Sedation and anesthesia in GI endoscopy

Transcription

1 GUIDELINE Seation an anesthesia in GI enoscopy This is one of a series of statements iscussing the use of GI enoscopy in common clinical situations. The Stanars of Practice Committee of the American Society for Gastrointestinal Enoscopy (ASGE) prepare this text. In preparing this guieline, a search of the meical literature was performe by using MEDLINE an PubMe atabases through May 2008 that relate to the topic of seation an anesthesia for gastrointestinal enoscopy by using the key wor(s) seation, anesthesia, propofol, gastrointestinal enoscopy, enoscopy, enoscopic proceures, an proceures. The search was supplemente by accessing the relate articles feature of PubMe, with articles ientifie on MEDLINE an PubMe as the references. Pertinent stuies publishe in English were reviewe. Aitional references were obtaine from the bibliographies of the ientifie articles an from recommenations of expert consultants. When little or no ata exist from well-esigne prospective trials, emphasis is given to results from large series an reports from recognize experts. Guielines for appropriate use of enoscopy are base on a critical review of the available ata an expert consensus at the time the guielines are rafte. Further controlle clinical stuies may be neee to clarify aspects of this guieline. This guieline may be revise as necessary to account for changes in technology, new ata, or other aspects of clinical practice. The recommenations were base on reviewe stuies an were grae on the strength of the supporting evience (Table 1). This guieline is intene to be an eucational evice to provie information that may assist enoscopists in proviing care to patients. This guieline is not a rule an shoul not be construe as establishing a legal stanar of care or as encouraging, avocating, requiring, or iscouraging any particular treatment. Clinical ecisions in any particular case involve a complex analysis of the patient s conition an available courses of action. Therefore, clinical consierations may lea an enoscopist to take a course of action that varies from these guielines. BACKGROUND Seation may be efine as a rug-inuce epression in the level of consciousness. The purpose of seation an analgesia is to relieve patient anxiety an iscomfort, improve the outcome of the examination, an iminish the patient s memory of the event. Practice guielines have been put forth by the American Society of Anesthesiologists (ASA) Committee for Seation an Analgesia by Non-Anesthesiologists, an approve by the ASGE. 1,2 Four stages of seation have been escribe, ranging from minimal to moerate, eep, an general anesthesia (Table 2). In general, most enoscopic proceures are performe with the patient uner moerate seation, a practice that was formerly referre to as conscious seation. At the level of moerate seation, the patient, while maintaining ventilatory an cariovascular function, is able to make purposeful responses to verbal or tactile stimulation. In contrast, a patient unergoing eep seation cannot be easily arouse but may still respon purposefully to repeate or painful stimulation. Airway support may be require for eep seation. At the level of general anesthesia, the patient is unarousable to painful stimuli, an cariovascular function may be impaire. The level of seation shoul be titrate to achieve a safe, comfortable, an technically successful enoscopic proceure. Knowlege of the pharmacologic profiles of seative agents is necessary to maximize the likelihoo that the esire level of seation is targete accurately. Iniviuals iffer in their response to seation, so patients may require ifferent levels of seation for the same proceure an patients may attain varying levels of seation uring a single proceure. Therefore, practitioners shoul possess the skills necessary to resuscitate or rescue a patient whose level of seation is eeper than initially intene. This statement will evaluate the strength of evience in the meical literature to provie guielines for the use of seation an anesthesia uring GI enoscopic proceures an is an upate of 3 previous ASGE ocuments. 2-4 This Guieline is being republishe ue to the fact that the original publication containe some uplicate material from an article that was originally publishe in Gastroenterology 2007;133: (DOI: ). Copyright ª 2008 by the American Society for Gastrointestinal Enoscopy /$34.00 oi: /j.gie PREPROCEDURE PREPARATION AND ASSESSMENT Patients shoul be informe of an agree to the aministration of seation/analgesia/anesthesia, incluing Volume 68, No. 5 : 2008 GASTROINTESTINAL ENDOSCOPY 815

2 Seation an anesthesia in GI enoscopy TABLE 1. Graes of recommenation Grae of recommenation Clarity of benefit Methoologic strength/supporting evience Implications 1A Clear Ranomize trials without important limitations Strong recommenation; can be applie to most clinical settings 1B Clear Ranomize trials with important limitations (inconsistent results, nonfatal methoologic flaws) 1Cþ Clear Overwhelming evience from observational stuies Strong recommenation; likely to apply to most practice settings Strong recommenation; can apply to most practice settings in most situations 1C Clear Observational stuies Intermeiate-strength recommenation; may change when stronger evience is available 2A Unclear Ranomize trials without important limitations Intermeiate-strength recommenation; best action may iffer epening on circumstances or patients or societal values 2B Unclear Ranomize trials with important limitations (inconsistent results, nonfatal methoologic flaws) Weak recommenation; alternative approaches may be better uner some circumstances 2C Unclear Observational stuies Very weak recommenation; alternative approaches likely to be better uner some circumstances 3 Unclear Expert opinion only Weak recommenation; likely to change as ata become available Aapte from Guyatt G, Sinclair J, Cook D, et al. Moving from evience to action: graing recommenationsa qualitative approach. In: Guyatt G, Rennie D, es. Users guies to the meical literature. Chicago: AMA Press; pp TABLE 2. Levels of seation an anesthesia Minimal seation (anxiolysis) Moerate seation (conscious seation) Deep seation General anesthesia Responsiveness Normal response to verbal stimulation Purposeful response to verbal or tactile stimulation Purposeful response after repeate or painful stimulation Unarousable even with painful stimulus Airway Unaffecte No intervention require Intervention may be require Intervention often require Spontaneous ventilation Cariovascular function Unaffecte Aequate May be inaequate Frequently inaequate Unaffecte Usually maintaine Usually maintaine May be impaire Moifie from Gross JB, Bailey PL, Connis RT, et al. Practice guielines for seation an analgesia by nonanesthesiologists. Anesthesiology 2002;96: iscussion of its benefits, risks, an limitations an possible alternatives. The anticipate level of seation shoul be congruent with the patient s expectation of the seation level whenever possible. There are no absolute guielines as to timing of cessation of oral intake before aministerion of seation because of the absence of supporting ata with regar to a irect relationship between uration of fasting an risk of pulmonary aspiration. The ASA guielines recommen that patients shoul not consume fluis or soli foos for a sufficient perio of time so as to permit aequate gastric emptying. 1 The ASA guielines state that patients shoul fast a minimum of 2 hours after consuming clear liquis an 6 hours after consuming light meals before the aministration of seation. The American College of Emergency Physicians 5 states, recent foo intake is not contrainicate for aministering proceural seation an analgesia, but shoul be consiere in choosing the timing an target of seation. In situations where gastric emptying is impaire or in emergency situations, the potential for pulmonary aspiration of gastric contents must be consiere in etermining 816 GASTROINTESTINAL ENDOSCOPY Volume 68, No. 5 :

