Sedation in endoscopic practice

Frameworks for trainee education in the nonoperating room setting

PURPOSE OF REVIEW

As the volume and types of procedures requiring anesthesiologist involvement in the nonoperating room anesthesia (NORA) setting continue to grow, it is important to create a formal curriculum and clearly define educational goals.

RECENT FINDINGS

A NORA rotation should be accompanied by a dedicated curriculum that should include topics such as education objectives, information about different interventional procedures, anesthesia techniques and equipment, and safety principles. NORA environment may be unfamiliar to anesthesia residents. The trainees must also learn the principles of efficiency, rapid recovery from anesthesia, and timely room turnover. Resident education in NORA should be an essential component of their training. The goals and objectives of the NORA educational experience should include not only developing the clinical knowledge necessary to implement the specific type of anesthetic desired for each procedure, but also the practical knowledge of care coordination needed to safely and efficiently work in the NORA setting.

SUMMARY

As educators, we must foster and grow a resident's resilience by continually challenging them with new clinical scenarios and giving them appropriate autonomy to take risks and move outside of their comfort zone. Residents should understand that exposure to such unique and demanding environment can be transformative.

Conscious sedation using propofol versus midazolam in cirrhotic patients during upper GI endoscopy: A comparative study

AIM

We aimed to assess the safety and efficacy of propofol versus midazolam in cirrhotic patients undergoing upper GI endoscopy.

METHODS

Ninety compensated cirrhotic patients (all met class I-III criteria according to the American Society of Anesthesia) were enrolled in this comparative study. They were classified into three groups according to scheduled pre-endoscopy sedation drugs; the midazolam group, which included 30 patients who received IV weight-dependent midazolam (0.05 mg/kg with additional doses of 1 mg every 2 min when necessary, up to a maximum dose of 0.1 mg/kg or 10 mg); the propofol group, which included 30 patients who received a propofol bolus dose according to age and weight (0.25 mg/kg with additional doses of 20-30 mg every 30-60 s when necessary, up to a maximum dose of 400 mg); and the combined group, which included 30 patients who received half a dose of midazolam and of propofol.

RESULTS

Prolonged postendoscopy recovery times were reported in the midazolam group, while shorter recovery times were reported in the propofol and combined groups. All patients in the propofol and combined groups gained consciousness shortly postendoscopy; however, only half of the midazolam group's patients gained consciousness after the standard recovery time (10-30 min). Highly significant differences were found among the three groups regarding consciousness level according to the Glasgow coma scale, as well as regarding the occurrence of hypoxia during endoscopy.

CONCLUSION

Considering safety and efficacy issues, propofol is better than midazolam in gastrointestinal endoscopy, especially in patients with liver cirrhosis.

Use of diphenhydramine as an adjunctive sedative for colonoscopy in patients on chronic opioid therapy: a randomized controlled trial

BACKGROUND AND AIMS

Chronic opioid use increases tolerance to sedatives. Diphenhydramine is recommended for difficult-to-sedate patients during endoscopic procedures. We hypothesized that the addition of diphenhydramine to midazolam and fentanyl would improve objective and subjective measures of procedural sedation.

METHODS

This randomized, double-blind, placebo-controlled trial included patients on chronic opioids undergoing colonoscopy. Patients were randomized to receive 50 mg of diphenhydramine intravenously (n = 61) or placebo (n = 58), in addition to fentanyl and midazolam. Baseline characteristics, amount of fentanyl and midazolam, procedure times, and adverse events were recorded. Quality of sedation was assessed by the physician and nurse. Patients rated pain and amnesia on a 10-point scale.

RESULTS

There was no difference in amounts of fentanyl (125.4 ± 56.2 μg vs 126.9 ± 53.5 μg, P = .88) and midazolam (4.9 ± 2.1 mg vs 5 ± 1.9 mg, P = .79) used. The mean sedation scores from the physician (6.2 ± 1.1 vs 5.3 ± 1.2, P =.0002) and nurses (5.6 ± 1.5 vs 5.1 ± 1.4, P =.04) were statistically significant in favor of the diphenhydramine arm. Patient scores for pain (2.05 ± 2.17 vs 3.09 ± 3.95, P =.047) and amnesia (7.8 ± 3.4 vs 6.5 ± 3.8, P =.047) favored the group that received diphenhydramine. Qualitative assessment showed no significant difference between the groups. There was no difference in induction time (P = .86), procedure duration (P = .98), or recovery time (P = .16). Hypotensive episodes were more common in the placebo group (P = .027).

