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Leroy PL, Krauss BS, Costa LR, Barbi E, Irwin MG, Carlson DW, Absalom A, Andolfatto G, Roback MG, Babl FE, Mason KP, Roelofse J, Costa PS, Green SM. Procedural sedation competencies: a review and multidisciplinary international consensus statement on knowledge, skills, training, and credentialing. Br J Anaesth 2024:S0007-0912(24)00498-7. [PMID: 39327154 DOI: 10.1016/j.bja.2024.07.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Revised: 07/01/2024] [Accepted: 07/06/2024] [Indexed: 09/28/2024] Open
Abstract
Procedural sedation is practised by a heterogeneous group of practitioners working in a wide array of settings. However, there are currently no accepted standards for the competencies a sedation practitioner should have, the content of sedation training programmes, and guidelines for credentialing. The multidisciplinary International Committee for the Advancement of Procedural Sedation sought to develop a consensus statement on the following: which competencies should medical or dental practitioners have for procedural sedation and how are they obtained, assessed, maintained, and privileged. Using the framework of Competency-Based Medical Education, the practice of procedural sedation was defined as a complex professional task requiring demonstrable integration of different competencies. For each question, the results of a literature review were synthetised into preliminary statements. Following an iterative Delphi review method, final consensus was reached. Using multispeciality consensus, we defined procedural sedation competence by identifying a set of core competencies in the domains of knowledge, skills, and attitudes across physical safety, effectiveness, psychological safety, and deliberate practice. In addition, we present a standardised framework for competency-based training and credentialing of procedural sedation practitioners.
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Affiliation(s)
- Piet L Leroy
- Department of Pediatrics, Maastricht University Medical Centre and School of Health Professions Education, Maastricht University, Maastricht, The Netherlands.
| | - Baruch S Krauss
- Department of Pediatrics, Harvard Medical School, Boston Children's Hospital, Boston, MA, USA
| | - Luciane R Costa
- Department of Pediatric Dentistry, Federal University of Goias, Goiania, Goias, Brazil
| | - Egidio Barbi
- Department of Pediatrics, Institute for Maternal and Child Health-IRCCS 'Burlo Garofolo', Trieste, Italy
| | - Michael G Irwin
- Department of Anaesthesiology, University of Hong Kong, Queen Mary Hospital, Hong Kong
| | - Douglas W Carlson
- Department of Pediatrics, Southern Illinois University School of Medicine, Springfield, IL, USA
| | - Anthony Absalom
- Department of Anaesthesia, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Gary Andolfatto
- University of British Columbia Department of Emergency Medicine, Lions Gate Hospital, North Vancouver, British Columbia, Canada
| | - Mark G Roback
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Franz E Babl
- Departments of Paediatrics and Critical Care, University of Melbourne, Emergency Department, Royal Children's Hospital, Emergency Research, Murdoch Children's Research Institute, Parkville, WA, Australia
| | - Keira P Mason
- Department of Anesthesia, Harvard Medical School, Boston Children's Hospital, Boston, MA, USA
| | - James Roelofse
- Departments of Anaesthesia, University of the Western Cape, Stellenbosch University, Tygerberg, Republic of South Africa
| | - Paulo S Costa
- Department of Pediatrics, Federal University of Goias, Goiania, Goias, Brazil
| | - Steven M Green
- Department of Emergency Medicine, Loma Linda University, Loma Linda, CA, USA
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Minciullo A, Filomeno L. Nurse-Administered Propofol Sedation Training Curricula and Propofol Administration in Digestive Endoscopy Procedures: A Scoping Review of the Literature. Gastroenterol Nurs 2024; 47:33-40. [PMID: 37937982 DOI: 10.1097/sga.0000000000000780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 07/21/2023] [Indexed: 11/09/2023] Open
Abstract
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.
