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REVIEW

CURRENT
OPINION Adult and pediatric anesthesia/sedation for
gastrointestinal procedures outside of the
operating room
Esther R. Michel Foehn

Purpose of review
This review presents current trends of safe and efficient anesthesia and sedation for adults and children for
gastrointestinal procedures outside of the operating room with a special focus on total intravenous
anesthesia (TIVA), target-controlled infusion (TCI), intravenous or topical lidocaine, and the use of the video
laryngoscope.
Recent findings
The concepts of a well tolerated and adequate anesthesia or sedation for gastrointestinal procedures
outside of the operating room have to meet the needs of the adult and pediatric patients and the special
requests of the gastroenterologists. Anesthesia and sedation of adults for gastrointestinal procedures with
TIVA or TCI and spontaneous breathing is well established. Many institutions perform anesthesia for
pediatric patients undergoing gastrointestinal procedures with an inhalational agent, especially in young
children and for short procedures. Unlike adults, in young children the airways frequently must be secured
with a tracheal tube or laryngeal mask. Respiration may be spontaneous, assisted, or controlled. TIVA and
TCI are increasingly chosen for older children and longer procedures. A local anesthetic administered
intravenously or topically to the upper airways and the use of the video laryngoscope can facilitate the
insertion of the endoscope.
Summary
Both anesthesiologists and nonanesthesiologists have to achieve a consensus and develop quality-
improvement strategies to provide safe and efficient anesthesia and sedation for gastrointestinal procedures
outside of the operating room for pediatric and adult patients. Techniques using TIVA, TCI, intravenous or
topical application of lidocaine, and the video laryngoscope may improve and facilitate gastrointestinal
procedures for the patients, the anesthesiologists, and the gastroenterologists.
Keywords
adult anesthesia, gastrointestinal procedures, lidocaine intravenous, lidocaine topical, outside of the
operating room, pediatric anesthesia, sedation, target-controlled infusion, total intravenous anesthesia,
video laryngoscope

INTRODUCTION anesthesia providers on the day of the procedure.


Anesthesia and sedation for gastrointestinal and Patients who require coordination of care during the
other procedures outside of the operating room perioperative period and patients who are already
for adult and pediatric patients are a fast growing hospitalized should be evaluated by the anesthesi-
division of medical service. The challenge in the ologist on the day before the procedure. Patients
future will be for anesthesiologists to meet the with complex medical comorbidities should have
increasing demand for activities outside of the oper-
ating room and at the same time guarantee a high
&&
level of safety for the patients [1 ]. Many patients Department of Anesthesia, Critical Care and Pain Medicine, Bethanien
undergoing these procedures are managed without Hospital, Zurich, Switzerland
an anesthesiologist present. Gastroenterologists Correspondence to Esther R. Michel Foehn, MD, Bethanien Hospital,
often care for both adult and pediatric patients by Toblerstrasse 51, 8044 Zurich, Switzerland. Tel: +41 43 268 74 55;
&& &
providing oral or intravenous sedation [1 ,2 ]. Most e-mail: esther.michel@alphacare.ch
patients, requiring anesthesia or sedation, are sched- Curr Opin Anesthesiol 2015, 28:469477
uled for same-day procedures and evaluated by the DOI:10.1097/ACO.0000000000000215

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Anesthesia outside the operating room

