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

Safety of endoscopist-guided sedation in a low-risk collective

INTRODUCTION

 Worldwide, gastrointestinal endoscopies are predominantly performed under sedation. National and international guidelines and recommendations contain very different specifications for the use of sedation in gastrointestinal endoscopy. These differences come from specific requirements for staffing during endoscopy.

AIM

 The aim of the study is to evaluate whether endoscopist-guided sedation without additional sedation assistance is not inferior to endoscopist-guided sedation with additional sedation assistance with respect to the rate of sedation-associated complications in a defined low-risk population (low-risk procedure and low-risk patient).

METHODS

 Prospective, multicenter, randomized study.

RESULTS

 27 German study centers participated in the study. A total of 30 569 endoscopies were recorded during the study period from 1.8.2015 to 10.3.2020. The final data analysis included 28 673 examinations (64.1 % esophagosgastroduodenoscopies and 35.9 % colonoscopies). In 307 (1.1 %) examinations, 322 sedation-associated complications occurred. Of these, 321 (1.1 %) were minor complications and one (0.003 %) was a major complication. There was no statistically significant difference in the frequency of sedation-associated complications between endoscopist-guided sedation with versus without additional sedation assistance. Within the legal framework, a "shadow" sedation assistant was present in the study group without sedation assistance. This assistant intervened because of sedation-associated complications in 101 (0.7 %) of the endoscopies.

CONCLUSION

 The study documents the safety of propofol-based endoscopist-guided sedation in a low-risk population. In 98.9 % of all endoscopies, no sedation-associated complication occurred or it was so minimal that no intervention (e. g., increase of oxygen supply) was necessary. The study cannot answer to what extent a serious complication was avoided by the active intervention of the "shadow" sedation assistance in the group without sedation assistance.The study proves in a randomized, prospective design that sedation in low-risk endoscopy (low-risk patient, low-risk procedure) can be performed as endoscopist-guided sedation without additional sedation assistance, without demonstrably accepting a reduction in safety.

Effect of remimazolam tosilate on the incidence of hypoxemia in elderly patients undergoing gastrointestinal endoscopy: A bi-center, prospective, randomized controlled study

Background: Remimazolam tosilate is a new ultra-short-acting benzodiazepine sedative medicine. In this study, we evaluated the effect of remimazolam tosilate on the incidence of hypoxemia during sedation in elderly patients undergoing gastrointestinal endoscopy. Methods: Patients in the remimazolam group received an initial dose of 0.1 mg/kg and a bolus dose of 2.5 mg of remimazolam tosilate, whereas patients in the propofol group received an initial dose of 1.5 mg/kg and a bolus dose of 0.5 mg/kg of propofol. Patients received ASA standard monitoring (heart-rate, non-invasive blood pressure, and pulse oxygen saturation) during the entire examination process. The primary outcome was the incidence of moderate hypoxemia (defined as 85%≤ SpO₂< 90%, >15s) during the gastrointestinal endoscopy. The secondary outcomes included the incidence of mild hypoxemia (defined as SpO₂ 90%-94%) and severe hypoxemia (defined as SpO₂< 85%, >15s), the lowest pulse oxygen saturation, airway maneuvers used to correct hypoxemia, patient's hemodynamic as well as other adverse events. Results: 107 elderly patients (67.6 ± 5.7 years old) in the remimazolam group and 109 elderly patients (67.5 ± 4.9 years old) in the propofol group were analyzed. The incidence of moderate hypoxemia was 2.8% in the remimazolam group and 17.4% in the propofol group (relative risk [RR] = 0.161; 95% confidence interval [CI], 0.049 to 0.528; p < 0.001). The frequency of mild hypoxemia was less in the remimazolam group, but not statistically significant (9.3% vs. 14.7%; RR = 0.637; 95% CI, 0.303 to 1.339; p = 0.228). There was no significant difference in the incidence of severe hypoxemia between the two groups (4.7% vs. 5.5%; RR = 0.849; 95% CI, 0.267 to 2.698; p = 0.781). The median lowest SpO₂ during the examination was 98% (IQR, 96.0%-99.0%) in patients in the remimazolam group, which was significantly higher than in patients in the propofol group (96%, IQR, 92.0%-99.0%, p < 0.001). Patients in the remimazolam group received more drug supplementation during endoscopy than patients in the propofol group (p = 0.014). There was a statistically significant difference in the incidence of hypotension between the two groups (2.8% vs. 12.8%; RR = 0.218; 95% CI, 0.065 to 0.738; p = 0.006). No significant differences were found in the incidence of adverse events such as nausea and vomiting, dizziness, and prolonged sedation. Conclusion: This study explored the safety of remimazolam compared with propofol during gastrointestinal endoscopy in elderly patients. Despite the increased supplemental doses during sedation, remimazolam improved risk of moderate hypoxemia (i.e., 85%≤ SpO₂ < 90%) and hypotension in elderly patients.

