**Sedation Related to Gastrointestinal Endoscopy**

Mitrut Paul, Mitrut Anca Oana,

Streba Liliana, Calina Daniela and Salplahta Daniel *University of Medicine and Pharmacy of Craiova Romania* 

### **1. Introduction**

22 Gastrointestinal Endoscopy

Based largely on the evidence of our studies we have suggested that the following guidelines be used before for preparation for upper GI endoscopy in the Asian setting. 1. Patients can eat two slices of bread with jam six hours before the procedure.

2. Clear liquids mainly water, plain tea, or king coconut water may be consumed

5. These guidelines apply to patients between 18 to 65 yr and who do not have any

[1] A SAGES Co endorsed ASGE guidelines. Preparation of patients for gastrointestinal

[2] Canadian Anesthetists' Society's new guidelines for fasting in elective/emergency

[3] Brady M, Kinn S, Stuart P. Preoperative fasting for adults to prevent perioperative

[4] Faigel D, A SAGES Co Endorsed ASGE Guidelines. Preparation of patients for

[6] Hunt JN, Spurrell WR. The pattern of emptying of the human stomatch . J Physiol 1951;

[7] American Society of Anaethesiologist Task Force on Preoperative Fasting. Practice

 http//www.fao.org/docret/011/ai474e/ai474e05.htm (Accessed 10 January 2009). [9] Minami II, MCallum RW. The physiology and pathophysiology of gastric emptying in

[10] Hunt JN. Mechanisms and disorders of gastric emptying. Annu Rev Med. 1983;34:219-

[11] Camilleri M. Integrated upper gastrointestinal response to food intake.

[12] De Silva AP, Amarasiri L, Liyanage MN, Kottachchi D, Dassanayake AS, de Silva HJ.

[13] Webster GJ, Boling TE, Greenfield SM, Hallyburton E, Kuarn AM, Vicary FR, Beck ER.

[14] Philips S, Hutchinson A, Davidson T. Preoperative drinking does not affect gastric

[15] Hutchinson A, Maltby JR, Reid CRG. Gastric fluid volume and pH in elective inpatients. Part I: coffee or orange juice versus overnight fast. Can J Anaesth 1988; 35: 12-15. [16] Webster GJ, Boling TE, Greenfield SM, Hallyburton E, Kuarn AM, Vicary FR, Beck ER. Drinking before endoscopy, milk or water? Gastrointest Endosc 1997; 45: 406-8.

One-hour fast for water and six-hour fast for solids prior to endoscopy provides good endoscopic vision and results in minimum patient discomfort. J Gastroenterol

Assessment of residual gastric volume and thirst in patients who drink before

guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration:application to healthy patients undergoing elctive

3. Patients who consume a rice based meal will have to fast for at least ten hours.

obvious motility disorders. Other patients may need longer fasting time.

complications. Cochrane Database Syst Rev; 2003:4CD004423.

gastrointestinal endoscopy, 2006. Cited \*\* Available from URL:

[5] Ljungqvist O, Soreide E. Preoperative fasting. Br J Surg 2003; 90: 400406.

according to thirst up to one hour before the procedure

4. Patients may take their medications before the procedure.

endoscopy. 2006. http://www. asges.org.

patients. Can J Anaesth 1990; 37: 905-6.

http//www.asges.org (Accessed 10 Jan 2009).

procedures. Anaesthesiology 1999;79:482-5. [8] FAO. Food outlook. November 2008 page 15. URL:

humans. Gastroenterology 1984; 86: 1592-1610.

Gastroenterology 2006;131:640-58.

gastroscopy. Gut 1996; 39: 360-2.

contents. Br J Anaesth 1993; 70: 6-9.

Hepatol (in press).

**4. References** 

113: 157-68.

29.

In the last ten years the number of worldwide gastrointestinal endoscopic procedures has significantly increased; the majority are ambulatory endoscopies with appropriate intravenous sedation and analgesia which seems to be used more and more frequent. By definition, sedation is a drug-induced depression in the level of consciousness. Moderate sedation current terminology replaces the previous terminology called conscious sedation (American Society of Anesthesiologists [ASA], 2002). Sedation and analgesia are being used in order to improve patient tolerance to endoscopic procedures by diminishing anxiety and discomfort. There are several sequent benefits: an adequate sedation allows the endoscopist to focus on the technical performance of the endoscopy, increases the rate of patients returning for follow-up examinations or for colonoscopic screening, prevents potentially harmful autonomic stress responses and improves the public reputation of the procedure. However, these benefits must be weighed against the complications (especially in the form of potential compromise of ventilatory function) and the added cost associated with the use of sedation and analgesia.

