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ORIENTATION TO THE GI UNITS FOR THE
ANESTHESIA PROVIDER
A survival guide for working in the GI units at BIDMC
Eswar Sundar
Director of
Clinical
Anesthesia-East
NOVEMBER 30, 2020 1
Welcome to the largest gastroenterology unit in the nation! On average about 120 GI
procedures are performed across the four locations in BIDMC every day. About half of
them with an anesthesia provider! I am hopeful that this manual will help you
navigate your day in the GI units.
The GI Units BIDMC has 4 GI units.
GI3 or ST3 is located in the East campus Stoneman building, on the third floor. It is on the
same floor as the Feldberg ORs . In GI3 almost all the cases are upper endoscopies or
colonoscopies. No advanced endoscopies are performed in the GI3 suite. Two procedural rooms
in GI3 are devoted to anesthesia cases. Moderate sedation cases also go on in other rooms
without anesthesia involvement.
GI4 or ST4 is also located in the East campus Stoneman building. It’s directly above the ST3
(GI3) unit. GI4 can be accessed by walking through the double doors next to the Anesthesia
Offices on the 4th floor. GI4 is the unit that performs most of the advanced endoscopies
including, ERCP, Single Balloon Enteroscopies (SBE), Endoscopic Ultrasound (EUS), esophageal
and colonic stent placements, radiofrequency ablation and cryoablation of esophageal dysplasia
and Obera (Intragastric balloons for weight loss) placement and removal. Simple EGD and
colonoscopies are also performed on patients deemed “high-risk.” Moderate sedation cases are
rarely performed in GI4 because of the nature of procedures.
West Procedural Center (WPC). This unit is located on the West campus on the
first floor of the Farr Building. There are two procedural rooms in the WPC, with one
predominantly used by anesthesia. Upper endoscopies, colonoscopies and EUS procedures are
done in the WPC. Moderate sedation cases also simultaneously go on in other rooms.
Harvard Vanguard Medical Associates at Kenmore (HVMA). This is an
offsite location in Kenmore square. It’s walking distance from the main campus, but you can
also drive there and park at a nearby garage. Cases are composed of EGDs, colonoscopies, and
endo-colons. Patients are generally healthy, and turnover is pretty rapid. There is no facility for
GAs at HVMA.
We shall address the workflow in each of these units separately.
NOVEMBER 30, 2020 2
GI3
Start Times GI3 units start cases at the following times. Please page the floor manager for all issues that lead to
delays.
There are two procedural rooms in GI3. Looking out from the nurses counter down the corridor, the
first room on the right is Rm1 and the one on the left is Rm2. On most days there are separate
endoscopist lists for the morning and afternoon. Usually solo anesthesia attendings are posted in these
rooms.
Harvard Vanguard or Atrius endoscopists are usually assigned Rm2, while other BIDMC endoscopists are
in Rm1.
Patient preparation Please check the machine and other critical equipment
before the start of the day. Anesthesia tech support can be
requested by paging 30951 (Anesthesia Tech East Remote).
Patients are listed on the “Anesthesia” white board with
the bay number in which they are situated. A nurse
practitioner is usually available in the holding area to do a
history and physical, while a GI nurse places an IV. The
anesthesia provider is required to review the H&P printout
or on the lap top screen in AIMS and make amendments as
needed. A BP cuff is usually placed on the patient’s arm in the holding area. Sometimes nursing might
request MAC for a patient originally booked under moderate sedation. The GI resource nurse will talk to
an endoscopist and make room/time for that patient.
The anesthesia provider gets consent and moves the patient into the procedure room. Sometimes the
endoscopists will get the consent in the room. In all cases, please ensure that all consents are signed
before sedation is initiated.
Anesthesia in GI3 Please see section under Anesthesia for GI procedures for general guidelines.
Specific to GI3, procedures are generally limited to EGD, colonoscopy or a combined EGD/colonoscopy.
Sometimes cardiology may perform TEEs as an add-on procedure in the afternoon.
