Consensus on Approving Propofol Sedation by Nonanesthesiologists

Andrea Riphaus

Disclosures

Abstract and Introduction

Abstract

Propofol sedation by nonanesthesiologists is still a highly controversial issue despite the fact that numerous studies have approved this sedation regimen for gastrointestinal endoscopy. A new position statement from a collaboration of four different American gastroenterology and hepatology societies outlines the latest recommendations for nonanesthesiologist administration of propofol.

Introduction

Over the past few years the interest in sedation for gastrointestinal endoscopy has grown worldwide, which is best reflected by a considerable increase in the use of sedation for diagnostic procedures.[1–3] This increase is, in turn, probably due to patients' preferences (for example, for colonoscopy) and an increase in the number of interventional measures being carried out.

Benzodiazepines, in combination with opioids, are the most commonly used agents for sedation; however, the use of propofol is increasing worldwide.[1,3] Propofol is equally well tolerated and has a substantially shorter wake-up time compared with benzodiazepines.[4] In addition, patients recover their psychomotor capacity (as tested in a driving simulator[5] and confirmed by a similar study by Horiuchi et al.[6]) much faster with propofol than benzodiazepines. A faster recovery potentially leads to a higher turnover of patients, which might be advantageous in the hospital and ambulatory setting, as postendoscopic monitoring capacity is often limited. A meta-analysis by Quadeer et al.[7] showed that the use of propofol for colonoscopy was associated with significantly fewer adverse effects compared with benzodiazepines, and had similar complication risks compared with benzodiazepines for esophagogastroduodenoscopy and endoscopic retrograde cholangiopancreatography.

Numerous studies have already confirmed the safety profile of nonanesthesiologist-administered propofol (NAAP). Rex et al.[8] published a worldwide study of the safety of endoscopist-directed administration of propofol. The mortality rate was 1 in 161,515 cases, which is a lower rate than for sedation with benzodiazepines, and not higher than the reported mortality rate with general anesthesia administered by an anesthesiologist.

However, the use of propofol, as for all other agents used for sedation, is not completely risk-free. In a risk factor analysis of 9,547 patients who received propofol for interventional upper endoscopy, multivariate analysis revealed that emergency intervention and a high propofol dose (>100 mg) were independent risk factors (regardless of who performed sedation) for cardiorespiratory complications.[9]

Staff training and appropriate selection of patients are crucial; small variations in the dose of propofol can cause sedation to be deeper than necessary, causing hypoxemia due to apnoic episodes. Furthermore, in contrast to midazolam (the most commonly used benzodiazepine) there is no antagonist for propofol. Both of these factors fuel the arguments of the critics of NAAP.

The latest position statement issued jointly by four gastroenterology societies—the AASLD, ACG, AGA, and ASGE[10]—provides an evidence-based assessment of propofol-mediated sedation regarding safety, efficacy, cost-effectiveness, and training issues for gastroenterologists and other nonanesthesiologists (mainly nursing staff) involved in the administration of propofol for gastrointestinal endoscopy. Some of the main conclusions are as follows: NAAP and standard sedation by nonanesthesiologists are comparable with respect to efficacy and safety; recovery time and time to sedation are shorter for NAAP compared with standard sedation; and anesthesiologist-administered propofol for healthy, low-risk patients results in high costs with no proven benefit.[10]

The authors of this position statement, and other international guideline committees dealing with the topic of NAAP in the past year, also recommend proper training for nonanesthesiologists to ensure that they are familiar with, and can minimize, potential adverse effects, and can deal with unavoidable sedation-related adverse effects;[10,11] patient safety is the main goal. Training programs have been established, but the duration and content of these programs are often very different. One issue that still remains is formulating a standardized, ideally worldwide, accepted curriculum to train nonanesthesiologists (that is, gastroenterologists and their nursing or assisting staff), as sufficient data for establishing proper training programs are missing.

The authors of the presented position statement came to an agreement on the following recommendations for training: the training program should provide didactic and practical, hands-on learning experiences; individuals administering propofol should be proficient in the management of upper and lower airway complications; training with life-size manikins and/or human simulators could improve learning; and preceptorship is an important element of training for physicians and nursing personnel.[10]

Ideally, training programs for NAAP should be evaluated by the appropriate societies and professional associations. An example to imitate might be the current national training program for nursing staff in Germany. Recognition of the need for qualification in the area of sedation arose from the preparation and publication of the first German evidence-based and consensus-based guideline on sedation in gastrointestinal endoscopy[11] by the German Society for Digestive and Metabolic Diseases (DGVS) and the German Society of Anesthesiology and Intensive Care Medicine (DGAI), a currently worldwide unique collaboration. This need was met by developing a curriculum for training courses. The curriculum was initially developed by the German Society for Endoscopy Assistance Personnel (DEGEA) in cooperation with physicians, and then approved by the DGVS. A major requirement for the approval of training programs is the documented cooperation of gastroenterologists, anesthesiologists and nurses. Within 1 year almost 100 courses with about 20 participants each were certified. The inclusion of anesthesiologists, which was requested by gastroenterologists, may enhance the acceptance of NAAP in anesthesiology under aspects of professional policy; there are numerous data supporting the performance of NAAP that cannot be ignored. It is expected that a position statement by the World Organisation of Digestive Endoscopy (OMED) and a sedation guideline on NAAP, which is currently being prepared by the European Society of Gastrointestinal Endoscopy (ESGE), will establish the inclusion of anesthesiologists in sedation guidelines and in training programs as standard, in line with the example of the German guideline.

Convincing our anesthesiologist colleagues that patient safety is the main goal in the evaluation of sedation guidelines, and convincing our gastroenterologist colleagues to keep defined conditions for patient safety (which are mainly adopted from anesthesiologists) could be the key to NAAP being generally accepted worldwide as a proven safe and cost-effective method for sedation in gastrointestinal endoscopy.

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