A Much Sought-After Drug—Propofol Sedation for GI Endoscopy: Always Better but Who Cares?

Abstract

Several hypnotic and analgesic strategies have beendevised for patients undergoing gastrointestinal (GI)endoscopy, ranging in a continuum from mild conscioussedation to general anesthesia.Endoscopic retrograde cholangiopancretography (ERCP)and endoscopic ultrasound (EUS) are particularly unpleas-ant diagnostic procedures for patients and more time con-suming than any other endoscopic procedure. Moreover,ERCP can be technically difficult and requires completepatient cooperation in order to be safely and successfullycompleted. Patients frequently are sedated for ERCP orEUS with intravenous bolus doses of benzodiazepines incombination with opioids, which are meant to improve thequality of sedation by providing analgesia. Deep sedation issometimes required.The introduction of propofol into clinical practice sig-nificantly changed the attitudes of both physicians andpatients towards sedation, with the result that propofolsedation for GI endoscopy has become common practiceworldwide. In recent years, propofol has been safely andeffectively used in advanced interventional endoscopicprocedures, such as ERCP and EUS, even for high-riskpatients [1]. Propofol is a hypnotic drug with rapid onsetand offset of action. Used as a single agent, it is commonlytitrated to attain deep sedation, whereas balanced propofolsedation (BPS), in which propofol use is associated withsmall doses of benzodiazepines and/or opioids, can besuccessfully titrated to attain moderate sedation.Several studies have shown that, when compared withconventional sedation, BPS with propofol, midazolam,and/or meperidine, yields higher physician and patientsatisfaction, better patient cooperation, and similar com-plication rates in patients undergoing therapeutic endo-scopic procedures. The total propofol dose may beexpected to be reduced by 50 % with BPS in comparisonwith propofol alone sedation.A critical advantage in dealing with BPS for moderatesedation is that it can be partially reverted, since antagonistsare available against both opioids and benzodiazepines.In the current issue of Digestive Diseases and Sciences,Tae Hoon Lee et al. [2] present the results of a randomizedprospective study comparing BPS (propofol, midazolam,and fentanyl) with propofol alone during moderate sedationfor ERCP and EUS. The authors demonstrate that propofolalone provides a shorter recovery time than BPS and iscomparably effective and safe. This paper is the naturalevolution of a previous study of the same authors in whichthey demonstrated a higher safety and efficacy of BPS incomparison with conventional sedation [3]. In this respect,Tae Hoon Lee et al. positively contribute to the knowledgeof sedation strategies for endoscopy.However, in another respect, they quietly and almostinadvertently hit a raw nerve in the ongoing debate aboutwho can/should provide propofol sedation. In both of theirstudies, sedation was provided by non-anesthesiologists,further adding to the body of literature indicating that theadministration of propofol by non-anesthesiologists may besafe and effective for selected patients undergoingadvanced endoscopic procedures.The subject of non-anesthesiologist administrationof propofol (NAAP), particularly for endoscopy, has