Deep Sedation and Anesthesia for Advanced Gastrointestinal Endoscopy: Challenging a Continuum

Anesthesia services are increasingly requested to care for patients undergoing complex invasive procedures in locations outside the operating blocks (NORA, nonoperative room anesthesia). In the endoscopy suite, anesthesiological assistance is usually requested for the most complex and lengthy procedures (an example is ERCP, endoscopic retrograde cholangiopancreatography, lasting up to 2 h), quite often performed in medically complicated fragile elderly patients. To successfully complete procedures which require immobility of the patients, deep sedation is mandatory: for the anesthesiologist, the challenge is to match patient’s comfort (no pain) and safety (no adverse effects/complications) with sedation, deep enough to be almost always a form of general anesthesia—the continuum—with the patient in prone position and spontaneous ventilation. Reviewing the most recent international contributions, we will discuss the periprocedural anesthesiological management in the endoscopy suite considering (1) the setting (location layout of the endoscopy suite and the work of the anesthesiologist), (2) the pharmacological armamentarium, (3) the optimization of the patient for the procedure (preprocedural evaluation, management, devices, and monitoring), and (4) the way to manage deep sedation/general anesthesia, prone position, and spontaneous ventilation: according to the most recent authoritative literature. “Sedation” in the endoscopy suite is a continuum between light sedation and a condition deep enough to be considered a form of general anesthesia while maintaining spontaneous ventilation: we are convinced that a dedicated anesthesiologist is more than needed for patient’s safety and comfort, allowing the endoscopists to concentrate on his demanding task.