Clin Endosc.  2014 Mar;47(2):141-150. 10.5946/ce.2014.47.2.141.

Endoscopic Sedation: From Training to Performance

• Lee TH
• Lee CK

• KMID: 2049001
• DOI: http://doi.org/10.5946/ce.2014.47.2.141

Abstract

Adequate sedation and analgesia are considered essential requirements to relieve patient discomfort and pain and ultimately to improve the outcomes of modern gastrointestinal endoscopic procedures. The willingness of patients to undergo sedation during endoscopy has increased steadily in recent years and standard sedation practices are needed for both patient safety and successful procedural outcomes. Therefore, regular training and education of healthcare providers is warranted. However, training curricula and guidelines for endoscopic sedation may have conflicts according to varying legal frameworks and/or social security systems of each country, and well-recognized endoscopic sedation training systems are not currently available in all endoscopy units. Although European and American curricula for endoscopic sedation have been extensively developed, general curricula and guidelines for each country and institution are also needed. In this review, an overview of recent curricula and guidelines for training and basic performance of endoscopic sedation is presented based on the current literature.

Keyword

Endoscopic sedation; Guideline; Education

MeSH Terms

Analgesia
Curriculum
Education
Endoscopy
Health Personnel
Humans
Patient Safety
Social Security

Reference

1. American Association for Study of Liver Diseases. American College of Gastroenterology. American Gastroenterological Association Institute. . Multisociety sedation curriculum for gastrointestinal endoscopy. Gastrointest Endosc. 2012; 76:e1–e25.

2. Dumonceau JM, Riphaus A, Beilenhoff U, et al. European curriculum for sedation training in gastrointestinal endoscopy: position statement of the European Society of Gastrointestinal Endoscopy (ESGE) and European Society of Gastroenterology and Endoscopy Nurses and Associates (ESGENA). Endoscopy. 2013; 45:496–504. PMID: 23702777.

3. Dumonceau JM, Riphaus A, Aparicio JR, et al. European Society of Gastrointestinal Endoscopy, European Society of Gastroenterology and Endoscopy Nurses and Associates, and the European Society of Anaesthesiology Guideline: non-anesthesiologist administration of propofol for GI endoscopy. Endoscopy. 2010; 42:960–974. PMID: 21072716.

4. Lee CK, Lee SH, Chung IK, et al. Balanced propofol sedation for therapeutic GI endoscopic procedures: a prospective, randomized study. Gastrointest Endosc. 2011; 73:206–214. PMID: 21168838.

5. Lee TH, Lee CK, Park SH, et al. Balanced propofol sedation versus propofol monosedation in therapeutic pancreaticobiliary endoscopic procedures. Dig Dis Sci. 2012; 57:2113–2121. PMID: 22615018.

6. Chun SY, Kim KO, Park DS, et al. Safety and efficacy of deep sedation with propofol alone or combined with midazolam administrated by nonanesthesiologist for gastric endoscopic submucosal dissection. Gut Liver. 2012; 6:464–470. PMID: 23170151.

7. Oh JE, Lee HJ, Lee YH. Propofol versus midazolam for sedation during esophagogastroduodenoscopy in children. Clin Endosc. 2013; 46:368–372. PMID: 23964333.

8. Kang SH, Hyun JJ. Preparation and patient evaluation for safe gastrointestinal endoscopy. Clin Endosc. 2013; 46:212–218. PMID: 23767028.

9. Yu YH, Han DS, Kim HS, et al. Efficacy of bispectral index monitoring during balanced propofol sedation for colonoscopy: a prospective, randomized controlled trial. Dig Dis Sci. 2013; 58:3576–3583. PMID: 23982208.

10. Cha JM, Jeun JW, Pack KM, et al. Risk of sedation for diagnostic esophagogastroduodenoscopy in obstructive sleep apnea patients. World J Gastroenterol. 2013; 19:4745–4751. PMID: 23922472.

