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

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Copyright 2015 Wolters Kluwer Health, Inc. All rights reserved.

Anesthesia outside the operating room
KEY POINTS

To provide safe and adequate anesthesia/sedation for
gastrointestinal procedures outside of the operating
room, the anesthesiologists and nonanesthesiologists
should find a consensus and develop quality-
improvement strategies.

TIVA, TCI: importance, advantages, disadvantages?

The application of intravenous or topical lidocaine for
the upper airways to facilitate the insertion of the
endoscope: benefit or risk?

Video laryngoscope to visualize the insertion of the
endoscope for gastrointestinal procedures: can it
prevent lesions of the mouth, uvula, hypopharynx,
epiglottis, and larynx caused by the endoscope?
their procedures performed in the main operating
room suite [36].
There may be differences in the physical con-
figuration of each hospital; some have dedicated
gastrointestinal procedure units and others may
have designated gastrointestinal rooms within a
larger operative suite. Regardless, it is essential that
every endoscopy location has a standardized anes-
thesia setup, including an anesthesia machine,
American Society of Anesthesiologists physical
status (ASA) standard monitoring, an anesthesia
cart, and a suction apparatus [36]. Good coordina-
tion and organization of the procedures in the main
operating room and outside locations is very
important for the safety of the patients and the
efficiency of all involved in services [7].
Many gastrointestinal procedures outside of the
operating room are of short duration. To maintain
effective throughput in managing the high volume
of gastrointestinal procedures, the teams should be
&& &
focused and efficient [1 ,2 ,7]. High-quality care
and safety for the patient in outside locations
requires expertise and experience of the anesthesi-
ologist and nonanesthesiologist services [811]. The
aim of this review is to highlight several tools used in
clinical practice to further improve adult and
pediatric anesthesia and sedation for gastrointesti-
nal procedures outside of the operating room and
the importance of a consensus between anesthesi-
ologists and nonanesthesiologists to develop qual-
&&
ity-improvement strategies [1 ,3,4,912].
ANESTHESIA AND SEDATION FOR
GASTROINTESTINAL PROCEDURES
OUTSIDE OF THE OPERATING ROOM IN
ADULTS
For esophagogastroduodenoscopy (EGD), recto-
scopy, colonoscopy, insertion of a Percutaneous
470 www.co-anesthesiology.com
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Endoscopic Gastrostomy (PEG) or Anorectal
Manometry (ARM), most adult patients of ASA status
I or II are usually managed by the gastroentero-
logy team without involvement of the anesthesia
&& &
service [1 ,2 ]. After the evaluation of the patient,
oral sedation (often midazolam) or intravenous
sedation (often propofol) is administered. The
patient breathes spontaneously and if necessary
supplemental oxygen is administered via a nasal
cannula. For EGD, a topical local anesthetic either
lidocaine or Cetacaine spray (14% benzocaine, 2%
butamben, and 2% tetracaine) is used to prepare
mouth and hypopharynx of the patient to enable
an easy insertion of the endoscope. The EGD is
usually performed in the left lateral decubitus
position [4,5].
For Endoscopic Retrograde Cholangio-Pancrea-
tography (ERCP), the patient may receive a premed-
ication (often midazolam or lorazepam) combined
with a gastric acid blocker (usually pantoprazole).
During the procedure, the patient is positioned in a
left lateral decubitus position and monitored with
Peripheral capillary Oxygen Saturation (SpO2), ECG,
and noninvasive blood pressure. An intravenous
cannula is inserted for administration of fluid and
medications. Oxygen is delivered via a nasal cannula
or facemask, and the End Exspiratory Carbon Diox-
ide (EECO2) is monitored. Administration of intra-
venous or topical lidocaine facilitates the insertion
&
of the endoscope [2 ,4]. Conscious sedation (patient
is sedated but answers questions and follows orders)
with midazolam and an opioid is usually performed
by nonanesthesia personnel [13,14]. Deep sedation
with propofol is administered by nonanesthesiolo-
gists or anesthesiologists and general anesthesia by
anesthesiologists only [1315] Deep sedation and
anesthesia is increasingly performed as TIVA or TCI
with propofol as single agent or in combination
with a small dose of a short-acting opioid such as
fentanyl, alfentanil, or remifentanil. During a TIVA
or TCI anesthesia, a Bispectral Index (BIS)-monitor-
ing to minimize the occurrence of awareness is
recommended. Patients should be able to maintain
spontaneous respiration [4,5].
