Download PDF
Open Access
CC BY-NC-ND 4.0 · Journal of Digestive Endoscopy 2015; 6(04): 158-162
DOI: 10.4103/0976-5042.173961
Original Article
Journal of Digestive Endoscopy

Endoscopist-directed balanced propofol sedation is safe and effective in patients undergoing outpatient colonoscopy

Authors

  • Joseph H. Nathan

    1   Bruce and Ruth Rappaport, Faculty of Medicine, Technion.Israel Institute of Technology, Haifa, Afula, Israel

  • Amir Klein

    1   Bruce and Ruth Rappaport, Faculty of Medicine, Technion.Israel Institute of Technology, Haifa, Afula, Israel
    2   Department of Gastroenterology, Rambam Health Care Campus, Haifa, Afula, Israel

  • Ian M. Gralnek

    1   Bruce and Ruth Rappaport, Faculty of Medicine, Technion.Israel Institute of Technology, Haifa, Afula, Israel
    3   Ha’Emek Medical Center, Institute of Gastroenterology and Hepatology, Afula, Israel

  • Iyad Khamaysi

    1   Bruce and Ruth Rappaport, Faculty of Medicine, Technion.Israel Institute of Technology, Haifa, Afula, Israel
    2   Department of Gastroenterology, Rambam Health Care Campus, Haifa, Afula, Israel
Further Information

Publication History

Publication Date:
01 October 2019 (online)

Also available at
 PDF Download Permissions and Reprints

Abstract

Background and Aims: Propofol administered in combination with other moderate sedation medications (balanced propofol sedation [BPS]) is an appealing and effective sedation regimen for gastrointestinal (GI) endoscopy procedures. However, product labeling dictates propofol be administered only by anesthesiology personnel. We evaluated the safety of endoscopist-directed as well as anesthesiologist-administered BPS during outpatient colonoscopy. Methods: We performed a retrospective cohort study using prospectively collected endoscopy data where endoscopist-directed BPS is standard practice. Measured patient outcomes included: BPS drug dosages, postcolonoscopy oxygen saturation levels, pulse, and systolic/diastolic blood pressures, need for mask bag ventilation or endotracheal intubation, aborted colonoscopy due to sedation, hospital admission postcolonoscopy, and mortality. Results: From April 1 to November 30, 2013, 1036 patients undergoing outpatient colonoscopy (mean age 56.4 years, 55% males, 32% American Society of Anesthesiologists [ASA] I, 59% ASA II, 9% ASA III) received endoscopist-directed BPS. During the same time period, 40 patients (mean age 66.6 years, 55% males, 33% ASA II, 67% ASA III) received anesthesiologist-administered BPS. Indications for colonoscopy for the endoscopist-directed BPS included 352 (34%) colorectal cancer screening/surveillance, 404 (39%) evaluation of lower GI symptoms, 156 (15%) positive fecal occult blood, and 124 (12%) inflammatory bowel disease. BPS dosages (mean ± standard deviation) per patient were Fentanyl 0.05 mg (fixed dose), midazolam 1.6 mg ± 0.5 mg (range: 1-5 mg), and propofol 104 mg ± 62 mg (range: 10-460 mg). Propofol doses correlated inversely with patient age (r = −0.35; P < 0.001), and the mean Propofol dose was lower as ASA score increased: ASA I - 115 mg, ASA II - 103 mg, and ASA III - 75 mg (P < 0.01). No patient required bag mask ventilation, endotracheal intubation, or hospital admission. There were no aborted colonoscopies secondary to sedation and no mortality. All patients were discharged directly to home. Conclusions: Endoscopist-directed BPS appears safe and effective for low-, intermediate- and high-risk patients undergoing outpatient colonoscopy.

Key words

Anesthesiology - balanced propofol sedation - colonoscopy - conscious sedation - endoscopy - moderate sedation - monitored anesthesia care - propofol
 