CONCLUSIONS

In patients on chronic opioid therapy, administration of diphenhydramine does not allow for lower doses of procedural sedatives but improves quality of sedation without increasing the number of adverse events. (Clinical trial registration number: NCT T01967433.).

Preprocedural Assessment for Sedation in Gastrointestinal Endoscopy

The role of the anesthesia service in sedation for gastrointestinal endoscopy (GIE) has been steadily increasing. The goals of preprocedural assessment are determined by the specific details of the procedure, the issues related to the illness that requires the endoscopy, comorbidities, the goals for sedation, and the risk of complications from the sedation and the endoscopic procedure. Rather than consider these issues as separate entities, they should be considered as part of a continuum of preparation for GIE. This is told from the perspective of an anesthesiologist who regularly participates in the full range of sedation for GIE.

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.

Modeling the costs and benefits of capnography monitoring during procedural sedation for gastrointestinal endoscopy

BACKGROUND AND STUDY AIMS

The addition of capnography to procedural sedation/analgesia (PSA) guidelines has been controversial due to limited evidence of clinical utility in moderate PSA and cost concerns.

PATIENTS AND METHODS

A comprehensive model of PSA during gastrointestinal endoscopy was developed to capture adverse events (AEs), guideline interventions, outcomes, and costs. Randomized, controlled trials and large-scale studies were used to inform the model. The model compared outcomes using pulse oximetry alone with pulse oximetry plus capnography. Pulse oximetry was assumed at no cost, whereas capnography cost USD 4,000 per monitor. AE costs were obtained from literature review and Premier database analysis. The model population (n = 8,000) had mean characteristics of age 55.5 years, body mass index 26.2 kg/m(2), and 45.3 % male.

RESULTS

The addition of capnography resulted in a 27.2 % and 18.0 % reduction in the proportion of patients experiencing an AE during deep and moderate PSA, respectively. Sensitivity analyses demonstrated significant reductions in apnea and desaturation with capnography. The median (95 % credible interval) number needed to treat to avoid any adverse event was 8 (2; 72) for deep and 6 (-59; 92) for moderate. Reduced AEs resulted in cost savings that accounted for the additional upfront purchase cost. Capnography was estimated to reduce the cost per procedure by USD 85 (deep) or USD 35 (moderate).

CONCLUSIONS

Capnography is estimated to be cost-effective if not cost saving during PSA for gastrointestinal endoscopy. Savings were driven by improved patient safety, suggesting that capnography may have an important role in the safe provision of PSA.

Practice patterns of sedation for colonoscopy

BACKGROUND

Sedative and analgesic medications have been used routinely for decades to provide patient comfort, reduce procedure time, and improve examination quality during colonoscopy.

OBJECTIVE

To evaluate trends of sedation during colonoscopy in the United States.

SETTING

Endoscopic data repository of U.S. gastroenterology practices (Clinical Outcomes Research Initiative, CORI database from 2000 until 2013).

PATIENTS

The study population was made up of patients undergoing a total of 1,385,436 colonoscopies.

INTERVENTIONS

Colonoscopy without any intervention or with mucosal biopsy, polypectomy, various means of hemostasis, luminal dilation, stent placement, or ablation.

MAIN OUTCOME MEASUREMENTS

Dose of midazolam, diazepam, fentanyl, meperidine, diphenhydramine, promethazine, and propofol used for sedation during colonoscopy.

RESULTS

During the past 14 years, midazolam, fentanyl, and propofol have become the most commonly used sedatives for colonoscopy. Except for benzodiazepines, which were dosed higher in women than men, equal doses of sedation were given to female and male patients. White patients were given higher doses than other ethnic groups undergoing sedation for colonoscopy. Except for histamine-1 receptor antagonists, all sedative medications were given at lower doses to patients with increasing age. The dose of sedatives was higher in colonoscopies associated with procedural interventions or of long duration.

LIMITATIONS

Potential for incomplete or incorrect documentation in the database.

