Nonanesthesiologist-administered Propofol Sedation Research Articles

Safety and tolerability outcomes of nonanesthesiologist-administered propofol using target-controlled infusion in routine GI endoscopy

Nonanesthesiologist-administered propofol (NAAP) is increasingly accepted, but data are limited on drug administration using target-controlled infusion (TCI) in clinical practice. TCI adjusts the drug infusion based on patient-specific parameters, maintaining a constant drug dose to reduce the risk of adverse events (AEs) because of drug overdosing and to enhance patient comfort. The aims of this study were to assess the rate of AEs and to evaluate patient satisfaction with NAAP using TCI in a retrospective cohort of 18,302 procedures. Low-risk patients (American Society of Anesthesiologists score I and II) undergoing outpatient GI endoscopic procedures, including EGDs and colonoscopies, were sequentially enrolled at IRCCS San Raffaele Hospital (Milan, Italy) between May 2019 and November2021. Data from 7162 EGDs and 11,140 colonoscopies were analyzed. Mean patient age was 59.1 ± 14.8 years, and mean body mass index was 24.9 ± 3.7 kg/m2. The male-to-female ratio was equal at 8798 (48.1%):9486 (51.9%). AEs occurred in 240 procedures (1.3%) out of the total cohort, with no differences between EGDs and colonoscopies (100 [1.4%] and 140 [1.2%], respectively; P= .418). Most patients (15,875 [98.9%]) indicated they would likely repeat the procedure with the same sedation protocol. Age (odds ratio, 1.02; 95% confidence interval, 1.01-1.03; P< .008) was the only independent factor associated with overall AEs. NAAP using TCI is an effective and safe sedation method for routine endoscopy. The proper propofol dosage based on individual patients and the presence of trained operators are crucial for NAAP sedation management.

Propofol sedation with a target-controlled infusion pump in elderly patients undergoing ERCP

Advanced age is an important risk factor for adverse events (AEs) during propofol sedation for endoscopic procedures. This study aimed to evaluate the safety and efficacy of nonanesthesiologist-administered propofol (NAAP) sedation with a target-controlled infusion (TCI) system in elderly patients during ERCP. This study retrospectively analyzed 482 patients who underwent ERCP under propofol sedation with a TCI system at Iwakuni Medical Center between January 2014 and October 2016. Patients were divided into 3 groups according to their age: group A,<70 years (n= 130); group B,≥70 and<85 years (n= 224); and group C,≥85 years (n= 125). We compared the propofol dose and AEs during ERCP. The median total infusion dose and minimum and maximum target blood concentrations of propofol were 336 mg, 2.2 μg/mL, and 2.2 μg/mL in group A; 184 mg, 1.0 μg/mL, and 1.4 μg/mL in group B; and 99 mg, .6 μg/mL, and 1.0 μg/mL in group C, respectively, with older groups requiring a lower dose (P< .0001). Hypotension was observed in 23 patients (4.8%), with no significant difference between groups (group A, 2.3%; group B, 6.3%; group C, 4.8%; P= .24). Hypoxemia was observed in 16 patients (3.3%), with no significant difference between groups (group A, 3.1%; group B, 4.9%; group C, .8%; P= .17). All AEs were immediately resolved, and no procedures were aborted. NAAP sedation with a TCI system during ERCP may be acceptable in elderly patients with a lower dose of propofol than that used in younger patients.

1858 Corneal Injury After Routine Gastrointestinal (GI) Endoscopy With Moderate Sedation

INTRODUCTION: Corneal abrasion is the most common ocular adverse event from deep sedation and general anesthesia. Its occurrence during moderate sedation for gastrointestinal (GI) endoscopy has not been previously reported. We report 5 cases of corneal abrasion following standard GI endoscopy under moderate sedation. CASE DESCRIPTION/METHODS: Retrospective chart review of ocular adverse events during endoscopy collected prospectively from our endoscopy quality system. 5 cases were identified from May 2013 to January 2019. All patients (4 men, 1 woman; age 45-76) underwent routine endoscopy (2 upper endoscopies, 2 colonoscopies, 1 upper endoscopy and colonoscopy) and noted ocular discomfort during recovery from the procedure. All procedures were performed under moderate sedation with 4 patients receiving non-anesthesiologist administered propofol sedation in our hospital endoscopy lab and the 5th patient receiving monitored anesthesia care (MAC) propofol sedation in the medical ICU. Procedure times ranged from 15 minutes to 2 hours 18 minutes. Oxygenation methods included two by nasal cannula (4L/min and 6L/min), two by non-rebreather mask (12 L/min), and one by Bilevel positive airway pressure mask (BiPAP). Ophthalmological examination confirmed the presence of a corneal abrasion in all cases. No patients had prior ocular disease or injury. DISCUSSION: Moderate sedation for GI endoscopy is very safe, but there exists a risk for corneal injury which has not been previously reported. Endoscopists and unit staff should be made aware of this complication, which is likely underrecognized. Training to ensure patient’s eyelids are fully closed during procedure, supplemental oxygen delivery systems are properly fitted and that there is no direct contact between the dependent eye and underlying head support can prevent this complication.

