Skip to main content

Sedation and Analgesic Considerations for Gastrointestinal Procedures

  • Chapter
  • First Online:
Pain Control in Ambulatory Surgery Centers

Abstract

Gastrointestinal (GI) procedures are performed in various settings and are important for prevention and treatment of various disease states. For many years, these procedures were commonly performed with a combination of opioids and benzodiazepines. However, in recent years, there has been a significant shift to propofol, allowing for both moderate and deep sedation. Propofol has been popular with patients and has sedative effects with no known antidote. Baseline vital signs, physical examination, and past medical history are always required for any patient who is to receive anesthesia. Further, sedation involving propofol requires airway expertise, since its delivery can result in hypoxia and respiratory depression. Of note, standard monitoring nationwide requires temperature, blood pressure, electrocardiogram, pulse oximetry, and quantitative continuous end tidal CO2 monitoring. Given that many GI procedures are performed in the lateral and prone positions, it is essential for safety to utilize all five standards monitors to provide safe anesthesia for these patients. While midazolam and fentanyl remain popular for many patients needing moderate sedation, a deeper level of sedation is most typically achieved with propofol related to increased patient satisfaction and ideal pharmacokinetics. New anesthetic agents such as the alpha-2 agonist dexmedetomidine are being evaluated to aid GI sedation. To reduce potential adverse events during GI procedural anesthesia, anesthesiology services are recommended for most patients and particularly in high-risk populations requiring deep sedation. In summary, the strongest emphasis should be placed on utilization of ASA standard monitors for all patients undergoing GI procedures. Continuous quantitative end tidal CO2 monitoring must be employed for safe delivery of sedation for any GI procedure.

This is a preview of subscription content, log in via an institution to check access.

Access this chapter

Subscribe and save

Springer+ Basic
EUR 32.99 /Month
  • Get 10 units per month
  • Download Article/Chapter or Ebook
  • 1 Unit = 1 Article or 1 Chapter
  • Cancel anytime
Subscribe now

Buy Now

Chapter
USD 29.95
Price excludes VAT (USA)
  • Available as PDF
  • Read on any device
  • Instant download
  • Own it forever
eBook
USD 99.00
Price excludes VAT (USA)
  • Available as EPUB and PDF
  • Read on any device
  • Instant download
  • Own it forever
Softcover Book
USD 129.99
Price excludes VAT (USA)
  • Compact, lightweight edition
  • Dispatched in 3 to 5 business days
  • Free shipping worldwide - see info

Tax calculation will be finalised at checkout

Purchases are for personal use only

Institutional subscriptions

Similar content being viewed by others

References

  1. An Astounding 19 Million Colonoscopies are Performed Annually in The United States – iData Research. https://idataresearch.com/an-astounding-19-million-colonoscopies-are-performed-annually-in-the-united-states/. Accessed March 21, 2020.

  2. Saunders R, Erslon M, Vargo J. Modeling the costs and benefits of capnography monitoring during procedural sedation for gastrointestinal endoscopy. Endosc Int Open. 2016;04(03):E340–51. https://doi.org/10.1055/s-0042-100719.

    Article  Google Scholar 

  3. Sidhu R, Turnbull D, Newton M, et al. Deep sedation and anaesthesia in complex gastrointestinal endoscopy: a joint position statement endorsed by the British Society of Gastroenterology (BSG), Joint Advisory Group (JAG) and Royal College of Anaesthetists (RCoA). Frontline Gastroenterol. 2019;10(2):141–7. https://doi.org/10.1136/flgastro-2018-101145.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Goudra B, Singh P. Critical analysis of guidelines for providing sedation to patients undergoing gastrointestinal endoscopy procedures. Anesth Essays Res. 2019;13(4):601. https://doi.org/10.4103/aer.aer_135_19.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Kaye AD, Jones MR, Viswanath O, et al. Guidelines ASIPP Guidelines for Sedation and Fasting Status of Patients Undergoing Interventional Pain Management Procedures. 2019. www.painphysicianjournal.com. Accessed March 21, 2020.

  6. Daabiss M. American society of anaesthesiologists physical status classification. Indian J Anaesth. 2011;55(2):111–5. https://doi.org/10.4103/0019-5049.79879.

    Article  PubMed  PubMed Central  Google Scholar 

  7. Lee JK, Lee YJ, Cho JH, et al. Updates on the sedation for gastrointestinal endoscopy. Clin Endosc. 2019;52(5):451–7. https://doi.org/10.5946/ce.2019.172.

