Intest Res.  2017 Oct;15(4):456-466. 10.5217/ir.2017.15.4.456.

Sedation for routine gastrointestinal endoscopic procedures: a review on efficacy, safety, efficiency, cost and satisfaction

• Lin OS

• KMID: 2396395
• DOI: http://doi.org/10.5217/ir.2017.15.4.456

Abstract

Most gastrointestinal endoscopic procedures are now performed with sedation. Moderate sedation using benzodiazepines and opioids continue to be widely used, but propofol sedation is becoming more popular because its unique pharmacokinetic properties make endoscopy almost painless, with a very predictable and rapid recovery process. There is controversy as to whether propofol should be administered only by anesthesia professionals (monitored anesthesia care) or whether properly trained non-anesthesia personnel can use propofol safely via the modalities of nurse-administered propofol sedation, computer-assisted propofol sedation or nurse-administered continuous propofol sedation. The deployment of non-anesthesia administered propofol sedation for low-risk procedures allows for optimal allocation of scarce anesthesia resources, which can be more appropriately used for more complex cases. This can address some of the current shortages in anesthesia provider supply, and can potentially reduce overall health care costs without sacrificing sedation quality. This review will discuss efficacy, safety, efficiency, cost and satisfaction issues with various modes of sedation for non-advanced, non-emergent endoscopic procedures, mainly esophagogastroduodenoscopy and colonoscopy.

Keyword

Colonoscopy; Propofol; Deep sedation; Endoscopy, digestive system; Anesthesia

MeSH Terms

Analgesics, Opioid
Anesthesia
Benzodiazepines
Colonoscopy
Conscious Sedation
Deep Sedation
Endoscopy
Endoscopy, Digestive System
Health Care Costs
Propofol
Analgesics, Opioid
Benzodiazepines
Propofol

Reference

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

2. Ghanouni A, Plumb A, Hewitson P, Nickerson C, Rees CJ, von Wagner C. Patients' experience of colonoscopy in the English Bowel Cancer Screening Programme. Endoscopy. 2016; 48:232–240. PMID: 26841268.

3. Italian Association of Hospital Gastroenterologists (AIGO). Radaelli F, Meucci G, Sgroi G, Minoli G. Technical performance of colonoscopy: the key role of sedation/analgesia and other quality indicators. Am J Gastroenterol. 2008; 103:1122–1130. PMID: 18445096.

4. 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.

5. Gross JB, Bachenberg KL, Benumof JL, et al. Practice guidelines for the perioperative management of patients with obstructive sleep apnea: a report by the American Society of Anesthesiologists Task Force on Perioperative Management of patients with obstructive sleep apnea. Anesthesiology. 2006; 104:1081–1093. PMID: 16645462.

6. Sami SS, Subramanian V, Ortiz-Fernández-Sordo J, et al. Performance characteristics of unsedated ultrathin video endoscopy in the assessment of the upper GI tract: systematic review and meta-analysis. Gastrointest Endosc. 2015; 82:782–792. PMID: 26371850.

7. Leung FW. Water-aided colonoscopy. Gastroenterol Clin North Am. 2013; 42:507–519. PMID: 23931857.

8. Rex DK, Imperiale TF, Portish V. Patients willing to try colonoscopy without sedation: associated clinical factors and results of a randomized controlled trial. Gastrointest Endosc. 1999; 49:554–559. PMID: 10228251.

9. Liu H, Waxman DA, Main R, Mattke S. Utilization of anesthesia services during outpatient endoscopies and colonoscopies and associated spending in 2003-2009. JAMA. 2012; 307:1178–1184. PMID: 22436958.

10. Predmore Z, Nie X, Main R, Mattke S, Liu H. Anesthesia service use during outpatient gastroenterology procedures continued to increase from 2010 to 2013 and potentially discretionary spending remained high. Am J Gastroenterol. 2017; 112:297–302. PMID: 27349340.

11. Childers RE, Williams JL, Sonnenberg A. Practice patterns of sedation for colonoscopy. Gastrointest Endosc. 2015; 82:503–511. PMID: 25851159.

