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S3 Guideline: Sedation for gastrointestinal endoscopy 2008

  • Klinikum Region Hannover , Agnes Karll Laatzen, Laatzen, Germany
A. Riphaus et al. S3 Guideline: Sedation for gastrointestinal endoscopy 2008. Endoscopy 2009; 41: 787 815.
The authors and Endoscopy wish to state that the Guide-
line S3 Guideline: Sedation for gastrointestional endosco-
py 2008published in the September issue (Endoscopy
2009; 41: 787 815) is an English translation of the Ger-
man Guideline, S3-Leitlinie Sedierung in der gastrointes-
tinalen Endoskopie2008, published in Zeitschrift für
Gastroenterologie (Z Gastroenterol 2008; 46: 1298 1330)
registered with the AWMF under Reg. No. 021/014.
Unfortunately this information was left out of the publica-
tion and we apologize for this omission.
Endoscopy 2009; 41: 996
This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited.
... Available evidence suggests that cost-effectiveness of routinely involving anesthesiologists in providing sedation for endoscopic procedures is questionable. German guidelines [24] Heart rate, arterial oxygen saturation and blood pressure should be routinely monitored before, during (every 3-5 minutes) and after administration of sedation/analgesia, regardless of the drug administered [26,27]. Since NAAP is not a general anaesthesia procedure and the target is moderate sedation, routine continue ECG monitoring is required only in selected patients with specific cardiovascular risk. ...
... According to German Guidelines [24], "for simple endoscopic examination and in lowrisk patients, sedation with propofol should be induced by a properly qualified physician and can then be (Table 2). ...
... NAAP and NAPS are uncommonly used in Italy [42] but are widely adopted in many countries, such as USA, Germany and Spain [2][3][4][5]41]. Their safety and efficacy have been recognised by many Guidelines and position Papers [2][3][4][5]24,39]. [46] propofol usage is limited to hospital settings, but prescription and administration by a specialist is not warranted, also according to some drug packages. ...
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Propofol sedation by non-anesthesiologists in GI endoscopy, despite generally considered a safe procedure, is still a matter of debate. Benefits of propofol sedation include rapid onset of action, greater patient comfort and fast recovery with prompt discharge from the endoscopy unit. The use of propofol for sedation in GI endoscopy, preceded by dedicated training courses, has been approved by several anaesthesiologist and gastroenterologist societies but an Italian position paper taking into account the Italian law is lacking. In the present document, the Italian Society of Digestive Endoscopy (SIED) Sedation Group, on behalf of the SIED, presents a series of updated position statements concerning propofol sedation in GI endoscopy. The paper summarizes the advantages of propofol, how it should be administered and how patients should be monitored. Moreover, details concerning proper training of non-anaesthesiologist personnel involved in its use are provided. Protocols concerning propofol use s must be shared with the hospital's anaesthesiology staff and approved by the hospital's Executive Director.
... When the portal pressure gradient rises above 10-12 mmHg, complications of portal hypertension can arise, including esophageal varices, ascites, and hepatorenal syndrome. 2 Cirrhotic patients commonly undergo upper gastrointestinal endoscopy (UGIE) for screening and/or treatment of portal hypertension-related complications. These endoscopic procedures can often cause pain or discomfort, and sedation is recommended to minimize anxiety and provide optimum conditions to perform the examination safely, and it also increases willingness to undergo a repeat procedure. ...
... 24 A cohort study conducted by Amoros et al. 36 demonstrated that even deep sedation with propofol did not precipitate subclinical or overt hepatic encephalopathy in cirrhotic patients. This observation was also confirmed by Riphaus et al. 2 in a prospective, randomized study comparing propofol with midazolam for pre-endoscopic sedation in cirrhotic patients during UGIE, and they concluded that propofol sedation results in better patient satisfaction and a shorter recovery time with less hypoxemia than standard sedation with midazolam, although no significant differences were reported in the endoscopy time. Moreover, Assy et al. confirmed a significant prolongation of the NCT results in only 10 of 40 patients (25%) with liver cirrhosis after sedation with midazolam, and it has been shown that other factors, like the level of patient education, might also influence the NCT results. ...