    Article  PubMed  PubMed Central  Google Scholar 

  8. Mallampati Score – an overview | ScienceDirect Topics. https://www.sciencedirect.com/topics/medicine-and-dentistry/mallampati-score. Accessed March 21, 2020.

  9. Mulder CJJ, Jacobs MAJM, Leicester RJ, et al. Guidelines for designing a digestive disease endoscopy unit: Report of the World Endoscopy Organization. Dig Endosc. 2013;25(4):365–75. https://doi.org/10.1111/den.12126.

    Article  PubMed  Google Scholar 

  10. Pall H, Lerner D, Khlevner J, et al. Developing the Pediatric gastrointestinal endoscopy unit. J Pediatr Gastroenterol Nutr. 2016;63(2):295–306. https://doi.org/10.1097/MPG.0000000000001189.

    Article  PubMed  Google Scholar 

  11. Mergener K, Tanner B. Setting up an endoscopy facility. 2019. doi:https://doi.org/10.1016/B978-0-323-41509-5.00002-5.

  12. Lin OS, Weigel W. Nonoperating room anesthesia for gastrointestinal endoscopic procedures. Curr Opin Anaesthesiol. 2018;31:486. https://doi.org/10.1097/ACO.0000000000000610.

    Article  PubMed  Google Scholar 

  13. Wehrmann T, Triantafyllou K. Propofol sedation in gastrointestinal endoscopy: a gastroenterologist’s perspective. Digestion. 2010;82:106. https://doi.org/10.1159/000285554.

    Article  CAS  PubMed  Google Scholar 

  14. Repici A, Hassan C. The endoscopist, the anesthesiologists, and safety in GI endoscopy. Gastrointest Endosc. 2017;85:109. https://doi.org/10.1016/j.gie.2016.06.025.

    Article  PubMed  Google Scholar 

  15. Tobias JD. Sedation of infants and children outside of the operating room. Curr Opin Anaesthesiol. 2015;28:478. https://doi.org/10.1097/ACO.0000000000000203.

    Article  PubMed  Google Scholar 

  16. Gerstenberger PD. Capnography and patient safety for endoscopy. Clin Gastroenterol Hepatol. 2010;8:423. https://doi.org/10.1016/j.cgh.2010.02.024.

    Article  PubMed  Google Scholar 

  17. Lightdale JR, Goldmann DA, Feldman HA, Newburg AR, DiNardo JA, Fox VL. Microstream capnography improves patient monitoring during moderate sedation: a randomized, controlled trial. Pediatrics. 2006;117:e1170. https://doi.org/10.1542/peds.2005-1709.

    Article  PubMed  Google Scholar 

  18. American Society of Anesthesiologists Martinench A. American Society of Anesthesiologists: ASA physical status classification system. In: Am Soc Anesthesiol Web site Internet; 2014.

    Google Scholar 

  19. Ebert TJ, Middleton AH, Makhija N. Ventilation monitoring during moderate sedation in GI patients. J Clin Monit Comput. 2017;31:53. https://doi.org/10.1007/s10877-015-9809-1.

    Article  PubMed  Google Scholar 

  20. Adams MA, Prenovost KM, Dominitz JA, et al. Predictors of use of monitored anesthesia care for outpatient gastrointestinal endoscopy in a capitated payment system. Gastroenterology. 2017;153:1496. https://doi.org/10.1053/j.gastro.2017.08.030.

    Article  PubMed  Google Scholar 

  21. Paz JC. Acute care handbook for physical therapists; 2014. https://doi.org/10.1016/B978-1-4557-2896-1.00008-1.

    Book  Google Scholar 

  22. Smith ZL, Mullady DK, Lang GD, et al. A randomized controlled trial evaluating general endotracheal anesthesia versus monitored anesthesia care and the incidence of sedation-related adverse events during ERCP in high-risk patients. Gastrointest Endosc. 2019;89:855. https://doi.org/10.1016/j.gie.2018.09.001.

    Article  PubMed  Google Scholar 

  23. Wadhwa V, Vargo JJ. Sedation and monitoring in endoscopy- clinical gastrointestinal edoscopy. 3rd ed. (Chandrasekhara V, Khashab M, Elmunzer J, Muthusamy R, eds.).; 2019. https://www-clinicalkey-com.proxy.lib.mcw.edu/#!/content/book/3-s2.0-B9780323415095000074. Accessed 21 Mar 2020.

