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Walayat S, Stadmeyer P, Hameed A, Sarfaraz M, Estrada P, Benson M, Soni A, Pfau P, Hayes P, Kile B, Cruz T, Gopal D. Sedation reversal trends at outpatient ambulatory endoscopic center vs in-hospital ambulatory procedure center using a triage protocol. World J Gastrointest Endosc 2024; 16:413-423. [PMID: 39072249 PMCID: PMC11271719 DOI: 10.4253/wjge.v16.i7.413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2024] [Revised: 05/22/2024] [Accepted: 06/19/2024] [Indexed: 07/08/2024] Open
Abstract
BACKGROUND Routine outpatient endoscopy is performed across a variety of outpatient settings. A known risk of performing endoscopy under moderate sedation is the potential for over-sedation, requiring the use of reversal agents. More needs to be reported on rates of reversal across different outpatient settings. Our academic tertiary care center utilizes a triage tool that directs higher-risk patients to the in-hospital ambulatory procedure center (APC) for their procedure. Here, we report data on outpatient sedation reversal rates for endoscopy performed at an in-hospital APC vs at a free-standing ambulatory endoscopy digestive health center (AEC-DHC) following risk stratification with a triage tool. AIM To observe the effect of risk stratification using a triage tool on patient outcomes, primarily sedation reversal events. METHODS We observed all outpatient endoscopy procedures performed at AEC-DHC and APC from April 2013 to September 2019. Procedures were stratified to their respective sites using a triage tool. We evaluated each procedure for which sedation reversal with flumazenil and naloxone was recorded. Demographics and characteristics recorded include patient age, gender, body mass index (BMI), American Society of Anesthesiologists (ASA) classification, procedure type, and reason for sedation reversal. RESULTS There were 97366 endoscopic procedures performed at AEC-DHC and 22494 at the APC during the study period. Of these, 17 patients at AEC-DHC and 9 at the APC underwent sedation reversals (0.017% vs 0.04%; P = 0.06). Demographics recorded for those requiring reversal at AEC-DHC vs APC included mean age (53.5 ± 21 vs 60.4 ± 17.42 years; P = 0.23), ASA class (1.66 ± 0.48 vs 2.22 ± 0.83; P = 0.20), BMI (27.7 ± 6.7 kg/m2 vs 23.7 ± 4.03 kg/m2; P = 0.06), and female gender (64.7% vs 22%; P = 0.04). The mean doses of sedative agents and reversal drugs used at AEC-DHC vs APC were midazolam (5.9 ± 1.7 mg vs 8.9 ± 3.5 mg; P = 0.01), fentanyl (147.1 ± 49.9 μg vs 188.9 ± 74.1 μg; P = 0.10), flumazenil (0.3 ± 0.18 μg vs 0.17 ± 0.17 μg; P = 0.13) and naloxone (0.32 ± 0.10 mg vs 0.28 ± 0.12 mg; P = 0.35). Procedures at AEC-DHC requiring sedation reversal included colonoscopies (n = 6), esophagogastroduodenoscopy (EGD) (n = 9) and EGD/colonoscopies (n = 2), whereas APC procedures included EGDs (n = 2), EGD with gastrostomy tube placement (n = 1), endoscopic retrograde cholangiopancreatography (n = 2) and endoscopic ultrasound's (n = 4). The indications for sedation reversal at AEC-DHC included hypoxia (n = 13; 76%), excessive somnolence (n = 3; 18%), and hypotension (n = 1; 6%), whereas, at APC, these included hypoxia (n = 7; 78%) and hypotension (n = 2; 22%). No sedation-related deaths or long-term post-sedation reversal adverse outcomes occurred at either site. CONCLUSION Our study highlights the effectiveness of a triage tool used at our tertiary care hospital for risk stratification in minimizing sedation reversal events during outpatient endoscopy procedures. Using a triage tool for risk stratification, low rates of sedation reversal can be achieved in the ambulatory settings for EGD and colonoscopy.
