Safety of propofol administered by registered nurses with gastroenterologist supervision in 2000 endoscopic cases

Nurse-Administered Propofol Sedation Training Curricula and Propofol Administration in Digestive Endoscopy Procedures: A Scoping Review of the Literature

Although efficacy and safety of nonanesthesiologist administration of propofol and nurse-administered propofol sedation practices have been amply demonstrated in patients at low American Society of Anesthesiologists physical status risk, they are still severely limited. To date, it is quite difficult to find a protocol or a shared training program. The aim of the study was to verify requirements, types of training, and operating methods described in the literature for the administration of propofol by a nurse. A scoping review of the literature was conducted in accordance with the PRISMA-ScR guidelines and in line with Arksey and O'Malley's framework, within four main databases of biomedical interest: MEDLINE, CINAHL, Scopus, and Web of Science. We selected studies published during the last 20 years, including only nurses not trained in anesthesia. Seventeen articles were eligible. Despite the differences between the training and administration methods, efficacy and safety of deep sedation managed by trained nurses were comparable, just like when sedation was administered by certified registered nurse anesthetists. Training programs have been investigated in detail by only a small number of studies, although its efficacy and safety have been widely demonstrated. It is important, then, to collect evidence that allows developing of unified international guidelines for training methods to offer safe and cost-effective quality sedation.

Bronchoscopist-Directed Continuous Flow Propofol Based Analgosedation during Flexible Interventional Bronchoscopy and EBUS

Sedation techniques in interventional flexible bronchoscopy and endobronchial ultrasound-guided transbronchial-needle aspiration (EBUS-TBNA) are inconsistent and the evidence for required general anesthesia under full anesthesiologic involvement is scarce. Moreover, we faced the challenge of providing bronchoscopic care with limited personnel. Hence, we retrospectively identified 513 patients that underwent flexible interventional bronchoscopy and/or EBUS-TBNA out of our institution between January 2020 and August 2022 to evaluate our deep analgosedation approach based on pethidine/meperidine bolus plus continuous flow adjusted propofol, the bronchoscopist-directed continuous flow propofol based analgosedation (BDcfP) in a two-personnel setting. Consequently, 502 out of 513 patients received BDcfP for analgosedation. We identified cardiovascular comorbidities, chronic obstructive pulmonary disease, and arterial hypertension as risk factors for periprocedural hypotension. Propofol flow rate did not correlate with hypotension. Theodrenaline and cafedrine might be used to treat periprocedural hypotension. Moreover, midazolam might be used to support the sedative effect. In conclusion, BDcfP is a safe and feasible sedative approach during interventional flexible bronchoscopy and EBUS-TBNA. In general, after the implementation of safety measures, EBUS-TBNA and interventional flexible bronchoscopy via BDcfP might safely be performed even with limited personnel.

A Bibliometric Analysis of Endoscopic Sedation Research: 2001-2020

Background and Aims: To evaluate endoscopic sedation research and predict research hot spots both quantitatively and qualitatively using bibliometric analysis. Methods: We extracted relevant publications from the Web of Science Core Collection (WoSCC) on 13 December 2020. We examined the retrieved data by bibliometric analysis (e.g., co-cited and cluster analysis, keyword co-occurrence) using the software CiteSpace and VOSviewer and the website of bibliometrics, the Online Analysis Platform of Literature Metrology (http://bibliometric.com/), to analyse and predict the trends and hot spots in this field. Main Results: We identified 2,879 articles and reviews on endoscopic sedation published between 2001 and 2020. Although the overall trend is increasing, with slight fluctuation in some years, there were significant increases in 2007 and 2012. In respect of the contributions on endoscopic sedation research, the United States (US) had the greatest number of publications, and it was followed by Japan and China. In addition, collaboration network analysis revealed that the most frequent collaboration was between the US and China. Six of the top ten most prolific research institutions were located in the US. The most publications on endoscopic sedation research in the past two decades were found primarily in journals on gastroenterology and hepatology. Keyword co-occurrence and co-citation cluster analysis revealed the most popular terms relating to endoscopic sedation in the manner of cluster labels; these included patient anxiety, tolerance, ketamine, propofol, hypoxia, nursing shortage, endoscopic ultrasonography, colorectal cancer, carbon dioxide insufflation, and water exchange (WE). Keyword burst detection suggested that propofol sedation, adverse event, adenoma detection rate (ADR), hypoxemia, and obesity were newly-emergent research hot spots. Conclusions: Our findings showed that hypoxia, adverse event, and ADR, along with conscious sedation and propofol sedation, have been foci of endoscopic sedation research over the past 20 years. The research focus has shifted from sedative drugs to sedative complications and endoscopy quality control, which means that there will be higher requirements and standards for sedative quality and endoscopy quality in the future.

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

BACKGROUND AND AIMS

The safety of endoscopist-directed nurse-administered propofol sedation (EDNAPS) has been demonstrated in low-risk patients (American Society of Anesthesiologists [ASA] class I and II). There are limited data regarding the safety of EDNAPS for endoscopic procedures in ASA class III patients. The purpose of this study was to determine the safety of EDNAPS for routine outpatient endoscopy in this population.

METHODS

We retrospectively reviewed all outpatient EGDs and colonoscopies performed with EDNAPS at the University of Utah from January 2015 to November 2018. Exclusion criteria were inpatient procedures, combined procedures, ASA IV or higher, use of continuous or bilevel positive airway pressure at the start of the procedure, or procedures performed by a nongastroenterologist. Major adverse events were defined as intubation or death. Minor adverse events were defined as hypoxia, hypotension, bradycardia, or need for airway interventions. Patients were stratified by procedure type and ASA I/II status and were compared with patients with ASA III status and matched according to age, gender, and the involvement of a fellow in a 3 to 1 fashion.

RESULTS

The final sample size was 18,910 colonoscopy procedures (17,205 patients) and 9178 EGD procedures (6827 patients). In both colonoscopy and EGD procedures, there were no major adverse events such as intubation, need for resuscitation, or death. The rates of any airway intervention, jaw thrust, oral nasal airway, or use of positive pressure ventilation were low in both procedure types and not different between ASA I/II and ASA III patients.

CONCLUSION

EDNAPS is safe in both ASA I/II and ASA class III patients undergoing routine outpatient endoscopy.

