Anesthesiologist-administered Propofol Research Articles

Efficacy and Safety of Non-Anesthesiologist Administration of Propofol Sedation in Endoscopic Ultrasound: A Propensity Score Analysis.

In spite of promising preliminary results, evidence supporting the use of non-anesthesiologist-administered propofol sedation (NAAP) in endoscopic ultrasound (EUS) procedures is still limited. The aim of this manuscript was to examine the safety and efficacy of NAAP as compared to anesthesiologist-administered propofol sedation in EUS procedures performed in a referral center. Out of 832 patients referred to our center between 2016 and 2019, after propensity score matching two groups were compared: 305 treated with NAAP and 305 controls who underwent anesthesiologist-administered propofol sedation. The primary outcome was the rate of major complications. The median age was 67 years and the proportion of patients with comorbidities was 31.8% in both groups. One patient in each group (0.3%) experienced a major complication, whereas minor complications were observed in 13 patients in the NAAP group (4.2%) and 10 patients in the control group (3.2%; p = 0.52). Overall pain during the procedure was 2.3 ± 1 in group 1 and 1.8 ± 1 in group 2 (p = 0.67), whereas pain/discomfort upon awakening was rated as 1 ± 0.5 in both groups (p = 0.72). NAAP is safe and effective even in advanced EUS procedures. Further randomized-controlled trials (RCTs) are warranted to confirm these findings.

Endoscopist-directed propofol is more efficient than anesthesiologist-administered propofol in patients at low-intermediate anesthetic risk.

Endoscopist-directed propofol (EDP) sedation is becoming more popular, with a reported safety and efficacy similar to anesthesiologist-administered propofol (AAP). The aim of this study is to compare the efficiency of EDP and AAP in patients of low-intermediate anesthetic risk. A prospective cost-effectiveness comparison study was conducted. The costs of the endoscopic procedures in the EDP and AAP group were calculated using the full cost methodology after breaking down the endoscopic activity into relative value units to allocate costs in an equitable way. To determine the effectiveness, adverse events related to endoscopic sedation and the number of incomplete procedures were registered for the EDP group and compared with those published by anesthesiologists for AAP. A total of 1165 and 18 919 endoscopic procedures were, respectively, included in the EDP and AAP groups. The average costs of EDP vs. AAP for gastroscopy, colonoscopy and endoscopic ultrasound were &OV0556; 182.81 vs. &OV0556; 332.93, &OV0556; 297.07 vs. &OV0556; 459.76, and &OV0556; 319.92 vs. &OV0556; 485.12, respectively. No significant differences were detected regarding the rate of overall adverse events (4.43 vs. 4.46%) or serious adverse events (0 vs. 0.17%); the rate of arterial hypotension was significantly lower in the EDP group: 0.34 vs. 1.78% [odds ratio (OR), 0.19; 95% confidence interval (CI), 0.08-0.46] and the desaturation rate was significantly lower in the AAP group: 3.26 vs. 1.29% (OR, 2.58; 95% CI, 1.85-3.60). No significant differences were found in terms of incomplete examinations (0.17 vs. 0.14%). In patients with low-intermediate anesthetic risk referred for an endoscopic examination, EDP appears to be more efficient than AAP.

Propofol administration by endoscopists versus anesthesiologists in gastrointestinal endoscopy: a systematic review and meta-analysis of patient safety outcomes.

With a growing demand for endoscopic services, the role of anesthesiologists in endoscopy units must be reassessed. The aim of this study was to compare patient outcomes in non-anesthesiologist-administered propofol (NAAP) versus anesthesiologist-administered propofol (AAP) during routine endoscopy. We systematically searched Medline, CINAHL, Embase, Web of Science, CENTRAL and the grey literature for studies comparing NAAP and AAP. Primary outcomes included endoscopy- and sedation-related complications. Secondary outcomes included measures of endoscopy quality and of patient and endoscopist satisfaction. We reported treatment effects using random-effects models. Of 602 articles identified, 5 met the inclusion criteria. Most studies included only patients with an American Society of Anesthesiologists (ASA) classification of I or II. Non-anesthesiologist-administered propofol did not result in increased rates of airway intervention (odds ratio [OR] 1.07, 95% confidence interval [CI] 0.29 to 3.95; 3443 patients) or hypotension (OR 1.47, 95% CI 0.40 to 5.41; 17 978 patients) but did result in higher rates of bradycardia (OR 3.68, 95% CI 1.65 to 8.17; 17 978 patients). Nonanesthesiologists administered lower propofol dosages than anesthesiologists (mean difference -61.79, 95% CI -114.46 to -9.12; 3443 patients), and their patients more commonly experienced awareness with recall (OR 19.99, 95% CI 7.88 to 50.76; 2090 patients). However, NAAP neither compromised patient willingness to repeat the procedure (OR 0.42, 95% CI 0.10 to 1.83; 2367 patients) nor lengthened total procedure time (mean difference -0.08, 95% CI -3.51 to 3.34; 2367 patients). Endoscopists may safely administer propofol without compromising procedural quality in patients classified as ASA I or II undergoing routine endoscopy. The results of this meta-analysis are limited by a lack of available high-quality studies. Further, large-scale studies are needed for definitive conclusions.

