SPECIAL ARTICLE

Endoscopy and sedation: an inseparable binomial for the gastroenterologist

Javier Crespo1,2 and Álvaro Terán1

1
Department of Digestive Diseases. Hospital Universitario Marqués de Valdecilla. Santander. IDIVAL. Facultad de Medicina. Universidad de Cantabria.
Cantabria, Spain. 2Presidente de la Comisión Nacional de Digestivo

Received: 08/03/2018 · Accepted: 08/03/2018

Correspondence: Javier Crespo. Department of Digestive Diseases. Hospital Universitario Marqués de Valdecilla.
Av. de Valdecilla, 25. 39008 Santander, Cantabria. Spain. e-mail: [email protected]

ABSTRACT Key words: Sedation. Propofol. Drug safety. Endoscopy.

The development of endoscopy and its increasing demand The development of multiple advanced diagnosis tech-
among the population have led to a growing need for niques, generalization of colorectal cancer screening pro-
propofol-based sedation techniques. Benefit is indisput- grams, availability of endoscopic therapy for various con-
able for both patients and endoscopists, but some aspects ditions, and growing patient demands have all led to an
require considering the “who” and “how” of sedation as exponential increase in sedation needs at endoscopy units,
related to safety and health care costs. overwhelming at times the ability of anesthesiology and
gastroenterology departments to respond adequately (1).
Propofol is first-choice in endoscopy for the European Soci-
ety of Gastrointestinal Endoscopy because of its fast onset Overall, the benefit of sedation is indisputable both from
of action and short half-life, and many reports exist on its the viewpoint of patient tolerability and endoscopist satis-
safety when used by gastroenterologists rather than anes- faction with a higher-quality procedure. However, sedation
thesiologists. requires carefully considering some aspects, including how
it should be administered and who should provide it during
In this issue of REED several originals support the effi- endoscopic procedures, which have remained a source of
ciency and safety of propofol even for complex, high-risk, significant debate for the last decade. A key aspect to con-
or protracted procedures such as endoscopic retrograde sider is patient safety, followed by increase in health care
cholangiopancreatography (ERCP) and enteroscopy. Propo- costs. Obviously, the incorporation of anesthesiologists to
fol may be safely and effectively administered by a team endoscopy units results in higher endoscopy costs, hence
with specific skills acquired through education and using a wondering whether an anesthetist is required for all seda-
specific procedure. However, difficulties arise in real-world tions performed at an endoscopy unit seems a rational
clinical practice that preclude such training, which in Spain thing to do. And any concerns should be approached from
should be included in the MIR (médico interno residente) a patient safety perspective.
specialization program curriculum. The Comisión Nacional
de Digestivo (Spanish National Commission on Digestive Historically, benzodiazepines (midazolam) have been most
Diseases), sensitive to this training gap, has included in commonly used, either alone or in association with opiates
their latest version of the MIR program (under assessment) (pethidine, fentanyl). While this regimen remains standard
four additional competences, with number 145 (training in in some Spanish centers, and is still recommended by
deep sedation) being most relevant here. In addition, the societies such as the American Society for Gastrointestinal
Spanish Society of Gastrointestinal Endoscopy (SEED) has Endoscopy (ASGE), it is now being supplanted by propo-
invested significant efforts in sedation training, with over fol-based sedation (propofol alone or in combination with
50 courses on sedation for endoscopists and nurses. Con- the above-mentioned drugs), which is considered as first-
tinuing education and training in this field (for instance, choice by other societies such as the European Society of
refresher courses on advanced cardiopulmonary resuscita- Gastrointestinal Endoscopy (ESGE) (2,3). This is because
tion) should be a goal for all endoscopy units. Because of propofol exhibits “almost” all the characteristics that are
the diversity found among hospitals, with single or multi- deemed desirable in this setting: rapid onset of action, short
ple endoscopy rooms, efforts should be made to persuade half-life, and metabolism scarcely effected by renal or liver
those in charge of gastroenterology and anesthesiology dysfunction. The one, non-negligible drawback of this drug
departments to establish the necessary care circuits in
order to guarantee patient safety by developing accurate
protocols and promoting consensus among the scientific
Crespo J, Terán Á. Endoscopy and sedation: an inseparable binomial for the
societies involved (Spanish Society for Digestive Diseas- gastroenterologist. Rev Esp Enferm Dig 2018;110(4):250-252.
es [SEPD], SEED and Spanish Society of Anaesthesiology,
Resuscitation and Pain Management [SEDAR]) and their DOI: 10.17235/reed.2018.5585/2018
respective national commissions.