3 Seation an anesthesia in GI enoscopy (1) the target level of seation, (2) whether the proceure shoul be elaye, or (3) whether the airway shoul be protecte by enotracheal intubation. All patients unergoing enoscopic proceures require preproceural evaluation to assess the risk of seation an to manage problems relate to preexisting meical conitions. A history an physical examination, with particular emphasis on seation-oriente issues, shoul be performe at the time of enoscopy. The following historic etails shoul be sought: (1) abnormalities of major organ systems; (2) snoring, strior, or sleep apnea; (3) rug allergies, current meications, an potential for rug interactions; (4) prior averse reaction(s) to seatives or anesthetics; (5) time of an type of last oral intake; an (6) tobacco, alcohol, or substance use. 1 The physical examination shoul inclue the following: measurement of vital signs, etermination of baseline level of consciousness, an examination of the heart an lungs an airway anatomy. 1 Table 3 shows the ASA classification use to risk stratify patients for seation. In aition, all women of chilbearing age shoul be querie about the possibility of pregnancy. Pregnancy testing may be consiere in women of chilbearing age unless they have ha a total hysterectomy, bilateral tubal ligation, or absent menses for 1 year (menopause). The preproceure assessment shoul be ocumente an a time out shoul be performe before patients are seate. This inclues verification of patient ientification an confirmation of correct proceure by the proceural team. UNSEDATED ENDOSCOPY Selecte patients may be able to unergo enoscopic proceures without seation. Small-iameter enoscopes (less than 6 mm) can improve the tolerability of upper enoscopy when seation is not use. 6,7 In general, topical anesthesia is use uring unseate enoscopy. Successful colonoscopy may be performe in selecte patients who receive no seation or seation only if neee. 8,9 Oler patients, men, patients who are not anxious, or patients without a history of abominal pain may have better tolerance of upper enoscopy or colonoscopy with little or no seation. For proceures performe without meications, the types of an levels of monitoring shoul be iniviualize. However, preparation shoul be the same as escribe for seation in the event that seation is aministere. TOPICAL ANESTHESIA TABLE 3. ASA classification Class I II III IV V E Description The patient is normal an healthy. The patient has mil systemic isease that oes not limit activities (eg, controlle hypertension or controlle iabetes without systemic sequelae). The patient has moerate or severe systemic isease that oes not limit the activities (eg, stable angina or iabetes with systemic sequelae). The patient has severe systemic isease that is a constant threat to life (eg, severe congestive heart failure, en-stage renal failure). The patient is morbi an is at a substantial risk of eath within 24 hours (with or without a proceure). Emergency status: in aition to inicating the unerlying ASA status (1-5), any patient unergoing an emergency proceure is inicate by suffix E. Topical pharyngeal sprays with liocaine, tetracaine, an benzocaine are often use for anesthetic purposes uring upper enoscopy, particularly when unseate enoscopy is performe. A meta-analysis of pharyngeal anesthesia use in conjunction with intravenous or intramuscular seation was associate with improve ease of enoscopy or improve patient tolerance as juge by the enoscopist uring upper enoscopy. 10 Topical anesthetic agents have been associate with serious averse effects, incluing aspiration, anaphylactoi reactions, an methemoglobinemia. SEDATION AND ANALGESIA AGENTS USED FOR ENDOSCOPY The level of seation require to perform a successful proceure may range from minimal seation to general anesthesia. Patient age, health status, concurrent meications, preproceural anxiety, an pain tolerance influence the level of seation require to achieve the esire result. The proceural variables inclue the egree of invasiveness, the level of proceure-relate iscomfort, the nee for the patient to lie relatively motionless (eg, EUS-FNA) an the uration of examination. Typically, iagnostic an uncomplicate therapeutic upper enoscopy an colonoscopy are successfully performe with moerate seation. Deeper levels of seation may be consiere for longer an more complex proceures, incluing, but not limite to, ERCP an EUS. Aitionally, eep seation or general anesthesia shoul be consiere for patients who have been ifficult to manage with moerate seation an are anticipate to be poorly responsive to seatives. This inclues patients who have ha long-term use of narcotics, benzoiazepines, alcohol, or neuropsychiatric meications. The choice of seative is largely operator epenent an is base on maximizing patient comfort while minimizing risks. The choice of seatives generally consists of benzoiazepines use either alone or in combination Volume 68, No. 5 : 2008 GASTROINTESTINAL ENDOSCOPY 817

4 Seation an anesthesia in GI enoscopy with an opiate. The most commonly use benzoiazepines are miazolam an iazepam. The efficacy of seation with these 2 benzoiazepines is comparable. 11 However, most enoscopists favor miazolam for its fast onset of action, short uration of action, an high amnestic properties. 3 Opiois, such as meperiine an fentanyl aministere intravenously, provie both analgesia an seation. Fentanyl has a more rapi onset of action an clearance an has a lower incience of nausea compare with meperiine. Combinations of benzoiazepine an opioi agents are frequently use for synergism. These pharmacologic profiles of the benzoiazepines an opiois are iscusse in a previously publishe ASGE ocument. 3 Specific antagonists of opiates (naloxone) an benzoiazepines (flumazenil) are available an shoul be present an reaily available in every enoscopy unit. Ajuncts to the benzoiazepine/narcotic combination inclue iphenhyramine, promethazine, an roperiol. These meications potentiate the action of the benzoiazepine/narcotic regimen; thus, a eeper level of seation may result. Droperiol is a neuroleptic agent in the same class as haloperiol with seative effects. Ranomize trials have emonstrate the efficacy of roperiol in patients unergoing therapeutic enoscopy, particularly those who are ifficult to seate The Foo an Drug Aministration (FDA) black box warning for roperiol states that the rug shoul be use only when first-line seative agents fail to provie aequate seation. 16 The use of roperiol is contrainicate in patients with prolongation of the QTc interval (efine as O440 millisecons in men an O450 millisecons in women), an its use shoul be avoie in patients who are at an increase risk for the evelopment of a prolonge QT interval. These risks inclue a history of congestive heart failure, braycaria, iuretic use, cariac hypertrophy, hypokalemia, hypomagnesemia, an use of other rugs that prolong the QT interval. Other risk factors may inclue age more than 65 years, alcohol abuse, an use of agents such as benzoiazepines, volatile anesthetics, an intravenous opiates. 17 Droperiol shoul be initiate at a low ose an ajuste upwar, with caution, as neee to achieve the esire effect. 