Start Times Monday Tuesday Wednesday Thursday Friday
AM 7:30 8:00 9:00 7:30 7:30
PM 12:30 7:30 12:30
NOVEMBER 30, 2020 3
A TALIS computer terminal, anesthesia machine, monitors,
and an omnicell are present in both rooms. The GI nurse who
is present with you during the procedure can help put the
monitoring leads and BP cuff on. All equipment, including
nasal cannulas, is available inside the corresponding
Omnicell drawer.
Endoscopies are done with the patient’s head oriented
towards the door, while colonoscopies are done with the
head of the stretcher away from the door. If it’s an endo
colon, you can detach the monitoring brick and rotate the
stretcher for the colonoscopy. Almost invariably most patient’s get MAC anesthesia in GI3. Occasional
patients will require either planned or unplanned general anesthesia.
Optimally, patients should be arousable as soon as possible after completion of the procedure.
Discharge within 30 min of arrival to the recovery room is part of the anesthesia care goals. The BP cuff
should be left on the arm as it will be used in the recovery room. Please continue to administer oxygen
while transporting to the recovery area.
Recovery The GI nurse will accompany you to the recovery area and help reestablish monitoring. Please ensure
that the patient is stable and arousable before leaving the patient to go to the designated AIMS laptop
to open and print the case record.
A brief handoff to the recovery nurse must include drugs administered and any anesthetic issues or
concerns. If appropriate, please complete the post anesthesia paper note before leaving the patient.
You can walk back to the holding area to see your next patient. If a patient has had a GA, the patient
will need to be transported to the Feldberg PACU with the GI nurse. Please remember to call ahead
before leaving the room to book a bay.
NOVEMBER 30, 2020 4
GI4
Start Times GI 4 units start cases on the following times.
There are 2 rooms (ERCP1 and ERCP2) that have fluroscopic capabilities and one room that does not
(EUS Room). These rooms may be staffed by 3 solo anesthesia attendings, one attending supervising
three CRNA’s, or two attendings with one covering two residents.
It is important that at least one anesthesia attending sits in at rounds with the GI physicians and fellows
at 7:00 to discuss the patients for the day. Please be ready to add any anesthesia concerns on any
patient, especially the ones that might need GA or need ICU care. Other providers can set up rooms and
see patients. An anesthesia tech is available on pager 30951 (Anesthesia Tech East Remote). Please
ensure the suction tubing reaches the patient and a small suction tip is available.
As previously noted, the GI4 suite performs a wide variety of endoscopic procedures. (Next section.)
Patient preparation Patient’s going into your room (EUS, ERCP1, or ERCP2) will be posted on the white board, along with the
bay they are in. Drugs are available in the Omnicell in the room and in the large Omnicell in the holding
area for less frequently used drugs.
A nurse practitioner is usually available in the holding area to
do a history and physical, while a GI nurse places an IV. The
anesthesia provider is required to review the H&P printout or
on the laptop screen in AIMS, make amendments as needed,
and obtain consent. A BP cuff is usually placed on the
patient’s arm in the holding area. The anesthesia provider
moves the patient into the procedure room. Sometimes the
endoscopists will get the consent in the room, so please
ensure that all consents are signed before sedation is initiated.
GI4 procedures and default anesthesia Please see section under Anesthesia for GI procedures.
Please ensure that all lines and cables can reach the patient. Our GI 4 unit is a referral center for some of
the sickest patients from around the state requiring an advanced endoscopic procedure. Obesity,
smoking, OSA, cholangitis, bowel obstructions, as well as a host of other significant comorbidities and
failed sedation are typical for patients in this unit. Despite these issues most patients do well with MAC.
Monday Tuesday Wednesday Thursday Friday
Start Times 7:30 8:00 8:45 7:30 7:30
NOVEMBER 30, 2020 5
Listed below are the common GI procedures, the type of anesthesia and typical patient position.
However, always use your clinical judgment and/or discuss with your colleagues, if you feel a patient’s
needs may be better served by an alternate form of anesthesia. Please always ask the GI nurse with you
where the patient is going to be, in what position, or if GA is required. Most CRNAs and anesthesia
attendings with you are pretty experienced and will be able to guide you through the position and
anesthetic requirements.