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Affiliation(s)
- Saqib Walayat
- Department of Gastroenterology, University of Illinois, Peoria, IL 61605, United States
| | - Peter Stadmeyer
- Department of Gastroenterology, University of Wisconsin, Madison, WI 53792, United States
| | - Azfar Hameed
- Department of Internal Medicine, Texas Health Denton, Denton, TX 76201, United States
| | - Minahil Sarfaraz
- Department of Internal Medicine, Allama Iqbal Medical College, Lahore 042, Pakistan
| | - Paul Estrada
- Department of Gastroenterology, Texas Tech University Health Services Center, El Paso, TX 79911, United States
| | - Mark Benson
- Department of Gastroenterology and Hepatology, University of Wisconsin, Madison, WI 53705, United States
| | - Anurag Soni
- Department of Gastroenterology and Hepatology, University of Wisconsin, Madison, WI 53705, United States
| | - Patrick Pfau
- Department of Gastroenterology and Hepatology, University of Wisconsin, Madison, WI 53705, United States
| | - Paul Hayes
- Finance Business Partners UW Health, University of Wisconsin, Madison, WI 53792, United States
| | - Brittney Kile
- UW Health Digestive Health Center Endoscopy, University of Wisconsin, Madison, WI 53792, United States
| | - Toni Cruz
- UW Health Digestive Health Center Endoscopy, University of Wisconsin, Madison, WI 53792, United States
| | - Deepak Gopal
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Wisconsin Hospitals and Clinics, Madison, WI 53705, United States
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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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Nam JH, Jang DK, Lee JK, Kang HW, Kim BW, Jang BI. Propofol Alone versus Propofol in Combination with Midazolam for Sedative Endoscopy in Patients with Paradoxical Reactions to Midazolam. Clin Endosc 2021; 55:234-239. [PMID: 34634857 PMCID: PMC8995981 DOI: 10.5946/ce.2021.126] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 05/19/2021] [Indexed: 11/14/2022] Open
Abstract
Background/Aims The efficacy of propofol in gastrointestinal endoscopy for patients with midazolam-induced paradoxical reactions remains unclarified. This study aimed to compare the efficacy and safety of propofol-based sedation in patients who previously experienced paradoxical reactions. Methods This was a prospective, single-blinded, randomized controlled pilot study. Participants with a history of paradoxical reactions to midazolam during a previous esophagogastroduodenoscopy were recruited and randomly assigned to group I (propofol monosedation) or group II (combination of propofol and midazolam). The primary endpoint was the occurrence of a paradoxical reaction. Results A total of 30 participants (mean age, 54.7±12.6 years; male, 19/30) were randomly assigned to group I (n=16) or group II (n=14). There were no paradoxical reactions in group I, but there were two in group II, without a significant difference (p=0.209). The mean dose of propofol was higher in group I than in group II (p=0.002). Meanwhile, the procedure and recovery times did not differ between groups. Conclusions Propofol-based sedation was safe and effective for patients who experienced paradoxical reactions to midazolam. However, caution is needed because few cases of paradoxical reaction again can happen in group II in which midazolam was readministered.
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Affiliation(s)
- Ji Hyung Nam
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea
| | - Dong Kee Jang
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea
| | - Jun Kyu Lee
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea
| | - Hyoun Woo Kang
- Department of Internal Medicine, Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea
| | - Byung-Wook Kim
- Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Incheon, Korea
| | - Byung Ik Jang
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
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Lee JS, Kim ES, Cho KB, Park KS, Lee YJ, Lee JY. Pain Intensity at Injection Site during Esophagogastroduodenoscopy Using Long- and Medium-Chain versus Long-Chain Triglyceride Propofol: A Randomized Controlled Double-Blind Study. Gut Liver 2021; 15:562-568. [PMID: 33115965 PMCID: PMC8283282 DOI: 10.5009/gnl20243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 08/26/2020] [Accepted: 09/06/2020] [Indexed: 11/04/2022] Open
Abstract
Background/Aims The intensities of injection pain resulting from the use of long- and medium-chain triglyceride (LCT/MCT) propofol and conventional LCT propofol during esophagogastroduodenoscopy (EGD) have yet to be compared. We aimed to determine the pain intensity caused by different formulations of propofol and to evaluate the formulation that would be preferred by patients as a sedative agent during their next procedure. Methods This study was a single-center, randomized, controlled, and double-blind trial. Pain intensity was estimated 30 seconds after propofol injection by an examiner who was blinded to the group assignment using a numeric (0-10) pain rating scale (NPRS). After 1 week, the patients were asked whether they could recall the pain and were willing to receive the same agent for their next EGD. Results One hundred twenty-nine patients were randomly assigned to LCT/MCT or LCT group. Although there was no significant difference in pain incidence between the LCT/MCT and LCT groups (52.9% vs 65.6%, p=0.156), the pain intensity was significantly lower in the LCT/MCT group (NPRS median [interquartile range]; 1 (0-2) vs 2 (0-5), p=0.005). After 1 week, fewer patients in the LCT/MCT group recalled the pain (19.1% vs 63.9%, p<0.001) and more patients in the LCT/MCT group were more willing to use the same agent for their next procedure (86.8% vs 72.1%, p=0.048) than in the LCT group. Conclusions LCT/MCT propofol significantly reduced injection pain intensity compared to LCT propofol during EGD and preferred by patients as a sedative agent during their next EGD.
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Affiliation(s)
- Joon Seop Lee
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, Korea
| | - Eun Soo Kim
- Department of Internal Medicine, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, Korea
| | - Kwang Bum Cho
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Kyung Sik Park
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Yoo Jin Lee
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Ju Yup Lee
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
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Park SY, Lee JK, Kim JW, Lee TH, Park CH, Jang JY, Kim BW, Jang BI. A Nationwide Survey on the Facilities and Personnel for Endoscopic Sedation: Results from 50 Qualified Endoscopy Units of Teaching Hospitals Accredited by the Korean Society of Gastrointestinal Endoscopy (KSGE). Clin Endosc 2021; 54:843-850. [PMID: 34256557 PMCID: PMC8652162 DOI: 10.5946/ce.2021.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 02/19/2021] [Indexed: 12/03/2022] Open
Abstract
Background/Aims This study aimed to determine the current status of facilities, equipment, and personnel for endoscopic sedation from endoscopy units of representative hospitals in South Korea.