CONCLUSION

The findings reflect on colonoscopy practice in the United States during the last 14 years and provide an incentive for future research on how sex and ethnicity influence sedation practices.

Nonoperating room anesthesia for the gastrointestinal endoscopy suite

Anesthesia services are increasingly being requested for gastrointestinal (GI) endoscopy procedures. The preparation of the patients is different from the traditional operating room practice. The responsibility to optimize comorbid conditions is also unclear. The anesthetic techniques are unique to the procedures, as are the likely events that require intervention by the anesthesia team. The postprocedure care is also unique. The future needs for anesthesia services in GI endoscopy suite are likely to expand with further developments of the technology.

Using efficiency analysis and targeted intervention to improve operational performance and achieve cost savings in the endoscopy center

BACKGROUND

With an increasing demand for endoscopy services, there is a greater need for efficiency within the endoscopy center. A validated methodology is important for evaluating efficiency in the endoscopy unit.

OBJECTIVE

To use the principles of operations management to establish a validated methodology for evaluating and enhancing operational performance in the endoscopy center.

DESIGN

Biphasic prospective study with pre-intervention and post-intervention efficiency data and analysis.

SETTING

Tertiary-care referral teaching hospital.

PATIENTS

Scheduled outpatients undergoing endoscopy.

INTERVENTION

Determination of the rate-limiting step, or bottleneck, of the endoscopy unit and reducing inefficiencies.

MAIN OUTCOME MEASUREMENTS

Staffing costs and a novel performance metric, True Completion Time (TCT).

RESULTS

Data were prospectively recorded for 2248 patients undergoing a total of 2713 procedures (phase I: 255 EGD, 305 colonoscopy, 91 EGD/colonoscopy, 375 EUS, 44 ERCP, 75 EUS/ERCP; phase II: 243 EGD, 328 colonoscopy, 99 EGD/colonoscopy, 335 EUS, 38 ERCP, 109 EUS/ERCP). The bottleneck of the operation was identified as the 10-bed communal pre-procedure/recovery room. On-time procedure starts increased by 51% (P < .001), and TCT was reduced by 12.2% (P < .001) across all cases studied. Overtime and per diem nursing costs were reduced by 30%, whereas full-time employee staff was reduced by 0.85. Annual cost savings were calculated as $312,618 or 11.02% of total operating expenses.

LIMITATIONS

This study is not directly tied to quality outcomes, and inpatient procedures transported to the endoscopy unit were not directly studied.

CONCLUSION

Room turnover time and room-to-endoscopist ratio are not necessarily the driving parameters behind endoscopy unit efficiency. A focus on developing a methodology for identifying factors constraining operational efficiency can improve performance and reduce costs in the endoscopy center.

Colorectal endoscopic submucosal dissection in Japan and Western countries

Various studies by Japanese endoscopists have demonstrated that colorectal endoscopic submucosal dissection (ESD) can overcome technical limitations of the endoscopic mucosal resection (EMR) technique such as piecemeal resection for flat lesions larger than 20 mm, resection of lesions involving the dentate line or the ileocecal valve and lesions with the non-lifting sign, and achieve higher en bloc resection rate. However, it is infrequently performed in Western countries in comparison with Japan, despite the advantages explained above. There are some differences between Japan and Western countries in environments and clinical settings for performing ESD in the colorectum. Endoscopists who perform colorectal ESD around the world are considering that refinements in ESD techniques, devices and training will be necessary to further reduce a higher risk of complications and longer procedure times before adoption of ESD can be recommended on a widespread international scale.

A survey of sedation practices for colonoscopy in Canada

BACKGROUND

There are limited data regarding the use of sedation for colonoscopy and concomitant monitoring practices in different countries.

METHODS

A survey was mailed to 445 clinician members of the Canadian Association of Gastroenterology and 80 members of the Canadian Society of Colon and Rectal Surgeons in May and June 2009.

RESULTS

Sixty-five per cent of Canadian Association of Gastroenterology members and 69% of Canadian Society of Colon and Rectal Surgeons members responded with the full survey. Most endoscopists reported using sedation for more than 90% of colonoscopies. The most common sedation regimen was a combination of midazolam and fentanyl. Propofol, either alone or with another drug, was used in 12% of cases. A higher proportion (94%) of adult gastroenterologists who routinely used propofol were highly satisfied compared with those using other sedative agents (45%; P<0.001). Fifty per cent of adult gastroenterologists and 29% of surgeons who were not currently using propofol expressed interest in starting to use it for routine colonoscopies. Only a single nurse was present in the endoscopy room during colonoscopy performed by two-thirds of the endoscopists.

