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

This Guideline is an official statement of the European Society of Gastrointestinal Endoscopy (ESGE) and the European Society of Gastroenterology and Endoscopy Nurses and Associates (ESGENA). It addresses the administration of propofol by non-anesthesiologists for gastrointestinal (GI) endoscopy.

Main Recommendations

1 We recommend that the type of endoscopic procedure and the patient’s American Society of Anesthesiologists (ASA) physical status, age, body mass index, Mallampati’s classification, and risk factors for obstructive sleep apnea (OSA) be assessed before each procedure with non-anesthesiologist administration of propofol (NAAP) (strong recommendation, moderate quality evidence).

2 We suggest primary involvement of an anesthesiologist in patients of ASA class ≥ 3, with a Mallampati’s class ≥ 3 or other conditions that put them at risk of airway obstruction (e. g. pharyngolaryngeal tumors), in patients who chronically receive significant amounts of narcotic analgesics, or in cases where a long-lasting procedure is anticipated (weak recommendation, low quality evidence).

3 We suggest consideration of capnographic monitoring during NAAP in specific situations including high risk patients, intended deep sedation, and long procedures (weak recommendation, high quality evidence).

4 We suggest propofol monotherapy except in particular situations (weak recommendation, high quality evidence).

5 We recommend administering propofol through intermittent bolus infusion or perfusor systems, including target-controlled infusion (TCI), and consideration of patient-controlled sedation (PCS) in particular situations (strong recommendation, high quality evidence).

6 We suggest that patients listen to self-selected music during upper and lower GI endoscopy procedures (weak recommendation, moderate quality evidence).

7 We do not suggest using pharyngeal anesthesia during propofol sedation for upper GI endoscopy (weak recommendation, moderate quality evidence).

8 We suggest using the post-anesthetic discharge scoring system (PADSS) to determine when patient recovery is sufficient to allow discharge (weak recommendation, low quality evidence).

9 Minimum discharge criteria should be fulfilled before discharging a patient. We recommend that patients who have received combined regimens, and all patients of ASA class > 2, should upon discharge be accompanied by a responsible person and refrain for 24 hours from driving, drinking alcohol, operating heavy machinery, or engaging in legally binding decisions. Advice should be provided verbally and in written form to the patient, including a 24-hour contact phone number (strong recommendation, low quality evidence).

10 For patients of ASA classes 1 – 2 who have received low dose propofol monotherapy, a 6-hour limit is suggested (weak recommendation, low quality evidence).