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Affiliation(s)
- Andrea Minciullo
- Andrea Minciullo, MSN, RN, is Head Nurse, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
- Lucia Filomeno, MSN, RN, is Research Fellow, Sapienza University of Rome, Rome, Italy
| | - Lucia Filomeno
- Andrea Minciullo, MSN, RN, is Head Nurse, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
- Lucia Filomeno, MSN, RN, is Research Fellow, Sapienza University of Rome, Rome, Italy
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Wehrmann T, Riphaus A, Eckardt AJ, Klare P, Kopp I, von Delius S, Rosien U, Tonner PH. Updated S3 Guideline "Sedation for Gastrointestinal Endoscopy" of the German Society of Gastroenterology, Digestive and Metabolic Diseases (DGVS) - June 2023 - AWMF-Register-No. 021/014. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:e654-e705. [PMID: 37813354 DOI: 10.1055/a-2165-6388] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/11/2023]
Affiliation(s)
- Till Wehrmann
- Clinic for Gastroenterology, DKD Helios Clinic Wiesbaden, Wiesbaden, Germany
| | - Andrea Riphaus
- Internal Medicine, St. Elisabethen Hospital Frankfurt Artemed SE, Frankfurt, Germany
| | - Alexander J Eckardt
- Clinic for Gastroenterology, DKD Helios Clinic Wiesbaden, Wiesbaden, Germany
| | - Peter Klare
- Department Internal Medicine - Gastroenterology, Diabetology, and Hematology/Oncology, Hospital Agatharied, Hausham, Germany
| | - Ina Kopp
- Association of the Scientific Medical Societies in Germany e.V. (AWMF), Berlin, Germany
| | - Stefan von Delius
- Medical Clinic II - Internal Medicine - Gastroenterology, Hepatology, Endocrinology, Hematology, and Oncology, RoMed Clinic Rosenheim, Rosenheim, Germany
| | - Ulrich Rosien
- Medical Clinic, Israelite Hospital, Hamburg, Germany
| | - Peter H Tonner
- Anesthesia and Intensive Care, Clinic Leer, Leer, Germany
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Lorenz P, Wehrmann T, Riphaus A, Eckardt AJ, Klare P, Koop I, Fischer N, Jansen PL. Leitlinienreport der aktualisierten S3-Leitlinie „Sedierung in der gastrointestinalen Endoskopie“ der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS). ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:e628-e653. [PMID: 37678314 DOI: 10.1055/a-2124-5746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Affiliation(s)
- Pia Lorenz
- Deutsche Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS), Berlin, Deutschland
| | - Till Wehrmann
- Klinik für Gastroenterologie, DKD Helios Klinik Wiesbaden, Wiesbaden, Deutschland
| | - Andrea Riphaus
- Innere Medizin, St. Elisabethen Krankenhaus Frankfurt Artemed SE, Frankfurt, Deutschland
| | - Alexander J Eckardt
- Klinik für Gastroenterologie, DKD Helios Klinik Wiesbaden, Wiesbaden, Deutschland
| | - Peter Klare
- Abteilung Innere Medizin Gastroenterologie, Diabetologie und Hämato-/Onkologie, Krankenhaus Agatharied, Hausham, Deutschland
| | - Ina Koop
- AWMF-Institut für Medizinisches Wissensmanagement, Marburg, Deutschland
| | - Nadine Fischer
- Deutsche Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS), Berlin, Deutschland
| | - Petra Lynen Jansen
- Deutsche Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS), Berlin, Deutschland
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Wehrmann T, Riphaus A, Eckardt AJ, Klare P, Kopp I, von Delius S, Rosien U, Tonner PH. Aktualisierte S3-Leitlinie „Sedierung in der gastrointestinalen Endoskopie“ der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS). ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:1246-1301. [PMID: 37678315 DOI: 10.1055/a-2124-5333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/09/2023]
Affiliation(s)
- Till Wehrmann
- Klinik für Gastroenterologie, DKD Helios Klinik Wiesbaden, Wiesbaden, Deutschland
| | - Andrea Riphaus
- Innere Medizin, St. Elisabethen Krankenhaus Frankfurt Artemed SE, Frankfurt, Deutschland
| | - Alexander J Eckardt
- Klinik für Gastroenterologie, DKD Helios Klinik Wiesbaden, Wiesbaden, Deutschland
| | - Peter Klare
- Abteilung Innere Medizin - Gastroenterologie, Diabetologie und Hämato-/Onkologie, Krankenhaus Agatharied, Hausham, Deutschland
| | - Ina Kopp
- Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e. V. (AWMF), Berlin, Deutschland
| | - Stefan von Delius
- Medizinische Klinik II - Innere Medizin - Gastroenterologie, Hepatologie, Endokrinologie, Hämatologie und Onkologie, RoMed Klinikum Rosenheim, Rosenheim, Deutschland
| | - Ulrich Rosien
- Medizinische Klinik, Israelitisches Krankenhaus, Hamburg, Deutschland
| | - Peter H Tonner
- Anästhesie- und Intensivmedizin, Klinikum Leer, Leer, Deutschland
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McKenzie P, Fang J, Davis J, Qiu Y, Zhang Y, Adler DG, Gawron AJ. Safety of endoscopist-directed nurse-administered balanced propofol sedation in patients with severe systemic disease (ASA class III). Gastrointest Endosc 2021; 94:124-130. [PMID: 33309879 DOI: 10.1016/j.gie.2020.11.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Accepted: 11/28/2020] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
| | - John Fang
- University of Utah, Salt Lake City, Utah, USA
| | | | - Yuqing Qiu
- University of Utah, Salt Lake City, Utah, USA
| | - Yue Zhang
- University of Utah, Salt Lake City, Utah, USA
