Surprising risks of deep sedation anesthesia during upper endoscopy and colonoscopy procedures
Anesthesiologist or nurse anesthetist involvement in routine cases increases the risk of serious adverse events
Each year in the United States, doctors perform around 14 million colonoscopies and seven million esophagogastroduodenoscopies (EGDs).
Most of these procedures are done for outpatient routine screening purposes in relatively healthy people. Some, though, are to investigate, and sometimes treat, bleeding and digestive issues.
Colonoscopies are procedures where a doctor inserts a flexible scope and camera through your rectum, to be able to inspect the inside of your colon.
In an EGD, also called an upper endoscopy, the doctor inserts the flexible scope and camera down your throat to be able to look inside your upper digestive track, including the esophagus, stomach, and duodenum.
The anesthesia provider issue
As a Houston medical malpractice lawyer, I have become very concerned about the number of cases where I have seen where people who were seriously injured from anesthesia given during upper endoscopies or colonoscopies.
Almost invariably, when I see such cases, the anesthesia was handled by a certified registered nurse anesthetist (CRNA) rather than anesthesiologist.
I am thinking now about a case in which I represented the family of a lady in her 40s who became unresponsive during an EGD that was supposed to be an outpatient procedure at a Memorial Hermann hospital in Houston. When she stopped breathing, the only anesthesia provider in the room was a nurse anesthetist. Nurses had to call an anesthesiologist to the room, but by then they could not reverse the permanent brain damage. It was not long until this lady died. What a tragic thing to happen for an elective, preventative, outpatient procedure.
This is why I always recommend that you know who will be providing anesthesia for you before going into an operation and procedure. Even further, I think it is a good idea to have an anesthesiologist in the room, rather than just a nurse anesthetist.
The better question: Are anesthesia providers really needed at all?
I think that it is clear that you are likely to have a better outcome if an anesthesiologist is in the room, rather than a CRNA, if something goes wrong while you are under anesthesia. But when it comes to routine upper endoscopies and colonoscopies, do you even need any anesthesia provider involved in the procedure?
There is little debate that having an anesthesia provider on hand to manage sedation for high-risk patients is appropriate. For example, that would be the case for people with congestive heart failure or respiratory issues, like emphysema.
The overwhelming majority of endoscopies are not done on high-risk patients, though.
Historically, the doctor performing an EGD or colonoscopy has managed sedation of the patient using short-acting opioid pain medications and benzodiazepines, like midazolam. This is called moderate conscious sedation.
In recent years, though, many doctors have brought in anesthesia providers to handle sedation, in what is often called monitored anesthesia care (MAC). Anesthesiologists and nurse anesthetists frequently use fast-acting Propofol to achieve a deeper sedation. Propofol is the same drug that was involved in the deaths of Michael Jackson and Joan Rivers.
From 2003 to 2009, the percentage of routine endoscopy patients who received MAC care from an anesthesia provider during their procedures has risen from 14% to 30%. That is a large increase, but the number varies greatly by region—in some regions of the country, the current figure is around 50%. When looking at endoscopies where an anesthesiologist or CNRA provided anesthesia, over half of the time it is in routine endoscopies for low-risk patients.
This is a dramatic rise in the use of anesthesia providers in procedure rooms for routine upper endoscopies and colonoscopies in healthy patients. Experts wonder why this has happened and have recently finished studies that uncovered some surprising findings.
Experts have recently published studies concluding that the likely reason for the over-use of anesthesia is money. In other words, many experts believe that doctors bring in anesthesia providers for these procedures because the doctors make more money.
There are two reasons that I believe that the experts are probably right on this point.
First, having an anesthesia provider involved in a routine endoscopy means that the doctor performing the endoscopy has to spend less time on the procedure, which translates into being able to do more endoscopies and make more money.
Second, insurance reporting bears this out. Anesthesia services in EGD and colonoscopy procedures have cost Medicare and private insurance companies over an extra $1 billion since 2009.
Having an anesthesia provided involved can make it less safe for the patient
The results of a study published in the January 2017 issue of the journal Gastrointestinal Endoscopy found that the risk of serious adverse events was significantly higher in cases where anesthesia providers were involved in routine endoscopy procedures.
The study found that there was a 13% increase in serious adverse events for routine endoscopies in which anesthesia providers were involved, as compared to those where the doctor performing the endoscopy handled conscious sedation himself.
As used in the study, a serious adverse event was any event occurring within 30 days of the endoscopy requiring cardiopulmonary resuscitation (CPR), an ER visit, a hospital admission, administration of a rescue/reversal medication, emergency surgery, procedure termination because of an adverse event, or an intra-procedure adverse event requiring intervention or blood transfusion.
You may have heard the saying, “If the only tool you have is a hammer, everything looks like a nail.” That rationale is what the experts believe is the cause for the significant increase in serious adverse events with anesthesia professionals.
Anesthesia providers are trained to provide deep sedation and general anesthesia, both of which are associated with an increased risk of serious adverse events. Some experts believe that anesthesia providers over-sedate routine endoscopy patients for extended periods of time, which can blunt protective reflexed and can contribute to unplanned heart and respiratory events.
What you can do to have a safer endoscopy
Experts have recommended taking the financial incentive out of the equation for doctors by having Medicare and private insurance companies bundle payments for routine endoscopy procedures. That means that there would be one set payment for the procedure, whether an anesthesia provider was involved or not.
In the meantime, there are some practical things that you can do to improve the safety of any routine endoscopy that you need to have done.
Many doctors and nurses will present anesthesia services as a built-in part of an upper endoscopy of colonoscopy, without discussing any other option.
Keep in mind two general principles. First, if you do not need deeper anesthesia for a procedure, then do not consent to it. Second, if you are in a situation when you need deeper anesthesia, then ask to have an anesthesiologist in the room.
Consider asking your doctor if conscious sedation is an option, rather than the deeper sedation that an anesthesia provider would want to do. Ask about the risks and benefits of types of sedation.
If your doctor recommends deeper monitored anesthesia care (MAC), then you should ask how that will be staffed by an anesthesia provider. Just in case something goes wrong, I always recommend having an anesthesiologist in the room during the procedure. Thus, ask your doctor if an anesthesiologist will be in the room the whole time, or will it be a nurse anesthetist (CRNA)? If the doctor says it will be a CRNA, ask where the anesthesiologist will be during your procedure. Also ask how many simultaneous procedures will he or be supervising, in other words how many nurse anesthetists will be working on procedures in different rooms, all under the supervision of one anesthesiologist.
Anesthesia lawyers here to help
The medical malpractice lawyers at Painter Law Firm are experienced in handling medical negligence cases involving anesthesia care. For a free consultation, call 281-580-8800.
Robert Painter is a medical malpractice lawyer at Painter Law Firm PLLC.
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This article was originally published in the September/October 2017 edition of "The Houston Lawyer" magazine [...]read more
On 4/1/2018, the new law will end the current practice where doctors can secretly enter a DNR order against patient and family wishes
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