EXAM 3: GI Anesthesia

Question 1

History of GI Endoscopic Procedures & Sedation:

____ used to administered Demerol and Versed - PACU backed up with over sedated patients

Patients were often under or over sedated - which led to poor outcomes (injury if moving, airway compromise if over-sedated).

Procedures were simple and quick.

2012 estimated over half of colonoscopies performed under ____.

Answer 1

Nurses

MAC

Question 2

Why are CRNAs necessary for GI procedures?

1) Need for more advanced sedation - ____ sleep, wakeup, and recovery. _____ is the ideal anesthetic for GI outpatient procedures offering a fast recovery & discharge. It has quick on/off w/ little to no drowsiness so you can d/c from PACU quicker. It also allows less wrestling w/ patients potentially causes injury to the patient and/or staff.
2) Non-anesthesia providers are unable to administer ____ levels of propofol.
3) Some GI procedures are more complex, challenging, and longer.
4) Anesthesia providers offer advanced sedation WITHOUT _______.
5) Anesthesia providers are competent _______ managers and rescuers.

Answer 2

1 - RAPID, propofol
2 - anesthetic
4 - oversedation
5 - airway

Question 3

GI procedures can be performed ______ (hospitals, specialty LTAC facilities, rehab, remote bedside procedures) and ______ (offices, clinics, outpatient surgery centers).

Answer 3

inpatient

outpatient

Question 4

GI procedures in the inpatient setting can perform/be performed on:

1) ASA __-__
2) BMI policies vary but many state > ___ (class III) and some > ___
3) Complex procedures even ________ approach
4) ERCPs requiring deeper sedation and ______
5) ____ procedures and ____ cases
6) Cases requiring general anesthetics and intubation
7) Endoscopic ultrasound _____ (EUS) procedures

Answer 4

1 - 1-4
2 - >45, >50
3 - percutaneous 
4 - intubation
5 - longer, prone
7 - guided

Question 5

Pre-Evaluation for GI Procedure:

1) What BMI is acceptable?
2) Are sleep apnea patients acceptable?
3) Risk of ______ exists. Some proceduralists want ____ before EGD.
- colonoscopy preps are sometimes not finished until hours before procedure
- deep sedation more than moderate/conscious sedation increases risk d/t loss of _______
4) Bloodwork: based on ______ (not routinely done unless indicated)

Answer 5

1 - varies
2 - yes
3 - aspiration - Bicitra - reflexes
4 - comorbidities

Question 6

GI procedures in the outpatient setting can perform/be performed on:

1) ASA __-__
2) BMI ____
3) _____ EGDs, ______ colonoscopies, and ______
4) Increasingly seeing CRNA only practices in outpatient GI clinics
5) Large volume of procedures in short amount of time - rapid turnover and discharge expected

Answer 6

1 - 1-3
2 - <45
3 - simple, screening, doubles

Question 7

GI endoscopic equipment includes a fiberoptic scope w/ extra lumens for _____ and _____ devices/wires, air ____ and _____ buttons, irrigation and washing, suction traps for ______.

Answer 7

biopsy
treatment
pressure
suction
biopsies

Question 8

Esophagogastroduodenoscopy (EGD) Indications:

1. ______ pain
2. ______
3. ulcers
4. ______
5. dysphagia
6. esophageal ________ with _____
7. food bolus
8. Halo for ______
9. stent for ______
10. ___ insertion
11. EUS w/ biopsy
12. double balloon
    - Etc.