• References

• 1 Baudet J-S, Borque P, Borja E et al. Use of sedation in gastrointestinal endoscopy: a nationwide survey in Spain. Eur J Gastroenterol Hepatol 2009; 21: 882-888
• 2 Paspatis GA, Manolaraki MM, Tribonias G et al. Endoscopic sedation in Greece: results from a nationwide survey for the Hellenic Foundation of gastroenterology and nutrition. Dig Liv Dis 2009; 41: 807-811
• 3 Heuss L, Froehlich F, Beglinger C. Nonanesthesiologist-administered propofol sedation: from the exception to standard practice. Sedation and monitoring trends over 20 years. Endoscopy 2012; 44: 504-511
• 4 Riphaus A, Macias Gomez C, Deviere J et al. Propofol, the preferred sedation for screening colonoscopy, is underused. Results of an international survey. Dig Liv Dis 2012; 44: 389-392
• 5 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
• 6 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 Anaesth 2010; 27: 1016-1030
• 7 Pelosi P. Retraction of endorsement: 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. Endoscopy 2012; 44: 302
• 8 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-anesthesiologist administration of propofol for GI endoscopy. Endoscopy 2010; 42: 960-974
• 9 Atkins D, Best D, Briss PA et al. Grading quality of evidence and strength of recommendations. BMJ 2004; 328: 1490
• 10 McQuaid KR, Laine L. A systematic review and meta-analysis of randomized, controlled trials of moderate sedation for routine endoscopic procedures. Gastrointest Endosc 2008; 67: 910-923
• 11 DeWitt J, LeBlanc J, McHenry L et al. Endoscopic ultrasound-guided fine needle aspiration cytology of solid liver lesions: a large single-center experience. Am J Gastroenterol 2003; 98: 1976-1981
• 12 Jung M, Hofmann C, Kiesslich R et al. Improved sedation in diagnostic and therapeutic ERCP: propofol is an alternative to midazolam. Endoscopy 2000; 32: 233-238
• 13 Riphaus A, Stergiou N, Wehrmann T. Sedation with propofol for routine ERCP in high-risk octogenarians: a randomized, controlled study. Am J Gastroenterol 2005; 100: 1957-1963
• 14 Meining A, Semmler V, Kassem AM et al. The effect of sedation on the quality of upper gastrointestinal endoscopy: an investigator-blinded, randomized study comparing propofol with midazolam. Endoscopy 2007; 39: 345-349
• 15 Singh H, Poluha W, Cheung M et al. Propofol for sedation during colonoscopy. Cochrane Database Syst Rev 2008; 4 CD006268
• 16 Rex DK, Deenadayalu VP, Eid E et al. Endoscopist-directed administration of propofol: a worldwide safety experience. Gastroenterology 2009; 137: 1229-1237; quiz 1518–1229
• 17 Qadeer MA, Vargo JJ, Khandwala F et al. Propofol versus traditional sedative agents for gastrointestinal endoscopy: a meta-analysis. Clin Gastroenterol Hepatol 2005; 3: 1049-1056
• 18 Wang D, Chen C, Chen J et al. The use of propofol as a sedative agent in gastrointestinal endoscopy: a meta-analysis. PLoS ONE 2013; 8: e53311
• 19 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
• 20 Frieling T, Heise J, Kreysel C et al. Sedation-associated complications in endoscopy – prospective multicentre survey of 191142 patients. Z Gastroenterol 2013; 51: 568-572
• 21 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: 2612-2627
• 22 Sethi S, Wadhwa V, Thaker A et al. Propofol versus traditional sedative agents for advanced endoscopic procedures: A meta-analysis. Dig Endosc 2014; 26: 515-524
• 23 Bo L-L, Bai Y, Bian J-J et al. Propofol vs traditional sedative agents for endoscopic retrograde cholangiopancreatography: a meta-analysis. World J Gastroenterol 2011; 17: 3538-3543
• 24 Hassan C, Rex DK, Cooper GS et al. Endoscopist-directed propofol administration versus anesthesiologist assistance for colorectal cancer screening: a cost-effectiveness analysis. Endoscopy 2012; 44: 456-464
• 25 Dumonceau JM. Nonanesthesiologist administration of propofol: it’s all about money. Endoscopy 2012; 44: 453-455
• 26 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
• 27 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: 2185-2190
• 28 Jover R, Zapater P, Polanía E et al. Modifiable endoscopic factors that influence the adenoma detection rate in colorectal cancer screening colonoscopies. Gastrointest Endosc 2013; 77: 381-389.e381