Effect of Remimazolam Tosilate on Respiratory Depression in Elderly Patients Undergoing Gastroscopy: A Multicentered, Prospective, and Randomized Study

Background

Remimazolam tosilate (RT) is a new type of γ-aminobutyric acid subtype A (GABA_A) receptor agonist, having the possibility to be an ideal sedative drug for procedural sedation. At present, there are few studies on the effect of RT on respiratory depression in elderly patients. We aimed to evaluate the effect of RT on respiratory depression in elderly patients undergoing gastroscopy.

Methods

This prospective, randomized, single-blinded trial recruited patients from eight centers in China between May 2022 and July 2022. A total of 346 elderly patients undergoing gastroscopy were randomly divided into RT group (0.2 mg/kg) or propofol group (1.5 mg/kg), respectively. The primary outcome was the incidence of respiratory depression. Secondary outcomes include the incidence of sedative-related adverse events, the success rate of sedation, time to fully alert, time to loss of consciousness (LOC), time to ready for discharge, as well as the the patients, endoscopists and anethetists' satisfaction.

Results

The incidence of respiratory depression was significantly reduced in the RT group compared with the propofol group (9.8% vs 17.9%, P=0.042). The time of LOC and fully alert in the RT group were longer than that in the propofol group (P < 0.05). The incidences of hypotention (50.9% vs 32.4%, P=0.001) and hypotension requiring treatment (5.8% vs 1.7%, P=0.031) were significantly higher in the propofol group than that in the RT group. The incidence and severity of injection pain were more frequently recorded in the propofol group than that in the RT group (40.5% vs 12.1%, P<0.05). There were no statistically significant differences between the two groups in terms of sedation success rates, time to ready for discharge, endoscopists and anethetists' satisfaction and other sedative-related adverse events.

Conclusion

RT may be a suitable alternative sedative agent for elderly patients undergoing gastroscopy due to its safety profile.

Factors Associated with Withdrawal Time in European Colonoscopy Practice: Findings of the European Colonoscopy Quality Investigation (ECQI) Group

The European Colonoscopy Quality Investigation (ECQI) Group aims to raise awareness for improvement in colonoscopy standards across Europe. We analyzed data collected on a sample of procedures conducted across Europe to evaluate the achievement of the European Society of Gastrointestinal Endoscopy (ESGE) mean withdrawal time (WT) target. We also investigated factors associated with WT, in the hope of establishing areas that could lead to a quality improvement. Methods: 6445 form completions from 12 countries between 2 June 2016 and 30 April 2018 were considered for this analysis. We performed an exploratory analysis looking at WT according to the ESGE definition. Stepwise multivariable logistic regression analysis was conducted to determine the most influential associated factors after adjusting for the other pre-specified variables. Results: In 1150 qualifying colonoscopies, the mean WT was 7.8 min. Stepwise analysis, including 587 procedures where all inputs were known, found that the variables most associated with mean WT were a previous total colonoscopy in the last five years (p = 0.0011) and the time of day the colonoscopy was performed (p = 0.0192). The main factor associated with a WT < 6 min was the time of day that a colonoscopy was performed. Use of sedation was the main factor associated with a higher proportion of WT > 10 min, along with a previous colonoscopy. Conclusions: On average, the sample of European practice captured by the ECQI survey met the minimum standard set by the ESGE. However, there was variation and potential for improvement.

Risk of adverse events in gastrointestinal endoscopy: Zero-inflated Poisson regression mixture model for count data and multinomial logit model for the type of event

BACKGROUND AND AIMS

We analyze the possible predictive variables for Adverse Events (AEs) during sedation for gastrointestinal (GI) endoscopy.

METHODS

We consider 23,788 GI endoscopies under sedation on adults between 2012 and 2019. A Zero-Inflated Poisson Regression Mixture (ZIPRM) model for count data with concomitant variables is applied, accounting for unobserved heterogeneity and evaluating the risks of multi-drug sedation. A multinomial logit model is also estimated to evaluate cardiovascular, respiratory, hemorrhagic, other AEs and stopping the procedure risk factors.

