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Abstract
GOALS To assess the factors associated with adenoma detection in propofol-sedated patients. BACKGROUNDS Low adenoma detection rate (ADR) are linked to increased risk of interval cancer and related deaths. Compared with air insufflation (AI) colonoscopy, the method of water exchange (WE) significantly decreased insertion pain and increased ADR in unsedated patients. Deep sedation with propofol has been increasingly used in colonoscopy. One report suggested that WE significantly increased ADR in propofol-sedated patients, but the factors associated with adenoma detection were not analyzed. STUDY Post hoc multiple logistic regression analyses were performed based on pooled data from 2 randomized controlled trials to assess the factors associated with adenoma detection in propofol-sedated patients. RESULTS Propofol-sedated patients (n=510) were randomized to AI and WE. The baseline characteristics were comparable. Multiple logistic regression analyses show that age, withdrawal time, indications (screening vs. diagnostic), and WE were significantly and independently associated with higher ADR. WE had fewer patients with inadequate Boston Bowel Preparation Scale score of <6. Despite a significantly shorter inspection time, WE had significantly higher overall ADR than AI, especially in those with adequate Boston Bowel Preparation Scale of ≥6. Right colon ADR (17.5% vs. 10.5%), flat ADR (32.3% vs. 19.4%), combined advanced and sessile serrated ADR (13.1% vs. 7.4%) of WE were significantly higher than those of AI. CONCLUSIONS WE enhanced quality of colonoscopy in propofol-sedated patients by significantly improving colon cleanliness and overall ADR. Colonoscopists with patients under propofol sedation might consider evaluating WE method for performance improvement.
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Safety of Target-Controlled Propofol Infusion by Gastroenterologists in Patients Undergoing Endoscopic Resection. Dig Dis Sci 2016; 61:3199-3206. [PMID: 27480084 DOI: 10.1007/s10620-016-4256-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 07/11/2016] [Indexed: 02/06/2023]
Abstract
BACKGROUND A target-controlled infusion (TCI) of a propofol system uses a pharmacokinetic model to achieve and maintain a selected target blood propofol concentration. The aim of this study was to assess whether the propofol TCI system could be safely used by gastroenterologists in patients undergoing endoscopic resection including endoscopic submucosal dissection (ESD) and endoscopic mucosal resection (EMR) compared with a manually controlled infusion (MCI) system. METHODS A total of 431 patients undergoing therapeutic endoscopy (178 ESD and 253 EMR) were consecutively included from November 2011 to August 2014. The patients were divided into the MCI (271) and TCI (160) propofol infusion groups. We compared adverse event rates in MCI and TCI groups and assessed independent risk factors for adverse events. RESULTS The total sedation-related adverse event rate was 5.8 % (25/431). Most of the events were minor, and the rate of major events was 0.5 % (2/431). There was no significant difference in adverse event rate between the MCI and TCI groups [5.5 % (15/271) vs. 6.3 % (10/160); P = 0.759]. In univariate analysis, the propofol infusion time was significantly associated with adverse events (94.88 vs. 59.45 min, P = 0.017). In the multivariate analysis, there were no significant factors associated with adverse events. TCI was not an independent risk factor for adverse events despite the fact that the TCI had a longer duration of infusion and higher total infusion dose (95 % CI, 0.343-2.216; P = 0.773). CONCLUSIONS TCI of propofol by gastroenterologists may provide safe sedation in patients undergoing ESD and EMR under careful respiratory monitoring.
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Thornley P, Al Beshir M, Gregor J, Antoniou A, Khanna N. Efficiency and patient experience with propofol vs conventional sedation: A prospective study. World J Gastrointest Endosc 2016; 8:232-238. [PMID: 26962405 PMCID: PMC4766256 DOI: 10.4253/wjge.v8.i4.232] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Revised: 12/07/2015] [Accepted: 12/23/2015] [Indexed: 02/05/2023] Open
Abstract
AIM: To determine whether anaesthesiologist-administered sedation with propofol (AAP) or endoscopist-administered conscious sedation (EAC) with fentanyl/midazolam shortens colonoscopy duration/total room time.
METHODS: This is a prospective, non-randomized, comparative study that enrolled patients greater than 18 years of age undergoing colonoscopy in a single Canadian academic outpatient endoscopy unit over a three-month consecutive period. Colonoscopies in this unit are performed both with AAP and EAC. Patient demographics, procedure-related data and adverse events were documented. Additionally, the level of procedure difficulty, and whether a staff endoscopist, trainee with assistance, or independent trainee, performed the procedure were documented. A validated modified 4-question, 5-point Likert scale telephone survey was used to assess patient satisfaction with colonoscopy. The telephone patient satisfaction survey was conducted 24-72 h following the procedure.