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Aim We aimed to assess the safety and efficacy of propofol versus midazolam in cirrhotic patients undergoing upper GI endoscopy. Methods Ninety compensated cirrhotic patients (all met class I–III criteria according to the American Society of Anesthesia) were enrolled in this comparative study. They were classified into three groups according to scheduled pre‐endoscopy sedation drugs; the midazolam group, which included 30 patients who received IV weight‐dependent midazolam (0.05 mg/kg with additional doses of 1 mg every 2 min when necessary, up to a maximum dose of 0.1 mg/kg or 10 mg); the propofol group, which included 30 patients who received a propofol bolus dose according to age and weight (0.25 mg/kg with additional doses of 20–30 mg every 30–60 s when necessary, up to a maximum dose of 400 mg); and the combined group, which included 30 patients who received half a dose of midazolam and of propofol. Results Prolonged postendoscopy recovery times were reported in the midazolam group, while shorter recovery times were reported in the propofol and combined groups. All patients in the propofol and combined groups gained consciousness shortly postendoscopy; however, only half of the midazolam group's patients gained consciousness after the standard recovery time (10–30 min). Highly significant differences were found among the three groups regarding consciousness level according to the Glasgow coma scale, as well as regarding the occurrence of hypoxia during endoscopy. Conclusion Considering safety and efficacy issues, propofol is better than midazolam in gastrointestinal endoscopy, especially in patients with liver cirrhosis.
... The term EDP refers to the administration of propofol directed/controlled by an endoscopist and under their responsibility (without the participation of an anesthesiologist) and encompasses and includes the previous concept of Nurse Administered Propofol Sedation (NAPS) [14]. In recent years, there has been an emergence of EDP sedation as documented in multiple studies [1,3,15,16] and practice guidelines/consensus documents that endorse its safety and efficacy [8,[17][18][19][20][21]. At the same time, the participation of anesthesiologists in endoscopy units [4] has increased in Western countries, without a corresponding increase in publications reporting the results of AAP in endoscopic procedures [3]. ...
Objective: Endoscopist-directed propofol (EDP) sedation is becoming more popular, with a reported safety and efficacy similar to anesthesiologist-administered propofol (AAP). The aim of this study is to compare the efficiency of EDP and AAP in patients of low-intermediate anesthetic risk. Methods: A prospective cost-effectiveness comparison study was conducted. The costs of the endoscopic procedures in the EDP and AAP group were calculated using the full cost methodology after breaking down the endoscopic activity into relative value units to allocate costs in an equitable way. To determine the effectiveness, adverse events related to endoscopic sedation and the number of incomplete procedures were registered for the EDP group and compared with those published by anesthesiologists for AAP. Results: A total of 1165 and 18 919 endoscopic procedures were, respectively, included in the EDP and AAP groups. The average costs of EDP vs. AAP for gastroscopy, colonoscopy and endoscopic ultrasound were &OV0556; 182.81 vs. &OV0556; 332.93, &OV0556; 297.07 vs. &OV0556; 459.76, and &OV0556; 319.92 vs. &OV0556; 485.12, respectively. No significant differences were detected regarding the rate of overall adverse events (4.43 vs. 4.46%) or serious adverse events (0 vs. 0.17%); the rate of arterial hypotension was significantly lower in the EDP group: 0.34 vs. 1.78% [odds ratio (OR), 0.19; 95% confidence interval (CI), 0.08-0.46] and the desaturation rate was significantly lower in the AAP group: 3.26 vs. 1.29% (OR, 2.58; 95% CI, 1.85-3.60). No significant differences were found in terms of incomplete examinations (0.17 vs. 0.14%). Conclusion: In patients with low-intermediate anesthetic risk referred for an endoscopic examination, EDP appears to be more efficient than AAP.