  24. Levitzky BE, Lopez R, Dumot JA, Vargo JJ. Moderate sedation for elective upper endoscopy with balanced propofol versus fentanyl and midazolam alone: a randomized clinical trial. Endoscopy. 2012;44(1):13–20. https://doi.org/10.1055/s-0031-1291421.

    Article  CAS  PubMed  Google Scholar 

  25. Brouillette DE, Leventhal R, Kumar S, et al. Midazolam versus diazepam for combined esophogastroduodenoscopy and colonoscopy. Dig Dis Sci. 1989;34(8):1265–71. https://doi.org/10.1007/BF01537276.

    Article  CAS  PubMed  Google Scholar 

  26. Sedative and Analgesic Drugs for Gastrointestinal Endoscopic Procedure | Amornyotin | Journal of Gastroenterology and Hepatology Research. http://www.ghrnet.org/index.php/joghr/article/view/779/893. Accessed March 21, 2020.

  27. Early DS, Lightdale JR, Vargo JJ, et al. Guidelines for sedation and anesthesia in GI endoscopy ASGE STANDARDS OF PRACTICE COMMITTEE. Gastrointest Endosc. 2018;87:327–37. https://doi.org/10.1016/j.gie.2017.07.018.

    Article  PubMed  Google Scholar 

  28. Effect of target controlled propofol infusion versus intermittent boluses during oesophagogastroduodenoscopy: a randomized controlled trial | African Health Sciences. https://www.ajol.info/index.php/ahs/article/view/192297. Accessed March 21, 2020.

  29. Ogawa T, Tomoda T, Kato H, Akimoto Y, Tanaka S, Okada H. Propofol sedation with a target-controlled infusion pump in elderly patients undergoing ERCP. Gastrointest Endosc. 2020;92:301. https://doi.org/10.1016/j.gie.2020.03.002.

    Article  PubMed  Google Scholar 

  30. Mu J, Jiang T, Xu XB, Yuen VM, Irwin MG. Comparison of target-controlled infusion and manual infusion for propofol anaesthesia in children. Br J Anaesth. 2018;120:1049–55. https://doi.org/10.1016/j.bja.2017.11.102.

    Article  CAS  PubMed  Google Scholar 

  31. Pambianco DJ, Cash BD. New horizons for sedation: the ultrashort acting benzodiazepine remimazolam. Tech Gastrointest Endosc. 2016;18(1):22–8. https://doi.org/10.1016/j.tgie.2016.02.004.

    Article  Google Scholar 

  32. Pastis NJ, Yarmus LB, Schippers F, et al. Safety and efficacy of remimazolam compared with placebo and midazolam for moderate Sedation during bronchoscopy. Chest. 2019;155(1):137–46. https://doi.org/10.1016/j.chest.2018.09.015.

    Article  PubMed  Google Scholar 

  33. Dinis-Oliveira RJ. Metabolic profiles of propofol and fospropofol: clinical and forensic interpretative aspects. 2018. https://doi.org/10.1155/2018/6852857.

  34. Eskander AE, El Baroudy NR, El Refay AS. Ketamine sedation in gastrointestinal endoscopy in children. Maced J Med Sci. 2016;4(3):392–6. https://doi.org/10.3889/oamjms.2016.085.

    Article  Google Scholar 

  35. Sleigh J, Harvey M, Voss L, Denny B. Ketamine - more mechanisms of action than just NMDA blockade. Trends Anaesth Crit Care. 2014;4(2–3):76–81. https://doi.org/10.1016/j.tacc.2014.03.002.

    Article  Google Scholar 

  36. Sivilotti MLA. Flumazenil, naloxone and the ‘coma cocktail’. Br J Clin Pharmacol. 2016;81(3):428–36. https://doi.org/10.1111/bcp.12731.

    Article  CAS  PubMed  Google Scholar 

  37. Conscious sedation using propofol versus midazolam in cirrhotic patients during upper GI endoscopy: a comparative study – Wahab – 2019 – JGH Open – Wiley Online Library. https://onlinelibrary.wiley.com/doi/pdf/10.1002/jgh3.12098. Accessed March 21, 2020.

  38. Mohamed F, Kandil Y. Propofol versus midazolam in sedation for upper gastrointestinal endoscopy. Int J Med Arts. 2019;0(0):0–0. https://doi.org/10.21608/ijma.2019.18082.1037.