Anesthesia Place Position
EGD/banding/EMR MAC Stretcher Left lateral
EUS MAC Stretcher Left lateral
Colonoscopy/EMR MAC Stretcher Left lateral
ERCP MAC Fluro table Prone
SPY MAC Fluro table Prone
SBE MAC Stretcher or Fluro
table Left Lateral
SBE ERCP MAC or GA Fluro table Prone
Duodenal or
esophageal Stent MAC or GA Fluro table Left lateral
Colonic Stent MAC Fluro table
Left lateral, but head
will be away from the
anesthesia machine!
Cryotherapy MAC Stretcher Left lateral
RF ablation MAC Stretcher Left lateral
Obera placement MAC Stretcher Left lateral
Obera removal GA Stretcher Left lateral
PEG MAC Stretcher Supine
FIGURE 1 ANESTHESIA TYPE, PLACE AND POSITION FOR ADVANCED ENDOSCOPIC PROCEDURES
NOVEMBER 30, 2020 6
Recovery As in the operating room, please direct and help prone patients to roll over back on to the stretcher.
Ideally, at the end of the procedure, the patient should be arousable. Among our anesthetic goals is the
ability to discharge patients within 30 min. of arrival to the recovery room. Please leave the BP cuff on
the arm, it will be used in the recovery room. Please administer oxygen while transporting to the
recovery area.
The GI nurse will accompany you to the recovery area
and help reestablish monitoring. Please ensure that the
patient is arousable and stable before leaving the
patient to go to the designated AIMS laptop to open
and print the case record.
A brief handoff to the recovery nurse must include
drugs administered and any anesthetic issues. If
appropriate, please complete the post anesthesia paper
note before leaving the patient.
You can walk back to the holding area side to see your
next patient. If a patient has had a GA, the patient will need to be transported to the Feldberg PACU
with the GI nurse. Please remember to call ahead before leaving the room to book a bay.
NOVEMBER 30, 2020 7
WPC
Start Times
Patient preparation Please check the machine and other critical equipment
before the start of the day. Please ensure the suction
tubing reaches the patient and a small suction tip is
available. Anesthesia tech support can be requested by
paging 30950 (Anesthesia Tech West Remote).
Patients are listed on the white board with the bay number
in which they are situated. A nurse practitioner is usually
available in the holding area to do a history and physical,
while a GI nurse places an IV. The anesthesia provider is
required to review the H&P printout or on the laptop
screen in AIMS, and make amendments as needed. Sometimes nursing might request MAC for a patient
inadvertently booked under moderate sedation. The GI resource nurse will talk to an endoscopist and
make room/time for that patient.
The anesthesia provider gets consent and moves the patient into the procedure room. Sometimes the
endoscopists will get the consent in the room, so please ensure that all consents are signed before
sedation starts.
Unlike the other GI units the patient is moved to the procedural room by taking the entire monitoring
brick with the patient and reestablishing monitoring in the procedure room by inserting the brick into
the rack.
Anesthesia Please see section under Anesthesia for GI procedures.
EGD, colonoscopies, endocolon, EUS and PEG placements
are common procedures done in WPC. See table under GI4
for positioning and anesthesia.
A TALIS computer terminal along with anesthesia machine
monitors and an omnicell are available. The GI nurse who is
present with you during the procedure can help put the
monitoring leads on. Nasal cannulas and other equipment
are available inside the Omnicell.
Endoscopies are done with the head away from the door,
while colonoscopies are done with the head of the stretcher towards the door. If it’s an endocolon, you
Monday Tuesday Wednesday Thursday Friday
Start Times 7:30 8:00 8:45 8:00 7:30
NOVEMBER 30, 2020 8
can detach the monitoring brick and rotate the stretcher for the colonoscopy. Almost invariably most
patient’s get MAC anesthesia in WPC.
Ideally, at the end of the procedure, the patient should be arousable. One of the anesthetic goals is to
have patients ready for discharge within 30 min of arrival to the recovery room. Please detach the
monitoring brick and take it with the patient back to the same bay they came from. Please administer
oxygen while transporting to the recovery area.
