Leitlinien in der Praxis: Sedierung in der gastrointestinalen Endoskopie

Zusammenfassung

Ziel der Leitlinie „Sedierung in der gastrointestinalen Endoskopie“ ist die Definition struktureller, gerätetechnischer und personeller Anforderungen, die zur Risikominimierung der Sedierung bei Endoskopien beitragen. Dieser Artikel kommentiert wesentliche Aspekte der Leitlinie – insbesondere unter anästhesiologischen Gesichtspunkten. Eine Überarbeitung der Leitlinie steht bevor, dementsprechend wird auch auf neuere Entwicklungen eingegangen.

Abstract

The guideline “Sedation for gastrointestinal endoscopy” (AWMF-register-no. 021/014) was published initially in 2008. Because of new and developing evidence, the guideline was updated in 2015. The aim of the guideline is to define the necessary structural, equipment and personnel requirements that contribute to minimizing the risk of sedation for endoscopy. In view of the high and increasing significance of gastrointestinal endoscopy, the guideline will remain highly relevant in the future. Essential aspects are the selection of sedatives/hypnotics, structural requirements, personnel requirements with regard to number, availability and training, management of complications and quality assurance. In this article, the development and evaluation of the evidence and its influence on the practical implementation, in particular for anaesthesia, are highlighted.

Kernaussagen

• Ein wesentlicher Gesichtspunkt der Leitlinie ist es, Komplikationen bei der Sedierung für endoskopische Eingriffe zu vermeiden.

• Endoskopische Prozeduren und Interventionen werden immer langwieriger und komplexer. Auch werden mehr ältere, z. T. multimorbide Patienten behandelt, da endoskopische Eingriffe zunehmend größere operative Eingriffe ersetzen können. Daher wird die Sicherheit der Sedierung auch in Zukunft von hoher Relevanz sein.

• Anhand einer Risikoeinstufung kann idealerweise vor einer geplanten Endoskopie festgelegt werden, ob ein Patient eine tiefe Sedierung und die Einbindung der Anästhesie benötigt.

• Seit Beginn des Jahrtausends wird vor allem Propofol für die Sedierung in der Endoskopie verwendet. Bei den Benzodiazepinen hat sich Midazolam gegenüber Diazepam durchgesetzt.

• Die Durchführung einer Sedierung durch nichtanästhesiologisches Personal wird bis heute diskutiert. Seit 2013 gibt es ein zertifiziertes Ausbildungscurriculum der DEGEA, das von den europäischen gastroenterologischen Gesellschaften übernommen wurde.

• Zur Überwachung der Vitalfunktionen sedierter Patienten sind Pulsoxymetrie und Blutdruckmessung obligat, bei Patienten mit kardialen Risikofaktoren zusätzlich ein EKG.

• Anästhesisten, die endoskopische Eingriffe betreuen, garantieren eine situativ angepasste, flexible Sedierung sowie die hämodynamische Kontrolle und Stabilität der Vitalzeichen.

• Da der Bedarf an endoskopischer Diagnostik und Therapie – auch in tiefer Sedierung – weiter steigen wird, sollten alle Anästhesisten mit dieser Leitlinie vertraut sein.

Schlüsselwörter

gastrointestinale Endoskopie - Sedierung - Propofol - Monitoring - Komplikationen

