anaesthesia used in endoscopy
TRANSCRIPT
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Anaesthesia in Gastroscopy and Colonoscopy
Adrian Castro (Bill) and Dr. Ross Wilson
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Background – Gastroscopy and Colonoscopy Both very common procedures
In 20111; Over 115,000 colonoscopies Over 70,000 gastroscopies
Both allow for visualisation and biopsy Gastroscopy – gastritis, ulcers, cancer,
H. Pylori infection, acid reflux, hiatus hernia, food intolerance, ERCP..
Colonoscopy – IBS, IBD, polyps, cancer, diverticulum, angiodysplasia..
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Role of Sedation and Anaestheia Relieve pts anxiety and discomfort of procedure
Reduce the pts memory of the event
Increase operator ease in performing the procedure
Improve outcome of the examination
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Pre-op Anaesthetic Assessment - 1 Informed Consent
Details of sedation/analgesia/anaesthesia, as well as -benefits, risks, limitations, possible alternatives
History Past anaesthetic/sedation experiences + any adverse
effects Major organ abnormalities – CDV, resp, kidney, neuro,
gastro Airway features – snoring, sleep apnoea, stridor Medications and Allergies Past medical history – medical conditions and past surgeries Substance use – alcohol, tobacco, other Women - possibility of pregnancy?
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Pre-op Anaesthetic Assessment - 2 Examination
Vitals – HR, BP, O2 saturation, RR, temp CDV and Resp assessment Airway Anatomy
Neck ROM Jaw Teeth Mallampati score
Inform patient of minimum fasting time2: 2hrs – clear fluids 6hrs – light solids
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Pre-op Anaesthetic Assessment – 3 No data supporting routine pre-op investigations in elective
GI endoscopy3
Relevant Investigations based on the pts history and risk factors FBC EUC LFT BSL Coags Group and Hold CXR ECG
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Particular Problems/Concerns Pregnancy Lactating Delayed gastric emptying Compromised CDV/Resp function Pts with renal or hepatic deficits Medication
Use of anti-thrombotics/anti-platelets Antibiotic therapy
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General Technique Level of anaesthetic used may range from:
nothing conscious sedation sedation GA Things to consider:
Health status – comorbidities Current medications Procedure Age Weight Procedural anxiety Pain tolerance Patient preference
Medications used Sedation + pain relief – midazolam, propofol, fentanyl, sevoflurane Anti-emetics
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Australian anaesthetists’ practice of sedation for GIT endoscopy in adult patients5 – combinations used
*Operator dependent; no optimal drug combination has been established for endoscopy 99 eligible respondents
1 – midazolam + fentanyl - gastroscopy 1 – Sevoflurane for ERCP 1 – Sevoflurane for colonoscopyFor the rest: 4% - Propofol 14% - Propofol + midazolam 6% - Propofol + fentanyl 61% - Propofol + midazolam + fentanyl 15% - Propofol + other drug (alfentanil, ketamine, remifentanil,
pethidine)
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Australian anaesthetists’ practice of sedation for GIT endoscopy in adult patients5
Midazolam usage in gastroscopy correlated with years post-Fellowship <10 years – 76% >10 years – 92% Not statistically significant for ERCP or colonoscopy
Propofol dosing Bolus method preferred Infusion rates higher in ERCP > colonoscopy >
gastroscopy
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Australian anaesthetists’ practice of sedation for GIT endoscopy in adult patients5 - Airway Management
Jaw Lift as required - G 97%, C 92%, E 80% Laryngeal Mask airway - 3%, 8%, 1% Endotracheal Tube - 0%, 0%, 19%
Consider use of ET tube if: Difficult airway to manage on assessment known aspiration risk
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Propofol Used for induction + maintenance of anaesthesia,
conscious sedation, sedation during ventilation MOA – uncertain
GABAA potentiation slower closing time Sodium channel blocker Role of endocannabinoid system
Dose – conscious sedation Adult –
IV 0.5-1.0 mg/kg over 1-5 minutes IV 1.5mg/kg/hr maintenance Bolus of 10-20mg if rapidly needed
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Propofol Duration of Effect (DOF) – 4-8 mins Pregnancy – possible CNS and resp depression Breastfeeding – appears safe Adverse effects
Common - pain on injection ~30%, bradycardia, hypotension, apnoea, flushed skin or rash, cough, induction excitation
Infrequent – arrhythmias, thrombosis, phlebitis Rare – anaphylactic reaction, seizure, fever,
pancreatitis
