patients / cases often require escalating sedation
including deep sedation and general anesthesia

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Anesthesia Controversy
 Is there a need for anesthesiologists caring for ASA I and II
patients undergoing colonoscopies?
• Not used routinely in Europe
 IV conscious sedation (mild-moderate sedation) using
midazolam fentanyl or MD (GI) directed deep sedation with
propofol
• Large data sets showing safe use

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Anesthesiologists: ASA I or II Colonoscopies

Pro CON
 Faster scope in  Increased costs
time
 Greater need for airway/respiratory
 Deeper level of
intervention
sedation
(increased  More hypotension (same outcomes)
patient comfort)
 Faster PACU
discharge
 Division of labor
(GIs focus the
on procedure
with more
successful
procedure in
some studies)

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 Specific Issues Impacting Care
Colonoscopy bowel prep
• Hypovolemia, electrolyte
abnormalities, nausea/vomiting,
patient discomfort
High volume, rapid turnover
• Efficiency while keeping patient
safety
Global NORA issues
• less resources, remote proximity
from anesthesia staff with identical
OR standards

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Common GI Pathologies Affecting Care
 IBD (Crohn’s, • Coagulopathy, low
Ulcerative Collitis) SVR, hepatitis C,
• Chronic pain, ETOH use
frustration with • GI cancer
chronic medical care • chemotherapy side
• Failure to thrive, effects, chronic pain
anemia • Zenker's
 IBS diverticulum, bowel
• Psychological co- obstruction, active
morbidities vomiting
 Hepatic pathology • Aspiration
precautions

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Co-Morbidity Specific Issues
 Obstructive Sleep Apnea/
Obesity
• Sensitivity to anesthetics
leading to decreased
oropharyngeal tone and
upper airway obstruction
 High dose chronic opioid
therapy
• Lower pain threshold, higher
anesthetic requirements,
greater risk for post-op
complications
 Pulmonary Hypertension, Right
Heart Failure
• Avoid hypercarbia/hypoxia
which increases PVR, ensure
adequate SVR (so SVR is not
< PVR)
• Low Left Ventricular EF
• Avoid high doses of
myocardial depressants
• Seizure disorder
• Low - moderate doses may
increase risk of severe
myoclonus or (rare) seizure
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