Gastroenterologist-Directed Propofol, Midazolam and Fentanyl for Endoscopic Sedation: Adverse Events During 4,213 Procedures

Abstract

Background: Propofol combined with low doses of midazolam and a narcotic provides excellent endoscopic sedation (Gastrointest Endosc 2004; 59:795-803). This retrospective review was designed to evaluate the safety and feasibility of gastroenterologist-administered propofol for endoscopic sedation. Methods: We reviewed all EGDs and colonoscopies (CL) performed by one of three MDs in a single private practice between 1/2/03 and 10/30/04. All procedures performed with propofol sedation were included in this report. Monitoring for pulse, BP, SaO2 and TCO2 was performed in all cases. An initial small bolus of an opioid (50-75 mcg of fentanyl or 25-50 mg of meperidine) and midazolam (0.5-1 mg) was given, followed by a bolus of propofol (5-15 mg), as per protocol (Gastrointest Endosc 2003; 58:725-32). Additional boluses of propofol (5-15 mg) were administered as required throughout the procedure. All decisions about dosing of medication were made jointly by the nurse and endoscopist. Data was retrieved from the practice's electronic database (Image Manager, Olympus Inc, Melville, NY) implemented 1/2/03, the nurses' medication log, personal interviews with nurses and MDs, and by review of all charts "flagged" by an AE. We defined AEs as: requirement of naloxone, flumazenil, or any other pharmacologic agent; use of mask ventilation or advanced airway support; aspiration; hospitalization; colonic perforation; death. Results: 4,213 endoscopic procedures were reviewed (EGD = 1,286, CL = 2,927). Mean patient age was 59 (range, 15-101 yrs). All patients were ASA class I-III. The drug doses (mean, range) during CL and EGD, respectively, were: propofol (mg) (99, 10-420) and (79, 5-330); midazolam (mg) (1, 0.5-3) and (1, 0.5-3.0); fentanyl (mcg) (74, 50-125) and (73, 50-100), and meperidine (mg) (45, 25-100) and (43, 12.5-75). Naloxone was administered to 1 patient for transient oxygen desaturation (<30 sec), and naloxone plus flumazenil was administered to a second patient for somnolence and transient oxygen desaturation (<30 sec). No patient required other pharmacologic intervention or airway support. We identified no cases of aspiration, hospitalization, or death. There were no colonic perforations. Conclusions: 1. Propofol, combined with small doses of a narcotic and midazolam, can be safely administered by gastroenterologists for endoscopic sedation, and 2. A well-trained sedation team is required to achieve comparable results.