The endoscopist, the anesthesiologists, and safety in GI endoscopy

Anesthesia for digestive tract endoscopy

PURPOSE OF REVIEW

Nonoperating room anesthesia for digestive tract endoscopy has its own specificities and requires practical training. Monitoring devices, anesthetic drugs, understanding of procedures and management of complications are critical aspects.

RECENT FINDINGS

New data are available regarding risk factors for intra- and postoperative complications (based on anesthesia registries), airway management, new anesthetic drugs, techniques of administration and management of advances in interventional endoscopy procedures.

SUMMARY

Digestive tract endoscopy is a common procedure that takes place outside the operating room most of the time and has become more and more complex due to advanced invasive procedures. Prior evaluation of the patient's comorbidities and a good understanding of the objectives and constraints of the endoscopic procedures are required. Assessing the risk of gastric content aspiration is critical for determining appropriate anesthetic protocols. The availability of adequate monitoring (capnographs adapted to spontaneous ventilation, bispectral index), devices for administration of anesthetic/sedative agents (target-controlled infusion) and oxygenation (high flow nasal oxygenation) guarantees the quality of sedation and patient' safety during endoscopic procedures. Knowledge of the specificities of each interventional endoscopic procedure (endoscopic retrograde cholangiopancreatography, submucosal dissection) allows preventing complications during anesthesia.

Comparative effectiveness of lidocaine sprays between sitting and supine position for patients undergoing upper gastrointestinal endoscopy: a prospective randomized controlled trial

BACKGROUND

Topical pharyngeal anesthesia has improved esophagogastroduodenoscopy (EGD) efficiency with smooth insertion, reducing pain and discomfort. Lidocaine spray is one of the safe and widely used methods. In practice, the patients walk, sit in a wheelchair, or lie on a trolley bed, and the lidocaine sprays are applied to those in sitting or supine positions for pre-endoscopic preparation. Although there is no current guidance technique, this study aims to compare the effects of lidocaine sprays between sitting (Group A; Gp A) and supine positions (Group B; Gp B) for patients undergoing unsedated EGD.

METHODS

This study was a single-center prospective randomized controlled trial. Unsedated EGD patients were randomly allocated the lidocaine spray in sitting or lidocaine spray in the supine position.

RESULTS

Lidocaine spray treatments were significantly different in the gag reflex (NRS; Gp A: 1.28 ± 0.67, Gp B: 1 ± 0.63, p = 0.0003), ease of esophageal instrumentation (NRS; Gp A: 7.68 ± 0.91, Gp B: 7.95 ± 0.66, p = 0.0042), and pain score (NRS; Gp A: 5.16 ± 2.08, Gp B: 4.53 ± 1.93, p = 0.0059). When considering modified Mallampati classification (MMC), MMC classes III and IV were significantly different in the same direction but MMC classes I and II were not.

CONCLUSION

The technique of spraying in the supine position was associated with less gagging, less pain, and easier esophageal instrumentation, especially in patients with MMC classes III and IV.

Comparison of Lidocaine Spray and Lidocaine Ice Popsicle in Patients Undergoing Unsedated Esophagogastroduodenoscopy: A Single Center Prospective Randomized Controlled Trial

Purpose

Esophagogastroduodenoscopy (EGD) under topical pharyngeal anesthesia has the advantage of avoiding the unwanted cardiopulmonary adverse events experienced following intravenous sedation. Lidocaine spray is a common anesthetic option and is safe for unsedated EGD. Although several studies have compared different topical anesthetic agents, their formulations, and delivery techniques, questions still remain concerning the optimal mode of administration. We have designed a lidocaine formulation in the form of an ice popsicle and compared its effectiveness and tolerability with lidocaine spray in patients undergoing unsedated EGD.

Methods

This was a single-center prospective randomized controlled trial. Unsedated EGD patients were randomly allocated the lidocaine spray [Group (Gp) A] or lidocaine ice popsicle (Gp B) formulation.

Results

In total, 204 unsedated EGD patients were evaluated. Compared to the spray, the lidocaine ice popsicle group showed better scores for effects in terms of endoscopist satisfaction (Gp A, 7.28±1.44; Gp B, 7.8±0.89; p=0.0022), gag reflex (Gp A, 1.3±0.66; Gp B, 1.02±0.61; p=0.0016), patient satisfaction (Gp A, 7.74±0.82; Gp B, 8.08±0.82; p=0.0039), discomfort (Gp A, 6.54±1.34; Gp B, 5.95±1.21; p=0.0012), and pain (Gp A, 5.38±1.85; Gp B, 4.51±2.01; p=0.0015).

Conclusion

Both the lidocaine spray and ice popsicle formulations are safe, effective options for diagnostic EGD with the ice popsicle exhibiting better performance. We propose the lidocaine ice popsicle formulation for topical pharyngeal anesthesia in patients undergoing unsedated diagnostic EGD and suggest it may be a suitable option during the COVID-19 pandemic.