RESULTS: Two hundred and thirty patients were enrolled during the study period with 126 patients in the AAP group and 104 patients in the EAC group. Mean procedure time was 18.3 ± 10.1 min in the AAP group and 14.7 ± 7.1 min in the EAC group (P = 0.002). Mean total room time was 36.8 ± 13.7 with AAP and 30.1 ± 11 min with EAC (P < 0.001). Multivariate analysis revealed the use of AAP (P = 0.002), resident participation (P < 0.001), diagnostic interventions (P = 0.033), therapeutic interventions (P < 0.001), lower body mass index (P = 0.008) and American Society of Anaesthesiologist class (P = 0.016), to be predictors of longer total room time. Patient age and gender were not significant predictors. After excluding cases in which trainees were involved, there was no significant difference in procedure time between the two groups (P = 0.941), however total room time was still prolonged in the AAP group (P = 0.019). The amount of pain experienced was lower with AAP (P = 0.02), with a trend toward overall higher patient satisfaction (P = 0.074). There were 2 sedation-related adverse events, both in the AAP group involving a patient with aspiration requiring hospitalization and a patient with hypoxia managed with bronchodilators.
CONCLUSION: EAC results in reduced total room time compared to AAP. Resident participation doubles procedure time regardless of sedation type.
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Birk J, Bath RK. Is the anesthesiologist necessary in the endoscopy suite? A review of patients, payers and safety. Expert Rev Gastroenterol Hepatol 2015; 9:883-5. [PMID: 25979248 DOI: 10.1586/17474124.2015.1041508] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
The use of propofol for sedation during endoscopy has been increasing, particularly given its association with superior patient satisfaction. Propofol sedation may also allow for higher quality endoscopy exams, increased efficiency of endoscopy suites and most particularly, permit better patient compliance with colonoscopy for colorectal cancer screening. However, propofol is typically provided by anesthesia specialists via monitored anesthesia care, and is associated with significant economic burden. Given the increasing use of monitored anesthesia care, which adds significant costs to endoscopy, payers are likely to react with changes in payer policies. One alternative to monitored anesthesia care is non-anesthesiologist administered propofol, which due to safety concerns and a lack of reimbursement has not been widely adopted in the US.
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Affiliation(s)
- John Birk
- Department of Medicine, Division of Gastroenterology and Hepatology, University of Connecticut, 263 Farmington Avenue, Farmington, CT 06030, USA
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de Paulo GA, Martins FP, Macedo EP, Gonçalves MEP, Mourão CA, Ferrari AP. Sedation in gastrointestinal endoscopy: a prospective study comparing nonanesthesiologist-administered propofol and monitored anesthesia care. Endosc Int Open 2015; 3:E7-E13. [PMID: 26134777 PMCID: PMC4423250 DOI: 10.1055/s-0034-1377835] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2014] [Accepted: 07/06/2014] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Adequate sedation is one of the cornerstones of good quality gastrointestinal endoscopy (GIE). Propofol sedation has increased significantly but there has been much debate over whether it can be administered by endoscopists. The aim of this prospective trial was to compare nonanesthesiologist-administered propofol (NAAP) and monitored anesthesia care (MAC). METHODS A total of 2000 outpatients undergoing GIE at Hospital Albert Einstein (São Paulo, Brazil), a tertiary-care private hospital, were divided into two matched groups: NAAP (n = 1000) and MAC (n = 1000). In NAAP, propofol doses were determined by the endoscopist. A second physician stayed in the room during the entire procedure, according to local regulations. In MAC, the anesthesiologist administered propofol. RESULTS In total, 1427 patients (71.3 %) were ASA (American Society of Anesthesiologists) class I and 573 were ASA class II. In NAAP, patients received more propofol + fentanyl (61.1 % vs. 50.5 %; P < 0.05) and there were fewer cases of deep sedation (44.7 % vs. 66.1 %; P < 0.05). Hypoxemia rates were similar (12.8 % for NAAP and 11.2 % for MAC; P = 0.3) but these reverted more rapidly in MAC (4.22 seconds vs. 7.26 seconds; P < 0.05). Agitation was more frequent in MAC (14.0 % vs. 5.6 %; P < 0.05). No later complications were observed. Patient satisfaction was very high and similar in both groups. CONCLUSION In this setting, NAAP was as safe and effective as MAC for healthy patients undergoing GIE. Clinical trial ref. no.: U1111-1134-4430.