17 Guielines for the use of roperiol have been publishe in a consensus statement issue by the ASGE (Table 4). 2 Seation uring pregnancy an lactation raises specific issues that are iscusse in a previous ASGE ocument. 18 Guielines for seation an anesthesia in the peiatric population have also been aresse in a previous ASGE ocument. 19 Propofol Propofol (2,6-iisopropyl phenol) is classifie as an ultrashort-acting hypnotic agent that provies seative, amnestic, an hypnotic effects with no analgesic properties. Propofol rapily crosses the bloo-brain barrier an TABLE 4. Guielines for the use of roperiol for enoscopic proceures Use only in select patients with: Inability to achieve an acceptable response or intolerance to stanar seatives Anticipate long proceure Obtain 12-lea ECG before proceure. Droperiol is contrainicate if the QTc is prolonge (O440 millisecons in males, O450 millisecons in females). Patients shoul remain on a cariac monitor uring the proceure an for 2-3 hours afterwar. Use with caution in patients at high risk for evelopment of prolonge QT synrome such as congestive heart failure, braycaria, cariac hypertrophy, hypokalemia/magnesemia, or other rugs known to prolong the QTc interval. Dosage: In aults, the initial ose shoul not excee 2.5 mg. Aitional oses shoul be in 1.25 mg aliquots to achieve the esire patient seation. causes a epression in consciousness that is likely relate to potentiation of the g-aminobutyric aci A receptor in the brain. 20 The rug is highly lipophilic. Two preparations exist. One is prepare as an oil/water emulsion consisting of 1% propofol, 10% soybean oil, 2.25% glycerol, an 1.2% egg lecithin. Therefore, propofol is contrainicate in patients with propofol allergy or hypersensitivity to eggs or soybean. 21 Another preparation has bisulfites; therefore, allergies/reactions to bisulfites also have to be taken into account. It is a pregnancy category B rug an shoul be use with caution uring lactation. Propofol is 98% plasma-protein boun, an it is metabolize primarily in the liver by conjugation to glucuronie an sulfate to prouce water-soluble compouns that are excrete by the kiney. Typically, the time from injection to the onset of seation is 30 to 60 secons. Its uration of effect is 4 to 8 minutes. The pharmacokinetic properties o not significantly change in patients with renal failure or moerately severe chronic liver isease. Dose reuction is require in patients with cariac ysfunction an in the elerly as a result of ecrease clearance of the rug. 22 Propofol potentiates the central nervous system effects of narcotic analgesics an seatives such as benzoiazepines, barbiturates, an roperiol; therefore, the ose requirements of these agents may be reuce. Pain on injection is frequent, occurring in up to 30% of patients receiving an intravenous bolus of propofol. 23 The cariovascular effects of propofol inclue ecreases in cariac output, systemic vascular resistance, an arterial pressure. 24 Negative cariac inotropy an respiratory epression can be seen with the use of propofol. These effects reverse rapily with ose reuction or interruption of rug infusion 25 an rarely require temporary ventilatory 818 GASTROINTESTINAL ENDOSCOPY Volume 68, No. 5 :

5 Seation an anesthesia in GI enoscopy support. There is no reversal agent for propofol. 26,27 Personnel specifically traine in the aministration of propofol with expertise in emergency airway management must be present uring use of this agent, an the patient s physiologic parameters must be continuously monitore (Table 5). Details of preproceure assessment, intraproceural monitoring an ocumentation, an postproceure recovery of patients unergoing seation with propofol are iscusse in a previously publishe ASGE training guieline. 4 Recently, a water-soluble prorug of propofol (fospropofol soium) has been evelope, 28 although it is not yet FDA approve. The prorug is activate to propofol after removal of the water-soluble moiety by enothelial alkaline phosphatase. Preliminary stuies suggest that it is relatively safe an effective for seation uring colonoscopy. 29 Aitional anesthetic agents that have been use for enoscopic proceures inclue ketamine, exmeetomiine, an inhalational agents. TABLE 5. Recommenations for propofol use uring enoscopy A seation team with appropriate eucation an training. At least 1 person who is qualifie in avance life support skills (ie, airway management, efibrillation an the use of resuscitative meications). Traine personnel eicate to the uninterrupte monitoring of the patient s clinical an physiologic parameters throughout the proceure Physiologic monitoring must inclue pulse oximetry, electrocariography, an intermittent bloo pressure measurement. Monitoring oxygenation by pulse oximetry is not a substitute for monitoring ventilatory function. Capnography shoul be consiere because it may ecrease the risks uring eep seation. Continuous monitoring will allow recognition of patients who have progresse to a eeper level of seation. Personnel shoul have the ability to rescue a patient who becomes unresponsive or unable to protect his or her airway or who loses spontaneous respiratory or cariovascular function. Age-appropriate equipment for airway management an resuscitation must be immeiately available. A physician shoul be present throughout propofol seation an remain immeiately available until the patient meets ischarge criteria. Who is qualifie to give propofol? The use of propofol for enoscopic seation has increase markely uring the past 10 years. Twenty-five percent of responents to one U.S. survey inicate that propofol is use for seation uring routine enoscopic proceures. 30 However, only 7.7% of these responents aminister propofol without an anesthesiologist or a nurse anesthetist. The use of propofol varies consierably from one region of the country to another, epening on a variety of factors such as reimbursement by insurance carriers for anesthesia services, institutional an state policies, an variations in practice patterns. 30 Propofol aministere by enoscopists or enoscopy nurses is more prevalent in other countries. 31 Sixty-eight percent of U.S. enoscopists using conventional seation inicate that they woul like to aminister propofol but are reluctant to o so because of a wiesprea perception of increase complication risks. 30 Aitionally, some enoscopists are either unwilling or unable to aminister propofol themselves because of local institutional policy, state regulatory restrictions, or concern for the meicolegal implications of off-label use of propofol. 32 These concerns are at least partly ue to the current FDA-approve prouct label, which states that propofol shoul be aministere only by iniviuals traine in the aministration of general anesthesia. 33 Nonanesthesiologist-aministere propofol for GI proceures is terme gastroenterologist-irecte propofol (GD-P). FDA-approve prouct labels can be use as evience in court in a case relate to the off-label use of GD- P in cases involving averse outcomes. 16 However, U.S. courts an jurisictions iffer on whether the label alone establishes the stanar of care in iniviual cases. At this time, ata an expert eitorial opinions have accrue supporting the use of GD-P, incluing enorsement by gastroenterology specialty societal guielines. U.S. courts an jurisictions may or may not consier this this mass of opinions an guielines supporting GD-P to be meicolegally reasonable or a respectable minority practice. The narrow therapeutic winow of propofol that istinguishes it from conventional seative hypnotics use for enoscopy increases the risk for cariopulmonary complications if it is not aministere appropriately. Hence, specific training in the aministration of propofol an patient monitoring uring use of this agent are require. The appropriate personnel an equipment for propofol aministration are liste in Table 5. The ASA Task Force recommens that patients receiving propofol shoul receive care consistent with eep seation an that those personnel shoul be capable of rescuing the patient from general anesthesia. 