Clinical Trial Register

Thai Clinical Trials Registry (TCTR) number TCTR20190502001.

Sedation During Endoscopy in Patients with Cirrhosis: Safety and Predictors of Adverse Events

BACKGROUND

Sedation during endoscopy in cirrhotic patients is typically via moderate sedation, most commonly using a combination of a benzodiazepine (i.e., midazolam) and narcotic (i.e., fentanyl) or with propofol using monitored anesthesia care (MAC). Here, we examined the safety of moderate sedation and MAC in patients with cirrhosis.

METHODS

This retrospective cohort study of cirrhotic patients undergoing endoscopy from a large academic medical center between 2010 and 2014 examined extensive clinical data including the following: past history, physical findings, laboratory results, and procedural adverse events. Adverse events were defined a priori and included hypoxia, hypotension, bleeding, and death.

RESULTS

We identified 2618 patients with cirrhosis who underwent endoscopic procedures; the mean age was 56 years, 36% were female, the mean Child-Pugh score was 9.3 (IQR: 8, 11), and Charlson Comorbidity Index score was 3.2 (IQR: 1, 4); 1157 had MAC; and 1461 had moderate sedation. There was no difference in the frequency of adverse events in MAC and moderate sedation groups, with a total of 15 adverse events (7/1157 MAC and 8/1461 moderate sedation). The most common procedure performed was esophagogastroduodenoscopy (EGD, n = 1667) and was associated with 10 adverse events. Overall, adverse events included bradycardia (1), hypoxia (7), bleeding (5), laryngospasm (1), and perforation (1). The frequency was similar for EGD, ERCP, and colonoscopy-each at a rate of 0.6%.

CONCLUSIONS

Adverse events in cirrhotic patients undergoing endoscopy appeared to be similar with moderate sedation or MAC, and the frequency was the same for different types of procedures.

Nonoperating room anesthesia for gastrointestinal endoscopic procedures

PURPOSE OF REVIEW

To assess the trends in nonoperating room anesthesia (NORA) for gastrointestinal endoscopy over the past few years, and to describe alternative methods of delivering propofol sedation in selected low-risk patients.

RECENT FINDINGS

The use of NORA for routine gastrointestinal endoscopic procedures has been rising steadily over the past decade in the United States, considerably increasing healthcare costs. Because of this, there have been attempts to develop nonanesthesiologist-administered propofol sedation methods in low-risk patients. There is controversy as to whether properly trained nonanesthesia personnel can use propofol safely via the modalities of nurse-administered propofol sedation, computer-assisted propofol sedation or nurse-administered continuous propofol sedation SUMMARY: The deployment of nonanesthesia-administered propofol sedation for low-risk procedures allows for optimal allocation of scarce anesthesia resources, which can be more appropriately used for more complex cases. This can address some of the current shortages in anesthesia provider supply, and can potentially reduce overall healthcare costs without sacrificing sedation quality. We also address the realm of anesthesia provider care for advanced endoscopic procedures including setup for administration of anesthesia, decision-making regarding placement of an endotracheal tube, and the potential need to move a challenging case to the operating room.

Sedation for routine gastrointestinal endoscopic procedures: a review on efficacy, safety, efficiency, cost and satisfaction

Most gastrointestinal endoscopic procedures are now performed with sedation. Moderate sedation using benzodiazepines and opioids continue to be widely used, but propofol sedation is becoming more popular because its unique pharmacokinetic properties make endoscopy almost painless, with a very predictable and rapid recovery process. There is controversy as to whether propofol should be administered only by anesthesia professionals (monitored anesthesia care) or whether properly trained non-anesthesia personnel can use propofol safely via the modalities of nurse-administered propofol sedation, computer-assisted propofol sedation or nurse-administered continuous propofol sedation. The deployment of non-anesthesia administered propofol sedation for low-risk procedures allows for optimal allocation of scarce anesthesia resources, which can be more appropriately used for more complex cases. This can address some of the current shortages in anesthesia provider supply, and can potentially reduce overall health care costs without sacrificing sedation quality. This review will discuss efficacy, safety, efficiency, cost and satisfaction issues with various modes of sedation for non-advanced, non-emergent endoscopic procedures, mainly esophagogastroduodenoscopy and colonoscopy.

In response to the editorial: "Will societies of anesthesiologists partake in the take-off of non-anesthesiologist administration of propofol?"

The editorial of Dr. Dumonceau comments on the discrepancies with the declarations done in regard to the article sent by titled Alvarez J. et al "Safety of the patient in deep sedation for endoscopico digestive procedures". We do not agree in the analysis of the mortality, with comparative studies between anesthesiologists and not anesthesiologists and with the conclusion of the editorial.