Disclaimer: This article is intended solely for informational and educational purposes only. It does not constitute medical advice.
Esophagogastroduodenoscopy (EGD) is a common procedure in gastroenterology that is used to examine a patient’s upper GI tract, which includes the esophagus, stomach, and duodenum. The approach to sedation and anesthesia management of esophagogastroduodenoscopy has shifted considerably over time, with increased attention being directed to patient comfort. Claims data from a large U.S. health plan showed anesthesia professional participation in EGD rising from 9.8% in 2003 to nearly 26% in 2007. The same analysis projected that it would exceed 50% by 2015 (52.9%) [1].
In a cross-sectional analysis of 428,947 anesthesia-directed endoscopic procedures from the National Anesthesia Clinical Outcomes Registry, serious complications occurred in 0.34% of cases, and 36 deaths were recorded [2]. Serious complications included cardiovascular, respiratory, neurologic, and drug-related events, patient injury, and unplanned admission. In adjusted models, EGD carried higher odds of serious complications than colonoscopy (OR 1.44; 95% CI 1.12–1.85) [2]. The authors proposed that the shared airway during upper endoscopy plays a role, noting that 44% of respiratory complications occurred during EGD, including endoscopic ultrasound and enteroscopy [2].
Other independent predictors were advancing age, ASA class 4 or 5, general anesthesia, overnight procedures, and longer case duration [2]. Because these associations may partly reflect sicker patients, more complex cases, and reverse causation, such as conversion from sedation to general anesthesia after an adverse event, they should not be read as evidence that general anesthesia itself is hazardous [2].
During EGD, topical anesthesia can be used to decrease the discomfort a patient experiences as the scope travels down the airway. A double-blind randomized trial of 539 analyzed patients undergoing elective EGD examined pharyngeal lidocaine given before a standardized regimen of midazolam and propofol [3]. Patients received either five puffs of 10% lidocaine spray (50 mg) or placebo. Propofol was titrated from an initial 40 mg bolus with 20 mg boluses to a Ramsay score of 2 to 4 [3]. Median propofol dose was lower with lidocaine (80 versus 100 mg), and deeper sedation was needed less often (7.5% versus 19.9%) [3]. Endoscopists rated the procedure as well tolerated with easy intubation more often in the lidocaine group (87.7% versus 73.8%) [3].
Coughing during intubation (12.7% versus 24.0%) and retching (3.4% versus 11.1%) were also less frequent, and no adverse events attributable to lidocaine were reported [3]. Patient-reported tolerance and satisfaction did not differ, likely because of the amnestic and anxiolytic effects of sedation, and coughing observed after the procedure was more frequent with lidocaine [3]. Patients older than 70 were excluded, so the results are not necessarily generalizable to older patients, who are also at greater risk of serious complications [2,3].
An alternative strategy is to reduce or eliminate sedation anesthesia by changing the equipment used for EGD. A prospective randomized study assigned 150 patients to conventional peroral EGD, transnasal small-caliber EGD, or peroral small-caliber EGD [4]. All patients received topical anesthesia and were offered midazolam (2.5 mg intravenously) only on demand or for intolerance [4]. Patients requiring deep sedation from the outset, those undergoing therapeutic procedures, and those with ASA grade III–IV were excluded, and 19.4% of screened patients requested sedation and were not enrolled [4]. This study found that the ultrathin transnasal device led to significantly less sedation, with 6% of patients requesting sedation compared to 18% in the peroral small-caliber group and 44% in the peroral conventional group [4].
For patients undergoing EGD, sedation can increase patient comfort and cooperability. However, in some patients, its use can be reduced, with potential cost-saving effects, through innovations in endoscope devices. In addition, topical pharyngeal anesthesia can reduce sedation requirements and airway reflexes in appropriate EGD patients, and clinicians should consider unsedated small-caliber endoscopy for selected patients.
References
- Inadomi JM, Gunnarsson CL, Rizzo JA, Fang H. Projected increased growth rate of anesthesia professional–delivered sedation for colonoscopy and EGD in the United States: 2009 to 2015. Gastrointest Endosc. 2010;72(3):580–586. https://doi.org/10.1016/j.gie.2010.04.040
- Lieber SR, Heller BJ, Martin CF, Howard CW, Crockett S. Complications of anesthesia services in gastrointestinal endoscopic procedures. Clin Gastroenterol Hepatol. 2020;18(9):2118–2127. https://doi.org/10.1016/j.cgh.2019.10.011
- Martín-Marcos I, Fernández-Morte N, Balsategui-Martín M, et al. Evaluation of pharyngeal lidocaine anesthesia for esophagogastroduodenoscopy: double-blind randomized control trial. Dig Endosc. 2022;34:808–815. https://doi.org/10.1111/den.14168
- Preiss C, et al. Unsedated small-caliber versus conventional EGD. Endoscopy. 2003;35:641–646. https://doi.org/10.1055/s-2003-41513