11. Lee SH, Kim SJ, Lee TH, et al. Human applications of submucosal endoscopy under conscious sedation for pure natural orifice transluminal endoscopic surgery. Surg Endosc. 2013; 27:3016–3020. PMID: 23397506.

12. Park CH, Min JH, Yoo YC, et al. Sedation methods can determine performance of endoscopic submucosal dissection in patients with gastric neoplasia. Surg Endosc. 2013; 27:2760–2767. PMID: 23389074.

13. Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy. Lichtenstein DR, Jagannath S, et al. Sedation and anesthesia in GI endoscopy. Gastrointest Endosc. 2008; 68:815–826. PMID: 18984096.

14. American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists. Practice guidelines for sedation and analgesia by non-anesthesiologists. Anesthesiology. 2002; 96:1004–1017. PMID: 11964611.

15. Kuwatani M, Kawakami H, Hayashi T, et al. Carbon dioxide insufflation during endoscopic retrograde cholangiopancreatography reduces bowel gas volume but does not affect visual analogue scale scores of suffering: a prospective, double-blind, randomized, controlled trial. Surg Endosc. 2011; 25:3784–3790. PMID: 21656068.

16. Knape JT, Adriaensen H, van Aken H, et al. Guidelines for sedation and/or analgesia by non-anaesthesiology doctors. Eur J Anaesthesiol. 2007; 24:563–567. PMID: 17568472.

17. Cohen LB, Delegge MH, Aisenberg J, et al. AGA institute review of endoscopic sedation. Gastroenterology. 2007; 133:675–701. PMID: 17681185.

18. Rex DK, Heuss LT, Walker JA, Qi R. Trained registered nurses/endoscopy teams can administer propofol safely for endoscopy. Gastroenterology. 2005; 129:1384–1391. PMID: 16285939.

19. Rex DK, Overley CA, Walker J. Registered nurse-administered propofol sedation for upper endoscopy and colonoscopy: why? when? how? Rev Gastroenterol Disord. 2003; 3:70–80. PMID: 12776004.

20. Fatima H, DeWitt J, LeBlanc J, Sherman S, McGreevy K, Imperiale TF. Nurse-administered propofol sedation for upper endoscopic ultrasonography. Am J Gastroenterol. 2008; 103:1649–1656. PMID: 18557709.

21. Riphaus A, Wehrmann T, Weber B, et al. S3-guidelines: sedation in gastrointestinal endoscopy. Z Gastroenterol. 2008; 46:1298–1330. PMID: 19012203.

22. Byrne MF, Chiba N, Singh H, Sadowski DC. Clinical Affairs Committee of the Canadian Association of Gastroenterology. Propofol use for sedation during endoscopy in adults: a Canadian Association of Gastroenterology position statement. Can J Gastroenterol. 2008; 22:457–459. PMID: 18478130.

23. DeMaria S Jr, Levine AI, Cohen LB. Human patient simulation and its role in endoscopic sedation training. Gastrointest Endosc Clin N Am. 2008; 18:801–813. PMID: 18922417.

24. Cohen LB, Wecsler JS, Gaetano JN, et al. Endoscopic sedation in the United States: results from a nationwide survey. Am J Gastroenterol. 2006; 101:967–974. PMID: 16573781.

25. Riphaus A, Rabofski M, Wehrmann T. Endoscopic sedation and monitoring practice in Germany: results from the first nationwide survey. Z Gastroenterol. 2010; 48:392–397. PMID: 20140841.

26. Heuss LT, Schnieper P, Drewe J, Pflimlin E, Beglinger C. Risk stratification and safe administration of propofol by registered nurses supervised by the gastroenterologist: a prospective observational study of more than 2000 cases. Gastrointest Endosc. 2003; 57:664–671. PMID: 12709694.

27. Cohen LB, Dubovsky AN, Aisenberg J, Miller KM. Propofol for endoscopic sedation: a protocol for safe and effective administration by the gastroenterologist. Gastrointest Endosc. 2003; 58:725–732. PMID: 14595310.