12. Riphaus A, Macias-Gomez C, Devière J, Dumonceau JM. Propofol, the preferred sedation for screening colonoscopy, is underused. Results of an international survey. Dig Liver Dis. 2012; 44:389–392. PMID: 22119619.

13. 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.

14. Lee MG, Hanna W, Harding H. Sedation for upper gastrointestinal endoscopy: a comparative study of midazolam and diazepam. Gastrointest Endosc. 1989; 35:82–84. PMID: 2619791.

15. Cole SG, Brozinsky S, Isenberg JI. Midazolam, a new more potent benzodiazepine, compared with diazepam: a randomized, double-blind study of preendoscopic sedatives. Gastrointest Endosc. 1983; 29:219–222. PMID: 6618119.

16. Horn E, Nesbit SA. Pharmacology and pharmacokinetics of sedatives and analgesics. Gastrointest Endosc Clin N Am. 2004; 14:247–268. PMID: 15121142.

17. Waring JP, Baron TH, Hirota WK, et al. Guidelines for conscious sedation and monitoring during gastrointestinal endoscopy. Gastrointest Endosc. 2003; 58:317–322. PMID: 14528201.

18. 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.

19. Wadhwa V, Issa D, Garg S, Lopez R, Sanaka MR, Vargo JJ. Similar risk of cardiopulmonary adverse events between propofol and traditional anesthesia for gastrointestinal endoscopy: a systematic review and meta-analysis. Clin Gastroenterol Hepatol. 2017; 15:194–206. PMID: 27451091.

20. 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.

21. Watkins TJ, Bonds RL, Hodges K, Goettle BB, Dobson DA, Maye JP. Evaluation of postprocedure cognitive function using 3 distinct standard sedation regimens for endoscopic procedures. AANA J. 2014; 82:133–139. PMID: 24902456.

22. Horiuchi A, Nakayama Y, Fujii H, Katsuyama Y, Ohmori S, Tanaka N. Psychomotor recovery and blood propofol level in colonoscopy when using propofol sedation. Gastrointest Endosc. 2012; 75:506–512. PMID: 22115604.

23. Willey J, Vargo JJ, Connor JT, Dumot JA, Conwell DL, Zuccaro G. Quantitative assessment of psychomotor recovery after sedation and analgesia for outpatient EGD. Gastrointest Endosc. 2002; 56:810–816. PMID: 12447290.

24. Qadeer MA, Vargo JJ, Khandwala F, Lopez R, Zuccaro G. Propofol versus traditional sedative agents for gastrointestinal endoscopy: a meta-analysis. Clin Gastroenterol Hepatol. 2005; 3:1049–1056. PMID: 16271333.

25. Wang D, Chen C, Chen J, et al. The use of propofol as a sedative agent in gastrointestinal endoscopy: a meta-analysis. PLoS One. 2013; 8:e53311. DOI: 10.1371/journal.pone.0053311. PMID: 23308191.

26. Tsai HC, Lin YC, Ko CL, et al. Propofol versus midazolam for upper gastrointestinal endoscopy in cirrhotic patients: a meta-analysis of randomized controlled trials. PLoS One. 2015; 10:e0117585. DOI: 10.1371/journal.pone.0117585. PMID: 25646815.

27. Inadomi JM, Gunnarsson CL, Rizzo JA, Fang H. Projected increased growth rate of anesthesia professional-delivered sedation for colonoscopy and EGD in the United States: 2009 to 2015. Gastrointest Endosc. 2010; 72:580–586. PMID: 20630511.

28. Khiani VS, Soulos P, Gancayco J, Gross CP. Anesthesiologist involvement in screening colonoscopy: temporal trends and cost implications in the Medicare population. Clin Gastroenterol Hepatol. 2012; 10:58–64.e1. PMID: 21782768.

29. Alharbi O, Rabeneck L, Paszat LF, et al. A population-based analysis of outpatient colonoscopy in adults assisted by an anesthesiologist. Anesthesiology. 2009; 111:734–740. PMID: 19741486.

