Training in patient monitoring and sedation and analgesia

Endoscopic Sedation: Medicolegal Considerations

Goals of endoscopic sedation are to provide patients with a successful procedure, and ensure that they remain safe and are relieved from anxiety and discomfort; agents should provide efficient, appropriate sedation and allow patients to recover rapidly. Sedation is usually safe and effective; however, complications may ensue. This paper outlines some medicolegal aspects of endoscopic sedation, including informed consent, possible withdrawal of consent during the procedure, standard of care for monitoring sedation, use of anesthesia personnel to deliver sedation, and new agents and devices.

Training and Competency in Sedation Practice in Gastrointestinal Endoscopy

The practice of endoscopic sedation requires a thorough understanding of preprocedural assessment, sedation pharmacology, intraprocedure monitoring, adverse event management, and postprocedural care. The training process has become increasingly standardized and entails knowledge and practice-based components. The use of propofol in particular requires a higher level of structured training owing to its narrow therapeutic window. Simulation has increased opportunities for practice-based training in a controlled environment. After completion of training, the endoscopist must demonstrate competence in theoretical understanding and technical ability to administer sedation. Although individual institutions have certification processes, there is a lack of validated, standardized methods to confirm competence.

Endoscopic sedation: from training to performance

Adequate sedation and analgesia are considered essential requirements to relieve patient discomfort and pain and ultimately to improve the outcomes of modern gastrointestinal endoscopic procedures. The willingness of patients to undergo sedation during endoscopy has increased steadily in recent years and standard sedation practices are needed for both patient safety and successful procedural outcomes. Therefore, regular training and education of healthcare providers is warranted. However, training curricula and guidelines for endoscopic sedation may have conflicts according to varying legal frameworks and/or social security systems of each country, and well-recognized endoscopic sedation training systems are not currently available in all endoscopy units. Although European and American curricula for endoscopic sedation have been extensively developed, general curricula and guidelines for each country and institution are also needed. In this review, an overview of recent curricula and guidelines for training and basic performance of endoscopic sedation is presented based on the current literature.

Sedation practices for routine diagnostic upper gastrointestinal endoscopy in Nigeria

AIM

To determine the sedation practices and preferences of Nigerian endoscopists for routine diagnostic upper gastrointestinal endoscopy.

METHODS

A structured questionnaire containing questions related to sedation practices and safety procedures was administered to Nigerian gastrointestinal endoscopists at the 2011 annual conference of the Society for Gastroenterology and Hepatology in Nigeria which was held at Ibadan, June 23-35, 2011.

RESULTS

Of 35 endoscopists who responded, 17 (48.6%) used sedation for less than 25% of procedures, while 14 (40.0%) used sedation for more than 75% of upper gastrointestinal endoscopies. The majority of respondents (22/35 or 62.9%) had less than 5 years experience in gastrointestinal endoscopy. The sedative of choice was benzodiazepine alone in the majority of respondents (85.7%). Opioid use (alone or in combination with benzodiazepines) was reported by only 5 respondents (14.3%). None of the respondents had had any experience with propofol. Non-anaesthesiologist-directed sedation was practiced by 91.4% of endoscopists. Monitoring of oxygen saturation during sedation was practiced by only 57.1% of respondents. Over half of the respondents (18/35 or 51.4%) never used supplemental oxygen for diagnostic upper gastrointestinal endoscopy.

CONCLUSION

Sedation for routine diagnostic upper gastrointestinal endoscopy in Nigeria is characterized by lack of guidelines, and differs markedly from that in developed countries.

Basic requirements of gastroenterologists to treat upper gastrointestinal bleeding: competency and sedation issues

This article reviews the components of adequate training required for a gastroenterologist to treat upper gastrointestinal bleeding (UGIB). The current status of endoscopic simulators is critically reviewed to determine whether these should be part of the UGIB armamentarium in the training of individuals and whether credentialing could be accomplished through this method of instruction. Finally, the author discusses the appropriate use of sedation in patients with UGIB.

Sedation and monitoring for gastrointestinal endoscopy: A nationwide web survey in Italy

BACKGROUND

Best strategy of sedation/analgesia in gastrointestinal (GI) endoscopy is still debated.

AIMS OF THE STUDY

To evaluate sedation and monitoring practice among Italian gastroenterologists and to assess their opinion about non-anaesthesiologist propofol administration.

METHODS

A 19-item survey was mailed to all 1192 members of the Italian Society of Digestive Endoscopy (SIED). For each respondent were recorded demographic data, medical specialty, years of practise and practise setting.

RESULTS

A total of 494 SIED members returned questionnaires, representing a response rate of 41.4%. The most employed sedation pattern was benzodiazepines for oesophagogastroduodenoscopies (EGDS) in 50.8% of procedures, benzodiazepines plus opioids for colonoscopy and enteroscopy in 39.5% and 35.3% of procedures, respectively, propofol for endoscopic retrograde colangiopancreatography (ERCP) and endoscopic ultrasound (EUS) in 42.3% and 35.6% of procedures, respectively. With regard to propofol use, 66% respondents stated that propofol was exclusively administered by anaesthesiologists. However, 76.9% respondents would consider non-anaesthesiologist propofol administration after appropriate training. Pulse oximetry is the most employed system for procedural monitoring. Supplemental O(2) is routinely administered by 39.3% respondents.

CONCLUSIONS

Use of sedation has become a standard practise during GI endoscopy in Italy. Pattern varies for each type of procedure. Pulse oximetry is the most employed system of monitoring. Administration of propofol is still directed by anaesthesiologists.

