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!