• 29 Bannert C, Reinhart K, Dunkler D et al. Sedation in screening colonoscopy: impact on quality indicators and complications. Am J Gastroenterol 2012; 107: 1837-1848
• 30 Amornyotin S, Prakanrattana U, Kachintorn U et al. Propofol-based sedation does not increase rate of perforation during colonoscopic procedure. Gastroenterol Insights 2010; 2: e4
• 31 Bielawska B, Day AG, Lieberman DA et al. Risk factors for early colonoscopic perforation include non-gastroenterologist endoscopists: a multivariable analysis. Clin Gastroenterol Hepatol 2014; 12: 85-92
• 32 Okholm C, Hadikhadem T, Andersen LT et al. No increased risk of perforation during colonoscopy in patients undergoing Nurse Administered Propofol Sedation. Scand J Gastroenterol 2013; 48: 1333-1338
• 33 Adeyemo A, Bannazadeh M, Riggs T et al. Does sedation type affect colonoscopy perforation rates?. Dis Colon Rectum 2014; 57: 110-114
• 34 Fatima H, DeWitt J, LeBlanc J et al. Nurse-administered propofol sedation for upper endoscopic ultrasonography. Am J Gastroenterol 2008; 103: 1649-1656
• 35 Vargo JJ, Delegge MH, Feld AD et al. Multisociety sedation curriculum for gastrointestinal endoscopy. Gastrointest Endosc 2012; 76: e1-e25
• 36 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
• 37 Igea F, Casellas JA, González-Huix F et al. Sedation for gastrointestinal endoscopy. Endoscopy 2014; 46: 720-731
• 38 Jensen JT, Vilmann P, Horsted T et al. Nurse-administered propofol sedation for endoscopy: a risk analysis during an implementation phase. Endoscopy 2011; 43: 716-722
• 39 Slagelse C, Vilmann P, Hornslet P et al. Nurse-administered propofol sedation for gastrointestinal endoscopic procedures: first Nordic results from implementation of a structured training program. Scand J Gastroenterol 2011; 46: 1503-1509
• 40 Schilling D, Leicht K, Beilenhoff U et al. Impact of S3 training courses “Sedation and Emergency Management in Endoscopy for Endoscopy Nurses and Assisting Personnel” on the process and structure quality in gastroenterological endoscopy in practices and clinics – results of a nationwide survey. Z Gastroenterol 2013; 51: 619-627
• 41 Quine MA, Bell GD, McCloy RF et al. Prospective audit of upper gastro- intestinal endoscopy in two regions of England: safety, staffing, and sedation methods. Gut 1995; 36: 462-667
• 42 Eckardt VF, Kanzler G, Schmitt T et al. Complications and adverse effects of colonoscopy with selective sedation. Gastrointest Endosc 1999; 49: 560-565
• 43 Bhananker SM, Posner KL, Cheney FW et al. Injury and liability associated with monitored anesthesia care: a closed claims analysis. Anesthesiology 2006; 104: 228-234
• 44 Gupta A. Preoperative screening and risk assessment in the ambulatory surgery patient. Curr Opin Anaesthesiol 2009; 22: 705-711
• 45 Mallampati SR, Gatt SP, Gugino LD et al. A clinical sign to predict difficult tracheal intubation: a prospective study. Can Anaesth Soc J 1985; 32: 429-434
• 46 American Society of Anesthesiologists. Physical Status Classification System. http://www.asahq.org/resources/clinical-information/asa-physical-status-classification-system Accessed: May 1, 2015
• 47 American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists. Practice guidelines for sedation and analgesia by non-anesthesiologists. Anesthesiology 2002; 96: 1004-1017
• 48 Enestvedt BK, Eisen GM, Holub J et al. Is the American Society of Anesthesiologists classification useful in risk stratification for endoscopic procedures?. Gastrointest Endosc 2013; 77: 464-471
• 49 Dietrich CG, Kottmann T, Diedrich A et al. Sedation-associated complications in endoscopy are not reduced significantly by implementation of the German S-3-guideline and occur in a severe manner only in patients with ASA class III and higher. Scand J Gastroenterol 2013; 48: 1082-1087
• 50 Friedrich K, Stremmel W, Sieg A. Endoscopist-administered propofol sedation is safe – a prospective evaluation of 10,000 patients in an outpatient practice. J Gastrointest Liver Dis 2012; 21: 259-263
• 51 Friedrich-Rust M, Welte M, Welte C et al. Capnographic monitoring of propofol-based sedation during colonoscopy. Endoscopy 2014; 46: 236-244