  • References

  • 1 Inadomi JM, Gunnarsson CL, Rizzo JA, Fang H. Projected increased growth rate of anesthesia professional-delivered sedation for colonoscopy and EGD in the United States: 2009 to 2015. Gastrointest Endosc 2010;72:580-6.
  • 2 AstraZeneca. NOVAPLUS® Diprivan® 1% Propofol Injectable Emulsion Product-manufactures Recommendations. Available from: http://www1.astrazeneca-us.com/pi/diprivan.pdf. [Last accessed on 2009 Nov 06].
  • 3 Lewis JR, Cohen LB. Update on colonoscopy preparation, premedication and sedation. Expert Rev Gastroenterol Hepatol 2013;7:77-87.
  • 4 Dumonceau JM, Riphaus A, Aparicio JR, Beilenhoff U, Knape JT, Ortmann M, et al. 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. Endoscopy 2010;42:960-74.
  • 5 Coté GA, Hovis RM, Ansstas MA, Waldbaum L, Azar RR, Early DS, et al. Incidence of sedation-related complications with propofol use during advanced endoscopic procedures. Clin Gastroenterol Hepatol 2010;8:137-42.
  • 6 Shafer A, Doze VA, Shafer SL, White PF. Pharmacokinetics and pharmacodynamics of propofol infusions during general anesthesia. Anesthesiology 1988;69:348-56.
  • 7 Gupta A, Stierer T, Zuckerman R, Sakima N, Parker SD, Fleisher LA. Comparison of recovery profile after ambulatory anesthesia with propofol, isoflurane, sevoflurane and desflurane: A systematic review. Anesth Analg 2004;98:632-41.
  • 8 Roseveare C, Seavell C, Patel P, Criswell J, Kimble J, Jones C, et al. Patient-controlled sedation and analgesia, using propofol and alfentanil, during colonoscopy: A prospective randomized controlled trial. Endoscopy 1998;30:768-73.
  • 9 Seifert H, Schmitt TH, Gültekin T, Caspary WF, Wehrmann T. Sedation with propofol plus midazolam versus propofol alone for interventional endoscopic procedures: A prospective, randomized study. Aliment Pharmacol Ther 2000;14:1207-14.
  • 10 Cohen LB, Dubovsky AN, Aisenberg J, Miller KM. Propofol for endoscopic sedation: A protocol for safe and effective administration by the gastroenterologist. Gastrointest Endosc 2003;58:725-32.
  • 11 Cohen LB, Hightower CD, Wood DA, Miller KM, Aisenberg J. Moderate level sedation during endoscopy: A prospective study using low-dose propofol, meperidine/fentanyl, and midazolam. Gastrointest Endosc 2004;59:795-803.
  • 12 Vargo JJ, Cohen LB, Rex DK, Kwo PY; American Association for the Study of Liver Diseases, American College of Gasteroenterology, American Gastroenterological Association, American Society for Gastrointestinal Endoscopy. Position statement: Nonanesthesiologist administration of propofol for GI endoscopy. Gastroenterology 2009;137:2161-7.
  • 13 FDA Upholds ASA Stance on Safe Use of Propofol. American Society of Anesthesiologists; 2010. Available from: http://www.asahq.org/for-members/advocacy/washington-alerts/fda-upholds-asa-stance-on-safe-use-of-propofol.aspx. [Last accessed on 2014 Nov 04].
  • 14 Cohen LB. Sedation issues in quality colonoscopy. Gastrointest Endosc Clin N Am 2010;20:615-27.
  • 15 McQuaid KR, Laine L. A systematic review and meta-analysis of randomized, controlled trials of moderate sedation for routine endoscopic procedures. Gastrointest Endosc 2008;67:910-23.
  • 16 Miner JR, Burton JH. Clinical practice advisory: Emergency department procedural sedation with propofol. Ann Emerg Med 2007;50:182-7, 187.e1.
  • 17 Services CfMM. Revised Interpretive Guidelines For Anesthesia Services in Hospitals. Available from: http://www.asahq.org/Washington/12-11-09%20RevisedANHospitalInterpretiveGuidelines.pdf2009. [Last accessed on 2014 Nov 04].
  • 18 Rex DK, Deenadayalu VP, Eid E, Imperiale TF, Walker JA, Sandhu K, et al. Endoscopist-directed administration of propofol: A worldwide safety experience. Gastroenterology 2009;137:1229-37.
  • 19 Clarke AC, Chiragakis L, Hillman LC, Kaye GL. Sedation for endoscopy: The safe use of propofol by general practitioner sedationists. Med J Aust 2002;176:158-61.
  • 20 Aisenberg J, Cohen LB, Piorkowski JD Jr. Propofol use under the direction of trained gastroenterologists: An analysis of the medicolegal implications. Am J Gastroenterol 2007;102:707-13.
  • 21 Chutkan R, Cohen J, Abedi M, Cruz-Correa M, Dominitz J, Gersin K, et al. Training guideline for use of propofol in gastrointestinal endoscopy. Gastrointest Endosc 2004;60:167-72.
  • 22 Riphaus A, Wehrmann T, Weber B, Arnold J, Beilenhoff U, Bitter H, et al. S3 guideline: Sedation for gastrointestinal endoscopy 2008. Endoscopy 2009;41:787-815.
  • 23 Australian and New Zealand College of Anaesthetists (ANZCA) 2014. Guidelines on Sedation and/or Analgesia for Diagnostic and Interventional Medical, Dental or Surgical Procedures. [Online]. Available From: http://www.anzca.edu.au/resources/professional-documents/pdfs/ps09-2014-guidelines-on-sedation-and-or-analgesia-for-diagnostic-and-interventional-medical-dental-or-surgical-procedures.pdf. [Last accessed on 2015 Mar 24].