Gastroenterology

Gastroenterology

Volume 137, Issue 4, October 2009, Pages 1229-1237
Gastroenterology

Imaging and Advanced Technology
Endoscopist-Directed Administration of Propofol: A Worldwide Safety Experience

https://doi.org/10.1053/j.gastro.2009.06.042Get rights and content

Background & Aims

Endoscopist-directed propofol sedation (EDP) remains controversial. We sought to update the safety experience of EDP and estimate the cost of using anesthesia specialists for endoscopic sedation.

Methods

We reviewed all published work using EDP. We contacted all endoscopists performing EDP for endoscopy that we were aware of to obtain their safety experience. These complications were available in all patients: endotracheal intubations, permanent neurologic injuries, and death.

Results

A total of 646,080 (223,656 published and 422,424 unpublished) EDP cases were identified. Endotracheal intubations, permanent neurologic injuries, and deaths were 11, 0, and 4, respectively. Deaths occurred in 2 patients with pancreatic cancer, a severely handicapped patient with mental retardation, and a patient with severe cardiomyopathy. The overall number of cases requiring mask ventilation was 489 (0.1%) of 569,220 cases with data available. For sites specifying mask ventilation risk by procedure type, 185 (0.1%) of 185,245 patients and 20 (0.01%) of 142,863 patients required mask ventilation during their esophagogastroduodenoscopy or colonoscopy, respectively (P < .001). The estimated cost per life-year saved to substitute anesthesia specialists in these cases, assuming they would have prevented all deaths, was $5.3 million.

Conclusions

EDP thus far has a lower mortality rate than that in published data on endoscopist-delivered benzodiazepines and opioids and a comparable rate to that in published data on general anesthesia by anesthesiologists. In the cases described here, use of anesthesia specialists to deliver propofol would have had high costs relative to any potential benefit.

Section snippets

Review of Published Cases

The following databases were searched: Ovid MEDLINE and PubMed (1966–November Week 1 2008), EMBASE (1980–2008 Week 45), CINAHL (1982–November Week 1 2008), Cochrane Database of Systematic Reviews (3rd Quarter 2008), and Cochrane Central Register of Controlled Trials (4th Quarter 2008).

The medical subject heading for propofol was combined with all subject headings for medical specialties, specialism, nursing, nursing care, nursing services, nurse's role, health personnel, hospital units, and

Results

Of the 28 centers providing previously unpublished cases, all had formal training programs in EDP. Twenty-three centers had didactic training sessions, and 13 required physicians and nurses performing EDP to pass a written test. Twenty-seven centers required trainees to do hands-on supervised administration of propofol, and one used a simulator for training in administration. All centers included training in airway assessment and management, and 5 centers included sessions with an

Discussion

In this report, we summarize published literature and previously unpublished cases about the safety of EDP for endoscopic procedures. Our results indicate that the safety record of propofol administration by endoscopists is superior to the published safety record of opioids and benzodiazepines by endoscopists for gastrointestinal endoscopy.59, 60, 61, 62, 63 Specifically, the overall death rate for EDP that we identified was 1 per 161,515 cases. By comparison, earlier published death rates for

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    To view this article's video abstract, go to theAGA's YouTube Channel.

    This article has an accompanying continuing medical education activity on page 1518. Learning Objective: Upon completion of reading this article, successful learners will be able to identify facts about propofol important for its use by non-anesthesiologists.

    Conflicts of interest The authors disclose the following: J.A. Walker is CEO of Dr. NAPS, LLC; T. Wehrmann received speaker's fees and research support from Fresenius-Kabi, Germany; A. Riphaus received speaker's fees from Fresenius-Kabi, Falk Pharma and Nycomed, Germany, and research support from Fresenius-Kabi, Germany. The remaining authors disclose no conflicts.

    Douglas K. Rex had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

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