30. Inadomi JM. Editorial: endoscopic sedation: who, which, when? Am J Gastroenterol. 2017; 112:303–305. PMID: 28154379.

31. Hassan C, Rex DK, Cooper GS, Benamouzig R. Endoscopist-directed propofol administration versus anesthesiologist assistance for colorectal cancer screening: a cost-effectiveness analysis. Endoscopy. 2012; 44:456–464. PMID: 22531982.

32. Dominitz JA, Baldwin LM, Green P, Kreuter WI, Ko CW. Regional variation in anesthesia assistance during outpatient colonoscopy is not associated with differences in polyp detection or complication rates. Gastroenterology. 2013; 144:298–306. PMID: 23103615.

33. Fleisher LA. Assessing the value of “discretionary” clinical care: the case of anesthesia services for endoscopy. JAMA. 2012; 307:1200–1201. PMID: 22436962.

34. Agrawal D, Rockey DC. Propofol for screening colonoscopy in low-risk patients: are we paying too much? JAMA Intern Med. 2013; 173:1836–1838. PMID: 23857456.

35. Rex DK, Vargo JJ. Anesthetist-directed sedation for colonoscopy: a safe haven or siren's song? Gastroenterology. 2016; 150:801–803. PMID: 26924093.

36. Repici A, Hassan C. The endoscopist, the anesthesiologists, and safety in GI endoscopy. Gastrointest Endosc. 2017; 85:109–111. PMID: 27986104.

37. Rex DK. The science and politics of propofol. Am J Gastroenterol. 2004; 99:2080–2083. PMID: 15554982.

38. Metwally M, Agresti N, Hale WB, et al. Conscious or unconscious: the impact of sedation choice on colon adenoma detection. World J Gastroenterol. 2011; 17:3912–3915. PMID: 22025879.

39. Paspatis GA, Tribonias G, Manolaraki MM, et al. Deep sedation compared with moderate sedation in polyp detection during colonoscopy: a randomized controlled trial. Colorectal Dis. 2011; 13:e137–e144. DOI: 10.1111/j.1463-1318.2011.02555.x. PMID: 21564466.

40. Adeyemo A, Bannazadeh M, Riggs T, Shellnut J, Barkel D, Wasvary H. Does sedation type affect colonoscopy perforation rates? Dis Colon Rectum. 2014; 57:110–114. PMID: 24316954.

41. Hsieh TK, Hung L, Kang FC, Lan KM, Poon PW, So EC. Anesthesia does not increase the rate of bowel perforation during colonoscopy: a retrospective study. Acta Anaesthesiol Taiwan. 2009; 47:162–166. PMID: 20015815.

42. Korman LY, Haddad NG, Metz DC, et al. Effect of propofol anesthesia on force application during colonoscopy. Gastrointest Endosc. 2014; 79:657–662. PMID: 24472761.

43. Lubarsky DA, Guercio JR, Hanna JW, et al. The impact of anesthesia providers on major morbidity following screening colonoscopies. J Multidiscip Healthc. 2015; 8:255–270. PMID: 26060404.

44. Wernli KJ, Brenner AT, Rutter CM, Inadomi JM. Risks associated with anesthesia services during colonoscopy. Gastroenterology. 2016; 150:888–894. PMID: 26709032.

45. Cooper GS, Kou TD, Rex DK. Complications following colonoscopy with anesthesia assistance: a population-based analysis. JAMA Intern Med. 2013; 173:551–556. PMID: 23478904.

46. Vargo JJ, Niklewski PJ, Williams JL, Martin JF, Faigel DO. Patient safety during sedation by anesthesia professionals during routine upper endoscopy and colonoscopy: an analysis of 1.38 million procedures. Gastrointest Endosc. 2017; 85:101–108. PMID: 26905938.

47. Vargo JJ. Big NAPS, little NAPS, mixed NAPS, computerized NAPS: what is your flavor of propofol? Gastrointest Endosc. 2007; 66:457–459. PMID: 17725935.

48. 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.

49. Orkin FK, Duncan PG. Substrate for healthcare reform: anesthesia's low-lying fruit. Anesthesiology. 2009; 111:697–698. PMID: 19707113.

50. 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.

