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Forward Progress of Sedation for Gastrointestinal Endoscopy Requires Taking a Step Back
Gastroenterology 2016;-:1–2
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CORRESPONDENCE Readers may submit letters to the editor concerning articles that appeared in Gastroenterology within one month of publication. Detailed guidelines regarding the content are included in the Instructions to Authors.
Forward Progress of Sedation for Gastrointestinal Endoscopy Requires Taking a Step Back Dear Editors: When the new operating system “Windows 10” was released, reviewer Walt Mossberg commented that “Microsoft takes a step back to move forward.”1 In this same regard, forward progress of sedation for gastrointestinal (GI) endoscopy requires taking a step back. From the findings of Wernli et al,2 the role of propofol and its administration during colonoscopy has come under debate. The philosophy, “you will sleep fantastically and wake up,” needs to be reexamined. In furthering this debate, 3 separate yet interlinked questions need to be answered. First, is providing sedation with a short-acting benzodiazepine and opioid really that inadequate? Second, do all patients undergoing GI endoscopy benefit from propofol sedation? Finally, does it require an anesthesia provider to administer propofol undergoing GI endoscopy? Let us examine each one of these questions. Across the world, the vast majority of screening colonoscopies and diagnostic endoscopies are performed either with conscious sedation or no sedation. Typically, conscious sedation involves the administration of midazolam and fentanyl, wherein spontaneous ventilation is maintained. Even without oxygen supplementation, the incidence of desaturation is negligible. Despite decreased patient satisfaction (compared with propofol sedation), superior safety makes conscious sedation a good option for screening colonoscopies. Even more, the incidence of aspiration is lower, the depth of sedation is better regulated, the rates of bleeding and colonic perforation are lower, and finally the chances of slipping into a state of deep general anesthesia are rare.3 The second question pertains to overenthusiasm for propofol deep sedation for all GI endoscopies, despite little to no evidence demonstrating the safety of such approach. Our own study demonstrated a much higher incidence of most complications including cardiac arrest and death, in patients undergoing GI endoscopy with propofol sedation compared with intravenous conscious sedation.4,5 Moreover, studies from reputed centers have similarly found high incidences of hypoxemia with propofol sedation, when administered by anesthesia providers. Finally, the third question concerns the regulatory requirement. Currently, in most developed countries, anesthesia providers administer propofol. In the United States, this category includes certified nurse anesthetists and trainee anesthesiologists under the supervision of a consultant anesthesiologist. Our own meta-analysis compared the safety of propofol administered by anesthesia and nonanesthesia providers during advanced endoscopic procedures. The results revealed that, although
patient and endoscopist satisfaction were higher in patents sedated by anesthesia providers, the cost was decreased safety.6 Evidently, a lighter degree of sedation provided by nonanesthesia providers contributed to the increased safety. With increasing scrutiny on the safety of propofol in GI endoscopy, the question becomes this: Where do we draw the line? The most common justification for extensive use of propofol in screening colonoscopy is superior patient satisfaction. Early detection and treatment of colon cancer reduces the financial and psychological burden for both the patient and the family. Nevertheless, none of these benefits justify rampant and often indiscriminate use of propofol for a screening colonoscopy. In light of the findings of Wernli et al, wherein they have demonstrated a 13% increase in all complications, a rethink is mandatory. In conclusion, everyone involved in providing sedation for GI endoscopy should take a step backward to move forward. An honest explanation of the risks and benefits of propofol sedation should be presented to every patient. Gastroenterologists should be prepared to administer conscious sedation to those who do not wish to have deep sedation/general anesthesia. Nurse-administered propofol sedation under the supervision of either a dedicated gastroenterologist or an anesthesiologist should be allowed. Owing to lighter levels of propofol sedation provided, this practice might retain the safety of conscious sedation. Required regulatory changes should be in place to effect such a change. It is better to allow interested endoscopists guide the nurses involved in providing propofol sedation. A new category of nurses and paramedical personnel can be trained in sedation administration. After all, the most obvious adverse event related to sedation is hypoxemia, the prevention and management of which does not have much to with education and knowledge. Q2 BASAVANA GOUDRA Department of Clinical Anesthesiology and Critical Care Perelman School of Medicine Philadelphia, Pennsylvania PREET MOHINDER SINGH Department of Anesthesiology and Critical Care Medicine All India Institutes of Medical Sciences Ansari Nagar East, New Delhi
References 1.
2. 3.
Windows 10 Review: Microsoft Takes a Step Back to Move Forward [Internet]. Re/code. [cited 2016 Jan 4]. Available from: http://recode.net/2015/07/28/wind ows-10-review-microsoft-takes-a-step- back-to-moveforward/. Wernli KJ, et al. Gastroenterology 2016;150:888–894. Goudra B, et al. J Clin Monit Comput 2015 Sep 12 [Epub ahead of print].
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4. 5.
Correspondence
Gastroenterology Vol.
Goudra B, et al. Saudi J Gastroenterol Off J Saudi Gastroenterol Assoc 2015;21:400–411. ASA Abstracts [Internet]. Available: www.asaabstra cts.com/strands/asaabstracts/abstract.htm;jsessionid ¼741875BC3BEEA104D7 D0E3B63AA80D69?year¼ 2015&index¼1&absnum¼4697. Accessed January 4, 2016.
6.
-,
No.
-
Goudra BG, et al. Dig Dis Sci 2015;60:2612–2627.
Conflicts of interest The authors disclose no conflicts.
http://dx.doi.org/10.1053/j.gastro.2016.02.091
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CORRESPONDENCE Readers may submit letters to the editor concerning articles that appeared in Gastroenterology within one month of publication. Detailed guidelines regarding the content are included in the Instructions to Authors.