Endoscopic Gastrostomy (PEG) or Anorectal


KEY POINTS Manometry (ARM), most adult patients of ASA status
 To provide safe and adequate anesthesia/sedation for I or II are usually managed by the gastroentero-
gastrointestinal procedures outside of the operating logy team without involvement of the anesthesia
&& &
room, the anesthesiologists and nonanesthesiologists service [1 ,2 ]. After the evaluation of the patient,
should find a consensus and develop quality- oral sedation (often midazolam) or intravenous
improvement strategies. sedation (often propofol) is administered. The
 TIVA, TCI: importance, advantages, disadvantages? patient breathes spontaneously and if necessary
supplemental oxygen is administered via a nasal
 The application of intravenous or topical lidocaine for cannula. For EGD, a topical local anesthetic either
the upper airways to facilitate the insertion of the lidocaine or Cetacaine spray (14% benzocaine, 2%
endoscope: benefit or risk?
butamben, and 2% tetracaine) is used to prepare
 Video laryngoscope to visualize the insertion of the mouth and hypopharynx of the patient to enable
endoscope for gastrointestinal procedures: can it an easy insertion of the endoscope. The EGD is
prevent lesions of the mouth, uvula, hypopharynx, usually performed in the left lateral decubitus
epiglottis, and larynx caused by the endoscope? position [4,5].
For Endoscopic Retrograde Cholangio-Pancrea-
tography (ERCP), the patient may receive a premed-
their procedures performed in the main operating ication (often midazolam or lorazepam) combined
room suite [36]. with a gastric acid blocker (usually pantoprazole).
There may be differences in the physical con- During the procedure, the patient is positioned in a
figuration of each hospital; some have dedicated left lateral decubitus position and monitored with
gastrointestinal procedure units and others may Peripheral capillary Oxygen Saturation (SpO2), ECG,
have designated gastrointestinal rooms within a and noninvasive blood pressure. An intravenous
larger operative suite. Regardless, it is essential that cannula is inserted for administration of fluid and
every endoscopy location has a standardized anes- medications. Oxygen is delivered via a nasal cannula
thesia setup, including an anesthesia machine, or facemask, and the End Exspiratory Carbon Diox-
American Society of Anesthesiologists physical ide (EECO2) is monitored. Administration of intra-
status (ASA) standard monitoring, an anesthesia venous or topical lidocaine facilitates the insertion
cart, and a suction apparatus [36]. Good coordina- &
of the endoscope [2 ,4]. Conscious sedation (patient
tion and organization of the procedures in the main is sedated but answers questions and follows orders)
operating room and outside locations is very with midazolam and an opioid is usually performed
important for the safety of the patients and the by nonanesthesia personnel [13,14]. Deep sedation
efficiency of all involved in services [7]. with propofol is administered by nonanesthesiolo-
Many gastrointestinal procedures outside of the gists or anesthesiologists and general anesthesia by
operating room are of short duration. To maintain anesthesiologists only [1315] Deep sedation and
effective throughput in managing the high volume anesthesia is increasingly performed as TIVA or TCI
of gastrointestinal procedures, the teams should be with propofol as single agent or in combination
&& &
focused and efficient [1 ,2 ,7]. High-quality care with a small dose of a short-acting opioid such as
and safety for the patient in outside locations fentanyl, alfentanil, or remifentanil. During a TIVA
requires expertise and experience of the anesthesi- or TCI anesthesia, a Bispectral Index (BIS)-monitor-
ologist and nonanesthesiologist services [811]. The ing to minimize the occurrence of awareness is
aim of this review is to highlight several tools used in recommended. Patients should be able to maintain
clinical practice to further improve adult and spontaneous respiration [4,5].
pediatric anesthesia and sedation for gastrointesti- In the elderly or patients who are obese or
nal procedures outside of the operating room and patients with significant medical comorbidities
the importance of a consensus between anesthesi- such as ASA status III or IV, usually an anesthesiol-
ologists and nonanesthesiologists to develop qual- ogist will provide sedation or anesthesia for ERCP,
&&
ity-improvement strategies [1 ,3,4,912]. EGD, rectoscopy and colonoscopy, insertion of a
&
PEG or an ARM [2 ,4,5]. During the EGD and ERCP,
ANESTHESIA AND SEDATION FOR the gastroenterologist and anesthesiologist share
GASTROINTESTINAL PROCEDURES the access to the patients airway. During a recto-
OUTSIDE OF THE OPERATING ROOM IN scopy, colonoscopy, insertion of a PEG or an ARM,
ADULTS the anesthesiologist has full access to the airway
For esophagogastroduodenoscopy (EGD), recto- of the patient. For gastrointestinal procedures
scopy, colonoscopy, insertion of a Percutaneous performed outside of the operating room, adult