... Surveys from the USA, Italy and Portugal showed that propofol administration was almost exclusively directed by anesthesiologists [18][19][20], while surveys from Germany and Spain displayed opposite results, with propofol administration being almost entirely directed by non-anesthesiologists [16,17]. One key difference may be the presence of national German and Spanish guidelines that support the use of propofol by non-anesthesiologists [22,23]. More significantly, the German Society for Anesthesia and Intensive Care Medicine actively participated in the design of the national German guideline, a feat that the American (ASGE) and European (ESGE) Societies for Gastrointestinal Endoscopy have not been able to replicate [11,12,24], although the European Society of Anesthesiology initially supported the use of NAAP but later retracted its support [13,14]. ...
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Background: Sedation in gastrointestinal endoscopy is rapidly evolving worldwide. However, this has led to significant disagreements, especially regarding the use of propofol by non-anesthesiologists. The aim of this study was to document the practices of Greek gastroenterologists regarding sedation and compare them to previous surveys. Methods: The study was conducted in 2 periods, December 2015 and June 2018. In each period, the same online questionnaire regarding endoscopic sedation practices was sent to all registered Greek gastroenterologists (509 and 547 gastroenterologists, respectively). Results: The response rates were 38.3% and 47.1%, respectively. In each period, 25.1% and 16.7% of physicians did not use sedation. Most gastroenterologists (approx. 70% in both instances) answered that they “almost never” collaborate with an anesthesiologist during endoscopy. Midazolam was by far the most popular sedation agent, used by almost 90% of physicians in both periods. Propofol was used by 30.8% and 27% of physicians, respectively. Physicians using propofol were significantly more satisfied with the sedation than other physicians, while propofol was the agent selected by most physicians if they were to undergo endoscopy themselves. Most physicians cited medicolegal reasons and inadequate training as chief reasons for not using propofol. Conclusions: Sedation use is widespread among Greek gastroenterologists. Although midazolam is the most commonly used agent, propofol is preferred (theoretically) by most physicians and achieves the best satisfaction. The introduction of a strict training curriculum for endoscopic sedation can effectively eliminate the barriers preventing gastroenterologists from administering propofol, while at the same time ensuring optimal patient safety during endoscopy.
... Endoscopic procedures, either diagnostic or therapeutic, can be performed under sedation, which is standard practice in most centers. 1 The overall the number and complexity of endoscopic procedures have increased due to the generalized routine usage of sedation, which diminishes anxiety, discomfort and/or pain for the patients, thus improving patient acceptance and satisfaction. [2][3][4][5] Sedation is also important to medical practitioners as it improves the quality of endoscopic examinations, the completion rate, and also treatment outcomes in therapeutic endoscopy, thus increasing endoscopists' satisfaction. 2 In the US, over the span of a decade, there has been a three-to four-fold increase in the prevalence of anesthesia involvement in routine outpatient endoscopic procedures on lowrisk patients, with propofol sedation rates increasing from 14% in 2003 to 48% in 2013 for Medicare patients. ...
Objectives: The aim of this project was to promote best discharge practice in sedated patients following endoscopic procedures in an endoscopy tertiary center in Shanghai, China. Introduction: Discharge of sedated patients is the final stage of the endoscopic procedure. Healthcare providers must ensure patient safety through timely and appropriate discharge from endoscopic procedures. Methods: A clinical audit was undertaken using the JBI Practical Application of Clinical Evidence System tool. Eight audit criteria that were representative of best-practice recommendations for the discharge of sedated patients following endoscopic procedures were used. A baseline audit was conducted, followed by the implementation of multiple strategies that were determined by the key stakeholders. The project was finalized with a follow-up audit to determine change in practice. Results: Improvements in practice were observed for all eight criteria. The most significant improvements were for the following criteria: an organizational policy exists, minimum discharge criteria are established, minimum discharge criteria are met before the patient is discharged (each from 0% to 100% compliance), patient received written and verbal discharge instructions (from 12% to 100% compliance), and discharge care plan is documented in the patient's medical file (from 0% to 88%). Criteria 4 (discharge is authorized by an appropriate staff member), 6 (staff member is appropriately trained and educated) and 7 (patient is accompanied by a responsible adult) achieved the least improvement in compliance rates, as baseline measures already showed a high degree of compliance. Overall, there was improvement in compliance for all best-practice recommendations. Conclusions: The project demonstrated positive changes in the discharge care of sedated patients following endoscopic procedures in an endoscopy tertiary center in Shanghai, China. A formalized organizational discharge policy is currently in place and a continuous cycle of audit and re-audit will need to be carried out in the future to keep the quality at a high and steady level.
