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General anesthesia for gastrointestinal (GI) endoscopies has gained popularity over the past two decades. Common procedures include esophagogastroduodenoscopy (EGD), colonoscopy, endoscopic ultrasound (where an ultrasound transducer is affixed to the distal tip of an endoscope), and endoscopic retrograde cholangiopancreatography (ERCP). Additional complex, minimally invasive procedures are emerging.
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Gastroenterologists can successfully sedate patients with benzodiazepines and opioids but propofol improves case times, turnover, and patient satisfaction, and cannot be administered by gastroenterologists in many practice locations. As GI procedures grow more complex and are increasingly performed on older and sicker patients, most gastroenterologists prefer to have an anesthesia provider in the room to maximize patient safety and comfort. Complications from GI endoscopic procedures include bleeding from wall trauma or a biopsy site, perforation, and aspiration.
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PRE-PROCEDURE CONCERNS
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All patients should undergo a preoperative assessment complete with a thorough medical, surgical, anesthesia, and allergy history. Physical exam includes current vital signs, an airway exam, cardiac and pulmonary assessment. Endoscopy procedures may be performed at freestanding endoscopy centers for stable patients with American Society of Anesthesiology (ASA) physical status 1, 2, or 3 within defined BMI parameters. The preop interview should ascertain the presence of obstructive sleep apnea, implanted defibrillator, morbid obesity, pulmonary hypertension, and other complex comorbid conditions.
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Colonoscopy patients undergo a bowel preparation regime prescribed by their gastroenterologist. All anesthesia candidates should be in a fasted state with greater than 2 hours without oral intake of clear liquids, and 6–8 hours without solid food depending on fat content of the food.
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ANESTHETIC CONSIDERATIONS
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Prior to the procedure, an intravenous (IV) catheter is placed, and patients are monitored per ASA standard monitoring guidelines (Table 98-1). Typically, the airway is not secured, and supplemental oxygen is provided by nasal cannula or a procedural oxygen mask (POM) enabling capnography monitoring. Endoscopic procedures require a continuum of deep sedation to general anesthesia (Table 98-2). The patency of the patient’s airway may become compromised as relaxation ensues. The anesthesia provider should continually assess the patient for airway obstruction. Lateral positioning with wedges and appropriate padding may help maintain an adequate position to facilitate respiratory exchange.
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