Impact of propofol sedation versus opioid/benzodiazepine sedation on colonoscopy outcomes: a systematic review with meta-analysis

Background and study aims  Choice of sedation (propofol vs opioid/benzodiazepine) has been studied in the literature and has shown variable outcomes. The majority of recent studies have evaluated propofol sedation (PS) versus opioids, benzodiazepines, or a combination of both. We performed a systematic review and meta-analysis of studies comparing PS to other sedation methods to assess the impact on colonoscopy outcomes. Methods  Multiple databases were searched and studies of interest were extracted. Primary outcome of the study was adenoma detection rate (ADR) and secondary outcomes included polyp detection rate (PDR), advanced adenoma detection rate (AADR), and cecal intubation rate (CIR). Results  A total of 11 studies met the inclusion criteria with a total of 177,016 patients (148,753 and 28,263 in the opioids/benzodiazepine group and PS group, respectively). Overall, ADR (RR: 1.07, 95 % CI 0.99-1.15), PDR (RR: 1.01, 95 % CI 0.93-1.10), and AADR (RR: 1.17, 95 % CI 0.92-1.48) did not improve with the use of PS. The CIR was slightly higher for propofol sedation group (RR 1.02, 95 % CI 1.00-1.03). Conclusion  Based on our analysis, PS and opioid/benzodiazepine sedation seem to have comparable ADR. Our results do not favor use of a particular sedation method and the choice of sedation should be individualized based on patient preference, risk factors and resource availability.

Low-dose midazolam and propofol use for conscious sedation during diagnostic endoscopy

To find the right sedation technique for different types of treatment methods and the right amount of sedatives so the chances of side effects happening can be reduced. This was a retrospective cohort analysis conducted on prospectively collected data. Patients who underwent esophagogastroduodenoscopy only (E group) were sub-divided into two subgroups: (a) Those who received 0.5 mg/kg of propofol (E-a), (b) Those who received 0.025 mg/kg of midazolam and 0.5 mg/kg of propofol (E-b). Patients who underwent esophagogastroduodenoscopy with colonoscopy (EC group) were also sub-divided into three subgroups: (a) Those who received 0.5 mg/kg of propofol (EC-a), (b) Those who received 0.025 mg/kg of midazolam and 0.5 mg/kg of propofol (EC-b), (c) Those who received 25 mg (12.5 mg if body weight < 50 kg or age > 70) of meperidine and 0.025 mg/kg of midazolam along with 0.5 mg/kg of propofol (EC-c). When the level of target was not reached, 10-20 mg of propofol was additionally injected. Sedation efficacy and safety were then compared among groups. E-b and EC-b decreased the overall amount of propofol and reduced side effect of temporary hypoxemia compared to E-a and EC-a. EC-b shortened patient recovery time compared to EC-c and reduced paradoxical reaction. In terms of the patient satisfaction and patient cooperation by endoscopists, there were no significant differences between EC-b and EC-c. Concomitant use of low dosages of both propofol and midazolam is found to be useful and safe when endoscopy needs to be performed.

Safety and efficacy of endoscopist-directed balanced propofol sedation during endoscopic retrograde cholangiopancreatography

Background

Endoscopist-directed balanced propofol sedation (BPS) appears to be safe and effective for routine endoscopy. However, there are limited data on its use in endoscopic retrograde cholangiopancreatography (ERCP). We evaluated the safety and efficacy of endoscopist-directed BPS for ERCP, and compared patient outcomes with anesthesiologist-administered moderate sedation.

Methods

This was a retrospective cohort study, using prospectively collected endoscopy data from a tertiary care medical center where endoscopist-directed BPS during ERCP is routine practice. Adverse outcomes included need for bag-mask ventilation or intubation, aborted ERCP due to sedation, hospital admission post-ERCP (outpatients)/change in the level of care (inpatients), and death within 24 h.

Results

A total of 501 patients underwent ERCP with the use of endoscopist-directed BPS: Cohort 1 - 380 (76%) inpatients, mean age 64.1, 46% male, 24% American Society of Anesthesiologists physical status (ASA) score I, 65% ASA II, 11% ASA III. Concurrently, 24 patients received anesthesiologist-administered moderate sedation: Cohort 2 - 19 (79%) inpatients, mean age 65.0, 67% male, 12% ASA I, 25% ASA II, 38% ASA III, 25% ASA IV. In Cohort 1, none of the adverse outcomes were observed. Propofol dose was inversely correlated with age (r=-0.42, P<0.001), ASA score (r=-0.19, P<0.001), and Mallampati score (r=-0.24, P<0.001). One patient in Cohort 2 who received anesthesiologist-administered BPS required bag-mask ventilation and the ERCP was prematurely aborted because of the sedation. There were no deaths from any cause within 24 h of ERCP.

Conclusion

Endoscopist-directed BPS appears safe, efficacious, and feasible for ASA I-III patients undergoing inpatient or ambulatory ERCP.

Deep sedation and anaesthesia in complex gastrointestinal endoscopy: a joint position statement endorsed by the British Society of Gastroenterology (BSG), Joint Advisory Group (JAG) and Royal College of Anaesthetists (RCoA)

In the UK, more than 2.5 million endoscopic procedures are carried out each year. Most are performed under conscious sedation with benzodiazepines and opioids administered by the endoscopist. However, in prolonged and complex procedures, this form of sedation may provide inadequate patient comfort or result in oversedation. As a result, this may have a negative impact on procedural success and patient outcome. In addition, there have been safety concerns on the high doses of benzodiazepines and opioids used particularly in prolonged and complex procedures such as endoscopic retrograde cholangiopancreatography. Diagnostic and therapeutic endoscopy has evolved rapidly over the past 5 years with advances in technical skills and equipment allowing interventions and procedural capabilities that are moving closer to minimally invasive endoscopic surgery. It is vital that safe and appropriate sedation practices follow the inevitable expansion of this portfolio to accommodate safe and high-quality clinical outcomes. This position statement outlines the current use of sedation in the UK and highlights the role for anaesthetist-led deep sedation practice with a focus on propofol sedation although the choice of sedative or anaesthetic agent is ultimately the choice of the anaesthetist. It outlines the indication for deep sedation and anaesthesia, patient selection and assessment and procedural details. It considers the setup for a deep sedation and anaesthesia list, including the equipment required, the environment, staffing and monitoring requirements. Considerations for different endoscopic procedures in both emergency and elective setting are also detailed. The role for training, audit, compliance and future developments are discussed.

Factors related to paradoxical reactions during propofol-induced sedated endoscopy

Objective: The factors related to paradoxical excitement during propofol-induced sedation remain unclear. We aimed to investigate this issue during sedated upper endoscopy. Material and methods: Among the health examinees scheduled for sedated upper endoscopy from June 2017 to December 2017, 421 participated in the study. Endoscopists were blinded to the information about the examinees and evaluated the development of paradoxical reactions. Propofol was exclusively used as the sedative agent via intermittent bolus injection. A multiple logistic regression analysis was performed to investigate the factors associated with paradoxical reactions. Results: The incidence of paradoxical reactions was 16.1%. Anxiety (adjusted odds ratio: 2.76; 95% confidence interval: 1.46 - 5.27; p = .002) and age (odds ratio: 0.92; 95% confidence interval: 0.89 - 0.96; p < .001) were significantly associated with paradoxical reactions. Of the nine items of the anxiety questionnaire, four had independent and significant associations with paradoxical reactions (i.e., excess worry, sleeping problems, somatic symptoms, and health concerns; odds ratios: 2.38, 2.71, 2.27 and 2.39, respectively). Conclusion: Propofol-induced paradoxical reactions tend to occur when an individual has anxiety and is of a young age. Further large population-based studies should be performed to confirm this phenomenon.

