Multisociety Sedation Curriculum for Gastrointestinal Endoscopy

Variation in Pediatric Anesthesiologist Sedation Practices for Pediatric Gastrointestinal Endoscopy

Background: Despite a worldwide shift toward anesthesiologist-administered sedation for gastrointestinal endoscopy in children, ideal sedation regimens remain unclear and best practices undefined. Aim: The aim of our study was to document variation in anesthesiologist-administered sedation for pediatric endoscopy. Outcomes of interest included coefficients of variation, procedural efficiency, as well as adverse events. Methods: IRB approval was obtained to review electronic health records of children undergoing routine endoscopy at our medical center during a recent calendar year. Descriptive and multivariate analyses were used to examine predictors of sedation practices. Results: 258 healthy children [2-21 years (median 15, (Q1-Q3 = 10-17)] underwent either upper and/or lower endoscopies with sedation administered by anesthesiologists (n = 21), using different sedation regimens (29) that ranged from a single drug administered to 6 sedatives in combination. Most patients did not undergo endotracheal tube intubation for the procedure (208, 81%), and received propofol (255, 89%) either alone or in combination with other sedatives. A total of 10 (3.8%) adverse events (9 sedation related) were documented to occur. The coefficient of variation (CV) for sedation times was high at 64.2%, with regression analysis suggesting 8% was unexplained by procedure time. Multivariable model suggested that longer procedure time (p < 0.0001), younger age (p < 0.0001), and use of endotracheal tube intubation (p = 0.02) were associated with longer sedation time. Discussion: We found great variation in anesthesiologist administered regimens for pediatric endoscopy at our institution that may be unwarranted, presenting may opportunities for minimizing patient risk, as well as for optimizing procedural efficiency.

Enhancing the current evidence on endoscopist-directed propofol-based sedation

During the last years, there is more and more scientific evidence about the safety and feasibility of non-anesthesiologist administration of propofol (NAAP) in gastrointestinal endoscopy, reducing sedation induction and recovery time as well as increasing patient and endoscopist satisfaction. Furthermore, a similar risk of adverse events compared with traditional agents or anesthesiologist administration of propofol (AAP) has been described. The present special issue of the Spanish Journal of Gastroenterology (Revista Española de Enfermedades Digestivas) focusses on NAAP in different settings, including complex endoscopic procedures.

Non-Operating Room Anesthesia in the Endoscopy Unit

The term, non-operating room anesthesia, describes a location remote from the main operating suites and closer to the patient, including areas that offer specialized procedures, like endoscopy suites, cardiac catheterization laboratories, bronchoscopy suites, and invasive radiology suites. There has been an exponential growth in such procedures and they present challenges in both organizational aspects and administration of anesthesia. This article explores the requirements for the location, preoperative evaluation and patient selection, monitoring, anesthesia technique, and postoperative management at these sites. There is a need to better define the role of the anesthesia personnel at these remote sites.

Capnography improves detection of apnea during procedural sedation for percutaneous transhepatic cholangiodrainage

BACKGROUND

Capnography provides noninvasive monitoring of ventilation and can enable early recognition of altered respiration patterns and apnea.

OBJECTIVE

To compare the detection of apnea and the prediction of oxygen desaturation and hypoxemia using capnography versus clinical surveillance during procedural sedation for percutaneous transhepatic cholangiodrainage (PTCD).

METHODS

Twenty consecutive patients scheduled for PTCD were included in the study. All patients were sedated during the procedure using midazolam and propofol. Aside from standard monitoring, additional capnographic monitoring was used and analyzed by an independent observer.

RESULTS

The mean (± SD) cumulative duration of apnea demonstrated by capnography was significantly longer than the mean cumulative duration of clinically detected apnea (207.5 ± 348.8 s versus 8.2 ± 17.9 s; P=0.015). The overall number of detected episodes of apnea was also significantly different (113 versus seven; P=0.012). There were 15 events of oxygen desaturation (decrease in oxygen saturation [SaO2] ≥ 5%), which were predicted in eight of 15 cases by capnography and in one of 15 cases by clinical observation. There were three events of hypoxemia (SaO2 <90%) that were predicted in three of three cases by capnography and in one of three cases by clinical observation.

CONCLUSION

Capnographic monitoring was superior to clinical surveillance in the detection of apnea and in the prediction of oxygen desaturation during procedural sedation for PTCD.