In the elderly or patients who are obese or
patients with significant medical comorbidities
such as ASA status III or IV, usually an anesthesiol-
ogist will provide sedation or anesthesia for ERCP,
EGD, rectoscopy and colonoscopy, insertion of a
&
PEG or an ARM [2 ,4,5]. During the EGD and ERCP,
the gastroenterologist and anesthesiologist share
the access to the patients airway. During a recto-
scopy, colonoscopy, insertion of a PEG or an ARM,
the anesthesiologist has full access to the airway
of the patient. For gastrointestinal procedures
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
Mask Airway (LMA) and ventilation is spontaneous.
After conclusion of the procedure, patients should
be recovered in a postoperative care unit until same-
day discharge criteria are fulfilled or transfer to a
ward for an extended overnight hospitalization is
appropriate [4].
For anesthesia/sedation in gastrointestinal pro-
cedures, patients with pulmonary and/or cardiac
or renal disease, liver cirrhosis, elderly patients,
patients who are obese, and pregnant women, there
are special considerations and drug doses used for
sedation that must be altered [16].
The risk of complications after gastrointestinal
procedures in anesthesia or sedation is relatively
low. A retrospective study of 165 527 colonoscopies
performed between January 2000 and November
2009 was conducted by Cooper et al. [17]: the total
rate of complications was 0.17% (n 284 pro-
cedures) and included aspiration 0.10% (n 173),
colon perforation 0.06% (n 101) and splenic injury
0.007% (n 12). An increased risk of aspiration and
aspiration pneumonia related to colonoscopies in
deep sedation (with anesthesia assistance) was
found compared with the same procedure in con-
scious sedation (without anesthesia assistance).
There was no significant increase in splenic injury
or colon perforation during procedures observed in
patients undergoing deep sedation [17].
Patient data of 118 004 colonoscopies performed
between January 2003 and October 2012 were ana-
lyzed retrospectively by Adeyemo et al. [18]: a rate of
colon perforation of 0.04% (n 48) was identified. In
patients undergoing diagnostic colonoscopy, there
was no increased risk of colonic perforation with deep
sedation compared with conscious sedation; how-
ever, therapeutic colonoscopy during deep sedation
was associated with a 3.4 times increased risk of
colonic perforation [18].
In both studies, predictors of complications
included increasing comorbidity and increasing
age (>70 years). For gastrointestinal procedures,
an anesthesiologist usually cares for patients of
ASA status III and IV and performs deep sedation.
The gastrointestinal procedures of the patients of
ASA status I and II are managed with conscious
sedation without the anesthesia service. The
inclusion of patients of ASA status III and IV may
be the most important reason for the increased rate
of complications related to deep sedation with anes-
thesia assistance described in various studies.
Mortality for gastrointestinal procedures out-
side of the operating room has decreased in recent
& &
years [2 ,8,1921,22 ]. Anesthesiologists, gastroen-
terologists, other nonanesthesiologists and their
societies are concentrating their efforts on
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improving the quality of treatment and safety for
the patients in remote locations with guidelines,
special training for providers, and consensus con-
ferences [2325].
PEDIATRIC ANESTHESIA AND SEDATION
FOR GASTROINTESTINAL PROCEDURES
OUTSIDE OF THE OPERATING ROOM
The management of infants and children for gastro-
intestinal procedures outside of the operating room
requires a different approach from the adult popu-
lation as described below.
For gastrointestinal procedures outside of the
operating room in older, mature children of ASA
status I or II, oral sedation with midazolam might be
appropriate, whereas others will require additional
intravenous sedation (often with propofol) by the
gastroenterology team. Gastroenterologists may uti-
lize lidocaine or Cetacaine spray to facilitate the
insertion of the endoscope. The gastroenterologists
have developed their own assessment tools and
guidelines for the sedation for gastrointestinal pro-
cedures [26].