Acute sedation-associated complications in GI endoscopy (ProSed 2 Study): results from the prospective multicentre electronic registry of sedation-associated complications

OBJECTIVES

Sedation has been established for GI endoscopic procedures in most countries, but it is also associated with an added risk of complications. Reported complication rates are variable due to different study methodologies and often limited sample size.

DESIGNS

Acute sedation-associated complications were prospectively recorded in an electronic endoscopy documentation in 39 study centres between December 2011 and August 2014 (median inclusion period 24 months). The sedation regimen was decided by each study centre.

RESULTS

A total of 368 206 endoscopies was recorded; 11% without sedation. Propofol was the dominant drug used (62% only, 22.5% in combination with midazolam). Of the sedated patients, 38 (0.01%) suffered a major complication, and overall mortality was 0.005% (n=15); minor complications occurred in 0.3%. Multivariate analysis showed the following independent risk factors for all complications: American Society of Anesthesiologists class >2 (OR 2.29) and type and duration of endoscopy. Of the sedation regimens, propofol monosedation had the lowest rate (OR 0.75) compared with midazolam (reference) and combinations (OR 1.0-1.5). Compared with primary care hospitals, tertiary referral centres had higher complication rates (OR 1.61). Notably, compared with sedation by a two-person endoscopy team (endoscopist/assistant; 53.5% of all procedures), adding another person for sedation (nurse, physician) was associated with higher complication rates (ORs 1.40-4.46), probably due to higher complexity of procedures not evident in the multivariate analysis.

CONCLUSIONS

This large multicentre registry study confirmed that severe acute sedation-related complications are rare during GI endoscopy with a very low mortality. The data are useful for planning risk factor-adapted sedation management to further prevent sedation-associated complications in selected patients.

TRIAL REGISTRATION NUMBER

DRKS00007768; Pre-results.

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.

Diagnostic Yield and Safety of Bronchoscopist-directed Moderate Sedation With a Bolus Dose Administration of Propofol During Endobronchial Ultrasound Bronchoscopy

BACKGROUND

The propofol use for moderate sedation (MS) during endobronchial ultrasound (EBUS) bronchoscopy is primarily restricted for use by an anesthesiologist because of safety concerns. The goals of this study were to demonstrate the safety and the diagnostic yield of the use of propofol by bronchoscopists and trained endoscopy nurses during EBUS bronchoscopy without intubation.

METHODS

We tested a bolus propofol administration protocol targeting MS for EBUS bronchoscopy. A fixed initial dose of 40 mg of propofol along with a fixed 50 mcg fentanyl dose were administered. Sedation assessment was performed every 2 minutes, and repeated bolus doses of propofol were given to maintain MS under the direction of the bronchoscopist.

RESULTS

A total of 122 subjects underwent EBUS bronchoscopy with a goal of MS from August 2015 to April 2017. In total, 110 subjects who underwent convex EBUS bronchoscopy under MS with propofol were included in the analysis. Median procedure duration was 57 minutes (range, 15 to 97 min). Deep sedation and agitation-related delay were occurred in 14 and 21 subjects, respectively. Hemodynamic instability and hypoxemia occurred in 23 subjects. However, there was no need for vasopressors or artificial airway placement. Median of total propofol dose per case was 560 mg. Diagnostic yield for malignancy and granuloma was 68%, and a median of 4 lymph node stations were sampled per subject. All specimens with adenocarcinoma were sufficient for genetic marker analysis. There were no major sedation-related complications.

CONCLUSION

A bolus administration of propofol during EBUS bronchoscopy provided excellent adequacy of sedation and well tolerance safety profile.

Comparative Study between Propofol and Dexmedetomidine for Conscious Sedation in Patients Undergoing Outpatient Colonoscopy

INTRODUCTION

Colonoscopy is a mildly painful procedure requiring conscious sedation. Though propofol is a widely used anesthetic agent in day-care procedures due to its rapid onset and quick recovery has a drawback of requiring resuscitation maneuvers more often than the conventional methods. Dexmedetomidine, a newly introduced, highly selective α2-adrenergic receptor agonist possessing hypnotic, sedative, anxiolytic, sympatholytic, and analgesic properties with impressive safety margin, needs to be explored for use in conscious sedation for colonoscopy procedure among South Indian population.

MATERIALS AND METHODS

A prospective randomized comparative study was conducted on patients aged between 25 and 60 years with the American Society of Anesthesiologist physical status classes I and II posted for colonoscopy under monitored anesthesia care. Study group was randomly divided into two groups and administered propofol and dexmedetomidine. The primary outcome variable was assessments of sedation scores between the two groups. Secondary outcome variables were pain score assessments, hemodynamic comparisons, and adverse events among the two groups. Appropriate statistical tests were applied to compare the findings.

RESULTS

After comparisons between the two groups, we found that patients on dexmedetomidine had similar sedation score as that of patients on propofol. However, there was a significantly higher incidence of systemic hypotension. Requirement of rescue analgesia and adverse events and other hemodynamic fluctuation were similar in both the groups.

CONCLUSION

We conclude that dexmedetomidine has similar efficacy as propofol for conscious sedation required during colonoscopy. Occurrence of systolic hypotension was, however, significantly more among the group receiving dexmedetomidine.

Sedation for routine gastrointestinal endoscopic procedures: a review on efficacy, safety, efficiency, cost and satisfaction

Most gastrointestinal endoscopic procedures are now performed with sedation. Moderate sedation using benzodiazepines and opioids continue to be widely used, but propofol sedation is becoming more popular because its unique pharmacokinetic properties make endoscopy almost painless, with a very predictable and rapid recovery process. There is controversy as to whether propofol should be administered only by anesthesia professionals (monitored anesthesia care) or whether properly trained non-anesthesia personnel can use propofol safely via the modalities of nurse-administered propofol sedation, computer-assisted propofol sedation or nurse-administered continuous propofol sedation. The deployment of non-anesthesia administered propofol sedation for low-risk procedures allows for optimal allocation of scarce anesthesia resources, which can be more appropriately used for more complex cases. This can address some of the current shortages in anesthesia provider supply, and can potentially reduce overall health care costs without sacrificing sedation quality. This review will discuss efficacy, safety, efficiency, cost and satisfaction issues with various modes of sedation for non-advanced, non-emergent endoscopic procedures, mainly esophagogastroduodenoscopy and colonoscopy.

A Review of Agents for Palliative Sedation/Continuous Deep Sedation: Pharmacology and Practical Applications

Continuous deep sedation at the end of life is a specific form of palliative sedation requiring a care plan that essentially places and maintains the patient in an unresponsive state because their symptoms are refractory to any other interventions. Because this application is uncommon, many providers may lack practical experience in this specialized area and resources they can access are outdated, nonspecific, and/or not comprehensive. The purpose of this review is to provide an evidence- and experience-based reference that specifically addresses those medications and regimens and their practical applications for this very narrow, but vital, aspect of hospice care. Patient goals in a hospital and hospice environments are different, so the manner in which widely used sedatives are dosed and applied can differ greatly as well. Parameters applied in end-of-life care that are based on experience and a thorough understanding of the pharmacology of those medications will differ from those applied in an intensive care unit or other medical environments. By recognizing these different goals and applying well-founded regimens geared specifically for end-of-life sedation, we can address our patients' symptoms in a more timely and efficacious manner.