51. Dumonceau JM, Riphaus A, Schreiber F, et al. Non-anesthesiologist administration of propofol for gastrointestinal endoscopy: European Society of Gastrointestinal Endoscopy, European Society of Gastroenterology and Endoscopy Nurses and Associates guideline. Updated June 2015. Endoscopy. 2015; 47:1175–1189. PMID: 26561915.

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

53. 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.

54. bng-Study-Group. Sieg A, Beck S, et al. Safety analysis of endoscopist-directed propofol sedation: a prospective, national multicenter study of 24,441 patients in German outpatient practices. J Gastroenterol Hepatol. 2014; 29:517–523. PMID: 24716213.

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

56. 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.

57. Sathananthan D, Young E, Nind G, et al. Assessing the safety of physician-directed nurse-administered propofol sedation in low-risk patients undergoing endoscopy and colonoscopy. Endosc Int Open. 2017; 5:E110–E115. PMID: 28210707.

58. Sipe BW, Rex DK, Latinovich D, et al. Propofol versus midazolam/ meperidine for outpatient colonoscopy: administration by nurses supervised by endoscopists. Gastrointest Endosc. 2002; 55:815–825. PMID: 12024134.

59. Walker JA, McIntyre RD, Schleinitz PF, et al. Nurse-administered propofol sedation without anesthesia specialists in 9152 endoscopic cases in an ambulatory surgery center. Am J Gastroenterol. 2003; 98:1744–1750. PMID: 12907328.

60. Poincloux L, Laquière A, Bazin JE, et al. A randomized controlled trial of endoscopist vs. anaesthetist-administered sedation for colonoscopy. Dig Liver Dis. 2011; 43:553–558. PMID: 21450542.

61. Rex DK, Overley C, Kinser K, et al. Safety of propofol administered by registered nurses with gastroenterologist supervision in 2000 endoscopic cases. Am J Gastroenterol. 2002; 97:1159–1163. PMID: 12014721.

62. Riphaus A. NAPS in 2016: why not everywhere? Endosc Int Open. 2017; 5:E222–E223. PMID: 28317019.

63. Dumonceau JM. Nonanesthesiologist administration of propofol: it's all about money. Endoscopy. 2012; 44:453–455. PMID: 22531981.

64. Rex DK. Effect of the centers for Medicare & Medicaid Services policy about deep sedation on use of propofol. Ann Intern Med. 2011; 154:622–626. PMID: 21536938.

65. Aisenberg J, Cohen LB, Piorkowski JD Jr. Propofol use under the direction of trained gastroenterologists: an analysis of the medicolegal implications. Am J Gastroenterol. 2007; 102:707–713. PMID: 17397402.

66. Mandel JE, Lichtenstein GR, Metz DC, Ginsberg GG, Kochman ML. A prospective, randomized, comparative trial evaluating respiratory depression during patient-controlled versus anesthesiologist-administered propofol-remifentanil sedation for elective colonoscopy. Gastrointest Endosc. 2010; 72:112–117. PMID: 20493481.

67. 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.

68. Roseveare C, Seavell C, Patel P, et al. Patient-controlled sedation and analgesia, using propofol and alfentanil, during colonoscopy: a prospective randomized controlled trial. Endoscopy. 1998; 30:768–773. PMID: 9932756.

69. Liu SY, Poon CM, Leung TL, et al. Nurse-administered propofol-alfentanil sedation using a patient-controlled analgesia pump compared with opioid-benzodiazepine sedation for outpatient colonoscopy. Endoscopy. 2009; 41:522–528. PMID: 19440955.

70. Pambianco DJ, Whitten CJ, Moerman A, Struys MM, Martin JF. An assessment of computer-assisted personalized sedation: a sedation delivery system to administer propofol for gastrointestinal endoscopy. Gastrointest Endosc. 2008; 68:542–547. PMID: 18511048.

71. Pambianco DJ, Vargo JJ, Pruitt RE, Hardi R, Martin JF. Computer-assisted personalized sedation for upper endoscopy and colonoscopy: a comparative, multicenter randomized study. Gastrointest Endosc. 2011; 73:765–772. PMID: 21168841.