Nonoperating room anesthesia for gastrointestinal endoscopic procedures.

To assess the trends in nonoperating room anesthesia (NORA) for gastrointestinal endoscopy over the past few years, and to describe alternative methods of delivering propofol sedation in selected low-risk patients. The use of NORA for routine gastrointestinal endoscopic procedures has been rising steadily over the past decade in the United States, considerably increasing healthcare costs. Because of this, there have been attempts to develop nonanesthesiologist-administered propofol sedation methods in low-risk patients. There is controversy as to whether properly trained nonanesthesia personnel can use propofol safely via the modalities of nurse-administered propofol sedation, computer-assisted propofol sedation or nurse-administered continuous propofol sedation SUMMARY: The deployment of nonanesthesia-administered propofol sedation for low-risk procedures allows for optimal allocation of scarce anesthesia resources, which can be more appropriately used for more complex cases. This can address some of the current shortages in anesthesia provider supply, and can potentially reduce overall healthcare costs without sacrificing sedation quality. We also address the realm of anesthesia provider care for advanced endoscopic procedures including setup for administration of anesthesia, decision-making regarding placement of an endotracheal tube, and the potential need to move a challenging case to the operating room.

Sedation for advanced procedures in the bronchoscopy suite: proceduralist or anesthesiologist?

This article focuses on the issue of sedation provided either by proceduralists or anesthesiologists for advanced bronchoscopy procedures. The relative merits of both approaches are presented. Current evidence from the literature and guideline recommendations relevant to this topic are reviewed. In general, patient and proceduralist satisfaction as well as patient safety are increased when intravenous sedation is provided for advanced bronchoscopic procedures. However, guidelines by various societies remain vague on defining the appropriate level of care required when providing sedation for these procedures. In addition, targeted depth of sedation varies considerably among practitioners. While in some settings, nonanesthesiologist-administered propofol sedation has been proven safe; nevertheless, its use is controversial, especially in the bronchoscopy suite. The role of the anesthesiologist in sedation for advanced bronchoscopy remains undefined. When deep sedation for prolonged interventional procedures is needed or when dealing with patients who have multiple comorbidities, an anesthesiologist should be involved.

SafAIRway: an airway training for pulmonologists performing a flexible bronchoscopy with nonanesthesiologist administered propofol sedation: A prospective evaluation.

Nonanesthesiologist administered propofol (NAAP) sedation for flexible bronchoscopy is controversial, because there is no established airway management (AM) training for pulmonologists. The aim was to investigate the performance and acceptance of a proposed AM algorithm and training for pulmonologists performing NAAP sedation. The algorithm includes using 3 maneuvers including bag mask ventilation (BMV), laryngeal tube (LT), and needle cricothyrotomy (NCT). During training (consisting of 2 sessions with a break of 9 weeks in between), these maneuvers were demonstrated and exercised, followed by 4 consecutive attempts to succeed with each of these devices. The primary outcome was the improvement of completion time needed for a competent airway. Secondary outcomes were the trainees' overall reactions to the training and algorithm, and the perceptions of psychological safety (PS). The 23 staff members of the Department of Pulmonology performed a total of 552 attempts at AM procedures (4 attempts at each of the 3 maneuvers in 2 sessions), and returned a total of 42 questionnaires (4 questionnaires were not returned). Median completion times of LT and NCT improved significantly between Sessions 1 and 2 (P = 0.005 and P = 0.04, respectively), whereas BMV was only marginally improved (P = 0.05). Trainees perceived training to be useful and expressed satisfaction with this training and the algorithm. The perception of PS increased after training. An AM algorithm and training for pulmonologists leads to improved technical AM skills, and is considered useful by trainees and raised their perception of PS during training. It thus represents a promising program.

Is capnography mandatory during sedation for endoscopy?

Is capnography mandatory during sedation for endoscopy?

Anesthesiologist-Administered Gastrointestinal Sedation: Time to Put It to Sleep?