Recovery A brief handoff to the recovery nurse must include drugs
administered and any anesthetic issues. If appropriate, please
complete the post anesthesia paper note before leaving the
patient.
If a patient has had a GA, the patient will need to be transported
to the West PACU on the 5th floor of the Rosenberg building with
the GI nurse. Please remember to call ahead before leaving the
room to book a bay.
NOVEMBER 30, 2020 9
HVMA at Kenmore HVMA is located off-site near Fenway Park. HVMA is walking distance from the hospital, although you
could drive and park at a designated garage. If you do park there, please remember to get your ticket
validated, as otherwise it gets expensive!
Anesthesia care is provided a few days a week.
You will need to be credentialed separately at
HVMA to work there. If you are assigned to
HVMA please email Mary Ann Vann for more
information as to how things work out there.
Most cases are EGDs and colonoscopies on
relatively healthy patients. There is no facility
to perform planned GA cases at HVMA.
Propofol is the predominant drug used there.
Cases are done with rapid turnover and
everyone usually breaks for lunch before
starting an afternoon list. There are plenty of
restaurants around!
NOVEMBER 30, 2020 10
MAC anesthesia for GI procedures
Many excellent anesthesiologists and CRNAs perform great MACs on complicated patients using just
Propofol. So timing and understanding the stages of a GI procedure are important.
It’s not our intention to teach you how to do a MAC. However below is the list of some of the common
drug combinations, which anesthesiologists use.
At BIDMC, routine spraying of the oropharynx with Benzocaine spray does not occur as it is considered
unnecessary for patients receiving deep sedation, leaves the patient with residual anesthesia, and can
be associated with methemoglobinemia in susceptible individuals. As providing sedation is the primary
objective and painful stimuli are limited and transient, opioids are rarely used. Other drugs that may be
needed during the procedure are mainly to stabilize hemodynamics (labetalol, phenylephrine,
ephedrine, glycopyrolate, etc.). Often during ERCP procedures, the endoscopists may request 0.2 mg of
glucagon IV. The GI nurses usually administer this. Glucagon helps with smooth muscle relaxation and
Insertion
•For Upper GI procedures, this is often the most stimulating time. Patients may need a slight jaw thrust to allow a large EUS or ERCP scope to enter. Insertion is complete when the scope reaches 20 cm and the sedation level can then be reduced.
•For colonoscopy, insertion is also very stimulating and requires more sedation. Abdominal pressure may be applied by nurses and may cause discommfort. Insertion is complete when the caecum/ileocaecal valve is visualized.
Stabilization
•For EUS, SBE and ERCP procedures, the scope has to be maneuvered to a location to visualize the ampulla or the head of the pancreas. This phase still requires some deep sedation though not as much as insertion.
Cannulation
•This is the process of getting a guide wire up the bile duct during ERCP and oftenis the longest part of the procedure. Once the scope is in a stable position, sedation levels can be decreased, as this phase is not very stimulating. However occasionally a patient can get bradycardic during balloon dilatation of the duct.
Removal
•Removal is lengthy during colonoscopy and sedation levels can be trimmed down as it's generally not stimulating. At about 30-40 cm the scope has usually reached the sigmoid colon and sedation can be turned off. Removal is also prolonged during SBE procedures and not stimulating.
•For most upper GI procedure removal is quick and sedation may be stopped at that point.
NOVEMBER 30, 2020 11
reduces peristalsis. Antiemetics, NSAIDS, and opioids are not routinely given for GI procedures but may
be indicated in certain situations. Many patients after an ERCP who are at high risk for pancreatitis may
get an indomethacin suppository at the end of the procedure.
Main drug Premed/adjuvant Adjuvant
Propofol only
Propofol Midazolam (1-2 mg)
Propofol Midazolam (1-2 mg) Ketamine 10-20 mg)
Propofol Dexmedetomidine bolus
We are proud of our excellent expertise in GI anesthesia! Our GI docs and anesthesia group attract the
most complicated and sick patients. Years of experience with MAC in this population has helped us
provide a safe and efficient service.
For more information please contact Dr. Soumya Mahapatra. Director of GI Anesthesia.
Let us know how we can improve this document and what other information may be useful to you!