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Facciorusso A, Turco A, Barnabà C, Longo G, Dipasquale G, Muscatiello N. Efficacy and Safety of Non-Anesthesiologist Administration of Propofol Sedation in Endoscopic Ultrasound: A Propensity Score Analysis. Diagnostics (Basel) 2020; 10:791. [PMID: 33036219 PMCID: PMC7601714 DOI: 10.3390/diagnostics10100791] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2020] [Revised: 10/02/2020] [Accepted: 10/05/2020] [Indexed: 11/21/2022] Open
Abstract
In spite of promising preliminary results, evidence supporting the use of non-anesthesiologist-administered propofol sedation (NAAP) in endoscopic ultrasound (EUS) procedures is still limited. The aim of this manuscript was to examine the safety and efficacy of NAAP as compared to anesthesiologist-administered propofol sedation in EUS procedures performed in a referral center. Out of 832 patients referred to our center between 2016 and 2019, after propensity score matching two groups were compared: 305 treated with NAAP and 305 controls who underwent anesthesiologist-administered propofol sedation. The primary outcome was the rate of major complications. The median age was 67 years and the proportion of patients with comorbidities was 31.8% in both groups. One patient in each group (0.3%) experienced a major complication, whereas minor complications were observed in 13 patients in the NAAP group (4.2%) and 10 patients in the control group (3.2%; p = 0.52). Overall pain during the procedure was 2.3 ± 1 in group 1 and 1.8 ± 1 in group 2 (p = 0.67), whereas pain/discomfort upon awakening was rated as 1 ± 0.5 in both groups (p = 0.72). NAAP is safe and effective even in advanced EUS procedures. Further randomized-controlled trials (RCTs) are warranted to confirm these findings.
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Affiliation(s)
- Antonio Facciorusso
- Gastroenterology Unit, Department of Medical Sciences, Ospedali Riuniti di Foggia, Viale Pinto 1, 71100 Foggia, Italy; (A.T.); (C.B.); (G.L.); (G.D.); (N.M.)
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Weinberg L, Grover H, Cowie D, Langley E, Heland M, Story DA. Attitudes of anesthetists towards an anesthesia-led nurse practitioner model for low-risk colonoscopy procedures: a cross-sectional survey. HUMAN RESOURCES FOR HEALTH 2020; 18:20. [PMID: 32183813 PMCID: PMC7076960 DOI: 10.1186/s12960-020-0458-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/05/2019] [Accepted: 02/17/2020] [Indexed: 06/10/2023]
Abstract
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.
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Affiliation(s)
- L. Weinberg
- Department of Anesthesia, Austin Hospital, 145 Studley Road, Heidelberg, Victoria 3084 Australia
- Department of Surgery, The University of Melbourne, Melbourne, Victoria Australia
| | - H. Grover
- Department of Anesthesia, Austin Hospital, 145 Studley Road, Heidelberg, Victoria 3084 Australia
| | - D. Cowie
- Department of Anesthesia, Austin Hospital, 145 Studley Road, Heidelberg, Victoria 3084 Australia
| | - E. Langley
- Department of Anesthesia Perioperative and Pain Medicine Unit, The University of Melbourne, Melbourne, Victoria Australia
| | - M. Heland
- Department of Anesthesia Perioperative and Pain Medicine Unit, The University of Melbourne, Melbourne, Victoria Australia
| | - D. A. Story
- Centre for Integrated Critical Care, The University of Melbourne, Melbourne, Victoria Australia
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Cabadas Avión R, Baluja A, Ojea Cendón M, Leal Ruiloba MS, Vázquez López S, Rey Martínez M, Magdalena López P, Álvarez-Escudero J. Effectiveness and safety of gastrointestinal endoscopy during a specific sedation training program for non-anesthesiologists. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2018; 111:199-208. [PMID: 30507244 DOI: 10.17235/reed.2018.5713/2018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
INTRODUCTION sedation is a key component for the improvement of sedation quality. A correct administration requires appropriate training. We performed a study to compare sedation effectiveness, safety and patient satisfaction when administered by gastroenterologists, with and without specific training. METHODS a training program enrolled a group of gastroenterologists (trained group, n = 4) and their results were compared to those from a non-trained group (n = 3). ASA 1-3 patients who had undergone sedation by a gastroenterologist using midazolam and fentanyl were included over a period of 30 months. Safety was assessed in terms of the complication rate, effectiveness was assessed via the rate of completed endoscopic procedures and patient satisfaction was evaluated via a phone interview the day after the procedure. RESULTS a total of 3,475 patients were sedated by gastroenterologists during the study period. Significant differences were found that favored the trained group for completed procedures (5.6% vs 8.9%). A lower rate of excessive sedation (1.3% vs 8.61%), hypoxemia (0.72% vs 2.49%) and post-procedural pain (1.8% vs 4.3%) were also achieved. Patient satisfaction surpassed 99.5% and there were no significant differences between groups. CONCLUSIONS our sedation training program improved the effectiveness and safety outcomes when compared to sedation administered by gastroenterologists without this specific training.