All children of ASA status III or IV should receive
anesthesia and sedation for gastrointestinal pro-
cedures by an anesthesia team preferably in the
main operating room.
Some categories of healthy ASA status I or II
children still require the care of an anesthesia team.
The anesthesiologist must evaluate the children,
assess their individual risks and plan the anesthesia
or sedation for the procedure [3,6,27]. The gastro-
intestinal procedures outside of the operating room
require full ASA monitoring with SpO2, EECO2,
ECG, and noninvasive blood pressure, and an intra-
venous cannula for the application of fluids and
anesthetic agents for anesthesia and sedation. To
minimize the occurrence of awareness during an
anesthesia with TIVA or TCI, BIS-monitoring is
recommended [28]. A high level of quality and
safety for the patients before, during, and after
anesthesia/sedation for the gastrointestinal pro-
cedures is very important [2731].
Induction with sevoflurane in children younger
than 4 years is sufficient for most procedures. The
inhalational agent may be combined with nitrous
oxide during induction. Placement of an intrave-
nous catheter is required. If necessary, a propofol
bolus to facilitate intubation may be administered.
For short procedures (1030 min) intubation with-
out relaxation is adequate; however, if relaxation is
required, a short-acting agent such as suxametho-
nium or atracurium should be administered. For
longer procedures, relaxation with atracurium or
rocuronium is appropriate.
www.co-anesthesiology.com 471
Anesthesia outside the operating room
Induction with sevoflurane followed by intra-
venous insertion is suggested for all children for
ERCP and a combination of EGD and colonoscopy
taking 60 min or longer. An intravenous propofol
bolus followed by an opioid is preferred. Lidocaine
intravenous or lidocaine spray/Cetacaine spray is
recommended for the upper airways. Usually, intu-
bation facilitated by muscle relaxation is required
followed by insertion of the endoscope. Anesthesia
is maintained with sevoflurane or switched to pro-
pofol TIVA or TCI. The EGD is performed with the
patient in the left lateral decubitus position. For
colonoscopy, the patient should be repositioned.
The bed is turned 908 to the right with the patients
head toward the anesthesia machine. An infant or
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.
For the care of children between 4 and 10 years
undergoing colonoscopy (3060 min), PEG (30 min)
and ARM (2030 min) induction is accomplished
with sevoflurane. Intravenous access is secured and
spontaneous ventilation is maintained with either a
face mask or LMA. During ARM, Botox may be
injected. It is quite a strong stimulus. The anesthesia
should be deepened with sevoflurane or a propofol
bolus intravenous prior to the Botox injection.
Whenever possible, spontaneous respiration is pre-
ferred during these gastrointestinal procedures.
After conclusion of the gastrointestinal pro-
cedure, it is important that the child recovers in a
fully equipped postanesthesia care unit with child
appropriate, well trained personal. Most children
will be discharged on the day of the procedure.
Depending on associated comorbidities and the
type of procedure, some children will require an
overnight stay.
The Pediatric Sedation Research Consortium ana-
lyzed prospectively collected data on 49 836 propofol
sedation/anesthesia procedures at 37 locations in the
USA between July 2004 and September 2007: there
were no deaths, cardiopulmonary resuscitation was
required twice (0.004%), and aspiration was observed
in four patients (0.008%). Less-serious events were
more common in sedation and anesthesia adminis-
trations such as desaturation (0.015%), central apnea
or airway obstruction (0.058%), stridor (0.005%),
laryngospasm (0.0096%), excessive secretions
(0.034%), and vomiting (0.0049%). These data
indicate that pediatric propofol sedation and anes-
thesia rarely have serious adverse events and out-
comes. However, the safety of this practice depends
on the ability of the sedation/anesthesia providers to
manage these less-important events. Therefore, the
training of the sedation/anesthesia providers is very
important [9].