11 However, there is abunant evience that propofol can be aministere safely by nonanesthesiologists. Because there are ata to support the safety of GD-P an the ability to safely use propofol at levels aequate to achieve moerate seation when GD-P is performe, the restricte use of propofol to anesthesiologists has been questione. 16 The ASGE, the American Gastroenterological Association, an the American College of Gastroenterology support the use of GD-P. In a joint statement, the 3 societies enorse physician-supervise nurse aministration of propofol when aequate training for its use has been achieve Volume 68, No. 5 : 2008 GASTROINTESTINAL ENDOSCOPY 819

6 Seation an anesthesia in GI enoscopy GD-P GD-P inclues propofol aministere irectly by gastroenterologists, aministere by registere nurses uner the irection of gastroenterologists (NAPS), an patientcontrolle systems (PCS). NAPS involves aministration of propofol an patient monitoring by a traine registere nurse who has no other responsibilities to patient care. 16 NAPS osing protocols vary. 5,35,36 Initial bolus oses of propofol of 10 to 60 mg are typically aministere; aitional bolus oses are aministere after a minimum interval of 20 to 30 secons between oses. 16 The amount of osing an epth of seation are titrate as appropriate for the proceural goals. It is important to note that propofol oes not possess analgesic properties so that, if it is aministere as the sole agent, eep seation may be require to keep the patient comfortable. 16 Propofol may be use as the sole seation agent or in combination with other seative-hypnotics (multirug propofol seation). When using a multirug protocol with propofol, the clinician may be able to exploit the therapeutic actions of the iniviual agents while reucing the possibility of seation ose-relate complications. As mentione above, when propofol is use alone for seation, higher oses are typically require to achieve aequate seation, which results in a level of eep seation. Thus, ose-relate propofol effects incluing hypotension, respiratory epression, or braycaria are more likely to occur. 37 These averse effects can be minimize through the use of combination propofol because analgesia an amnesia can be achieve with the other agents an resultant lower oses of propofol. Subsequently, moerate seation is more likely to be achieve. 38,39 Precise titration of propofol is possible when lower bolus oses of propofol are use. In aition, the ability to reverse the concomitantly aministere opio an benzoiazepine meications can be maintaine with naloxone an flumazenil, respectively. 16,25,40 Although combination propofol may theoretically ecrease the rapi recovery benefit seen with propofol alone, this has not been borne out in clinical practice. 39 In a ranomize controlle trial of propofol alone titrate to eep seation compare with 3 ifferent regimens of balance propofol seation titrate to moerate seation in subjects unergoing elective colonoscopy, the balance regimens were associate with a significantly shorter recovery times than was propofol alone. Target-controlle seation involves a pharmacokinetically base moel with an infusion system that may or may not be computer controlle. The system then ajusts the meication to the esire plasma concentration or physiologic parameters. An open loop system ajusts to a target rug concentration. A close loop system uses feeback from a real-time measure of rug effect an esire level of seation. This may involve either TABLE 6. Avantages an isavantages of propofol for seation Avantages Rapi onset Favorable pharmacoynamics Mil antiemetic properties Potentially more effective Rapi termination of effect Expeite recovery Disavantages o o o Potency Potential to inuce general anesthesia Potential to cause hemoynamic an respiratory epression No pharmacologic antagonist patient or physician-controlle aministration of the meications. PCS with propofol has been reporte in several ranomize trials. Kulling et al 41 ranomize 150 patients to 3 seation arms: PCS with propofol/alfentanil (group I), continuous propofol/alfentanil infusion (group II), an nurse-aministere miazolam/meperiine (group III). Group I exhibite a high egree of patient satisfaction an more complete recovery at 45 minutes compare with conventional seation an analgesia. In a similar stuy, Ng et al 42 ranomize 88 patients unergoing colonoscopy to PCS with propofol alone or miazolam alone. Patients receiving propofol PCS exhibite significantly shorter mean recovery times (43 minutes vs 61 minutes) an improve comfort. PCS for ERCP, however, has not been successful. In a pilot stuy of a software system esigne to eliver a ceiling for the plasma propofol concentration, only 80% of patients receive safe an fully effective seation. 43 Propofol efficacy/safety for enoscopic seation Stuies have emonstrate an avantage of seation with propofol for enoscopy over seation with an opioi/benzoiazephine combination for several important outcomes, although there are some isavantages to its use 16 (Table 6). Data o support that propofol aministration is superior to other agents with regar to recovery time an physician satisfaction. 16,44 Aitionally, at ischarge, propofol-seate patients have better scores on psychomotor testing, reflective of greater learning, memory, an mental spee. 38 Similarly propofol use provies similar 45,46 or higher levels of patient satisfaction However, a benefit in this regar over traitional 820 GASTROINTESTINAL ENDOSCOPY Volume 68, No. 5 :

7 Seation an anesthesia in GI enoscopy benzoiazepine/narcotic combinations has not been uniformly emonstrate. 40 Stuies have shown a high level of safety for propofol monotherapy an combination therapy that compares favorably with conventional seative agents. However, none of the trials are aequately powere to emonstrate superior safety of propofol compare with traitional seative regimens. A meta-analysis of 12 ranomize controlle trials totaling 1162 patients compare the relative safety of GD-P an benzoiazepine/opioi seation. 52 The risk of seation complications with stuy en points of hypoxemia an hypotension were similar for all proceures except colonoscopy, where the risk was lower with propofol. When the 2002 ASA Practice Guielines for Seation an Analgesia by Non-Anesthesiologists was publishe, it was unclear whether propofol aministere moerate or eep seation was associate with a more averse outcomes than when similar levels of seation with other agents was achieve. 1 Since that publication, more than 500,000 subjects have receive propofol for enoscopic seation. 38,47,49-56 From these ata, the use of propofol in appropriate patients with traine personnel is associate with an excellent safety profile. Transient hypoxia occurs in 3% to 7% of cases an transient hypotension in 4% to 7%. Time to recovery range between 14 an 18 minutes. In a retrospective review of NAPS in several centers an involving greater than 36,000 enoscopies, the rate of clinical averse events, efine as apnea or airway compromise that require assiste ventilation (bag-mask), range from 0.1% to 0.2%. 