European Society of Gastrointestinal Endoscopy, European Society of Gastroenterology and Endoscopy Nurses and Associates, and the European Society of Anaesthesiology Guideline: Non-anesthesiologist administration of propofol for GI endoscopy

Propofol sedation by non-anesthesiologists is an upcoming sedation regimen in several countries throughout Europe. Numerous studies have shown the efficacy and safety of this sedation regimen in gastrointestinal endoscopy. Nevertheless, this issue remains highly controversial. The aim of this evidence- and consensus-based set of guideline is to provide non-anesthesiologists with a comprehensive framework for propofol sedation during digestive endoscopy. This guideline results from a collaborative effort from representatives of the European Society of Gastrointestinal Endoscopy (ESGE), the European Society of Gastroenterology and Endoscopy Nurses and Associates (ESGENA) and the European Society of Anaesthesiology (ESA). These three societies have endorsed the present guideline.

The guideline is published simultaneously in the Journals Endoscopy and European Journal of Anaesthesiology.

References

• 1 Baudet J-S, Borque P, Borja E. et al . Use of sedation in gastrointestinal endoscopy: a nationwide survey in Spain.  Eur J Gastroenterol Hepatol. 2009;  21 882-888
• 2 Radaelli F, Meucci G, Sgroi G, Minoli G. and the Italian Association of Hospital Gastroenterologists (AIGO) . Technical performance of colonoscopy: the key role of sedation/analgesia and other quality indicators.  Am J Gastroenterol. 2008;  103 1122-1130
• 3 McQuaid K R, Laine L. A systematic review and meta-analysis of randomized, controlled trials of moderate sedation for routine endoscopic procedures.  Gastrointest Endosc. 2008;  67 910-923
• 4 Heuss L T, Froehlich F, Beglinger C. Changing patterns of sedation and monitoring practice during endoscopy: results of a nationwide survey in Switzerland.  Endoscopy. 2005;  37 161-166
• 5 Rex D, Deenadayalu V, Eid E. et al . Endoscopist-directed administration of propofol: a worldwide safety experience.  Gastroenterology. 2009;  137 1229-1237
• 6 Paspatis G, Manolaraki M, Tribonias G. et al . Endoscopic sedation in Greece: results from a nationwide survey for the Hellenic Foundation of gastroenterology and nutrition.  Dig Liv Dis. 2009;  41 807-811
• 7 Riphaus A, Rabofski M, Wehrmann T. Endoscopic sedation and monitoring practice in Germany: results from the first nationwide survey.  Zeitschrift für Gastroenterologie. 2010;  48 392-397
• 8 Harbour R, Miller J. A new system for grading recommendations in evidence based guidelines.  BMJ. 2001;  323 334-336
• 9 Dewitt J, McGreevy K, Sherman S, Imperiale T F. Nurse-administered propofol sedation compared with midazolam and meperidine for EUS: a prospective, randomized trial.  Gastrointest Endosc. 2008;  68 499-509
• 10 Jung M, Hofmann C, Kiesslich R, Brackertz A. Improved sedation in diagnostic and therapeutic ERCP: propofol is an alternative to midazolam.  Endoscopy. 2000;  32 233-238
• 11 Riphaus A, Stergiou N, Wehrmann T. Sedation with propofol for routine ERCP in high-risk octogenarians: a randomized, controlled study.  Am J Gastroenterol. 2005;  100 1957-1963
• 12 Meining A, Semmler V, Kassem A M. et al . The effect of sedation on the quality of upper gastrointestinal endoscopy: an investigator-blinded, randomized study comparing propofol with midazolam.  Endoscopy. 2007;  39 345-349
