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Revista Española de Enfermedades Digestivas

Print version ISSN 1130-0108

Rev. esp. enferm. dig. vol.110 n.4 Madrid Apr. 2018

https://dx.doi.org/10.17235/reed.2018.5282/2017 

ORIGINAL PAPERS

Severe cardiorespiratory complications derived from propofol sedation monitored by an endoscopist

Sergio Maestro-Antolín1  , Bruno Moreira-Da-Silva1  , Fernando Santos-Santamarta1  , Arancha Germade1  , Laura Pérez-Citores1  , Ana Santamaría1  , Rosa-Eva Madrigal1  , Esther Saracibar1  , Javier Barcenilla-Laguna1  , Francisco Igea-Arisqueta1  , Antonio-Germán Pérez-Millán1 

1Sección de Aparato Digestivo. CAUPA. Hospital Río Carrión. Palencia. España

INTRODUCTION

Deep sedation with propofol monitored by an endoscopist in different endoscopy units is a controversial subject and the source of conflicts of interest between the various scientific societies of Anesthesiology and Gastroenterology. Safety has been evaluated and confirmed in many previously published scientific studies. A 2013 meta-analysis 1 concluded that endoscopy sedation with propofol by the endoscopist is safe and there was no difference with regard to cardiorespiratory complications compared with sedation by anesthesiologists. In 2016, a registry study from the United States concluded that endoscopy sedation by an endoscopist is safer, with a lower number of adverse effects than that by anesthetists 2. Complex endoscopic examinations may be more conflictive, such as the case of endoscopic ultrasound (EUS) or endoscopic retrograde cholangiopancreatography (ERCP). However, many recent Spanish studies support the use of propofol by an endoscopist due to its safety and low rate of adverse effects compared with traditional sedation 3,4,5.

METHODS

Sources of information

The objective of the study was to assess the rate of cardiorespiratory complications during different endoscopic techniques with propofol sedation monitored by an endoscopist, between 2011 and 2016. A retrospective study was performed using data obtained from our computerized database. All endoscopies are recorded and coded by diagnosis. Once the examination is complete, the endoscopist enters into the database identifying the propofol dose required in order to obtain deep sedation of the patient. Deep sedation was achieved in all examinations except for endoscopy procedures, both diagnostic and therapeutic, where the patient did not wish to be sedated. Propofol infusion was performed via an intravenous bolus (20 mg every 30 seconds) for diagnostic gastroscopies, whereas sedation was performed via a pump-controlled perfusion for therapeutic gastroscopies, colonoscopies, EUS and ERCP. The Alaris(r) perfusion pumps by CareFusion were used in the study. The mean dose of propofol used in gastroscopies was 95 ± 15 mg, 195 ± 45 mg for colonoscopies, 257 ± 32 mg for EUS and 355 ± 50 mg for CRPE. Finally, the endoscopist and the nurse verified all sedation-derived complications in the database. Prior to the examination, the nursing staff interviewed the patient in order to determine their ASA risk and to define any cardiorespiratory comorbidities before the test.

Statistical analysis

The SPSS software was used to perform the statistical analysis and p < 0.01 was set as statistical significance.

RESULTS

During the study period, 33,195 examinations in 29,524 patients (16,584 colonoscopies, 12,964 gastroscopies, 2,194 endoscopic ultrasounds and 1,453 ERCPs) were analyzed. The demographic characteristics are summarized in table 1.

Table 1 Demographic characteristics 

EUS: endoscopic ultrasound; ERCP: endoscopic retrograde cholangiopancreatography; n.s.: non-significant.

Forty-three cardiorespiratory complications (0.13%) were observed and the majority were severe desaturations, which amounted to 39 complications (0.12%). Severe desaturation is defined as the presence of oxygen saturation in the arterial blood at < 88%. Of these complications, 25 (64%) responded to a combined maneuver of opening the airway and interrupting the drug infusion, and an ambu bag was required on 12 occasions (30%). This included five colonoscopies (0.04%), five gastroscopies (0.1%) and five ERCP procedures (0.4%). Orotracheal intubation by the Intensive Medicine Department was only required in two cases (6%), one ASA IV case with amyotrophic lateral sclerosis who underwent a gastroscopy for hematemesis and another case who suffered bronchoaspiration during a colonoscopy performed due to rectal bleeding.

