Do you need an anesthesiologist for an 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:
http://well.blogs.nytimes.com/2012/05/28/waking-up-to-major-colonoscopy-bills/
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.
Introducing …, THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel. Publication date August 31, 2014 by Pegasus Books. Available on all major online book vendors. THE DOCTOR AND MR. DYLAN can be ordered in print or ebook from Amazon.com. To reach the Amazon webpage, click on the book cover image below:
Brief description: Stanford professor Dr. Nico Antone leaves the wife he hates and the job he loves to return to Hibbing, Minnesota where he spent his childhood. He believes his son’s best chance to get accepted into a prestigious college is to graduate at the top of his class in this remote Midwestern town. His son becomes a small town hero and academic star, while Dr. Antone befriends Bobby Dylan, a deranged anesthetist who renamed and reinvented himself as a younger version of the iconic rock legend who grew up in Hibbing. An operating room death rocks their world, and Dr. Antone’s family and his relationship to Mr. Dylan are forever changed.
Equal parts legal thriller and medical thriller, The Doctor and Mr. Dylan examines the dark side of relationships between a doctor and his wife, a father and his son, and a man and his best friend. Set in a rural Northern Minnesota world reminiscent of the Coen brothers’ Fargo, The Doctor and Mr. Dylan details scenes of family crises, operating room mishaps, and courtroom confrontation, and concludes in a final twist that will leave readers questioning what is of value in the world we live in.
Amazon Review: 5.0 out of 5 stars I thoroughly enjoyed reading this September 5, 2014
By dlb
This book gives you some insight as to the life of a physician.
Many of us wind up in hospitals to undergo some procedure or another and our life is in their hands. It was so interesting to read about their side of the story and the effects it all has on them. The influence of friends and family plays a part in all our lives and so often we forget how much help that can be, too. Dr. Novak follows the path that Carol Cassella blazed in the genre of Anesthesiologist authors.
I thoroughly enjoyed reading this book.
By Mark in Manhattan on September 24, 2014
Format: Kindle Edition
Great beginning. Terrific ending. I’m a junkie for courtroom drama, and this book reminds me of John Grisham’s best. Hard to believe it was written by a doctor. The Dylan character is a hoot. A top-notch novel.
A real page turner!
By Maddiepup on October 1, 2014
Format: Kindle Edition
This book get your attention from the first page — a real page turner. A great mystery with humor intertwined. A great read!!
Learn more about Rick Novak’s fiction writing at
Filed under: ANESTHESIA PATIENT QUESTIONS BLOG Tagged: ambulatory anesthesia, Anesthesia, anesthesia blog, anesthesia for endoscopy, anesthesiologist, anesthesiology, death in surgery, Joan Rivers' death in endoscopy, laryngospasm, midazolam, outpatient endoscopy centers, propofol, RIchard Novak MD, RIck Novak MD, risks of anesthesia, upper gi endoscopy anesthesia