Methods A questionnaire survey was conducted on 50 qualified endoscopy units accredited by the Korean Society of Gastrointestinal Endoscopy.
Results All included endoscopy units had regulations and educational programs regarding sedation training for endoscopists and nursing personnel. There present one assisting nurse during endoscopy in 35 units (70%) and at least two nurses in 12 units (24.0%). All endoscopy units had examination rooms equipped with oxygen supply and suction systems. Endoscopist-directed sedation was performed in 48 units (96.0%). Propofol-based sedation was the most used sedation method. All units had a separate recovery bay. The daily number of patients per bed was greater than 10 in 17 units (34.0%). In 26 (52.0%) units, a single nurse cared for ≥10 patients per day. All the units fulfilled the discharge criteria.
Conclusions This study presents data regarding endoscopic sedation clinical practice in 50 endoscopy units in South Korea. This study presents the current status of endoscopic sedation clinical practice in 50 qualified endoscopy units accredited by the KSGE, which provide excellent quality management.
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Affiliation(s)
- Seon-Young Park
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Jun Kyu Lee
- Department of Internal Medicine, Dongguk University Ilsan Hospital, Goyang, Korea
| | - Jung-Wook Kim
- Department of Internal Medicine, Kyung Hee University College of Medicine, Seoul, Korea
| | - Tae Hee Lee
- Institute for Digestive Research, Soonchunhyang University Seoul Hospital, Seoul, Korea
| | - Chang-Hwan Park
- Department of Internal Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Jae-Yong Jang
- Department of Internal Medicine, Kyung Hee University College of Medicine, Seoul, Korea
| | - Byung-Wook Kim
- Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Incheon, Korea
| | - Byung Ik Jang
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Korea
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Nishizawa T, Yoshida S, Toyoshima O, Matsuno T, Irokawa M, Arano T, Ebinuma H, Suzuki H, Kanai T, Koike K. Risk Factors for Prolonged Hospital Stay after Endoscopy. Clin Endosc 2021; 54:851-856. [PMID: 33721977 PMCID: PMC8652156 DOI: 10.5946/ce.2020.292] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 12/30/2020] [Indexed: 01/21/2023] Open
Abstract
Background/Aims The recovery room used after endoscopy has limited capacity, and an efficient flow of the endoscopy unit is desired. We investigated the duration of hospital stay after endoscopy and the risk factors for prolonged hospital stay among outpatients.
Methods We retrospectively studied consecutive patients who underwent esophagogastroduodenoscopy or colonoscopy at the Toyoshima Endoscopy Clinic. We collected data on age, sex, body weight, midazolam and pethidine dosage, respiratory depression during endoscopy, and duration of hospital stay after endoscopy (scope out to check out). Risk factors for prolonged hospital stay (>100 minutes) were identified using multiple logistic regression analysis.
Results We enrolled 3,898 patients, including 3,517 (90.2%) patients tested under sedation and 381 (9.8%) patients tested without sedation. Overall, 442 (11.3%) patients had prolonged stay (>100 min). The mean time difference between sedation group and non-sedation group was 44.2 minutes for esophagogastroduodenoscopy and 39.1 minutes for colonoscopy. Age (odds ratio [OR], 1.025; 95% confidence interval [CI], 1.014−1.036), female sex (OR, 1.657; 95% CI, 1.220−2.249), and midazolam dose (OR, 1.019; 95% CI, 1.013−1.026) were independently associated with prolonged hospital stay after esophagogastroduodenoscopy, with similar results for colonoscopy.
Conclusions Old age, female sex, and midazolam dose were independent risk factors for prolonged hospital stay after endoscopy.
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Affiliation(s)
- Toshihiro Nishizawa
- Gastroenterology, Toyoshima Endoscopy Clinic, Tokyo, Japan.,Department of Gastroenterology and Hepatology, International University of Health and Welfare, Narita Hospital, Narita, Japan
| | - Shuntaro Yoshida
- Gastroenterology, Toyoshima Endoscopy Clinic, Tokyo, Japan.,Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Osamu Toyoshima
- Gastroenterology, Toyoshima Endoscopy Clinic, Tokyo, Japan.,Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tatsuya Matsuno
- Gastroenterology, Toyoshima Endoscopy Clinic, Tokyo, Japan.,Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Masataka Irokawa
- Gastroenterology, Toyoshima Endoscopy Clinic, Tokyo, Japan.,Gastroenterology, Sanraku Hospital, Tokyo, Japan
| | - Toru Arano
- Gastroenterology, Toyoshima Endoscopy Clinic, Tokyo, Japan.,Gastroenterology, The Fraternity Memorial Hospital, Tokyo, Japan
| | - Hirotoshi Ebinuma
- Department of Gastroenterology and Hepatology, International University of Health and Welfare, Narita Hospital, Narita, Japan
| | - Hidekazu Suzuki
- Department of Gastroenterology and Hepatology, Tokai University School of Medicine, Isehara, Japan
| | - Takanori Kanai
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Kazuhiko Koike
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
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