Gastroenterological Endoscopy. Группа авторов

a reduced risk of dose-related adverse reactions.^13,46,47 However, most guidelines recommend the use of propofol monosedation.^{4,5,6,11,12,13,14,15,16,17}

      4.4.5 Who Should Perform Endoscopic Sedation?

      This question is still a matter of debate within the medical community.^3,47 Some anesthesiologists believe that only those trained in the administration of general anesthesia should administer propofol, and that the use of propofol by nonanesthesiologists is unsafe. While the package insert of propofol restricts its use to anesthesiologists, this insert was created in the late 1980s before evidence accumulated that nonanesthesiologists can safely administer propofol for endoscopic procedures. Of course, it is necessary for endoscopists and nursing staff to be able to manage the typical adverse effects of propofol and be trained in life support techniques.^3,47 All currently available guidelines state that the endoscopist is not permitted to administer propofol and to monitor the patient. This task must be done by an additional person, who has the sole responsibility to administer the sedative and to monitor the patient.^{4,5,6,11,12,13,14,15,16,17} This person can be an anesthesiologist (monitored anesthesia care [MAC]), a specially trained nonanesthesiologist physician (NAAP sedation), or a dedicated nurse (nurse-administered propofol sedation, NAPS). The mode of propofol application is, in most countries, regulated by law, for example, in most states of the United States and in France, the use of propofol is restricted to anesthesiologists; therefore, the only mode of propofol sedation is MAC in these countries. However, there is no proven clinical benefit of providing MAC for low-risk patients (ASA I–II) undergoing routine endoscopic procedures, and it is suggested that MAC should be reserved for patients with an increased risk of sedation-related complications.^6,47 Recently, it was shown that NAAP is safe in patients with obstructive sleep apnea, and that the use of MAC in ASA I and II patients for upper endoscopy and colonoscopy is not cost-effective.⁴⁸ The use of NAAP or even NAPS is now recommended by most international guidelines for patients with a lower risk profile (excluding ASA class IV–V and those with expected difficult airway management).^3,4,5,6 Furthermore, NAAP and NAPS should only be performed where appropriately trained staff and facilities for monitoring and providing proper airway management, including availability of supplemental oxygen and equipment for advanced cardiac life support, are available. To optimize patient safety, many guidelines recommend regular participation in structured education curricula for teams involved in NAAP/NAPS.^4,5,6

      4.5 Postprocedure Care

      4.5.1 Monitoring during Recovery

      Following conclusion of the procedure the patient remains at risk for cardiopulmonary complications because the sedation/anesthesia medications have not been completely metabolized, while at the same time the procedure stimulation is gone. Therefore, postprocedural monitoring of the cardiopulmonary system by qualified staff is necessary. This monitoring should take place in a separate recovery room/area with equipment for appropriate cardiopulmonary monitoring and resuscitation.³ No defined recommendations regarding postprocedure monitoring exist. Because most of the serious adverse effects of sedation occur within 30 minutes after the last administration of benzodiazepines and opioids,⁴⁹ patients should be monitored for at least 30 minutes in a recovery room. Furthermore, patients who have obstructive sleep apnea and patients who have received reversal agents need special postsedation management based on ASA guidelines, because prolonged recovery times or rebound may occur in these patients.³

      4.5.2 Discharge

      There is no consensus on the duration of postprocedure monitoring, because it varies widely based on the individual patient, type of sedation, and procedure performed. Some authors recommend patients can be safely discharged approximately 30 minutes after the last application of sedation/analgesia/anesthesia agents if no adverse effects have occurred.⁴⁹ Others would discharge the patient once vital signs are stable and the patient has reached an appropriate level of consciousness.¹⁷ Therefore, defined discharge criteria might be useful for objective guidance. Various scoring systems exist, of which the Aldrete score is the most commonly used.⁵⁰ It evaluates respiration, oxygen saturation, blood pressure, consciousness, and activity. Irrespective of which scoring system is used, a checklist to assess discharge criteria (suggested minimum criteria are shown in

Table 4.4) is recommended. The results should be documented before the patient is allowed to leave the endoscopy unit, and with an accompanying adult.^3,4,5,6 In general, patients should have sufficient return of their motor skills, with the ability to walk, tolerate liquids, and dress themselves. The patient should be strongly advised not to drive a car or operate machinery until full recovery can safely be expected. The exact time until the patient will regain the ability to drive or work depends on the half-life of the drugs administered, the patient’s comorbidity, and intended activities (e.g., employment as a traffic pilot, heavy equipment operator, etc.). Time to full recovery using psychomotor tests is significantly less after monosedation with propofol as compared to midazolam monotherapy or midazolam/opioid sedation.³ Driving skills return to baseline levels within 2 hours after last propofol administration.^51,52,53 However, whether patients should be allowed to drive after propofol monosedation remains uncertain.³ Patients should be able to drive, work, and engage in legally binding decisions the day after the procedure (current European guidelines recommend an interval of 6–12 hours).^4,5,6 Furthermore, patients should be provided written instructions because of amnesic effects of the procedural sedation.^4,5,6

Table 4.4 Criteria for home discharge after endoscopic sedation

• Stable vital signs for at least 1 h

• Ability to dress, walk, and micturate without difficulty

• No excessive pain or nausea

• Intake of oral fluids without difficulty

• Adult escort

• Postsedation care at home available

• Written and verbal instructions outlining possible complications

• Phone number to be called in case of emergency

      References

      [1] Cohen LB, Ladas SD, Vargo JJ, et al. Sedation in digestive endoscopy: the Athens international position statements. Aliment Pharmacol Ther. 2010; 32(3):425–442

      [2] Abraham NS, Fallone CA, Mayrand S, et al. Sedation versus no sedation in the performance of diagnostic upper gastrointestinal endoscopy: a Canadian randomized controlled cost-outcome study. Am J Gastroenterol. 2004; 99(9):1692–1699

      [3] Müller M, Wehrmann T. How best to approach endoscopic sedation? Nat Rev Gastroenterol Hepatol. 2011; 8(9):481–490

      [4] Riphaus A, Wehrmann T, Weber B, et al. S3 Guideline: sedation for gastrointestinal endoscopy. Endoscopy. 2009; 41:787–815

      [5] Riphaus A, Wehrmann T, Hausmann J, et al; German Society of General and Visceral Surgery. German Crohn’s disease / ulcerative colitis Association e. V. German Society of Anaesthesiology and Intensive Care Medicine e. V. (DGAI). Gesellschaft Politics and Law in Health Care (GPRG). S3-guidelines “sedation in gastrointestinal endoscopy” 2014 (AWMF register no. 021/014) [in German] Z Gastroenterol. 2015; 53(8):802–842

      [6] Dumonceau JM, Riphaus A, Aparicio JR, et al; NAAP Task Force Members. 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(11):960–974

      [7] Ladas SD, Aabakken L, Rey JF, et al; European Society of Gastrointestinal Endoscopy Survey of National Endoscopy Society Members. Use of sedation for routine diagnostic upper gastrointestinal endoscopy: a European Society of Gastrointestinal Endoscopy Survey