Safety of nurse-administered propofol sedation using PCA pump for outpatient colonoscopy in Chinese patients: a pilot study

Attitudes of anesthetists towards an anesthesia-led nurse practitioner model for low-risk colonoscopy procedures: a cross-sectional survey

BACKGROUND

The mounting pressure on the Australian healthcare system is driving a continual exploration of areas to improve patient care and access and to maximize utilization of our workforce. We hypothesized that there would be support by anesthetists employed at our hospital for the design, development, and potential implementation of an anesthesia-led nurse practitioner (NP) model for low-risk colonoscopy patients.

METHODS

We conducted a cross-sectional, mixed methods study to ascertain the attitudes and acceptability of anesthetists towards a proposed anesthesia-led NP model for low-risk colonoscopy patients. An online survey using commercial software and theoretical questions pertaining to participants' attitudes towards an anesthesia-led NP model was e-mailed to consultant anesthetists. Participants were also invited to participate in a voluntary 20-min face-to-face interview.

RESULTS

A total of 60 survey responses were received from a pool of 100 anesthetists (response rate = 60%, accounting for 8.04% margin of error). Despite the theoretical benefits of improved patient access to colonoscopy services, most anesthetists were not willing to participate in the supervision and training of NPs. The predominant themes underlying their lack of support for the program were a perception that patient safety would be compromised compared to the current model of anesthesia-led care, the model does not meet the Australian and New Zealand College of Anesthetists guidelines for procedural sedation and analgesia, and the program may be a public liability prone to litigation in the event of an adverse outcome. Concerns about consumer acceptance and cost-effectiveness were also raised. Finally, participants thought the model should be pilot tested to better understand consumer attitudes, logistical feasibility, patient and proceduralist attitudes, clinical governance, and, importantly, patient safety.

CONCLUSIONS

Most anesthetists working in a single-center university hospital did not support an anesthesia-led NP model for low-risk colonoscopy patients. Patient safety, violations of the current Australian and New Zealand College of Anesthetists guidelines on procedural sedation, and logistical feasibility were significant barriers to the acceptance of the model.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry, 12619001036101.

Safety of applying midazolam-ketamine-propofol sedation combination under the supervision of endoscopy nurse with patient-controlled analgesia pump in colonoscopy

AIM

To compare the results of midazolam-ketamine-propofol sedation performed by an endoscopy nurse and anaesthetist during colonoscopy in terms of patient satisfaction and safety.

METHODS

American Statistical Association (ASA) I-II 60 patients who underwent colonoscopy under sedation were randomly divided into two groups: sedation under the supervision of an anaesthetist (SSA) and sedation under the supervision of an endoscopy nurse (SSEN). Both groups were initially administered 1 mg midazolam, 50 mg ketamine and 30-50 mg propofol. Continuation of sedation was performed by the anaesthetist in the SSA group and the nurse with a patient-controlled analgesia (PCA) pump in the SSEN group. The total propofol consumption, procedure duration, recovery times, pain using the visual analogue scale (VAS) and satisfaction score of the patients, and side effects were recorded. In addition, the patients were asked whether they remembered the procedure and whether they would prefer the same method in the case of re-endoscopy.

RESULTS

Total propofol consumption in the SSEN group was significantly higher (P < 0.05) than that in the SSA group. When the groups were compared in terms of VAS score, recovery time, patient satisfaction, recall of the procedure, re-preference for the same method in case of re-endoscopy, and side effects, there were no significant differences (P > 0.05) between the two groups. No long-term required intervention side effects were observed in either group.

CONCLUSION

Colonoscopy sedation in ASA I-II patients can be safely performed by an endoscopy nurse using PCA pump with the incidence of side effects and patient satisfaction levels similar to sedation under anaesthetist supervision.

Use of anesthesia on the rise in gastrointestinal endoscopy

Conscious sedation has been the standard of care for many years for gastrointestinal endoscopic procedures. As procedures have become more complex and lengthy, additional medications became essential for adequate sedation. Often time's deep sedation is required for procedures such as endoscopic retrograde cholangiography which necessitates higher doses of narcotics and benzodiazepines or even use of other medications such as ketamine. Given its pharmacologic properties, propofol was rapidly adopted worldwide to gastrointestinal endoscopy for complex procedures and more recently to routine upper and lower endoscopy. Many studies have shown superiority for both the physician and patient compared to standard sedation. Nevertheless, its use remains highly controversial. A number of studies worldwide show that propofol can be given safely by endoscopists or nurses when well trained. Despite this wealth of data, at many centers its use has been prohibited unless administered by anesthesiology. In this commentary, we review the use of anesthesia support for endoscopy in the United States based on recent data and its implications for gastroenterologists worldwide.

Nurse-administered propofol sedation for gastrointestinal endoscopic procedures: first Nordic results from implementation of a structured training program

INTRODUCTION

Proper training to improve safety of NAPS (nurse-administered propofol sedation) is essential.

OBJECTIVE

To communicate our experience with a training program of NAPS.

MATERIALS AND METHODS

In 2007, a training program was introduced for endoscopists and endoscopy nurses in collaboration with the Department of Anaesthesiology. During a 2.5-year period, eight nurses were trained. Propofol was given as monotherapy. The training program for nurses consisted of a 6-week course including theoretical and practical training whereas the training program for endoscopists consisted of 2.5 h of theory. Patients were selected based on strict criteria including patients in ASA (American Society of Anesthesiologists) group I-III.

RESULTS

2527 patients undergoing 2.656 gastrointestinal endoscopic procedures were included. The patients were ASA group I, II and III in 34.7%, 56% and 9,3%, respectively. Median dose of propofol was 300 mg. No mortality was noted. 119 of 2527 patients developed short lasting hypoxia (4.7%); 61 (2.4%) needed suction; 22 (0.9%) required bag-mask ventilation and 8 (0.3%) procedures had to be discontinued. In 11 patients (0.4%), anesthetic assistance was called due to short lasting desaturation. 34 patients (1.3%) experienced a change in blood pressure greater than 30%.

CONCLUSION

NAPS provided by properly trained nurses according to the present protocol is safe and only associated with a minor risk (short lasting hypoxia 4.7%). National or international structured training programs are at present few or non-existing. The present training program has documented its value and is suggested as the basis for the current development of guidelines.