Patients with associated comorbidities address to the gastroscopist to perform an endoscopy without being evaluated for their pathologies that could influence the procedures used in sedation. In addition, in cases where the examination is more invasive or conducted in a larger time interval, the level of sedation should be optimized to achieve an ideal procedure (ASA, 2002; Faigel *et al*., 2002).

The practice of sedation varies from country to country, determined by cultural differences in pain perception and expectations of patients and physicians. A recent international study of 21 centers in 10 European countries and in Canada reported that the use of sedation during endoscopy varies from 0% to 100% at different sites: it was used in 44% of all procedures in Asia, 56% in Europe, and 72% in Canada, Central America and South Latin America. In the United States, only flexible sigmoidoscopy is performed without sedation (Wang&Lin, 1999). Such diversity reflects social, cultural, regulatory and economic consideration.

Best practices for analgesia and sedation during gastrointestinal endoscopy are still debated. Ensuring an adequate sedation and analgesia influences some aspects of endoscopic procedures such as quality of examination, patient cooperation, patient and performing physician satisfaction (Bell, 2004).

There are several practical issues with implications for endoscopic sedation (Thomson *et al*., 2010):

Sedation Related to Gastrointestinal Endoscopy 25

asthma (AB), smoking and age are not necessarily problematic; biological age is more

**2.1.1 Selection criteria of patients for sedation in gastrointestinal endoscopy in an** 

• - BMI > 35: not recommended for sedation in ambulatory endoscopy, only in hospitals

**2.1.2 Exclusion criteria of patients for sedation in gastrointestinal endoscopy in an** 

• Cardiovascular: history of heart attack, hypertension (diastolic arterial blood pressure > 100 mmHg), angina (angina crisis > 3 times/week or during effort), arrhythmias,

• Respiratory: upper respiratory tract infection, corticodependent bronchial asthma or

• Metabolic disorders: chronic alcohol consumption, insulin-dependent diabetes, renal

• - BMI = 31-34 – anesthesiologist decides if recommends sedation

• Good general condition (eg. the patient can safely climb two floors)

asthma that requires chronic beta 2 agonists treatment, COPD

• Drugs: steroids, MAOIs, anticoagulants, antiarrhythmics

• Hemoleucogram if indicated (eg in case of menorrhagia)

morning dose, hypoglycemic medication instead should be omitted.

• Serum ionogram, after treatment with diuretics

• History of drug allergies or anesthesia problems

• Neurological: stroke or transient ischemic attack, hard controlled epilepsy

• Blood: sickle cell anemia, hemophilia, anemia after gastrointestinal bleeding

**2.1.3 Minimum investigation required for sedation in ambulatory gastrointestinal** 

Patient preparation is very important for sedation in ambulatory gastrointestinal endoscopy. During the pre-endoscopic examination, patients receive an informed consent about the risks of intravenous sedation. They also receive information leaflets and get the opportunity

Patients will initially be consulted and informed in writing about the medication which will be given, will be instructed not to drive vehicles and not to work with machinery 24 – 48 hours after the investigation, to avoid alcohol, to avoid the use of sedatives and to not sign official and financial documents. Antihypertensive medication should be continued with the

important than chronological age.

**ambulatory unit (Lytle, 2005)** 

• Age 6 months – 70 years

**ambulatory unit (Lytle, 2005)** 

cardiac insufficiency

failure, liver disorders

**endoscopy (Lytle, 2005)** 

• Body mass index (BMI) • Blood pressure measurement

• ECG in patients over 60 years

to ask questions (Clarks, 2007).

• Weight • Height

• Patient weight – preferably BMI < 30

• ASA I and II


There are also disadvantages: more time for post procedural patient's recovery, higher costs, does not allow patients to leave the endoscopy unit immediately after the procedure and return to work after the sedation or analgesia.

To obtain maximum benefit it is desirable for gastrointestinal endoscopy to have a building designed or adapted specifically for this purpose, so that patients can be treated safely, quickly and efficiently.

Medical clinics with "one day" profile, fit for the activity of digestive endoscopy, are usually self clinics (individual or collective), with one basic specialty, with individual financial assurance for the location, secured space, related facilities, personnel policy and independent accounting and financial management which enables maximum efficiency for development. These can also be clinics attached to the base hospital or ambulatory clinical departments.

These "one day" clinics have in general in the operational structure their own specialized diagnostic services through clinical, paraclinical and laboratory investigations designed to substantiate both gastrointestinal endoscopy indication and anesthetic-endoscopic protocol which is to be established by the anesthesiologist in collaboration with the physician and patient. On this occasion, the staff repeated contact with the patients creates an atmosphere of trust and mutual affection beneficial in relation to the gastrointestinal endoscopy which is expected to be made.

Endoscopy room should be equipped with: good lighting, air conditioning, centralized administration of medical fluids, modern equipment for anesthesia and monitoring, pulse oximeter, resuscitation equipment (Sitcai, 2005).