37 No patients require enotracheal intubation, an none ha permanent injury or eath. There have been other publishe series showing similar results. 16,35,54,57 In a recent abstract by Deenaayalu et al, 56,57 a worlwie multicenter safety review of more than 521,000 patients was conucte. Mask ventilation rates were 0.4:1000 patients for upper enoscopy an 0.1:1000 patients for colonoscopy. Enotracheal intubations, neurologic injuries, an eath occurre in 4, 1, an 3 patients, respectively. The 3 eaths occurre in patients with significant comorbi illnesses such as wiely metastatic malignancy an polysubstance abuse. Propofol use for complex GI proceures Propofol may have clinically significant avantages compare with conventional seative-hypnotic agents when use for prolonge or complex therapeutic proceures where eep seation is the targete level of seation. Two ranomize controlle trials with 80 an 198 patients, respectively, compare propofol alone with miazolam alone for ERCP. 55,56 Improve patient cooperation an a significantly shorter onset of effective seation an reuctions in proceure an recovery room times were seen in the propofol group. No ifference in patient assessment of seation quality was seen. Two patients in the propofol group ha prolonge apnea that necessitate iscontinuation of the proceure an temporary ventilatory support. Important limitations of these stuies inclue the lack of concomitant opiate aministration in the nonpropofol seation regimen an absence of enoscopist blining. Vargo et al 46 conucte a ranomize controlle trial comparing GD-P with meperiine/miazolam for elective ERCP an EUS in 75 patients. In this stuy, a gastroenterologist eicate to aministration an monitoring aministere propofol while using capnography to etect apnea or hypercapnea. Patients ranomize to propofol exhibite a faster inuction time an a shorter mean recovery time (19 vs 71 minutes), coul perform inepenent transfer after the proceure, an were able to achieve a return to baseline foo intake an activity level more quickly. A recent stuy emonstrate the safety of propofol when aministere to high-risk elerly patients unergoing ERCP. One hunre fifty high-risk (ASA class RIII) octogenarians were ranomize to receive propofol or combine miazolam an meperiine. 58 The propofol group was more cooperative, but the proceure tolerability was similar. The mean recovery time was shorter with fewer hypoxic episoes in the propofol group. In these stuies, untowar effects such as hypotension an hypoxemia occurre equally. Therefore, for complex proceures propofol appears to be at least comparable in efficacy an safety to conventional seation. INTRAPROCEDURAL MONITORING Monitoring may etect changes in pulse, bloo pressure, ventilatory status, cariac electrical activity, an clinical an neurologic status before clinically significant events occur. For both moerate an eep seation, the level of consciousness must be perioically assesse in aition to ocumentation of heart rate, bloo pressure, respiratory rate, an oxygen saturation. These physiologic parameters shoul be assesse an recore at a frequency that epens on the type an amount of meication aministere, the length of the proceure, an the general conition of the patient. At a minimum, this shoul be (1) before the proceure is begun, (2) after aministration of seative-analgesic agents, (3) at regular intervals uring the proceure, (4) uring initial recovery, an (5) just before ischarge. If recoring is performe automatically, evice alarms shoul be set to alert the care team to critical changes in patient status. 1 Equipment an meications for emergent resuscitation shoul be immeiately available when seation an analgesia are being aministere. An iniviual other than the physician performing the enoscopy who unerstans the stages of seation, has the ability to monitor an interpret the patient s physiologic parameters, an possesses the skills to initiate appropriate intervention in the event of an averse seation event shoul monitor the patient throughout the Volume 68, No. 5 : 2008 GASTROINTESTINAL ENDOSCOPY 821

8 Seation an anesthesia in GI enoscopy proceure. 16 This person must be certifie in basic or avance cariac life support. If moerate seation is achieve, this person assigne may also perform tasks of short uration that may be interrupte. If eep seation is unertaken, this iniviual shoul have no proceurerelate responsibilities other than observation an monitoring of the patient. 16 When eep seation is aministere, at least one other person in the room shoul have avance cariac life support certification, be able to provie a secure airway, an be able to provie bag ventilation. 1,5,16 Monitoring techniques The ASA guielines recommen continuous electrocariogram (ECG) monitoring of patients with significant cariovascular isease or arrhythmia uring moerate seation. 1 Other patients who may benefit from ECG monitoring inclue those with a history of significant pulmonary isease, elerly patients, an those in whom prolonge proceures are anticipate. The necessity of ECG monitoring in healthy patients is unclear. In aition, all patients receiving intravenous seation shoul be monitore with noninvasive bloo pressure evices. Oximetry effectively etects oxygen esaturation an hypoxemia in patients unergoing seation an analgesia. 59 Measurement of oxygen saturation is relatively insensitive to the earliest signs of hypoventilation because significant changes in arterial partial pressure of oxygen may occur with little alteration in oxygen saturation. This is particularly true for those iniviuals receiving supplemental oxygen. Therefore, monitoring of ventilatory function must also inclue patient observation or auscultation throughout the proceure. Risk factors for hypoxemia inclue a baseline oxygen saturation of less than 95%, an emergency inication for the enoscopic proceure, a proceure of long uration, ifficulty with esophageal intubation, an the presence of comorbi illness. 60 Despite the lack of ata linking pulse oximetry to a reuction in complications, both the ASA an ASGE recommen that pulse oximetry be use uring all enoscopic proceures. 1,3 The routine aministration of supplemental oxygen has been shown to reuce the magnitue of oxygen esaturation uring enoscopic proceures. The ASA Task Force recommens that supplemental oxygen shoul be consiere for moerate seation an shoul be aministere uring eep seation unless specifically contrainicate for a particular patient or proceure. Furthermore, if hypoxemia is anticipate or evelops uring seation/analgesia, supplemental oxygen shoul be aministere. 1 However, one stuy suggeste that routine oxygen supplementation results in a higher rate of cariopulmonary unplanne events relate to conscious seation. 61 Capnography is a noninvasive approach to measure respiratory activity that is base on the principle that carbon ioxie absorbs light in the infrare region of the electromagnetic spectrum. Quantification of the absorption leas to the generation of a curve that represents a real-time isplay of the patient s respiratory activity. It more reaily etects hypoventilation compare with pulse oximetry or visual observation an thereby provies an opportunity for early recognition of epresse respiratory activity. Capnography can be achieve through the use of en-tial carbon ioxie monitoring. Given that hypoxemia resulting from epresse respiratory activity is a principal risk factor for averse respiratory events uring seation, integrating capnography into patient monitoring protocols may improve safety. 