Endoscopist-Directed Propofol as an Adjunct to Standard Sedation: A Canadian Experience

Abstract

Background Sedation practices vary widely by region. In Canada, endoscopist-directed administration of a combination of fentanyl and midazolam is standard practice. A minority of cases are performed with propofol. Aims To describe the safety of nonanaesthetist administered low-dose propofol as an adjunct to standard sedation. Methods This was a single-centre retrospective study of patients having undergone endoscopic procedures with propofol sedation between 2004 and 2012 in a teaching hospital in Montreal. Procedures were performed by gastroenterologists trained in Advanced Cardiovascular Life Support. Sedation was administered by intravenous bolus by a registered nurse, under the direction of the endoscopist. Outcomes of procedures were collected in the context of a retrospective chart review using the hospital’s endoscopy database. Results Of patients undergoing endoscopies at our centre, 4930 patients received propofol as an adjunct to standard sedation with fentanyl and midazolam. Cecal intubation rate for colonoscopies (n = 2921) was 92.0%. Gastroscopies (n = 1614), flexible sigmoidoscopies (n = 28), endoscopic retrograde cholangiopancreatography (n = 331) and percutaneous endoscopic gastrostomy insertion (n = 36) had success rates, defined as successful completion of the procedure within anatomical limits, of 99.0, 96.4, 94.0 and 91.7%, respectively. The average dose of propofol used for each procedure was 34.5 ± 20.8 mg. Fentanyl was used in 67.4% of procedures at an average dose of 94.3 ± 17.5 mcg. Midazolam was used in 92.7% of cases at an average dose of 3.0 ± 0.7 mg. Reversal agents (naloxone or flumazenil) were used in 0.43% of the cases (n = 21). Patients who received propofol were discharged uneventfully within the usual postprocedure recovery time. One patient required sedation-related hospitalization. For patients having received propofol in addition to standard sedation agents, 99.6% experienced no adverse events. There were no mortalities. Conclusion The use of low-dose propofol as an adjunct to fentanyl and midazolam, administered by a registered nurse under the direction of the endoscopist was safe and effective in patients at our centre.

Safety Profile of Endoscopist-directed Balanced Propofol Sedation for Procedural Sedation

“…Many countries, other than United States, continue to use nurse-administered propofol sedation for endoscopic procedures both as monotherapy [28][29][30] and as BPS. [31][32][33] McKenzie et al 34 from Utah recently published their data on EDBPS from 2015 to 2018, demonstrating the safety of EDBPS. AEs occurred in 334 (17.6%) patients, all of which were transient and easily treated.…”

“…To our knowledge, ours is the first endoscopy unit in the United States to reinstate EDBPS since propofol use was restricted to anesthesiologists and nurse anesthetists in 2009. Many countries, other than United States, continue to use nurse-administered propofol sedation for endoscopic procedures both as monotherapy28–30 and as BPS 31–33. McKenzie et al34 from Utah recently published their data on EDBPS from 2015 to 2018, demonstrating the safety of EDBPS.…”

Updated S3 Guideline “Sedation for Gastrointestinal Endoscopy” of the German Society of Gastroenterology, Digestive and Metabolic Diseases (DGVS) – June 2023 – AWMF-Register-No. 021/014

“…The safety of NAPS sedation has been documented in numerous international, mostly prospective, studies [34,125,[398][399][400][401][402][403][404][405][406].…”

Aktualisierte S3-Leitlinie „Sedierung in der gastrointestinalen Endoskopie“ der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS)

“…Die Sicherheit einer NAPS-Sedierung konnte in zahlreichen internationalen, zumeist prospektiven, Studien 34 125 398 399 400 401 402 403 404 405 406 dokumentiert werden.…”

“…Sedierung kann anschließend von einer entsprechend ausgebildeten und erfahrenen Person (Arzt, Gesundheits-und Krankenpflegepersonal/ Medizinische Fachangestellte) überwacht und fortgeführt werden. Empfehlungsgrad 0, starker Konsens Die Sicherheit einer NAPS-Sedierung konnte in zahlreichen internationalen, zumeist prospektiven, Studien[34,125,[398][399][400][401][402][403][404][405][406]] dokumentiert werden. Die bisherige Empfehlung 3.3.3.1c ist zu der Empfehlung 3.4 (bisher 3.3.2.1) redundant und wurde in den früheren Leitlinien-Fassungen von 2008 und 2014 belassen, um unter dem Primat der Patientensicherheit die Bedeutung dieses Passus ("die sedierende Person ist ausschließlich für die Durchführung, Überwachung und Dokumentation der Sedierung zuständig") zu betonen.…”