    Article  Google Scholar 

  39. Rabiee A, Moshiree B. Upper and lower endoscopy for gastrointestinal (GI) bleeding in pregnancy. In: Non-obstetric surgery during pregnancy: Springer; 2019. p. 155–64. https://doi.org/10.1007/978-3-319-90752-9_12.

  40. Chung F, Abdullah HR, Liao P. STOP-bang questionnaire a practical approach to screen for obstructive sleep apnea. Chest. 2016;149(3):631–8. https://doi.org/10.1378/chest.15-0903.

    Article  PubMed  Google Scholar 

  41. ​Standards for Postanesthesia Care | American Society of Anesthesiologists (ASA). Am Soc Anesthesiol. 2019.

    Google Scholar 

  42. Postanesthesia Care - Practice Considerations. American Association of Nurse Anesthetists.

    Google Scholar 

  43. Stein K. Clarifying the confusion of adult emergence delirium. AANA J. 2017;85(3):223.

    Google Scholar 

  44. Cui V, Tedeschi CM, Kronzer VL, McKinnon SL, Avidan MS. Protocol for an observational study of delirium in the post-anaesthesia care unit (PACU) as a potential predictor of subsequent postoperative delirium. BMJ Open. 2017;7(7):e016402. https://doi.org/10.1136/bmjopen-2017-016402.

    Article  PubMed  PubMed Central  Google Scholar 

  45. Wadhwa V, Gupta K, Vargo JJ. Monitoring standards in sedation and analgesia: the odyssey of capnography in sedation for gastroenterology procedures. Curr Opin Anaesthesiol. 2019;32(4):453–6. https://doi.org/10.1097/ACO.0000000000000756.

    Article  PubMed  Google Scholar 

  46. Becker DE, Haas DA. Recognition and management of complications during moderate and deep sedation part 1: respiratory considerations. Anesth Prog. 2011;58(2):82–92. https://doi.org/10.2344/0003-3006-58.2.82.

    Article  PubMed  PubMed Central  Google Scholar 

  47. Steven E. Abram, MD; Michael C. Francis M. Hazards of sedation for interventional pain procedures – anesthesia patient safety foundation. Anesth Patient Saf Found. 2012;27(2).

    Google Scholar 

  48. Memtsoudis SG, Cozowicz C, Nagappa M, et al. Society of anesthesia and sleep medicine guideline on intraoperative management of adult patients with obstructive sleep apnea. Anesth Analg. 2018;127(4):967–87. https://doi.org/10.1213/ANE.0000000000003434.

    Article  PubMed  PubMed Central  Google Scholar 

  49. Edgcombe H, Carter K, Yarrow S. Anaesthesia in the prone position. Br J Anaesth. 2008;100(2):165–83. https://doi.org/10.1093/bja/aem380.

    Article  CAS  PubMed  Google Scholar 

  50. ​Standards for Basic Anesthetic Monitoring | American Society of Anesthesiologists (ASA). Am Soc Anesthesiol. 2015.

    Google Scholar 

  51. Weaver J. The latest ASA mandate: CO(2) monitoring for moderate and deep sedation. Anesth Prog. 2011;58(3):111–2. https://doi.org/10.2344/0003-3006-58.3.111.

    Article  PubMed  PubMed Central  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Alan David Kaye .

Editor information

Editors and Affiliations

Rights and permissions

Reprints and permissions

Copyright information

© 2021 The Author(s), under exclusive license to Springer Nature Switzerland AG

About this chapter

Check for updates. Verify currency and authenticity via CrossMark

Cite this chapter

Fuller, M.C., Harrison, K., Tullis, E., Jones, M.R., Cornett, E.M., Kaye, A.D. (2021). Sedation and Analgesic Considerations for Gastrointestinal Procedures. In: Rajput, K., Vadivelu, N., Kaye, A.D., Shah, R.V. (eds) Pain Control in Ambulatory Surgery Centers. Springer, Cham. https://doi.org/10.1007/978-3-030-55262-6_18

Download citation

  • DOI: https://doi.org/10.1007/978-3-030-55262-6_18

  • Published:

  • Publisher Name: Springer, Cham

  • Print ISBN: 978-3-030-55261-9

  • Online ISBN: 978-3-030-55262-6

  • eBook Packages: MedicineMedicine (R0)

Publish with us

Policies and ethics