Safety of endoscopist-directed nurse-administered balanced propofol sedation in patients with severe systemic disease (ASA class III)

Training and Resources Related to the Administration of Sedation by Nurses During Digestive Endoscopy: A Cross-Sectional Study

BACKGROUND

The healthcare professional who performs sedation for digestive endoscopy procedures is usually the nurse. Therefore, knowledge and training on the part of the nurse is an important factor for the correct sedation of the patient and may affect, among other factors, the quality of health care and the recovery and well-being of the patient.

OBJECTIVE

To determine the training opportunities and resources available to the specialists involved in digestive endoscopy services in hospitals in Spain in which sedation is performed by the nursing staff.

METHODS

This was a descriptive cross-sectional study performed in the Digestive Endoscopy Service at Toledo University Hospital and nearby hospitals in central Spain. The sample consisted of 75 nurses who administer sedation in digestive endoscopic procedures.

RESULTS

Regarding the training of nurses, the vast majority were generalist nurses, and only a small percentage obtained specialized training through ongoing training. Most had been working in the service for more than two years, and very few had previous experience in sedation, although the vast majority currently applied sedation. Life support training was also critical. There were significant differences in the availability of resources between different hospitals.

CONCLUSIONS

The training of nurses who perform sedation in digestive endoscopy services could be improved since there is a high proportion of personnel without specific training in sedation before starting to work in the service. It is crucial to implement targeted and ongoing training programs to improve competencies in this area, as they are essential to ensure the safety and effectiveness of the procedure. Given the variability in resources and personnel training that exists between different hospitals, it seems important to establish standards at the institutional level.

Improving Endoscopy Nursing Staff's Patient Management Through the Implementation of an Education Initiative

Endoscopic procedure areas have high-volume, fast-paced work environments. This practice requires a diverse range of knowledge and skills that are continuously changing with the evolution of high-acuity procedures and the shift toward routine use of anesthesia services. Endoscopy nursing staff have recently shown higher levels of stress and emotional exhaustion than their colleagues in similar practice settings. Patient management and recovery from anesthesia are identified by this group of nurses as a perceived stressor with high priority for improvement in competencies. Standardized education in collaboration with anesthesia services regarding these topics does not exist. As an improvement initiative, a standardized education guide was developed and implemented in an urban endoscopy unit situated within a Level 1 trauma center to improve nursing staff's patient management, knowledge, and readiness. Nursing knowledge was evaluated before and after the delivery of an educational presentation. Results demonstrated a substantial improvement in nursing knowledge and preparedness for complex procedures and high-acuity patients. Implementation of a similar standardized endoscopy nursing education guide has the potential to positively impact endoscopy nursing staff's knowledge and preparedness related to complex endoscopy patient care delivery, possibly relieving a source of stress for endoscopy staff and improving patient safety.

Effect of moderate versus deep sedation on recovery following outpatient gastroscopy in older patients: a randomized controlled trial

BACKGROUND

Although gastrointestinal endoscopy with sedation is increasingly performed in older patients, the optimal level of sedation remains open to debate. In this study, our objective was to compare the effects of moderate sedation (MS) and deep sedation (DS) on recovery following outpatient gastroscopy in elderly patients.

METHODS

In this randomized, partially blinded, controlled trial, we randomly divided 270 patients older than 60 years who were scheduled for elective outpatient gastroscopy into the MS or DS group based on the Modified Observer's Assessment of Alertness/Sedation (MOAA/S) scale. The primary outcome was the duration of stay in the post-anesthesia care unit (PACU). Secondary outcomes included the duration of the total hospital stay, frequency of retching, bucking, and body movements during the examination, endoscopist and patient satisfaction, and sedation-associated adverse events during the procedure.

RESULTS

A total of 264 patients completed the study, of whom 131 received MS and 133 received DS. MS was associated with a shorter PACU stay [16.15 ± 9.01 min vs. 20.02 ± 11.13 min, P < 0.01] and total hospital stay [27.32 ± 9.86 min vs. 30.82 ± 12.37 min, P < 0.05], lesser hypoxemia [2.3% (3/131) vs. 12.8% (17/133), P < 0.01], use of fewer vasoactive drugs (P < 0.001), and more retching (P < 0.001). There was no difference in the incidence of bucking and body movements or endoscopist and patient satisfaction between the two groups.

CONCLUSION

Compared to deep sedation, moderate sedation may be a preferable choice for American Society of Anesthesiologists (ASA) Grade I-III elderly patients undergoing outpatient gastroscopies, as demonstrated by shorter PACU stays and total hospital stays, lower sedation-associated adverse events, and similar levels of endoscopist and patient satisfaction.

Prevention of peri-interventional hypothermia during endoscopic retrograde cholangiopancreatography using a forced-air heating system

Background and study aims Perioperative hypothermia is associated with significant complications and can be prevented with forced-air heating systems (FAHS). Whether hypothermia occurs during prolonged endoscopic sedation is unclear and prevention measures are not addressed in endoscopic sedation guidelines. We hypothesized that hypothermia also occurs in a significant proportion of patients undergoing endoscopic interventions associated with longer sedation times such as endoscopic retrograde cholangiopancreaticography (ERCP), and that FAHS may prevent it. Patients and methods In this observational study, each patient received two consecutive ERCPs, the first ERCP following current standard of care without FAHS (SOC group) and a consecutive ERCP with FAHS (FAHS group). The primary endpoint was maximum body temperature difference during sedation. Results Twenty-four patients were included. Median (interquartile range) maximum body temperature difference was -0.9°C (-1.2; -0.4) in the SOC and -0.1°C (-0.2; 0) in the FAHS group ( P < 0.001). Median body temperature was lower in the SOC compared with the FAHS group after 20, 30, 40, and 50 minutes of sedation. A reduction in body temperature of > 1°C ( P < 0.001) and a reduction below 36°C ( P = 0.01) occurred more often in the SOC than in the FAHS group. FAHS was independently associated with reduced risk of hypothermia ( P = 0.006). More patients experienced freezing in the SOC group ( P = 0.004). Hemodynmaic and respiratory stability were comparable in both groups. Conclusions Hypothermia occurred in the majority of patients undergoing prolonged endoscopic sedation without active temperature control. FAHS was associated with higher temperature stability during sedation and better patient comfort.