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The primary goal is to prevent and if necessary
immediately treat any adverse events occurring
before, during, and after pediatric anesthesia/seda-
tion [911,2931].
The article To Err is Human from the American
Institute of Medicine in 2000 states, anesthesia is an
area in which very impressive improvements in
safety have been made [32]. But children are a very
vulnerable population with special risks. Multidis-
ciplinary consensus between anesthesiologists and
nonanesthesiologists involved in anesthesia/seda-
tion of children is essential [12,24,25,31]. More well
designed studies and trials of pediatric anesthesia/
sedation for procedures outside of the operating
&
room are needed [33 ].
TOTAL INTRAVENOUS ANESTHESIA AND
TARGET-CONTROLLED INFUSION
TIVA and TCI with propofol alone or with remifen-
tanil are well established in adult anesthesia/seda-
tion for gastrointestinal procedures outside of the
operating room. Endoscopist-directed adminis-
tration of propofol was evaluated in a worldwide
safety study with 646 080 identified cases and found
to be well tolerated. Endotracheal intubations were
performed in 11 cases (0.002%), permanent neuro-
logic injuries occurred in none, and four patients
(0.0006%) out of the 646 080 cases died. The overall
number of patients requiring mask ventilation was
489 (0.086%) out of 569 220 cases. Mask ventilation
was necessary during EGD in 0.1% and during colo-
noscopy in 0.01%. The mortality rate was lower than
in data of sedation on endoscopist-delivered benzo-
diazepines and opioids [8].
Another significant safety analysis of endoscop-
ist-directed propofol sedation was performed in
Germany. In a prospective, national multicenter
study of 24 441 patients in 53 German outpatient
practices, endoscopist-directed administration of
propofol was demonstrated to be a well tolerated
procedure. Major adverse events occurred in four
patients (0.016%): three mask ventilations and one
laryngospasm. Minor events were observed in 112
patients (0.46%), hypoxia being the most common
minor event. All patients with adverse events recov-
&
ered without persistent impairment [22 ].
In many institutions, pediatric anesthesia for
gastrointestinal procedures is performed with an
inhalational agent, often with sevoflurane, especi-
ally in small children and for short procedures. The
inhalational agent may be combined with nitrous
oxide during induction. TIVA and TCI with propofol
as single agent or with remifentanil are increasingly
utilized in pediatric anesthesia, especially for older
children and longer procedures. TIVA and TCI are
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Number 4
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 Adult and pediatric anesthesia/sedation in gastrointestinal procedures Michel
Table 1. The advantages of target-controlled infusion
compared with total intravenous anesthesia and
inhalational anesthesia
Precise and smooth onset and end of anesthesia
Less risk of intraoperative movement
Less changes in heart rate (bradycardia/tachycardia)
Less changes in blood pressure (hypotension/hypertension)
Reduction in intracranial pressure
Preservation of hypoxic pulmonary vasoconstriction
Prediction of time of recovery
After anesthesia patient is alert, feels comfortable, ready to be
discharged from the hospital shortly after the procedure
good options, especially if a patient presents with a
history of severe PONV despite PONV-prophylaxis,
emergence delirium syndrome, or an enhanced risk
of malignant hyperthermia. TIVA may be recom-
mended for infants older than 6 months and 5 kg
body weight. TCI may be recommended for children
older than 3 years and 15 kg body weight. TIVA and
TCI are suggested for anesthesia/sedation of infants
and children for procedures with an expected
duration of more than 30 min. TIVA and TCI tech-
niques of adults are very well established for short as
well as for long procedures. Advantages and disad-
vantages of TCI and TIVA are shown in Tables 13
and were presented at the European Society of
Anaesthesiology European Society of Anaesthesiol-
ogy Conference in Paris, June 2012 [34].
