Safety and efficacy of non-anesthesiologist administration of propofol sedation during esophagogastroduodenoscopy in the intensive care unit

Abstract

Background and study aims Propofol sedation is an increasingly popular method of sedation for gastrointestinal endoscopic procedures. The safety and efficacy of the non-anesthesiologist administration of propofol (NAAP) sedation has been demonstrated in the ambulatory setting. However, NAAP sedation in intensive care unit (ICU) patients has not been reported. The purpose of this study is to determine safety and efficacy of NAAP sedation in an ICU population.

Methods We retrospectively reviewed esophagogastroduodenoscopies (EGD) performed with NAAP sedation in our intensive care units from June 2014 to September 2016. All EGDs were performed for evaluation of gastrointestinal bleeding. The primary end point of this study was to analyze the incidence of sedation-related adverse events (AEs). The secondary end points included successful completion of procedure and any endoscopic interventions performed.

Results Two of 161 procedures (1.2 %) had sedation-related AEs requiring procedure termination. One hundred forty-six of 161 procedures (90.7 %) were successfully completed. Incomplete procedures were due to excess heme, retained food or obstructive lesions (13/161, 8.1 %). Endoscopic intervention was performed successfully in 17/24 cases (70.8 %) that had endoscopically treated lesions identified. One hundred six of 161 patients (66 %) were American Society of Anesthesiologists (ASA) classification III or IV.

Conclusion Our retrospective analysis demonstrated that EGDs can be successfully completed in ICU patients using NAAP sedation. When procedures cannot be completed, it is rarely due to sedation-related AEs. NAAP sedation further allows adequate examination and successful treatment of high-risk lesions. NAAP sedation appears safe and effective for endoscopic procedures in the ICU setting.

• References

• 1 Crespo J, Terán Á. Endoscopy and sedation: an inseparable binomial for the gastroenterologist. Rev Española Enfermedades Dig 2018; 110: 250-252
• 2 Pérez-Cuadrado-Robles E, Ferreira A, García-Cano J. Enhancing the current evidence on endoscopist-directed propofol-based sedation. Rev Española Enfermedades Dig 2018; 110: 215-216
• 3 Triantafillidis JK, Merikas E, Nikolakis D. et al. Sedation in gastrointestinal endoscopy: Current issues. World J Gastroenterol 2013; 19: 463
• 4 Folino T, Parks LPropofol. StatPearls Publishing; 2017 Available at: http://www.ncbi.nlm.nih.gov/pubmed/28613634
• 5 Ng JM, Kong CF, Nyam D. Patient-controlled sedation with propofol for colonoscopy. Gastrointest Endosc 2001; 54: 8-13
• 6 Cohen LB, Hightower CD, Wood DA. et al. Moderate level sedation during endoscopy: a prospective study using low-dose propofol, meperidine/fentanyl, and midazolam. Gastrointest Endosc 2004; 59: 795-803
• 7 Uzman S, Gurbulak B, Gurbulak EK. et al. A comparison of propofol and midazolam/meperidine sedation in upper gastrointestinal endoscopy. Wideochir Inne Tech Maloinwazyjne 2016; 11: 178-185
• 8 VanNatta ME, Rex DK. Propofol alone titrated to deep sedation versus propofol in combination with opioids and/or benzodiazepines and titrated to moderate sedation for colonoscopy. Am J Gastroenterol 2006; 101: 2209-2217
• 9 Vargo JJ, Cohen LB, Rex DK. et al. Position statement: Nonanesthesiologist administration of propofol for GI endoscopy. Hepatology 2009; 50: 1683-1689
• 10 Newman LH, McDonald JC, Wallace PG. et al. Propofol infusion for sedation in intensive care. Anaesthesia 1987; 42: 929-937
• 11 Marinella MA. Propofol for sedation in the intensive care unit: essentials for the clinician. Respir Med 1997; 91: 505-510
• 12 Grounds RM, Lalor JM, Lumley J. et al. Propofol infusion for sedation in the intensive care unit: preliminary report. Br Med J (Clin Res Ed) 1987; 294: 397-400
• 13 McVay T, Fang JC, Taylor L. et al. Safety analysis of bariatric patients undergoing outpatient upper endoscopy with non-anesthesia administered propofol sedation. Obes Surg 2017; 27: 1501-1507
• 14 Yusoff IF, Raymond G, Sahai AV. Endoscopist administered propofol for upper-GI EUS is safe and effective: a prospective study in 500 patients. Gastrointest Endosc 2004; 60: 356-360
• 15 Horiuchi A, Nakayama Y, Hidaka N. et al. Low-dose propofol sedation for diagnostic esophagogastroduodenoscopy: results in 10,662 adults. Am J Gastroenterol 2009; 104: 1650-1655
• 16 Gouda B, Gouda G, Borle A. et al. Safety of non-anesthesia provider administered propofol sedation in non-advanced gastrointestinal endoscopic procedures: A meta-analysis. Saudi J Gastroenterol 2017; 23: 133-143
• 17 Rex DK, Overley CA, Walker J. Registered nurse-administered propofol sedation for upper endoscopy and colonoscopy: Why? When? How?. Rev Gastroenterol Disord 2003; 3: 70-80 [cited 2018 May 1]
• 18 Laine L, Jensen DM. Management of patients with ulcer bleeding. Am J Gastroenterol 2012; 107: 345-360
• 19 Lupei MI, Chipman JG, Beilman GJ. et al. The association between ASA status and other risk stratification models on postoperative intensive care unit outcomes. Anesth Analg 2014; 118: 989-994
• 20 Hopkins TJ, Raghunathan K, Barbeito A. et al. Associations between ASA Physical Status and postoperative mortality at 48 h: a contemporary dataset analysis compared to a historical cohort. Perioper Med (London, England) 2016; 5: 29
• 21 Uzman S, Yilmaz Y, Toptas M. et al. A retrospective analysis of postoperative patients admitted to the intensive care unit. Hippokratia 2016; 20: 38-43
• 22 Sathananthan D, Young E, Nind G. et al. Assessing the safety of physician-directed nurse-administered propofol sedation in low-risk patients undergoing endoscopy and colonoscopy. Endosc Int Open 2017; 5: E110-E115
• 23 Sieg A, Beck S. bng-Study-Group. et al. Safety analysis of endoscopist-directed propofol sedation: a prospective, national multicenter study of 24 441 patients in German outpatient practices. J Gastroenterol Hepatol 2014; 29: 517-523
• 24 Schilling D, Rosenbaum A, Schweizer S. et al. Sedation with propofol for interventional endoscopy by trained nurses in high-risk octogenarians: a prospective, randomized, controlled study. Endoscopy 2009; 41: 295-298
• 25 Jensen JT, Vilmann P, Horsted T. et al. Nurse-administered propofol sedation for endoscopy: a risk analysis during an implementation phase. Endoscopy 2011; 43: 716-722
• 26 Dumonceau J-M, Riphaus A, Schreiber F. et al. Non-anesthesiologist administration of propofol for gastrointestinal endoscopy: European Society of Gastrointestinal Endoscopy, European Society of Gastroenterology and Endoscopy Nurses and Associates Guideline – Updated June 2015. Endoscopy 2015; 47: 1175-1189
• 27 Early DS, Lightdale JR. et al. ASGE Standards of Practice Committee. GUIDELINE Guidelines for sedation and anesthesia in GI endoscopy. Gastroinest Endosc 2018; 87: 327-337