• 13 Singh H, Poluha W, Cheung M. et al . Propofol for sedation during colonoscopy.  Cochrane database of systematic reviews. 2008;  CD006268
• 14 Qadeer M A, Vargo J J, Khandwala F. et al . Propofol versus traditional sedative agents for gastrointestinal endoscopy: a meta-analysis.  Clin Gastroenterol Hepatol. 2005;  3 1049-1056
• 15 Vargo J J, Bramley T, Meyer K, Nightengale B. Practice efficiency and economics: the case for rapid recovery sedation agents for colonoscopy in a screening population.  J Clin Gastroenterol. 2007;  41 591-598
• 16 Riphaus A, Wehrmann T, Weber B. et al . S3 Guideline: Sedation for gastrointestinal endoscopy 2008.  Endoscopy. 2009;  41 787-815
• 17 Lichtenstein D R, Jagannath S, Baron T H. et al . Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy. Sedation and anesthesia in GI endoscopy.  Gastrointest Endosc. 2008;  68 815-826
• 18 Knape J TA, Adriaensen H, van Aken H. et al . Guidelines for sedation and/or analgesia by non-anaesthesiology doctors.  Eur J Anaesth. 2007;  24 563-567
• 19 Cohen L B, Delegge M H, Aisenberg J. et al . AGA Institute review of endoscopic sedation.  Gastroenterology. 2007;  133 675-701
• 20 Byrne M F, Chiba N, Singh H, Sadowski D C.. Clinical Affairs Committee of the Canadian Association of Gastroenterology . Propofol use for sedation during endoscopy in adults: a Canadian Association of Gastroenterology position statement.  Can J Gastroenterol. 2008;  22 457-459
• 21 Rex D K, Heuss L T, Walker J A, Qi R. Trained registered nurses/endoscopy teams can administer propofol safely for endoscopy.  Gastroenterology. 2005;  129 1384-1391
• 22 Rex D K, Overley C A, Walker J. Registered nurse-administered propofol sedation for upper endoscopy and colonoscopy: Why? When? How?.  Rev Gastroenterol Dis. 2003;  3 70-80
• 23 Fatima H, Dewitt J, Leblanc J. et al . Nurse-administered propofol sedation for upper endoscopic ultrasonography.  Am J Gastroenterol. 2008;  103 1649-1656
• 24 Tohda G, Higashi S, Wakahara S. et al . Propofol sedation during endoscopic procedures: safe and effective administration by registered nurses supervised by endoscopists.  Endoscopy. 2006;  38 360-367
• 25 Maffei M, Dumortier J, Dumonceau J M. Self-training in unsedated transnasal EGD by endoscopists competent in standard peroral EGD: prospective assessment of the learning curve.  Gastrointest Endosc. 2008;  67 410-418
• 26 Beilenhoff U, Engelke M, Kern-Wächter E. et al .DEGEA-Curriculum Sedierung und Notfallmanagement in der Endoskopie für Endoskopiepflege-und-assistenzpersonal. http://www.degea.de/typo3/fileadmin/Fachinformationen/Sedierung/DEGEA-Curriculum.pdf; Accessed on Nov 15, 2009
• 27 DeMaria S, Levine A I, Cohen L B. Human patient simulation and its role in endoscopic sedation training.  Gastrointest Endosc Clin N Am. 2008;  18 801-813
• 28 Heuss L T, Schnieper P, Drewe J. et al . Risk stratification and safe administration of propofol by registered nurses supervised by the gastroenterologist: a prospective observational study of more than 2000 cases.  Gastrointest Endosc. 2003;  57 664-671
• 29 Cohen L B, Dubovsky A N, Aisenberg J, Miller K M. Propofol for endoscopic sedation: a protocol for safe and effective administration by the gastroenterologist.  Gastrointest Endosc. 2003;  58 725-732
• 30 Eckardt V F, Kanzler G, Schmitt T. et al . Complications and adverse effects of colonoscopy with selective sedation.  Gastrointest Endosc. 1999;  49 560-565
• 31 Quine M A, Bell G D, McCloy R F. et al . Prospective audit of upper gastrointestinal endoscopy in two regions of England: safety, staffing, and sedation methods.  Gut. 1995;  36 462-467
