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Anaesthesia for Gastro-intestinal Endoscopy
Key Points
- Endoscopy suites are non-operating-room anaesthesia (NORA) locations: ensure the same monitoring, emergency drugs and trained personnel required in theatre.
- Most diagnostic upper GI procedures can be performed with titrated propofol sedation in ASA I–II adults, but a rapid-sequence GA with tracheal intubation is safer when aspiration risk, severe comorbidity (ASA ≥ III), obesity/OSA or active bleeding are present.
- Capnography is mandatory for all levels of sedation deeper than minimal, and strongly recommended for obese or OSA patients even during moderate sedation.
- Disease-specific physiology (renal, hepatic, cardiac) markedly alters drug choice and dose
- Active variceal haemorrhage is an anaesthetic airway emergency—secure the airway early, restore circulating volume and coordinate closely with the endoscopist for haemostasis.
Disease Processes Frequently Encountered
| Condition | Anaesthetic relevance | Peri-procedural strategy |
|---|---|---|
| Visceral hypersensitivity (e.g. IBS, coeliac disease) | ↑ pain scores and sedative/analgesic requirements | Offer anxiolysis; incremental propofol ± small opioid/ketamine doses |
| Severe aortic stenosis (Heyde syndrome) | GI bleeding from angiodysplasia; fixed cardiac output | Invasive BP, gentle induction; avoid tachycardia & hypotension; expedite valve intervention post-endoscopy |
| Neuro-endocrine tumours / carcinoid | Risk of serotonin-mediated flushing, bronchospasm, hypotension | Continue octreotide infusion peri-op (50 µg h⁻¹); have rescue bolus 100 µg IV ready |
| Obesity / OSA | Difficult mask ventilation, desaturation, altered propofol PK | Ramp position, HFNO pre-oxygenation, capnography; consider GA with ETT for BMI > 40 kg m⁻² |
| End-stage renal disease | Midazolam and fentanyl context-sensitive half-lives unchanged; avoid oral Na phosphate purgatives | Use polyethylene-glycol bowel prep; titrate sedatives cautiously, monitor for apnoea |
| Cirrhosis / portal hypertension | Delayed midazolam clearance; high aspiration risk; possibility of encephalopathy | Prefer propofol-based TIVA; avoid benzodiazepines or use minimal dose; intubate for active bleeding or Grade ≥ 2 encephalopathy |
Sedation versus General Anaesthesia
| Factor suggesting deep sedation / GA | Examples |
|---|---|
| High aspiration risk | Gastroparesis, obstruction, achalasia, active haematemesis |
| Need to control ventilation | Severe COPD, morbid obesity, OSA with STOP-Bang ≥ 5 |
| Anticipated long therapeutic procedure | ESD, ERCP, POEM |
| Uncooperative / confused patient | Dementia, intellectual disability, severe anxiety |
| Haemodynamic instability | Sepsis, variceal bleed |
- Propofol infusion (25–100 µg kg⁻¹ min⁻¹) with BIS guidance provides rapid recovery; supplement with remifentanil 0.05–0.1 µg kg⁻¹ min⁻¹ to blunt sympathetic responses and reduce total hypnotic dose.
Drug and Dose Modifications in Organ Failure
| Organ dysfunction | Sedation drug of choice | Dosing notes |
|---|---|---|
| Renal failure | Midazolam 0.5 mg boluses (max 2 mg) ± fentanyl 25 µg | Active metabolites accumulate only minimally; avoid morphine/meperidine |
| Decompensated cirrhosis | Propofol TCI (2–3 µg mL⁻¹) | Midazolam clearance ↓ 50 %; small doses risk prolonged recovery & encephalopathy |
| Severe COPD/OSA | Dexmedetomidine loading 0.5 µg kg⁻¹ over 10 min then 0.3–0.7 µg kg⁻¹ h⁻¹ | Minimal respiratory depression; expect bradycardia—treat with glycopyrrolate |
| NYHA III–IV heart failure | Titrate propofol 20 mg aliquots; consider ketofol | Avoid big swings in SVR; invasive BP for EF < 30 % |
Anaesthetic Conduct for Gastroscopy
Pre-procedural
- Risk stratify: ASA class, airway, aspiration, procedure complexity.