Answer 8

1. abdominal
2. reflux/GERD
3. ulcers
4. H. pylori
5. dysphagia
6. esophageal strictures w/ dilation
7. food bolus
8. Barret’s esophagus
9. gastric stenosis
10. PEG

Question 9

Outpatient EGD Indications:

1. _____ problems - not screening based
2. _______ pain
3. ______
4. Evaluating
   -
   -
   -
   - _____ response to treatment
5. biopsies for ____

Answer 9

1. diagnosing
2. abdominal
3. dysphagia
4. Evaluating
   
   • GERD,
   • NV,
   • blood in GI tract
   • gastric ulcer response to treatment
5. H pylori bacteria

Question 10

Anesthesia Equipment for EGD:

1) _____ setup at bedside
2) ____ ____ for airway rescue if necessary (usually no anesthesia machine)
3) _____ at bedside but typically not needed - may be shared w/ GI equipment cart
4) ______ ______ since 2011 (new standard)

Answer 10

1 - GETA (laryngoscope, ETT)
2 - ambu bag
3 - suction
4 - ETCO2 monitor (capnography)

Question 11

Side stream ETCO2-measuring nasal cannula is ________! Document ETCO2 detection w/ ____ not _____ value.

Answer 11

required
plus sign (+)  - not number value (inaccurate d/t contaminated sample)

Question 12

ETCO2 monitoring is a standard of practice per AANA and ASA for ______ to _____ sedation. Malpractice coverage is based on accepted standards of practice.

Answer 12

moderate to deep

Standard 9: Ventilation: continuously monitor ventilation by clinical observation and confirmation of continuous expired CO2 during moderate sedation, deep sedation, or GA…….

*enhances safety - not just relying on O2 sat which is often a late response

Question 13

Various GI Societies:

2012: Universal adoption of capnography for moderate sedation in adults undergoing endoscopy and colonoscopy has NOT been shown to improve patient safety or clinical outcomes and significantly increases costs for moderate sedation - currently no data that supports ASA’s recommendation for use of capnography during endoscopic procedures in adults where moderate sedation is targeted.
2018: New Guideline - capnography has been demonstrated to detect depressed respiratory activity before transient hypoxemia, but a clear link between transient hypoxemia and serious cardiopulmonary unplanned events during sedated endoscopy has NOT been establish. Integrating capnography into patient monitoring protocols for endoscopic procedures w/ _____ sedation has NOT been shown to improve patient safety; however, there is evidence supporting its use in procedures targeting ____ sedation.

Answer 13

moderate
deep

**they distinguish moderate from deep sedation but from an anesthesia perspective, they are both MAC sedation and require ETCO2 monitoring

Question 14

Medicare Definitions of Sedation: Slide 19

Monitored Anesthesia Care (MAC): Indications for MAC depend on the nature of the procedure, patient’s clinical condition, and/or the potential need to convert to a general or regional anesthetic

1. ________ sedation/analgesia is included in MAC.
2. W/ ____ sedation/analgesia, a drug induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation.

The ability to independently maintain ventilatory function may be impaired - patients may require assistance in maintaining a patent airway and spontaneous ventilation may be inadequate.

3. ________ sedation/analgesia: a drug induced depression of consciousness during which patients can respond to verbal commands either alone or accompanied by light tactile stimulation
4. __ _____ are required to maintain a patient airway and spontaneous ventilation is adequate. CMS & ASA does NOT define moderate or conscious sedation as ________.
5. ______ : drug induced state during which patients respond normally to verbal commands. Although cognitive function and coordination may be impaired, ventilator and cardiovascular functions are unaffected…again, not anesthesia

Answer 14

1. deep anesthesia/analgesia
2. deep anesthesia/analgesia
3. Moderate
4. NO interventions
   
   • anesthesia
5. minimal sedation

Slide 19

Question 15

Review slide 20 - Becker’s GI & Endoscopy guidelines for sedation/anesthesia

1. All pts undergoing endoscopic procedures should be evaluated to assess their risk of sedation related to ________.
2. Use a combo of an ____ & ____ for a safe and effective regimen for achieving minimal to moderate sedation for upper endoscopy and colonoscopy in pts without risk factors for adverse events related to sedation.
3. In certain clinical circumstances, practitioners should also use an agent like ______, ____, or ____ in combo with conventional sedative drugs.
4. Providers should undergo specific training in administering endoscopic sedation. Providers should have the necessary skills for the dx and mngt of sedation related adverse events, including rescue from a level of sedation deeper than intended.