• 32 Bhananker S M, Posner K L, Cheney F W. et al . Injury and liability associated with monitored anesthesia care: a closed claims analysis.  Anesthesiology. 2006;  104 228-234
• 33 Williams E J, Taylor S, Fairclough P. et al . Are we meeting the standards set for endoscopy? Results of a large-scale prospective survey of endoscopic retrograde cholangio-pancreatograph practice.  Gut. 2007;  56 821-829
• 34 Gupta A. Preoperative screening and risk assessment in the ambulatory surgery patient.  Cur Opin Anaesth. 2009;  22 705-711
• 35 ASA .Physical Status Classification System. http://www.asahq.org/clinical/physicalstatus.htm; Accessed on Apr 15, 2010
• 36 Mallampati S R, Gatt S P, Gugino L D. et al . A clinical sign to predict difficult tracheal intubation: a prospective study.  Can Anaesth Soc J. 1985;  32 429-434
• 37 Gross J B, Bailey P L, Connis R T. et al . Practice guidelines for sedation and analgesia by non-anesthesiologists.  Anesthesiology. 2002;  96 1004-1017
• 38 Külling D, Orlandi M, Inauen W. Propofol sedation during endoscopic procedures: how much staff and monitoring are necessary?.  Gastrointest Endosc. 2007;  66 443-449
• 39 Yusoff I F, Raymond G, Sahai A V. Endoscopist administered propofol for upper-GI EUS is safe and effective: a prospective study in 500 patients.  Gastrointest Endosc. 2004;  60 356-360
• 40 Horiuchi A, Nakayama Y, Katsuyama Y. et al . Safety and driving ability following low-dose propofol sedation.  Digestion. 2008;  78 190-194
• 41 Smith M R, Bell G D, Fulton B. et al . A comparison of winged steel needles and Teflon cannulas in maintaining intravenous access during gastrointestinal endoscopy.  Gastrointest Endosc. 1993;  39 33-36
• 42 al-Qorain A, Adu-Gyamfi Y, Larbi E B, al-Shedokhi F. The effect of supplemental oxygen in sedated and unsedated patients undergoing upper gastrointestinal endoscopy.  J Int Med Res. 1993;  21 165-170
• 43 Bell G D, Quine A, Antrobus J H. et al . Upper gastrointestinal endoscopy: a prospective randomized study comparing continuous supplemental oxygen via the nasal or oral route.  Gastrointest Endosc. 1992;  38 319-325
• 44 Bowling T E, Hadjiminas C L, Polson R J. et al . Effects of supplemental oxygen on cardiac rhythm during upper gastrointestinal endoscopy: a randomised controlled double blind trial.  Gut. 1993;  34 1492-1497
• 45 Crantock L, Cowen A E, Ward M, Roberts R K. Supplemental low flow oxygen prevents hypoxia during endoscopic cholangiopancreatography.  Gastrointest Endosc. 1992;  38 418-420
• 46 Gross J B, Long W B. Nasal oxygen alleviates hypoxemia in colonoscopy patients sedated with midazolam and meperidine.  Gastrointest Endosc. 1990;  36 26-29
• 47 Haines D J, Bibbey D, Green J R. Does nasal oxygen reduce the cardiorespiratory problems experienced by elderly patients undergoing endoscopic retrograde cholangiopancreatography?.  Gut. 1992;  33 973-975
• 48 Iwao T, Toyonaga A, Shigemori H. et al . Supplemental oxygen during endoscopic variceal ligation: effects on arterial oxygenation and cardiac arrhythmia.  Am J Gastroenterol. 1995;  90 2186-2190
• 49 Patterson K W, Noonan N, Keeling N W. et al . Hypoxemia during outpatient gastrointestinal endoscopy: the effects of sedation and supplemental oxygen.  J Clin Anesth. 1995;  7 136-140
• 50 Rozario L, Sloper D, Sheridan M J. Supplemental oxygen during moderate sedation and the occurrence of clinically significant desaturation during endoscopic procedures.  Gastroenterol Nursing. 2008;  31 281-285