• 52 Mehta PP, Kochhar G, Kalra S et al. Can a validated sleep apnea scoring system predict cardiopulmonary events using propofol sedation for routine EGD or colonoscopy? A prospective cohort study. Gastrointest Endosc 2014; 79: 436-444
• 53 Kerker A, Hardt C, Schlief H-E et al. Combined sedation with midazolam/propofol for gastrointestinal endoscopy in elderly patients. BMC Gastroenterol 2010; 10: 11
• 54 Martínez JF, Aparicio JR, Compañy L et al. Safety of continuous propofol sedation for endoscopic procedures in elderly patients. Rev Esp Enferm Dig 2011; 103: 76-82
• 55 Park TY, Choi JS, Oh H-C et al. Assessment of safety of non-anesthesiologist-assisted endoscopic retrograde cholangiopancreatography based on performance status in elderly patients. J Gastroenterol Hepatol 2014; 29: 1943-1948
• 56 Horiuchi A, Nakayama Y, Tanaka N et al. Propofol sedation for endoscopic procedures in patients 90 years of age and older. Digestion 2008; 78: 20-23
• 57 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: 137-142
• 58 Wani S, Azar R, Hovis CE et al. Obesity as a risk factor for sedation-related complications during propofol-mediated sedation for advanced endoscopic procedures. Gastrointest Endosc 2011; 74: 1238-1247
• 59 Friedman M, Tanyeri H, La Rosa M et al. Clinical predictors of obstructive sleep apnea. Laryngoscope 1999; 109: 1901-1907
• 60 Deng L, Li C-L, Ge S-J et al. STOP questionnaire to screen for hypoxemia in deep sedation for young and middle-aged colonoscopy. Dig Endosc 2012; 24: 255-258
• 61 Boese ML, Ransom RK, Roadfuss RJ et al. Utility of the Berlin Questionnaire to screen for obstructive sleep apnea among patients receiving intravenous sedation for colonoscopy. AANA J 2014; 82: 38-45
• 62 Qaseem A, Dallas P, Owens DK et al. Diagnosis of obstructive sleep apnea in adults: a clinical practice guideline from the American College of Physicians. Ann Intern Med 2014; 161: 210-220
• 63 Chung F, Yegneswaran B, Liao P et al. STOP questionnaire: a tool to screen patients for obstructive sleep apnea. Anesthesiology 2008; 108: 812-821
• 64 Chung F, Yang Y, Liao P. Predictive performance of the STOP-Bang score for identifying obstructive sleep apnea in obese patients. Obes Surg 2013; 23: 2050-2057
• 65 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: e0117585
• 66 Riphaus A, Wehrmann T, Weber B et al. S3 Guideline: Sedation for gastrointestinal endoscopy 2008. Endoscopy 2009; 41: 787-815
• 67 Lichtenstein DR, Jagannath S, Baron TH et al. Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy. Sedation and anesthesia in GI endoscopy. Gastrointest Endosc 2008; 68: 815-826
• 68 Riphaus A, Wehrmann T, Hausmann J et al. S3-guidelines “sedation in gastrointestinal endoscopy” 2014 (AWMF register no. 021/014) [in German]. Z Gastroenterol 2015; 53: 802-842
• 69 Walder B, Riphaus A, Dumonceau JM. Reply to Külling et al. Endoscopy 2011; 43: 637-638
• 70 Smith MR, Bell GD, Fulton B et al. A comparison of winged steel needles and Teflon cannulas in maintaining intravenous access during gastrointestinal endoscopy. Gastrointest Endosc 1993; 39: 33-36
• 71 Rozario L, Sloper D, Sheridan MJ. Supplemental oxygen during moderate sedation and the occurrence of clinically significant desaturation during endoscopic procedures. Gastroenterol Nurs 2008; 31: 281-285
• 72 Patterson KW, Noonan N, Keeling NW et al. Hypoxemia during outpatient gastrointestinal endoscopy: the effects of sedation and supplemental oxygen. J Clin Anesth 1995; 7: 136-140
• 73 Iwao T, Toyonaga A, Shigemori H et al. Supplemental oxygen during endoscopic variceal ligation: effects on arterial oxygenation and cardiac arrhythmia. Am J Gastroenterol 1995; 90: 2186-2190
• 74 Haines DJ, Bibbey D, Green JR. Does nasal oxygen reduce the cardiorespiratory problems experienced by elderly patients undergoing endoscopic retrograde cholangiopancreatography?. Gut 1992; 33: 973-975
• 75 Gross JB, Long WB. Nasal oxygen alleviates hypoxemia in colonoscopy patients sedated with midazolam and meperidine. Gastrointest Endosc 1990; 36: 26-29
• 76 Crantock L, Cowen AE, Ward M et al. Supplemental low flow oxygen prevents hypoxia during endoscopic cholangiopancreatography. Gastrointest Endosc 1992; 38: 418-420
