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Revista Española de Enfermedades Digestivas

versión impresa ISSN 1130-0108

Rev. esp. enferm. dig. vol.102 no.4 Madrid abr. 2010




Sedation with propofol controlled by endoscopists during percutaneous endoscopic gastrostomy

Sedación con propofol controlada por endoscopista durante la realización de gastrostomía percutánea



C. García-Suárez, L. López-Rosés, P. Olivencia, A. Lancho, A. González-Ramírez, E. Santos, D. Carral, E. Castro and S. Ávila

Department of Gastroenterology. Hospital Xeral-Calde. Lugo, Spain





Background: propofol is a hypnotic used with increasing frequency for sedation during endoscopic procedures. Most of the reports published related with its employment by non-anaesthesiologists, refers to basic endoscopy, with little reference to its use in advanced endoscopy.
Objective: to evaluate the efficacy and safety of propofol sedation administered by endoscopists, while performing percutaneous endoscopic gastrostomy, an advanced technique that is usually performed in high anesthetic level risk patients.
Material and methods: prospective study of a series of endoscopic gastrostomy performed consecutively in our department; the sedation was carried out exclusively with propofol. The staff in the room consisted of two medical gastroenterologists, a nurse and a nursing assistant. Propofol was administered by bolus doses adjusted to patient weight. Arterial oxygen saturation, heart rate and blood pressure were monitored; respiratory activity was monitored visually by observing respiratory excursions of the patient.
Results: we included 47 patients, with an average age of 82 years. 87% were ASA III and the rest, ASA IV. The mean dose of propofol was 51 mgr. Complications were recorded: 8 cases of desaturation and two of hypotension, all of them minor and quickly reversible. All procedures were carried out successfully, at a median time of 8 minutes.
Conclusion: the propofol sedation carried out by non-anaesthesiologist trained staff, seems to appear as a safe and effective procedure while performing percutaneous endoscopic gastrostomy.

Key words: Propofol. Percutaneous endoscopic gastrostomy. Sedation by non-anaesthesiologists.


Introducción: el propofol es un hipnótico usado cada vez con más frecuencia para la sedación durante procedimientos endoscópicos. La mayor parte de los trabajos publicados en relación con su empleo por personal no anestesista se refiere a exploraciones de endoscopia básica, siendo escasas las referencias a su empleo en endoscopia avanzada.
Objetivo: valorar la eficacia y la seguridad de la sedación mediante propofol administrado por endoscopistas, durante la realización de gastrostomía endoscópica percutánea, técnica avanzada y generalmente aplicada sobre pacientes de riesgo anestésico alto.
Material y métodos: estudio prospectivo de una serie de gastrostomías endoscópicas realizadas consecutivamente en nuestro servicio; las sedaciones se llevaron a cabo exclusivamente con propofol. El personal presente en la sala consistió en dos médicos gastroenterólogos, una enfermera y una auxiliar de enfermería. El propofol se administró en bolos, ajustando las dosis al peso de los pacientes. Se monitorizaron la saturación arterial de oxígeno, la frecuencia cardiaca y la tensión arterial. La actividad respiratoria se controló de forma visual mediante la observación de las excursiones respiratorias de los enfermos.
Resultados: se incluyeron 47 pacientes, con una edad media de 82 años. El 87% fueron ASA III y el resto ASA IV. La dosis media de propofol fue de 51 mg. Como complicaciones se registraron 8 casos de desaturación y dos de hipotensión, todas leves y rápidamente reversibles. Todos los procedimientos se llevaron a cabo satisfactoriamente, en un tiempo medio de 8 minutos.
Conclusión: la sedación mediante propofol llevada a cabo por personal entrenado no anestesista parece mostrarse como un método seguro y eficaz durante la realización de gastrostomía percutánea endoscópica.

Palabras clave: Propofol. Gastrostomía percutánea endoscópica. Sedación por no anestesistas.