RESULTS

In 7.55% of cases, one or more AEs occurred, most frequently cardiovascular (3.26%) or respiratory (2.77%). Our ZIPRM model identifies one population for non-zero counts. The AE-group reveals that age >75 years yields 46% more AEs than age <66 years; Body Mass Index (BMI) ≥27 27% more AEs than BMI <21; emergency 11% more AEs than routine. Any one-point increment in the American Society of Anesthesiologists (ASA) score and the Mallampati score determines respectively a 42% and a 16% increment in AEs; every hour prolonging endoscopy increases AEs by 41%. Regarding sedation with propofol alone (the sedative of choice), adding opioids to propofol increases AEs by 43% and adding benzodiazepines by 51%. Cardiovascular AEs are increased by age, ASA score, smoke, in-hospital, procedure duration, midazolam/fentanyl associated with propofol. Respiratory AEs are increased by BMI, ASA and Mallampati scores, emergency, in-hospital, procedure duration, midazolam/fentanyl associated with propofol. Hemorrhagic AEs are increased by age, in-hospital, procedure duration, midazolam/fentanyl associated with propofol. The risk of suspension of the endoscopic procedure before accomplishment is increased by female gender, ASA and Mallampati scores, and in-hospital, and it is reduced by emergency and procedure duration.

CONCLUSIONS

Age, BMI, ASA score, Mallampati score, in-hospital, procedure duration, other sedatives with propofol increase the risk for AEs during sedation for GI endoscopy.

CIRSE Standards of Practice on Analgesia and Sedation for Interventional Radiology in Adults

This CIRSE Standards of Practice document provides best practices for the safe administration of procedural sedation and analgesia for interventional radiology procedures in adults. The document is aimed at health professionals involved in the provision of sedation and analgesia during interventional radiology procedures. The document has been developed by a writing group consisting of physicians with internationally recognised expertise in interventional radiology, and analgesia and sedation.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry, 12619001036101.

Safety and efficacy of non-anesthesiologist administration of propofol sedation during esophagogastroduodenoscopy in the intensive care unit

Background and study aims  Propofol sedation is an increasingly popular method of sedation for gastrointestinal endoscopic procedures. The safety and efficacy of the non-anesthesiologist administration of propofol (NAAP) sedation has been demonstrated in the ambulatory setting. However, NAAP sedation in intensive care unit (ICU) patients has not been reported. The purpose of this study is to determine safety and efficacy of NAAP sedation in an ICU population. Methods  We retrospectively reviewed esophagogastroduodenoscopies (EGD) performed with NAAP sedation in our intensive care units from June 2014 to September 2016. All EGDs were performed for evaluation of gastrointestinal bleeding. The primary end point of this study was to analyze the incidence of sedation-related adverse events (AEs). The secondary end points included successful completion of procedure and any endoscopic interventions performed. Results  Two of 161 procedures (1.2 %) had sedation-related AEs requiring procedure termination. One hundred forty-six of 161 procedures (90.7 %) were successfully completed. Incomplete procedures were due to excess heme, retained food or obstructive lesions (13/161, 8.1 %). Endoscopic intervention was performed successfully in 17/24 cases (70.8 %) that had endoscopically treated lesions identified. One hundred six of 161 patients (66 %) were American Society of Anesthesiologists (ASA) classification III or IV. Conclusion  Our retrospective analysis demonstrated that EGDs can be successfully completed in ICU patients using NAAP sedation. When procedures cannot be completed, it is rarely due to sedation-related AEs. NAAP sedation further allows adequate examination and successful treatment of high-risk lesions. NAAP sedation appears safe and effective for endoscopic procedures in the ICU setting.

Etomidate Sedation for Advanced Endoscopic Procedures

BACKGROUND AND STUDY AIM

Although propofol is widely used for sedation for endoscopic procedures, concerns remain regarding cardiopulmonary adverse events. Etomidate has little effect on the cardiovascular and respiratory systems, but patient satisfaction analysis is lacking. We compared the efficacy and safety of balanced propofol and etomidate sedation during advanced endoscopic procedures.

METHODS

As a randomized noninferiority trial, balanced endoscopic sedation was achieved using midazolam and fentanyl, and patients were randomly assigned to receive propofol (BPS) or etomidate (BES) as add-on drug. The main outcomes were sedation efficacy measured on a 10-point visual analog scale (VAS) and safety.

RESULTS

In total, 186 patients (94 in the BPS group and 92 in the BES group) were evaluated. BES did not show noninferiority in terms of overall patient satisfaction, with a difference in VAS score of -0.35 (97.5 % confidence interval -1.03 to ∞, p = 0.03). Among endoscopists and nurses, BES showed noninferiority to BPS, with differences in VAS scores of 0.06 and 0.08, respectively. Incidence of cardiopulmonary adverse events was lower in the BES group (27.7 versus 14.1 %, p = 0.023). Hypoxia occurred in 5.3 and 1.1 % of patients in the BPS and BES group (p = 0.211). Myoclonus occurred in 12.1 % (11/92) in the BES group. BES had lower risk of overall cardiopulmonary adverse events (odds ratio 0.401, p = 0.018).

CONCLUSIONS

BES was not noninferior to BPS in terms of patient satisfaction. However, BES showed better safety outcomes in terms of cardiopulmonary adverse events.