In the ongoing debate regarding sedation administered during gastrointestinal (GI) endoscopy, supporters of sedation administered by anesthesia providers (AAP) argue that anesthesiologists best handle complications involving the airways. Furthermore, the product label for propofol, the most commonly used sedative for GI endoscopy, states: ‘‘it should be administered only by persons trained in the administration of general anesthesia.’’ Supporters of nonanesthesiologist-administered propofol (NAAP) sedation, specifically nurse-administered propofol administration under the guidance of the endoscopist, argue that the safety profile of NAAP is equivalent to AAP while being costeffective. For lowand average-risk procedures, overwhelming worldwide data support the hypothesis that NAAP has a comparable safety profile to AAP if sedation is administered after proper training, and according to implemented guidelines [1]. In this issue of Digestive Diseases and Sciences, Goudra et al. [2] conducted a comparative meta-analysis evaluating respiratory complications of AAPor NAAP-administered sedation during advanced GI endoscopic procedures. The authors provide data with regard to 3018 advanced GI endoscopic procedures carried out using NAAP-administered sedation and 2374 AAP-administered procedures. Regarding non-advanced GI endoscopy, a prior populationbased analysis studying complications of sedation reported that the use of anesthesiologist services was associated with a higher complication frequency, specifically respiratory adverse events [3], a finding not supported by the data reported by Goudra et al. who described similar pooled hypoxia rates in patients undergoing advanced endoscopic procedures sedated with propofol, irrespective of administering provider, although the rate of airway interventions such as jaw thrust, chin lift, mask ventilation, or endotracheal intubation was higher in the AAP group. As AAPs administered higher doses of propofol, patient satisfaction and endoscopist satisfaction were increased if AAP-administered sedation was used. Satisfaction might have been further influenced by the observed preference for co-administration of adjuvants used in AAP sedation, whereas propofol alone was preferentially administered in the NAAP group. Nevertheless, higher dosages of propofol administered during GI sedation usually increase complication rates [4], particularly hypotension and bradycardia, which were not evaluated in the study by Goudra et al. It would have been interesting to see whether the observed beneficial satisfaction of AAP sedation came at the expense of higher cardiovascular adverse events. Limitations to the study of Goudra et al. include the exclusive selection of non-randomized prospective trials for analysis as there exist no randomized control trials comparing hypoxia, airway intervention rates, and patient satisfaction after endoscopic sedation. Furthermore, potential biases such as differences in baseline patient and endoscopist characteristics were not analyzed. While NAAP sedation for GI endoscopy has successfully and safely been introduced to countries such as Germany [5], it remains unlikely that NAAP will be soon introduced in other countries despite literature supporting its safety and lower cost, due to financial and political issues. When moderate sedation is provided by a US endoscopist, a separate charge for this service is not permitted & Kilian Friedrich Kilian.Friedrich@med.uni-heidelberg.de

Feasibility of non-anesthesiologist-administered propofol sedation for emergency endoscopic retrograde cholangiopancreatography.

Background. The safety of non-anesthesiologist-administered propofol (NAAP) sedation in emergent endoscopic retrograde cholangiopancreatography (ERCP) has not been fully clarified. Thus, the aim of this study was to assess the safety of NAAP sedation in emergent ERCP. Materials and Methods. We retrospectively analyzed 182 consecutive patients who had obstructive jaundice and who underwent ERCP under NAAP sedation. The patients were divided into Group A (with mild acute cholangitis or without acute cholangitis) and Group B (moderate or severe acute cholangitis). And technical safety and adverse events were assessed. Results. The adverse events were hypoxia (31 cases), hypotension (26 cases), and bradycardia (2 cases). There was no significant difference in the rate of each adverse event of hypoxia and bradycardia in either group. Although the rate of transient hypotension associated in Group B was higher than that in Group A, it was immediately improved with conservative treatment. Moreover, there were no patients who showed delayed awakening, or who developed other complications. Conclusions. In conclusion, NAAP sedation is feasible even in emergent ERCP. Although some transient adverse events (e.g., hypotension) were observed, no serious adverse events occurred. Thus, propofol can be used in emergent ERCP but careful monitoring is mandatory.

Current role of non-anesthesiologist administered propofol sedation in advanced interventional endoscopy.

Complex and lengthy endoscopic examinations like endoscopic ultrasonography and/or endoscopic retrograde cholangiopancreatography benefit from deep sedation, due to an enhanced quality of examinations, reduced discomfort and anxiety of patients, as well as increased satisfaction for both the patients and medical personnel. Current guidelines support the use of propofol sedation, which has the same rate of adverse effects as traditional sedation with benzodiazepines and/or opioids, but decreases the procedural and recovery time. Non-anesthesiologist administered propofol sedation has become an option in most of the countries, due to limited anesthesiology resources and the increasing evidence from prospective studies and meta-analyses that the procedure is safe with a similar rate of adverse events with traditional sedation. The advantages include a high quality of endoscopic examination, improved satisfaction for patients and doctors, as well as decreased recovery and discharge time. Despite the advantages of non-anesthesiologist administered propofol, there is still a continuous debate related to the successful generalization of the procedures.