Answer 15

1. pre-existing medical decisions
2. opioid and benzo
3. diphenhydramine, promethazine, or droperidol

Question 16

8 guidelines for sedation and anesthesia in GI endoscopy continued…

5. Routine monitoring of _____, ____, and ______ in addition to clinical observation for cardiopulmonary status changes during all endoscopic procedures under sedation. Providers should consider ______ administration for mod. sedation, during deep sedation and if hypoxemia is anticipated or develops
6. Consider _______ monitoring for patients undergoing endoscopy targeting deep sedation
7. Consider anesthesia provider-administered sedation for patients with multiple ________ or risk of ________ during complex endoscopic procedures.
8. Endoscopists should use _____ based sedation when it is expected to improve patient safety, comfort, procedural efficiency and successful completion of the procedure.

Answer 16

5. blood pressure, oxygen saturation, heart rate
   - supplemental oxygen
6. capnography
7. cormorbidities, airway compromise
8. propofol

Question 17

Points from the 2018 GI Sedation Guidelines:

1) Balanced sedation using benzos, opioids, and smaller amount of Propofol (moderate sedation) administered by ____, shown to be safe & effective.
2) Anesthesia provider-administered sedation is more expensive (large amounts of Propofol) and does ___ result in improved safety.
3) Higher _____ risks with deep sedation administered by anesthesia providers compared to lighter sedation via –endoscopists-directed propofol by RNs.
4) Anesthesia providers are _____ for more complex and/or long procedures, deep sedation, ASA IV &V, high tolerance patients.
5) Despite no safety benefit, use of anesthesia providers continue to _____ for low-risk endoscopy and colonoscopy procedures - use of anesthesia providers appears to be associated with ______ practices

Answer 17

1 - RN
2 - NOT
3 - aspiration
4 - needed
5 - increase - reimbursement

Question 18

Who cares about moderate vs. deep anesthesia?

Medicare defines the difference: ______ models can be influenced by sedation differences and ______ drives decisions about who should do GI anesthesia.

GI societies care: 2018 GI Endoscopy Guideline Position Statement addresses sedation - it also recommends what they think is safest and most cost-effective sedation.

Answer 18

reimbursement, reimbursement

Question 19

EGD Anesthetic Technique:

1) You are sharing the _____ with the endoscope. If masking is needed, the procedure must be temporarily ________.
2) Assess bite block placement - propofol _____ may displace prior to scope insertion.
3) Timing is crucial to avoid _____ and ______ - you want to ensure the ___ ____ is eliminated prior to procedure.
4) GOAL: eliminate ____ WITHOUT eliminating ______
5) Administer systemic _______ (suppresses cough some)
6) Cetacaine spray??
7) ______ can help prevent gag/cough/bucking but use w/ caustion.

Answer 19

airway - interrupted

yawn

coughing, bucking, gag reflex

gag, respirations

lidocaine

fentanyl

Question 20

Using cetacaine spray during EGD can be problematic:

1) It can cause _______.
2) The aerosolized version can cause potential _____ from the hot scope light.

There is a non-aerosolized form of benzocaine hurricane spray that can be squirted into the back of the patient’s throat instead of the spray.

Answer 20

methemoglobinemia

FIRE (no risk w/ the non-aerosolized form)

Question 21

LONGER EGD are required for multiple _____, burning _____, clipping ____ _____, and Barrett’s treatment.