The performance of endoscopic procedures under sedation and analgesia has become increasingly common in clinical practice, due on the one hand to the greater complexity and length of some of them and on the other partly because of the demand from patients to not be subjected to uncomfortable or painful examinations. Usually in endoscopic procedures, conscious sedation was used which was carried out with the use of benzodiazepines alone or in association with opioids. But in recent years, and in view of the good results published in medical literature, the number of endoscopists who have begun using more powerful hypnotic drugs, particularly propofol while practicing deeper levels of sedation (1-3), has increased. This has generated much controversy over who should be responsible for the sedation and monitoring of patients and whether non anesthesiologists are prepared or not to use propofol, mainly due to the narrow therapeutic index of this drug. The debate has been partially solved with the emergence of several clinical management guidelines published by various scientific societies, which set conditions to be fulfilled by staff dedicated to both conscious and deep sedation, and situations in which it must be carried out by anesthesiologists (4-12). However, despite the great number of published studies about sedation controlled by physicians or certified nurses, in gastrointestinal endoscopy (13-15), there are very few of them that value its use in advanced endoscopic procedures (2,16-20). That is why we decided to prospectively evaluate the safety and quality of sedation with propofol controlled by endoscopists during the practice of percutaneous endoscopic gastrostomy, a procedure of some technical complexity and usually indicated in patients with anesthetic high risk, both of which put the procedure in the proximity of the generally accepted threshold necessary to consider the presence of an anesthesiologist.


Materials and methods

A prospective descriptive study was conducted that included all patients referred to the Endoscopy Unit of our department for the placement of a gastrostomy tube, from March to October 2008.

The procedure was performed in all cases using the pull technique and propofol was the only drug used for sedation.

Allergy to propofol, egg or soy, decompensated lung or heart disease, a history of anesthetic complications or difficulty in intubation of the airway, pregnancy, lactation and being under eighteen years old were considered exclusion causes for entry in the study.

Before the procedure the following parameters were recorded: reason for Gastrostomy indication, comorbidities, age, sex, weight and anesthetic risk according to ASA classification (Table I). All patients and/or their families were told the nature of the intervention and sedation, possible alternatives and potential risks. Each signed a specific document of informed consent.

Staff who participated in the explorations consisted of two medical gastroenterologists, a nurse and a nursing assistant. Doctors, one of them ran the endoscope and the other dealt with the abdominal side of the technique. The nurse was in charge of patient monitoring and administration of propofol at the orders of the doctors and with the help of the auxiliary to manipulate the endoscopic accessory equipment.

In all cases, antibiotic prophylaxis was provided and, via nasal cannula at a flow rate of four liters per minute, oxygen was administered to the patients throughout the procedure. Monitoring consisted of pulse-oximetry, continuous heart rate recording, and automatically at three minute intervals blood pressure measurement, starting immediately before beginning the procedure and continuing until the patient returned to his baseline, until after completion. The control of respiratory function was evaluated by observing the patient's respiratory movements. Propofol was administered via bolus, with an initial dose of 0.5 mg/kg, and successive 10 to 20 mg every 30-60 seconds to reach the desired level of sedation, followed by further boluses of 10 to 20 mg, as required. Safety was controlled by the calibration of the alarms to oxygen saturation < 90%, heart rate between 50 and 120 beats per minute and systolic blood pressure between 90 and 180 mmHg.

The quality of sedation was assessed by doctors, based on the immobility of the patient during the examination and whether or not restraint maneuvers were necessary. Complications were recorded as were the measures implemented to control them. Monitoring was continued until patients were able to score at or above 9 for a modified Aldrete scale (Table II), at which time they were discharged from the unit. The data analysis was performed using SPSS 11.


Were included in the study 47 patients, whose characteristics were as follows (Table III):

- Sex: 26 men and 21 women. Age: the average age was 82 years. 29 patients were over 80 years of age, and only two were under 70.

- Anesthetic risk: 87% (41 patients) were ASA III. The rest were ASA IV (Table III).

- The average weight was 66 kg (45-85).

- Indication for gastrostomy: dementia 24, AVCA 18, Parkinson 3, ELA 2.

- Dose of propofol: the average dose was 51 mg, ranging between 20 and 91 mg.

