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H. Pylori infection, acid reflux, hiatus hernia, food intolerance, ERCP.. Colonoscopy IBS, IBD, polyps, cancer, diverticulum, angiodysplasia..
endoscopy3
Relevant Investigations based on the pts history and risk factors FBC EUC LFT BSL Coags Group and Hold CXR ECG
Particular Problems/Concerns
Pregnancy
Lactating Delayed gastric emptying
General Technique
Level of anaesthetic used may range from:
Things to consider: Health status comorbidities Current medications Procedure Age Weight Procedural anxiety Pain tolerance Patient preference
Medications used Sedation + pain relief midazolam, propofol, fentanyl, sevoflurane Anti-emetics
Australian anaesthetists practice of sedation for GIT endoscopy in adult patients5 combinations used
*Operator dependent; no optimal drug combination has been established for endoscopy
99 eligible respondents 1 midazolam + fentanyl - gastroscopy 1 Sevoflurane for ERCP 1 Sevoflurane for colonoscopy For the rest: 4% - Propofol 14% - Propofol + midazolam 6% - Propofol + fentanyl 61% - Propofol + midazolam + fentanyl 15% - Propofol + other drug (alfentanil, ketamine, remifentanil, pethidine)
Fellowship
<10 years 76% >10 years 92%
Propofol dosing
Bolus method preferred
Australian anaesthetists practice of sedation for GIT endoscopy in adult patients5 - Airway Management
Jaw Lift as required Laryngeal Mask airway Endotracheal Tube -
Propofol
Used for induction + maintenance of anaesthesia,
Propofol
Duration of Effect (DOF) 4-8 mins
Pregnancy possible CNS and resp depression Breastfeeding appears safe Adverse effects
Common - pain on injection ~30%, bradycardia, hypotension,
apnoea, flushed skin or rash, cough, induction excitation Infrequent arrhythmias, thrombosis, phlebitis Rare anaphylactic reaction, seizure, fever, pancreatitis
Midazolam
Used for induction of anaesthesia, conscious sedation, sedation
during ventilation
MOA binds to benzodiazepine site
promotes binding of GABA to GABAA receptors increase chloride enters neurons neuron hyperpolarisation less firing effects
Dose conscious sedation Adult
IV 2-2.5mg, 1-1.5 if elderly or debilitated 1mg doses as needed
Midazolam
DOF 15-80 mins
Pregnancy avoid in late 3TM and during labour Breastfeeding limited data; highly protein bound, short half life
Fentanyl
Used as opioid adjunct during anaesthesia
MOA bind to opioid receptors (m, d, k) in central and
peripheral neurons G-protein coupled receptors inhibit neurotransmitter release decrease pain signals transmitted analgesia
Dose
Adult
IV 50-100ug initially
IV 25-50ug as required
Fentanyl
DOF 30-60 mins
Pregnancy prolonged high doses can cause respiratory
Sevoflurane
Used for induction and maintenance of anaesthesia
MOA uncertain
Enhance inhibitory ion channel activity and inhibit excitatory
activity in:
brain hypnosis + amnesia Spinal cord immobility in response to painful stimuli
Dose
Adults/child
Up to 8% inspired conc. in O2 +/- nitrous oxide; fresh gas flow
>2L/min
0.5-3% +/- NO2
Sevoflurane
R malignant hyperpyrexia
Intraoperative Monitoring/Intervention5
Recommended by ANZCA
Oxygen administration Pulse oximetry Non Invasive BP
IV Fluids
ECG Capnography
Complications
Risks associated with various agents
Risk of aspiration
bleeding, infection
Post-op Management
Patient extubated after awake and protecting airway
Handover to post-op staff and monitored ~1 hour
Oxygen therapy Pulse oximeter Blood pressure ECG Other vitals
References
1.
Australian Council on Healthcare Standards (ACHS). Gastrointestinal Endoscopy version 1. Retrospective data in full. Australasian Clinical Indicator Report 20042011. Sydney NSW; ACHS; 2012
Lichtenstein DR, Jagannath S, Baron TH, Anderson MA, Banerjee S, Dominitz JA, Fanelli RD, Gan SI, Harrison ME, Ikenberry SO, Shen B, Stewart L, Khan K, Vargo JJ, Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy. Sedation and anesthesia in GI endoscopy. Gastrointest Endosc. 2008 Nov;68(5):815-26. ASGE Standards of Practice Committee, Levy MJ, Anderson MA, Baron TH, Banerjee S, Dominitz JA, Gan SI, Harrison ME, Ikenberry SO, Jagannath S, Lichtenstein D, Shen B, Fanelli RD, Stewart L, Khan K. Position statement on routine laboratory testing before endoscopic procedures. Gastrointest Endosc. 2008, Nov;68(5):827-32.
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Joo HS, Wong J, Naik VN, Savoldelli GL. The Value of screening preoperative chest x-rays: a systematic review. Can J Anaesth. 2005, Jun-Jul;52(6):588-74.
Padmanabhan U, Leslie K. Australian anaesthetists practice of sedation for gastrointestinal endoscopy in adult patients. Anaesth Intensive Care. 2008, May;36(3):436-41. ASGE Standards of Practice Committee, Anderson MA, Ben-Menachem T, Gan SI, Appalaneni V, Banerjee S, Cash BD, Fisher L, Harrison ME, Fanelli RD, Fukami N, Ikenberry SO, Jain R, Khan K, Krinsky ML, Lichtenstein DR, Maple JT, Shen B, Strohmeyer L, Baron T, Dominitz JA. Management of antithrombotic agents for endoscopic procedures. Gastrointest Endosc. 2009, Dec;70(6):1060-70. RACGP, PSA, ASCEPT. Australian Medicines Handbook 2011. Adelaide, SA. 2011. Chahl LA. Opioids mechanism of action. Aust Prescr. 1996;19:63-5. Pardo M, Sonner JM. Manual of Anesthesia Practice Pocket Clinician. 1st ed. New York: Cambridge University Press; 2007.
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