الفهرس 
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Abstract
SUMMARY
Endoscopy is a team activity, requiring the collaborative talents of many
people of different backgrounds and training. It is difficult to overstate
the importance of an appropriate environment and professional support
staff, in order to maintain patient comfort and safety, and to optimize
clinical outcomes. Procedures are performed by many different types of
doctor, including gastroenterologists, anesthesiologists, surgeons,
internists (general physicians), some family practitioners and radiologists.
Nowadays some procedures are performed by specially trained nurses.
There are also many different types of supporting staff.
Anesthesiologists also must play a more active role in the preoperative
assessment and preparation of the patients to avoid costly delays and lastminute
cancellations. The role of the anesthesiologist has evolved from
that of a physician primarily concerned with providing optimal conditions
and minimizing pain immediately after the procedure to that of a
physician responsible for ensuring that patients with coexisting medical
conditions are optimally managed before, during, and after the procedure.
Gastrointestinal endoscopic procedures under anesthesia are performed in
a distant location from the operating theater. Nonoperating room
anesthesia (NORA) has its own risks. With advances in medical
technologies in the last 2 decades, new and more noninvasive, minimally
invasive and even increasingly complex diagnostic and therapeutic
interventions in sicker patients are performed outside the operating
theater, leading to an ever-growing demand for NORA.
Remote anesthesia is usually conducted in a place unfamiliar to the
anesthesiologists and does not tend to accommodate an anesthetic
machine or related equipments. Under these circumstances, extra
responsibilities fall on the anesthesiologists.
Nevertheless, it is still the responsibility of the anesthesiologists to
provide safe anesthesia even in an uncomfortably challenging, foreign, or
occasionally hostile location.
Moreover, the foreign workplace can also pose a risk to the
anesthesiologists, as they frequently injure themselves by falling over
cables or hitting their heads on unexpected objects while moving around
an unfamiliar, dimly lit environment, such as the ultrasound room which
is kept dark to facilitate the imaging display.
The level of anesthetic intervention to perform a successful procedure
may range from minimal sedation to general anesthesia. Patient age,
health status, concurrent medications, preprocedural anxiety, and pain
tolerance influence the level of sedation required to achieve the desired
result. The procedural variables include the degree of invasiveness, the
level of procedure-related discomfort, the need for the patient to lie
relatively motionless (eg, endoscopic ultrasound-guided fine needle
aspiration (EUS-FNA)) and the duration of examination. Typically,
diagnostic and uncomplicated therapeutic upper endoscopy and
colonoscopy are successfully performed with moderate sedation. Deeper
levels of sedation may be considered for longer and more complex
procedures, including, but not limited to, ERCP and EUS. Additionally,
deep sedation or general anesthesia should be considered for patients who
have been difficult to manage with moderate sedation and are anticipated
to be poorly responsive to sedatives. This includes patients who have had
long-term use of narcotics, benzodiazepines, alcohol, or neuropsychiatric
medications. The choice of sedative is largely anesthesiologists
dependent and is based on maximizing patient comfort while minimizing
risks.
Over the past decades, the number of pediatric endoscopies has increased
rapidly. As specialized teams of pediatric gastroenterologists, pediatric
anesthetists, pediatric intensive care physicians and pediatric endoscopy
nurses are available in many medical centers, safe and effective
procedures have been established. In contrast to adults, endoscopic
examinations in children are usually performed under deep sedation or
general anesthesia to reduce emotional stress caused by separation from
parents and the preparation for the procedure itself. At many institutions,
anesthesia care providers administer the sedation or anesthesia for all or
most pediatric endoscopies.
Also; Sedation in elderly patients requires awareness of their increased
response to sedative agents. A multiplicity of physiological processes
contributes to the increase in sensitivity and sedation risk in elderly
patients.
Endoscopic procedures are often necessary in patients with chronic
liver disease. The evaluation of such patients should include an
assessment of hepatic synthetic function and identification of
neuropsychiatric findings suggestive of hepatic encephalopathy. It may
be possible, in some cases, to perform diagnostic EGD without
administration of sedation; this is desirable to eliminate the risks of
sedation, especially encephalopathy. Nonetheless, most patients
undergoing upper and lower endoscopy require sedation. Currently, the
use of propofol is preferred to benzodiazepines and opioids for
endoscopic sedation of patients with advanced liver disease due to its
short biologic half-life and low risk of provoking hepatic encephalopathy.
Patients with renal failure undergoing GI Endoscopy are at a
substantial risk for increased morbidity and mortality, because they often
have other comorbidities, including hypertension, diabetes, peripheral
vascular disease, and cardiac disease. Renal failure has various
consequences on homeostasis that are not only restricted to water and
electrolyte abnormalities, but affect many organ systems, making
intraprocedural management of these patients especially challenging.
The safety and efficacy of GI endoscopy during pregnancy is not
well studied. The fetus is particularly sensitive to maternal hypoxemia
and hypotension that can potentially lead to fetal compromise. It is
therefore imperative to know the potential risks to the fetus and to
balance these risks with clear indications when endoscopic intervention is
necessary. Additionally, caution needs to be exercised with the use of
certain medications because they may be transferred to the infant from
the breast milk.