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Affiliation(s)
| | - Aurora Baluja
- Anestesiología, Hospital universitario Santiago Compostela, España
| | | | | | | | | | | | - Julián Álvarez-Escudero
- Anestesiología y Reanimación, Complejo Hospitalario Universitario de Santiago de Compostela. Universidad de Santiago de Compostela, España
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Cabadas Avion R, Ojea Cendón M, Leal Ruiloba MS, Baluja González MA, Sobrino Ramallo J, Álvarez Escudero J. Prospective analysis of the complications, efficacy, and satisfaction level on the sedation performed by anaesthetists in gastrointestinal endoscopy. ACTA ACUST UNITED AC 2018; 65:504-513. [PMID: 30055768 DOI: 10.1016/j.redar.2018.06.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 06/13/2018] [Accepted: 06/25/2018] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To describe the anaesthesia/sedation complications during gastrointestinal endoscopy, as well as comparing scheduled procedures versus urgent procedures. METHODS A protocol was developed to define the anaesthesia/sedation in gastrointestinal endoscopy, where the anaesthetist should always be present. These include ASA 3 and 4 patients, complex tests such as polypectomies, endoscopic retrograde cholangiopancreatography (ERCP) or endoscopic ultrasound, deep sedation, or patients with probable difficult airway management. An analysis was made of the safety based on the complications recorded from the data directly collected automatically from the monitors, both during the sedation and in the recovery unit. An analysis was also performed on the risk factors associated with cardiorespiratory complications, the effectiveness based on the completed tests and the overall level of satisfaction through an interview using a satisfaction scale. RESULTS The study included a total of 3746 patients over a 7 year-period. The incidence of major complications was low, especially haemodynamic and respiratory complications. An incidence of hypoxaemia of 3% was found in scheduled endoscopy versus 5.7% in urgent endoscopy (P<.05). The rate of hypotension was also low, with significant differences between scheduled and urgent endoscopy (6.4% vs. 18.8%, P<.001). In present study, no test had to be suspended due to poor patient tolerance, and the satisfaction was high in more than 99% of cases. CONCLUSION The participation of the anaesthetist in sedation for gastrointestinal endoscopy has shown excellent results in this study, in terms of safety and efficacy, mainly in the most serious patients and complex tests, as well as a high level of satisfaction.
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Affiliation(s)
| | - M Ojea Cendón
- Servicio de Anestesiología, Hospital Povisa, Vigo, España
| | | | - M A Baluja González
- Servicio de Anestesiología, Hospital Clínico Universitario de Santiago, Santiago de Compostela, España
| | | | - J Álvarez Escudero
- Servicio de Anestesiología, Hospital Clínico Universitario de Santiago, Santiago de Compostela, España
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Conigliaro R, Fanti L, Manno M, Brosolo P. Italian Society of Digestive Endoscopy (SIED) position paper on the non-anaesthesiologist administration of propofol for gastrointestinal endoscopy. Dig Liver Dis 2017; 49:1185-1190. [PMID: 28951114 DOI: 10.1016/j.dld.2017.08.038] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2017] [Revised: 07/30/2017] [Accepted: 08/24/2017] [Indexed: 12/11/2022]
Abstract
Propofol sedation by non-anesthesiologists in GI endoscopy, despite generally considered a safe procedure, is still a matter of debate. Benefits of propofol sedation include rapid onset of action, greater patient comfort and fast recovery with prompt discharge from the endoscopy unit. The use of propofol for sedation in GI endoscopy, preceded by dedicated training courses, has been approved by several anaesthesiologist and gastroenterologist societies but an Italian position paper taking into account the Italian law is lacking. In the present document, the Italian Society of Digestive Endoscopy (SIED) Sedation Group, on behalf of the SIED, presents a series of updated position statements concerning propofol sedation in GI endoscopy. The paper summarizes the advantages of propofol, how it should be administered and how patients should be monitored. Moreover, details concerning proper training of non-anaesthesiologist personnel involved in its use are provided. Protocols concerning propofol use s must be shared with the hospital's anaesthesiology staff and approved by the hospital's Executive Director.
