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Do you need an anesthesiologist for upper gastrointestinal endoscopy? In the aftermath of Joan Rivers’ tragic death following an upper endoscopy procedure at a New York outpatient surgery center, every news bureau is discussing this topic. Because I have no inside information on Joan Rivers’ medical care during her procedure, I will not judge her physicians, rather I will attempt to answer the specific question:
Do you need an anesthesiologist for an upper gastrointestinal endoscopy?
The answer to the question is: it depends. It depends on 1) your health, 2) the conscious sedation skills of your gastroenterologist, and 3) the facility you have your endoscopy at.
1) YOUR HEALTH. The majority of endoscopies in the United States are performed under conscious sedation. Conscious sedation is administered by a registered nurse, under specific orders from the gastroenterologist. The typical drugs are Versed (midazolam) and fentanyl. Versed is a benzodiazepine, or Valium-like medication, that is superb in reducing anxiety, sleepiness, and producing amnesia. Fentanyl is a narcotic pain reliever, similar to a short-acting morphine. The combination of these two types of medications renders a patient sleepy but awake. Most patients can minimal or no recollection of the endoscopy procedure when under the influence of these two drugs. I can speak from personal experience, as I had an endoscopy myself, with conscious sedation with Versed and fentanyl, and I remembered nothing of the procedure.
If you are a reasonably healthy adult, you should be fine having the procedure under conscious sedation. Patients with high blood pressure, diabetes, asthma, obesity, mild to moderate sleep apnea, advanced age, or stable cardiac disease are have conscious sedation for colonoscopies in America every day, without significant complications.
Certain patients are not good candidates for conscious sedation, and require an anesthesiologist for sedation or general anesthesia. Included in this category are a) patients on large doses of chronic narcotics for chronic pain, who are tolerant to the fentanyl and are therefore difficult to sedate, b) certain patients with morbid obesity, c) certain patients with severe sleep apnea, and d) certain patients with severe heart or breathing problems.
2) THE CONSCIOUS SEDATION SKILLS OF YOUR GASTROENTEROLOGIST. Most gastroenterologists are comfortable directing registered nurses in the administration of conscious sedation drugs. Some, however, are not. These gastroenterologists will disclose this to their patients, and recommend that an anesthesiologist administer general anesthesia for the procedure.
3) THE FACILITY YOU HAVE YOUR ENDOSCOPY AT. Most endoscopy facilities have nurses and gastroenterologists comfortable with conscious sedation. Some do not. The facility you are referred to may have a consistent policy of having an anesthesiologist administer general anesthesia with propofol for all endoscopies. If this is true, they should disclose this to you, the patient, before you arrive for the procedure. A facility which always utilizes general anesthesia means that you, the patient, will incur one extra physician bill for your procedure, from an anesthesiologist.
I refer you to an article from the New York Times, which summarizes the anesthesiologist-propofol-for-endoscopy phenomenon in the New York region in 2012:
One last point: If the drugs Versed and fentanyl are used, there exist specific and effective antidotes for each drug if the patient becomes oversedated. The antagonist for Versed is Romazicon (flumazenil), and the antagonist for fentanyl is Narcan (naloxone). If these drugs are injected promptly into the IV of an oversedated patient, the patient will wake up in seconds, before any oxygen deprivation affects the brain or heart.
Propofol, however, has no specific antagonist. Propofol only wears off as it is redistributed out of the blood stream into other tissues, and its blood level declines. A propofol overdose can cause obstruction of breathing, and/or depression of breathing, such that the blood oxygen level is insufficient for the brain and heart. The Food and Drug Administration (FDA) mandates that a Black Box warning be included in the packaging of every box of propofol. That warning states that propofol “should be administered only by persons trained in the administration of general anesthesia and not involved in the conduct of the surgical/diagnostic procedure.”
Anesthesiologists are experts at using propofol. I administer propofol to 99% of my patients who are undergoing general anesthesia for a surgical procedure. Anesthesiologists are experts at managing airways and breathing. Individuals who are not trained to administer general anesthesia should never administer propofol to a patient, in a hospital or in an outpatient surgery center.
I serve as the medical director of an outpatient surgery center in Palo Alto, California. We perform a variety of orthopedic, head and neck, plastic, ophthalmic, and general surgery procedures safely each year. In addition, our gastroenterologists perform thousands of endoscopies each year. I review the charts of the endoscopy patients as well as the surgical patients prior to the procedures, and in our center, approximately 99% of endoscopies can be safely performed under Versed and fentanyl conscious sedation, without the need for an anesthesiologist attending to the patient.
If you have an endoscopy, ask questions. Will you receive conscious sedation with drugs like Versed and fentanyl, or will an anesthesiology professional administer propofol? You deserve to know.
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Published in September 2017: The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.
KIRKUS REVIEW
In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.
Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.
Nuanced characterization and crafty details help this debut soar.
Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:
Learn more about Rick Novak’s fiction writing at ricknovak.com by clicking on the picture below:
Would you discuss the necessity of using versed. Is there a need for Versed beyond relieving anxiety and erasing memories? Are there some procedures/surgeries where it is more necessary than others. Would you respect a patient’s wishes to avoid versed or get another anesthesiologist or try to change their mind? If so, why?
Versed is commonly used prior to surgery as an intravenous drug to decrease a patient’s anxiety. It is optional, and not an absolute requirement. I recommend the medication for most patients, because most patients are anxious about surgery and anesthesia. If a patient objects, there is little problem with proceeding without Versed.
Thank you for this article. I was given 430 or 470 mg of Propofol and 20 mg of lidocaine (according to records) by a CRNA for a colonoscopy and an EGD w/dilation performed on the same day. I am a 54 y/o female, 160 lbs who was in very good health. Since then I am having short term memory problems, fumbling for words and misspeaking words. I also have shortness of breath and a lot of other problems.
The doses of propofol and lidocaine given are within the standard of care.
The symptoms you are describing are not likely due to the propofol doses. Unless something else went amiss during your anesthesia care, I would not attribute your symptoms to the anesthetic drugs.
Concerned…..yesterday, I was given 100 Fentanyl and 4 versed (hand written on my outpatient sheet) and experienced vomiting, headaches, loss of memory….
Are these side effects common? I’ve been sedated before with no complications. 44 yr. old Female, 120 lbs, good health.
The doses you were given are typical doses of standard medications. Every patient is different, and it’s not unusual for a petite (120 pound) patient to feel oversedated after a procedure. I recommend you tell future anesthesia professionals or sedating nurses that you are particularly sensitive to doses of this nature.
Thank you for the wonderful article.
I had an upper endoscopy today and specifically requested versed and no propofol. They do not administer fentynel any more. I have had this procedure done before using the versed/fentanyl combo, and have been aware of what was going on during the procedure.
My concern is that when I was supposedly given the versed i immediately went to sleep, when given versed in the past times has just relaxed me. The next thing I know I was being woken after the procedure and told I was gagging so they asked if they could give me propofol and did. Does this happen?
The standard is for the anesthesia provider to discuss the options for your anesthetic prior to you receiving any drugs, and for you to have the opportunity to ask any questions you have. If you requested no propofol and only Versed, and they agreed to do that, then it would be below the standard of care for them to ask you mid-procedure, when you’re already drugged, whether it was OK to give you propofol.
But an issue with your description is that most anesthesia providers would not agree to sedate you for an upper GI endoscopy with Versed only–it would usually not be an effective technique to use just this one drug for that procedure. Most anesthesia providers would give you an informed consent discussion prior to the anesthetic that if the Versed alone was not effective, then they could/would have to administer propofol (or add fentanyl) so that the procedure could be successfully performed.