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Adult and pediatric anesthesia/sedation in gastrointestinal procedures Michel

patients rarely need a tracheal tube or Laryngeal improving the quality of treatment and safety for
Mask Airway (LMA) and ventilation is spontaneous. the patients in remote locations with guidelines,
After conclusion of the procedure, patients should special training for providers, and consensus con-
be recovered in a postoperative care unit until same- ferences [2325].
day discharge criteria are fulfilled or transfer to a
ward for an extended overnight hospitalization is
appropriate [4]. PEDIATRIC ANESTHESIA AND SEDATION
For anesthesia/sedation in gastrointestinal pro- FOR GASTROINTESTINAL PROCEDURES
cedures, patients with pulmonary and/or cardiac OUTSIDE OF THE OPERATING ROOM
or renal disease, liver cirrhosis, elderly patients, The management of infants and children for gastro-
patients who are obese, and pregnant women, there intestinal procedures outside of the operating room
are special considerations and drug doses used for requires a different approach from the adult popu-
sedation that must be altered [16]. lation as described below.
The risk of complications after gastrointestinal For gastrointestinal procedures outside of the
procedures in anesthesia or sedation is relatively operating room in older, mature children of ASA
low. A retrospective study of 165 527 colonoscopies status I or II, oral sedation with midazolam might be
performed between January 2000 and November appropriate, whereas others will require additional
2009 was conducted by Cooper et al. [17]: the total intravenous sedation (often with propofol) by the
rate of complications was 0.17% (n 284 pro- gastroenterology team. Gastroenterologists may uti-
cedures) and included aspiration 0.10% (n 173), lize lidocaine or Cetacaine spray to facilitate the
colon perforation 0.06% (n 101) and splenic injury insertion of the endoscope. The gastroenterologists
0.007% (n 12). An increased risk of aspiration and have developed their own assessment tools and
aspiration pneumonia related to colonoscopies in guidelines for the sedation for gastrointestinal pro-
deep sedation (with anesthesia assistance) was cedures [26].
found compared with the same procedure in con- All children of ASA status III or IV should receive
scious sedation (without anesthesia assistance). anesthesia and sedation for gastrointestinal pro-
There was no significant increase in splenic injury cedures by an anesthesia team preferably in the
or colon perforation during procedures observed in main operating room.
patients undergoing deep sedation [17]. Some categories of healthy ASA status I or II
Patient data of 118 004 colonoscopies performed children still require the care of an anesthesia team.
between January 2003 and October 2012 were ana- The anesthesiologist must evaluate the children,
lyzed retrospectively by Adeyemo et al. [18]: a rate of assess their individual risks and plan the anesthesia
colon perforation of 0.04% (n 48) was identified. In or sedation for the procedure [3,6,27]. The gastro-
patients undergoing diagnostic colonoscopy, there intestinal procedures outside of the operating room
was no increased risk of colonic perforation with deep require full ASA monitoring with SpO2, EECO2,
sedation compared with conscious sedation; how- ECG, and noninvasive blood pressure, and an intra-
ever, therapeutic colonoscopy during deep sedation venous cannula for the application of fluids and
was associated with a 3.4 times increased risk of anesthetic agents for anesthesia and sedation. To
colonic perforation [18]. minimize the occurrence of awareness during an
In both studies, predictors of complications anesthesia with TIVA or TCI, BIS-monitoring is
included increasing comorbidity and increasing recommended [28]. A high level of quality and
age (>70 years). For gastrointestinal procedures, safety for the patients before, during, and after
an anesthesiologist usually cares for patients of anesthesia/sedation for the gastrointestinal pro-
ASA status III and IV and performs deep sedation. cedures is very important [2731].
The gastrointestinal procedures of the patients of Induction with sevoflurane in children younger
ASA status I and II are managed with conscious than 4 years is sufficient for most procedures. The
sedation without the anesthesia service. The inhalational agent may be combined with nitrous
inclusion of patients of ASA status III and IV may oxide during induction. Placement of an intrave-
be the most important reason for the increased rate nous catheter is required. If necessary, a propofol
of complications related to deep sedation with anes- bolus to facilitate intubation may be administered.
thesia assistance described in various studies. For short procedures (1030 min) intubation with-
Mortality for gastrointestinal procedures out- out relaxation is adequate; however, if relaxation is
side of the operating room has decreased in recent required, a short-acting agent such as suxametho-
& &
years [2 ,8,1921,22 ]. Anesthesiologists, gastroen- nium or atracurium should be administered. For
terologists, other nonanesthesiologists and their longer procedures, relaxation with atracurium or
societies are concentrating their efforts on rocuronium is appropriate.