• 77 Bowling TE, Hadjiminas CL, Polson RJ et al. Effects of supplemental oxygen on cardiac rhythm during upper gastrointestinal endoscopy: a randomised controlled double blind trial. Gut 1993; 34: 1492-1497
• 78 Bell GD, Quine A, Antrobus JH et al. Upper gastrointestinal endoscopy: a prospective randomized study comparing continuous supplemental oxygen via the nasal or oral route. Gastrointest Endosc 1992; 38: 319-325
• 79 Sharma VK, Nguyen CC, Crowell MD et al. A national study of cardiopulmonary unplanned events after GI endoscopy. Gastrointest Endosc 2007; 66: 27-34
• 80 Froehlich F, Harris JK, Wietlisbach V et al. Current sedation and monitoring practice for colonoscopy: an International Observational Study (EPAGE). Endoscopy 2006; 38: 461-469
• 81 Riphaus A, Rabofski M, Wehrmann T. Endoscopic sedation and monitoring practice in Germany: results from the first nationwide survey. Z Gastroenterol 2010; 48: 392-397
• 82 Vargo JJ, Zuccaro G, Dumot JA et al. Automated graphic assessment of respiratory activity is superior to pulse oximetry and visual assessment for the detection of early respiratory depression during therapeutic upper endoscopy. Gastrointest Endosc 2002; 55: 826-831
• 83 Qadeer MA, Rocio Lopez A, Dumot JA et al. Hypoxemia during moderate sedation for gastrointestinal endoscopy: causes and associations. Digestion 2011; 84: 37-45
• 84 Qadeer MA, Vargo JJ, Dumot JA et al. Capnographic monitoring of respiratory activity improves safety of sedation for endoscopic cholangiopancreatography and ultrasonography. Gastroenterology 2009; 136: 1568-1576; quiz 1819–1520
• 85 Lightdale JR, Goldmann DA, Feldman HA et al. Microstream capnography improves patient monitoring during moderate sedation: a randomized, controlled trial. Pediatrics 2006; 117: e1170-e1178
• 86 American Society of Anesthesiologists Committee. ASA Standards for 2011 – Capnography. Available from: http://www.capnography.com Accessed: April 28, 2015
• 87 Statement by the American Society of Gastrointestinal Endoscopy, American College of Gastroenterology and the American Gastroenterological Association. Universal adoption of capnography for moderate sedation in adults undergoing upper endoscopy and colonoscopy has not been shown to improve patient safety or clinical outcomes and significantly increases costs for moderate sedation. Available from: http://www.asge.org/assets/0/71542/71544/90dc9b63-593d-48a9-bec1-9f0ab3ce946a.pdf Accessed: April 28, 2015
• 88 Beitz A, Riphaus A, Meining A et al. Capnographic monitoring reduces the incidence of arterial oxygen desaturation and hypoxemia during propofol sedation for colonoscopy: a randomized, controlled study (ColoCap Study). Am J Gastroenterol 2012; 107: 1205-1212
• 89 Slagelse C, Vilmann P, Hornslet P et al. The role of capnography in endoscopy patients undergoing nurse-administered propofol sedation: a randomized study. Scand J Gastroenterol 2013; 48: 1222-1230
• 90 Wehrmann T, Grotkamp J, Stergiou N et al. Electroencephalogram monitoring facilitates sedation with propofol for routine ERCP: a randomized, controlled trial. Gastrointest Endosc 2002; 56: 817-824
• 91 Paspatis GA, Chainaki I, Manolaraki MM et al. Efficacy of bispectral index monitoring as an adjunct to propofol deep sedation for ERCP: a randomized controlled trial. Endoscopy 2009; 41: 1046-1051
• 92 Imagawa A, Fujiki S, Kawahara Y et al. Satisfaction with bispectral index monitoring of propofol-mediated sedation during endoscopic submucosal dissection: a prospective, randomized study. Endoscopy 2008; 40: 905-909
• 93 Drake LM, Chen SC, Rex DK. Efficacy of bispectral monitoring as an adjunct to nurse-administered propofol sedation for colonoscopy: a randomized controlled trial. Am J Gastroenterol 2006; 101: 2003-2007
• 94 von Delius S, Salletmaier H, Meining A et al. Bispectral index monitoring of midazolam and propofol sedation during endoscopic retrograde cholangiopancreatography: a randomized clinical trial (the EndoBIS study). Endoscopy 2012; 44: 258-264
• 95 Jang SY, Park HG, Jung MK et al. Bispectral index monitoring as an adjunct to nurse-administered combined sedation during endoscopic retrograde cholangiopancreatography. World J Gastroenterol 2012; 18: 6284-6289