Answer 21

biopsies
ulcers
bleeding tissues

Question 22

EGD complications include:

1) ______ after polyp removal or biopsy
2) ______ of esophagus (possibly d/t coughing)
* perforation & bleeding more common during _____ sedation.
3) ______: most important sedation related complication - can be d/t _____ and/or actively ______
4) _______ damage
5) ____, ____, ____, ____ damage

Answer 22

1 - bleeding
2 - perforation - propofol
3 - aspiration - vomiting, bleeding
4 - laryngopharyngeal damage
5 - tooth, lip, mouth, tongue

Question 23

EGD Anesthetic Technique Pearls

1) Once beyond the larynx, _____ anesthesia is required.
2) _____ based on biopsies - do not want to over sedate.
3) Run the O2 flows up to ___-___L/min (nasal burns, ulcerations can occur) - during _____ events, the higher O2 flows keeps the patient oxygenated (but poor ventilation).
4) Know your GI doctors and the difference in their _____ and procedures. Some GI doctors will check before starting but others proceed w/out checking w/ you.
5) Using only Propofol sedation keeps patients rolling into and out of PACU _____

Answer 23

1 - LESS
2 - timing
3 - 6-10 L/min - apneic
4 - timing - some docs may use a lot of lube which can cause more coughing/gagging
5 - rapidly (Fort uses lidocaine & propofol)

Question 24

Outpatient Colonoscopy Indications:

1) Age 50 colorectal cancer ______ to detect & _____ potentially cancerous polyps (younger if family history of colorectal cancer).
2) ____ bleeding - ____ is likely but definitive diagnosis is still needed.
3) Change in ____ ____
4) ____ pain
5) Unresolved _____
6) evaluation of _____ or ______
7) _____ mass for resection

Answer 24

1 - screening - biopsy
2 - rectal - hemorrhoids 
3 - bowel habits
4 - diverticular 
5 - diarrhea
6 - Crohn's disease, ulcerative colitis 
7 - tattooing

Question 25

Colonoscopy Anesthetic Technique: 1) Will NOT require diminishing the ___ ____ - coughing and bucking are _____ 2) can produce greater ____ for the patient from pressure/blowing air 3) The doctor is heading toward the cecum - staff tracks the time the cecum is reached until the end of the procedure (typically ___ minutes from the time they reach the cecum until the end unless there are polyps) 4) Some identify and remove polyps on the way in AND out, some just on the way out. 5) you can begin exam with much ____ sedation than w/ EGD - but requires ____ sedation w/ abdominal pressure/scope manipulation.

Answer 25

1 - gag reflex, uncommon 2 - discomfort 3 - 6 minutes (watch markings on scope to know when they are backing out/near end) 5 - LESS at beginning, more later

Question 26

Colonoscopy may be delayed (last longer if: 1) there are _____ _____ to remove and/or biopsy 2) poor prep 3) poor vision from bubbles - ____ added to irrigation to help 4) ____ colon 5) hard to reach ___ 6) Bovie pad required for hot biopsy

Answer 26

1. multiple polyps 3 - simethicone 4. spasming 5. polyps

Question 27

Review pictures on slides 35-37. snare technique &hot biopsy

Answer 27

snare technique & hot biopsy

Question 28

Colonoscopy Anesthetic Technique Pearls: 1) May do a brief ___ _____ before inserting endoscope - this will tell you whether the patient is deep enough to proceed. 2) Repeatedly watch the endoscope _____ - it's unreliable to identify where you're at in the colon. 3) Know your GI doctor & their preferences - they may be slow in, quick out or vice versa. 4) Retroflex hemorrhoid eval at the end can _____ if patient is too light. 5) Abdominal pressure required to aid in getting to cecum can be pain inducing requiring extra _____ 6) Waking up w/ less than ___ cm of scope is not a problem - don't give more propofol - whisper that the procedure is ending and to remain still and they will be still.