In the sub-analysis by type of examination, there were three complications during colonoscopy (0.08% and 0 deaths), six complications during gastroscopy (0.15% and one death of a 92-year-old patient in the endoscopy room due to bronchoaspiration secondary to hematemesis caused by esophageal varices), 12 complications during EUS (0.23% and no deaths), and 22 complications during ERCP (0.41% and no deaths). Statistically significant differences (p < 0.01) were only found in the ERCP group. The associated diseases according to the type of examination are summarized as a percentage in table 2.

Table 2 Associated diseases according to the type of examination 

COPD: chronic obstructive pulmonary disease; OSAS: obstructive sleep apnea syndrome; EUS: endoscopic ultrasound; ERCP: endoscopic retrograde cholangiopancreatography; n.s.: non-significant.

DISCUSSION

Due to the aforementioned reasons and currently available data, we believe that the ability of an endoscopist to be in charge of deep sedation during endoscopy is unquestionable. This is due to the low risk of cardiorespiratory complications derived from the procedure. An adequate training of health professionals in the deep sedation area is required. However, prospective studies should be conducted in order to confirm these claims as our study had a limitation due to the retrospective nature.

Even though the economic impact was not the objective of our study, we should not dismiss this aspect. Many studies have demonstrated the increase in healthcare costs due to the presence of an anesthetist in the endoscopy room, even though this does not result in a clear benefit in terms of safety or efficacy 6,7,8. This is important due to the current economic crisis within the health sector.

However, we should take one step further. Even though, as we have shown in complex and/or prolonged endoscopies such as ERCP, the number of complications may be higher than that observed in other endoscopic techniques, the rate of overall complications associated with sedation monitored by endoscopists is similar or lower compared with the previously published studies of conventional sedation 9. The high rate of complications associated with this procedure may be explained by the more advanced age of this population.

BIBLIOGRAFÍA

1. Wang D1, Chen C, Chen J, et al. The use of propofol as a sedative agent in gastrointestinal endoscopy: a meta-analysis. PLoS One 2013;8(1):e53311. DOI: 10.1371/journal.pone.0053311. [ Links ]

2. 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 ]

3. Redondo-Cerezo E1, Sánchez-Robaina A, Martínez Cara JG, et al. Gastroenterologist-guided sedation with propofol for endoscopic ultrasonography in average-risk and high-risk patients: a prospective series. Eur J Gastroenterol Hepatol 2012;25(5):506-12. [ Links ]

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5. Huertas C, Figa M, Hombrados M, et al. Safety of propofol sedation by trained nurses during endoscopic procedures in ASA III-IV patients: results of a prospective registry. Gastrointestinal Endoscopy 2010;71AB155. DOI: 10.1016/j.gie.2010.03.188 [ Links ]

6. Horiuchi A1, Nakayama Y, Kajiyama M, et al. Safety and effectiveness of propofol sedation during and after outpatient colonoscopy. World J Gastroenterol 2012;18(26):3420-5. DOI: 10.3748/wjg.v18.i26.3420. [ Links ]

7. Dumonceau JM. Nonanesthesiologist administration of propofol: it's all about money. Endoscopy 2012;44:453-5. DOI: 10.1055/s-0031-1291658 [ Links ]

8. 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. [ Links ]

9. Birk J, Bath RK. Is the anesthesiologist necessary in the endoscopy suite? A review of patients, payers and safety. Expert Rev Gastroenterol Hepatol 2015;9:883-5. DOI: 10.1586/17474124.2015.1041508 [ Links ]

Received: October 06, 2017; Accepted: March 12, 2018

Correspondence: Sergio Maestro-Antolín. Department of Digestive Diseases. CAUPA. Hospital Río Carrión. Av. Donantes de Sangre, s/n. 34005 Palencia, Spain. e-mail: sergipalen@hotmail.com