Whether you're reimbursed for monitored anesthesia care (MAC) or the endoscopy nurse and the treating physician sedate the patient, here are six ways to fine-tune your endoscopy anesthesia.

Establish anesthetic criteria for patients
Laws and insurance company policies vary by state. Patient needs do not. If your facility is able to offer MAC with an anesthesiologist and/or CRNA (see "Is MAC Necessary for Flexible Endoscopy?"), the provider will be schooled in presedation assessment, anesthetic administration, intraprocedure monitoring and discharge criteria for patients.

If anesthesia professionals are not available for the procedure, review the standards applied to your patients. "Anesthesia for healthy patients could probably be done safely by the endoscopist," says anesthesiologist Alan Marco, MD, of Toledo, Ohio. "But how do you decide that the patient is 'sick enough' to need someone with real training in anesthesia?"

While an ACLS-trained OR nurse knows how to assess and respond to an emergency, an endoscopy nurse must develop other skills to properly oversee and monitor anesthesia, says Sharon Lesser, RN, of University of Maryland Hospital in Baltimore. Conscious sedation training is also needed.

Streamline your pre-operative patient assessment
Patients should arrive about an hour before the procedure. When the patient comes to the procedure room, the endoscopy nurse must be able to review the patient's chart for anesthetic history and ask about known allergies. During pre-op education, the patient may have been instructed to stop certain prescriptions (Coumadin, for example) a few days before the endoscopy. Make sure the patient complied. The nurse must be able to assess compliance with NPO requirements before the procedure. Lastly, the nurse must be able not only to start a peripheral IV line, place the patient on the cardiac monitor, automatic blood pressure cuff and oxygen saturation monitor, but she also must know how to monitor the patient during the procedure.

In the case of bronchoscopy, for example, having the procedure team monitor oxygenation is extremely important because hypoxia is the most common complication during the procedure. The patient's oxygen flow rate should be adjusted according to the patient's pulse oximetry (it should not drop below 90 percent). The suction port of a bronchoscope can aspire up to 14 liters of oxygen. Suctioning-induced hypoxia can be diminished by briefly limiting suctioning, says Ms. Lesser.

If you're outsourcing anesthesia in your center, know who is responsible for conducting the pre-operative patient assessment '- either the center or the anesthesia group, says John Poisson, the COO of Physicians Endoscopy, a corporate partner in nine endoscopy centers. Also consider the financial impact on your patient from outsourced anesthesia, says Mr. Poisson. Two or three RNs/ LPNs doing pre-assessment for a center that does 15,000 cases per year represent a significant strain on your bottom line.

Know the risks and interventions
In addition to hypoxia, other complication risks during endoscopy include drug reactions (IV conscious sedation patients are at risk for over-sedation, for example), bleeding, pneumothorax, hypothermia, infection and irregular heartbeat. Your OR team should be familiar with the protocols for assessing and responding to any type of complication. A plan should be in place to deal with each type of emergency that arises with an anesthetized patient on the table.

For example, the OR team can intervene to control bleeding by using the scope to perform suctioning at the site, or using the scope to visualize topical application of a vascoconstricting drug such as Epinephrine, according to Ms. Lesser. Depending on the procedure, for massive bleeding, the team may move the patient from a supine-affected side to minimize aspiration of blood in the lungs, or it may intubate the patient to protect an airway with a massive hemoptysis.

Fatal complications are rare during flexible endoscopy. In a study by Daneshmend and colleagues, the death rate was estimated as one per every 7,500 to 11,000 procedures.

Refine your drug regimen
In many upper GI procedures, the anesthesia provider uses lidocaine or Novocain to anesthetize the upper airway before doing IV conscious sedation. One common approach for bronchoscopy, says Ms. Lesser, is to place 5 ccs of 4% lidocaine (200 mg) in a nebulizer and have the patient breathe deeply. This takes about 20 minutes, she says. Once completed, the anesthesia provider places the patient in a supine position. For other procedures, a lidocaine throat spray is used.

The other sedative drug administrations are a bit more complicated and the potential risks are higher (see "The Cost of Sedatives" on page 64). Propofol, benzodiazepines and/or opiates are commonly used in combination for IV sedation. Other, less common combinations include mixtures of ketamine and lidocaine, along with propofol. In some cases, antihistamines (such as benedryl or phenergen) are used as adjuncts. The goal is strictly to help the patient overcome anxiety and get cooperation from the patient, according to Amil Minocha, MD, the director of the division of digestive diseases at the University of Mississippi Medical Center in Jackson, Miss. Sometimes deep sedation is the only thing that works. He differentiates between "sedation" and "anesthesia," saying that the case moves from sedation to anesthesia when the patient is so deeply sedated that verbal and eye contact are lost.

Hone your sedation technique
Sedation techniques vary widely according to provider preference. "I try to give an anesthetic that I would want for me or a member of my family: midazolam for anxiety, fentanyl for pain and propofol for decreased awareness or sleepiness," says Jay Horowitz, CRNA, of Sarasota, Fla. (Florida is one state where carriers typically reimburse for MAC during endoscopy.) The practitioner describes his standard approach as "very safe" for all age groups in PS I, II and III categories, with no reported PONV, no recall, and PACU discharge and ambulatory status within 30 minutes.

Here's how: He administers 50 mcg fentanyl and 1 mg midazolam and a propofol bolus of 30 to 50 mg. He then uses an infusion pump running propofol at 100 mcg/kg/min.

"Depending on the speed the endoscopist works, I leave the pump running until the ileo-cecal valve is identified by a fast-working endoscopist or until the scope is withdrawn to 50 cm by a slower endoscopist," he says.

For EGD, Mr. Horowitz administers 50 mcg of fentanyl, 1 mg midazolam, 120mg xylocaine and a slightly bigger propofol bolus (40-80mg) and runs the pump at 100 mcg/kg/min just until the scope is past the epiglottis.

He explains, "Propofol is expensive. These techniques allow me to administer very small amounts of propofol. I probably average 100-150 mg of propofol for a colonoscopy and 60-100 mg propofol for an EGD. Some of my colleagues do not administer fentanyl or midazolam and only give intermittent syringe boluses of propofol."

Many believe that opiates cause most adverse events that occur during sedation. "But because of effective opiate blockers (such as naloxone), opiate-related deaths are rare," says Dr. Minocha, citing a study that concludes that for every seven deaths from sedation, one is caused by opiates, and six are by benzodiazepines.

Prevent complications
Dr. Minocha's top tips:

• Be sure patients sign informed-consent forms.
• Have appropriate CPR/emergency equipment in the OR or procedure room.
• Perform patient anesthetic evaluation according to established anesthesia protocols.
• Assess NPO compliance.
• Use monitors for pulse, heart rate and breathing (particularly higher-risk patients).
• Monitor for post-op complications, which can range from 30 minutes to about 2 hours.
• Issue written instructions at discharge. Don't even let alert and responsive patients drive themselves home.

Routine, but not without risks
Anesthesia for flexible endoscopy, especially upper-GI endoscopy, is generally considered a fairly routine proposition, but that is not to say that sedation is without its risks.