Providing Deep Sedation for Advanced Endoscopic Procedures: The Esthetics of Endoscopic Anesthetics

Excerpt

With gastroenterologists firmly established as therapeutic endoscopists, the anesthesia requirements for advanced endoscopic procedures are approaching those of specialized surgical interventions. It is often stated that although there are minor surgeries, there is no such thing as minor anesthetics. Stated another way, “monitored anesthesia care” (more recently referred to as “deep sedation”) is just as risky as general anesthesia administered in a standard operating room (OR). Indeed, the available evidence suggests that the risks of providing anesthesia in locations such as endoscopy suites are higher than in conventional ORs. Our own study highlighted the dangers of providing deep sedation for patients undergoing all types of endoscopic procedures: The risk of propofol sedation for interventional procedures such as endoscopic retrograde cholangiopancreatography (ERCP), endoscopic ultrasound, and therapeutic endoscopy are among the highest for any sedated endoscopic procedure. The reasons are many: The intensity of stimulation encountered during these procedures is similar to many minor surgeries; the airway management is complex and requires constant attention; the incidence of hypoxemia is high, and the time available for recognition and management is limited; and finally, there are several cases of venous air embolism reported during ERCP and esophageal balloon dilation [1‐3]. In our analysis, we cited studies such as one by Metzner et al. [4] who in their analysis of anesthesia-related claims concluded that ~50 % of all out-of-OR-related deaths occurred during gastrointestinal (GI) endoscopy, and about half of these deaths were sedation-related. A more recent study concluded that propofol sedation is associated with a 13 % increase in all complications in patients undergoing colonoscopy. Providing sedation for GI endoscopy is thus an area with many undisputed challenges, controversies, and even some conspiracy theories [5, 6]. …