Ludwig T. Heuss

Background and Study Aims: Little is known about how practices in sedation and in monitoring during gastrointestinal endoscopy and the complication rates of sedation have changed over time. The aim of this nationwide survey was to assess the present practice among Swiss gastroenterologists, with a particular focus on the use of propofol, and to compare the results with similar data obtained in 1990. Patients and Methods: At the end of 2003 a questionnaire (similar to the one used in 1990) was sent to all 249 Swiss gastroenterologists. The response rate was 72.3 %. Data from 179 953 endoscopies performed during the previous 12 months were analyzed for the study. Results: In 2003 sedation was used in 78 % of esophagogastroduodenoscopies and colonoscopies (compared with 60 % in 1990), with midazolam being the most commonly used medication. The drugs were mostly administered by the endoscopy nurse, via an intravenous cannula. Oximetry monitoring was used in more than 95 % of examinations (compared with 2.5 % in 1990). The overall sedation-related morbidity was 0.18 % and the mortality rate was 0.0014 %. Of the 180 respondents, 77 (43 %) reported that they been using propofol regularly for a median time period of 23 months. The 62 respondents (34 %) who used propofol without the assistance of an anesthesiologist had performed a total of 82 620 procedures. The morbidity (defined as the need for bag-ventilation) in this group of patients was 0.19 % and no deaths were reported. Conclusions: The use of sedation in gastrointestinal endoscopy has markedly increased over the last 13 years and the use of electronic monitoring has become standard practice. A significant percentage of Swiss gastroenterologists report that they use propofol, mainly in a hospital setting.

Background: Using gentler endoscopes and improved sedation, great strides have been made in enhancing patients’ comfort and acceptance of endoscopic procedures. Because morbidity and mortality have been associated with benzodiazepines in endoscopic sedation, safer alternatives were sought. Propofol (2,6-diisopropylphenol), a rapid and short-acting anesthetic, initially used in the 1980’s for general anesthesia induction and maintenance, is a promising candidate. Methods: This review article examines experiences and literature references of propofol’s use in endoscopic procedures. Three critical questions are posed: What are the major advantages and potential risks of propofol? When should propofol be used? Who should administer propofol, how should it be administered, and what type of monitoring is required? Results: With considerable inter-patient variability, the propofol dose must be carefully titrated according to the individual patient’s response. Factors influencing dosage include age, ASA class, patient’s height and procedure duration. Propofol’s primary risk is its narrow therapeutic range which necessitates careful patient monitoring. Conclusions: Propofol’s advantages over benzodiazepines and narcotics include a more rapid onset of action, full relief of discomfort and rapid recovery to alertness without residual sedative effects or anterograde amnesia, thereby making this drug a cost-effective and, with proper monitoring, safe choice.

Background: We compared the accuracy and practicability of a new combined ear sensor device measuring pulse oximetry and transcutaneous carbon dioxide tension. Methods: Validation studies were done by comparing the results of the combined sensor with arterial blood gas measurements. In an observational part, monitoring data were obtained from 25 patients undergoing colonoscopy, sedated with midazolam and alfentanil and from 8 patients without sedation. Results: There was an excellent correlation between the oxygen saturation and carbon dioxide tension measurements comparing the combined sensor with arterial blood gas analysis (R 0.96 and 0.93, respectively). A mean rise in transcutaneous carbon dioxide tension of 7.6 mm Hg was detectable during sedation with midazolam/alfentanil and of 2.3 mm Hg without sedation. Conclusion: Combined POX/PcCO2 monitoring at the ear lobe is a novel approach to improve patient safety during sedation and may be helpful in preventing an unintentional slide into a state of deep sedation with impairment of ventilation.

Summary: Aim: To characterize the safety of endoscopic procedures and propofol use as administered by nurses in a cohort of elderly patients.Methods: During 19 months all endoscopy patients > 70 years were eligible for this prospective observational study. Patients were assigned to group A (70–85 years) or group B (> 85 years). Records from all patients < 70 years treated during the same period served as controls. Specially trained nurses administered the propofol and monitored for complications (decrease in the peripheral oxygen saturation, mean arterial pressure or heart rate).Results: There were 1435 endoscopic procedures in group A and 351 in group B. There was no procedure or sedation‐related mortality, nor a significantly greater need for emergency intervention than in the control group. Two patients required short mask ventilation but recovered without sequelae. Compared with younger patients, there was a significant increase in risk for a short oxygen desaturation < 90% and a decrease in oxygen saturation > 5%. Arterial hypotension occurred significantly more often in the control group than among the aged patients.Conclusions: This present study documents that gastrointestinal endoscopic procedures are safe and well tolerated even in the very elderly. Nurse‐administered propofol is a safe and reasonable sedation method in these patients.