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Affiliation(s)
- Gustavo Andrade de Paulo
- Universidade Federal de São Paulo – Gastroenterology, São Paulo, Brazil,Hospital Albert Einstein – Endoscopy, São Paulo, Brazil,Corresponding author Gustavo Andrade de Paulo Universidade Federal de São Paulo - GastroenterologyAv. Dr. Altino Arantes 701/51São PauloSP 04042033Brazil+55-11-972833606
| | | | | | | | | | - Angelo P. Ferrari
- Universidade Federal de São Paulo – Gastroenterology, São Paulo, Brazil,Hospital Albert Einstein – Endoscopy, São Paulo, Brazil
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Abstract
Concerns about the safety of endoscopist-directed propofol (EDP) have been voiced that propofol should be given only by healthcare professionals trained in the administration of general anesthesia. Here we discuss the safety and drawbacks of EDP for routine endoscopic procedures. Currently, both diagnostic and therapeutic endoscopy are well tolerated and accepted by both patients and endoscopists due to the application of sedation in most clinics worldwide. Accordingly, propofol use is increasing in many countries. It is crucial for endoscopists to be very familiar with the use of propofol or a combination of drugs. However, the controversy regarding the administration of sedation by an endoscopist or an anesthesiologist continues. Until now, there have been no randomized control trials comparing sedation induced by propofol administered by an endoscopist or by an anesthesiologist. It might be difficult to perform this kind of study. For the convenience and safety of sedative endoscopy, it would be important that EDP be generally applied to endoscopic procedures, and for more safety, an anesthesiologist may automatically take care of particular patients at high risk of suffering from propofol side effects.
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Affiliation(s)
- Eun Hye Kim
- Division of Gastroenterology, Department of Internal Medicine, Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sang Kil Lee
- Division of Gastroenterology, Department of Internal Medicine, Institute of Gastroenterology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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Santos MELD, Maluf-Filho F, Chaves DM, Matuguma SE, Ide E, Luz GDO, Souza TFD, Pessorrusso FCS, Moura EGHD, Sakai P. Deep sedation during gastrointestinal endoscopy: propofol-fentanyl and midazolam-fentanyl regimens. World J Gastroenterol 2013; 19:3439-46. [PMID: 23801836 PMCID: PMC3683682 DOI: 10.3748/wjg.v19.i22.3439] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2012] [Revised: 12/22/2012] [Accepted: 01/11/2013] [Indexed: 02/06/2023] Open
Abstract
AIM To compare deep sedation with propofol-fentanyl and midazolam-fentanyl regimens during upper gastrointestinal endoscopy. METHODS After obtaining approval of the research ethics committee and informed consent, 200 patients were evaluated and referred for upper gastrointestinal endoscopy. Patients were randomized to receive propofol-fentanyl or midazolam-fentanyl (n = 100/group). We assessed the level of sedation using the observer's assessment of alertness/sedation (OAA/S) score and bispectral index (BIS). We evaluated patient and physician satisfaction, as well as the recovery time and complication rates. The statistical analysis was performed using SPSS statistical software and included the Mann-Whitney test, χ² test, measurement of analysis of variance, and the κ statistic. RESULTS The times to induction of sedation, recovery, and discharge were shorter in the propofol-fentanyl group than the midazolam-fentanyl group. According to the OAA/S score, deep sedation events occurred in 25% of the propofol-fentanyl group and 11% of the midazolam-fentanyl group (P = 0.014). Additionally, deep sedation events occurred in 19% of the propofol-fentanyl group and 7% of the midazolam-fentanyl group according to the BIS scale (P = 0.039). There was good concordance between the OAA/S score and BIS for both groups (κ = 0.71 and κ = 0.63, respectively). Oxygen supplementation was required in 42% of the propofol-fentanyl group and 26% of the midazolam-fentanyl group (P = 0.025). The mean time to recovery was 28.82 and 44.13 min in the propofol-fentanyl and midazolam-fentanyl groups, respectively (P < 0.001). There were no severe complications in either group. Although patients were equally satisfied with both drug combinations, physicians were more satisfied with the propofol-fentanyl combination. CONCLUSION Deep sedation occurred with propofol-fentanyl and midazolam-fentanyl, but was more frequent in the former. Recovery was faster in the propofol-fentanyl group.