72. Lin OS, Kozarek RA, Tombs D, et al. The first US clinical experience with computer-assisted propofol sedation: a retrospective observational comparative study on efficacy, safety, efficiency, and endoscopist and patient satisfaction. Anesth Analg. 2017; 9. 17. DOI: 10.1213/ANE.0000000000001898.

73. Vargo J, Howard K, Petrillo J, Scott J, Revicki DA. Development and validation of the patient and clinician sedation satisfaction index for colonoscopy and upper endoscopy. Clin Gastroenterol Hepatol. 2009; 7:156–162. PMID: 18930167.

74. Lin OS, La Selva D, Kozarek RA, et al. One year experience with computer-assisted propofol sedation for colonoscopy. World J Gastroenterol. 2017; 23:2964–2971. PMID: 28522914.

75. Lin OS, La Selva D, Tombs D, Kozarek RA, Ross AS. One year experience with computer-assisted propofol sedation for esophagogastroduodenoscopy. Gastrointest Endosc. 2016; 83(5 Suppl):AB534–AB535.

76. Horiuchi A, Graham DY. Special topics in procedural sedation: clinical challenges and psychomotor recovery. Gastrointest Endosc. 2014; 80:404–409. PMID: 24981806.

77. Vargo JJ, Bramley T, Meyer K, Nightengale B. Practice efficiency and economics: the case for rapid recovery sedation agents for colonoscopy in a screening population. J Clin Gastroenterol. 2007; 41:591–598. PMID: 17577116.

78. Koch J, Tombs D, Lin OS, et al. Economic impact of computer assisted propofol sedation. Gastroenterology. 2016; 150(4 Suppl 1):S101.

79. Singh PM, Borle A, Goudra BG. Use of computer-assisted drug therapy outside the operating room. Curr Opin Anaesthesiol. 2016; 29:506–511. PMID: 27054414.

80. Hirshman S, Mattke S, Liu H. Anesthesia service use and the uptake of screening colonoscopies. Med Care. 2017; 55:623–628. PMID: 28002204.

81. Liu H, Mattke S, Predmore ZS. Medicare coverage of anesthesia services during screening colonoscopies for patients at low risk of sedation-related complications. JAMA Intern Med. 2015; 175:1848–1850. PMID: 26348629.

82. Martínez JF, Aparicio JR, Compañy L, et al. Safety of continuous propofol sedation for endoscopic procedures in elderly patients. Rev Esp Enferm Dig. 2011; 103:76–82. PMID: 21366368.

83. Riphaus A, Geist C, Schrader K, Martchenko K, Wehrmann T. Intermittent manually controlled versus continuous infusion of propofol for deep sedation during interventional endoscopy: a prospective randomized trial. Scand J Gastroenterol. 2012; 47:1078–1085. PMID: 22631051.

84. Lin OS, Kozarek RA, Tombs D, Ross AS. Nurse administered propofol continuous infusion sedation (NAPCIS): a new paradigm for GI procedure sedation. Gastroenterology. 2017; 152(5 Suppl 1):S1314.

85. Goudra BG, Singh PM. SEDASYS, sedation, and the unknown. J Clin Anesth. 2014; 26:334–336. PMID: 24916898.

86. Brill JV, Jain R, Margolis PS, et al. A bundled payment framework for colonoscopy performed for colorectal cancer screening or surveillance. Gastroenterology. 2014; 146:849–853.e9. PMID: 24480681.

87. Patel K, Presser E, George M, McClellan M. Shifting away from fee-for-service: alternative approaches to payment in gastroenterology. Clin Gastroenterol Hepatol. 2016; 14:497–506. PMID: 26122765.

88. Dorn SD. The road ahead 3.0: changing payments, changing practice. Clin Gastroenterol Hepatol. 2016; 14:785–789. PMID: 27062930.

89. Lieberman D, Allen J. New approaches to controlling health care costs: bending the cost curve for colonoscopy. JAMA Intern Med. 2015; 175:1789–1791. PMID: 26348112.

90. Robinson JC, Brown TT, Whaley C, Finlayson E. Association of reference payment for colonoscopy with consumer choices, insurer spending, and procedural complications. JAMA Intern Med. 2015; 175:1783–1789. PMID: 26348851.