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Non-Anesthesiologist Administered Propofol Sedation for Endoscopic Procedures: a Worldwide Safety Review
Viju P Deenadayalu¹, Emely F Eid¹, John S Goff², John A Walker³, Lawrence B Cohen⁴, Ludwig T Heuss⁵, Shajan Peter⁵, Christoph Beglinger⁵, James Sinnott⁶, Patrick D Gerstenberger⁷, Anthony C Clarke⁸, Harold Munnings⁹, Magdy Z Rofail¹⁰, Iyad M Subei¹¹, Rodger A Sleven¹², Akira Horiuchi¹³, Kuldip Sandhu¹⁴, Paul A Jordan¹⁵, Douglas K Rex¹
1. Department of Medicine, Indiana University Medical Center, Indianapolis, IN, USA, 2. Rocky Mountain Gastroenterology Associates, Lakewood, CO, USA, 3. Gastroenterology Consultants, P.C., Medford, OR, USA, 4. Department of Medicine, Mt. Sinai Medical Center, New York, NY, USA, 5. Department of Gastroenterology, University Hospital of Basel, Basel, Switzerland, 6. Valdosta Medical Clinic, Valdosta, GA, USA, 7. Digestive Health Associates, P.C., Durango, CO, USA, 8. Mugga Wara and Bridabella Endoscopy Centres, Garran, ACT, Australia, 9. The Centre for Digestive Health, Nassau, Bahamas, 10. Reid Outpatient Surgery Center, Richmond, IN, USA, 11. Jeddah Center for Liver and Digestive Diseases, Erfan & Badego General Hospital, Jeddah, Saudi Arabia, 12. West Hills Gastroenterology Associates, P.C., Portland, OR, USA, 13. Department of Gastroenterology, Showa Inan General Hospital, Komagene, Japan, 14. Capitol Gastroenterology Consultants Medical Group, Inc, Carmichael, CA, USA, 15. WK/University Hospital Gastroenterology, Bossier City, LA, USA

Background: Propofol administration for endoscopic procedures by anesthesia specialists is costly. Non-anesthesiologist administered propofol sedation (NAP) is rapidly evolving but is controversial due to concerns about safety, mainly respiratory depression. Our goal was to determine the overall number of endotracheal intubations, neurologic injuries, and deaths and mask ventilations associated with NAP for endoscopic procedures. Methods: We reviewed all published abstracts and papers utilizing NAP for endoscopic procedures. To the best of our knowledge, we also contacted all gastroenterologists performing NAP for endoscopy to participate in our safety review. All contacted gastroenterologists submitted their updated data on safety. To perform our literature search, we queried Ovid Medline (1966-August 2007). The following complications were available in all patients: endotracheal intubations, neurologic injuries, and death. We also investigated whether mask ventilation was more frequent with EGDs versus colonoscopies, when available. Results: A total of 456,918 (213,527 published and 243,391 unpublished) NAP procedures were collected in our database. Endotracheal intubations, neurologic injuries, and deaths were 4, 1, and 3, respectively (data available for all patients). The deaths occurred in a patient with widely metastatic pancreatic cancer, a severely handicapped patient with mental retardation, and a patient with an extensive history of polysubstance abuse. In 2 of the 3 deaths, a decision to withdraw life support was made by the families of the patients. The overall number of cases requiring mask ventilation was 322 out of 400,769 cases with data available. Mask ventilation rates were compared between EGDs and colonoscopies for studies and sites specifying risk by procedure type. Fifty of 123,768 patients and 11 of 97,429 patients required mask ventilation during their EGD or colonoscopy, respectively (p<0.001; chi-square test). In the remaining 261 patients requiring mask ventilation, the type of endoscopic procedure performed was unclear. Conclusions: The administration of propofol by non-anesthesiologists for endoscopic procedures is safe. Mask ventilation was required more frequently with EGDs compared to colonoscopies. NAP is one feasible solution to the high costs associated with anesthesiologist-delivered sedation for endoscopy.