Safety of non-anesthesia provider administered propofol sedation in non-advanced gastrointestinal endoscopic procedures: A meta-analysis

BACKGROUND/AIMS

The aim of the study was to evaluate the safety of non-anesthesia provider (NAPP) administered propofol sedation in patients undergoing non-advanced gastrointestinal (GI) endoscopic procedures.

MATERIALS AND METHODS

Pubmed, Embase, Cochrane central register of controlled trials, Scopus, and Web of Science databases were searched for prospective observational trials involving non-advanced endoscopic procedures. From a total of 608 publications, 25 [colonoscopy (9), upper GI endoscopy (5), and combined procedures (11)] were identified to meet inclusion criteria and were analyzed. Data was analyzed for hypoxia rates, airway intervention rates, and airway complication rates.

RESULTS

A total of 137,087 patients were involved. A total of 2931 hypoxia episodes (defined as an oxygen saturation below 90%) were reported with a pooled hypoxia rate of 0.014 (95% CI being 0.008-0.023). Similarly, pooled airway intervention rates and pooled airway complication rates were 0.002 (95% CI being 0.006-0.001) and 0.001 (95% CI being 0.000-0.001), respectively.

CONCLUSIONS

The rates of adverse events in patients undergoing non-advanced GI endoscopic procedures with NAPP sedation are extremely small. Similar data for anesthesia providers is not available. It is prudent for anesthesia providers to demonstrate their superiority in prospective randomized controlled trials, if they like to retain exclusive ownership over propofol sedation in patients undergoing GI endoscopy.

Sedation and Monitoring in the Pediatric Patient during Gastrointestinal Endoscopy

Sedation is a fundamental component of pediatric gastrointestinal procedures. The 2 main types of sedation for pediatric endoscopy remain general anesthesia and procedural sedation. Although anesthesiologist-administered sedation protocols are more common, there is no ideal regimen for endoscopy in children. This article discusses specific levels of sedation for endoscopy as well as various regimens that can be used to achieve each. Risks and considerations that may be specific to performing gastrointestinal procedures in children are reviewed. Finally, potential future directions for sedation and monitoring that may change the practice of pediatric gastroenterology and ultimately patient outcomes are examined.

Considerable Variability of Procedural Sedation and Analgesia Practices for Gastrointestinal Endoscopic Procedures in Europe

Background/Aims:

The use of moderate to deep sedation for gastrointestinal endoscopic procedures has increased in Europe considerably. Because this level of sedation is a risky medical procedure, a number of international guidelines have been developed. This survey aims to review if, and if so which, quality aspects have been included in new sedation practices when compared to traditional uncontrolled sedation practices.

Methods:

A questionnaire was sent to the National Associations of Nurse Anesthetists in Europe and the National Delegates of the European Section and Board of Anaesthesiology from January 2012 to August 2012.

Results:

Huge variation in practices for moderate to deep sedation were identified between and within European countries in terms of safety, type of practitioners, responsibilities, monitoring, informed consent, patient satisfaction, complication registration, and training requirements. Seventy-five percent of respondents were not familiar with international sedation guidelines. Safe sedation practices (mainly propofol-based moderate to deep sedation) are rapidly gaining popularity.

Conclusions:

The risky medical procedure of moderate to deep sedation has become common practice for gastrointestinal endoscopy. Safe sedation practices requiring adequate selection of patients, adequate monitoring, training of sedation practitioners, and adequate after-care, are gaining attention in a field that is in transition from uncontrolled sedation care to controlled sedation care.

Target-Controlled Infusion of Propofol in Training Anesthesiology Residents in Colonoscopy Sedation: A Prospective Randomized Crossover Trial

BACKGROUND

Propofol is widely used in sedation for colonoscopy, but its adverse effects on cardiovascular and respiratory systems are still concerning. The present study investigated whether target controlled infusion (TCI) of propofol could provide a better sedation quality than manually controlled infusion (MCI) in training inexperienced anesthesiology residents.

MATERIAL/METHODS

Eighteen training residents were allocated into 2 groups receiving TCI and MCI training in their first month in the endoscopy center, while receiving MCI and TCI training instead in their second month. The last 2 patients at the end of each month were included to analyze the sedation quality of TCI and MCI techniques by comparing satisfaction of endoscopist and patients based on the visual analogue scale (VAS). Heart rate (HR), mean blood pressure (MAP), SpO2, and recovery time were also compared as the secondary outcomes.

RESULTS

The demographic data were similarly distributed among the TCI and MCI patients. Endoscopist's satisfaction score in the TCI group was significantly higher than in the MCI group, 81.3±7.2 versus 74.2±9.5 (P=0.003), but the patients' satisfaction score was similar between the 2 groups. More stable hemodynamic status was obtained in the TCI group, manifested as higher lowest MAP and lower highest MAP than in the MCI group. Lowest SpO2 in the TCI group was significantly higher than in the MCI group. Patients in the TCI group recovered earlier than in the MCI group.

CONCLUSIONS

TCI is a more effective and safer technique for anesthesiology residents in sedation for colonoscopy.

The role of sedation in endobronchial ultrasound-guided transbronchial needle aspiration: Systematic review

BACKGROUND

Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive procedure that has become an important tool in diagnosis and staging of mediastinal lymph node (LN) lesions in lung cancer. Adequate sedation is an important part of the procedure since it provides patient's comfort and potentially increases diagnostic yield. We aimed to compare deep sedation (DS) versus moderate sedation (MS) in patients undergoing EBUS-TBNA procedure.

METHODS

PubMed, EMBASE, MEDLINE, and Cochrane Library were searched for English studies of clinical trials comparing the two different methods of sedations in EBUS-TBNA until December 2015. The overall diagnostic yield, LN size sampling, procedural time, complication, and safety were evaluated.

RESULTS

Six studies with 3000 patients which compared two different modalities of sedation in patients performing EBUS-TBNA were included in the study. The overall diagnostic yield of DS method was 52.3%-100% and MS method was 46.1%-85.7%. The overall sensitivity of EBUS-TBNA of DS method was 98.15%-100% as compared with 80%-98.08% in MS method. The overall procedural times were 27.2-50.9 min and 20.6-44.1 min in DS and MS groups, respectively. The numbers of LN sampled were between 1.33-3.20 nodes and 1.36-2.80 nodes in DS and MS groups, respectively. The numbers of passes per LN were 3.21-3.70 passes in DS group as compared to 2.73-3.00 passes in MS group. The mean of LN size was indifferent between two groups. None of the studies included reported serious adverse events.

