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

Abstract

Background and study aims: The use of sedation (e. g., of short-acting propofol) for gastrointestinal endoscopy has shown an upward trend in the USA and Europe over the last decade. To improve patient’s safety different nationwide guidelines have been developed. This survey aimed at providing nationwide re-evaluated data 3 years after the implementation of consent- and evidence-based national guideline on sedation for gastrointestinal endoscopy.

Methods: A 24-item survey regarding current practices of endoscopy, sedation and monitoring in gastrointestinal endoscopy was sent to 4 405 members of the German Society of Digestive and Metabolic Diseases (DGVS).

Results: A total of 741/4405 (17 %) questionnaires were returned. Compared to 2007 we documented a further increase of the use of sedation during the performance of esophagogastro-duodenoscopies (EGDs) (82 vs. 74 % in 2007) and colonoscopies (91 vs. 87 % in 2007), accompanied with an increased rate of using propofol as a sedative agent in 97 vs. 74 % of the cases in 2007. In contrast the use of midazolam substantially decreased to 69 % versus 82 % in 2007. Most commonly used sedation regimens are still propofol ± benzodiazepines (43 vs. 38 % in 2007), while a combination of midazolam ± opioid decreased to 15 % versus 35 % in 2007. Unchanged to data from 2007, patients were routinely monitored by pulse oximetry (99 %). Routine use of an automated blood pressure monitoring increased to 40 % (versus 29 % in 2007) and the use of electrocardiography monitoring nearly doubled to 24 vs. 13 % in 2007. Supplemental oxygen is nowadays routinely administered in 64 % compared to 34 % of the cases in 2007. Regarding the administration of sedation we observed a profound increase of nurse-administered propofol sedation (NAPS; 73 % in 2011, 39 % in 2007) with a decrease of endoscopist-directed propofol sedation (29 % in 2011 vs. 59 % in 2007). However, monitored anaesthesia care was still only rarely used in Germany (2 %).

Conclusion: After the implementation of the first national sedation guideline the use of propofol has become the most popular sedation regime in Germany, mainly administered as NAPS by trained nurses as a standard procedure. Automated blood pressure measurements and ECG recording were more often implemented in the monitoring practice and also the routine use of supplemental oxygen has been clearly improved.

Zusammenfassung

Einleitung: Der Einsatz von Sedierung (z. B. dem kurz wirksamen Propofol) für die gastrointestinale Endoskopie zeigt steigende Tendenz für die USA und Europa im letzten Jahrzehnt. Zur Verbesserung der Patientensicherheit wurden daher verschiedenen nationale Leitlinien entwickelt. Ziel der aktuellen Umfrage war die Re-Evaluation der 2007 erstmalig erhobenen Daten zur Sedierung und Monitoring in Deutschland 3 Jahre nach Implementierung der ersten evidenz- und konsensbasierten nationalen Leitlinie zur Sedierung in der gastrointestinalen Endoskopie.

Methodik: Es wurde ein 24 Punkte enthaltener Fragebogen an die 4405 Mitglieder der Deutschen Gesellschaft für Verdauungs- und Stoffwechselerkrankungen gesendet (DGVS).

Ergebnisse: Insgesamt wurden 741/4405 Fragebogen zurückgesandt (17 %). Die Befragten führten im Mittel 27 Gastroskopien (ÖGD) und 26 Koloskopien pro Woche durch. Es zeigt sich ein weiterer Anstieg der Sedierungsfrequenz sowohl bei den ÖGDs (82 vs. 74 % in 2007) als auch bei den Koloskopien (91 vs. 87 % in 2007) im Vergleich zu 2007. Dies war mit einem weiteren Anstieg der Sedierung mittels Propofol auf 97 % im Vergleich zu 74 % in 2007 vergesellschaftet. Dagegen ist die Verwendung von Midazolam mit 69 % im Vergleich zu 82 % in 2007 zurückgegangen. Am häufigsten verwendeten Sedierungsregime unverändert: Propofol ± Benzodiazepine (43 vs. 38 % in 2007), während die Kombination aus Midazolam ± Opioid auf 15 % sank (versus 35 % in 2007). Unverändert zu 2007 war der routinemäßige Einsatz Pulsoximetrie in 99 %. Die Verwendung der automatisierten Blutdruckmessung stieg auf 40 % (versus 29 % in 2007), die Verwendung der Elektrokardiografie (EKG) verdoppelte sich auf 24 % (versus 13 % in 2007). Die routinemäßige Sauerstoffgabe wurde mit 64 % im Vergleich zu 34 % in 2007 nahezu verdoppelt. Die Verabreichung der Propofol-Sedierung zeigte einen klaren Trend zur Gabe durch Assistenzpersonal (sog. nurse-administered-propofol-sedation; NAPS: 73 % in 2011 vs. 39 % in 2007), deutlicher Abfall der Sedierungsfrequenz durch Endoskopiker (29 % in 2011 vs. 59 % in 2007) und weiterhin selten durch Anästhesisten (2 %).

Diskussion: Drei Jahre nach Implementierung der ersten nationalen Leitlinie zur Sedierung in der gastrointestinalen Endoskopie zählt die Verwendung von Propofol zum beliebtesten Sedierungregime in Deutschland, hauptsächlich verabreicht durch entsprechend ausgebildetes Assistenzpersonal. Die automatisierte Blutdruckmessung und EKG-Monitoring wurden deutlich gesteiger, die routinemäßige Verwendung von Sauerstoff verbessert.

Schlüsselwörter

Sedierung in der gastrointestinalen Endoskopie - nationale Umfrage - Propofol-Midazolam - nurse-administered-propofol-sedation

Key words

endoscopic sedation - nationwide survey - propofol-midazolam - non-anaesthesiologist propofol sedation

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