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Affiliation(s)
- Rita Conigliaro
- Gastroenterology and Digestive Endoscopy Unit, Ospedale S. Agostino-Estense Hospital/Hospital-University Institution, Modena, Italy.
| | - Lorella Fanti
- Division of Gastroenterology and Gastrointestinal Endoscopy, Vita-Salute San Raffaele, University-Scientific Institute San Raffaele, Milan, Italy
| | - Mauro Manno
- Digestive Endoscopy Unit, Ospedale di Carpi, Ramazzini Hospital, Carpi, Modena, Italy
| | - Piero Brosolo
- Gastroenterology Unit, Ospedale S. Maria degli Angeli Hospital, Pordenone, Italy
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Curriculum for the administration of sedation outside the operating room in patients over 12 years of age☆,☆☆. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2017. [DOI: 10.1097/01819236-201707000-00010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Rubiano-Pinzón AM, Burbano-Paredes CC, Hernández-Caicedo ÁC, Rincón-Valenzuela DA, Benavides-Caro CA, Restrepo-Palacio S, Grillo-Ardila CF, Amaya-Guio J, Cañón-Muñoz M, Rincón-Aguilar JE, Moreno LÁ, Rey-Tovar MH, Hernández-Restrepo FJ, Martínez-Rebolledo CP, Grillo-Ardila EK, Cortés-Díaz D. Curriculum for the administration of sedation outside the operating room in patients over 12 years of age. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2017. [DOI: 10.1016/j.rcae.2017.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Currículo para la administración de sedación fuera del quirófano en pacientes mayores de 12 años. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2017. [DOI: 10.1016/j.rca.2017.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Jokelainen J, Udd M, Kylänpää L, Mustonen H, Halttunen J, Lindström O, Pöyhiä R. How patient-controlled sedation is adopted in clinical practice of sedation for endoscopic retrograde cholangiopancreatography? A prospective study of 1196 cases . Scand J Gastroenterol 2017; 52:166-172. [PMID: 27705012 DOI: 10.1080/00365521.2016.1242024] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Patient-controlled sedation (PCS) has been shown to be a valid choice for sedation during endoscopic retrograde cholangiopancreatography (ERCP) in randomized studies. However, large-scale studies are lacking. MATERIAL AND METHODS A single center, prospective observational study to determine how sedation for ERCP is administered in clinical setting. All 956 patients undergoing 1196 ERCPs in the endoscopy unit of Helsinki University Central Hospital 2012-2013, methods of sedation and adverse events associated with different sedations were recorded. RESULTS PCS was attempted a total of 685 times (57%), successful use of PCS was achieved with 526 patients (77% of attempts). PCS device was operated by the anesthesiologist or anesthesia nurse 268 times (22%). PCS was more likely chosen for younger (80.6% for < =60 years vs. 63.8% for >60 years, p<.001) patients and by trainee anesthetists. Anesthesiologist administered propofol sedation was used 240 times (20%). The risk of failure of PCS was increased, if systolic arterial pressure was <90 mmHg, dosage of PCS >17 ml, duration of procedure exceeded 23 min. The risk of failure was lower in patients with primary sclerosing cholangitis (PSC) and if sedation was deeper RASS < =-2. Uneventful PCS was associated with less respiratory and cardiovascular depression than other methods. There were no statistically significant differences in safety profiles with all the methods of sedation. CONCLUSIONS PCS is readily implemented in clinical practice, is suitable for younger and low-risk patients and is associated with less cardiorespiratory adverse effects.
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Affiliation(s)
- Jarno Jokelainen
- a Department of Anesthesia and Intensive Care Medicine , Helsinki University Central Hospital, Helsinki Finland , Haartmaninkatu 4 , Helsinki , Finland
| | - Marianne Udd
- b Department of Gastroenterological and General Surgery , Helsinki University Central Hospital , Helsinki , Finland
| | - Leena Kylänpää
- b Department of Gastroenterological and General Surgery , Helsinki University Central Hospital , Helsinki , Finland
| | - Harri Mustonen
- b Department of Gastroenterological and General Surgery , Helsinki University Central Hospital , Helsinki , Finland
| | - Jorma Halttunen
- b Department of Gastroenterological and General Surgery , Helsinki University Central Hospital , Helsinki , Finland
| | - Outi Lindström
- b Department of Gastroenterological and General Surgery , Helsinki University Central Hospital , Helsinki , Finland
| | - Reino Pöyhiä
- a Department of Anesthesia and Intensive Care Medicine , Helsinki University Central Hospital, Helsinki Finland , Haartmaninkatu 4 , Helsinki , Finland
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The Current Status of Nurse-Administered Propofol Sedation in Endoscopy: An Evidence-Based Practice Nurse Fellowship Project. Gastroenterol Nurs 2017; 38:297-304. [PMID: 25756320 DOI: 10.1097/sga.0000000000000099] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
The Society for Gastroenterology Nurses and Associates (SGNA) launched a nurse fellowship program in 2011 to promote evidence-based practice. Each accepted applicant was challenged to select a relevant topic, explore the current research, and translate this information to daily practice. The author, an SGNA Fellow, selected the topic, nurse-administered propofol sedation, that has been a prevailing subject in endoscopy for many years. A significant amount of literature has been written on the drug's safety and efficacy. This article explores a brief history of the practice and the future of this controversial drug for procedural sedation. A review of current literature is explored with an emphasis on the past 5 years as well as a discussion on regulatory limitations that have been placed on the practice of non-anesthesiologist-administered propofol sedation.