Capnography during deep sedation with propofol by nonanesthesiologists: a randomized controlled trial.

Propofol, a short-acting hypnotic drug, is increasingly administered by a diverse group of specialists (e.g., cardiologists, gastroenterologists) during diagnostic and therapeutic procedures. Standard monitoring during sedation comprises continuous pulse oximetry with visual assessment of the patient's breathing pattern. Because undetected hypoventilation is a common pathway for complications, capnographic monitoring of exhaled carbon dioxide has been advocated. We examined whether the use of capnography reduces the incidence of hypoxemia during nonanesthesiologist-administered propofol sedation in patients who did not receive supplemental oxygen routinely. An open, stratified, randomized controlled trial was conducted in 427 healthy adult women during minor gynecology procedures in an outpatient clinic in the Netherlands. Patients were randomly assigned to receive either standard respiratory monitoring (standard care) or standard respiratory monitoring combined with capnography (capnography group). To replicate usual clinical practice, capnography monitoring was performed by the same medical team that provided sedation. The primary end point was the incidence of hypoxemia, defined as oxygen saturations <91%. From April 2010 to January 2011, 427 patients were enrolled. In the capnography group, 206 patients and in the standard care group, 209 patients were analyzed. The percentage of patients with a hypoxemic episode was 25.7% (53 of 206) in the capnography group and 24.9% (52 of 209) in the standard care group, resulting in an absolute difference of 0.8% (-7.5 to 9.2%). We were unable to confirm an additive role for capnography in preventing hypoxemia during elective nonanesthesiologist-administered propofol (monotherapy) sedation in healthy women in whom supplemental oxygen is not routinely administered. Based on the confidence interval, the benefit of adding capnography is at most an absolute hypoxemia reduction of 7.5%, suggesting that adding it in this practice setting to the routine monitoring strategy does not necessarily improve patient safety in daily practice.

Safety of Nonanesthesiologist-administered Propofol Sedation in Endoscopic Ultrasound

Background: Sedation during complex endoscopic procedures is important for comfort and safety of patient and ensures smooth and efficient completion of the procedure. This article evaluates safety of nonanesthesiologist-administered propofol (NAAP) sedation during endoscopic ultrasound. Materials and methods: Patients undergoing endoscopic ultrasound (EUS) with propofol sedation at Center for Liver and Digestive diseases (CLD), Holy Family Hospital, Rawalpindi, Pakistan were included. The primary outcome variable was the frequency of any sedation-related complication. Results: One hundred and ten patients fulfilling the inclusion criteria were enrolled in the study. Sixty (54.5%) patients were male and 50 (45.5%) were females. The mean age of study patients was 49 ± 18 years. The mean propofol dose was 203 ± 119 mg. There were 41% (n = 45) in ASA class I, 40% (n = 44) in ASA class II and 19% (n = 21) in ASA class III. The most common endosonographic finding was mediastinal and/ or abdominal lymphadenopathy (30.9%, n = 34) followed by a pancreatic mass in 21.8% (n = 24) patients, and a space occupying lesion (SOL) in liver in 15.5% (n = 16) patients. There were three cases with gallbladder mass (2.7%), two cases with CBD mass (1.8%), three cases (2.7%) with esophageal growth and 10 (9.1%) cases with gastric masses. Most of the patients, i.e. 98.2% (n = 108) had no sedation-related complication. Only 1.8% (n = 2) patients developed sedation-related minor complications who only required bag mask ventilation and subsequently recovered without any sequel. Conclusion: NAAP for endoscopic sedation is safe in patients undergoing EUS.