[An established anesthesia team-care model: over 12000 cases in a digestive endoscopy unit]

BACKGROUND AND OBJECTIVE

The growing demand for digestive and other endoscopic procedures outside the operating room, both in terms of type of endoscopy and number of patients, requires reorganization of the anesthesiology department's workload. We describe 2 years of our hospital digestive endoscopy unit's experience with a now well-established care model involving both anesthesiologists and nurse anesthetists.

MATERIAL AND METHODS

After previously reviewing the medical records of outpatients and conducting a telephone interview about state of health, nurse anesthetists administered a combination of propofol and remifentanil through a target-controlled infusion system under an anesthesiologist's direct supervision.

RESULTS

The ratio of anesthesiologists to nurses ranged from 1:2 to 1:3 according to the complexity of the examination procedure. Over 12000 endoscopies (simple to advanced) in a total of 11853 patients were performed under anesthesia during the study period. Airway management maneuvers were required by 4.9% of the patients; 0.18% required bag ventilation for respiratory depression, and 0.084% required bolus doses of a vasopressor to treat hypotension or atropine to treat bradycardia. The procedure had to be halted early in 9 patients (0.07%). No patient required orotracheal intubation and none died. Nor were any complications related to sedation recorded.

CONCLUSION

The results suggest that this care model can safely accommodate a large caseload in anesthesia at an optimum level of quality.

Sedation in digestive endoscopy: the Athens international position statements

BACKGROUND

Guidelines and practice standards for sedation in endoscopy have been developed by various national professional societies. No attempt has been made to assess consensus among internationally recognized experts in this field.

AIM

To identify areas of consensus and dissent among international experts on a broad range of issues pertaining to the practice of sedation in digestive endoscopy.

METHODS

Thirty-two position statements were reviewed during a 1 (1/2)-day meeting. Thirty-two individuals from 12 countries and four continents, representing the fields of gastroenterology, anaesthesiology and medical jurisprudence heard evidence-based presentations on each statement. Level of agreement among the experts for each statement was determined by an open poll.

RESULTS

The principle recommendations included the following: (i) sedation improves patient tolerance and compliance for endoscopy, (ii) whenever possible, patients undergoing endoscopy should be offered the option of having the procedure either with or without sedation, (iii) monitoring of vital signs as well as the levels of consciousness and pain/discomfort should be performed routinely during endoscopy, and (iv) endoscopists and nurses with appropriate training can safely and effectively administer propofol to low-risk patients undergoing endoscopic procedures.

CONCLUSIONS

While the standards of practice vary from country to country, there was broad agreement among participants regarding most issues pertaining to sedation during endoscopy.

Procedural sedation and obesity: waters left uncharted

BACKGROUND

Moderate sedation during endoscopy may pose increased risks among obese patients.

OBJECTIVE

To review the literature that considers aspects of sedation within the obese population and to identify gaps in our knowledge.

DESIGN

Literature-based review.

RESULTS

There may be increased risks among obese patients undergoing moderate sedation. In particular, the presence of obstructive sleep apnea may identify a subset of patients at higher risk for complications.

LIMITATIONS

English language literature only.

CONCLUSIONS

Although obesity may be associated with increased risks of procedural sedation, future studies should better clarify such risks to better inform clinical decision making.

Making every colonoscopy count: Ensuring quality in endoscopy

The last few years have seen a burgeoning interest in the measurement of clinical performance and its impact on quality standards. The advent of the National Bowel Cancer Screening Program has highlighted the many deficiencies that exist in the provision of colonoscopy services in Australia. These include the absence of an agreed tool to measure the quality of colonoscopy on either an individual, departmental or regional basis and the absence of an endoscopic or colonoscopy training curriculum or an agreed standard for colonoscopy trainers. This review will discuss the current status and shortfalls of measuring quality in colonoscopy, highlight some recent initiatives by the Gastroenterological Society of Australia and articulate a direction for the future.

Human patient simulation and its role in endoscopic sedation training

Patient simulation is now considered to be a valid method for the education and evaluation of providers of sedation. Using full-scale human simulators to provide a realistic setting, participants can acquire skills for patient monitoring, administration of sedation medications, and the recognition and management of critical events. Although obstacles to its implementation exist, it appears likely that simulation training will become an integral part of training for providers of procedural sedation.

Endoscopic sedation: medicolegal considerations

The availability of endoscopy as a diagnostic and therapeutic tool has caused the number of procedures performed in the United States to greatly increase; additionally, the volume and complexity of endoscopic procedures performed under sedation, including difficult procedures performed on frail and severely ill patients, has increased. The goals of endoscopic sedation are to provide patients with a successful procedure and to ensure that they remain safe and are relieved from anxiety and discomfort; agents should provide efficient, appropriate sedation and allow patients to recover rapidly. Sedation is usually both safe and effective; however, complications may ensue. This article will explore medicolegal aspects of sedation, such as the importance of informed consent for sedation, the difficulties of assessing withdrawal of consent in a sedated patient, and the need for sedation monitoring which meets accepted standard of care. Controversies involving GI directed propofol and the use of anesthesia personnel to deliver sedation for endoscopy are also discussed.

Endoscopic sedation: equipment and personnel

Endoscopic sedation is changing, in response to economic pressures, regulatory requirements, and new technology. Each endoscopy unit must tailor its personnel and equipment practices to its particular case mix, sedation preferences, and to its external environment. This article discusses sedation-related considerations regarding procedure room design, equipment for drug administration, equipment for patient monitoring, equipment for managing emergencies, and staff selection, training, and responsibilities.