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Álvarez J, Cabadas R, de la Matta M. Patient safety under deep sedation for digestive endoscopic procedures. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2016; 109:137-143. [PMID: 28004964 DOI: 10.17235/reed.2016.4572/2016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Deep sedation with Propofol has become popular in recent years. The safety of this technique when administered by non-anaesthesiologists has created much controversy which at times is masked in a contentious debate on the economic sustainability of the health system. In 2011, the Spanish Society of Anaesthesiology, Resuscitation and Pain Therapy, along with 20 other organisations from European countries, revoked the recommendations of the European Society of Gastrointestinal Endoscopy on the administration of Propofol by non-anaesthesiologists, citing that it is "extremely dangerous for the safety and quality of endoscopic procedures". The FDA in 2005 had already rejected the use of Propofol by non-anaesthesiologists in the United States, a prohibition which was reiterated in 2010 and is still in force, basing its evidence, among others, on the recommendations and guidelines of the Joint Commission and the Declaration of Helsinki. In Spain, the data sheet of Propofol restricts the use of the drug to anaesthesiologists and intensivists in intensive care units. In our opinion, the key elements to discuss (which we develop in our paper) are those related to: a) the morbidity and mortality of sedation (which is the same as speaking about the factors that influence its safety); b) the appropriate professionals to use this technique; and c) economic aspects related to the use of said technique. Our conclusion is that a technique cannot be declared safe when a high percentage of patients present with varying respiratory depression (and therefore hypoxaemia) and hypotension. We are confident that the collaboration of the Spanish Society of Digestive Pathology and the Spanish Society of Digestive Endoscopy with the Spanish Society of Anaesthesiology, Resuscitation and Pain Therapy is the first step towards finding a satisfactory solution for everyone, and especially for our patients.
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Affiliation(s)
- Julián Álvarez
- Anestesiología y Reanimación, Complejo Hospitalario Universitario de Santiago de Compostela. Universidad de Santiago de Compostela, España
| | - Rafael Cabadas
- Anestesiología y Cuidados Intensivos, Hospital Povisa (Vigo), España
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Burtea DE, Dimitriu A, Maloş AE, Săftoiu A. Current role of non-anesthesiologist administered propofol sedation in advanced interventional endoscopy. World J Gastrointest Endosc 2015; 7:981-986. [PMID: 26265991 PMCID: PMC4530331 DOI: 10.4253/wjge.v7.i10.981] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Revised: 06/21/2015] [Accepted: 07/23/2015] [Indexed: 02/05/2023] Open
Abstract
Complex and lengthy endoscopic examinations like endoscopic ultrasonography and/or endoscopic retrograde cholangiopancreatography benefit from deep sedation, due to an enhanced quality of examinations, reduced discomfort and anxiety of patients, as well as increased satisfaction for both the patients and medical personnel. Current guidelines support the use of propofol sedation, which has the same rate of adverse effects as traditional sedation with benzodiazepines and/or opioids, but decreases the procedural and recovery time. Non-anesthesiologist administered propofol sedation has become an option in most of the countries, due to limited anesthesiology resources and the increasing evidence from prospective studies and meta-analyses that the procedure is safe with a similar rate of adverse events with traditional sedation. The advantages include a high quality of endoscopic examination, improved satisfaction for patients and doctors, as well as decreased recovery and discharge time. Despite the advantages of non-anesthesiologist administered propofol, there is still a continuous debate related to the successful generalization of the procedures.