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Anesthesia outside the operating room

Induction with sevoflurane followed by intra- The primary goal is to prevent and if necessary
venous insertion is suggested for all children for immediately treat any adverse events occurring
ERCP and a combination of EGD and colonoscopy before, during, and after pediatric anesthesia/seda-
taking 60 min or longer. An intravenous propofol tion [911,2931].
bolus followed by an opioid is preferred. Lidocaine The article To Err is Human from the American
intravenous or lidocaine spray/Cetacaine spray is Institute of Medicine in 2000 states, anesthesia is an
recommended for the upper airways. Usually, intu- area in which very impressive improvements in
bation facilitated by muscle relaxation is required safety have been made [32]. But children are a very
followed by insertion of the endoscope. Anesthesia vulnerable population with special risks. Multidis-
is maintained with sevoflurane or switched to pro- ciplinary consensus between anesthesiologists and
pofol TIVA or TCI. The EGD is performed with the nonanesthesiologists involved in anesthesia/seda-
patient in the left lateral decubitus position. For tion of children is essential [12,24,25,31]. More well
colonoscopy, the patient should be repositioned. designed studies and trials of pediatric anesthesia/
The bed is turned 908 to the right with the patients sedation for procedures outside of the operating
&
head toward the anesthesia machine. An infant or room are needed [33 ].
small child can be turned 908 to the right on the
operating room table with the head toward the
anesthesia machine without moving the table. TOTAL INTRAVENOUS ANESTHESIA AND
For the care of children between 4 and 10 years TARGET-CONTROLLED INFUSION
undergoing colonoscopy (3060 min), PEG (30 min) TIVA and TCI with propofol alone or with remifen-
and ARM (2030 min) induction is accomplished tanil are well established in adult anesthesia/seda-
with sevoflurane. Intravenous access is secured and tion for gastrointestinal procedures outside of the
spontaneous ventilation is maintained with either a operating room. Endoscopist-directed adminis-
face mask or LMA. During ARM, Botox may be tration of propofol was evaluated in a worldwide
injected. It is quite a strong stimulus. The anesthesia safety study with 646 080 identified cases and found
should be deepened with sevoflurane or a propofol to be well tolerated. Endotracheal intubations were
bolus intravenous prior to the Botox injection. performed in 11 cases (0.002%), permanent neuro-
Whenever possible, spontaneous respiration is pre- logic injuries occurred in none, and four patients