Key words

gastrointestinal endoscopy - sedation - propofol - monitoring - complications

Publication History

Article published online:
16 March 2021

• Literatur

• 1 Riphaus A, Wehrmann T, Hausmann J. et al. [S3-guidelines „Sedation in gastrointestinal endoscopy“ 2014 (AWMF register no. 021/014)]. Z Gastroenterol 2015; 53: 802-842
• 2 Riphaus A, Wehrmann T, Weber B. et al. [S3-guidelines – Sedation in gastrointestinal endoscopy]. Z Gastroenterol 2008; 46: 1298-1330
• 3 Sidhu R, Turnbull D, Newton M. et al. Deep sedation and anaesthesia in complex gastrointestinal endoscopy: a joint position statement endorsed by the British Society of Gastroenterology (BSG), Joint Advisory Group (JAG) and Royal College of Anaesthetists (RCoA). Frontline Gastroenterol 2019; 10: 141-147
• 4 Predmore Z, Nie X, Main R. et al. Anesthesia service use during outpatient gastroenterology procedures continued to increase from 2010 to 2013 and potentially discretionary spending remained high. Am J Gastroenterol 2017; 112: 297-302
• 5 Liu H, Waxman DA, Main R. et al. Utilization of anesthesia services during outpatient endoscopies and colonoscopies and associated spending in 2003–2009. JAMA 2012; 307: 1178-1184
• 6 Riphaus A, Geist F, Wehrmann T. Endoscopic sedation and monitoring practice in Germany: re-evaluation from the first nationwide survey 3 years after the implementation of an evidence and consent based national guideline. Z Gastroenterol 2013; 51: 1082-1088
• 7 Dewitt J, McGreevy K, Sherman S. et al. Nurse-administered propofol sedation compared with midazolam and meperidine for EUS: a prospective, randomized trial. Gastrointest Endosc 2008; 68: 499-509
• 8 Quine MA, Bell GD, McCloy RF. et al. Prospective audit of upper gastrointestinal endoscopy in two regions of England: safety, staffing, and sedation methods. Gut 1995; 36: 462-467
• 9 Tohda G, Higashi S, Wakahara S. et al. Propofol sedation during endoscopic procedures: safe and effective administration by registered nurses supervised by endoscopists. Endoscopy 2006; 38: 360-367
• 10 Sieg A, bng-Study-Group. Beck S. et al. Safety analysis of endoscopist-directed propofol sedation: a prospective, national multicenter study of 24 441 patients in German outpatient practices. J Gastroenterol Hepatol 2014; 29: 517-523
• 11 Leslie K, Allen ML, Hessian EC. et al. Safety of sedation for gastrointestinal endoscopy in a group of university-affiliated hospitals: a prospective cohort study. Br J Anaesth 2017; 118: 90-99
• 12 Sneyd JR. Making sense of propofol sedation for endoscopy. Br J Anaesth 2017; 118: 6-7
• 13 Matharoo M, Haycock A, Sevdalis N. et al. A prospective study of patient safety incidents in gastrointestinal endoscopy. Endosc Int Open 2017; 5: E83-E89
• 14 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: 101-108
• 15 Jia H, Pan Y, Guo X. et al. Water exchange method significantly improves adenoma detection rate: A multicenter, randomized controlled trial. Am J Gastroenterol 2017; 112: 568-576
• 16 Braunstein ED, Rosenberg R, Gress F. et al. Development and validation of a clinical prediction score (the SCOPE score) to predict sedation outcomes in patients undergoing endoscopic procedures. Aliment Pharmacol Ther 2014; 40: 72-82
• 17 Kothari D, Feuerstein JD, Moss L. et al. An open-access endoscopy screen correctly and safely identifies patients for conscious sedation. Gastroenterol Rep (Oxf) 2016; 4: 281-286
• 18 Corso RM, Piraccini E, Agnoletti V. et al. Clinical use of the STOP-BANG questionnaire in patients undergoing sedation for endoscopic procedures. Minerva Anestesiol 2012; 78: 109-110
• 19 Martin JF, Niklewski PJ, White JD. The rise, fall, and future direction of computer-assisted personalized sedation. Curr Opin Anaesthesiol 2019; 32: 480-487
• 20 Lazzaroni M, Bianchi Porro G. Preparation, premedication and surveillance. Endoscopy 2003; 35: 103-111
• 21 Inadomi JM, Gunnarsson CL, Rizzo JA. et al. Projected increased growth rate of anesthesia professional-delivered sedation for colonoscopy and EGD in the United States: 2009 to 2015. Gastrointest Endosc 2010; 72: 580-586
• 22 Khiani VS, Soulos P, Gancayco J. et al. Anesthesiologist involvement in screening colonoscopy: temporal trends and cost implications in the medicare population. Clin Gastroenterol Hepatol 2012; 10: 58-64 e51
• 23 compendium.ch®. Fachinfo Propofol-®Lipuro. Juni 2018. Im Internet (Stand: 07.12.2020): http://compendium.ch/product/1006291-propofol-lipuro-1-1-g-100ml/mpro
• 24 Smith AJ. FDA rejects ACG petition: Propofol remains in the realm of anesthesiologists. Gastroenterology & Endoscopy News 2010; 61: 11
• 25 Vargo J. Update on endoscopist-administered propofol sedation for endoscopic procedures. Gastroenterol Hepatol (N Y) 2011; 7: 189-197
• 26 American Society of Anesthesiologists. FDA Upholds ASA Stance on Safe Use of Propofol. August 19, 2010. Im Internet (Stand: 07.12.2020): http://www.asahq.org/about-asa/newsroom/news-releases/2010/08/fda-upholds-asa-stance-on-safe-use-of-propofol
