How many personnel and how much monitoring are really necessary for nonanesthesiologist administration of propofol for gastrointestinal endoscopy?

We would like to congratulate the European Society of Gastrointestinal Endoscopy (ESGE), the European Society of Gastroenterology and Endoscopy Nurses and Associates (ESGENA), and the European Society of Anesthesiology (ESA) for the joint effort to formulate and endorse a guideline for the nonanesthesiologist administration of propofol (NAAP) for gastrointestinal endoscopy [1]. During the past few years NAAP has become the standard of practice in most gastrointestinal endoscopy units in Switzerland. We read the current European guideline with great interest and were surprised by the recommendations given, and particularly their evidence levels and recommendation grades stated, concerning personnel and monitoring in sections 6.2.1. and 6.2.2., respectively, of the paper.

Most initial studies concerning NAAP were performed using several staff members in the endoscopy suite and multiple monitoring devices until it became evident that NAAP was at least as safe as traditional sedation with benzodiazepines and opioids. It is not justified to transform the “methods section” of these early publications into a current guideline requiring a dedicated person whose only task is to administer propofol and to monitor the patient regardless of the type of endoscopic procedure. There has never been a controlled study showing that a third staff member in the endoscopy room makes NAAP any safer. Therefore it is not justified to state evidence level 1++ and recommendation grade A for the requirement of an additional person who has propofol administration and monitoring as his/her sole task. Actually, as the European guideline admits in section 6.2.1., this recommendation is mostly based on “expert opinion” reflecting evidence level 4 with recommendation grade D, only.

During simple endoscopic procedures, including esophagogastroduodenoscopy (EGD) and colonoscopy, NAAP can be performed with moderate sedation. Actually, the 2008 guideline of the American Society for Gastrointestinal Endoscopy (ASGE) concerning sedation in gastrointestinal endoscopy [2] and the ASGE 2010 standards of practice communication concerning minimum staffing requirements for endoscopist-directed sedation [3], state that for patients receiving moderate sedation the assistant who administers the sedatives and monitors the patient may also perform minor, interruptible tasks (e. g. biopsy or polypectomy) once the patient's level of sedation and vital signs are stable. Only if deep sedation is undertaken or more intensive or prolonged endoscopic interventions are performed, should a second nurse assist in the procedure.

Furthermore, as the guideline by Dumonceau et al. correctly states in section 6.2.2., the utility of blood pressure monitoring during NAAP has not been studied. Therefore, it is not justified to state evidence level 2++ with recommendation grade B for its use.

A large cohort study, including 27 061 EGD and colonoscopy procedures with the primary focus on staff and monitoring requirement, demonstrated that propofol sedation was safe when administered by an endoscopy team consisting of one physician endoscopist and one endoscopy nurse, without additional personnel or monitoring other than pulse oximetry [4]. This and some other studies [5] [6] suggest that NAAP is safe for selected procedures and patients without the presence of a dedicated person (evidence level 2+). Accordingly, NAAP in this manner is performed each year during many thousands of procedures in most Swiss endoscopy suites at private gastroenterology practices as well as at hospitals.

We are certain that the authors of the European NAAP guideline acknowledge our suggestions and request that the evidence levels and recommendation grades concerning staffing and blood pressure monitoring have to be adjusted in the updated online version of the guideline and its next printed publication.

References

• 1 Dumonceau J M, Riphaus A, Aparicio J R et al. European Society of Gastrointestinal Endoscopy, European Society of Gastroenterology and Endoscopy Nurses and Associates, and the European Society of Anesthesiology guideline: non-anesthesiologist administration of propofol for GI endoscopy.  Endoscopy. 2010;  42 960-974
• 2 Lichtenstein D R, Jagannath S, Baron T H et al. ASGE Standards of Practice Committee. Sedation and anesthesia in GI endoscopy.  Gastrointest Endosc. 2008;  68 815-826
• 3 Jain R, Ikenberry S O, Anderson M A et al. ASGE Standards of Practice Committee. Minimum staffing requirements for the performance of GI endoscopy.  Gastrointest Endosc. 2010;  72 469-470
• 4 Külling D, Orlandi M, Inauen W. Propofol sedation during endoscopic procedures: how much staff and monitoring are necessary?.  Gastrointest Endosc. 2007;  66 443-449
• 5 Cohen L B, Dubovsky A N, Aisenberg J, Miller K M. Propofol for endoscopic sedation: a protocol for safe and effective administration by the gastroenterologist.  Gastrointest Endosc. 2003;  58 725-732
• 6 Yusoff I F, Raymond G, Sahai A V. Endoscopist administered propofol for upper-GI EUS is safe and effective: a prospective study in 500 patients.  Gastrointest Endosc. 2004;  60 356-360