The Scope of Things

The Farmer & the Cowhand: Endoscopy & Anesthesia

Oh, the farmer and the cowman should be friends.
Oh, the farmer and the cowman should be friends.
One man likes to push a plow,
The other likes to chase a cow,
But that’s no reason why they cain’t be friends.
~From the musical "Oklahoma", by Rodgers and Hammerstein, 1943

WE TALK A LOT IN ENDOSCOPY about feeling like the ugly stepsister of the surgical suite. Unfortunately, this seems even truer when we compete with the surgeons for the use of anesthesia services for MAC, or monitored anesthesia care.

Synchronicities of my life. About the time that your beloved EndoNurse editor Kathy Dix told me that she’d like an editorial on sedation issues in endoscopy, I was appointed the chair of the endoscopy subcommittee looking at issues of limited availability of MAC for endoscopic cases at my local hospital. You see, our elective outpatients needing MAC can only be scheduled in our endoscopy "block" on Tuesday mornings, now scheduling two+ months in advance. Surgical blocks are released at 24 hours’ notice, good for use of the anesthesia time for inpatients, but far from ideal for those pesky outpatient colons that need to achieve a day off work, a ride, and a goo-free prep with limited advance notice.

I discussed the issue with my favorite CRNA. She gives excellent anesthesia, and seems to enjoy the rapid turnover of the endoscopy cases. So whence comes my perception that anesthesia doesn’t enjoy sedating for endoscopy?

"It’s simple," I was told. You see, it’s really about anesthesia’s comfort level with the hurly-burly that is endoscopy. I was told that for the most part, anesthesia in the OR sets the room temp, and actually commands the room, no matter what the surgeons would like to believe. Our anesthesia colleagues also are accustomed to being in the room first, to having full preoperative labs, and to doing more prolonged procedures than the rapid take- off/rapid landing sedation requested by endoscopists.

Furthermore, the level of sedation we expect (a non-moving, comfortable patient) is a deeper degree of sedation than what is defined by anesthesia as conscious sedation. "I don’t want to feel anything" may be an unrealistic expectation that we place upon the anesthesiologist’s shoulders. The American Association of Nurse Anesthetists states that patients who receive conscious sedation "… usually are able to speak and respond to verbal cues throughout the procedure, communicating any discomfort they experience to the provider. A brief period of amnesia may erase any memory of the procedure." They speak and respond to verbal cues? May erase memory of the procedure? I like my conscious sedation a bit deeper than that for the average colonoscopy patient, especially as I need to convince the polyp-farmers to return in three to five years!

So what are the other MAC issues from endoscopy’s point of view? In addition to the delay in scheduling our elective MAC cases, the endoscopists doing advanced procedures (complex ERCPs and EUS) cannot get MAC during the early hours of the workday; they are accommodated late in the afternoon and early evening, particularly when coordination with radiology complicates the timing. As anyone who has done or assisted in a tough ERCP can attest, our completion rates likely fall in proportion to the room’s collective fatigue level.

Endoscopy needs MAC services more than ever before. A bolus of thick-necked, morbidly obese folk needing endoscopy, the liberalization of use of fentanyl patches in chronic pain management, even the increase in the diagnosis of sleep apnea, leads to an oversupply of those best served by endoscopy with MAC.

So, our farmer-cowhand issues with the anesthesiologists break down to a simple economic diagram. Our demand for MAC spirals up while our availability of anesthesia has remained flat. The fix is multifactorial, and much of it rests with us.

From the endoscopy side, we are looking at moderating our MAC demand. We have surgeons who, never having learned the skill of conscious sedation, use MAC for all cases. We have endoscopists who, with a diagnosis of sleep apnea, even if CPAP is not used by the patient, insist on MAC. We have cases that simply need a non-narcotic drug to adequately sedate, but do not require the specialized cardiopulmonary support that our anesthesia friends bring to the table, and who would likely fare well with propofol administered by a CRNA under endoscopy physician guidance, or fospropofol, which may be released next year to be used by non-anesthesiologists.

Anesthesiologists are irreproducible resources in our hospital, helping to support us with sedation in our riskiest and frailest endoscopy subjects. But endoscopy units need to take responsibility to analyze and then use our limited MAC anesthesia resources wisely.

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