Expert: Ronald Levy, M.D. - 2/12/2010

Question
QUESTION: I have been having difficulty swallowing and esophageal spasms.  I had a barium swallow and was diagnosed with a Schatzki ring (narrowing) of my esophagus.  I was referred to a gastroenterologist for an upper GI endoscopy to see what else might be going on and to stretch the esophagus if needed.  My question relates to the anesthesia used for this type of endoscopy. I have high blood pressure (usually controlled by meds, but on occasion does go up).  I am also overweight (285) and have an enlarged heart due to having (previously) undiagnosed HBP. I was told to show up at the endoscopy center having fasted and was given a pamphlet that was big on liability language, but had no details for preparing for the procedure or information about the procedure itself.   So, I researched the procedure and conscious sedation that is used.  I read that conscious sedation is safe, but can also be dangerous if not handled correctly and that one of the most important things during the sedation is for a dedicated qualified person to monitor the patient, so that if their respiration/oxygen levels drop, immediate emergency resuscitation procedures can be performed.  I also learned that if an opiate (Fentanyl) is used with Versed (which would be, in my case), these risks can be increased.   I called the endoscopy center to ask questions about my concerns re: the sedation and found out that a nurse would be administering the anesthesia and not an anesthesiologist.  I talked to the nurse, and he was not able to address my concerns very well nor did he sound very competent.  He also told me I shouldn’t take my blood pressure medication the morning of the procedure as the drugs they would give me already lower blood pressure.  This contradicts what my doctor told me (he told me to take it).  I also read that you should stop taking aspirin or NSAIDs 5 days before the procedure and when I asked my doctor about this, he said that I don’t need to worry about stopping any medication.  So, at this point, I am concerned about the competency of my doctor as well as the endoscopy center where the procedure is to be performed.  I cancelled my procedure and I’m not sure what to do now.  Every time I have had any type of anesthesia before, the procedure was always performed in a hospital as an outpatient procedure.  I looked up other gastroenterologists and most of them seemed to be associated with an endoscopy center.  I have also read about a study where a high percentage of elderly patients died (3%) within 30 days of having upper GI endoscopies.  So, I am very concerned about having this procedure done.  The only time I have ever had problems with anesthesia before were during childbirth (epidural given twice, did not work at all) and during dental implant surgery, nitrous oxide did not work and made me upset and uncooperative but was still very aware of what was going on.  They ended up using conscious sedation instead  (I believe).

Do you have any advice as to how I can go about finding a doctor who uses an anesthesiologist when performing endoscopies?  Am I right to be want to be in the capable hands of a doctor (anesthesiologist) instead of a nurse?  Given my health history, would there normally be any complications with conscious sedation?
Thank you very much for your time and any advice you can offer.

ANSWER: You are not wrong about wanting to be in a doctor's hands and most of what you read is correct. What I recommend is to go to your local teaching hospital (a hospital associated with either a medical school or a residency training program). List you don't list your state, I can't tell you which one. The GI docs there will most likely work with the anesthesiologists who will perform your anesthetic. Generally we recommend to take your BP meds. As far as aspirin, this is more related to the GI docs and they are concerned with bleeding and aspirin inhibits platelet function. The 3% deaths is probably more related to their underlying disease and not the fact that they had endoscopy. It would be difficult for me to say whether you would be a candidate for conscious sedation although based on your history, I might recommend a general anesthetic.


Ronald Levy, MD
Professor of Anesthesiology
UTMB-Galveston

---------- FOLLOW-UP ----------

QUESTION: Thank you very much, Dr. Levy.  I live in northern California.  I'm not sure if the hospitals here in the Bay Area can compare to the hospitals in your area, with the Houston Medical Center so close by.  (I am originally from Texas and lived in Houston for 15 years.)  The only one I can think of here is Stanford, which I hear is excellent, although I'm not sure how I would go about getting my insurance to cover it, since I live in San Jose. I would appreciate any other recommendations you could give for a teaching hospital, if you know of any in the San Francisco Bay Area.  

Also, why would you perhaps recommend general anesthetic for me rather than conscious sedation? Is it safer than conscious sedation?  Are you referring to my health history or my history with anesthesia?

Thank you very much for your expertise and your advice.

Answer
UC San Franscisco has an excellent reputation so I would start there. The only reason I might recommend general (based on nothing other than your letter) is that you might be at risk for aspiration so I would want to secure your airway. This is not to say that if you go to UCSF and they say sedation that they are wrong. They are seeing you and your record so go with their recommendation.

Ronald Levy, MD
Professor of Anesthesiology
UTMB-Galveston