CONCLUSIONS

Results of the present survey suggest that gastroenterologists in Canada use sedation for colonoscopy in more than 90% of their patients. There was higher satisfaction among gastroenterologists who used propofol routinely for all colonoscopies. Most endoscopy rooms were staffed by a single nurse, which may limit further increases in the use of propofol. Further studies are needed to determine optimal staffing of endoscopy units with and without the use of propofol. Sedation practices of general surgery endoscopists need to be evaluated.

Impact of endoscopy-based research on quality of life in healthy volunteers

AIM: To study the impact of an endoscopy-based long-term study on the quality of life in healthy volunteers (HV).

METHODS: Ten HV were included into a long-term prospective endoscopy-based placebo-controlled trial with 15 endoscopic examinations per person in 5 different drug phases. Participants completed short form-36 (SF-36) and visual analog scale-based questionnaires (VAS) for different abdominal symptoms at days 0, 7 and 14 of each drug phase. Analyses were performed according to short- and long-term changes and compared to the control group.

RESULTS: All HV completed the study with duration of more than 6 mo. Initial quality of life score was comparable to a general population. Analyses of the SF-36 questionnaires showed no significant changes in physical, mental and total scores, either in a short-term perspective due to different medications, or to potentially endoscopic procedure-associated long-term cumulative changes. Analogous to SF-36, VAS revealed no significant changes in total scores for pathological abdominal symptoms and remained unchanged over the time course and when compared to the control population.

CONCLUSION: This study demonstrates that quality of life in HV is not significantly affected by a long-term endoscopy-based study with multiple endoscopic procedures.

Endoscopic sedation in Greece: results from a nationwide survey for the Hellenic Foundation of gastroenterology and nutrition

BACKGROUND AND STUDY AIMS

Recent surveys regarding practices in sedation during endoscopic procedures are limited, particularly in Greece where they are nonexistent. This survey was designed to provide national data on sedation practices in Greece.

METHODS

A 27-item survey regarding practices of endoscopy and sedation was mailed nationwide to 502 members of the Hellenic Society of Gastroenterology.

RESULTS

A total of 201 questionnaires were returned (40%). Survey respondents performed an average of 48 oesophagogastroduodenoscopies (EGD) and 35 colonoscopies per month. 50 of the respondents, who perform endoscopic retrograde cholangiopancreatography (ERCP), conducted an average of 10 ERCP per month. 15 of the respondents, who perform endoscopic ultrasound (EUS), conducted an average of 6 EUS per month. Respondents administered sedation intravenously in 64% of EGD, 78% of colonoscopies, 100% of ERCP and 100% of EUS. 125 of the respondents (62.1%) reported the use of synergistic sedation (benzodiazepines plus opioids), 71 of the respondents (35.3%) reported the use of benzodiazepines alone and 68 of the respondents (33.8%) reported the use of propofol based sedation in selected cases (more than one response was permitted). In most cases, propofol administration was directed by an anaesthesiologist. The majority of the respondents monitored vital signs and pulse oximetry (90% and 96%, respectively).

CONCLUSION

The use of sedation and physiologic monitoring in Greece is now standard practice during endoscopy. Benzodiazepines, either alone or combined with an opioid, are used by the majority of endoscopists, while propofol is used in selected cases, mainly in the presence of an anaesthesiologist.

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.

Scope creep: when nursing practice moves beyond traditional boundaries: an evidence-based example using procedural sedation

The finite boundaries of the scope of nursing practice are constantly changing. One could expect that with new technology and advances in science, the interventions and assessments nurses perform will change over time. The practice of nursing is governed by nursing, however, it is often challenged by our partners in medicine, and frequently driven by time constraints or reimbursement issues. This article reviews a case example in which nurses were asked to expand their practice to assume responsibility for duties that were once traditionally performed by physicians. An evaluation of a practice problem using an evidence-based approach applying the PICO (population, intervention, comparison, outcome) method is explored. Proposed steps to minimize risk and staff moral distress are also described.