Deep sedation and anaesthesia in complex gastrointestinal endoscopy: a joint position statement endorsed by the British Society of Gastroenterology (BSG), Joint Advisory Group (JAG) and Royal College of Anaesthetists (RCoA)

Abstract

In the UK, more than 2.5 million endoscopic procedures are carried out each year. Most are performed under conscious sedation with benzodiazepines and opioids administered by the endoscopist. However, in prolonged and complex procedures, this form of sedation may provide inadequate patient comfort or result in oversedation. As a result, this may have a negative impact on procedural success and patient outcome. In addition, there have been safety concerns on the high doses of benzodiazepines and opioids used particularly in prolonged and complex procedures such as endoscopic retrograde cholangiopancreatography. Diagnostic and therapeutic endoscopy has evolved rapidly over the past 5 years with advances in technical skills and equipment allowing interventions and procedural capabilities that are moving closer to minimally invasive endoscopic surgery. It is vital that safe and appropriate sedation practices follow the inevitable expansion of this portfolio to accommodate safe and high-quality clinical outcomes. This position statement outlines the current use of sedation in the UK and highlights the role for anaesthetist-led deep sedation practice with a focus on propofol sedation although the choice of sedative or anaesthetic agent is ultimately the choice of the anaesthetist. It outlines the indication for deep sedation and anaesthesia, patient selection and assessment and procedural details. It considers the setup for a deep sedation and anaesthesia list, including the equipment required, the environment, staffing and monitoring requirements. Considerations for different endoscopic procedures in both emergency and elective setting are also detailed. The role for training, audit, compliance and future developments are discussed.

Confocal laser endomicroscopy under propofol-based sedation for early gastric cancer and pre-cancerous lesions is associated with better diagnosing accuracy: a retrospective cohort study in China

“…Compared with benzodiazepines and opioids, sedation with propofol can improve the quality of endoscopy, such as increasing the detecting rate of advanced lesions (22) and polyp (16). But sedation is also considered with an added risk of complications, especially a risk of cardiopulmonary compromise (23). There is a great amount of evidence to con rm that sedation during GI endoscopy is carried out with a high degree of safety.…”

“…The limited sta ng of anesthesiologists is the main restriction factor. Although extensive data have demonstrated the safety and e cacy of non-anesthesiologist-administered propofol sedation, the American Society of Anesthesiologists and other anesthesiology societies continue to maintain that propofol sedation should be performed only by anesthesia providers (23,27). The advantages may include the decreased distractions to endoscopist, and the increased throughput through the endoscopic unit.…”

LMA Gastro™ airway is feasible during upper gastrointestinal interventional endoscopic procedures in high risk patients: a single-center observational study

“…Nonoperating room anesthesia in the gastroenterology suite is a growing field in anesthesiology practice [1,2]. While the majority of gastrointestinal endoscopies are performed under conscious sedation by non-anesthesia personnel, there is a shift towards deep sedation or general anesthesia for advanced procedures and interventions [3]. Especially for patients with ASA physical status ≥3, high BMI, obstructive sleep apnea and severe comorbidities, the presence of an anesthesiologist is recommended [3][4][5].…”

“…While the majority of gastrointestinal endoscopies are performed under conscious sedation by non-anesthesia personnel, there is a shift towards deep sedation or general anesthesia for advanced procedures and interventions [3]. Especially for patients with ASA physical status ≥3, high BMI, obstructive sleep apnea and severe comorbidities, the presence of an anesthesiologist is recommended [3][4][5]. General anesthesia is associated with shorter procedure times, higher complete resection rates, a decreased incidence of coughing and lower perforation rates [6][7][8].…”

High-flow nasal oxygenation versus standard oxygenation for gastrointestinal endoscopy with sedation. The prospective multicentre randomised controlled ODEPHI study protocol

“…Sedation during upper and/or lower GIE improves the quality of examination, patient comfort and allows performing complex procedures 2–4. The recent British guidelines suggest that deep sedation, under the responsibility of anaesthesiologists, should also be considered for, but not limited to, cholangiopancreatography endoscopic retrograde, digestive echoendoscopy and any prolonged therapeutic procedure 5…”