62 Currently, there is insufficient evience to support its use uring routine upper an lower enoscopic seation. 47,63,64 Data are available, however, to support its use uring ERCP an EUS. A recent ranomize controlle trial using the combination of an opioi an benzoiazepine for elective ERCP an EUS foun significantly less hypoxemia in the subjects who receive seation with capnography compare with stanar monitoring. 65 The ASA recommens carbon ioxie monitoring, stating capnography shoul be consiere for all patients receiving eep seation an for patients whose ventilation cannot be observe irectly uring moerate seation. 1 Bispectral (BIS) inex monitoring is an electroencephalographic (EEG)-base metho of assessing a patient s level of consciousness by using a complex algorithm to generate a weighte inex. 66 In 2 stuies 67,68 BIS monitoring values exhibite a significant lag time compare with the clinical assessment of the level of seation. Aitionally, titration with BIS was not associate with any improvement in clinical outcomes, such as recovery times, or any reuction in propofol ose. In aition, the new BIS algorithm was not foun to be useful for seation with benzoiazepine/ opioi seation. Other EEG-base systems use to guie propofol aministration uring ERCP resulte in improve patient tolerance, shorter recovery time, an fewer hemoynamic sie effects. 69,70 The use of EEG monitoring may have a role in the future for elivery of seation uring selecte enoscopic proceures. Computer-assiste personalize seation (CAPS) uses multiple physiologic feeback parameters, incluing electrocariography, capnography, an automate response monitoring, which perioically assess patient response to otic an vibratory stimuli. CAPS has been use in 24 patients unergoing ambulatory upper enoscopy an colonoscopy. 71 Oxygen esaturation occurre in only 6% of subjects to whom minimal to moerate seation was elivere. No evice-relate averse events occurre. A small case series emonstrates the feasibility of CAPS an may provie enoscopists an alternative safe an effective means to eliver propofol without the assistance of an anesthesiologist. Recently, the results of a multicenter ranomize controlle trial that compare CAPS with the combination of an opioi an benzoiazepine in 1000 patients unergoing ambulatory upper enoscopy an colonoscopy was presente. CAPS was superior to stanar seation in terms of a significantly shorter uration an less severity of hypoxemia an recovery parameters. 822 GASTROINTESTINAL ENDOSCOPY Volume 68, No. 5 :

9 Seation an anesthesia in GI enoscopy Patient satisfaction was high in both groups. CAPS is not yet FDA approve. After completion of enoscopic proceures, patients are to be observe for averse effects from either instrumentation or seation. Stanarize ischarge criteria shoul be use to assess recovery from seation. Postproceure monitoring has been iscusse in a previously publishe ASGE guieline. 3 ANESTHESIOLOGIST ASSISTANCE FOR ENDOSCOPIC PROCEDURES Seation-relate risk factors, the epth of seation, an the urgency an type of enoscopic proceure play important roles in etermining whether the assistance of an anesthesiologist is neee. Patient risk factors inclue significant meical conitions such as extremes of age; severe pulmonary, cariac, renal, or hepatic isease; pregnancy; the abuse of rugs or alcohol; uncooperative patients; a potentially ifficult airway for positive-pressure ventilation; an iniviuals with anatomy that is associate with more ifficult intubation. The ASA Task Force states that airway management may be ifficult in patients with the following situations: (1) previous problems with anesthesia or seation, (2) a history of strior, snoring, or sleep apnea, (3) ysmorphic facial features, such as Pierre-Robin synrome or trisomy 21, (4) oral abnormalities, such as a small opening (!3 cm in an ault), eentulous, protruing incisors, loose or cappe teeth, high arche palate, macroglossia, tonsillar hypertrophy, or a nonvisible uvula, (5) neck abnormalities, such as obesity involving the neck an facial structures, short neck, limite neck extension, ecrease hyoi-mental istance (!3 cm in an ault), neck mass, cervical spine isease or trauma, tracheal eviation, or avance rheumatoi arthritis, an (6) jaw abnormalities such as micrognathia, retrognathia, trismus, or significant malocclusion. 11 The ASA Task Force guielines states that the presence of one or more seation-relate risk factors couple with the potential for eep seation will increase the likelihoo of averse seation-relate events. If the practitioner confronte with these situations is not traine in managing these complex patients, consultation with an anesthesiologist to provie seation shoul be consiere (Table 7). 11 ECONOMICS OF GI ENDOSCOPY Gastroenterologists in the Unite States have routinely seate patients as a part of the enoscopic service. In recent years, a greater number of enoscopists use anesthesiologists or nurse anesthetists to provie seation. Numerous factors are riving this transition, incluing increasing use of propofol, efforts to offset falling reimbursements, an effective marketing by anesthesiologists. 72 The routine assistance of an anesthesiologist for TABLE 7. Guieline for anesthesiology assistance uring GI enoscopy Anesthesiologist assistance may be consiere in the following situations: Prolonge or therapeutic enoscopic proceures requiring eep seation Anticipate intolerance to stanar seatives Increase risk for complication because of severe comorbiity (ASA greater than class III) Increase risk for airway obstruction because of anatomic variant average-risk patients unergoing stanar upper an lower enoscopic proceures is cost prohibitive. In fact, some health carriers may not reimburse for anesthesia assistance uring routine enoscopy. RECOMMENDATIONS Refer to Table 1 for recommenation graes. 1. Aequate an safe seation can be achieve in most patients unergoing routine esophagogastrouoenoscopy an colonoscopy by using an intravenous benzoiazepine an opioi combination (1B). 2. In patients who are not aequately seate with an intravenous benzoiazepine an opioi combination, the aition of other intravenous agents such as roperiol, promethiazine, or iphenhyramine (Benaryl) may allow aequate an safe seation to be achieve (1B). 3. Seation proviers must have a thorough unerstaning of meications use for enoscopic seation an the skills necessary for the iagnosis an treatment of cariopulmonary complications (3). 4. Noninvasive bloo measurement an pulse oximetry are supplemental toan o not replaceclinical observation of the patient uring enoscopic seation. Newer methos of monitoring are available but ata to assess their impact on clinical outcomes is lacking, an their routine use for seation must be iniviualize (2B). 5. During moerate seation, the person assigne responsibility for patient assessment may also perform tasks that are interruptible an of short uration. When eep seation is planne, this iniviual shoul be eicate to observation an monitoring an have no other proceure-relate responsibilities (3). 6. Extene monitoring techniques may provie sensitive measures of patient s ventilatory function (capnography) an level of seation (BIS inex monitoring); however, there is insufficient evience in the literature to support the routine use of extene monitoring evices uring moerate seation. The ASA states that Volume 68, No. 5 : 2008 GASTROINTESTINAL ENDOSCOPY 823