1130-0108/2018/110/4/250-252 • REVISTA ESPAÑOLA DE ENFERMEDADES DIGESTIVAS REV ESP ENFERM DIG 2018:110(4):250-252
© Copyright 2018. SEPD y © ARÁN EDICIONES, S.L. DOI: 10.17235/reed.2018.5585/2018
 Endoscopy and sedation: an inseparable binomial for the gastroenterologist 251

is its narrow therapeutic window, with overdosing resulting including propofol, midazolam, fentanyl, and others (com-
in hypoventilation and apnea. This adverse effect is shared petence 143); and knowledge of both basic and advanced
by benzodiazepines and opiates, but antidotes capable of cardiopulmonary resuscitation techniques, and the ability
immediate reversal are available for these compounds to recognize and manage sedation-related complications
(flumazenil and naloxone, respectively). Despite this poten- (competence 144). Finally, the Comisión Nacional (Spanish
tial risk of propofol, abundant reports on the safety of its use National Commission on Digestive Diseases), suggests a
by trained professionals during endoscopy are available in competence (competence number 145) referring to training
the literature. We highlight three studies because of their in deep sedation, an aspect that will be developed once
high number of procedures assessed: a meta-analysis pub- the new program has seen the light of day. Furthermore,
lished in 2013, a US registration study reported in 2016, and other training modalities such as clinical simulation may
a meta-analysis from 2017, all of which conclude that propo- be extraordinarily useful for the teaching of endoscopic
fol sedation by the endoscopist is safe, with no increase in sedation. Clinical simulation is a widely used tool in edu-
cardiorespiratory or other complications when compared to cational itineraries for specialties such as anesthesiology
sedation by an anesthesiologist (4-6). In the present issue of or intensive medicine, and to a far lesser extent for clinical
REED, additional scientific evidence is provided supporting specialties such as ours. It allows training in procedures
the fact that gastroenterologist-guided propofol sedation such as advanced airway management, addressing serious
during endoscopy is both efficient and safe (7-12). In this and/or uncommon clinical scenarios, and coordination of
respect, the work by Maestro-Antolín et al. on 33,195 proce- health care teams in complex predicaments, always within
dures shows that, in their hands, sedation as administered a safe context and in association with subsequent reflective
by a trained endoscopist is safe, effective, and efficient analysis. Experiencing these training activities has yielded
(7). The second paper assesses the efficacy and safety of highly satisfactory results in a number of services, includ-
conscious sedation in a small number of patients under- ing ours, among all sorts of professionals (gastroenterol-
going colonoscopy, and obtains a similar result (8). In the ogists, anesthetists, nurses, nursing assistants). This kind
third paper (9), which reports on 661 patients undergoing of instruments also has its place in the newer MIR training
complex, high-risk procedures such as ERCP, the authors program. Continuing education or training in this setting
conclude that sedation is safe when performed by trained (for example, refresher courses on advanced cardiopul-
gastroenterologists, although, as expected, with more com- monary resuscitation) should be regarded as a goal in all
plications as compared to other endoscopic procedures; endoscopy units.
complications are associated with ASA ≥ III, older age, high
body mass index (BMI), and prolonged procedure duration. A final point on safety is the need for adequate data collec-
Similarly, sedation for a protracted, labor-intensive proce- tion regarding endoscopic sedation, as well as other endo-
dure such as enteroscopy is also safe in the hands of a scopic procedures, in order to allow self-assessments and
gastroenterologist (10). However, in the present issue of audits, as only in this way shall we be able to confirm our
REED not only is gastroenterologist-administered sedation adherence to quality standards in terms of patient satis-
shown to be safe. López-Muñoz et al. audit their results faction and safety, or otherwise to detect deviations to be