Answer 28

``` 1 - digital exam 2 - markings 4 - stimulate 5 - propofol 6 - <20 cm ```

Question 29

Colonoscopy Complications: 1) _____ d/t pressure to aid in preventing loops on way to cecum (most of the time, you never treat - just tell doctor) 2) _____ colon from large loops in colon 3) _______: air under pressure fills stomach causing vomiting of gastric contents; prolonged colonoscopy w/ large amounts of air travels up through GI tract 4) ___ especially from long procedures requiring a lot of pressure for cecum destination

Answer 29

1 - vagal 2 - perforated colon 3 - aspiration 4 - pain

Question 30

Positioning for endoscopy: ___ ____ position regardless of colonoscopy or EGD NO _____/_____ roll required. Slight ___ ___ for EGDs and colonoscopy to aid in _____ prevention. Knees slightly ____.

Answer 30

left lateral no chest/axillary roll head up - aspiration bent

Question 31

Most Common Drugs Used During Endoscopy: 1) Levsin IV Push: ______, ______ (dosage per GI doc) 2) Glucagon IV Push: GI ____ _____ _____ (dose usually __mg IV push) 3) Robinul IV Push: GI ______, _______ (__-__ mg IV push given prior to procedure to dry oral cavity) 4) Simethicone irrigation: reduces ___ _____ (given by endoscopist through endoscope to increase visualization)

Answer 31

1 - anticholinergic, antispasmodic 2 - smooth muscle relaxant - 1 mg 3 - anticholinergic, antisialogogue - 0.2-0.4 mg 4 - gas bubbles

Question 32

Sleep apnea patients are challenging but manageable. You can use a ____ ____ w/ endoscope through cut hole but can be difficult and most doctors do not like that. There is a specific ____ w/ bag and _____measurement available. _____ is also an option, but secretions may necessitate Robinul first.

Answer 32

face mask CPAP - ETCO2 ketamine

Question 33

Will high flow O2 help us during EGD? (Review) 1. Oxygen flows of __ L/min nasal prongs increased the period of saturation greater than 95% in obese patients. 2. Preoxygenation immediately ____ to endoscopy scope insertion. 3. Saturation can remain high until ____________. 4. Some studies use 5 L/min some have used 10 L/min via nasal cannula. BEWARE: Patients report nasal passage___, ____, ____ with too high of flows Some use high flow nasal cannula (HFNC) delivering oxygen up to 70 L/min.

Answer 33

Slide 45-46 are review of apneic oxygenation in man (study) and apneic mass flow of oxygen diagram. 1. 5 2. prior 3. redistribution of propofol 4. burn, ulceration, irritation

Question 34

Endoscopic ultrasound (EUS) and endoscopic retrograde cholangiopancreatography (ERCP) procedures can become _____ but most are under 30 minutes. These may require multiple _____ w/ differing specimen processing which can prolong the procedure. These are mostly performed under ____ ____. EUS patients can benefit from ____ to control post-op pain if multiple biopsies are taken.

Answer 34

lengthy biopsies deep sedation fentanyl

Question 35

Endoscopic retrograde cholangiopancreatography (ERCP) can be a lengthy procedure). It is most often performed in ____ positioning (some perform in supine). It can be done under ____ _____ or ____ _____. You may or may not administer opioids before or after ____ testing. A spy glass can be utilized for ___ ____ exploration (smaller scope - long procedure).

Answer 35

prone deep sedation, tracheal intubation pressure bile duct

Question 36

1. _____ is the goal (especially outpatient). 2. GI docs have double digit cases to do so slow recovery means ____ cases. Quick evals, quick asleep, quick awake, quick report in recovery is the expectation. 3. Our goal is to ensure the ____ of our patient as we provide sedation.

Answer 36

1. SPEED 2. delayed 3. SAFETY

Question 37

Flexible sigmoidoscopy is a procedure from the rectum to the _____ - it usually only lasts a few _____ and requires very LITTLE sedation.

Answer 37

sigmoid | seconds

Question 38

REMEMBER: 1) You're an anesthesia provider and delivering anesthesia so use ______. 2) You are the only one who can completely manage the patient's ______. 3) You are the safest and most cost-effective sedation option they have. 4) The _____ start and recovery requires anesthesia providers.

Answer 38

1 - capnography 2 - airway 4 - fastest