Endoscopic sedation: from training to performance

Training and Resources Related to the Administration of Sedation by Nurses During Digestive Endoscopy: A Cross-Sectional Study

BACKGROUND

The healthcare professional who performs sedation for digestive endoscopy procedures is usually the nurse. Therefore, knowledge and training on the part of the nurse is an important factor for the correct sedation of the patient and may affect, among other factors, the quality of health care and the recovery and well-being of the patient.

OBJECTIVE

To determine the training opportunities and resources available to the specialists involved in digestive endoscopy services in hospitals in Spain in which sedation is performed by the nursing staff.

METHODS

This was a descriptive cross-sectional study performed in the Digestive Endoscopy Service at Toledo University Hospital and nearby hospitals in central Spain. The sample consisted of 75 nurses who administer sedation in digestive endoscopic procedures.

RESULTS

Regarding the training of nurses, the vast majority were generalist nurses, and only a small percentage obtained specialized training through ongoing training. Most had been working in the service for more than two years, and very few had previous experience in sedation, although the vast majority currently applied sedation. Life support training was also critical. There were significant differences in the availability of resources between different hospitals.

CONCLUSIONS

The training of nurses who perform sedation in digestive endoscopy services could be improved since there is a high proportion of personnel without specific training in sedation before starting to work in the service. It is crucial to implement targeted and ongoing training programs to improve competencies in this area, as they are essential to ensure the safety and effectiveness of the procedure. Given the variability in resources and personnel training that exists between different hospitals, it seems important to establish standards at the institutional level.

Oral Breathing Facilitates Endoscopic Operability Compared With Nasal Breathing in Peroral Endoscopy: A Randomized Controlled Trial

INTRODUCTION

Unsedated peroral endoscopy, including ultrathin endoscopy (UE) and conventional endoscopy (CE), is feasible in clinical practice but requires improved endoscopic operability and patient tolerance. Currently, the impact of the breathing method on these factors remains unclear. We conducted the first randomized controlled trial comparing oral breathing (OB) and nasal breathing (NB) during both UE and CE to assess their influence.

METHODS

About 252 eligible patients undergoing CE or UE were randomly assigned to OB or NB groups. Endoscopists and patients rated endoscopic operability and patient tolerance using a 100-mm visual analog scale. Visibility from the oral cavity to the middle pharynx was recorded.

RESULTS

OB led to a higher rate of improved visibility from the oral cavity to the middle pharynx compared with NB, ranging from 79.3% to 81.0%. Multivariate correlation analyses showed significantly lower visual analog scale scores for endoscopic operability with OB compared with NB in both UE and CE groups ( P < 0.05). No significant differences were found in the overall evaluation of patient tolerance between OB and NB groups in UE and CE, whereas the smaller diameter of UE exhibited better patient tolerance compared with CE. Discriminant analysis comparing endoscope types and breathing methods revealed that UE with OB outperformed other combinations in the overall evaluation of endoscopic operability and patient tolerance ( P < 0.05).

DISCUSSION

OB facilitates endoscopic operability compared with NB in peroral endoscopy. UE with OB is recommended as the preferred choice for unsedated peroral endoscopy in daily practice.

Differential dosing of oxycodone in combination with propofol in diagnostic painless gastroscopy in elderly patients: A prospective randomized controlled trial

OBJECTIVE

The aim of this study is to investigate the safety and efficacy of different doses of oxycodone in combination with propofol during painless gastroscopy.

METHODS

120 patients underwent painless gastroscopy under general anesthesia. According to the different doses of oxycodone, patients were divided into 4 groups, group A (oxycodone 0.025 mg/kg + propofol), group B (oxycodone 0.05 mg/kg + propofol) and group C (oxycodone 0.1 mg/kg + propofol), control group (propofol alone), with 30 cases in each group. The general characteristics of all patients were then evaluated. Mean arterial pressure (MAP), heart rate (HR) and peripheral capillary oxygen saturation (SpO2) were recorded at different time points, including the time before anesthesia (T0), failure of the lash reflex (T1), successful placement of the mirror (T2), removal of the mirror (T3) and waking up (T4). The intraoperative propofol dosage and the operative time of gastroscopy were recorded. The occurrence of adverse effects in the 4 groups was also compared.