in a praiseworthy quality program, and show that propo- addressed. Variables necessary to establish a sedation level
fol may be safely and effectively administered by a team include age, BMI, ASA grade, and Mallampati classification,
with specific competences acquired in a training program as well as patient comorbidity and type of endoscopic pro-
and using a specific procedure (11). Finally, other authoring cedure. In our view, multidisciplinary care protocols need
team headed by Julián-Gómez designed and carried out to be developed that explicitly include these aspects. During
a clinical trial comparing different sedation schemes (12). a procedure and over the recovery period sedation should
be documented according to standard protocols in every
As has been seen, the scientific literature dealing with the hospital.
safety of endoscopy sedation both by anesthesiologists and
non-anesthesiologists (endoscopists, specialist nurses) is Patients undergoing sedation should be cared for and mon-
rife, and recommendations are available on the training itored by trained health care professionals. As gastroen-
needs of providers other than anesthetists. However, train- terologists we are no doubt prepared to sedate or guide
ing difficulties are manifold in real-world practice. It is a sedation for our patients. However, there is also no doubt
relevant fact that this competence, so much needed at pres- that getting rid of our anesthetist colleagues in endoscopy
ent, was not included in the gastroenterology curriculum units would be a serious error. As the ASGE, ESGE, and
established within the MIR program in Spain, hence we SEED point out in their respective clinical guidelines, com-
lack formal education on this subject matter. Although the plex patients and procedures may occur (with increasing
efforts of the Spanish Society of Gastrointestinal Endosco- frequency in both cases) where the presence of an anes-
py (SEED) should be commended, with over 50 courses on thesiologist is advisable (2,3,13). Because of the diversity
propofol-based sedation for endoscopists and nurses, their found among hospitals, where endoscopy rooms may be
courses have limitations, including their voluntary atten- single or multiple, efforts should be locally invested so that
dance and lack of exposure to serious adverse effects given the people in charge of gastroenterology and anesthesi-
their low incidence. The Comisión Nacional de Digestivo ology departments implement the necessary care circuits
(Spanish National Commission on Digestive Diseases), sen- to guarantee patient safety by developing accurate pro-
sitive to this deficiency in resident physician training, has tocols. However, we are certain that the problem will not
developed a new gastroenterology curriculum (currently be definitely solved until consensus is reached among the
under evaluation) that includes four sedation competences scientific societies involved (Spanish Society for Digestive
future specialists will have to accredit: knowledge of the Diseases [SEPD], SEED and Spanish Society of Anaesthe-
various classifications of sedation risk (competence 142); siology, Resuscitation and Pain Management [SEDAR]) and
practical use of the drugs indicated for endoscopic sedation, their respective national commissions. A few months ago

REV ESP ENFERM DIG 2018:110(4):250-252

DOI: 10.17235/reed.2018.5585/2018
252 J. Crespo and Á. Terán

our national commission made an offer that remains valid endoscopy: a systematic review and meta-analysis. Clin Gastroenterol He-
to the Comisión Nacional de Anestesiología y Reanimación patol 2017;15:194-206. DOI: 10.1016/j.cgh.2016.07.013
(Spanish National Commission on Anaesthesiology and
7. Maestro Antolín S, Moreira Da Silva B, Santos Santamarta F, et al.
Resuscitation). This effort will likely improve our prepared- Complicaciones cardiorespiratorias graves derivadas de la sedación
ness and, most importantly, our patients’ safety. con propofol controlado por endoscopista en nuestra unidad en los úl-
timos 6 años. Rev Esp Enferm Dig 2018;110(4):237-9. DOI: 10.17235/
reed.2018.5282/2017
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