10 Seation an anesthesia in GI enoscopy automate monitoring for apnea (capnography) shoul be consiere for patients receiving eep seation an for all patients in whom ventilatory function cannot be observe aequately (1B). 7. Propofol has the avantages of more rapi onset of action an shorter recovery time compare with traitional seative regimens. However, clinically important benefits in average-risk patients unergoing upper enoscopy an colonoscopy have not been consistently emonstrate with regar to patient satisfaction an safety. Therefore, the routine use of propofol in average-risk patients cannot be enorse (1B). 8. Propofol can be safely an effectively given by nonanesthesiology physicians an nurses provie they have unergone appropriate training an creentialing in aministration an rescue from potential pulmonary an cariovascular complications (1C). 9. A patient targete for one level of seation may become more eeply seate than planne. Therefore, an iniviual aministering seation/analgesia shoul be traine to an possess the skills necessary to rescue a patient who has reache a level of seation eeper than that intene. Thus, a physician targeting moerate seation must be able to rescue a patient who is eeply seate. Similarly, an ability to rescue a patient from general anesthesia is necessary when proviing eep seation (3). 10. The assistance of an anesthesia specialist shoul be consiere for ASA physical status III, IV, an V patients. Other possible inications for involvement of an anesthesia professional uring seation inclue emergency enoscopic proceures, complex enoscopic proceures, an patients with a history of (1) averse reaction to seation, (2) inaequate response to moerate seation, (3) anticipate intolerance of stanar seatives (eg, alcohol or substance abuse), an (4) those at increase risk for seation-relate complications, such as patients with severe comorbiities or with anatomic variants preictive of increase risk for airway obstruction or ifficult intubation (eg, morbi obesity or sleep apnea) (3). 11. An anesthesia specialist is not cost-effective for average-risk patients unergoing routine upper an lower enoscopic proceures (3). Abbreviations: ASA, American Society of Anesthesiologists; ASGE, American Society for Gastrointestinal Enoscopy; BIS, bispectral inex; CAPS, computer-assiste personalize seation; ECG, electrocariogram; EEG, electroencephalogram; FDA, Foo an Drug Aministration; GD-P, gastroenterologist-irecte propofol; NAPS, propofol aministere by registere nurses uner the irection of gastroenterologists; PCS, patient-controlle seation. REFERENCES 1. Practice guielines for seation an analgesia by non-anesthesiologists. Anesthesiology 2002;96: Faigel DO, Baron TH, Golstein JL, et al. Stanars Practice Committee, American Society for Gastrointestinal Enoscopy: guielines for the use of eep seation an anesthesia for GI enoscopy. Gastrointest Enosc 2002;56: Waring JP, Baron TH, Hirota WK, et al. Guielines for conscious seation an monitoring uring gastrointestinal enoscopy. Gastrointest Enosc 2003;58: Chutkan R, Cohen J, Abei M, et al. Training guieline for use of propofol in gastrointestinal enoscopy. Gastrointest Enosc 2004;60: Gowin SA, Caro DA, Wolf SJ, et al. Clinical policy: proceural seation an analgesia in the emergency epartment. Ann Emerg Me 2005;45: Horiuchi A, Nakayama Y. Unseate ultrathin EGD by using a 5.2-mm iameter vieoscope: evaluation of acceptability an iagnostic accuracy. Gastrointest Enosc 2006;64: Nelson DB, Block KP, Bosco JJ, et al. Technology status evaluation report: ultrathin enoscopes esophagogastrouoenoscopy. Gastrointest Enosc 2000;51: Rex DK, Imperiale TF, Portish V. Patients willing to try colonoscopy without seation: associate clinical factors an results of a ranomize controlle trial. Gastrointest Enosc 1999;49: Leung FW, Mann SK, Salera R, et al. Options for screening colonoscopy without seation: sequel to a pilot stuy in U.S. veterans. Gastrointest Enosc 2008;67: Evans LT, Saberi S, Kim HM, et al. Pharyngeal anesthesia uring seate EGDs: is the spray beneficial? A meta-analysis an systematic review. Gastrointest Enosc 2006;63: Zakko SF, Seifert HA, Gross JB. A comparison of miazolam an iazepam for conscious seation uring colonoscopy in a prospective ouble-blin stuy. Gastrointest Enosc 1999;49: Wille RT, Barnett JL, Chey WD, et al. Routine roperiol pre-meication improves seation for ERCP. Gastrointest Enosc 2000;52: Cohen J, Haber GB, Dorais JA, et al. A ranomize, ouble-blin stuy of the use of roperiol for conscious seation uring therapeutic enoscopy in ifficult to seate patients. Gastrointest Enosc 2000;51: Faigel DO, Metz DC, Kochman ML. Torsae e pointes complicating the treatment of bleeing esophageal varices: association with neuroleptics, vasopressin, an electrolyte imbalance. Am J Gastroenterol 1995;90: Yimcharoen P, Fogel EL, Kovacs RJ, et al. Droperiol, when use for seation uring ERCP, may prolong the QT interval. Gastrointest Enosc 2006;63: Cohen LB, Delegge MH, Aisenberg J, et al. AGA Institute review of enoscopic seation. Gastroenterology 2007;133: Foo an Drug Aministration Web site. Available at: gov/mewatch/safety/2001/inapsine.htm. Accesse August 24, Qureshi WA, Rajan E, Aler DG, et al. ASGE guieline: guielines for enoscopy in pregnant an lactating women. Gastrointest Enosc 2005;61: Lee KK, Anerson MA, Baron TH, et al. Stanars of Practice Committee, American Society for Gastrointestinal Enoscopy: Moifications in enoscopic practice for peiatric patients. Gastrointest Enosc 2008; 67: Trapani G, Altomare C, Liso G, et al. Propofol in anesthesia: mechanism of action, structure-activity relationships, an rug elivery. Curr Me Chem 2007;7: Chutkan R, Cohen J, Abei M, et al. Training guieline for use of propofol in gastrointestinal enoscopy. Gastrointest Enosc 2004;60: Morcos WE, Payne JP. The inuction of anaesthesia with propofol (Diprivan) compare in normal an renal failure patients. Postgra Me J 1985;61(3 Suppl): Stark RD, Binks SM, Dutka VN, et al. A review of the safety an tolerance of propofol (Diprivan). Postgra Me J 1985;61(3 Suppl): GASTROINTESTINAL ENDOSCOPY Volume 68, No. 5 :

11 Seation an anesthesia in GI enoscopy 24. White PF. Propofol pharmacokinetics an pharmacoynamics. Semin Anesth 1988;7: Short TG, Plummer JL, Chui PT. Hypnotic an anaesthetic interactions between miazolam, propofol an alfentanil. Br J Anaesth 1992;69: Nelson DB, Barkun AN, Block KP, et al. American Society for Gastrointestinal Enoscopy Technology Committee: propofol use uring gastrointestinal enoscopy. Gastrointest Enosc 2001;53: Kimmey MB, Al-Kawas FH, Gannan RM, et al. Technology assessment status evaluation: monitoring equipment for enoscopy: American Society for Gastrointestinal Enoscopy. Gastrointest Enosc 1995;42: Vargo JJ, Bramley T, Meyer K, et al. Practice efficiency an economics: the case for rapi recovery seation agents for colonoscopy in a screening population. J Clin Gastroenterol 2007;416: Cohen LB. Clinical trial: a ose-response stuy of fospropofol isoium for moerate seation uring colonoscopy. Aliment Pharmacol Ther 2008;27: Cohen LB, Wecsler JS, Gaetano JN, et al. Enoscopic seation in the Unite States: results from a nationwie survey. Am J Gastroenterol 2006;101: Heuss L, Froehlich F, Beglinger C. Changing pattern of seation an monitoring practice uring enoscopy: results of a nationwie survey in Switzerlan. Enoscopy 2005;37: Aisenberg J, Cohen LB, Piorkowski JD. Propofol use uner the irection of traine gastroenterologists: an analysis of the meicolegal implications. Am J Gastroenterol 2007;101: American Society of Anesthesiology. Statement on safe use of propofol October 27, Available at: publications AnServices/stanars/37.pf. Accesse March 5, Joint statement of a working group from the American College of