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Revista Española de Enfermedades Digestivas

versión impresa ISSN 1130-0108

Rev. esp. enferm. dig. vol.110 no.4 Madrid abr. 2018 


Enhancing the current evidence on endoscopist-directed propofol-based sedation

Enrique Pérez-Cuadrado-Robles1  2  , Alexandre Ferreira3  , Jesús García-Cano4 

1Department of Gastroenterology. Cliniques Universitaires Saint-Luc. Brussels, Belgium

2Department of Endoscopy. Hôpital Beaujon. Clichy, France

3Department of Gastroenterology. Hospital Beatriz Ângelo. Loures, Portugal

4Department of Gastroenterology. Hospital Virgen de la Luz. Cuenca, Spain

During the last years, there is more and more scientific evidence about the safety and feasibility of non-anesthesiologist administration of propofol (NAAP) in gastrointestinal endoscopy 1, reducing sedation induction and recovery time as well as increasing patient and endoscopist satisfaction 2. Furthermore, a similar risk of adverse events compared with traditional agents 3 or anesthesiologist administration of propofol (AAP) has been described 4. The present special issue of the Spanish Journal of Gastroenterology (Revista Española de Enfermedades Digestivas) focusses on NAAP in different settings, including complex endoscopic procedures.

Several meta-analysis and well-designed randomized controlled trials in non-advanced endoscopy concluded that NAAP is safe 5, with a similar rate of adverse events compared to AAP 6. Moreover, these outcomes have been similar in specific populations as cirrhotic patients 7. Advanced procedures as endoscopic retrograde cholangiopancreatography (ERCP), endoscopic ultrasound, balloon-assisted enteroscopy and endoscopic submucosal dissection benefit from deep sedation, because of a higher quality of the examinations, increased satisfaction for both the patients and medical personnel, and shorter recovery and discharge times 8,9. Sethi S et al. 10, in a meta-analysis of nine prospective randomized trials comparing propofol with traditional sedative agents for advanced endoscopy, concluded that propofol is associated with shorter recovery time and better sedation and amnesia level, without an increased risk of cardiopulmonary complications. Other similar meta-analysis 11 comparing NAAP-administered propofol sedation for advanced endoscopic procedures with those of AAP reported the safety of NAAP sedation at the cost of decreased patient and endoscopist satisfaction. Moreover, anesthesiology support may be necessary in 0.4% of cases 12.

Regarding ERCP, propofol sedation is safe 13,14, leading to shorter recovery time without an increase of cardiopulmonary side effects 15, and similar cannulation rates 16. The current observational prospective study by Luzón Solanas et al. 17, published in this issue, assesses the safety of endoscopist-directed nurse-administered propofol-based sedation in 661 patients who underwent an ERCP. Overall, they concluded an adverse event rate of 9.6%, according to previously published data 18. However, one major limitation in the comparability within studies is the composite outcome of "adverse event", including in most of cases hypoxemia (transient, clinically relevant or leading to airway maneuvers) and hypotension. These events can be frequent and have no clinical consequences in most cases. Thus, the clinical relevance of these findings and the heterogeneous definition of this main outcome leads to a difficult interpretation, particularly in the case of hypoxemia. Additionally, different patient populations of diverse studies considering ERCP may not be comparable. In the present report, the hypoxemia rate was 5.7% and an additional manoeuvre was required in all cases. Anyway, the risk factors associated with an increased adverse event rate are quite similar within different reports 19. The authors concluded that age, body mass index, and the duration of the exploration were independent predictors of adverse events in multivariate analysis.

In a second paper by López-Roses et al. 20 with focus on balloon-assisted enteroscopy, they reported a minor adverse event rate of 22.7% in a single-cohort of 44 procedures. This outcome may have been influenced by the high comorbidity (68%) and ASA-III status rates (20.5%). However, all adverse events were managed successfully by simple maneuvers and no major complications were observed.

Overall, a trained professional dedicated to the administration and supervision of sedation 21 is essential in daily practice to ensure the success of the procedure and the NAAP for our patients. Finally, this special number contributed important knowledge of NAAP, suggesting that endoscopist-directed propofol-based sedation is safe in gastrointestinal endoscopy 22. A dedicated issue to this topic is widely justified by the exponential increase in the use of propofol by gastroenterologists in our country 23. Hopefully, further randomized controlled trials will confirm these outcomes in specific advanced procedures for selected populations.


1. 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(12):1175-89. DOI: 10.1055/s-0034-1393414 [ Links ]

2. Cohen LB, Wecsler JS, Gaetano JN, et al. Endoscopic sedation in the United States: results from a nationwide survey. Am J Gastroenterol 2006;101:967-74. DOI: 10.1111/j.1572-0241.2006.00500.x [ Links ]

3. Wadhwa V, Issa D, Garg S, et al. 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(2):194-206. DOI: 10.1016/j.cgh.2016.07.013 [ Links ]

4. Vargo JJ, Niklewski PJ, Williams JL, et al. Patient safety during sedation by anesthesia professionals during routine upper endoscopy and colonoscopy: an analysis of 1.38 million procedures. Gastrointest Endosc 2017;85(1):101-8. DOI: 10.1016/j.gie.2016.02.007 [ Links ]