• 51 Sharma V K, Nguyen C C, Crowell M D. et al . A national study of cardiopulmonary unplanned events after GI endoscopy.  Gastrointest Endosc. 2007;  66 27-34
• 52 Froehlich F, Harris J K, Wietlisbach V. et al . Current sedation and monitoring practice for colonoscopy: an International Observational Study (EPAGE).  Endoscopy. 2006;  38 461-469
• 53 Vargo J J, Zuccaro G, Dumot J A. et al . Automated graphic assessment of respiratory activity is superior to pulse oximetry and visual assessment for the detection of early respiratory depression during therapeutic upper endoscopy.  Gastrointest Endosc. 2002;  55 826-831
• 54 Qadeer M A, Vargo J J, Dumot J A. et al . Capnographic monitoring of respiratory activity improves safety of sedation for endoscopic cholangiopancreatography and ultrasonography.  Gastroenterology. 2009;  136 1568-1576; quiz 1819 – 1520
• 55 Lightdale J R, Goldmann D A, Feldman H A. et al . Microstream capnography improves patient monitoring during moderate sedation: a randomized, controlled trial.  Pediatrics. 2006;  117 e1170-e1178
• 56 Drake L M, Chen S C, Rex D K. Efficacy of bispectral monitoring as an adjunct to nurse-administered propofol sedation for colonoscopy: a randomized controlled trial.  Am J Gastroenterol. 2006;  101 2003-2007
• 57 Imagawa A, Fujiki S, Kawahara Y. et al . Satisfaction with bispectral index monitoring of propofol-mediated sedation during endoscopic submucosal dissection: a prospective, randomized study.  Endoscopy. 2008;  40 905-909
• 58 Paspatis G A, Chainaki I, Manolaraki M M. et al . Efficacy of bispectral index monitoring as an adjunct to propofol deep sedation for ERCP: a randomized controlled trial.  Endoscopy. 2009;  41 1046-1051
• 59 Wehrmann T, Grotkamp J, Stergiou N. et al . Electroencephalogram monitoring facilitates sedation with propofol for routine ERCP: a randomized, controlled trial.  Gastrointest Endosc. 2002;  56 817-824
• 60 American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists . Practice guidelines for sedation and analgesia by non-anesthesiologists.  Anesthesiology. 2002;  96 1004-1017
• 61 American Society of Anesthesiologists Task Force on Preanesthesia Evaluation . Practice advisory for preanesthesia evaluation: a report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation.  Anesthesiology. 2002;  96 485-496
• 62 Ely E W, Truman B, Shintani A. et al . Monitoring sedation status over time in ICU patients: reliability and validity of the Richmond Agitation-Sedation Scale (RASS).  JAMA. 2003;  289 2983-2991
• 63 Muller S, Borowics S M, Fortis E AF. et al . Clinical efficacy of dexmedetomidine alone is less than propofol for conscious sedation during ERCP.  Gastrointest Endosc. 2008;  67 651-659
• 64 Paspatis G A, Manolaraki M M, Vardas E. et al . Deep sedation for endoscopic retrograde cholangiopancreatography: intravenous propofol alone versus intravenous propofol with oral midazolam premedication.  Endoscopy. 2008;  40 308-313
• 65 Ong W C, Santosh D, Lakhtakia S, Reddy D N. A randomized controlled trial on use of propofol alone versus propofol with midazolam, ketamine, and pentazocine “sedato-analgesic cocktail” for sedation during ERCP.  Endoscopy. 2007;  39 807-812
• 66 Disma N, Astuto M, Rizzo G. et al . Propofol sedation with fentanyl or midazolam during oesophagogastroduodenoscopy in children.  Eur J Anaesth. 2005;  22 848-852