ferred during these gastrointestinal procedures. (0.0006%) out of the 646 080 cases died. The overall
After conclusion of the gastrointestinal pro- number of patients requiring mask ventilation was
cedure, it is important that the child recovers in a 489 (0.086%) out of 569 220 cases. Mask ventilation
fully equipped postanesthesia care unit with child was necessary during EGD in 0.1% and during colo-
appropriate, well trained personal. Most children noscopy in 0.01%. The mortality rate was lower than
will be discharged on the day of the procedure. in data of sedation on endoscopist-delivered benzo-
Depending on associated comorbidities and the diazepines and opioids [8].
type of procedure, some children will require an Another significant safety analysis of endoscop-
overnight stay. ist-directed propofol sedation was performed in
The Pediatric Sedation Research Consortium ana- Germany. In a prospective, national multicenter
lyzed prospectively collected data on 49 836 propofol study of 24 441 patients in 53 German outpatient
sedation/anesthesia procedures at 37 locations in the practices, endoscopist-directed administration of
USA between July 2004 and September 2007: there propofol was demonstrated to be a well tolerated
were no deaths, cardiopulmonary resuscitation was procedure. Major adverse events occurred in four
required twice (0.004%), and aspiration was observed patients (0.016%): three mask ventilations and one
in four patients (0.008%). Less-serious events were laryngospasm. Minor events were observed in 112
more common in sedation and anesthesia adminis- patients (0.46%), hypoxia being the most common
trations such as desaturation (0.015%), central apnea minor event. All patients with adverse events recov-
&
or airway obstruction (0.058%), stridor (0.005%), ered without persistent impairment [22 ].
laryngospasm (0.0096%), excessive secretions In many institutions, pediatric anesthesia for
(0.034%), and vomiting (0.0049%). These data gastrointestinal procedures is performed with an
indicate that pediatric propofol sedation and anes- inhalational agent, often with sevoflurane, especi-
thesia rarely have serious adverse events and out- ally in small children and for short procedures. The
comes. However, the safety of this practice depends inhalational agent may be combined with nitrous
on the ability of the sedation/anesthesia providers to oxide during induction. TIVA and TCI with propofol
manage these less-important events. Therefore, the as single agent or with remifentanil are increasingly
training of the sedation/anesthesia providers is very utilized in pediatric anesthesia, especially for older
important [9]. children and longer procedures. TIVA and TCI are