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Gastroenterologist-guided sedation with propofol for endoscopic ultrasonography in average-risk and high-risk patients: a prospective series. Eur J Gastroenterol Hepatol 2012; 24:506-12. [PMID: 22330236 DOI: 10.1097/meg.0b013e328350fcbd] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE Only a few reports have addressed non-anesthesiologist-administered propofol for endoscopic ultrasonography (EUS), but none specifically in high-risk patients. Our aim was to study the application of a propofol sedation protocol for EUS in average-risk and high-risk patients. METHODS This was a prospective observational study including 446 patients referred for EUS. We analyzed the induction time, procedure duration, recovery times, and patients' comfort and safety. Sedation was administered by a trained nurse, under the guidance of the endoscopist. We continuously monitored vital signs as well as patient cooperation and tolerance. Complications, patient, and endoscopist satisfaction were analyzed. RESULTS No major complications occurred. The rate of minor complications was 9%, the most frequent being hypoxemia (8%). One hundred and thirty-eight high-risk patients were included [American Society of Anesthesiologists (ASA) III-IV]. Average-risk patients received higher propofol doses (202.9 ± 84.8 vs. 164.8 ± 84.3; P=0.003). No differences were found in the rate of complications or procedure-related variables. Overall patient and endoscopist satisfaction was excellent. The logistic regression model identified propofol doses (P=0.02) as a risk factor and ASA-I classification (P=0.03) as a protective factor for the appearance of complications. CONCLUSION Non-anesthesiologist-administered propofol for upper EUS in high-risk and average-risk patients is safe and could be routinely offered to high-risk and elderly patients.
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Vemulapalli KC, Rex DK. Guidelines for an Optimum Screening Colonoscopy. CURRENT COLORECTAL CANCER REPORTS 2012. [DOI: 10.1007/s11888-011-0109-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Correia LM, Bonilha DQ, Gomes GF, Brito JR, Nakao FS, Lenz L, Rohr MRS, Ferrari AP, Libera ED. Sedation during upper GI endoscopy in cirrhotic outpatients: a randomized, controlled trial comparing propofol and fentanyl with midazolam and fentanyl. Gastrointest Endosc 2011; 73:45-51, 51.e1. [PMID: 21184869 DOI: 10.1016/j.gie.2010.09.025] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2010] [Accepted: 09/14/2010] [Indexed: 02/08/2023]
Abstract
BACKGROUND Patients with liver cirrhosis frequently undergo diagnostic or therapeutic upper GI endoscopy (UGIE), and the liver disease might impair the metabolism of drugs usually administered for sedation. OBJECTIVE AND SETTING To compare sedation with a combination of propofol plus fentanyl and midazolam plus fentanyl in cirrhotic outpatients undergoing UGIE. DESIGN A prospective, randomized, controlled trial was conducted between February 2008 and February 2009. MAIN OUTCOMES MEASUREMENTS Efficacy (proportion of complete procedures using the initial proposed sedation scheme), safety (occurrence of sedation-related complications), and recovery time were measured. RESULTS Two hundred ten cirrhotic patients referred for UGIE were randomized to 2 groups: midazolam group (0.05 mg/kg plus fentanyl 50 μg intravenously) or propofol group (0.25 mg/kg plus fentanyl 50 μg intravenously). There were no differences between groups regarding age, sex, weight, etiology of cirrhosis, and Child-Pugh or American Society of Anesthesiologists classification. Sedation with propofol was more efficacious (100% vs 88.2%; P < .001) and had a shorter recovery time than sedation with midazolam (16.23 ± 6.84 minutes and 27.40 ± 17.19 minutes, respectively; P < .001). Complication rates were similar in both groups (14% vs 7.3%; P = .172). LIMITATIONS Single-blind study; sample size. CONCLUSION Both sedation schemes were safe in this setting. Sedation with propofol plus fentanyl was more efficacious with a shorter recovery time compared with midazolam plus fentanyl. Therefore, the former scheme is an alternative when sedating cirrhotic patients undergoing UGIE.
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Affiliation(s)
- Lucianna Motta Correia
- Disciplina de Gastroenterologia Clínica, Universidade Federal de São Paulo, São Paulo, Brasil
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Herszényi L, Lakatos G, Tulassay Z. [Quality colonoscopy: assumptions and expectations]. Orv Hetil 2010; 151:1331-9. [PMID: 20693144 DOI: 10.1556/oh.2010.28930] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Colonoscopy has become accepted as the most effective method of screening of the colon for neoplasia. Evidences prove that utilization of colonoscopy has increased dramatically in the past few years, largely because of increased rates of CRC screening. Effectiveness and safety of colonoscopy depend on the quality of examination, and growing body of evidence suggests that the quality of colonoscopy varies in clinical practice. Quality assurance of colonoscopy could be expected to contribute significantly to improved patient care. There is a clear need for evidence-based quality measures to ensure the quality of colonoscopy. In this review we present an overview of literature concerning criteria for best practice and important quality indicators for colonoscopy.
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Affiliation(s)
- László Herszényi
- Semmelweis Egyetem, Altalános Orvostudományi Kar II. Belgyógyászati Klinika, MTA Gasztroenterológiai és Molekuláris Medicina Kutatócsoport, Budapest, Szentkirályi u. 46. 1088.
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Current World Literature. Curr Opin Anaesthesiol 2009; 22:539-43. [DOI: 10.1097/aco.0b013e32832fa02c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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