Guidelines Issued for Nonanesthesiologist Administration of Propofol for GI Endoscopy

Laurie Barclay, MD

December 08, 2009

December 8, 2009 — Four gastroenterology/hepatology societies have reviewed, approved, and issued recommendations for nonanesthesiologist administration of propofol (NAAP) for gastrointestinal (GI) endoscopy. The American Association for the Study of Liver Diseases, the American College of Gastroenterology, the American Gastroenterological Association Institute, and the American Society for Gastrointestinal Endoscopy have all collaborated to produce these guidelines.

The new guidelines are published in the December issues of Gastroenterology, Hepatology, the American Journal of Gastroenterology, and GIE: Gastrointestinal Endoscopy. A representative from each of the 4 issuing societies collaborated to issue the position statement, offering an evidence-based evaluation of propofol-mediated sedation administered by properly trained gastroenterologists and other nonanesthesiologists.

Who Is Allowed to Administer Propofol?

The position statement emphasizes that nonanesthesiologists can safely administer propofol for GI endoscopy, provided they are properly trained and select patients wisely, using criteria provided in the new guidelines. Propofol sedation administered by endoscopists now exceeds 600,000 patients, with a low rate of serious adverse events.

"Based on the evidence, the administration by nonanesthesiologists of propofol versus sedation with commonly used agents is comparable with respect to their efficacy and safety profiles," Lawrence B. Cohen, MD, chair of the Sedation Task Force, said in a news release.

"Gastroenterologists and registered nurses in many countries have successfully acquired the skills necessary to safely administer propofol-based sedation.... Although there are no cost-effectiveness data comparing NAAP to anesthesiologist-administered propofol sedation for GI endoscopy, it is known that the use of anesthesiologist-administered sedation for healthy, low-risk patients undergoing routine GI endoscopy results in higher costs with no proven benefit with respect to patient safety or procedural efficacy."

Propofol is an ultra-short-acting sedative agent without analgesic effects, but with sedative and amnestic effects at subhypnotic doses. US Food and Drug Administration approval information and product label state that when used to induce and maintain anesthesia, propofol ''should be administered only by persons trained in the administration of general anesthesia.'' Since propofol was first used in the 1980s, it has become widely used for sedation during endoscopy and other procedures.

Two methods for administering propofol under the supervision of an endoscopist include nurse-administered propofol sedation (NAPS) and combination or balanced propofol sedation (BPS). Small, titrated bolus doses of propofol are administered both in NAPS and BPS, but NAPS uses propofol as a single agent and is titrated to deep sedation, whereas BPS combines propofol with a small induction dose of a narcotic and/or benzodiazepine to achieve moderate sedation.

"Proper training and patient selection are crucial for the safe practice of NAAP sedation," the statement authors write. "Most studies show that NAAP sedation is superior to standard sedation regimens regarding time to sedation and time to recovery. Patient satisfaction with propofol sedation ranges from equivalent to slightly superior when compared to standard sedation."

Recommendations for Use of NAAP

Specific recommendations regarding the use of NAAP for GI endoscopy include the following:

  • The safety profile of NAAP is equivalent to that of "standard" sedation. For upper endoscopy and colonoscopy, the safety of NAAP is the same as that of a narcotic and a benzodiazepine in terms of risks for hypoxemia, hypotension, and bradycardia.

  • When administered during endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS), the safety profile of NAAP appears to be equivalent to that of standard sedation. However, definitive conclusions about the use of NAAP for these procedures cannot be drawn because of insufficient worldwide experience with NAAP in these settings.

  • NAAP is effective for GI endoscopy. Compared with sedation with commonly used agents, the time for sedation induction is shorter with NAAP used during upper endoscopy, colonoscopy, ERCP, and EUS. Compared with sedation using a narcotic and a benzodiazepine, administration of NAAP is associated with shorter recovery time from upper endoscopy, colonoscopy, ERCP, and EUS. Reported patient satisfaction with NAAP is equivalent or slightly better than that reported with standard sedation.

  • Economic considerations for NAAP suggest that it is cost-effective for GI endoscopy and that it is more cost-effective than standard sedation for ERCP and EUS. Practice efficiency for NAAP is also superior to that seen for sedation with commonly used agents. For healthy, low-risk patients undergoing routine GI endoscopy, using anesthesiologist-administered sedation costs more with no proven benefit regarding patient safety or procedural efficacy.

"Both didactic and hands-on experience as well as airway training and a preceptorship are currently believed to be important elements of a training program," the statement authors write.

Training Guidelines for NAAP

Specific training guidelines for NAAP for GI endoscopy include the following:

  • The skills and abilities that must be acquired to practice NAAP are distinct and separate from those required for standard sedation. Training programs for NAAP should involve practical, hands-on learning experiences as well as didactic curricula.

  • Clinicians administering propofol should be proficient in handling complications involving the upper and lower airway. Mastery is required of manual techniques for reestablishing airway patency, using oral and nasal airway devices, and properly ventilating with bag-mask. Clinicians administering propofol must be certified in basic life support or advanced cardiac life support. Acquiring these skills is facilitated by training with life-size manikins and/or human simulators.

  • An important element of training for physicians and nursing personnel learning to administer propofol is preceptorship, or practical experience and training supervised by an anesthesiologist, qualified endoscopist, or other appropriate expert.

  • To lower the incidence of apnea and hypoxemia during ERCP/EUS and upper endoscopy/colonoscopy, clinicians using NAAP should be trained in using apnography. This monitoring device measures the concentration of exhaled carbon dioxide, displayed as a numerical readout and waveform tracing.

"The use of anesthesiologist-administered propofol for healthy individuals undergoing elective endoscopy without risk factors for sedation-related complications is very costly, with no demonstrated improvement in patient safety or procedural outcome," the study authors conclude. "Further comparative trials of [NAPS] and [BPS] are warranted."

Gastroenterology. 2009;137:2161-2167. Abstract

Note: The guidelines are also published in the December issues of Hepatology, the American Journal of Gastroenterology, and GIE: Gastrointestinal Endoscopy.


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