CONCLUSIONS

Using MS in EBUS-TBNA has comparable diagnostic yield and safety profile to DS. The decision on the method of sedation for EBUS-TBNA should be individually selected based on operator experience, patient preference, as well as duration of the anticipated procedure.

Safety of Non-anesthesia Provider-Administered Propofol (NAAP) Sedation in Advanced Gastrointestinal Endoscopic Procedures: Comparative Meta-Analysis of Pooled Results

BACKGROUND AND AIMS

The aim of the study was to evaluate the safety of non-anesthesia provider (NAAP)-administered propofol sedation for advanced endoscopic procedures with those of anesthesia provider (AAP).

METHODS

PubMed, EMBASE, Cochrane Central Register of Controlled Trials, Scopus, and Web of Science databases were searched for prospective observational trials involving advanced endoscopic procedures. From a total of 519 publications, 26 were identified to meet inclusion criteria (10 AAPs and 16 NAAPs) and were analyzed. Data were analyzed for hypoxia rate, airway intervention rates, endoscopist, and patient satisfaction scores and total propofol administered.

RESULTS

Total number of procedures in NAAP and AAP groups was 3018 and 2374, respectively. Pooled hypoxia (oxygen saturation less than 90 %) rates were 0.133 (95 % CI 0.117-0.152) and 0.143 (95 % CI 0.128-0.159) in NAAP and AAP, respectively. Similarly, pooled airway intervention rates were 0.035 (95 % CI 0.026-0.047) and 0.133 (95 % CI 0.118-0.150), respectively. Pooled patient satisfaction rate, pooled endoscopist satisfaction rate, and mean propofol administered dose for NAAP were 7.22 (95 % CI 7.17-7.27), 6.03 (95 % CI 5.94-6.11), and 251.44 mg (95 % CI 244.39-258.49) in that order compared with 9.82 (95 % CI 9.76-9.88), 9.06 (95 % CI 8.91-9.21), and 340.32 mg (95 % CI 327.30-353.33) for AAP.

CONCLUSIONS

The safety of NAAP sedation compared favorably with AAP sedation in patients undergoing advanced endoscopic procedures. However, it came at the cost of decreased patient and endoscopist satisfaction.

Clinical impact of gastroenterologist-administered propofol during esophagogastroduodenoscopy: a randomized comparison at a single medical clinic

BACKGROUND

Although midazolam is widely used during endoscopic procedures by endoscopists, propofol has been recently favored for its rapid action and metabolism. The aim of this study is to compare the clinical advantages between propofol and midazolam use during screening esophagogastroduodenoscopy (EGD) for gastric cancer and post-procedure management at a medical clinic.

METHODS

One hundred six healthy patients aged 20-69 years requesting sedation for screening EGD from October 2012 to May 2013 at a single clinic in Japan were randomly assigned to propofol (n = 54) or midazolam (n = 52). Medications were given by bolus injection, and the dose was adjusted by body weight. Sedation level and tolerability during EGD and recovery time were assessed. Sedation level and tolerability were evaluated by American Society of Anesthesiologists responsiveness levels and four levels of the gag reflex, respectively. For safety purposes, endoscopists and nurses were trained in administering propofol and an anesthesiologist was on call at all times.

RESULTS

No statistically significant differences were found between the two groups in sedation level and patient tolerability. Full recovery time in the propofol group (4.7 min) was significantly shorter than that in the midazolam group (24 min, P < 0.01).

CONCLUSIONS

Regarding post-procedure management of patients in a medical clinic, propofol use might not necessitate a recovery room and excessive assessment tasks because of rapid recovery time without any prolonged reaction, which causes patient compliance. (

CLINICAL TRIAL REGISTRATION NUMBER

UMIN000009142.).

Sedation in gastrointestinal endoscopy: a prospective study comparing nonanesthesiologist-administered propofol and monitored anesthesia care

INTRODUCTION

Adequate sedation is one of the cornerstones of good quality gastrointestinal endoscopy (GIE). Propofol sedation has increased significantly but there has been much debate over whether it can be administered by endoscopists. The aim of this prospective trial was to compare nonanesthesiologist-administered propofol (NAAP) and monitored anesthesia care (MAC).

METHODS

A total of 2000 outpatients undergoing GIE at Hospital Albert Einstein (São Paulo, Brazil), a tertiary-care private hospital, were divided into two matched groups: NAAP (n = 1000) and MAC (n = 1000). In NAAP, propofol doses were determined by the endoscopist. A second physician stayed in the room during the entire procedure, according to local regulations. In MAC, the anesthesiologist administered propofol.

RESULTS

In total, 1427 patients (71.3 %) were ASA (American Society of Anesthesiologists) class I and 573 were ASA class II. In NAAP, patients received more propofol + fentanyl (61.1 % vs. 50.5 %; P < 0.05) and there were fewer cases of deep sedation (44.7 % vs. 66.1 %; P < 0.05). Hypoxemia rates were similar (12.8 % for NAAP and 11.2 % for MAC; P = 0.3) but these reverted more rapidly in MAC (4.22 seconds vs. 7.26 seconds; P < 0.05). Agitation was more frequent in MAC (14.0 % vs. 5.6 %; P < 0.05). No later complications were observed. Patient satisfaction was very high and similar in both groups.

CONCLUSION

In this setting, NAAP was as safe and effective as MAC for healthy patients undergoing GIE. Clinical trial ref. no.: U1111-1134-4430.

Propofol versus traditional sedative agents for advanced endoscopic procedures: a meta-analysis

BACKGROUND AND AIM

The optimum method for sedation for advanced endoscopic procedures is not known. Propofol deep sedation has a faster recovery time than traditional sedative agents, but may be associated with increased complication rates. The aim of the present study was to pool data from all available studies to systematically compare the efficacy and safety of propofol with traditional sedative agents for advanced endoscopic procedures.

METHODS

Databases including PubMed, Embase, Web of Science and the Cochrane Central Register of Controlled Trials updated as of January 2013 were searched. Main outcome measures were procedure duration, recovery time, incidence of complications (hypotension, hypoxia), sedation level, patient cooperation and amnesia during advanced endoscopic procedures such as endoscopic retrograde cholangiopancreatography, endoscopic ultrasonography, and deep small bowel enteroscopy.

RESULTS

Nine prospective randomized trials with a total of 969 patients (485 propofol, 484 conscious sedation) were included in the meta-analysis. Pooled mean difference in procedure duration between propofol and traditional sedative agents was -2.3 min [95% CI: -6.36 to 1.76, P = 0.27], showing no significant difference in procedure duration between the two groups. Pooled mean difference in recovery time was -30.26 min [95% CI: -46.72 to -13.80, P < 0.01], showing significantly decreased recovery time with propofol. There was also no significant difference between the two groups with regard to hypoxia and hypotension.

CONCLUSIONS

Propofol for advanced endoscopic procedures is associated with shorter recovery time, better sedation and amnesia level without an increased risk of cardiopulmonary complications. Overall patient cooperation was also improved with propofol sedation.

