Anesthesia for complex endoscopy: a made-to-measure suit

We were particularly interested by the editorial on new frontiers of anesthesia in endoscopy, recently published in Endoscopy [1]. This editorial, commenting on a report by Lara et al. [2] on adverse events of anesthesiological procedures in the endoscopy setting, takes the opportunity to state “a new paradigm” and to highlight some key messages. We really appreciated this new approach which finally surmounts the inheritance of a strict separation between general anesthesia in the operating room and sedation in the endoscopy suite. Advances in pharmacology and in monitoring allow performance everywhere of a continuum of anesthesiological techniques, ranging from simple monitored anesthesia care to very deep anesthesia with a wide number of options. The choice should be made on a case-by-case basis after a comprehensive evaluation of the individual patient. Sedation in advanced endoscopy is very often a challenge for providers. The high number of adverse events reported by Lara et al. and by other authors [3] often corresponds to reality. However, when the basic data are examined, the quality of sedation is not always as good as expected. In the study by Lara et al., many sedations had been performed without real control of the effect-site concentration of propofol [4] and by providers who were not always specifically dedicated to endoscopy The question is not, therefore, sedation vs. general anesthesia, but rather, how can the quality of anesthesia care be improved? Over the last year, at our tertiary referral center, over 2100 complex endoscopies with anesthesiological support were performed. However, focusing only on the 1365 ERCPs, 1124 (82 %) were performed with general anesthesia, 140 (10 %) with deep sedation (with propofol and/or remifentanil by means of target-controlled infusion, sevorane by nasal cannula, midazolam and opioids) administered by the anesthesiologist, 99 (7 %) with conscious sedation (midazolam and fentanyl) administered by the endoscopist, and 2 procedures without any sedation. Despite the high number of ERCPs, no life-threatening adverse event occurred. It is also interesting to observe that although only three anesthesiologists performed over 95 % of the activity, the anesthesiological techniques were wide-ranging, for both airways management (endotracheal intubation, nasopharyngeal cannula, or simply jaw thrust) and drugs employed for anesthesia/sedation, and showed similar profiles in safety and efficacy. On what were our choices based? The answer to this question is not simple, because anesthesiological evaluation requires a multimodal approach. We think that, before selecting from the range of options, the anesthesiologist should be able to assess at least three parameters: the skills of the entire team of providers, patient condition, and logistics (availability of equipment, the available range of medical and economic resources, facilities for coping with adverse events, etc). They are the cornerstones on which we must build our medical support. When the experience, as a team, of the clinicians and paramedical staff, and the endoscopic logistics are favorable, as well as the mental and physical status of the patient and the logistic resources, we can safely increase the number of sedations at the expense of general anesthesia [5]. In our case the high rate of general anesthesia is related to the poor clinical condition of most patients (ASA physical status III – IV) and to the need for a quick turnover. Indeed the correct titration of intravenous drugs used for sedation usually entails delay in achieving an adequate plasma concentration that is useful for obtaining immobility of the patient. Especially in this field, the synergy between anesthesiologists and endoscopists should be improved, with reciprocal provision of information so that they are always on the same wavelength. We encourage all colleagues to improve the quality of care, looking at the wide range of possibilities regarding techniques and new devices, always keeping in mind that there is no a priori better anesthesia strategy, but only a better anesthesia strategy for each individual patient.