Preparación con picosulfato sódico/citrato de magnesio en dosis fraccionadas para colonoscopias en turno de mañana realizadas entre las 2 y 6 horas posteriores a la ingesta de líquidos

BackgroundSplit dosage of bowel preparations has been shown to substantially improve bowel cleansing. AimTo compare the split dose (SD) sodium picosulphate/magnesium oxide/anhydrous citric acid (Citrafleet®) regimen for morning colonoscopies with standard cleansing the day before. MethodsConsecutive outpatients were randomized to receive Citrafleet® the day before colonoscopy or SD, in whom the second half was administered on an individual basis from 2 to 6hours before the procedure. No bisacodyl was administered. All procedures were performed with non-anesthesiologist administered propofol sedation. The Boston scale was used to assess the quality of bowel preparation (adequate cleansing if score ≥ 6, with no score of 0/1 in any segment). ResultsA total of 193 patients were included. Overall bowel cleansing was significantly better in the SD group (7 vs. 5.2, p<0.001), as well as in the cecum (2.4 vs. 1.4, p < 0.001), ascending colon (2.5 vs. 1.6, p<0.001) and transverse colon (2.4 vs. 2, p=0.004). A significant proportion of SD patients had adequate bowel cleansing (71% vs. 30%, p<0.001). Patients in the SD group drank a greater amount of liquid (4.9 vs. 4 liters, p=0.006) and more frequently perceived the cleansing process to be easy or very easy to complete (89 vs. 68%, p=0.04), although they slept significantly fewer hours (6.5 vs. 7.9, p<0.001). No bronchoaspiration pneumonia was reported. ConclusionsSD Citrafleet® 2 to 6hours before colonoscopy increased the rate of procedures with adequate bowel cleansing by 40%, especially in the proximal colon, allowed more liquids to be drunk and increased the perception of ease in completing the preparation, with no sedation-related complications.

Nonanesthesiologist-administered propofol sedation for colonoscopy is safe and effective

Propofol is increasingly being used in sedated colonoscopy. This paper assesses the safety and efficacy of nonanesthesiologist-administered propofol in a large series of colonoscopies. A prospective registry of consecutive American Society of Anesthetics (ASA) class I and II outpatients undergoing colonoscopy was carried out. Propofol, administered by a nurse under an endoscopist's supervision, was the sole sedative agent used. Of the 1000 patients (563 women/437 men, mean age 57, range 8-89 years) included in the study, 57.4% showed ASA I and 42.6% ASA II characteristics. The cecal intubation rate was 96.9%. 48.2% of the procedures were for therapeutic purposes. The mean propofol dose was 177 mg (range 50-590 mg). Doses correlated inversely with patient age (r=-0.38; P<0.001) and were lower in ASA II patients (P<0.001) and in diagnostic (rather than therapeutic) exams (P<0.001). The average recovery time (from extracting the colonoscope to patient discharge) was 18.6 min (range 4-75) and longer in ASA II patients (P=0.05). A pulse oximetry saturation of less than 90% and a decrease in systolic blood pressure of more than 20 mmHg were observed in 24 (2.4%) and 385 (35.8%) patients, respectively. Both events were more frequent in patients older than 65 years (P<0.05); the latter was more common in ASA II patients. Colonoscopy under endoscopist-controlled propofol sedation in low-risk patients is safe and effective, allowing for a complete exploration, although patients at least 65 years old and/or classified as ASA II are more likely to present a decrease in blood pressure and have a prolonged recovery time.

Multisociety sedation curriculum for gastrointestinal endoscopy

Multisociety sedation curriculum for gastrointestinal endoscopy

Nonanesthesiologist-administered propofol sedation: from the exception to standard practice. Sedation and monitoring trends over 20 years

The practice of sedation, including monitoring practice for digestive endoscopy, continues to evolve throughout the world. In many countries, including Switzerland, there is a trend towards increased utilization of sedation during both routine and advanced endoscopic procedures. Sedation improves patient satisfaction with endoscopy and also improves the quality of the examination. In addition, a trend can be observed towards an increasing use of propofol as the preferred sedative drug. Here we review the latest published data from surveys describing sedation and monitoring practice in different countries and compare them with our own data from successive nationwide surveys among Swiss gastroenterologists over a period of 20 years. This development between these socioeconomically very similar Western industrialized countries, however, shows some unique and surprising differences. In Germany and Switzerland, propofol use has become increasingly widespread, in Switzerland even to the extent that during the last few years propofol has overtaken benzodiazepine sedation, with an absolute majority of Swiss gastroenterologists using it without the assistance of an anesthesiologist. In addition, the change in Switzerland reflects a successful generalization of nonanesthesiologist-administered propofol (NAAP) sedation from the hospital setting to private practice.

Non-anesthesiologist Administered Propofol Sedation is Standard Practice for Endoscopists in Switzerland: Sedation and Monitoring Trends Over 20 Years

Non-anesthesiologist Administered Propofol Sedation is Standard Practice for Endoscopists in Switzerland: Sedation and Monitoring Trends Over 20 Years

Non-anesthesiologist Administered Propofol Sedation for Endoscopic Procedures: A Worldwide Safety Review

Non-anesthesiologist Administered Propofol Sedation for Endoscopic Procedures: A Worldwide Safety Review