Safety and effectiveness of anesthesiologist-administered Propofol versus Propofol and Nalbuphine for deep sedation during and after outpatient colonoscopy

Safety and effectiveness of anesthesiologist-administered Propofol versus Propofol and Nalbuphine for deep sedation during and after outpatient colonoscopy

Routine Propofol Sedation Increases Risk During Colonoscopy

The use of anesthesiologist-administered propofol sedation for colonoscopy is increasing in the U.S. (JW Gastroenterol April 13 2012 and JW

Endoscopic Sedation in Pediatric Practice

Best sedation practices for pediatric endoscopy involve the consideration of many patient factors, including age, medical history, clinical status, and anxiety level, as well as physician access to anesthesia support. A recent survey of pediatric gastroenterologists suggests that endoscopist-administered intravenous (iv) sedation and anesthesiologist-administered propofol represent common sedation regimens in children. Technical advances in ventilatory monitoring are contributing to increased patient safety for all children undergoing gastrointestinal procedures, regardless of sedation type.

Efficiency of propofol versus midazolam and fentanyl sedation at a pediatric teaching hospital: a prospective study

Many pediatric endoscopists are adopting propofol in their practices, with the expectation that propofol will increase their overall efficiency. To compare the efficiency of propofol versus midazolam and fentanyl by measuring elapsed times between initial intravenous administration and patient discharge at a pediatric teaching hospital. Endoscopy times were prospectively collected for consecutive patients who were undergoing either anesthesiologist-administered propofol or endoscopist-administered midazolam and fentanyl. The effect of the type of sedation on these times was assessed by using multiple linear regression by adjusting for other candidate predictors, including concomitant use of other sedatives, endotracheal intubation by anesthesiologists, and the presence of fellow trainees. Time to onset of sedation (time sedation started to scope in), procedure time (endoscope in to endoscope out), discharge time (endoscope out to hospital discharge), and total time (sedation started to hospital discharge). The times for 134 children (mean age 12 +/- 5 years) to receive propofol sedation were compared with those of 195 children (13 +/- 5 years) who received midazolam and fentanyl. Midazolam and fentanyl cases disproportionately included EGDs (P < .001) and patients who were classified as American Society of Anesthesiologists I (P < .03). Patients who received propofol had shorter times until sedated, similar procedure times, longer discharge times, and comparable total times. Multivariate analyses confirmed that fellow participation prolonged the procedure times (P < .0001), and endotracheal intubation prolonged propofol times (P <. 01), but adjusting for these did not change the comparison results. Anesthesiologist-administered propofol sedation in a pediatric teaching endoscopy unit may not lead to faster hospital times when compared with endoscopist-administered midazolam and fentanyl. These results are not explained by controlling for patient characteristics, the presence of a trainee, the sedative doses, or endotracheal intubation for airway management.

Will Men or Machines Control Sedation During Endoscopy

Anesthesiologists often administer propofol during routine endoscopic procedures, but this approach is not cost-effective, and some insurers prohibit it. One alternative to anesthesiologist-administered propofol is computer-assisted personalized sedation (CAPS). The CAPS device monitors patients’ heart rates, blood pressures, electrocardiograms, oximetries, and capnography information and automatically infuses sedatives to achieve moderate sedation. Levels of sedation are determined by monitoring whether patients respond to verbal stimulus by pushing a button. If the patients do not respond, the CAPS device assumes that they are in deep sedation and interrupts the sedative infusion. To evaluate the safety and efficacy …

Response to Abraham S. Horn, D.O., F.A.C.O.I.

LETTER TO THE EDITOR: I appreciated the comments of Dr. Horn regarding his adoption of anesthesiologist-administered propofol in his practice. Dr. Horn appears to be a seasoned clinician with a long track record of safe endoscopy. His use of propofol is based on the belief that it is the best for his patients. While no one can argue that the data do support an improvement in a number of parameters with propofol, I believe one has a hard argument to make that, compared to gastroenterologist-provided sedation with a narcotic-benzodiazepine combination, these differences warrant administration to all patients by an anesthesiologist. The societal costs of such a strategy are enormous and not sustainable. In addition, a consensus statement from our three GI Societies on conscious sedation will soon appear, which also endorses the very selective use of anesthesiologist-provided propofol. I could ask the anesthesiologist to give propofol for all my patients undergoing endoscopy or maybe train one of our nurses to give it. Why do I not do this? Because I do not believe it is necessary. Like Dr. Horn, I do believe there are patients who require anesthesiologist support because of an inability to adequately sedate due to chronic narcotic use, alcoholism, etc., and I employ their services for these cases. In contrast to Dr. Horn's practice, however, there are a number of physicians in the United States who clearly use anesthesiologists with the principal goal of improving throughput and not necessarily because of a belief that propofol is better. This is the practice I believe is gaming the system.