Forward Progress of Sedation for Gastrointestinal Endoscopy Requires Taking a Step Back Dear Editors: When the new operating system “Windows 10” was released, reviewer Walt Mossberg commented that “Microsoft takes a step back to move forward.”1 In this same regard, forward progress of sedation for gastrointestinal (GI) endoscopy requires taking a step back. From the findings of Wernli et al,2 the role of propofol and its administration during colonoscopy has come under debate. The philosophy, “you will sleep fantastically and wake up,” needs to be reexamined. In furthering this debate, 3 separate yet interlinked questions need to be answered. First, is providing sedation with a short-acting benzodiazepine and opioid really that inadequate? Second, do all patients undergoing GI endoscopy benefit from propofol sedation? Finally, does it require an anesthesia provider to administer propofol undergoing GI endoscopy? Let us examine each one of these questions. Across the world, the vast majority of screening colonoscopies and diagnostic endoscopies are performed either with conscious sedation or no sedation. Typically, conscious sedation involves the administration of midazolam and fentanyl, wherein spontaneous ventilation is maintained. Even without oxygen supplementation, the incidence of desaturation is negligible. Despite decreased patient satisfaction (compared with propofol sedation), superior safety makes conscious sedation a good option for screening colonoscopies. Even more, the incidence of aspiration is lower, the depth of sedation is better regulated, the rates of bleeding and colonic perforation are lower, and finally the chances of slipping into a state of deep general anesthesia are rare.3 The second question pertains to overenthusiasm for propofol deep sedation for all GI endoscopies, despite little to no evidence demonstrating the safety of such approach. Our own study demonstrated a much higher incidence of most complications including cardiac arrest and death, in patients undergoing GI endoscopy with propofol sedation compared with intravenous conscious sedation.4,5 Moreover, studies from reputed centers have similarly found high incidences of hypoxemia with propofol sedation, when administered by anesthesia providers. Finally, the third question concerns the regulatory requirement. Currently, in most developed countries, anesthesia providers administer propofol. In the United States, this category includes certified nurse anesthetists and trainee anesthesiologists under the supervision of a consultant anesthesiologist. Our own meta-analysis compared the safety of propofol administered by anesthesia and nonanesthesia providers during advanced endoscopic procedures. The results revealed that, although
patient and endoscopist satisfaction were higher in patents sedated by anesthesia providers, the cost was decreased safety.6 Evidently, a lighter degree of sedation provided by nonanesthesia providers contributed to the increased safety. With increasing scrutiny on the safety of propofol in GI endoscopy, the question becomes this: Where do we draw the line? The most common justification for extensive use of propofol in screening colonoscopy is superior patient satisfaction. Early detection and treatment of colon cancer reduces the financial and psychological burden for both the patient and the family. Nevertheless, none of these benefits justify rampant and often indiscriminate use of propofol for a screening colonoscopy. In light of the findings of Wernli et al, wherein they have demonstrated a 13% increase in all complications, a rethink is mandatory. In conclusion, everyone involved in providing sedation for GI endoscopy should take a step backward to move forward. An honest explanation of the risks and benefits of propofol sedation should be presented to every patient. Gastroenterologists should be prepared to administer conscious sedation to those who do not wish to have deep sedation/general anesthesia. Nurse-administered propofol sedation under the supervision of either a dedicated gastroenterologist or an anesthesiologist should be allowed. Owing to lighter levels of propofol sedation provided, this practice might retain the safety of conscious sedation. Required regulatory changes should be in place to effect such a change. It is better to allow interested endoscopists guide the nurses involved in providing propofol sedation. A new category of nurses and paramedical personnel can be trained in sedation administration. After all, the most obvious adverse event related to sedation is hypoxemia, the prevention and management of which does not have much to with education and knowledge. Q2 BASAVANA GOUDRA Department of Clinical Anesthesiology and Critical Care Perelman School of Medicine Philadelphia, Pennsylvania PREET MOHINDER SINGH Department of Anesthesiology and Critical Care Medicine All India Institutes of Medical Sciences Ansari Nagar East, New Delhi
References 1.
2. 3.
Windows 10 Review: Microsoft Takes a Step Back to Move Forward [Internet]. Re/code. [cited 2016 Jan 4]. Available from: http://recode.net/2015/07/28/wind ows-10-review-microsoft-takes-a-step- back-to-moveforward/. Wernli KJ, et al. Gastroenterology 2016;150:888–894. Goudra B, et al. J Clin Monit Comput 2015 Sep 12 [Epub ahead of print].
COR 5.4.0 DTD YGAST60539_proof 30 July 2016 3:04 am ce
61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 113 114 115 116 117 118 119 120
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4. 5.
Correspondence
Gastroenterology Vol.
Goudra B, et al. Saudi J Gastroenterol Off J Saudi Gastroenterol Assoc 2015;21:400–411. ASA Abstracts [Internet]. Available: www.asaabstra cts.com/strands/asaabstracts/abstract.htm;jsessionid ¼741875BC3BEEA104D7 D0E3B63AA80D69?year¼ 2015&index¼1&absnum¼4697. Accessed January 4, 2016.
6.
-,
No.
-
Goudra BG, et al. Dig Dis Sci 2015;60:2612–2627.
Conflicts of interest The authors disclose no conflicts.
http://dx.doi.org/10.1053/j.gastro.2016.02.091
COR 5.4.0 DTD YGAST60539_proof 30 July 2016 3:04 am ce
Q1
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