... Both anesthetic techniques were found to be safe and effective for the study, without causing changes in the time of realization [13], the awakening after sedation of the patients who received inhaled sevoflurane was significantly shorter than those who received only propofol reducing by 50% their stay in the recovery area. In those patients in whom only propofol was administered a much deeper anesthetic level was evidenced since only 13% of the patients required the use of rescue boluses unlike the group that received sevoflurane where it had been used in 35%, twice the number of patients when comparing with the group that only received propofol during the induction and maintenance of sedation. ...
... Nevertheless, sedation with propofol exhibits a relatively narrow margin of safety in terms of the respiratory and cardiovascular compromise, as it can commonly be implicated in the occurrence of apneic events, loss of airway protective reflexes or upper airway patency and hemodynamic deterioration. Apparently, the adaption of a more individualized approach in propofol administration could aim towards the elimination of adverse events [12,[22][23][24]. ...
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Aim Sedation is considered as a prerequisite for the safe and effective conclusion of Bioenterics Intragastric Balloon (BIB) removal (our aim was to ascertain the most appropriate body size scalars for propofol dosing and assess the efficacy and safety of a sedative approach involving the infusion of propofol for BIB removal. Method Retrospective analysis of prospectively collected data of 414 adults scheduled to undergo BIB removal. Our primary end-point was to delineate the relationship between propofol dosing and body size descriptors namely body mass index, total body weight, ideal body weight, lean body weight (LBW) and normalized LBW. Sedative efficacy of this practice, anesthesia or procedural-related adverse events and patients’ satisfaction level served as secondary outcome parameters. Results Propofol dose (mg/kg/min) was positively related to all body weight descriptors in an important manner (p < 0.001). Among them, LBW was singled out as the body size descriptor to best capture the appropriate needs of propofol (R² = 0.432; p = 0.000). Hypoxemia, hemodynamic compromise, gastroesophageal reflux or moderate movement occurred rarely; all of them were readily reversed. The majority of participants had no recollection of the noxious phase of the procedure or declared at least adequately satisfied from the experience (84% and 95%, respectively). Conclusion LBW could serve as relatively more accurate dosing scalar compared to actual or ideal body weight descriptors, in obese individuals undergoing BIB removal under propofol sedation. The conscious/deep sedation based on propofol infusion emerges as a feasible and efficacious sedative approach for this procedure.
... 62 63 Endoscopy units should adhere to pre-existing safe sedation guidelines. [64][65][66] This involves ensuring sedation is given with age and comorbidities in mind, and with appropriate monitoring. [67][68][69][70] Any occasion where naloxone, flumazenil or ventilation is required owing to oversedation should be recorded and investigated. ...
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Guidelines advise precautionary measures for possible adverse events that may occur due to sedation during endoscopic procedures. To avoid complications, intraprocedural and postprocedural monitoring during recovery is considered important. However, since not many studies have reported on hypoxemia during the recovery period, findings for specific monitoring methods are insufficient. The aim of this retrospective study was to determine the incidence of hypoxemia during the recovery period using continuous central-monitoring by pulse oximetry and to characterize the hypoxemia cases. Among the 4065 consecutive esophagogastroduodenoscopy (EGD) procedures under planned moderate sedation, 84 (2.1%) procedures developed unexpected hypoxemia (SpO2 ≤ 90%). Hypoxemia was observed during the procedure, at the end of the procedure, and during the recovery period in 21, 17, and 46 (1.1%) procedures, respectively. More than half of the hypoxemia cases occurred during the recovery period. Many hypoxemia cases were characterized by neither serious co-morbid illness nor low body mass index which have been reported as risk factors of hypoxemia. The lack of risk factors is no guarantee that hypoxemia will not occur. Therefore, continuous monitoring by pulse oximetry is more important during the recovery period and is recommended in all EGD procedures under planned moderate sedation.
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