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Adult and pediatric anesthesia/sedation in gastrointestinal procedures Michel

Table 1. The advantages of target-controlled infusion Table 3. Disadvantages of target-controlled infusion and
compared with total intravenous anesthesia and total intravenous anesthesia compared with inhalational
inhalational anesthesia anesthesia
Precise and smooth onset and end of anesthesia Intravenous placement of the cannula in the awake child may be
Less risk of intraoperative movement difficult. In anxious children or children and adults with a difficult
intravenous access an inhalational induction may be preferable
Less changes in heart rate (bradycardia/tachycardia)
Propofol intravenous produces a burning sensation in the awake
Less changes in blood pressure (hypotension/hypertension) patient
Reduction in intracranial pressure
Awareness is more frequent: BIS-monitoring may be helpful to
Preservation of hypoxic pulmonary vasoconstriction minimize awareness, but cannot guarantee to avoid it
Prediction of time of recovery Propofol syndrome
After anesthesia patient is alert, feels comfortable, ready to be
discharged from the hospital shortly after the procedure

opioids such as sufentanil, alfentanil, fentanyl,


morphine. Other drugs like ketamine, clonidine,
good options, especially if a patient presents with a and dexamethasone may also be useful adjuncts
history of severe PONV despite PONV-prophylaxis, [3842]. Regional anesthesia can be combined with
emergence delirium syndrome, or an enhanced risk TIVA and TCI anesthesia/sedation and provides
of malignant hyperthermia. TIVA may be recom- excellent intraoperative and postoperative analgesia
mended for infants older than 6 months and 5 kg [43]. For TIVA anesthesia and sedation, the doses of
body weight. TCI may be recommended for children propofol and remifentanil are suggested in Table 4.
older than 3 years and 15 kg body weight. TIVA and TIVA and TCI are precise and elegant methods to
TCI are suggested for anesthesia/sedation of infants perform anesthesia and sedation [44]. There are
and children for procedures with an expected different models for TCI with propofol. The first
duration of more than 30 min. TIVA and TCI tech- model developed was the Diprifusor [45,46]. After
niques of adults are very well established for short as its patent expired, other models were developed
well as for long procedures. Advantages and disad- like the Marsh model [4651], the Schnider model
vantages of TCI and TIVA are shown in Tables 13 [4651], the Kataria model with the Katfuser
and were presented at the European Society of [46,51], the Paedfuser model for children [52], and
&
Anaesthesiology European Society of Anaesthesiol- the White model [53,54 ].
ogy Conference in Paris, June 2012 [34]. The above-mentioned open TCI systems can be
At Bethanien Hospital and Schulthess Klinik, programmed with any pharmacokinetic model and
Zurich, Switzerland, TIVA and TCI anesthesia/seda- allow either plasma-site-targeting or effect-site-tar-
tion are performed with propofol and remifentanil geting. The goal of the effect-site-targeting mode is
in adults and TIVA of infants older than 6 months
and TCI of children older than 3 years for various
procedures including operations of more than 12 h Table 4. Total intravenous anesthesia for adults and
duration and postoperative sedation with propofol children
up to 72 h. Propofol syndrome has not been TIVA for adults:
observed [3537]. Moderate propofol dosages are Anesthesia: Propofol 1% 66100150 mg/kg/min ->
used. Rather than increasing the dosage of propofol, 469 mg/kg/h IV
propofol and remifentanil are combined with non- Sedation: Propofol 1% 335066 mg/kg/min ->
opioids such as paracetamol, novalgin, NSAIDs, and 234 mg/kg/h IV
Anesthesia: Remifentanil 0.10.4 mg/kg/min IV
Sedation: Remifentanil 0.050.1 mg/kg/min IV
Table 2. Advantages of target-controlled infusion and total
TIVA for children:
intravenous anesthesia compared with inhalational
Anesthesia: Propofol 1% 100150200 mg/kg/min ->
anesthesia
6912 mg/kg/h IV
PONV less frequent and less severe
Sedation: Propofol 1% 100150166 mg/kg/min ->
Emergence syndrome less frequent and less severe 6910 mg/kg/h IV
No risk of malignant hyperthermia Anesthesia: Remifentanil 0.10.4 mg/kg/min IV
Separation of anesthesia provision from respiration Sedation: Remifentanil 0.050.1 mg/kg/min IV
Reduced atmospheric pollution
IV, intravenous; TIVA, total intravenous anesthesia.

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Anesthesia outside the operating room