• 67 Paspatis G A, Charoniti I, Manolaraki M. et al . Synergistic sedation with oral midazolam as a premedication and intravenous propofol versus intravenous propofol alone in upper gastrointestinal endoscopies in children: a prospective, randomized study.  J Pediatr Gastroenterol Nutr. 2006;  43 195-199
• 68 Padmanabhan U, Leslie K, Eer A S. et al . Early cognitive impairment after sedation for colonoscopy: the effect of adding midazolam and/or fentanyl to propofol.  Anesth Analg. 2009;  109 1448-1455
• 69 VanNatta M E, Rex D K. 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
• 70 Fanti L, Agostoni M, Arcidiacono P G. et al . Target-controlled infusion during monitored anesthesia care in patients undergoing EUS: propofol alone versus midazolam plus propofol. A prospective double-blind randomised controlled trial.  Dig Liv Dis. 2007;  39 81-86
• 71 Crepeau T, Poincloux L, Bonny C. et al . Significance of patient-controlled sedation during colonoscopy. Results from a prospective randomized controlled study.  Gastroenterol Clin Biol. 2005;  29 1090-1096
• 72 Külling D, Fantin A C, Biro P. et al . Safer colonoscopy with patient-controlled analgesia and sedation with propofol and alfentanil.  Gastrointest Endosc. 2001;  54 1-7
• 73 Heuss L T, Drewe J, Schnieper P. et al . Patient-controlled versus nurse-administered sedation with propofol during colonoscopy. A prospective randomized trial.  Am J Gastroenterol. 2004;  99 511-518
• 74 Leslie K, Absalom A, Kenny G NC. Closed loop control of sedation for colonoscopy using the Bispectral Index.  Anaesthesia. 2002;  57 693-697
• 75 Pambianco D J, Whitten C J, Moerman A. et al . An assessment of computer-assisted personalized sedation: a sedation delivery system to administer propofol for gastrointestinal endoscopy.  Gastrointest Endosc. 2008;  68 542-547
• 76 Leslie K, Clavisi O, Hargrove J. Target-controlled infusion versus manually-controlled infusion of propofol for general anaesthesia or sedation in adults.  Cochrane database of systematic reviews. 2008;  CD006059
• 77 Bechtold M L, Puli S R, Othman M O. et al . Effect of music on patients undergoing colonoscopy: a meta-analysis of randomized controlled trials.  Dig Dis Sci. 2009;  54 19-24
• 78 Rudin D, Kiss A, Wetz R V, Sottile V M. Music in the endoscopy suite: a meta-analysis of randomized controlled studies.  Endoscopy. 2007;  39 507-510
• 79 Tam W WS, Wong E LY, Twinn S F. Effect of music on procedure time and sedation during colonoscopy: a meta-analysis.  World J Gastroenterol. 2008;  14 5336-5343
• 80 Lee D WH, Chan K-W, Poon C-M. et al . Relaxation music decreases the dose of patient-controlled sedation during colonoscopy: a prospective randomized controlled trial.  Gastrointest Endosc. 2002;  55 33-36
• 81 Evans L T, Saberi S, Kim H M. et al . Pharyngeal anesthesia during sedated EGDs: is “the spray” beneficial? A meta-analysis and systematic review.  Gastrointest Endosc. 2006;  63 761-766
• 82 Othman M O, Bradley A G, Choudhary A. et al . Variable stiffness colonoscope versus regular adult colonoscope: meta-analysis of randomized controlled trials.  Endoscopy. 2009;  41 17-24
• 83 Lee D WH, Li A CN, Ko C-W. et al . Use of a variable-stiffness colonoscope decreases the dose of patient-controlled sedation during colonoscopy: a randomized comparison of 3 colonoscopes.  Gastrointest Endosc. 2007;  65 424-429
• 84 Maple J T, Keswani R N, Hovis R M. et al . Carbon dioxide insufflation during ERCP for reduction of postprocedure pain: a randomized, double-blind, controlled trial.  Gastrointest Endosc. 2009;  70 278-283