28. Külling D, Orlandi M, Inauen W. Propofol sedation during endoscopic procedures: how much staff and monitoring are necessary? Gastrointest Endosc. 2007; 66:443–449. PMID: 17725933.

29. Yusoff IF, Raymond G, Sahai AV. Endoscopist administered propofol for upper-GI EUS is safe and effective: a prospective study in 500 patients. Gastrointest Endosc. 2004; 60:356–360. PMID: 15332023.

30. Bell GD, Quine A, Antrobus JH, et al. Upper gastrointestinal endoscopy: a prospective randomized study comparing continuous supplemental oxygen via the nasal or oral route. Gastrointest Endosc. 1992; 38:319–325. PMID: 1607083.

31. Bowling TE, Hadjiminas CL, Polson RJ, Baron JH, Foale RA. Effects of supplemental oxygen on cardiac rhythm during upper gastrointestinal endoscopy: a randomised controlled double blind trial. Gut. 1993; 34:1492–1497. PMID: 8244130.

32. Crantock L, Cowen AE, Ward M, Roberts RK. Supplemental low flow oxygen prevents hypoxia during endoscopic cholangiopancreatography. Gastrointest Endosc. 1992; 38:418–420. PMID: 1511813.

33. Haines DJ, Bibbey D, Green JR. Does nasal oxygen reduce the cardiorespiratory problems experienced by elderly patients undergoing endoscopic retrograde cholangiopancreatography? Gut. 1992; 33:973–975. PMID: 1644341.

34. Rozario L, Sloper D, Sheridan MJ. Supplemental oxygen during moderate sedation and the occurrence of clinically significant desaturation during endoscopic procedures. Gastroenterol Nurs. 2008; 31:281–285. PMID: 18708832.

35. Vargo JJ, Zuccaro G Jr, Dumot JA, Conwell DL, Morrow JB, Shay SS. Automated graphic assessment of respiratory activity is superior to pulse oximetry and visual assessment for the detection of early respiratory depression during therapeutic upper endoscopy. Gastrointest Endosc. 2002; 55:826–831. PMID: 12024135.

36. Qadeer MA, Vargo JJ, Dumot JA, et al. Capnographic monitoring of respiratory activity improves safety of sedation for endoscopic cholangiopancreatography and ultrasonography. Gastroenterology. 2009; 136:1568–1576. PMID: 19422079.

37. Lightdale JR, Goldmann DA, Feldman HA, Newburg AR, DiNardo JA, Fox VL. Microstream capnography improves patient monitoring during moderate sedation: a randomized, controlled trial. Pediatrics. 2006; 117:e1170–e1178. PMID: 16702250.

38. Drake LM, Chen SC, Rex DK. Efficacy of bispectral monitoring as an adjunct to nurse-administered propofol sedation for colonoscopy: a randomized controlled trial. Am J Gastroenterol. 2006; 101:2003–2007. PMID: 16968506.

39. Imagawa A, Fujiki S, Kawahara Y, et al. Satisfaction with bispectral index monitoring of propofol-mediated sedation during endoscopic submucosal dissection: a prospective, randomized study. Endoscopy. 2008; 40:905–909. PMID: 19023932.

40. Paspatis GA, Chainaki I, Manolaraki MM, et al. Efficacy of bispectral index monitoring as an adjunct to propofol deep sedation for ERCP: a randomized controlled trial. Endoscopy. 2009; 41:1046–1051. PMID: 19967620.

41. Wehrmann T, Grotkamp J, Stergiou N, et al. Electroencephalogram monitoring facilitates sedation with propofol for routine ERCP: a randomized, controlled trial. Gastrointest Endosc. 2002; 56:817–824. PMID: 12447291.

42. Ely EW, Truman B, Shintani A, et al. Monitoring sedation status over time in ICU patients: reliability and validity of the Richmond Agitation-Sedation Scale (RASS). JAMA. 2003; 289:2983–2991. PMID: 12799407.

