Anesthesia Considerations in Endoscopy Christy Johnson, MSNA, CRNA Nurse Anesthetist Hanover Anesthesia Group Memorial Regional Medical Center

Objectives ● The participant will be able to verbalize how anesthesia became involved in Endoscopy ● The participant will be able to recognize a possible “complicated” patient ● The participant will be able to identify an obstructed airway and simple corrective measures

History ● In office based procedures sedation was provided by RN ● Increased co-morbidity brought more cases into the hospital setting ● Use of Propofol increased the speed of procedure and recovery ● Gastroenterologist comfort level increased with Anesthesia in charge of the airway ●

Anesthesia Perspective ● How healthy is the patient? – Obesity – CRF – IDDM – Lung/Heart disease

ASA Physical Status Classifcation ● ASA 1 : A normal healthy patient ● ASA 2 : Patient with mild systemic disease ● ASA 3 : Patient with severe systemic disease ● ASA 4 : Patient with severe systemic disease that is a constant threat to life ● ASA 5 : A moribund patient who is not expected to survive without the operation ● ASA 6 : A delcared brain-dead patient whose organs are being harvested

Airway Assessment ● Decreased neck range of motion ● Decreased mouth opening ● Large tongue ● Redundant airway tissue

Airway Assessment

Monitoring Capabilities ● Supplemental Oxygen ● Working IV ● Pulse Ox, NBP, EKG ● Suction ● Readily accessible rescue drugs ● Accessible crash cart

Current Patient Condition ● Screening – Screening is typically 50 year old undergoing their first Colonoscopy – Can “assume” this patient is prepped and medically optomized for the procedure ● Diagnostic – Something is wrong with this patient – What is it??? – How sick is this patient?

Levels of Sedation ● Sedation is defined as a drug induced depression in the level of consciousness to relieve anxiety and discomfort, improve the outcome of the procedure, and diminish the patient's memory of the event

Levels of Sedation ● Light Sedation (Anxiolysis) – Patient is easily aroused – Airway is unaffected – Spontaneous ventilation is unaffected – Cardiovascular function is unaffected ● Moderate Sedation (Conscious sedation) – Patient responds to verbal or touch stimuli – No intervention necessary for airway – Adequate spontaneous ventilation – Cardiovascular usually maintained

Levels of Sedation ● Deep Sedation – Patient responds to repeated or painful stimuli – Airway intervention may be required – Spontaneous ventilation may be inadequate – Cardiovascular function is usually maintained ● General Anesthesia – Patient is unarousable even to painful stimuli – Airway intervention is often required – Spontaneous ventilation is usually inadequate – Cardiovascular function may be impaired

Scenario ● During an EGD, the patient begins to snore. What is the anesthetist thinking? ● Breathing becomes more erratic. Sats decreased to 85% ● What is the antedote for Propofol? ● What do we need to do? ● Why is IV access such a concern?

References ● Stoelting RK, Miller RD. Basics of Anesthesia. Fifth Edition. 2007; ● Sedation and anesthesia in GI endoscopy. Gastrointestinal Endoscopy 2008, 68;