to achieve a user-defined target-effect-site concen- improve the predictive performance and accuracy
&
tration as rapidly as possible by manipulating the for the patients [53,54 ]. TCI is not yet approved by
concentration around the target. The provider choo- the Food and Drug Administration in the USA. TIVA
ses the target concentration. The pump gives the and TCI are open-loop systems.
drug dose to achieve the target without overshoot. There are promising tools trying to bridge the
Patient parameters like weight, height, lean body gap toward a closed-loop system.
mass, age, and sex influence the drug dose delivered These include a patient-controlled system,
by the pump. which is a combination of TCI and Patient Con-
In the Marsh model, the rate constants are fixed, trolled Analgesia with a patient-demand function
but the compartment volumes and clearances are [55]. The computer-assisted personalized sedation
proportional to the weight of the patient. Initially, system is able to monitor SpO2, EECO2, ECG, and
relatively large doses are administered and the target patient responsiveness to auditory commands while
concentration is reached quickly. The Marsh model titrating propofol in small dosages [56].
should be used in the plasma-site-targeting mode. It The SEDASYS incorporates comprehensive
was developed for adults and later adapted and patient monitoring and is able to stop the propo-
tested for children aged 19 years. The Marsh model fol infusion. In Europe, SEDASYS is approved for
is mainly used for adults and works well in young routine colonoscopy and screening of the upper
and fit individuals and also in patients who are gastrointestinal tract. In Canada, it is approved for
morbidly obese. It is less accurate in the elderly routine colonoscopies in conscious sedation [57].
and very sick patients. BIS-monitoring with continuous feedback to the
The Schnider model was derived from combined TCI pump that adjusts the dose is investigated [58].
pharmacokinetic and pharmacodynamic modeling The measurement and analysis during anesthesia of
studies. In the Schnider model, the compartment exhaled end-tidal-propofol by mass spectrometry
volumes V1, V3 and the rate constants k13 and k31 with feedback to the propofol-pump was tested in a
are fixed. The compartment volume V2 and the rate clinical study recently. The concentrations in the
constants k12 and k21 adjust for age. The rate con- expired air reflected the plasma concentrations of
stant k10 adjusts according to total weight, lean propofol as well as the depth of anesthesia assessed
body mass, and height. The Schnider model delivers by BIS-monitoring [59].
very small initial doses in the plasma-site-targeting These new techniques help to make TCI anes-
mode, and therefore should be used in the effect- thesia/sedation even more precise and accurate. But
targeting mode, in which larger initial doses are these modern tools are not able to close the open-
administered. These initial doses are still smaller loop systems completely yet, therefore the expertise
and the target concentration is reached more slowly of anesthesiologists is still needed.
than in the Marsh model. The Schnider model was Propofol alternatives for anesthesia/sedation in
tested in adults and children aged 516 years. It is gastrointestinal endoscopy include inhalational
recommended for adults and works well also in the agents such as sevoflurane and intravenous drugs,
elderly and critically ill patients. It may be used for for example, midazolam, ketamine, dexmedetomi-
children aged 1016 years respectively minimal dine, remifentanil, and remimazolam (CNS 7056) as
body weight of 30 kg up to young adults. It is less discussed in a review 2014 [60].
accurate in individuals who are morbidly obese than
the Marsh model.
The Katarian model with the Katfuser was INTRAVENOUS AND TOPICAL LIDOCAINE
studied in children aged 315 years and 1561 kg The administration of intravenous lidocaine or of
body weight. It is recommended for children aged topical lidocaine spray for the airway attenuates
816 years and 2061 kg body weight. The Paed- laryngeal and respiratory reflex responses such as
fuser model was especially developed for children coughing, expiration reflex, spasmodic panting,
and tested in children aged 118 years and 561 kg and apnea [6163]. This facilitates the insertion
body weight. It is recommended and accurate in of a laryngoscope or video laryngoscope, tracheal
patients aged 316 years and 1561 kg body weight tube, LMA, bronchoscope, or an endoscope for
[4652]. gastrointestinal procedures. A recent meta-analysis
The TCI dosages vary and depend on the used suggests both intravenous and topical lidocaine
TCI model, age, and an interindividual variation in are also effective for preventing laryngospasm in
&
propofol clearance of the patient. None of the children during airway manipulation [64 ]. In
models accounts fully for the extent of interindivid- addition, intravenous and inhaled lidocaine may
ual variation in propofol clearance, but the newer attenuate histamine-evoked bronchoconstriction
models, for example, the White model seem to [65].

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Adult and pediatric anesthesia/sedation in gastrointestinal procedures Michel