Propofol use in endoscopic retrograde cholangiopancreatography and endoscopic ultrasound

Compared to standard endoscopy, endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) are often lengthier and more complex, thus requiring higher doses of sedatives for patient comfort and compliance. The aim of this review is to provide the reader with information regarding the use, safety profile, and merits of propofol for sedation in advanced endoscopic procedures like ERCP and EUS, based on the current literature.

Endoscopist-directed propofol: pros and cons

Concerns about the safety of endoscopist-directed propofol (EDP) have been voiced that propofol should be given only by healthcare professionals trained in the administration of general anesthesia. Here we discuss the safety and drawbacks of EDP for routine endoscopic procedures. Currently, both diagnostic and therapeutic endoscopy are well tolerated and accepted by both patients and endoscopists due to the application of sedation in most clinics worldwide. Accordingly, propofol use is increasing in many countries. It is crucial for endoscopists to be very familiar with the use of propofol or a combination of drugs. However, the controversy regarding the administration of sedation by an endoscopist or an anesthesiologist continues. Until now, there have been no randomized control trials comparing sedation induced by propofol administered by an endoscopist or by an anesthesiologist. It might be difficult to perform this kind of study. For the convenience and safety of sedative endoscopy, it would be important that EDP be generally applied to endoscopic procedures, and for more safety, an anesthesiologist may automatically take care of particular patients at high risk of suffering from propofol side effects.

Is the type of insufflation a key issue in gastro-intestinal endoscopy?

Endoscopic procedures continue to play an emerging role in diagnosing and treating upper and lower gastrointestinal (GI) disorders. In particular, the introduction of colonoscopy in bowel cancer screening has underlined its promising role in decreasing the incidence of colorectal cancer and reducing tumour related mortality. To achieve these goals patients need to contemplate endoscopic examinations as painless and fearless procedures. The use of carbon dioxide (CO₂) as an alternative insufflation gas in comparison to air has been considered as an essential key to improving patients' acceptance in undergoing endoscopic procedures. CO₂ is absorbed quickly through the bowel mucosa causing less luminal distension and potentially less abdominal pain. However, its exact role has not been defined completely. In particular, the beneficial use of CO₂ in upper GI endoscopy and in sedated patients is still conflicting. In the present review, we aimed to assess the current evidence for using CO₂ in endoscopy and to evaluate its potential role in the future.

Safety of non-anaesthesiologist-administered propofol sedation in ERCP

BACKGROUND AND STUDY AIMS

Propofol is increasingly being used for sedation purposes during endoscopic retrograde cholangiopancreatography (ERCP). This study aimed to evaluate the safety of non-anaesthesiologist administration of propofol (NAAP) during therapeutic ERCP.

PATIENTS AND METHODS

Patients, who underwent ERCP at Centre for Liver and Digestive Diseases, Holy Family Hospital, Rawalpindi, were included in the study. Propofol sedation was administered by a physician who was a non-anaesthesiologist certified in basic and advanced cardiac life support. The total study duration was 6 months. The primary outcome variable was the frequency of any sedation-related complication.

RESULTS

A total of 156 patients (41% males and 59% females) were enrolled in the study. The mean propofol dose used during the procedure was 201±132 mg. The mean propofol dose, when adjusted to weight and duration of procedure, was 0.05±0.04 mg kg(-1)min(-1). According to the American Society of Anesthesiologists (ASA) classification, 136 (87%) patients were placed in ASA class I and II and 20 (13%) patients were of ASA class III. Only two patients developed sedation-related complication: one minor requiring bag-mask ventilation and other major requiring mechanical ventilation via endotracheal intubation. Both were managed by the trained non-anaesthesiologist and gastroenterologist at the place of procedure. No patients required cardiopulmonary resuscitation and admission to the intensive care unit. There were no sedation-related deaths.

CONCLUSION

NAAP sedation can be considered safe for low-risk patients (ASA class I and II) undergoing ERCP. The presence of a trained anaesthetist is advisable in high-risk patients (ASA class III and higher) with significant co-morbidities.

Sedation levels during propofol administration for outpatient colonoscopies

The levels of sedation required for patients to comfortably undergo colonoscopy with propofol were examined. One hundred patients undergoing colonoscopy with propofol were enrolled. In addition to standard-of-care monitoring, sedation level was monitored with the Patient State Index (PSI) obtained from a brain function monitor, transcutaneous carbon dioxide (tcpCO2) was monitored with the TCM TOSCA monitor, and end-tidal carbon dioxide was monitored via nasal cannula. The Ramsay Sedation Score (RSS) was also assessed and recorded. After baseline data were obtained from the first 40 consecutive patients enrolled in the study, the remaining 60 patients were randomized into two groups. In one group the PSI value was blinded from the anesthesiologist and in the second group the PSI was visible and the impact of this information on the management of the sedation was analyzed. Overall 96% of patients reached levels of deep sedation and 89% reached levels of general anesthesia. When comparing the blinded to PSI versus unblinded groups, the blinded group had a significantly lower PSI and higher RSS and tcpCO2, indicating the blinded group was maintained at a deeper sedation level with more respiratory compromise than the unblinded group. Patients undergoing colonoscopy under propofol sedation delivered by a bolus technique are frequently taken to levels of general anesthesia and are at risk for respiratory depression, airway obstruction, and hemodynamic compromise.

Comparison of moderate versus deep sedation for endobronchial ultrasound transbronchial needle aspiration

RATIONALE

Most bronchoscopic procedures are performed using moderate sedation achieved by combining a short-acting benzodiazepine with an opioid agent. Propofol (2.6-diisopropylphenol), a short-acting hypnotic agent, has been increasingly used to provide deep sedation in the endoscopy community with an acceptable safety profile.

OBJECTIVES

To compare the impact of moderate versus deep sedation on the adequacy and diagnostic yield of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA).

METHODS

A retrospective review of prospectively collected data was performed at two academic institutions with interventional pulmonary fellowships using two methods of sedation during EBUS (deep vs. moderate sedation). Rapid on-site cytologic evaluation was used on all procedures in both groups. EBUS-TBNA nodal sampling was considered adequate if the aspirate yielded a specific diagnosis or lymphocytes. EBUS-TBNA was considered diagnostic if a lymph node aspirate yielded a specific diagnosis or if subsequent surgical sampling or prolonged radiographic surveillance revealed no nodal pathology.

MEASUREMENTS AND MAIN RESULTS

No difference was observed in the indication for EBUS-TBNA between the two groups. More lymph nodes were sampled per patient in the deep sedation group (314 nodes from 163 patients; 2.2 nodes per patient) than in the moderate sedation group (181 lymph nodes from 146 patients; 1.4 nodes per patient; P < 0.01). The EBUS-TBNA diagnostic yield was higher for the deep sedation group (80% of patients) than for the moderate sedation group (66% of patients; P < 0.01).

CONCLUSIONS

Diagnostic yield and number of lymph nodes sampled using deep sedation is superior to moderate sedation in patients undergoing EBUS-TBNA. Prospective studies accounting for other factors including patient selection and cost are needed.