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Midazolam Used for induction of anaesthesia, conscious sedation,
sedation during ventilation MOA – binds to benzodiazepine site
promotes binding of GABA to GABAAreceptors increase chloride entersneurons neuron hyperpolarisation less firing effects
Dose – conscious sedation Adult –
IV 2-2.5mg, 1-1.5 if elderly or debilitated 1mg doses as needed
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Midazolam DOF – 15-80 mins Pregnancy – avoid in late 3TM and during labour Breastfeeding – limited data; highly protein bound, short
half life feed as usual after surgery Care: renal and hepatic impairment Adverse Effects
C – hypotension, hiccup, cough I – pain on injection, erythema, rash, laryngospasm,
bronchospasm, N/V, headache R – arrhythmia, cardiorespiratory arrest, anaphylactic reaction
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Fentanyl Used as opioid adjunct during anaesthesia MOA – bind to opioid receptors (m, d, k) in central
and peripheral neurons G-protein coupled receptors inhibit neurotransmitter release decrease pain signals transmitted analgesia
Dose – Adult –
IV 50-100ug initially IV 25-50ug as required
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Fentanyl DOF – 30-60 mins Pregnancy – prolonged high doses can cause
respiratory depression in newborn + withdrawal syndrome
Breastfeeding – Safe to use occasional doses of opioids Monitor for sedation or other effects
Adverse Effects C – rash, erythema, bradycardia, N/V, constipation R – chest wall rigidity (very high/rapid IV doses)
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Sevoflurane Used for induction and maintenance of anaesthesia MOA – uncertain
Enhance inhibitory ion channel activity and inhibit excitatory activity in: brain hypnosis + amnesia Spinal cord – immobility in response to painful stimuli
Dose – Adults/child
Up to 8% inspired conc. in O2 +/- nitrous oxide; fresh gas flow >2L/min
0.5-3% +/- NO2
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Sevoflurane
Pregnancy – safe Breastfeeding – no adverse effects expected Adverse Effects
C – shivering, N/V I – arrhythmias R – malignant hyperpyrexia
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Intraoperative Monitoring/Intervention5
Recommended by ANZCA Oxygen administration Pulse oximetry Non Invasive BP
IV Fluids ECG Capnography
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Complications Risks associated with various agents
Risk of aspiration
Surgical risks - GIT perforation, bleeding, infection
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Post-op Management Patient extubated after awake and protecting
airway Handover to post-op staff and monitored ~1 hour
Oxygen therapy Pulse oximeter Blood pressure ECG Other vitals
Limitations for 24hr – no driving, operating heavy machinery, signing legal documents, drinking alcohol
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References1. Australian Council on Healthcare Standards (ACHS). Gastrointestinal Endoscopy version 1. Retrospective data in
full. Australasian Clinical Indicator Report 2004–2011. Sydney NSW; ACHS; 2012
2. Lichtenstein DR, Jagannath S, Baron TH, Anderson MA, Banerjee S, Dominitz JA, Fanelli RD, Gan SI, Harrison ME, Ikenberry SO, Shen B, Stewart L, Khan K, Vargo JJ, Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy. Sedation and anesthesia in GI endoscopy. Gastrointest Endosc. 2008 Nov;68(5):815-26.
3. ASGE Standards of Practice Committee, Levy MJ, Anderson MA, Baron TH, Banerjee S, Dominitz JA, Gan SI, Harrison ME, Ikenberry SO, Jagannath S, Lichtenstein D, Shen B, Fanelli RD, Stewart L, Khan K. Position statement on routine laboratory testing before endoscopic procedures. Gastrointest Endosc. 2008, Nov;68(5):827-32.
4. Joo HS, Wong J, Naik VN, Savoldelli GL. The Value of screening preoperative chest x-rays: a systematic review. Can J Anaesth. 2005, Jun-Jul;52(6):588-74.
5. Padmanabhan U, Leslie K. Australian anaesthetists’ practice of sedation for gastrointestinal endoscopy in adult patients. Anaesth Intensive Care. 2008, May;36(3):436-41.
6. ASGE Standards of Practice Committee, Anderson MA, Ben-Menachem T, Gan SI, Appalaneni V, Banerjee S, Cash BD, Fisher L, Harrison ME, Fanelli RD, Fukami N, Ikenberry SO, Jain R, Khan K, Krinsky ML, Lichtenstein DR, Maple JT, Shen B, Strohmeyer L, Baron T, Dominitz JA. Management of antithrombotic agents for endoscopic procedures. Gastrointest Endosc. 2009, Dec;70(6):1060-70.
7. RACGP, PSA, ASCEPT. Australian Medicines Handbook 2011. Adelaide, SA. 2011.
8. Chahl LA. Opioids – mechanism of action. Aust Prescr. 1996;19:63-5.
9. Pardo M, Sonner JM. Manual of Anesthesia Practice – Pocket Clinician. 1st ed. New York: Cambridge University Press; 2007.