RESULTS

General characteristics, gastroscopy operative time and SpO2 did not differ significantly between the 4 groups (P > .05). However, group C had the lowest amount of propofol during gastroscopy (P < .05). At T1, groups A, B, and C had a faster HR than the control group (P < .05). At T2, groups A, B, and C had a lower MAP than the control group (P < .05). Groups B and C had fewer adverse effects than groups A and the control group (P < .05). Importantly, groups B and C had a shorter recovery time than groups A and the control group (P < .05), but no statistically significant differences were found between groups B and C.

CONCLUSION

0.05 mg/kg oxycodone in combination with propofol can be used safely and effectively for painless gastroscopy, with the advantages of a low propofol dose, maintenance of hemodynamic stability and few adverse effects.

Academy of Medicine, Singapore clinical guideline on the use of sedation by non-anaesthesiologists during gastrointestinal endoscopy in the hospital setting

INTRODUCTION

In Singapore, non-anaesthesiologists generally administer sedation during gastrointestinal endoscopy. The drugs used for sedation in hospital endoscopy centres now include propofol in addition to benzodiazepines and opiates. The requirements for peri-procedural monitoring and discharge protocols have also evolved. There is a need to develop an evidence-based clinical guideline on the safe and effective use of sedation by non-anaesthesiologists during gastrointestinal endoscopy in the hospital setting.

METHODS

The Academy of Medicine, Singapore appointed an expert workgroup comprising 18 gastroenterologists, general surgeons and anaesthesiologists to develop guidelines on the use of sedation during gastrointestinal endoscopy. The workgroup formulated clinical questions related to different aspects of endoscopic sedation, conducted a relevant literature search, adopted Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology and developed recommendations by consensus using a modified Delphi process.

RESULTS

The workgroup made 16 recommendations encompassing 7 areas: (1) purpose of sedation, benefits and disadvantages of sedation during gastrointestinal endoscopy; (2) pre-procedural assessment, preparation and consent taking for sedation; (3) Efficacy and safety of drugs used in sedation; (4) the role of anaesthesiologist administered sedation during gastrointestinal endoscopy; (5) performance of sedation; (6) post-sedation care and discharge after sedation; and (7) training in sedation for gastrointestinal endoscopy for non-anaesthesiologists.

CONCLUSION

These recommendations serve to guide clinical practice during sedation for gastrointestinal endoscopy by non-anaesthesiologists in the hospital setting.

Efficacy of an Oxycodone-Propofol Combination versus a Fentanyl-Propofol Combination in Conscious Sedation during Therapeutic Endoscopic Retrograde Cholangiopancreatography in Elderly Patients

BACKGROUND

With a rapidly aging population, the need for endoscopic retrograde cholangiopancreatography (ERCP) is increasing. The commonly used sedation anesthesia in ERCP is a combination of propofol and fentanyl, even though fentanyl may cause some adverse reactions such as respiratory depression.

OBJECTIVES

This study aimed to evaluate the efficacy of oxycodone combined with propofol versus fentanyl combined with propofol for sedation anesthesia during ERCP.

METHODS

A total of 193 patients aged from 65 to 80 years undergoing ERCP were enrolled and randomized into two groups: an "oxycodone combined with propofol" group (group OP, n = 97) and a "fentanyl combined with propofol" group (group FP, n = 96). The rate of perioperative adverse events as well as the recovery time, patients' satisfaction, and endoscopists' satisfaction were noted.

RESULTS

There was no difference in the frequency of hypotension or bradycardia between the two groups, but there were more episodes of desaturation (SpO2 <90% for >10 s in 8.3%), postoperative nausea (7.3%), and vomiting (5.2%) in group FP than in group OP. Patients' satisfaction in group FP was lower than that in group OP. The recovery time was longer in group FP than in group OP.

CONCLUSIONS

Oxycodone combined with propofol was effective in ERCP, with a low incidence of perioperative adverse events.

