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

2. 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

3. 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 ●

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

5. 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

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

7. Airway Assessment

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

9. 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?

10. 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

11. 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

12. 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

13. 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?

14. References ● Stoelting RK, Miller RD. Basics of Anesthesia. Fifth Edition. 2007; 540-551. ● Sedation and anesthesia in GI endoscopy. Gastrointestinal Endoscopy 2008, 68; 815-826.