Gastroenterology (ACG), the American Gastroenterological Association (AGA), an the American Society for Gastrointestinal Enoscopy (ASGE): recommenations on the aministration of seation for the performance of enoscopic proceures. Available at: org/wmspage.cfm?parm1z371. Accesse March 5, Rex DK, Overley C, Kinser K, et al. Safety of propofol aministere by registere nurses with gastroenterologist supervision in 2000 enoscopic cases. Am J Gastroenterol 2002;97: Heuss LT, Schnieper P, Drewe J, et al. Risk stratification an safe aministration of propofol by registere nurses supervise by the gastroenterologist: a prospective observational stuy of more than 2000 cases. Gastrointest Enosc 2003;57: Rex DK, Heuss LT, Walker JA, Qi R. Traine registere nurses/enoscopy teams can aminister propofol safely for enoscopy. Gastroenterology 2005;129: Cohen LB, Hightower CD, Woo DA, et al. Moerate level seation uring enoscopy: a prospective stuy using low-ose propofol, meperiine/fentanyl, an miazolam. Gastrointest Enosc 2004;59: VanNatta ME, Rex DK. Propofol alone titrate to eep seation versus propofol in combination with opiois an/or benzoiazepines an titrate to moerate seation for colonoscopy. Am J Gastroenterol 2006;101: Kern SE, Xie G, White JL, et al. A response surface analysis of propofol remifentanil pharmacoynamic interaction in volunteers. Anesthesiology 2004;100: Kulling D, Fantin AC, Biro P, et al. Safer colonoscopy with patient controlle analgesia an seation with propofol an alfentanil. Gastrointest Enosc 2001;54: Ng JM, Kong CF, Nyam D. Patient-controlle seation with propofol for colonoscopy. Gastrointest Enosc 2001;54: Gillham MJ, Hutchinson RC, Carter R, et al. Patient-maintaine seation for ERCP with a target-controlle infusion of propofol: a pilot stuy. Gastrointest Enosc 2001;54: McQuai KR, Laine L. A systematic review an meta-analysis of ranomize, controlle trials of moerate seation for routine enoscopic proceures. Gastrointest Enosc 2008;67: Ulmer BJ, Hansen JJ, Overley CA, et al. Propofol versus miazolam/fentanyl for outpatient colonoscopy: aministration by nurses supervise by enoscopists. Clin Gastroenterol Hepatol 2003;1: Vargo JJ, Zuccaro G, Dumot JA, et al. Gastroenterologist-aministere propofol versus meperiine an miazolam for avance upper enoscopy: a prospective, ranomize trial. Gastroenterology 2002;123: Koshy G, Nair S, Norkus EP, et al. Propofol versus miazolam an meperiine for conscious seation in GI enoscopy. Am J Gastroenterol 2000;95: Sipe BW, Rex DL, Latinovich D, et al. Propofol versus miazolam/meperiine for outpatient colonoscopy aministration by nurses supervise by enoscopists. Gastrointest Enosc 2002;55: Paspatis GA, Manolaraki M, Xirouchakis G, et al. Synergistic seation with miazolam an propofol versus miazolam an pethiine in colonoscopies: a prospective, ranomize stuy. Am J Gastroenterol 2002;97: Reimann FM, Samson U, Dera I, et al. Synergistic seation with low ose miazolam an propofol for colonoscopies. Enoscopy 2000; 32: Toha G, Higashi S, Wakahara S, et al. Propofol seation uring enoscopic proceures: safe an effective aministration by registere nurses supervise by enoscopists. Enoscopy 2006;38: Qaeer MA, Vargo JJ, Khanwala F, et al. Propofol versus traitional seative agents for gastrointestinal enoscopy: a meta-analysis. Clin Gastroenterol Hepatol 2005;3: Kulling D, Orlani M, Inauren W. Propofol seation uring enoscopic proceures: how much staff an monitoring are necessary? Gastrointest Enosc 2007;66: Jung M, Hofmann C, Kiesslich R, et al. Improve seation in iagnostic an therapeutic ERCP: propofol is an alternative to miazolam. Enoscopy 2000;32: Wehrmann T, Kokabpick S, Lembcke B, et al. Efficacy an safety of intravenous propofol seation uring routine ERCP: a prospective, controlle stuy. Gastrointest Enosc 1999;49: Walker, McIntyre RRD, Schleinitz PF, et al. Nurse-aministere propofol seation without anesthesia specialists in 9152 enoscopic cases in an ambulatory surgery center. Am J Gastroenterol 2003;98: Deenaayalu VP, Ei EF, Goff JS, et al. Non-anesthesiologist aministere propofol seation for enoscopic proceures: a worlwie safety review [abstract]. Gastrointest Enosc 2008;67:AB Riphaus A, Stergiou N, Wehrmann T. Seation with propofol for routine ERCP in high-risk octogenarians: a ranomize, controlle stuy. Am J Gastroenterol 2005;100: Council on Scientific Affairs American Meical Association. The use of pulse oximetery uring conscious seation. JAMA 1993;270: Griffin SM, Chung SCS, Leung JWC, et al. Effect of intranasal oxygen on hypoxia an tachycaria uring enoscopic cholangiopancreatography. BMJ 1990;300: Sharma VK, Nguyen CC, Crowell MD, et al. A national stuy of cariopulmonary unplanne events after GI enoscopy. Gastrointest Enosc 2007;66: Lightale JR, Golmann DA, Felman HA, et al. Microstream capnography improves patient monitoring uring moerate seation: a ranomize, controlle trial. Peiatrics 2006;117: Nelson DB, Freeman ML, Silvis SE, et al. A ranomize, controlle trial of transcutaneous carbon ioxie monitoring uring ERCP. Gastrointest Enosc 2000;51: Vargo JJ, Zuccaro G, Dumot JA, et al. Automate graphic assessment of respiratory activity is superior to pulse oximetry an visual assessment for the etection of early respiratory epression uring therapeutic upper enoscopy. Gastrointest Enosc 2002;55: Qaeer MA, Vargo JJ, Dumot JA, et al. Capnography prevents hypoxemia uring ERCP an EUS: a ranomize controlle trial [abstract]. Gastrointest Enosc 2008;67:AB Drover DR, Lemmens HJ, Pierce ET, et al. Patient State Inex: titration of elivery an recovery from propofol, alfentanil, an nitrous oxie anesthesia. Anesthesiology 2002;97: Volume 68, No. 5 : 2008 GASTROINTESTINAL ENDOSCOPY 825

12 Seation an anesthesia in GI enoscopy 67. Drake LM, Chen SC, Rex DK. Efficacy of bispectral monitoring as an ajunct to nurse-aministere propofol seation for colonoscopy: a ranomize controlle trial. Am J Gastroenterol 2006;101: Chen SC, Rex DK. An initial investigation of bispectral inex monitoring as an ajunct to nurse-aministere propofol seation for colonoscopy. Am J Gastroenterol 2004;99: Krugliak P, Ziff B, Rusabrov Y, et al. Propofol versus miazolam for conscious seation guie by processe EEG uring enoscopic retrograe cholangiopancreatography: a prospective, ranomize, oubleblin stuy. Enoscopy 2000;32: Wehrmann T, Grotkamp J, Stergiou N, et al. Electroencephalogram monitoring facilitates seation with propofol for routine ERCP: a ranomize, controlle trial. Gastrointest Enosc 2002;56: Pambianco DJ, Whitten CJ, Moerman A, et al. An assessment of computer-assiste personalize seation: a seation elivery system to aminister propofol for gastrointestinal enoscopy. Gastrointest Enosc 2008;68: Aisenberg J, Brill JV, Laabaum U, et al. Seation for gastrointestinal enoscopy: new practices, new economics. Am J Gastroenterol 2005;100: Prepare by: STANDARDS OF PRACTICE COMMITTEE Davi R. Lichtenstein, MD Sanjay Jagannath, MD To H. Baron, MD, Chair Michelle A. Anerson, MD Subhas Banerjee, MD Jason A. Dominitz, MD, MHS Robert D. Fanelli, MD, SAGES Representative S. Ian Gan, MD M. Ewyn Harrison, MD Steven O. Ikenberry, MD Bo Shen, MD Leslie Stewart, SGNA Representative Khali Khan, MD, NAPSGHAN Representative John J. Vargo, MD, MPH This ocument is a prouct of the Stanars of Practice Committee. This ocument was reviewe an approve by the Governing Boar of the American Society for Gastrointestinal Enoscopy. This ocument was reviewe an enorse by the Society of American Gastrointestinal an Enoscopic Surgeons Guielines Committee an Boar of Governors. 826 GASTROINTESTINAL ENDOSCOPY Volume 68, No. 5 :