Nurse-administered propofol sedation without anesthesia specialists in 9152 endoscopic cases in an ambulatory surgery center

Combination propofol-alfentanil anesthesia for electroconvulsive therapy in patients receiving monoamine oxidase inhibitors

Two patients who had failed outpatient treatment of depression were given electroconvulsive therapy while simultaneously being treated with monoamine oxidase inhibitors. Both were administered propofol-alfentanil anesthesia without complications.

An initial investigation of bispectral monitoring as an adjunct to nurse-administered propofol sedation for colonoscopy

BACKGROUND AND AIMS

Bispectral (BIS) monitoring has been used to evaluate depth of sedation in intensive care and surgical patients. We sought to explore its utility as a monitoring device for nurse-administered propofol sedation (NAPS) during colonoscopy.

METHODS

Fifty consecutive patients (ASA I or II) receiving NAPS for outpatient colonoscopy were evaluated. BIS scores, sedation scores, and propofol dosing were correlated. The nurses assessed the usefulness of BIS by questionnaire.

RESULTS

The mean (SD) dose of propofol required to produce a BIS value </= 60 was 109.4 (43.9) mg and an Observer's Assessment of Alertness/Sedation (OAA/S) score of 1 (deep sedation) was 91.4 (44.8) mg (p < 0.0001). The mean times required to achieve BIS values </= 60 (188 +/- 147.1 s) and </= 70 (164.3 +/- 95.1 s) were significantly longer than the mean time required to achieve an OAA/S of 1 (117.4 +/- 93.0 s, p= 0.0007). Similarly, during the recovery phase, there was a lag time of 197.9 s between mean (SD) time required from the last dose of propofol to an OAA/S of 5 (372.1 +/- 197.1 s) and the mean (SD) time required from the last dose of propofol to a BIS value >/= 90 or return to baseline (570 +/- 279.9 s, p < 0.0001). The mean (SD) BIS value in the maintenance phase of sedation was 58.9 (8.53), with a range of 22-88. Nurses administering propofol rated the usefulness of BIS at a mean of 2.85 (maximum usefulness scored as 4) in guiding the dosing of propofol sedation during the maintenance phase of sedation. No patient required mask ventilation or endotracheal intubation.

CONCLUSIONS

The BIS index in its current version is not useful in titrating boluses of propofol to an adequate level of sedation, because there is a substantial lag time between decrease of BIS scores to <70 and OAA/S scores indicative of deep sedation. There is also a substantial lag time between recovery of alertness and return of BIS scores to normal. A controlled trial of whether BIS values can assist in avoiding unnecessary propofol dosing during the maintenance phase of sedation appears warranted.

Moderate level sedation during endoscopy: a prospective study using low-dose propofol, meperidine/fentanyl, and midazolam

BACKGROUND

Propofol provides several benefits over benzodiazepine and narcotic agents as a sedative medication for endoscopic procedures, including faster recovery and improved patient satisfaction. However, its use generally has been limited to anesthesiologists because of the risks associated with deep sedation.

METHODS

One hundred patients undergoing colonoscopy or EGD were sedated with low-dose propofol, midazolam, and fentanyl (or meperidine). Depth of sedation was assessed at 2-minute intervals by an independent observer by using the American Society of Anesthesiologists criteria. Recovery time was determined by using paired neuropsychometric tests. A post-procedure satisfaction survey and 24-hour follow-up questionnaires were administered.

RESULTS

For colonoscopy and EGD, respectively, the mean propofol dose was 98 mg and 79 mg, the mean midazolam dose was 0.9 mg and 0.8 mg, the mean fentanyl dose was 69 mcg and 63 mcg, and the mean meperidine dose was 42 mg (for both procedures). There were 628 assessments of the level of sedation performed during 74 colonoscopies and 101 assessments during 26 EGDs. The level of sedation was minimal in 77%, moderate in 21%, and deep in 2% of assessments. Nine of the 13 episodes of deep sedation were recorded during colonoscopy and 4 during EGD. In no instance was more than a single assessment of deep sedation recorded during one procedure. Ninety-eight percent of patients were satisfied with the sedation, and 71% returned to their usual activities within 2 hours of discharge. There was no serious adverse event.

CONCLUSIONS

Endoscopic sedation with low-dose propofol, a narcotic agent, and midazolam produces a moderate level of sedation. The quality of sedation and measures of recovery are comparable with the results reported with standard-dose propofol.

A nursing perspective on sedation and nurse-administered propofol for endoscopy

Although the role of nurses in endoscopic sedation and monitoring varies widely, our experience has been that an active role of nurses in the administration of sedation and in patient monitoring has been safe for patients, has allowed expansion of the use of propofol in GI endoscopy in a cost-effective fashion, and has been satisfying to patients and nurses. In addition, in some instances nurse administration of sedation has improved the efficiency of the endoscopy unit. The role of nurses in endoscopic sedation and monitoring continues to develop, and we are enthusiastic about an active role for nurses.

Risk management regarding sedation/analgesia

Because the definition of standard of care changes with time, it is difficult to predict whether any given technique or practice will be ultimately viewed as the next advance in care or will be discarded as unnecessary or cumbersome. It is too early to tell whether deep sedation/analgesia with propofol or some other ultrashort acting anesthetic will emerge as the sedative/analgesic of choice for routine endoscopic practice. It seems that deep sedation with propofol provides some advantages over current narcotic/benzodiazepine combinations in many circumstances, but potential risks exist. Further information, including careful documentation of the complications that occur with this and similar agents, be they attributable to the drug or the level of sedation, are eagerly awaited. For now, it seems prudent to continue to recommend that the level of sedation/analgesia be appropriate to the perceived need and that patients continue to have their procedures performed with safety, comfort, and competence as the overriding concerns.

Review article: registered nurse-administered propofol sedation for endoscopy

Propofol has several attractive properties that render it a potential alternative sedative agent for endoscopy. Compared with meperidine and midazolam, it has an ultra-short onset of action, short plasma half-life, short time to achieve sedation, faster time to recovery and discharge, and results in higher patient satisfaction. Shorter times to achieve sedation enhance efficiency in the endoscopy unit. Multiple studies have documented the safe administration of propofol by non-anaesthesiologists. Administration by registered nurses is more cost-effective than administration by anaesthesiologists. However, the administration of propofol by a registered nurse supervised only by the endoscopist is controversial because the drug has the potential to produce sudden and severe respiratory depression. More information is needed on how training nurses and endoscopists should proceed to give propofol, as well as the optimal level of monitoring to ensure the safety of nurse-administered propofol.