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Orel R, Brecelj J, Dias JA, Romano C, Barros F, Thomson M, Vandenplas Y. Review on sedation for gastrointestinal tract endoscopy in children by non-anesthesiologists. World J Gastrointest Endosc 2015; 7:895-911. [PMID: 26240691 PMCID: PMC4515424 DOI: 10.4253/wjge.v7.i9.895] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Revised: 06/05/2015] [Accepted: 06/18/2015] [Indexed: 02/05/2023] Open
Abstract
AIM To present evidence and formulate recommendations for sedation in pediatric gastrointestinal (GI) endoscopy by non-anesthesiologists. METHODS The databases MEDLINE, Cochrane and EMBASE were searched for the following keywords "endoscopy, GI", "endoscopy, digestive system" AND "sedation", "conscious sedation", "moderate sedation", "deep sedation" and "hypnotics and sedatives" for publications in English restricted to the pediatric age. We searched additional information published between January 2011 and January 2014. Searches for (upper) GI endoscopy sedation in pediatrics and sedation guidelines by non-anesthesiologists for the adult population were performed. RESULTS From the available studies three sedation protocols are highlighted. Propofol, which seems to offer the best balance between efficacy and safety is rarely used by non-anesthesiologists mainly because of legal restrictions. Ketamine and a combination of a benzodiazepine and an opioid are more frequently used. Data regarding other sedatives, anesthetics and adjuvant medications used for pediatric GI endoscopy are also presented. CONCLUSION General anesthesia by a multidisciplinary team led by an anesthesiologist is preferred. The creation of sedation teams led by non-anesthesiologists and a careful selection of anesthetic drugs may offer an alternative, but should be in line with national legislation and institutional regulations.
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Mason K. Challenges in paediatric procedural sedation: political, economic, and clinical aspects. Br J Anaesth 2014; 113 Suppl 2:ii48-62. [DOI: 10.1093/bja/aeu387] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
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Rhee NA, Vilmann P, Hassan H, Hendel JW, Holst JJ, Vilsbøll T, Knop FK. The use of double-balloon enteroscopy in retrieving mucosal biopsies from the entire human gastrointestinal tract. Scand J Gastroenterol 2014; 49:1143-9. [PMID: 24998781 DOI: 10.3109/00365521.2014.934912] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The aim of this explorative study was to evaluate double-balloon enteroscopy (DBE) as a new tool for collecting mucosal biopsies from well-defined parts of the entire small and large bowel in patients with type 2 diabetes and in matched healthy subjects. MATERIAL AND METHODS Twelve subjects with type 2 diabetes and 12 body mass index and age-matched healthy subjects underwent anterograde and retrograde DBE under nurse-administered propofol sedation on two separate days. We attempted to collect two mucosal biopsies from every 30 cm from pylorus to rectum. RESULTS A mean of 21 biopsy sites were sampled in the diabetic group versus 25 in the healthy group. In 4 out of 24 patients (2 [17%] from each group) sampling from the entire gastrointestinal system was possible. Mean depth of maximal insertion (anterograde) was 478 ± 32 cm in patients with type 2 diabetes versus 465 ± 44 cm in healthy subjects (p = 0.81) and with retrograde access 230 ± 36 cm (type 2 diabetes) versus 207 ± 26 cm (healthy subjects). CONCLUSIONS DBE is a minimally invasive way of collecting fresh biopsies from the entire gastrointestinal tract and, thus provides research and clinical communities with a new possibility to access hitherto unexplored human anatomy and physiology.
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Affiliation(s)
- Nicolai Alexander Rhee
- Center for Diabetes Research, Department of Medicine, Gentofte Hospital, University of Copenhagen , Hellerup , Denmark
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Sieg A, Beck S, Scholl SG, Heil FJ, Gotthardt DN, Stremmel W, Rex DK, Friedrich K. Safety analysis of endoscopist-directed propofol sedation: a prospective, national multicenter study of 24 441 patients in German outpatient practices. J Gastroenterol Hepatol 2014; 29:517-23. [PMID: 24716213 DOI: 10.1111/jgh.12458] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND AIM Since 2008, there exists a German S3-guideline allowing non-anesthesiological administration of propofol for gastrointestinal endoscopy. In this prospective, national, multicenter study, we evaluated the safety of endoscopist-administered propofol sedation (EDP) in German outpatient practices of Gastroenterology. METHODS In this multicenter survey of 53 ambulatory practices of Gastroenterology, we prospectively evaluated 24 441 patients that had received EDP. We recorded adverse events during the endoscopic procedure and additionally retrieved questionnaires investigating subjective parameters 24 h after the endoscopic procedure. RESULTS In 24 441 patients 13 793 colonoscopies, 6467 esophagogastroduodenoscopies, and 4181 double examinations were performed. In this study, 52.1% of the patients received propofol mono-sedation, and 47.9% received a combination of midazolam and propofol. Major adverse events occurred in four patients (0.016%) enrolled to this study (three mask ventilations and one laryngospasm). Minor adverse events were observed in 112 patients (0.46%) with hypoxemia being the most common minor event. All patients with adverse events recovered without persistent impairment. Minor adverse events occurred more frequently in patients sedated with propofol mono compared to propofol and midazolam (P < 0.0001) and correlated with increasing propofol dosages (P < 0.001; Pearson correlation coefficient r = 0.044). Twenty-four hours after the endoscopy, patients sedated with propofol plus midazolam stated a significantly reduced sensation of pain (P < 0.01) and improved symptoms of dizziness, nausea and vomiting (P < 0.001) compared to patients having received propofol mono-sedation. CONCLUSION Four years after the implementation of a German S3-Guideline for endoscopic sedation, we demonstrated that EDP is a safe procedure.