At Bethanien Hospital and Schulthess Klinik,
Zurich, Switzerland, TIVA and TCI anesthesia/seda-
tion are performed with propofol and remifentanil
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
duration and postoperative sedation with propofol
up to 72 h. Propofol syndrome has not been
observed [3537]. Moderate propofol dosages are
used. Rather than increasing the dosage of propofol,
propofol and remifentanil are combined with non-
opioids such as paracetamol, novalgin, NSAIDs, and
Table 2. Advantages of target-controlled infusion and total
intravenous anesthesia compared with inhalational
anesthesia
PONV less frequent and less severe
Emergence syndrome less frequent and less severe
No risk of malignant hyperthermia
Separation of anesthesia provision from respiration
Reduced atmospheric pollution
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Table 3. Disadvantages of target-controlled infusion and
total intravenous anesthesia compared with inhalational
anesthesia
Intravenous placement of the cannula in the awake child may be
difficult. In anxious children or children and adults with a difficult
intravenous access an inhalational induction may be preferable
Propofol intravenous produces a burning sensation in the awake
patient
Awareness is more frequent: BIS-monitoring may be helpful to
minimize awareness, but cannot guarantee to avoid it
Propofol syndrome
opioids such as sufentanil, alfentanil, fentanyl,
morphine. Other drugs like ketamine, clonidine,
and dexamethasone may also be useful adjuncts
[3842]. Regional anesthesia can be combined with
TIVA and TCI anesthesia/sedation and provides
excellent intraoperative and postoperative analgesia
[43]. For TIVA anesthesia and sedation, the doses of
propofol and remifentanil are suggested in Table 4.
TIVA and TCI are precise and elegant methods to
perform anesthesia and sedation [44]. There are
different models for TCI with propofol. The first
model developed was the Diprifusor [45,46]. After
its patent expired, other models were developed
like the Marsh model [4651], the Schnider model
[4651], the Kataria model with the Katfuser
[46,51], the Paedfuser model for children [52], and
&
the White model [53,54 ].
The above-mentioned open TCI systems can be
programmed with any pharmacokinetic model and
allow either plasma-site-targeting or effect-site-tar-
geting. The goal of the effect-site-targeting mode is
Table 4. Total intravenous anesthesia for adults and
children
TIVA for adults:
Anesthesia: Propofol 1% 66100150 mg/kg/min ->
469 mg/kg/h IV
Sedation: Propofol 1% 335066 mg/kg/min ->
234 mg/kg/h IV
Anesthesia: Remifentanil 0.10.4 mg/kg/min IV
Sedation: Remifentanil 0.050.1 mg/kg/min IV
TIVA for children:
Anesthesia: Propofol 1% 100150200 mg/kg/min ->
6912 mg/kg/h IV
Sedation: Propofol 1% 100150166 mg/kg/min ->
6910 mg/kg/h IV
Anesthesia: Remifentanil 0.10.4 mg/kg/min IV
Sedation: Remifentanil 0.050.1 mg/kg/min IV
IV, intravenous; TIVA, total intravenous anesthesia.
www.co-anesthesiology.com 473
Anesthesia outside the operating room
to achieve a user-defined target-effect-site concen-
tration as rapidly as possible by manipulating the
concentration around the target. The provider choo-
ses the target concentration. The pump gives the
drug dose to achieve the target without overshoot.
Patient parameters like weight, height, lean body
mass, age, and sex influence the drug dose delivered
by the pump.
In the Marsh model, the rate constants are fixed,
but the compartment volumes and clearances are
proportional to the weight of the patient. Initially,
relatively large doses are administered and the target
concentration is reached quickly. The Marsh model
should be used in the plasma-site-targeting mode. It
was developed for adults and later adapted and
tested for children aged 19 years. The Marsh model
is mainly used for adults and works well in young
and fit individuals and also in patients who are
morbidly obese. It is less accurate in the elderly
and very sick patients.
The Schnider model was derived from combined
pharmacokinetic and pharmacodynamic modeling
studies. In the Schnider model, the compartment
volumes V1, V3 and the rate constants k13 and k31
are fixed. The compartment volume V2 and the rate
constants k12 and k21 adjust for age. The rate con-
stant k10 adjusts according to total weight, lean
body mass, and height. The Schnider model delivers
very small initial doses in the plasma-site-targeting
mode, and therefore should be used in the effect-
targeting mode, in which larger initial doses are
administered. These initial doses are still smaller
and the target concentration is reached more slowly
than in the Marsh model. The Schnider model was
tested in adults and children aged 516 years. It is
recommended for adults and works well also in the
elderly and critically ill patients. It may be used for
children aged 1016 years respectively minimal
body weight of 30 kg up to young adults. It is less
accurate in individuals who are morbidly obese than
the Marsh model.
