Sedation is commonly used for routine colonoscopies, but is it always necessary and does it always need to be administered by an anesthesiologist? Perhaps not, argue two anesthesiologists.
Joshua W. Sappenfield, MD, and Jeffrey D. White, MD, both from the University of Florida in Gainesville, write in a review that it "can be debated whether the presence of an anesthesiologist is truly necessary, helpful, or detrimental to the performance of successful screening colonoscopy."
Sedation may not always be needed, they argue, and light sedation can be administered by another healthcare professional.
The review was published in the August issue of Current Opinion in Anesthesiology.
The authors point out that in many countries unsedated screening colonoscopy is the standard of care, even though patients may prefer some sedation or at least have the option of asking for it during the procedure.
Some countries also allow propofol sedation to be delivered by nonanesthesiologists, with reportedly few cardiorespiratory complications.
In contrast, in the United States there has been a persistent increase in the number of low-risk patients, defined as American Society of Anesthesiologist (ASA) 1 and 2, receiving endoscopy (including screening colonoscopy) under high-cost anesthesia-delivered sedation, even though the guidelines of many commercial insurers state that this should not be reimbursed unless there is a demonstrated need.
In an era of increasing cost consciousness, healthcare costs are being heavily scrutinized and every expenditure is closely reviewed for medical necessity.
Starting a Conversation
The authors emphasize that they are not calling for an immediate change in current practice or suggesting this should become the standard of care.
"We're just trying to present facts and start a conversation," White said in a statement. "We don't want our review to be used as fodder to say, 'All right, anesthesiologists are superfluous.' "
He pointed out that anesthesiologists definitely have a place in the endoscopy suite, "but our function as academicians is to inform our fellow anesthesiologists about what is happening out there in the world so they can know what may or may not be coming."
"We're supposed to be advancing science and not be afraid of facts," White added. "And the facts are that you can actually have a colonoscopy unsedated."
Who Needs Sedation?
In their review, the authors cite several recent studies that addressed the question of sedation.
A large study of a cohort of 12 574 patients found that 77% did not require sedation (JAMA Intern Med. 2016;176:894-902). The authors note that key factors influencing the use of sedation include patient comfort, endoscopist skill, level of experience, technique (using water-exchange and carbon dioxide insufflation instead of air), and new-generation equipment (ultraslim endoscopes).
Another article (J South Med Univ. 2016;37:482-487) outlined a risk-stratification model for patients undergoing colonoscopy and found that independent risk factors for needing sedation or analgesia were elevated patient anxiety about pain during the procedure, experience level of the endoscopist, and low body mass index.
However, Sappenfield and White point out that patients are generally not happy to undergo colonoscopies without sedation, and multiple studies show that patients prefer to be sedated.
In addition, some research also suggests that the use of sedation may improve the rates of cecal intubation, examination completion, and polyp detection, while other research shows that a similar rate of cecal intubation can occur without it.
The authors also note that not only are more patients in the United States receiving sedation, they are also getting monitored anesthesia care, which usually implies propofol administration.
Some countries in Europe and Asia allow propofol to be administered without the supervision of an anesthesiologist, and other healthcare professionals appear to be able to safely administer propofol for endoscopic procedures.
But Sappenfield and White note that given the side effects of propofol, including risk of heart attack and brain damage, an anesthesiologist is a critical safeguard, especially because the gastroenterologist is focused on the colonoscopy.
"In a production-heavy environment where people are trying to get rapid turnovers, they may be inappropriately going past what is safe for the patient in an area where you may need someone with the appropriate knowledge and training to rescue you," Sappenfield said in a statement.
Risk stratification screening tools are needed to help preselect the patients that will likely request or require sedation for their colonoscopy.
A large multi-institutional randomized control trial would be necessary to rule out potential confounders as well as determine "whether there is a safety benefit or detriment to having anesthesiologist-directed care in the setting of routine colonoscopies in ASA 1 and 2 patients," they conclude.
"Further discussion would be necessary regarding what the monetary value of that effect is if a small difference were to be detected," they add.
The authors received no outside funding for writing the review and have reported no relevant financial relationships.
Curr Opin Anaesthesiol. 2018;31:463-468. Abstract
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Cite this: Are Anesthesiologists Always Needed for Routine Colonoscopy? - Medscape - Sep 03, 2018.