• 85 Riss S, Akan B, Mikola B. et al . CO2 insufflation during colonoscopy decreases post-interventional pain in deeply sedated patients: a randomized controlled trial.  Wien Klin Wochenschr. 2009;  121 464-468
• 86 Fukada T, Ozaki M. Microbial growth in propofol formulations with disodium edetate and the influence of venous access system dead space.  Anaesthesia. 2007;  62 575-580
• 87 Tallis G F, Ryan G M, Lambert S B. et al . Evidence of patient-to-patient transmission of hepatitis C virus through contaminated intravenous anaesthetic ampoules.  J Viral Hepat. 2003;  10 234-239
• 88 Riker R R, Glisic E K, Fraser G L. Propofol infusion syndrome: difficult to recognize, difficult to study.  Crit Care Med. 2009;  37 3169-3170
• 89 Picard P, Tramèr M R. Prevention of pain on injection with propofol: a quantitative systematic review.  Anesth Analg. 2000;  90 963-969
• 90 Newman D H, Azer M M, Pitetti R D, Singh S. When is a patient safe for discharge after procedural sedation? The timing of adverse effect events in 1367 pediatric procedural sedations.  Ann Emerg Med. 2003;  42 627-635
• 91 Aldrete J A. Modifications to the postanesthesia score for use in ambulatory surgery.  J Perianesth Nurs. 1998;  13 148-155
• 92 Chung F, Chan V W, Ong D. A post-anesthetic discharge scoring system for home readiness after ambulatory surgery.  J Clin Anesth. 1995;  7 500-506
• 93 Amornyotin S, Chalayonnavin W, Kongphlay S. Recovery pattern and home-readiness after ambulatory gastrointestinal endoscopy.  J Med Assoc Thai. 2007;  90 2352-2358
• 94 Ead H. From Aldrete to PADSS: Reviewing discharge criteria after ambulatory surgery.  J Perianesth Nurs. 2006;  21 259-267
• 95 Willey J, Vargo J J, Connor J T. et al . Quantitative assessment of psychomotor recovery after sedation and analgesia for outpatient EGD.  Gastrointest Endosc. 2002;  56 810-816
• 96 Riphaus A, Gstettenbauer T, Frenz M B, Wehrmann T. Quality of psychomotor recovery after propofol sedation for routine endoscopy: a randomized and controlled study.  Endoscopy. 2006;  38 677-683
• 97 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
• 98 Pitetti R, Davis P J, Redlinger R. et al . Effect on hospital-wide sedation practices after implementation of the 2001 JCAHO procedural sedation and analgesia guidelines.  Arch Pediatric Adolesc Med. 2006;  160 211-216
• 99 Cohen L B, Wecsler J S, Gaetano J N. et al . Endoscopic sedation in the United States: results from a nationwide survey.  Am J Gastroenterol. 2006;  101 967-974
• 100 Aisenberg J, Cohen L B, Piorkowski J D. Propofol use under the direction of trained gastroenterologists: an analysis of the medicolegal implications.  Am J Gastroenterol. 2007;  102 707-713
• 101 Cotton P B. Analysis of 59 ERCP lawsuits; mainly about indications.  Gastrointest Endosc. 2006;  63 378-382; quiz 464

1 Both authors collaborated equally to this work.

2 NAAP Task Force Members: L. Aabakken, Rikshospitalet – Radiumhospitalet Medical Center, Oslo, Norway; A. Axon, The General Infirmary, Leeds, United Kingdom; A. Axon, Parlane Plowden, Leeds, United Kingdom; G. Costamagna, Policlinico A. Gemelli, Rome, Italy; E. Giostra, Geneva University Hospitals, Geneva, Switzerland; P. Hornslet, Gentofte Hospital, Copenhagen University, Hellerup, Denmark; S. Ladas, ”Attikon” University General Hospital Medical School, Athens, Greece; T. Marek, Silesian Academy of Medicine, Katowice, Poland; M. Dinis-Ribeiro, Portuguese Oncology Center Porto, CINTESIS/Porto Faculty of Medicine, Portugal.