Comparison of Fentanyl versus Meperidine in Combination with Midazolam for Sedative Colonoscopy in Korea

Background/Aims

Combination of midazolam and opioids is used widely for endoscopic sedation. Compared with meperidine, fentanyl is reportedly associated with rapid recovery, turnover rate of endoscopy room, and quality of endoscopy. We compared fentanyl with meperidine when combined with midazolam for sedative colonoscopy.

Methods

A retrospective, cross-sectional, 1:2 matching study was conducted. Induction and recovery time were compared as the primary outcomes. Moreover, cecal intubation time, withdrawal time, total procedure time of colonoscopy, paradoxical reaction, adenoma detection rate, and adverse effect of midazolam or opioids were assessed as the secondary outcomes.

Results

A total of 129 subjects (43 fentanyl vs. 86 meperidine) were included in the analysis. The fentanyl group showed significantly more rapid induction time (4.5±2.7 min vs. 7.5±4.7 min, p<0.001), but longer recovery time (59.5±25.6 min vs. 50.3±10.9 min, p=0.030) than the meperidine group. In multivariate analysis, the induction time of the fentanyl group was 3.40 min faster (p<0.001), but the recovery time was 6.38 min longer (p=0.046) than that of the meperidine group. There was no difference in withdrawal time and adenoma detection rate between the two groups.

Conclusions

The fentanyl group had more rapid sedation induction time but longer recovery time than the meperidine group.

Dexmedetomidine vs propofol as sedation for implantation of neurostimulators: A single-center single-blinded randomized controlled trial

BACKGROUND

During the lead implantation of most spinal cord neurostimulators, the patient has to be comfortable and without pain. However, the patient is expected to provide feedback during electrical mapping. Titrating sedatives and analgesics for this double goal can be challenging. In comparison with our standard sedative agent propofol, the pharmacological profile of dexmedetomidine is more conducive to produce arousable sedation. The latter, however, is associated with hemodynamic side effects. We investigated whether dexmedetomidine is preferable over propofol during neurostimulator implantation.

METHODS

This single-center single-blinded randomized controlled trial included 72 patients with an indication for a neurostimulator, randomized to sedation with either propofol (0.5 mg/kg for 10 minutes, followed by 2.0 mg/kg/h) or dexmedetomidine (1 μg/kg for 10 minutes, followed by 0.6 μg/kg/h). The primary outcome was patient satisfaction with the sedation. The secondary outcomes were patient's and operator's comfort, number of titration adjustments, standard intraoperative hemodynamic and respiratory parameters and side effects.

RESULTS

Data of 69 patients (dexmedetomidine n = 35; propofol n = 34) were analyzed. Those receiving dexmedetomidine were more satisfied with the sedation than those receiving propofol; i.e. with sedation delivery (median 100.0 vs 83.3, P < .01), procedural recall (median 95.8 vs 83.3, P = .03), and sedation side effects (median 90.0 vs 83.3, P = .01). Fewer changes in the dexmedetomidine titration were necessary to maintain arousable sedation. Over time, mean arterial pressure and heart rate were significantly lower in the dexmedetomidine group. Hemodynamic side effects were comparable across groups.

CONCLUSIONS

Dexmedetomidine sedation resulted in higher patient satisfaction and allowed for better arousable sedation than sedation with propofol. Although differences in hemodynamic parameters were found between the groups, these differences were not regarded as clinically relevant.

Innovation in sedation and analgesia training

PURPOSE OF REVIEW

We reviewed evidence of recent innovations in sedation education and discuss experiences with sedation training in Taiwan.