- Complications (Table IV): arterial desaturation (Sa O2 below 90%): 8 episodes in 8 patients (17%). Hypotension (systolic BP less than 90 mmHg): 2 episodes in 2 patients (4.2%). Bradycardia (P less than 50 beats per minute): no episode. All complications quickly reversed after applying simple maneuvers, such as increased oxygen flow, traction of the mandible or rapid infusion of saline. There were no serious complications and no need of life support.

- Time spent performing art: 8 minutes (range 6 to 20).

- Postprocedure time until discharge from the Unit: 11 minutes (range 8 to 25).

- Technical success: 100%.


Propofol (2-6 diisopropilphenol) is an ultra fast-acting drug with hypnotic and an amnesic and slightly analgesic effect, which has a short half life, allowing rapid recovery of the patient. These properties make it a very useful agent for sedation in endoscopic procedures. However, their therapeutic window is narrow, forcing a fit of the dose to avoid causing deterioration of cardiorespiratory function. For this reason and because of not having an antidote, the non- anesthesiologist use of propofol by doctors has raised controversy. However, in recent years numerous studies have been published and they have demonstrated an acceptable safety and efficacy when propofol sedation during endoscopic procedures was controlled directly by endoscopists or by properly trained nurses, although most of these studies were carried out during basic endoscopic procedures, and in lower anesthetic risk patients, with few studies relating to advanced endoscopy or in patients with a higher anesthetic risk (16-22).

Percutaneous endoscopic gastrostomy is a technique which has increased in demand, with a technical complexity that ranges from advanced endoscopic procedures and is generally applicable to elderly, debilitated and patients who are carriers of comorbidities. For these reasons, and because of the lack of written references, we carried out a prospective study to evaluate safety and efficacy of propofol sedation controlled by endoscopists themselves during this procedure.

In assessing the results of the study, we must underline that the population tested was in full high anesthetic risk groups, ASA III and IV, with an average age over 80. On the other hand it is important to stress the low weight of many of them (66 kg on average) and the short time in which the procedure were completed (8 minutes on average). All these factors explain the very low dose of propofol that were applied, 51 mg of average, much lower than those reported during examinations such as colonoscopies, ERCP or EUS (23).

There were complications in 21% of cases, all mild and easily reversible. There were no serious complications. In 17% of patients desaturations were observed, which was somewhat higher than that evidenced in other works, as in that of Riphaus (16), which were observed in 11%, probably in relation to the characteristics mentioned above for our patients. Importantly, because it was one of the objectives of the study, exploration tolerance by the patients was excellent, without it being necessary to use physical restraint maneuvers. Technical success was achieved in all cases and exploration was not discontinued in any of them before completion.

The study also highlights the short period of stay in the Endoscopy Unit until discharge after completion of exploration. Patients were monitored until they regained their previous baseline, confirmed by a modified Aldrete scale. The average 11 minutes of our patients is again far from the usual time needed to discharge patients sedated with benzodiazepines and opiates (24,25).

As for the measures taken for monitoring, pulse-oximetry and control of blood pressure and heart rate were recorded. A capnograph was not used, controlling respiratory function by visual observation of respiratory movements of the patients. The main clinical guidelines on sedation in gastrointestinal endoscopy stress the absence of studies demonstrating the need for capnography in these cases, although they recommend its use for various other reasons such as the room being dark or because the patient´s position prevents the observation of the respiratory excursions or the color of the patient (5,8). In our case, the patients were supine and the endoscopy room was well lit during the entire procedure, so we had no difficulty at all times to monitor the respiratory status of patients.

In conclusion, the results of this study seem to support that the use of propofol by non-anesthesiologists is a valid option, safe and reliable while performing advanced endoscopic procedures in anesthetic risk population. In any case, our group is calling for joint development, between gastroenterologists and anesthesiologists, of protocols in endoscopic sedation and monitoring, as well as conducting training and retraining, as a way to get the best cost/benefit possible in the care to our patients.



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Leopoldo López Rosés.
Ronda de la República Argentina, 11.
27002 Lugo.

Received: 27-10-09.
Accepted: 29-10-09.

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