No increased risk of perforation during colonoscopy in patients undergoing Nurse Administered Propofol Sedation

OBJECTIVE

Nurse Administered Propofol Sedation (NAPS) contributes to a deeper sedation of the patients, making them unable to respond to pain and an increased incidence of perforations has been speculated. The objective of this study was to evaluate the risk of perforations during colonoscopies performed with either NAPS or conventional sedation regimes.

MATERIAL AND METHODS

Data were retrospectively retracted from medical journals from 1 January 2007 to 31 December 2011. All journals were examined and cross-referenced to reveal any perforations. We analyzed all colonoscopies in regard to nature of the procedure (diagnostic vs therapeutic), experience of the endoscopist and ASA-classification of the patients.

RESULTS

A total of 6371 colonoscopies were performed, of which 3155 were performed under propofol sedation. There were 16 perforations (0.25%); 10 of these performed during NAPS and 6 during conventional colonoscopy (p = 0.454, OR: 1.7 (95% CI: 0.6-5.7)). There were 4874 diagnostic and 1497 therapeutic colonoscopies, with a majority of the perforations (94%) occurring during a diagnostic procedure (p = 0.389). No statistically difference was found in the incidence of perforations caused by an experienced or less experienced endoscopist (p = 0.589).

CONCLUSION

The risk of colonic perforations during colonoscopy was not found to be significantly higher in patients undergoing NAPS compared to patients undergoing conventional sedation, although a tendency may exist. Furthermore, we found no correlation to neither experience of the endoscopist, nature of the procedure nor sex of the patients. Larger and prospective studies are needed to further evaluate on this subject.

Sedation-associated complications in endoscopy are not reduced significantly by implementation of the German S-3-guideline and occur in a severe manner only in patients with ASA class III and higher

INTRODUCTION

The German guideline for sedation in gastrointestinal endoscopy was published in 2008. Several recommendations in this guideline, especially concerning staffing and structural requirements for sedation, have low evidence and therefore are subject to discussion in the field.

AIM

Comparison of endoscopic complications in a department specialized for gastrointestinal and pulmological diseases before and after implementation of the German guideline grouped in sedation-associated and non-sedation-associated complications.

METHODS

Prospective documentation of complications with retrospective analysis of two patient groups (before guideline: 1.5.2008-30.4.2010; after guideline: 1.5.2010-30.4.2012) at which the sedation technique remained the same (balanced propofol sedation, BPS).

RESULTS

Both investigation periods covered almost 7000 procedures. Interventional and general complications were nonsignificantly elevated in the latter group (1.27% before vs. 1.55% after guideline, p = 0.08). Saturation decline (in both groups 0.26%) was unchanged, and circulation-associated complications (0.27% vs. 0.13%, p = 0.07) were reduced nonsignificantly. Necessity for the administration of flumazenil and for intensive care monitoring was reduced in a nonsignificant manner after the implementation of the guideline. Severe complications (reanimation, apnea, and death) were unchanged, and no patient with ASA I-II suffered from a severe complication. Propofol consumption was higher after guideline implementation.

CONCLUSIONS

The recommendations of the new German sedation guideline do not significantly reduce complications in endoscopic procedures. Especially, procedures involving patients with ASA classes I and II do not require an additional staff member solely for sedation. Prospective randomized studies might be necessary to optimize the utilization of resources.

Deep sedation during gastrointestinal endoscopy: propofol-fentanyl and midazolam-fentanyl regimens

AIM

To compare deep sedation with propofol-fentanyl and midazolam-fentanyl regimens during upper gastrointestinal endoscopy.

METHODS

After obtaining approval of the research ethics committee and informed consent, 200 patients were evaluated and referred for upper gastrointestinal endoscopy. Patients were randomized to receive propofol-fentanyl or midazolam-fentanyl (n = 100/group). We assessed the level of sedation using the observer's assessment of alertness/sedation (OAA/S) score and bispectral index (BIS). We evaluated patient and physician satisfaction, as well as the recovery time and complication rates. The statistical analysis was performed using SPSS statistical software and included the Mann-Whitney test, χ² test, measurement of analysis of variance, and the κ statistic.

RESULTS

The times to induction of sedation, recovery, and discharge were shorter in the propofol-fentanyl group than the midazolam-fentanyl group. According to the OAA/S score, deep sedation events occurred in 25% of the propofol-fentanyl group and 11% of the midazolam-fentanyl group (P = 0.014). Additionally, deep sedation events occurred in 19% of the propofol-fentanyl group and 7% of the midazolam-fentanyl group according to the BIS scale (P = 0.039). There was good concordance between the OAA/S score and BIS for both groups (κ = 0.71 and κ = 0.63, respectively). Oxygen supplementation was required in 42% of the propofol-fentanyl group and 26% of the midazolam-fentanyl group (P = 0.025). The mean time to recovery was 28.82 and 44.13 min in the propofol-fentanyl and midazolam-fentanyl groups, respectively (P < 0.001). There were no severe complications in either group. Although patients were equally satisfied with both drug combinations, physicians were more satisfied with the propofol-fentanyl combination.

CONCLUSION

Deep sedation occurred with propofol-fentanyl and midazolam-fentanyl, but was more frequent in the former. Recovery was faster in the propofol-fentanyl group.

Safety and effectiveness of low-dose propofol sedation during and after esophagogastroduodenoscopy in child A and B cirrhotic patients

BACKGROUND

Effective and safe sedation for patients with liver cirrhosis is problematic.

AIM

To examine the safety and effectiveness of low-dose propofol sedation during and after esophagogastroduodenoscopy (EGD) in cirrhotic patients.

METHODS

Study 1 was a prospective study in cirrhotic patients who underwent diagnostic EGD under propofol sedation. Propofol was given by bolus injection with an age-adjusted standard protocol consisting of 40 mg for patients <70 years, 30 mg for patients aged 70-89 years; additional injections of 20 mg propofol were given up to a maximum of 120 mg. The principal parameter was the occurrence of adverse events within 24 h after EGD. Secondary parameters included successful procedures, complications, and full recovery within 60 min. In Study 2, the residual effects of propofol were evaluated using a driving simulator and blood propofol concentrations in a subset of cirrhotic patients undergoing EGD and compared with healthy individuals. The principal parameter was driving ability.

RESULTS

Study 1: Consecutive cirrhotic patients were entered and all 163 successfully completed EGD. The mean dose of propofol was 46 mg (range 30-120 mg). No complications occurred. Full recovery had occurred in 100 % 60 min after the procedure. No adverse events occurred within 24 h after EGD. Study 2: There were no significant differences in blood propofol levels between cirrhotic patients (n = 21) and healthy individuals (n = 20) after sedation. In cirrhotic patients, there was no deterioration in driving ability as compared with healthy individuals.

CONCLUSION

Low-dose propofol sedation provided safe and effective sedation for EGD in cirrhotic patients with rapid recovery.