Usefulness of discharge standards in outpatients undergoing sedative endoscopy: a propensity score-matched study of the modified post-anesthetic discharge scoring system and the modified Aldrete score

Background

This study aimed to evaluate the usefulness of discharge standards in outpatients undergoing sedative endoscopy by comparing the modified post-anesthetic discharge scoring system (MPADSS) and the modified Aldrete score.

Methods

We prospectively enrolled 376 outpatients who underwent gastrointestinal endoscopy under midazolam sedation; 181 outpatients were assessed regarding discharge after sedative endoscopy using the MPADSS (group M), and 195 patients were assessed by the modified Aldrete score (group A). The clinical characteristics, types of endoscopy, endoscopic outcomes, and anesthesia outcomes were evaluated between the two groups. We compared discharge score, recovery time, and adverse events using propensity-score matching.

Results

Propensity-score matching created 120 matched pairs. The proportion of patients who had a recovery time within 60 min after endoscopy was significantly higher in group A than that in group M (42.5% versus 25.0%, respectively; P < 0.01). The proportion of patients who required > 120 min of recovery time after endoscopy was significantly lower in group A than that in group M (0.0% versus 5.0%, respectively; P = 0.03). However, significantly more patients had drowsiness at discharge in group A compared with group M (19.1% versus 5.0%, respectively; P < 0.01). There was no significant difference in the adverse event rate within 24 h of discharge between the groups.

Conclusions

Patients assessed by the modified Aldrete score were allowed to discharge earlier than those assessed by the MPADSS. However, a patient’s level of consciousness should be assessed carefully, especially in patients who visit the hospital alone.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12876-022-02549-7.

Safety Profile of Endoscopist-directed Balanced Propofol Sedation for Procedural Sedation: An Experience at a Hospital-based Endoscopy Unit

BACKGROUND

Nurse-administered propofol sedation was restricted to anesthesiologists in 2009, a practice that has contributed to spiraling health care costs in the United States.

AIM

The aim of this study was to evaluate the safety of endoscopist-directed balanced propofol sedation (EDBPS).

MATERIALS AND METHODS

We identified patients undergoing endoscopy with EDBPS from January 1, 2017, to June 20, 2017, and abstracted their medical records. Adverse events (AEs) included: hypoxia (oxygen saturation < 90%); hypotension [(a) systolic blood pressure < 90 mm Hg, (b) systolic blood pressure decline of >50 mm Hg, (c) decline in mean arterial pressure of >30%]; bradycardia (heart rate of < 40 beats/min). Logistic regression identified factors independently associated with AEs.

RESULTS

A total of 1897 patients received EDBPS during the study period [mean age: 55 y (SD=11.4 y); 56.4% women]. Patients received median doses of 50 µg fentanyl, 2 mg of midazolam, and a mean propofol dose of 160±99 mg. There were no major complications (upper 95% confidence interval, 0.19%). Overall, 334 patients (17.6%) experienced a clinically insignificant AE: 65 (3.4%) experienced transient hypoxia, 277 patients (14.6%) experienced hypotension, 2 had transient bradycardia. In bivariate analysis, older age was associated with risk for hypotension, propofol dose was associated with transient hypoxemia, and procedure duration was associated with both hypotension and transient hypoxia. In multivariate analysis, only procedure length was associated with AEs (odds ratio scale 10; odds ratio=1.07; 95% confidence interval, 1.05-1.09, P<0.001).

CONCLUSIONS

EDBPS is safe for endoscopic sedation. Given the higher cost of anesthesia-administered propofol, endoscopists should reinstate EDBPS by revising institutional sedation policies.

Safety of endoscopist-administered deep sedation with propofol in patients ASA III

INTRODUCTION

Deep sedation controlled by the endoscopist is safe in patients with low anesthetic risk (ASA I-II). However, scarce evidence is available in patients with intermediate risk (ASA III).

OBJETIVE

To evaluate the safety of deep sedation with propofol controlled by the usual endoscopy staff (endoscopist, nurse, assistant) in outpatients classified as ASA III and the risk factors for the occurrence of complications during deep sedation in these patients.

DESIGN

This observational and single-centre cross-sectional study includes consecutive patients undergoing non-complex procedures in which deep sedation is administered by the endoscopy staff. Patients were divided into group I (ASA=III) and group II (ASA<III).

RESULTS

A total of 562 patients were included, 80 (14.2%) group I. Complications related to deep sedation were more frequent in group I (23.8% vs 14.5%; p=0.036), mainly mild desaturations (13.8% vs 7.5%; p=0.058). Emergency intervention or exitus were not registered. The adjusted analysis identified age as the one independent baseline risk factor for developing global adverse events.

CONCLUSION

ASA III patients developed more sedation-related complications that ASA I-II patients. However these complications were mild and do not prevent to correctly perform the procedure.