Nurse-administered propofol sedation for endoscopy: a risk analysis during an implementation phase

Background and study aims: The aim of the present study was to perform a risk analysis during the implementation phase of nurse-administered propofol sedation (NAPS) and to validate our structured training program.

Patients and methods: A structured training program was developed both for endoscopists and for endoscopy nurses who were administering propofol sedation. The nurses’ program comprised a 6-week course including theoretical and practical training in airway management, and the endoscopists’ program consisted of 2.5 h of theory and a short course in practical airway management. In the implementation phase, data from 1822 endoscopic procedures in 1764 patients were prospectively collected. All adverse events related to sedation were recorded (defined as oxygen saturation < 92 %, airway handling, assisted ventilation, need for intubation, change in blood pressure > 20 mmHg).

Results: 78 cases of hypoxemia were documented in 1764 patients (4.4 %), in 56/983 upper endoscopies (5.7 %) and 22/754 lower endoscopies (2.9 %) (P = 0.007). Assisted ventilation was necessary in 19 cases (1.1 %) and anesthesiologic assistance was requested 10 times. Two patients required endotracheal intubation. A change in blood pressure was recorded in 451 patients (26 %). Independent risk factors were type of intervention and level of experience of the staff performing the sedation.

Conclusion: These results were obtained after development of a structured training program both for endoscopists and nurses using propofol for sedation, and can be used as basis for further comparison. NAPS for endoscopic procedures is safe when performed by personnel properly trained in airway handling and sedation with propofol, and has considerable advantages compared with conventional sedation for endoscopy.

References

• 1 Carlsson U, Grattidge P. Sedation for upper gastrointestinal endoscopy: a comparative study of propofol and midazolam.  Endoscopy. 1995;  27 240-243
• 2 Vargo J J, Zuccaro Jr G, Dumot J A et al. Gastroenterologist-administered propofol versus meperidine and midazolam for advanced upper endoscopy: a prospective, randomized trial.  Gastroenterology. 2002;  123 8-16
• 3 Sipe B W, Rex D K, Latinovich D et al. Propofol versus midazolam/meperidine for outpatient colonoscopy: administration by nurses supervised by endoscopists.  Gastrointest Endosc. 2002;  55 815-825
• 4 Ulmer B J, Hansen J J, Overley C A et al. Propofol versus midazolam/fentanyl for outpatient colonoscopy: administration by nurses supervised by endoscopists.  Clin Gastroenterol Hepatol. 2003;  1 425-432
• 5 Qadeer M A, Vargo J J, Khandwala F et al. Propofol versus traditional sedative agents for gastrointestinal endoscopy: a meta-analysis.  Clin Gastroenterol Hepatol. 2005;  3 1049-1056
• 6 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
• 7 Weston B R, Chadalawada V, Chalasani N et al. Nurse-administered propofol versus midazolam and meperidine for upper endoscopy in cirrhotic patients.  Am J Gastroenterol. 2003;  98 2440-2447
• 8 Dewitt J, McGreevy K, Sherman S, Imperiale T F. Nurse-administered propofol sedation compared with midazolam and meperidine for EUS: a prospective, randomized trial.  Gastrointest Endosc. 2008;  68 499-509
• 9 Singh H, Poluha W, Cheung M et al. Propofol for sedation during colonoscopy.  Cochrane Database Syst Rev 2008;  4 CD006268
• 10 Koshy G, Nair S, Norkus E P et al. Propofol versus midazolam and meperidine for conscious sedation in GI endoscopy.  Am J Gastroenterol. 2000;  95 1476-1479
• 11 Nightingale P, Healy T E, Hargreaves J et al. Propofol in emulsion form: induction characteristics and venous sequelae.  Eur J Anaesthesiol. 1985;  2 361-368
• 12 Rex D K, Heuss L T, Walker J A, Qi R. Trained registered nurses/endoscopy teams can administer propofol safely for endoscopy.  Gastroenterology. 2005;  129 1384-1391
• 13 Heuss L T, Schnieper P, Drewe J et al. Risk stratification and safe administration of propofol by registered nurses supervised by the gastroenterologist: a prospective observational study of more than 2000 cases.  Gastrointest Endosc. 2003;  57 664-671
• 14 Walker J A, McIntyre R D, Schleinitz P F et al. Nurse-administered propofol sedation without anesthesia specialists in 9152 endoscopic cases in an ambulatory surgery center.  Am J Gastroenterol. 2003;  98 1744-1750
• 15 Chernik D A, Gillings D, Laine H et al. Validity and reliability of the Observer's Assessment of Alertness/Sedation Scale: study with intravenous midazolam.  J Clin Psychopharmacol. 1990;  10 244-251
• 16 Wehrmann T, Riphaus A. Sedation with propofol for interventional endoscopic procedures: a risk factor analysis.  Scand J Gastroenterol. 2008;  43 368-374
• 17 Fatima H, DeWitt J, LeBlanc J et al. Nurse-administered propofol sedation for upper endoscopic ultrasonography.  Am J Gastroenterol. 2008;  103 1649-1656
• 18 Kulling D, Orlandi M, Inauen W. Propofol sedation during endoscopic procedures: how much staff and monitoring are necessary?.  Gastrointest Endosc. 2007;  66 443-449
• 19 Rex D K, Deenadayalu V P, Eid E et al. Endoscopist-directed administration of propofol: a worldwide safety experience.  Gastroenterology. 2009;  137 1229-1237
• 20 Cote G A, Hovis R M, Ansstas M A et al. Incidence of sedation-related complications with propofol use during advanced endoscopic procedures.  Clin Gastroenterol Hepatol. 2010;  8 137-142