43. Picard P, Tramèr MR. Prevention of pain on injection with propofol: a quantitative systematic review. Anesth Analg. 2000; 90:963–969. PMID: 10735808.

44. McQuaid KR, Laine L. A systematic review and meta-analysis of randomized, controlled trials of moderate sedation for routine endoscopic procedures. Gastrointest Endosc. 2008; 67:910–923. PMID: 18440381.

45. Newman DH, Azer MM, Pitetti RD, Singh S. When is a patient safe for discharge after procedural sedation? The timing of adverse effect events in 1367 pediatric procedural sedations. Ann Emerg Med. 2003; 42:627–635. PMID: 14581914.

46. Jung M, Hofmann C, Kiesslich R, Brackertz A. Improved sedation in diagnostic and therapeutic ERCP: propofol is an alternative to midazolam. Endoscopy. 2000; 32:233–238. PMID: 10718389.

47. Aldrete JA, Kroulik D. A postanesthetic recovery score. Anesth Analg. 1970; 49:924–934. PMID: 5534693.

48. Zakko SF, Seifert HA, Gross JB. A comparison of midazolam and diazepam for conscious sedation during colonoscopy in a prospective double-blind study. Gastrointest Endosc. 1999; 49:684–689. PMID: 10343209.

49. Tohda G, Higashi S, Wakahara S, Morikawa M, Sakumoto H, Kane T. Propofol sedation during endoscopic procedures: safe and effective administration by registered nurses supervised by endoscopists. Endoscopy. 2006; 38:360–367. PMID: 16680635.

50. Training Committee of the American Society for Gastrointestinal Endoscopy. Vargo JJ, Ahmad AS, et al. Training in patient monitoring and sedation and analgesia. Gastrointest Endosc. 2007; 66:7–10. PMID: 17591466.

51. Cohen LB, Ladas SD, Vargo JJ, et al. Sedation in digestive endoscopy: the Athens international position statements. Aliment Pharmacol Ther. 2010; 32:425–442. PMID: 20456310.

52. Dinis-Ribeiro M, Vargo JJ. Sedation by non-anesthesiologists: are opioids and benzodiazepines outdated? Digestion. 2010; 82:100–101. PMID: 20407255.

53. Levitzky BE, Lopez R, Dumot JA, Vargo JJ. Moderate sedation for elective upper endoscopy with balanced propofol versus fentanyl and midazolam alone: a randomized clinical trial. Endoscopy. 2012; 44:13–20. PMID: 22068700.

54. Vargo JJ, Cohen LB, Rex DK, et al. Position statement: nonanesthesiologist administration of propofol for GI endoscopy. Gastroenterology. 2009; 137:2161–2167. PMID: 19961989.

55. Chen SC, Rex DK. Review article: registered nurse-administered propofol sedation for endoscopy. Aliment Pharmacol Ther. 2004; 19:147–155. PMID: 14723606.

56. Cohen LB, Cattau E, Goetsch A, et al. A randomized, double-blind, phase 3 study of fospropofol disodium for sedation during colonoscopy. J Clin Gastroenterol. 2010; 44:345–353. PMID: 19996984.

57. Rex DK, Deenadayalu VP, Eid E, et al. Endoscopist-directed administration of propofol: a worldwide safety experience. Gastroenterology. 2009; 137:1229–1237. PMID: 19549528.

58. Ulmer BJ, Hansen JJ, Overley CA, et al. Propofol versus midazolam/fentanyl for outpatient colonoscopy: administration by nurses supervised by endoscopists. Clin Gastroenterol Hepatol. 2003; 1:425–432. PMID: 15017641.

59. VanNatta ME, Rex DK. Propofol alone titrated to deep sedation versus propofol in combination with opioids and/or benzodiazepines and titrated to moderate sedation for colonoscopy. Am J Gastroenterol. 2006; 101:2209–2217. PMID: 17032185.