Abstract
Sedation in Endoscopy by Endoscopist
Dr Pradermchai Kongkam
Chulalongkorn University, Bangkok, Thailand
Currently, endoscopy is widely used for both diagnostic and therapeutic purposes. In general, procedures are performed in the specific endoscopy suit separating from operating room. Most endoscopists sedate patients themselves to facilitate procedures and minimize expenses. Ideal endoscopic sedation should provide painless procedure, safety, cost effective sedation, friendly used medications with rapid onset/ brief duration/ fast recovery, handy intra and post-procedural monitoring. This article aims to recapitulate commonly suggested approaches for endoscopists to reach such high-quality sedation.
To reach the objective, pre-procedural assessment includes history, physical examination, information of the procedure and good documentation. Question must lay emphasis on the topic of cardiac or pulmonary disease, neurological disease particularly seizure history, stridor/ snoring/ sleep apnea, adverse reaction to sedation, current medication, allergy, alcohol or drug abuse and time of last oral intake. Physical examination should focus on vital signs, weight, heart, lung, level of consciousness and airway. Airway assessment using Mallampati score is recommended. ASA classification should be defined prior to procedure. Patients classified as ASA class IV or V should be sedated by anesthetists rather than endoscopists. Detail of the procedure should be incorporated into the assessment. Well-designed documentations including consent forms, procedural monitoring records and procedural explanation in layman word should be ready in place and carefully filled. After all cautious pre-procedural assessment, if patients are felt unsuitable to be sedated by endoscopists, a consultation to anesthetist is strongly recommended despite rescheduling of the procedure may be required.
During the procedure, moderate or deep sedation is mostly a required level for endoscopy. To manage potential complications from sedation, endoscopist or physician who is in charge of sedation must be certified by a course of advanced cardiac life support (ACLS) and other members should pass the basic course. During sedation, one member must be specifically assigned to monitor vital signs and other essential parameters from monitoring equipments without significant interrupting events. All members must be well trained in sedation and familiar with sedation process, medications/ antidotes and resuscitation procedures.
Commonly used medications include meperidine, midazolam, fentanyl, naloxone, diazepam, midazolam and flumazenil. Periodical review of these medication properties and sedation related complication should be reviewed in each endoscopy unit although all those medication have been being used for long time. Propofol is increasingly used by endoscopists because of its desired properties. Several GI societies acknowledge utilization of this medication by endoscopists however well prepared condition is required. Nevertheless, it must be noted here that US FDA currently still states “Propofol should be administered only by persons trained in the administration of general anesthesia”. The most important disadvantage of propofol is its rapid transitioning of level of consciousness from moderate to deeper level. In addition, no antidote is available for propofol. Therefore, well trained person with adequate equipments and good monitoring are mandatory for sedation with propofol by endoscopist.
Standard intra-procedural monitoring of vital signs and oxygen saturation are generally recommended. Routine supplemental oxygen in moderate and deep sedation is recommended by ASA and ASGE despite some conflicting data regarding delayed diagnosis of hypoventilation. Sufficient post procedural monitoring is obligatory particularly in the level of consciousness and adequate ventilation. Aldrete scoring system is friendly used scheme to assess ability of patients to be discharged from monitoring.
In conclusion, to reach the ideal sedation by endoscopist, well trained persons, sufficient equipments, good practice and attitude are required. More importantly, limitation must be honestly accepted and “call for help” should be made without necessitation when needed. Then everyone will reach their goal and utilize all the resources properly.
