Anaesthesia in Gastroscopy and Colonoscopy

Adrian Castro (Bill) and Dr. Ross Wilson

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..

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

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?

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

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

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

General Technique
Level of anaesthetic used may range from:
Things to consider: Health status comorbidities Current medications Procedure Age Weight Procedural anxiety Pain tolerance Patient preference

nothing conscious sedation sedation GA

Medications used Sedation + pain relief midazolam, propofol, fentanyl, sevoflurane Anti-emetics

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 colonoscopy For the rest: 4% - Propofol 14% - Propofol + midazolam 6% - Propofol + fentanyl 61% - Propofol + midazolam + fentanyl 15% - Propofol + other drug (alfentanil, ketamine, remifentanil, pethidine)

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

Australian anaesthetists practice of sedation for GIT endoscopy in adult patients5 - Airway Management
Jaw Lift as required Laryngeal Mask airway Endotracheal Tube -

G 97%, C 92%, E 80%

3%, 0%, 8%, 0%, 1% 19%

Consider use of ET tube if:

Difficult airway to manage on assessment known aspiration risk

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

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

Midazolam
Used for induction of anaesthesia, conscious sedation, sedation

during ventilation
MOA binds to benzodiazepine site

promotes binding of GABA to GABAA receptors increase chloride enters neurons neuron hyperpolarisation less firing effects
Dose conscious sedation Adult
IV 2-2.5mg, 1-1.5 if elderly or debilitated 1mg doses as needed

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

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

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)

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

Sevoflurane

Pregnancy safe Breastfeeding no adverse effects expected Adverse Effects

C shivering, N/V I arrhythmias

R malignant hyperpyrexia

Intraoperative Monitoring/Intervention5
Recommended by ANZCA
Oxygen administration Pulse oximetry Non Invasive BP

IV Fluids
ECG Capnography

Complications
Risks associated with various agents

Risk of aspiration

Surgical risks - GIT perforation,

bleeding, infection

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

References
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Australian Council on Healthcare Standards (ACHS). Gastrointestinal Endoscopy version 1. Retrospective data in full. Australasian Clinical Indicator Report 20042011. Sydney NSW; ACHS; 2012
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. 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.

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