Gastroenterologist-directed sedation safe and effective for endoscopic procedures

Aug 3 2007

The use of an evidence-based sedation protocol for endoscopic procedures improves the quality of practice and reduces the incidence of sedation-related adverse events, according to an AGA Institute Review of Endoscopic Sedation published in the August issue of Gastroenterology, the official journal of the American Gastroenterological Association (AGA) Institute.

"The AGA Institute supports the administration of sedation by gastroenterologists performing endoscopic procedures on average risk patients, provided that they have proper training and experience, stated Nicholas LaRusso, MD, AGAF, President of the AGA Institute. "Patients should feel comfortable undergoing an endoscopic procedure, including the administration of intravenous sedation, by a gastroenterologist who is trained and licensed."

The use of sedation during endoscopic procedures, including colonoscopies and upper endoscopies, is considered a medical necessity by gastroenterologists, with more than 98 percent utilizing sedation during these procedures. By reducing a patient's anxiety and discomfort during the procedure, gastroenterologists are able to better ensure that they are performing a thorough exam while minimizing the patient's risk of injury and improving their tolerability.

"Due to the widespread use of sedation during endoscopy procedures, it is of great importance that gastroenterologists implement sedation protocols in their practices to improve the quality of practice and minimize the risk of sedation-related adverse events," according to Lawrence Cohen, MD, AGAF, associate clinical professor at The Mount Sinai Hospital, New York, and co-author of the paper.

The review was based on an evidence-based analysis of the literature, whenever possible. In areas in which evidence from controlled studies was absent, data from case series, retrospective database studies and expert opinions in endoscopy and anesthesia were used. The AGA Institute Review generated 16 summary statements and recommendations on the use of sedation in endoscopies:

1. Preprocedure patient evaluations should be performed and documented prior to endoscopy procedures to enable gastroenterologists to identify pertinent patient history and physical findings that may affect sedation outcomes.
2. There are instances when the use of an anesthesia professional should be considered during endoscopy procedures including patients with ASA physical status of IV and V (patients with severe systemic disease or patients who are morbid or at substantial risk of death) and patients with a history of being difficult to sedate
3. Endoscopists should be familiar with the unique pharmacologic properties of all agents used for sedation and reversal during the procedures, including time of onset, peak response, duration of effect, patient variations in responsiveness to the drugs and potential drug-drug interactions.
4. Most patients can be sedated with a combination of opioids (which induce analgesic and sedative effects) and benzodiazepines (which induce minimal sedation, amnesia, muscle relaxation and anesthesia). For difficult-to-sedate patients, an adjunctive agent may be combined with conventional sedation.
5. Gastroenterologist-directed administration of propofol is safe and effective for patients. Specialized training is required for the physician and nursing staff prior to implementing a propofol sedation program.
6. Medical professionals who administer sedation should possess the ability to recognize and rescue patients who fall into a level of sedation deeper than originally intended.
7. The use of noninvasive monitoring devices , pulse oximetry, automated noninvasive blood pressure, and others , are supplemental to clinical observation of the patient.
8. New methods of monitoring are currently undergoing clinical evaluation. Their routine use for moderate sedation cannot be recommended currently based upon the available literature. These methods include capnography, a noninvasive technique to measure CO2 in expired gases, and BIS monitoring, a noninvasive method of assessing a patient's level of consciousness.
9. Physicians targeting moderate sedation for their patients should be capable of rescuing a patient who enters deep sedation. Those targeting deep sedation should be trained in advanced airway management and treatment of cardiorespiratory complications.
10. Endoscopists training for sedation should emphasize an understanding of medications used for endoscopic sedation and the skills necessary for the diagnosis and treatment of cardiopulmonary complication as well as current certification in advanced cardiac life support (ACLS).
11. The gastroenterological professional societies should encourage member training and certification in sedation, as well as continuing education and recertification, such as the upcoming Fourth Annual Endoscopic Sedation: Preparing for the Future, which is jointly sponsored by the Mount Sinai School of Medicine, the Digestive Disease Research Foundation and the AGA Institute.
12. The endoscopist should conduct an informed face-to-face consent discussion with the patient prior to the procedure to provide information including the risks, benefits and alternatives to the proposed sedation and to answer the patient's questions.
13. Endoscopists should be ACLS certified and provide sedation in keeping with expert practice guidelines and with institutional and state guidelines. Endoscopy units should conform to practice guidelines as well.
14. Gastroenterologist-directed propofol sedation is medicolegally reasonable, but requires appropriate endoscopist training, patient selection and adherence to protocols for administration.
15. The majority of patients undergoing endoscopy can be satisfactorily sedated using standard drug combinations; however, the pharmacologic properties of these agents make them suboptimal for brief, ambulatory procedures. The increase in the use of propofol for endoscopic sedation indicates that improved sedation methods are needed.
16. New drugs and drug-delivery systems are being developed for endoscopic sedation. Their effectiveness, safety, impact on functional recovery (the time for patient to resume normal activity), patient and physician satisfaction, staffing requirements, and economic impact should be compared with conventional methods of sedation.

"Efforts are ongoing to improve endoscopic sedation, including the evaluation of new drugs and the re-assessment of current agents, as well as the development of new methods of delivery," said Mark DeLegge, MD, AGAF, professor of medicine, Medical University of South Carolina, and co-author of the paper. "While there are several promising prospects on the horizon, we must make every effort to ensure that our procedures are safe and well tolerated with the agents that are currently available to us."