Reply to White et al.

We thank Drs. White and Draganov for their comments concerning the European Society of Gastrointestinal Endoscopy and European Society of Gastroenterology and Endoscopy Nurses and Associates (ESGE-ESGENA) guideline on non-anesthesiologist administration of propofol (NAAP) for gastrointestinal endoscopy [1]. Indeed, between 2010 and 2015, our recommendation has changed following the publication of three randomized controlled trials (RCTs), from “Capnography cannot be recommended as standard” to “We suggest consideration of capnographic monitoring during NAAP in specific situations including high risk patients, intended deep sedation, and long procedures.” As detailed in the section 5.2.2 of the 2015 Guideline Update, we considered that the data from new RCTs were insufficient to further support the use of capnographic monitoring, in particular its generalization. This is in line with a recent statement by the American Society of Gastrointestinal Endoscopy, the American College of Gastroenterology, and the American Gastroenterological Association [2].

We thank Drs. White and Draganov for attracting our attention to the US closed claims analysis. To be conclusive, we think that more direct evidence should come from future RCTs focused on high-risk patients who undergo long-lasting procedures, with morbidity and mortality rates as the strongest end points, and the need for bag mask ventilation and endotracheal intubation as surrogate parameters. The current lack of evidence regarding cost-effectiveness should also be addressed.

Regarding the routine use of nasal oxygen supplementation, evidence suggests that, during gastrointestinal endoscopy, it reduces the frequency of hypoxemic events [3] but that it can be associated with carbon dioxide retention [4]. We considered that the “safety-buffer” effect of prophylactic oxygen supplementation was more important than its possible disadvantages. Again, this important question should be addressed in RCTs focused on clinically relevant outcomes to support possible changes in the next update of the ESGE-ESGENA guideline.

• References

• 1 Dumonceau J-M, Riphaus A, Schreiber F et al. 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. Endoscopy 2015; 47: 1175-1189
• 2 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 at: http://www.asge.org/assets/0/71542/71544/90dc9b63-593d-48a9-bec1-9f0ab3ce946a.pdf Accessed: March 2, 2016
• 3 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
• 4 Nelson DB, Freeman ML, Silvis SE et al. A randomized, controlled trial of transcutaneous carbon dioxide monitoring during ERCP. Gastrointest Endosc 2000; 51: 288-295