The Katarian model with the Katfuser was
studied in children aged 315 years and 1561 kg
body weight. It is recommended for children aged
816 years and 2061 kg body weight. The Paed-
fuser model was especially developed for children
and tested in children aged 118 years and 561 kg
body weight. It is recommended and accurate in
patients aged 316 years and 1561 kg body weight
[4652].
The TCI dosages vary and depend on the used
TCI model, age, and an interindividual variation in
propofol clearance of the patient. None of the
models accounts fully for the extent of interindivid-
ual variation in propofol clearance, but the newer
models, for example, the White model seem to
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improve the predictive performance and accuracy
&
for the patients [53,54 ]. TCI is not yet approved by
the Food and Drug Administration in the USA. TIVA
and TCI are open-loop systems.
There are promising tools trying to bridge the
gap toward a closed-loop system.
These include a patient-controlled system,
which is a combination of TCI and Patient Con-
trolled Analgesia with a patient-demand function
[55]. The computer-assisted personalized sedation
system is able to monitor SpO2, EECO2, ECG, and
patient responsiveness to auditory commands while
titrating propofol in small dosages [56].
The SEDASYS incorporates comprehensive
patient monitoring and is able to stop the propo-
fol infusion. In Europe, SEDASYS is approved for
routine colonoscopy and screening of the upper
gastrointestinal tract. In Canada, it is approved for
routine colonoscopies in conscious sedation [57].
BIS-monitoring with continuous feedback to the
TCI pump that adjusts the dose is investigated [58].
The measurement and analysis during anesthesia of
exhaled end-tidal-propofol by mass spectrometry
with feedback to the propofol-pump was tested in a
clinical study recently. The concentrations in the
expired air reflected the plasma concentrations of
propofol as well as the depth of anesthesia assessed
by BIS-monitoring [59].
These new techniques help to make TCI anes-
thesia/sedation even more precise and accurate. But
these modern tools are not able to close the open-
loop systems completely yet, therefore the expertise
of anesthesiologists is still needed.
Propofol alternatives for anesthesia/sedation in
gastrointestinal endoscopy include inhalational
agents such as sevoflurane and intravenous drugs,
for example, midazolam, ketamine, dexmedetomi-
dine, remifentanil, and remimazolam (CNS 7056) as
discussed in a review 2014 [60].
INTRAVENOUS AND TOPICAL LIDOCAINE
The administration of intravenous lidocaine or of
topical lidocaine spray for the airway attenuates
laryngeal and respiratory reflex responses such as
coughing, expiration reflex, spasmodic panting,
and apnea [6163]. This facilitates the insertion
of a laryngoscope or video laryngoscope, tracheal
tube, LMA, bronchoscope, or an endoscope for
gastrointestinal procedures. A recent meta-analysis
suggests both intravenous and topical lidocaine
are also effective for preventing laryngospasm in
&
children during airway manipulation [64 ]. In
addition, intravenous and inhaled lidocaine may
attenuate histamine-evoked bronchoconstriction
[65].
Volume 28
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 Adult and pediatric anesthesia/sedation in gastrointestinal procedures Michel
For short procedures such as the EGD (ca.
1030 min) intravenous lidocaine is preferred.
The intravenous lidocaine dose is 1.5 mg/kg intra-
venous for patients younger than 60 years, 1 mg/kg
intravenous for patients 6080 years, 0.5 mg/kg
intravenous for patients older than 80 years, and
12 mg/kg intravenous in children older than
3 years. This reduces the laryngeal and respiratory
reflex responses significantly after 2 min and lasts
for approximately 10 min. At the same time, it
attenuates the burning sensation of an intravenous
induction with propofol. The strongest stimulus
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
procedure, the laryngeal and respiratory reflexes are
intact again and the risk of aspiration is minimized.