• 96 Yu YH, Han D-S, Kim HS et al. Efficacy of bispectral index monitoring during balanced propofol sedation for colonoscopy: a prospective, randomized controlled trial. Dig Dis Sci 2013; 58: 3576-3583
• 97 Park WY, Shin Y-S, Lee SK et al. Bispectral index monitoring during anesthesiologist-directed propofol and remifentanil sedation for endoscopic submucosal dissection: a prospective randomized controlled trial. Yonsei Med J 2014; 55: 1421-1429
• 98 American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Practice advisory for preanesthesia evaluation: a report by the American Society of Anesthesiologists Task Force on Preanesthesia Evaluation. Anesthesiology 2002; 96: 485-496
• 99 Ely EW, Truman B, Shintani A et al. Monitoring sedation status over time in ICU patients: reliability and validity of the Richmond Agitation-Sedation Scale (RASS). JAMA 2003; 289: 2983-2991
• 100 Chawla S, Katz A, Attar BM et al. Endoscopic retrograde cholangiopancreatography under moderate sedation and factors predicting need for anesthesiologist directed sedation: A county hospital experience. World J Gastrointest Endosc 2013; 5: 160-164
• 101 Cotton PB. Income and outcome metrics for the objective evaluation of ERCP and alternative methods. Gastrointest Endosc 2002; 56: S283-S290
• 102 Wang D, Wang S, Chen J et al. Propofol combined with traditional sedative agents versus propofol- alone sedation for gastrointestinal endoscopy: a meta-analysis. Scand J Gastroenterol 2013; 48: 101-110
• 103 Horiuchi A, Nakayama Y, Fujii H et al. Psychomotor recovery and blood propofol level in colonoscopy when using propofol sedation. Gastrointest Endosc 2012; 75: 506-512
• 104 Horiuchi A, Nakayama Y, Kajiyama M et al. Safety and effectiveness of propofol sedation during and after outpatient colonoscopy. World J Gastroenterol 2012; 18: 3420-3425
• 105 Paspatis GA, Charoniti I, Manolaraki M et al. Synergistic sedation with oral midazolam as a premedication and intravenous propofol versus intravenous propofol alone in upper gastrointestinal endoscopies in children: a prospective, randomized study. J Pediatr Gastroenterol Nutr 2006; 43: 195-199
• 106 Paspatis G, Manolaraki M, Vardas E et al. Deep sedation for endoscopic retrograde cholangiopancreatography: intravenous propofol alone versus intravenous propofol with oral midazolam premedication. Endoscopy 2008; 40: 308-313
• 107 Crepeau T, Poincloux L, Bonny C et al. Significance of patient-controlled sedation during colonoscopy. Results from a prospective randomized controlled study. Gastroenterol Clin Biol 2005; 29: 1090-1096
• 108 Heuss LT, Drewe J, Schnieper P et al. Patient-controlled versus nurse-administered sedation with propofol during colonoscopy. A prospective randomized trial. Am J Gastroenterol 2004; 99: 511-518
• 109 Pambianco DJ, Vargo JJ, Pruitt RE et al. Computer-assisted personalized sedation for upper endoscopy and colonoscopy: a comparative, multicenter randomized study. Gastrointest Endosc 2011; 73: 765-772
• 110 Dumonceau JM, Riphaus A, Wehrmann T. Preparation, sedation, and monitoring. Endoscopy 2012; 44: 403-407
• 111 Mazanikov M, Udd M, Kylänpää L et al. A randomized comparison of target-controlled propofol infusion and patient-controlled sedation during ERCP. Endoscopy 2013; 45: 915-919
• 112 Mazanikov M, Udd M, Kylänpää L et al. Patient-controlled sedation with propofol and remifentanil for ERCP: a randomized, controlled study. Gastrointest Endosc 2011; 73: 260-266
• 113 Fanti L, Gemma M, Agostoni M et al. Target Controlled Infusion for non-anaesthesiologist propofol sedation during gastrointestinal endoscopy: The first double blind randomized controlled trial. Dig Liver Dis 2015; 47: 566-571
• 114 Xu C-X, Chen X, Jia Y et al. Stepwise sedation for elderly patients with mild/moderate COPD during upper gastrointestinal endoscopy. World J Gastroenterol 2013; 19: 4791-4798
• 115 Wang MC, Zhang LY, Zhang YL et al. Effect of music in endoscopy procedures: systematic review and meta-analysis of randomized controlled trials. Pain Med 2014; 15: 1786-1794
• 116 Evans LT, Saberi S, Kim HM et al. Pharyngeal anesthesia during sedated EGDs: is “the spray” beneficial? A meta-analysis and systematic review. Gastrointest Endosc 2006; 63: 761-766