RECENT FINDINGS

Current Status of Sedation Training: Didactic training and supervised clinical mentoring are common methods of sedation training. Although training course designed by professional societies to meet individual hospital credentialing requirements, the course content and training expectations vary and are likely inadequate to non-anesthesiologist sedation practitioners. Less Common Forms of Sedation Training: These include screen-based simulation, high-fidelity manikin-based simulation. Screen-based simulation sedation training is popular, convenient, and relatively inexpensive. Although there are numerous courses available, course content has not been standardized. High-fidelity simulation has been accepted to improve knowledge, self-confidence, awareness of emergency, crisis resource management, and teamwork, but it is costly, time intensive, and requires expertise in using simulation equipment. Although screen-based training is attractive and convenient, there is no evidence to suggest that it can replace high-fidelity simulation. Another recently developed education modality is virtual reality simulation. It has gained recent popularity as an immersive approach to medical training, but minimal content has been developed for sedation training. Beyond training, several other potential innovations may improve sedation effectiveness and patient safety. These include adherence to practice guidelines established by professional organizations, utilization of a pre-procedure sedation checklist, interpreting capnography, and implementation of real-time bedside drug displays that provide predictions of concentrations and their associated effects.

SUMMARY

Effective sedation education and training, especially for nonanesthesiologists, is essential to improve patient safety for procedural sedation. Several innovative approaches have been proposed and are relatively early in their development and implementation. Further studies designed to assess the impact of these new training modalities on patient safety and outcomes are warranted.

Propofol for gastrointestinal endoscopy

Most gastrointestinal endoscopic procedures are now performed with sedation. Moderate sedation using benzodiazepines and opioids continues 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. According to published values, endoscopist-directed propofol has a lower mortality rate than endoscopist-delivered benzodiazepines and opioids, and a comparable rate to general anesthesia by anesthesiologists. Rapid recovery has a major impact on patient satisfaction, post-procedure education and the general flow of the endoscopy unit. According to estimates, the absolute economic benefit of endoscopist-directed propofol implementation in a screening setting is probably substantial, with 10-year savings of $3.2 billion in the USA. Guidelines concerning the use of propofol emphasize the need for adequate training and certification in sedation by non-anesthetists.

Education and Training Guidelines for the Board of the Korean Society of Gastrointestinal Endoscopy

The Korean Society of Gastrointestinal Endoscopy (KSGE) developed a gastrointestinal (GI) endoscopy board in 1995 and related regulations. Although the KSGE has acquired many specialists since then, the education and training aims and guidelines were insufficient. During GI fellowship training, obtaining sufficient exposure to some types of endoscopic procedures is difficult. Fellows should acquire endoscopic skills through supervised endoscopic procedures during GI fellowship training. Thus, the KSGE requires training guidelines for fellowships that allow fellows to perform independent endoscopic procedures without supervision. This document is intended to provide principles that the Committee of Education and Training of the KSGE can use to develop practical guidelines for granting privileges to perform accurate GI endoscopy safely. The KSGE will improve the quality of GI endoscopy by providing guidelines for fellowships and supervisors.

Efficacy of midazolam- versus propofol-based sedations by non-anesthesiologists during therapeutic endoscopic retrograde cholangiopancreatography in patients aged over 80 years

BACKGROUND AND AIM

As society ages, the need for endoscopic retrograde cholangiopancreatography (ERCP) is increasing. This prospective comparative study evaluated the safety and efficacy of midazolam- versus propofol-based sedations by non-anesthesiologists during therapeutic ERCP in patients over 80 years of age.

METHODS

A total of 100 patients over 80 years of age who required therapeutic ERCP were enrolled and randomly received midazolam + fentanyl (MF group) or propofol + fentanyl (PF group) sedation. Endoscopic sedation was titrated to a moderate level and carried out by trained registered nurses. Main outcome measurements were sedation safety in terms of cardiopulmonary components and efficacy measured on a 10-point visual analogue scale (VAS).

RESULTS

Regarding safety, hypoxia occurred in seven (14%) in the MF group and in eight patients (16%) in the PF group (P = 0.779). Increased O₂ supply was more frequent in the PF group (32% vs 42%), albeit not significantly so. There were no differences in the frequency of hypotension, bradycardia or tachycardia between the two groups. Mean VAS score for overall satisfaction with sedation by patients, endoscopists, and nurses and the scores for pain during the procedures were not different between the two groups. There was no significant difference in the procedure outcomes or rate of ERCP-related complications.