For short procedures such as the EGD (ca. in outside locations [7176]. In combination with
1030 min) intravenous lidocaine is preferred. intravenous or topical lidocaine application, the
The intravenous lidocaine dose is 1.5 mg/kg intra- video laryngoscope facilitates the insertion of the
venous for patients younger than 60 years, 1 mg/kg endoscope for gastrointestinal procedures. In
intravenous for patients 6080 years, 0.5 mg/kg addition, the video laryngoscope permits visualiza-
intravenous for patients older than 80 years, and tion of the endoscope during insertion into the
12 mg/kg intravenous in children older than mouth and hypopharynx for EGD or ERCP and
3 years. This reduces the laryngeal and respiratory may prevent lesions of the mouth, uvula, hypophar-
reflex responses significantly after 2 min and lasts ynx, epiglottis, and larynx by the endoscope. A
for approximately 10 min. At the same time, it review about cranial nerve injuries with supraglottic
attenuates the burning sensation of an intravenous airway devices was published in 2015 [77]. Further
induction with propofol. The strongest stimulus investigations are required.
during EGD is the insertion of the endoscope. After
intravenous lidocaine, the insertion of the endo-
scope is smooth. If the patient wakes up after the CONCLUSION
procedure, the laryngeal and respiratory reflexes are For gastrointestinal procedures outside of the
intact again and the risk of aspiration is minimized. operating room, the concepts of well tolerated
Possible disadvantages of intravenous lidocaine and efficient anesthesia and sedation have to meet
include bradycardia and hypotension; therefore, it the special needs of pediatric and adult patients and
should be used with caution in patients taking the requests of gastroenterologists and anesthesiol-
b-blockers, calcium antagonists, digitalis, and other ogists. Anesthesia and sedation with TIVA and TCI
antiarrhythmic agents, especially in the presence of for gastrointestinal procedures is well established
pre-existing bradycardia. for adults. It is increasingly used in older children
For longer procedures such as the combination and for longer procedures. But especially for young
of EGD and colonoscopy (60 min or longer) or an children and for short gastrointestinal procedures,
ERCP (60 min or longer), it is a good option to use an inhalational anesthesia is the technique of
lidocaine spray topical at the upper airways to facili- choice in many hospitals. Anesthesia and sedation
tate the insertion of the endoscope. Cave: One spray techniques with TIVA and TCI, intravenous or
of lidocaine 4% 0.25 ml is equivalent to 10 mg. topical lidocaine and the use of the video laryngo-
Possible disadvantage of topical lidocaine may be scope may improve and facilitate gastrointestinal
persistent dysfunction of the larynx after extubation procedures for the patients, the anesthesiologists,
or LMA removal with the potential risk of aspiration, and the gastroenterologists. Our primary goal is
especially after short procedures. high quality of care and safety of the patient for
Intravenous lidocaine is especially useful for anesthesia and sedation independent of the pro-
anesthesia or sedation for short procedures includ- vider. This goal depends on the expertise and
ing gastrointestinal procedures outside of the oper- experience of the provider team. Anesthesia and
ating room. With intravenous lidocaine, the sedation for gastrointestinal and other procedures
insertion of the endoscope is smooth and con- outside of the operating room is a fast growing
sequently the dose of opioids can be reduced or division of medical practice. To be able to guarantee
avoided. Advantages include fast wake up, no respir- a high level of quality and safety of the anesthesia and
atory depression, and timely return of laryngeal and sedation for the patients during these procedures, the
respiratory reflexes. anesthesiologists and nonanesthesiologists have to
Intravenous lidocaine increases the depth of find a consensus and develop quality-improvement
anesthesia of propofol and of sevoflurane [66,67]. strategies. Consensus conferences of the national
Perioperative administered lidocaine intravenous as organizations of the anesthesiologists, gastroenterol-
a bolus or as a continuous infusion and for local or ogists, other involved nonanesthesiologists, and gov-
regional anesthesia reduces pain before, during, and ernment officials are held in the USA, Canada,
after operations and procedures [43,6870]. Australia, the European Union, Norway, Switzerland,
Eastern Europe, and countries of Asia, South America,
and Africa.
VIDEO LARYNGOSCOPE
The video laryngoscope may become a new standard Acknowledgements
of care not only in the management of the difficult None.
or failed airway in the operating room, emergency
room, and ICU, but also for the insertion of the Financial support and sponsorship
endoscope for procedures in the operating room and None.

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Anesthesia outside the operating room

23. Werner Ch, Smith A, Van Aken H. Guidelines on nonanaesthesiologist


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Endoscopy ESGE, European Society of Gastroenterology and Endoscopy
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