- Fast according to guidelines (solids 6 h; clears 2 h; extend if gastroparesis).
- Prepare IVs, suction, difficult-airway kit and HFNO
Intra-procedural
- Monitoring: ECG, NIBP, SpO₂, ETCO₂, temperature.
- Shared airway: communicate with endoscopist; consider bite-block with oxygen/ETCO₂ port.
- Ventilation adjuncts: HFNO at 40–60 L min⁻¹ prolongs safe apnoea time in obese/OSA patients.
- Topical anaesthesia: 10 % lidocaine spray (max total lignocaine for topical 9 mg kg⁻¹ of LBW).
- Position: left lateral with 15° head-up to improve FRC and reduce regurgitation.
Post-procedural
- Observe in recovery with SpO₂ & ETCO₂ until fully awake and protective reflexes intact.
- Discharge only when ambulating, vital signs stable, able to tolerate oral fluids, and accompanied home.
Emergency: Acute Variceal Bleeding
| Step | Key actions |
|---|---|
| Airway | RSI with videolaryngoscopy and cricoid pressure; two suction lines; consider 30° head-up. |
| Resuscitation | Target MAP > 65 mmHg, Hb ≈ 8 g dL⁻¹; avoid over-transfusion. |
| Pharmacology | Terlipressin 2 mg IV then 1 mg q4 h, or octreotide 50 µg bolus → 50 µg h⁻¹; ceftriaxone 2 g IV. |
| Endoscopic therapy | Band ligation first-line for oesophageal varices; cyanoacrylate for gastric varices; be ready for balloon tamponade or SEMS if uncontrolled. |
| Post-procedure | ICU; continue vasoactive & antibiotics 2–5 days; restart non-selective β-blocker when stable. |
Links
References:
- The anaesthetist’s role in the endoscopy suite. WITS part 2 refresher 2017. C Quan
- British Society of Gastroenterology. Guidelines on Sedation in Gastrointestinal Endoscopy. 2023.
- American Society of Anesthesiologists & ASGE. Guidelines for Sedation and Anaesthesia in GI Endoscopy. 2018.
- European Society of GI Endoscopy. S3 Guideline: Sedation for Gastrointestinal Endoscopy. 2023.
- Baveno VII Faculty. Renewing Consensus in Portal Hypertension. J Hepatol. 2022.
- AASLD. Guidance on Management of Variceal Haemorrhage in Cirrhosis. 2021.
- de Franchis R, et al. Portal Hypertension VII: Proceedings of the 7th Baveno Workshop. Springer; 2022.
- Chee D, et al. Nasotracheal intubation. StatPearls [Internet]. Updated 2024.
- Singla D, et al. Intranasal dexmedetomidine vs midazolam for paediatric dental sedation. Int J Paediatr Dent. 2023.
- Nordsletten L, et al. Tranexamic acid mouthwash reduces post-extraction bleeding. J Oral Maxillofac Surg. 2019.
- Hashab MA, et al. ASGE sedation and anaesthesia guideline update. Gastrointest Endosc. 2018.
- Allman K, Wilson I, O’Donnell A. Oxford Handbook of Anaesthesia. Vol. 4. Great Clarendon Street, Oxford, OX2 6DP, United Kingdom: Oxford University Press; 2016.
- Goudra B, Singh PM. Anesthesia for gastrointestinal endoscopy: A subspecialty in evolution? Saudi J Anaesth. 2015 Jul-Sep;9(3):237-8. doi: 10.4103/1658-354X.154691. PMID: 26240538; PMCID: PMC4478812.
Summaries:
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