CONCLUSIONS

There were no significant differences of safety and efficacy between midazolam- and propofol-based sedation in patients over 80 years of age. Increased O₂ supply was more frequent in the propofol group, but the prevalence of hypoxia did not differ significantly.

Training and Competency in Sedation Practice in Gastrointestinal Endoscopy

The practice of endoscopic sedation requires a thorough understanding of preprocedural assessment, sedation pharmacology, intraprocedure monitoring, adverse event management, and postprocedural care. The training process has become increasingly standardized and entails knowledge and practice-based components. The use of propofol in particular requires a higher level of structured training owing to its narrow therapeutic window. Simulation has increased opportunities for practice-based training in a controlled environment. After completion of training, the endoscopist must demonstrate competence in theoretical understanding and technical ability to administer sedation. Although individual institutions have certification processes, there is a lack of validated, standardized methods to confirm competence.

A phase II study on the efficacy and safety of procedural analgesia with fentanyl buccal tablet in cancer patients for the placement of indwelling central venous access systems

Background

Pain in cancer patients is often related to oncologic therapies and diagnostic procedures. The placement of fully implantable venous access systems is a very common procedure in oncology patients. Local anaesthesia is the method most commonly used to overcome pain related to this surgical procedure, but the local anaesthetic may be unable to completely eradicate all pain. This study investigates the effectiveness and safety of fentanyl buccal tablet (FBT), administered by OraVescent® technology, in reducing procedural pain related to the placement of indwelling central venous access systems (Ports) in opioid-naïve cancer patients.

Methods

Inpatients who required an indwelling vascular access (Port) were preoperatively assessed with a self-assessment questionnaire on anxiety and pain. A 100 μg FBT was administered 10 min before preparation of the operating field. A self-assessment scale for pain experienced during the procedure was administered at the end of the procedure. Vital signs and the presence of any side effects or bothersome symptoms were monitored during the procedure, at the end, and 4 h later.

Results

From October 2012 to June 2014, 65 patients were enrolled in the study. A total of 61 (93.9 %) patients perceived no or a little pain during the procedure. Four patients (6.2 %) reported a lot of pain. No patient reported very severe pain. This data is significant in terms of the lower than expected presence of pain (Fisher test p = 0.0018) as assessed in our previous experience without procedural analgesia. The most common side effects of FBT was drowsiness, experienced by 28 patients at the end of the procedure (43.1 %), significantly reduced (p < 0.01) to 8 patients after 4 h (12.5 %). Nausea was present in 6 cases at the end of the procedure (9.2 %) and in 7 cases 4 h later (10.9 %). Vomiting was present in 3 cases at the end (4.7 %) and in 2 other patients after 4 h (7.8 %). No significant change of vital parameters was observed between the baseline and the subsequent measurements in all patients studied.

Conclusions

The significant improvement in the number of patients experiencing little or no pain, accompanied by a lower number of non-severe side effects, suggests that FBT is a valid, practical and safe method of procedural analgesia. It will be necessary to perform further studies, taking into account the need for standard antiemetic pre-medication to minimise the incidence of nausea and vomiting.

International digestive endoscopy network 2014: turnpike to the future

Social networks are useful in the study of relationships between individuals or entire populations, and the ties through which any given social unit connects. Those represent the convergence of the various social contacts of that unit. Consequently, the term "social networking service" (SNS) became extremely familiar. Similar to familiar SNSs, International Digestive Endoscopy Network (IDEN) 2014 was based on an international network composed of an impressive 2-day scientific program dealing with a variety of topics for gastrointestinal (GI) diseases, which connects physicians and researchers from all over the world. The scientific programs included live endoscopic demonstrations and provided cutting-edge information and practice tips as well as the latest advances concerning upper GI, lower GI, and pancreatobiliary endoscopy. IDEN 2014 featured American Society for Gastrointestinal Endoscopy-Korean Society of Gastrointestinal Endoscopy (ASGE-KSGE)-joint sessions prepared through cooperation between ASGE and KSGE. Furthermore, IDEN 2014 provided a special program for young scientists called the 'Asian Young Endoscopist Award Forum' to foster networks, with many young endoscopists from Asian countries taking an active interest and participation.