Abstract
ABSTRACTBackgroundSedation practices vary widely by region. In Canada, endoscopist-directed administration of a combination of fentanyl and midazolam is standard practice. A minority of cases are performed with propofol.AimsTo describe the safety of nonanaesthetist administered low-dose propofol as an adjunct to standard sedation.MethodsThis was a single-centre retrospective study of patients having undergone endoscopic procedures with propofol sedation between 2004 and 2012 in a teaching hospital in Montreal. Procedures were performed by gastroenterologists trained in Advanced Cardiovascular Life Support. Sedation was administered by intravenous bolus by a registered nurse, under the direction of the endoscopist. Outcomes of procedures were collected in the context of a retrospective chart review using the hospital’s endoscopy database.ResultsOf patients undergoing endoscopies at our centre, 4930 patients received propofol as an adjunct to standard sedation with fentanyl and midazolam. Cecal intubation rate for colonoscopies (n = 2921) was 92.0%. Gastroscopies (n = 1614), flexible sigmoidoscopies (n = 28), endoscopic retrograde cholangiopancreatography (n = 331) and percutaneous endoscopic gastrostomy insertion (n = 36) had success rates, defined as successful completion of the procedure within anatomical limits, of 99.0, 96.4, 94.0 and 91.7%, respectively. The average dose of propofol used for each procedure was 34.5 ± 20.8 mg. Fentanyl was used in 67.4% of procedures at an average dose of 94.3 ± 17.5 mcg. Midazolam was used in 92.7% of cases at an average dose of 3.0 ± 0.7 mg. Reversal agents (naloxone or flumazenil) were used in 0.43% of the cases (n = 21). Patients who received propofol were discharged uneventfully within the usual postprocedure recovery time. One patient required sedation-related hospitalization. For patients having received propofol in addition to standard sedation agents, 99.6% experienced no adverse events. There were no mortalities.ConclusionThe use of low-dose propofol as an adjunct to fentanyl and midazolam, administered by a registered nurse under the direction of the endoscopist was safe and effective in patients at our centre.
Highlights
Sedation during endoscopy improves the quality of the examination by increasing patient satisfaction and decreases the rate of incomplete procedures [1,2]
Combinations of propofol and fentanyl and of propofol and midazolam were administered in 1.8% (n = 91) and 27.1% (n = 1336), respectively
There were no deaths or need for mechanical ventilation. This large retrospective study supports the use of low-dose endoscopist-directed propofol as an adjunct to standard sedation in select patients undergoing routine endoscopy
Summary
Sedation during endoscopy improves the quality of the examination by increasing patient satisfaction and decreases the rate of incomplete procedures [1,2]. In Canada, endoscopist-directed administration of a combination of an opioid and a benzodiazepine (commonly fentanyl and midazolam) is standard practice, while only a minority of cases are performed with propofol. In a recent Canadian survey, only 13% of adult gastroenterologists reported using propofol in routine colonoscopies, usually administered by an anaesthesiologist [3] Fentanyl and midazolam both have a rapid onset of action and a relatively short half-life. Certain patients may be refractory to these medications or intolerant to endoscopic procedures In these cases, the use of low-dose propofol as an adjunct to standard agents allows for more effective sedation without prolonging recovery times [4,5]. Conclusion: The use of low-dose propofol as an adjunct to fentanyl and midazolam, administered by a registered nurse under the direction of the endoscopist was safe and effective in patients at our centre
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