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Westfelt P, Hedman L, Axelsson Lindkvist M, Enochsson L, Felländer-Tsai L, Schmidt PT. Training nonanesthetist administration of propofol for gastrointestinal endoscopy in scenario-based full-scale hybrid simulation--a pilot study. Scand J Gastroenterol 2013; 48:1354-8. [PMID: 24041148 DOI: 10.3109/00365521.2013.836753] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The use of nonanesthetist-administered propofol (NAAP) in GI endoscopy has long been controversial. In the setting of NAAP, acute situations can develop during endoscopy and thus training before starting with NAAPs is considered crucial. The aim was to evaluate a pilot study on crew resource management (CRM)-based training of teams of endoscopists and endoscopy nurses in NAAP in a full-scale hybrid simulation consisting of a full-scale human patient simulator and an endoscopy simulator. Our hypothesis was that the training would increase the self-efficacy of the participants. MATERIAL AND METHODS Four scenarios were created, each with typical side effects of propofol administration. All scenarios included the need for prompt decision-making and treatment. Colonoscopy, gastroscopy or endoscopic retrograde cholangiopancreatography (ERCP) cases were assigned to the course participants in coherence with their main clinical expertise in order to facilitate situated and contextualized training. Twenty-one participants (ten doctors and eleven nurses) completed a questionnaire on self-efficacy before and after the course. A questionnaire regarding the quality and yield of the course was also completed. RESULTS For all participants, the self-efficacy score was 26.0 (24.0-28.0; interquartile range) before training and 30.0 (27.0-30.5) after training (p = 0.0003). The ten doctors had a self-efficacy score before training of 26.5 (25.0-29.5) and 30.0 (29.0-33.0) after (p = 0.0078). The eleven nurses scored 24.0 (22.0-26.0) before and 28.0 (27.0-30.0) after training (p = 0.0098). CONCLUSIONS Systematic target focused scenario-based training with hybrid simulation of NAAP in endoscopy resulted in increased self-efficacy in both nurses and physicians.
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Affiliation(s)
- Petter Westfelt
- Department of Anesthesia and Intensive Care, Karolinska University Hospital , Stockholm , Sweden
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Okholm C, Hadikhadem T, Andersen LT, Donatsky AM, Vilmann P, Achiam MP. No increased risk of perforation during colonoscopy in patients undergoing Nurse Administered Propofol Sedation. Scand J Gastroenterol 2013; 48:1333-8. [PMID: 24063514 DOI: 10.3109/00365521.2013.837951] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
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.
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Affiliation(s)
- Cecilie Okholm
- Department of Surgery, Herlev Hospital, University of Copenhagen , Herlev , Denmark
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Amornyotin S. Sedation and monitoring for gastrointestinal endoscopy. World J Gastrointest Endosc 2013; 5:47-55. [PMID: 23424050 PMCID: PMC3574612 DOI: 10.4253/wjge.v5.i2.47] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2012] [Revised: 07/11/2012] [Accepted: 12/01/2012] [Indexed: 02/05/2023] Open
Abstract
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.
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Affiliation(s)
- Somchai Amornyotin
- Somchai Amornyotin, Department of Anesthesiology and Siriraj Gastrointestinal Endoscopy Center, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand
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Ibarra P. Analysis of a poor outcome during deep sedation: potential impact of the 2011 SCARE recommendations for sedation by non-anesthesiologists. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2012. [DOI: 10.1016/s2256-2087(12)40007-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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Ibarra P. Análisis de un desenlace trágico con sedación profunda: potencial impacto de las recomendaciones SCARE 2011 de sedación por no anestesiólogos. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2012. [DOI: 10.1016/s0120-3347(12)70007-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Analysis of a poor outcome during deep sedation: potential impact of the 2011 SCARE recommendations for sedation by non-anesthesiologists. COLOMBIAN JOURNAL OF ANESTHESIOLOGY 2012. [DOI: 10.1097/01819236-201240010-00008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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