• 117 de la Morena F, Santander C, Esteban C et al. Usefulness of applying lidocaine in esophagogastroduodenoscopy performed under sedation with propofol. World J Gastrointest Endosc 2013; 5: 231-239
• 118 Heuss LT, Hanhart A, Dell-Kuster S et al. Propofol sedation alone or in combination with pharyngeal lidocaine anesthesia for routine upper GI endoscopy: a randomized, double-blind, placebo-controlled, non-inferiority trial. Gastrointest Endosc 2011; 74: 1207-1214
• 119 Tallis GF, Ryan GM, Lambert SB et al. Evidence of patient-to-patient transmission of hepatitis C virus through contaminated intravenous anaesthetic ampoules. J Viral Hepatitis 2003; 10: 234-239
• 120 Fukada T, Ozaki M. Microbial growth in propofol formulations with disodium edetate and the influence of venous access system dead space. Anaesthesia 2007; 62: 575-580
• 121 Picard P, Tramèr MR. Prevention of pain on injection with propofol: a quantitative systematic review. Anesth Analg 2000; 90: 963-969
• 122 Müller M, Wehrmann T, Eckardt AJ. Prospective evaluation of the routine use of a nasopharyngeal airway (Wendl Tube) during endoscopic propofol-based sedation. Digestion 2014; 89: 247-252
• 123 Molina-Infante J, Arias A, Vara-Brenes D et al. Propofol administration is safe in adult eosinophilic esophagitis patients sensitized to egg, soy, or peanut. Allergy 2014; 69: 388-394
• 124 Newman DH, Azer MM, Pitetti RD et al. When is a patient safe for discharge after procedural sedation? The timing of adverse effect events in 1367 pediatric procedural sedations. Ann Emerg Med 2003; 42: 627-635
• 125 Chung F, Chan VW, Ong D. A post-anesthetic discharge scoring system for home readiness after ambulatory surgery. J Clin Anesth 1995; 7: 500-506
• 126 Aldrete JA. Modifications to the postanesthesia score for use in ambulatory surgery. J Perianesth Nurs 1998; 13: 148-155
• 127 Amornyotin S, Chalayonnavin W, Kongphlay S. Recovery pattern and home-readiness after ambulatory gastrointestinal endoscopy. J Med Assoc Thai 2007; 90: 2352-2358
• 128 Trevisani L, Cifalà V, Gilli G et al. Post-Anaesthetic Discharge Scoring System to assess patient recovery and discharge after colonoscopy. World J Gastrointest Endosc 2013; 5: 502-507
• 129 Willey J, Vargo JJ, Connor JT et al. Quantitative assessment of psychomotor recovery after sedation and analgesia for outpatient EGD. Gastrointest Endosc 2002; 56: 810-816
• 130 Horiuchi A, Nakayama Y, Hidaka N et al. Low-dose propofol sedation for diagnostic esophagogastroduodenoscopy: results in 10,662 adults. Am J Gastroenterol 2009; 104: 1650-1655
• 131 Watkins TJ, Bonds RL, Hodges K et al. Evaluation of postprocedure cognitive function using 3 distinct standard sedation regimens for endoscopic procedures. AANA J 2014; 82: 133-139
• 132 Pitetti R, Davis PJ, Redlinger R et al. Effect on hospital-wide sedation practices after implementation of the 2001 JCAHO procedural sedation and analgesia guidelines. Arch Ped Adol Med 2006; 160: 211-216
• 133 Aisenberg J, Cohen LB, Piorkowski JD. Propofol use under the direction of trained gastroenterologists: an analysis of the medicolegal implications. Am J Gastroenterol 2007; 102: 707-713
• 134 Cotton PB. Analysis of 59 ERCP lawsuits; mainly about indications. Gastrointest Endosc 2006; 63: 378-382
• 135 Sherlock A, Brownie S. Patients’ recollection and understanding of informed consent: a literature review. ANZ J Surg 2014; 84: 207-210
• 136 Song JH, Yoon HS, Min BH et al. Acceptance and understanding of the informed consent procedure prior to gastrointestinal endoscopy by patients: a single-center experience in Korea. Korean J Intern Med 2010; 25: 36-43
• 137 Siao D, Sewell JL, Day LW. Assessment of delivery methods used in the informed consent process at a safety-net hospital. Gastrointest Endosc 2014; 80: 61-68
• 138 Adler DG, Kawa C, Hilden K et al. Nurse-administered propofol sedation is safe for patients with obstructive sleep apnea undergoing routine endoscopy: a pilot study. Dig Dis Sci 2011; 56: 2666-2671
• 139 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
• 140 Coté GA, Hovis CE, Hovis RM et al. A screening instrument for sleep apnea predicts airway maneuvers in patients undergoing advanced endoscopic procedures. Clin Gastroenterol Hepatol 2010; 8: 660-665.e661