• 27 Dumonceau JM, Riphaus A, Aparicio JR. et al. European Society of Gastrointestinal Endoscopy, European Society of Gastroenterology and Endoscopy Nurses and Associates, and the European Society of Anaesthesiology Guideline: Non-anaesthesiologist administration of propofol for GI endoscopy. Eur J Anaesthesiol 2010; 27: 1016-1030
• 28 Perel A. Non-anaesthesiologists should not be allowed to administer propofol for procedural sedation: A Consensus Statement of 21 European National Societies of Anaesthesia. Eur J Anaesthesiol 2011; 28: 580-584
• 29 DGAI, DGGG. Einsatz von Lachgas zur Schmerztherapie unter der Geburt – Gemeinsame Stellungnahme der Deutschen Gesellschaft für Anästhesiologie und Intensivmedizin (DGAI) der Deutschen Gesellschaft für Gynäkologie und Geburtshilfe (DGGG). Anaesthesiol Intensivmed 2014; 55: 679-682
• 30 Goyal R, Hasnain S, Mittal S. et al. A randomized, controlled trial to compare the efficacy and safety profile of a dexmedetomidine-ketamine combination with a propofol-fentanyl combination for ERCP. Gastrointest Endosc 2016; 83: 928-933
• 31 Schnider T, Minto C. Context sensitive decrement times of remimazolam. Anesth Analg 2013; 117: 285
• 32 Kuzhively J, Pandit JJ. Anesthesia and airway management for gastrointestinal endoscopic procedures outside the operating room. Curr Opin Anaesthesiol 2019; 32: 517-522
• 33 Kim SH, Park M, Lee J. et al. The addition of capnography to standard monitoring reduces hypoxemic events during gastrointestinal endoscopic sedation: a systematic review and meta-analysis. Ther Clin Risk Manag 2018; 14: 1605-1614
• 34 Barnett S, Hung A, Tsao R. et al. Capnographic monitoring of moderate sedation during low-risk screening colonoscopy does not improve safety or patient satisfaction: A prospective cohort study. Am J Gastroenterol 2016; 111: 388-394
• 35 Allen ML. Safety of deep sedation in the endoscopy suite. Curr Opin Anaesthesiol 2017; 30: 501-506
• 36 Riccio CA, Sarmiento S, Minhajuddin A. et al. High-flow versus standard nasal cannula in morbidly obese patients during colonoscopy: A prospective, randomized clinical trial. J Clin Anesth 2019; 54: 19-24
• 37 Drake MG. High-flow nasal cannula oxygen in adults: an evidence-based assessment. Ann Am Thorac Soc 2018; 15: 145-155
• 38 Lin Y, Zhang X, Li L. et al. High-flow nasal cannula oxygen therapy and hypoxia during gastroscopy with propofol sedation: a randomized multicenter clinical trial. Gastrointest Endosc 2019; 90: 591-601
• 39 Terblanche NCS, Middleton C, Choi-Lundberg DL. et al. Efficacy of a new dual channel laryngeal mask airway, the LMA^® Gastro^™ Airway, for upper gastrointestinal endoscopy: a prospective observational study. Br J Anaesth 2018; 120: 353-360
• 40 Goudra B, Singh PM. Airway management during upper GI endoscopic procedures: State of the art review. Dig Dis Sci 2017; 62: 45-53
• 41 Leslie K, Sgroi J. Sedation for gastrointestinal endoscopy in Australia: what is the same and what is different?. Curr Opin Anaesthesiol 2018; 31: 481-485
• 42 Sneyd JR, OʼSullivan EP. Modified supraglottic airway for gastroscopy: an advance in patient safety?. Br J Anaesth 2018; 120: 209-211
• 43 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
• 44 Lin OS. Sedation for routine gastrointestinal endoscopic procedures: a review on efficacy, safety, efficiency, cost and satisfaction. Intest Res 2017; 15: 456-466
• 45 Alvarez J, Cabadas R, de la Matta M. Patient safety under deep sedation for digestive endoscopic procedures. Rev Esp Enferm Dig 2017; 109: 137-143
• 46 Applegate RL, Lenart J, Malkin M. et al. Advanced monitoring is associated with fewer alarm events during planned moderate procedure-related sedation: A 2-part pilot trial. Anesth Analg 2016; 122: 1070-1078
• 47 Behrens A, Labenz J, Schuler A. et al. [How safe is sedation in gastrointestinal endoscopy? A multicentre analysis of 388,404 endoscopies and analysis of data from prospective registries of complications managed by members of the Working Group of Leading Hospital Gastroenterologists (ALGK)]. Z Gastroenterol 2013; 51: 432-436
• 48 Leslie K, Allen ML, Hessian E. et al. Survey of anaesthetistsʼ practice of sedation for gastrointestinal endoscopy. Anaesth Intensive Care 2016; 44: 491-497
• 49 Goudra BG, Singh PM, Sinha AC. Anesthesia for ERCP: Impact of anesthesiologistʼs experience on outcome and cost. Anesthesiol Res Pract 2013; 2013: 570518
• 50 Yamaguchi D, Yamaguchi N, Takeuchi Y. et al. Comparison of sedation between the endoscopy room and operation room during endoscopic submucosal dissection for neoplasms in the upper gastrointestinal tract. BMC Gastroenterol 2017; 17: 127
• 51 Feldman LS, Lee L, Fiore J. What outcomes are important in the assessment of Enhanced Recovery After Surgery (ERAS) pathways?. Can J Anaesth 2015; 62: 120-130
• 52 Lee L, Tran T, Mayo NE. et al. What does it really mean to “recover” from an operation?. Surgery 2014; 155: 211-216
• 53 Brumby AM, Heiberg J, Te C. et al. Quality of recovery after gastroscopy, colonoscopy, or both endoscopic procedures: an observational pilot study. Minerva Anestesiol 2017; 83: 1161-1168
• 54 DGAI, BDA. Kerndatensatz Anästhesie. Anaesthesiol Intensivmed 2010; 51: S33-S55