5. Gouda B, Gouda G, Borle A, et al. Safety of non-anesthesia provider administered propofol sedation in non-advanced gastrointestinal endoscopic procedures: a meta-analysis. Saudi J Gastroenterol 2017;23(3):133-43.DOI: 10.4103/sjg.SJG_501_16 [ Links ]

6. Ferreira AO, Torres J, Barjas E, et al. Non-anesthesiologist administration of propofol sedation for colonoscopy is safe in low risk patients: results of a noninferiority randomized controlled trial. Endoscopy 2016;48(8):747-53. DOI: 10.1055/s-0042-105560 [ Links ]

7. 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(2):e0117585. DOI: 10.1371/journal.pone.0117585 [ Links ]

8. Burtea DE, Dimitriu A, Malos AE, et al. Current role of non-anesthesiologist administered propofol sedation in advanced interventional endoscopy. World J Gastrointest Endosc 2015;10;7(10):981-6. DOI: 10.4253/wjge.v7.i10.981 [ Links ]

9. Kikuchi H, Hikichi T, Watanabe K, et al. Efficacy and safety of sedation during endoscopic submucosal dissection of gastric cancers using a comparative trial of propofol versus midazolam. Endosc Int Open 2018;6(1):E51-7. DOI: 10.1055/s-0043-122225 [ Links ]

10. Sethi S, Wadhwa V, Thaker A, et al. Propofol versus traditional sedative agents for advanced endoscopic procedures: a meta-analysis. Dig Endosc 2014;26(4):515-24. DOI: 10.1111/den.12219 [ Links ]

11. Goudra BG, Singh PM, Gouda G, et al. Safety of non-anesthesia provider-administered propofol (NAAP) sedation in advanced gastrointestinal endoscopic procedures: comparative meta-analysis of pooled results. Dig Dis Sci 2015;60(9):2612-27. DOI: 10.1007/s10620-015-3608-x [ Links ]

12. Jensen JT, Hornslet P, Konge L, et al. High efficacy with deep nurse-administered propofol sedation for advanced gastroenterologic endoscopic procedures. Endosc Int Open 2016;4(1):E107-11. DOI: 10.1055/s-0041-107899 [ Links ]

13. Pérez-Cuadrado Robles E, González Ramírez A, Lancho Seco Á, et al. Safety and risk factors for difficult endoscopist-directed ERCP sedation in daily practice: a hospital-based case-control study. Rev Esp Enferm Dig 2016;108(5):240-5. DOI: 10.17235/reed.2016.4206/2016 [ Links ]

14. Ikeuchi N, Itoi T, Gotoda T, et al. Feasibility of non-anesthesiologist-administered propofol sedation for emergency endoscopic retrograde colangiopancreatography. Gastroenterol Res Pract 2015;2015:685476. DOI: 10.1155/2015/685476 [ Links ]

15. Bo LL, Bai Y, Bian JJ, et al. Propofol vs traditional sedative agents for endoscopic retrograde cholangiopancreatography: a meta-analysis. World J Gastroenterol 2011;14;17(30):3538-43. DOI: 10.3748/wjg.v17.i30.3538 [ Links ]

16. Mehta PP, Vargo JJ, Dumot JA, et al. Does anesthesiologist-directed sedation for ERCP improve deep cannulation and complication rates? Dig Dis Sci 2011;56(7):2185-90. DOI: 10.1007/s10620-011-1568-3 [ Links ]

17. Luzón Solanas L, Ollero Domenche L, Sierra Moros EM, et al. Safety of deep sedation with propofol controlled by the endoscopist in endoscopic retrograde cholangiopancreatography (ERCP): prospective study in a tertiary hospital. Rev Esp Enferm Dig 2018;110(4):217-22. DOI: 10.17235/2018.5262/2017 [ Links ]

18. Coté GA, Hovis RM, Ansstas MA, et al. Incidence of sedation-related complications with propofol use during advanced endoscopic procedures. Clin Gastroenterol Hepatol 2010;8(2):137-42. DOI: 10.1016/j.cgh.2009.07.008 [ Links ]

19. Yang JF, Farooq P, Zwilling K, et al. Efficacy and safety of propofol-mediated sedation for outpatient endoscopic retrograde cholangiopancreatography (ERCP). Dig Dis Sci 2016;61(6):1686-91. DOI: 10.1007/s10620-016-4043-3 [ Links ]

20. López Rosés L, Álvarez B, González Ramírez A, et al. Viabilidad de la enteroscopia monobalón realizada bajo sedación dirigida por endoscopista. Rev Esp Enferm Dig 2018;110(4):240-5. DOI: 10.17235/2018.5245/2017 [ Links ]

21. Vargo JJ, DeLegge MH, Feld AD, et al. Multisociety sedation curriculum for gastrointestinal endoscopy. Gastrointest Endosc 2012;76(1):e1-25. DOI: 10.1038/ajg.2012.112 [ Links ]

22. González-Huix Lladó F. Sedation for endoscopy in 2016 - Is endoscopist-guided sedation safe in complex situations? Rev Esp Enferm Dig 2016;108(5):237-9. DOI: 10.17235/reed.2016.4383/2016 [ Links ]

23. Lucendo AJ, González-Huix F, Tenias JM, et al. Gastrointestinal endoscopy sedation and monitoring practices in Spain: a nationwide survey in the year 2014. Endoscopy 2015;47(4):383-90. DOI: 10.1055/s-0034-1391672 [ Links ]