Possible disadvantages of intravenous lidocaine
include bradycardia and hypotension; therefore, it
should be used with caution in patients taking
b-blockers, calcium antagonists, digitalis, and other
antiarrhythmic agents, especially in the presence of
pre-existing bradycardia.
For longer procedures such as the combination
of EGD and colonoscopy (60 min or longer) or an
ERCP (60 min or longer), it is a good option to use
lidocaine spray topical at the upper airways to facili-
tate the insertion of the endoscope. Cave: One spray
of lidocaine 4% 0.25 ml is equivalent to 10 mg.
Possible disadvantage of topical lidocaine may be
persistent dysfunction of the larynx after extubation
or LMA removal with the potential risk of aspiration,
especially after short procedures.
Intravenous lidocaine is especially useful for
anesthesia or sedation for short procedures includ-
ing gastrointestinal procedures outside of the oper-
ating room. With intravenous lidocaine, the
insertion of the endoscope is smooth and con-
sequently the dose of opioids can be reduced or
avoided. Advantages include fast wake up, no respir-
atory depression, and timely return of laryngeal and
respiratory reflexes.
Intravenous lidocaine increases the depth of
anesthesia of propofol and of sevoflurane [66,67].
Perioperative administered lidocaine intravenous as
a bolus or as a continuous infusion and for local or
regional anesthesia reduces pain before, during, and
after operations and procedures [43,6870].
VIDEO LARYNGOSCOPE
The video laryngoscope may become a new standard
of care not only in the management of the difficult
or failed airway in the operating room, emergency
room, and ICU, but also for the insertion of the
endoscope for procedures in the operating room and
0952-7907 Copyright 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright 2015 Wolters Kluwer Health, Inc. All rights reserved.
in outside locations [7176]. In combination with
intravenous or topical lidocaine application, the
video laryngoscope facilitates the insertion of the
endoscope for gastrointestinal procedures. In
addition, the video laryngoscope permits visualiza-
tion of the endoscope during insertion into the
mouth and hypopharynx for EGD or ERCP and
may prevent lesions of the mouth, uvula, hypophar-
ynx, epiglottis, and larynx by the endoscope. A
review about cranial nerve injuries with supraglottic
airway devices was published in 2015 [77]. Further
investigations are required.
CONCLUSION
For gastrointestinal procedures outside of the
operating room, the concepts of well tolerated
and efficient anesthesia and sedation have to meet
the special needs of pediatric and adult patients and
the requests of gastroenterologists and anesthesiol-
ogists. Anesthesia and sedation with TIVA and TCI
for gastrointestinal procedures is well established
for adults. It is increasingly used in older children
and for longer procedures. But especially for young
children and for short gastrointestinal procedures,
an inhalational anesthesia is the technique of
choice in many hospitals. Anesthesia and sedation
techniques with TIVA and TCI, intravenous or
topical lidocaine and the use of the video laryngo-
scope may improve and facilitate gastrointestinal
procedures for the patients, the anesthesiologists,
and the gastroenterologists. Our primary goal is
high quality of care and safety of the patient for
anesthesia and sedation independent of the pro-
vider. This goal depends on the expertise and
experience of the provider team. Anesthesia and
sedation for gastrointestinal and other procedures
outside of the operating room is a fast growing
division of medical practice. To be able to guarantee
a high level of quality and safety of the anesthesia and
sedation for the patients during these procedures, the
anesthesiologists and nonanesthesiologists have to
find a consensus and develop quality-improvement
strategies. Consensus conferences of the national
organizations of the anesthesiologists, gastroenterol-
ogists, other involved nonanesthesiologists, and gov-
ernment officials are held in the USA, Canada,
Australia, the European Union, Norway, Switzerland,
Eastern Europe, and countries of Asia, South America,
and Africa.
Acknowledgements
None.
Financial support and sponsorship
None.
www.co-anesthesiology.com 475
Anesthesia outside the operating room
Conflicts of interest
There are no conflicts of interest.
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