Sedation and monitoring for gastrointestinal endoscopy

The safe sedation of patients for diagnostic or therapeutic procedures requires a combination of properly trained physicians and suitable facilities. Additionally, appropriate selection and preparation of patients, suitable sedative technique, application of drugs, adequate monitoring, and proper recovery of patients is essential. The goal of procedural sedation is the safe and effective control of pain and anxiety as well as to provide an appropriate degree of memory loss or decreased awareness. Sedation practices for gastrointestinal endoscopy (GIE) vary widely. The majority of GIE patients are ambulatory cases. Most of this procedure requires a short time. So, short acting, rapid onset drugs with little adverse effects and improved safety profiles are commonly used. The present review focuses on commonly used regimens and monitoring practices in GIE sedation. This article is to discuss the decision making process used to determine appropriate pre-sedation assessment, monitoring, drug selection, dose of sedative agents, sedation endpoint and post-sedation care. It also reviews the current status of sedation and monitoring for GIE procedures in Thailand.

Safety and efficacy of deep sedation with propofol alone or combined with midazolam administrated by nonanesthesiologist for gastric endoscopic submucosal dissection

Background/Aims

Endoscopic submucosal dissection (ESD) is accepted as a treatment for gastric neoplasms and usually requires deep sedation. The aim of this study was to evaluate the safety and efficacy profiles of deep sedation induced by continuous propofol infusion with or without midazolam during ESD.

Methods

A total of 135 patients scheduled for ESDs between December 2008 and June 2010 were included in this prospective study and were randomly assigned to one of two groups: the propofol group or the combination group (propofol plus midazolam).

Results

The propofol group reported only one case of severe hypoxemia with no need of mask ventilation or intubation. Additionally, 18 cases of mild hypotension were observed in the propofol group, and 11 cases were observed in the combination group. The combination group had a lower mean total propofol dose (378 mg vs 466 mg, p<0.012), a longer mean recovery time (10.5 minutes vs 7.9 minutes, p=0.027), and a lower frequency of overall adverse events (32.8% vs 17.6%, p=0.042).

Conclusions

Deep sedation induced by continuous propofol infusion was shown to be safe during ESD. The combination of continuous propofol infusion and intermittent midazolam injection can decrease the total dose and infusion rate of propofol and the overall occurrence of adverse events.

Safety and effectiveness of propofol sedation during and after outpatient colonoscopy

AIM: To study the safety and effectiveness of propofol sedation for outpatient colonoscopy.

METHODS: Propofol was given by bolus injection with an age-adjusted standard protocol consisting of 60 mg for patients < 70 years old, 40 mg for patients age 70-89 years, and 20 mg for those ≥ 90 years, and additional injections of 20 mg propofol were given up to a maximum of 200 mg. The principal parameters were the occurrence of adverse events within 24 h after colonoscopy and overall satisfaction for this procedure. Secondary parameters included successful procedure, respiratory depression, and other complications.

RESULTS: Consecutive patients were entered prospectively and all 2101 entered successfully completed outpatient colonoscopy. The mean dose of propofol used was 96.4 mg (range 40-200 mg). Younger patients required higher doses of propofol than older patients (20-40 years vs≥ 61 years: 115.3 ± 32 mg vs 89.7 ± 21 mg, P < 0.001). Transient supplemental oxygen supply was needed by five patients (0.2%); no other complications occurred. The questionnaires were completed by 1820 (87%) of 2101 patients and most rated their overall satisfaction as excellent (80%) or good (17%). The majority (65%) of patients drove home or to their office after their colonoscopy. Most (99%) were willing to repeat the same procedure. No incidents occurred within 24 h after colonoscopy.

CONCLUSION: Propofol sedation using a dose < 200 mg proved both safe and practical for outpatient colonoscopy.

Prospective description of coughing, hemodynamic changes, and oxygen desaturation during endoscopic sedation

BACKGROUND

Deep sedation is increasingly used for endoscopy. The impact of sedation level on hemodynamic status, oxygenation, and aspiration risk is incompletely described.

AIMS

To describe the incidence of intraprocedural cough, hemodynamic changes, oxygen desaturation, and their relationship to clinical factors and sedation level.

METHODS

Detailed prospective recordings of hemodynamic changes, oxygen desaturation, and cough during 757 nonemergent endoscopic procedures done under sedation using propofol, midazolam, and/or fentanyl.

RESULTS

Thirteen percent of patients had at least one cough and 3% had prolonged cough. Cough was more common in nonsmokers (P = 0.05), upper endoscopy (P < 0.0001), with propofol (P = 0.0008), longer procedures (P = 0.0001), and hiccups (P = 0.01). The association between supine positioning during colonoscopy and cough approached significance (P = 0.06). Oxygen desaturation was rare (4%) and associated only with deep sedation (P = 0.02). Mean systolic and diastolic blood pressure (BP) dropped by 7.3 and 5.6% respectively. Decreases in systolic BP were more common in whites (P = 0.03), males (P = 0.004), nonsmokers (P = 0.04), during colonoscopy (P < 0.0001), and in patients receiving midazolam and fentanyl (P = 0.01). Heart rate (HR) dropped >20% from baseline in 15% of patients and was more common during colonoscopy (P = 0.002). HR increased >20% in 20% of patients and was more common with coughing (P < 0.0001) and in younger patients (P = 0.0002). No patient required pharmacologic treatment of BP or HR.

CONCLUSIONS

We have described procedural predictors of cough that may help clinicians reduce the risk of aspiration during endoscopy. Hemodynamic changes during endoscopy are common but largely clinically insignificant.

Gastroenterologist-guided sedation with propofol for endoscopic ultrasonography in average-risk and high-risk patients: a prospective series

OBJECTIVE

Only a few reports have addressed non-anesthesiologist-administered propofol for endoscopic ultrasonography (EUS), but none specifically in high-risk patients. Our aim was to study the application of a propofol sedation protocol for EUS in average-risk and high-risk patients.

METHODS

This was a prospective observational study including 446 patients referred for EUS. We analyzed the induction time, procedure duration, recovery times, and patients' comfort and safety. Sedation was administered by a trained nurse, under the guidance of the endoscopist. We continuously monitored vital signs as well as patient cooperation and tolerance. Complications, patient, and endoscopist satisfaction were analyzed.

RESULTS

No major complications occurred. The rate of minor complications was 9%, the most frequent being hypoxemia (8%). One hundred and thirty-eight high-risk patients were included [American Society of Anesthesiologists (ASA) III-IV]. Average-risk patients received higher propofol doses (202.9 ± 84.8 vs. 164.8 ± 84.3; P=0.003). No differences were found in the rate of complications or procedure-related variables. Overall patient and endoscopist satisfaction was excellent. The logistic regression model identified propofol doses (P=0.02) as a risk factor and ASA-I classification (P=0.03) as a protective factor for the appearance of complications.

CONCLUSION

Non-anesthesiologist-administered propofol for upper EUS in high-risk and average-risk patients is safe and could be routinely offered to high-risk and elderly patients.