Anesthesiologist or Non- Anesthesiologist-Administered Propofol and Cardiopulmonary Complications for Endoscopy: Which Is Safer?

Background: Propofol-mediated endoscopy is gaining popularity due to its enhanced recovery profile when compared to standard sedation. There is no data comparing anesthesiologist (A) or non-anesthesiologist (NA) administered propofol. Purpose: To evaluate cardiopulmonary complications with propofol-mediated sedations utilizing a multicenter endoscopic outcomes database Methods: A and NA cases were gathered from the Clinical Outcomes Research Initiative (CORI) database from 1/16/98-6/30/03. Cardiopulmonary complications (CPC) included: chest pain, bradycardia, tachycardia, hypoxia, vasovagal reaction, respiratory distress, hypotension and hypertension. Clinical variables analyzed included age, gender, ASA physiologic classification, procedure type (EGD, colonoscopy, ERCP), and personnel administering propofol (A vs NA) An adjusted relative risk (NA numerator, A denominator) with 95% CI was calculated for each clinical variable. Results: 9,761 NA and 4,811 A procedures were analyzed. Procedures included colonoscopy: 9,219, EGD:4894, and ERCP 310. Increasing age and gender were not associated with an increased risk of CPC. Advanced ASA classification was associated increased CPE risk. PME under MAC/anesthesiologist was associated with a reduced CPE risk (see table). Conclusion: Advancing ASA is associated with increased CPC risk in non-anesthesiologist-administered propofol procedures, and is present throughout the ASA spectrum The administration of propofol by anesthesiologists is associated with a decreased CPC risk.

Use of Propofol in High Risk PEG and Direct PEJ Placements

Propofol is being increasingly utilized in endoscopies yet there have been no published reports of its use in patients undergoing percutaneous endoscopic gastrostomies and direct jejunostomies. The aim of this study is to evaluate the use of anesthesiologist-administered propofol for the placement of PEG's and direct PEJ's for malignant dysphagia. In this retrospective review, all patients from July 2002 to July 2003 at Memorial Sloan Kettering who underwent PEG or PEJ procedures with propofol were evaluated. There were 151 procedures: 126 PEG's and 25 direct PEJ's. The mean age was 61.8 years (32-87 yrs) and 113 pts (75%) were considered higher risk for airway-related complications due to a history of a head and neck cancer. The mean ASA class was 2.8, correlating to a patient with a severe disease process. The mean Mallampati airway classification was 2.1, correlating to an airway that can be intubated without difficulty. The mean dose of propofol was 2.2 mg/kg (0.1-12.1mg/kg) with 93 pts also receiving midazolam (mean 3.3mg) and 14 receiving fentanyl (mean 48mcg). The mean duration of sedation was 22.2 minutes. Minor complications occurred in 25 pts (16.6%): 13 (8.6%) fevers, 12 (7.9%) systolic blood pressure drops of >25%, and 1 (0.6%) oxygen desaturation <90%. Major complications occurred in 4 pts (2.6%): 3 (2%) aspiration pneumonias and 1 death (0.6%). The patients with aspiration pneumonia were treated successfully with antibiotics. The death occurred in a patient with pharyngeal cancer. She had an uneventful procedure and was found in respiratory arrest from an unclear cause 6 hours post-operatively. Compared to the overall group, the group with complications had no differences in mean age, duration of procedure, ASA class, Mallampati score, dose of propofol, ratio with head and neck cancer, and ratio receiving midazolam. The complication rates are comparable to previous reports of PEG procedures performed with midazolam and meperidine which showed a mortality of 1%, major complications of 3% which included perforations, and minor complications of 13% which included fever and aspirations.1 Similar complication rates were found in direct PEJ procedures which found hypoxemia in 2%, hypotension in 2%, and major complications in 1.8%.2 In conclusion, anesthesiologist-administered propofol sedation is suitable for PEG and PEJ placements in high risk patients with a comparable complication rate to sedation by midazolam and meperidine.1 Larson et al. Gastroenterology 1987 Jul;93(1):48 2 Shike et al. Gastrointest Endosc 1996 Nov;44(5):536