Jim Kling

October 22, 2013

SAN DIEGO — Whether propofol is administered by a certified registered nurse anesthetist who is supervised by an anesthesiologist or is unsupervised, the safety record is similar, according to a study conducted at one ambulatory endoscopy center. The finding could have significant cost implications for centers.

Patients tend to express greater satisfaction with propofol because it improves the efficiency of procedures. However, because the drug has a narrow therapeutic window and the potential for deep sedation, its labeling states that it should be administered only by individuals trained in general anesthesiology.

At Digestive Healthcare in Raleigh, North Carolina, propofol was adopted in 2008, said Murtaza Parekh, MD, who is a community gastroenterologist there. Initially, anesthesiologists supervised the certified registered nurse anesthetists. "Over time, as we got more comfortable with propofol, we felt it would be more cost effective to employ a nurse-only model," he told Medscape Medical News. The switch occurred in 2012.

Dr. Parekh and his team conducted a retrospective study comparing the 2 propofol protocols at Digestive Healthcare. He presented the results here at the American College of Gastroenterology 2013 Annual Scientific Meeting.

The researchers evaluated 99,818 consecutive propofol procedures conducted by a certified registered nurse anesthetist. Of these, 70,436 procedures were supervised by an anesthesiologist and 29,382 were not.

All patients had an American Society of Anesthesiologists (ASA) score of 1 to 3.

The researchers analyzed adverse events that occurred during or immediately after the procedure. They compared the frequency of a variety of adverse events with the 2 propofol protocols. There were no procedure-related deaths in either group.

Table. Adverse Events With the 2 Protocols

Event Supervised Administration, n (%) Unsupervised Administration, n (%) P Value
Aspiration 14 (0.020) 8 (0.027) .475512
Desaturation 53 (0.075) 23 (0.078) .87417
Laryngospasm 17 (0.024) 12 (0.041) .158105
Cardiac 14 (0.020) 6 (0.020) .955827
Perforation 8 (0.011) 1 (0.003) .227715
Splenic injury 0 (0.000) 1 (0.003) N/A


The unsupervised protocol seems to be "a more cost-effective means of delivering propofol," said Dr. Parekh. "We were able to reduce the overall cost to patients."

He emphasized that the center had a stringent patient selection criteria, but noted that these results are "certainly applicable to other centers that have the same mix of patients and the same selection criteria."

Because the study was sequential, it is important to be sure that the groups of patients are comparable, said Samir Gupta, MD, from the University of California at San Diego, who attended the presentation. "If the groups are comparable, then it really shows a very low risk of complications" with the unsupervised protocol, Dr. Gupta told Medscape Medical News.

Although complications were rare, Dr. Gupta wondered whether anesthesiologists might be valuable in the case of severe events. Is it possible that severe complications in the study population "might have been prevented if an anesthesiologist had been in the room?" he asked.

Dr. Parekh and Dr. Gupta have disclosed no relevant financial relationships.

American College of Gastroenterology (ACG) 2013 Annual Scientific Meeting and Postgraduate Course: Abstract 1. Presented October 14, 2013.


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