Sedation for Gastrointestinal Endoscopy Clinical Practice

720 Guidelines

Moderate or superficial sedation: A drug- induced depression of conscience during Sedation for gastrointestinal which patients respond correctly to verbal endoscopy commands and mild tactile stimulation. No intervention is necessary to maintain Clinical practice guidelines of the airway permeability, and spontaneous spanish society of digestive endoscopy ventilation is adequate. Cardiovascular functioning is usually preserved. Deep sedation: A drug-induced depression F. Igea, J. A. Casellas, F. González-Huix, C. Gómez-Oliva, J. S. Baudet, G. Cacho, of conscience during which patients can- M. A. Simón, E. De la Morena, A. Lucendo, F. Vida not be easily awakened but respond to repeated or painful stimuli. The ability to Coordinator: Leopoldo López-Rosés maintain ventilation independently may On behalf of the Spanish Society of Digestive Endoscopy (SEED) be impaired. Patients may need help to keep their airway permeable, and spontaneous ventilation may be inadequate. Car- Introduction dence-based recommendations in accord- diovascular function is usually preserved. ! ance with the SIGN classification at the General anesthesia: This involves a drug- Sedation for gastrointestinal endoscopic end [2]. Each intial darft was reviewed by induced loss of conscience in which pa- procedures has become indispensable, all authors, and corrections deemed rele- tients do not respond to stimuli. The abil- hence sedation is now a mandatory re- vant were incorporated in order to pro- ity to maintain ventilation independently quirement to be offered to all patients be- vide a definitive edition. The notion be- is often impaired. Patients usually require fore an endoscopic exam following the hind the development of these guidelines help to keep their airway permeable, and discussion of its benefits, risks, draw- was to obtain a concise, clear text with positive-pressure ventilation may be backs, and alternative options. Patient se- scientific rigor and readily applicable to needed when spontaneous breathing or dation pursues a dual purpose – on the clinical practice. neuromuscular function is depressed. one hand the achievement of a good per- Cardiovascular function may become im- ceived quality by suppressing pain; on paired [4]. the other hand an avoidance of untimely Sedation goals. Sedation levels Dosis titration and pharmacological varia- movements that may compromise effica- ! bility: A well-known, key principle in se- cy and safety. In the past twenty years a The goals of sedation and analgesia in- dative administration is that drugs must huge amount of papers were published clude decreasing anxiety, relieving dis- be administered in escalated doses – ef- showing that properly trained non-anes- comfort and pain, and reducing the mem- fects being assessed at each step – until thetist doctors and nurses may effectively, ory of endoscopic procedures [3, 4]. Seda- the desired action is achieved. While cer- safely, and efficiently take responsibility tion levels should be adjusted to each in- tain patient characteristics may help pre- for the administration of sedatives and dividual’s needs and each procedure to dict the required dose for adequate seda- painkillers, as well as patient monitoring ensure safety, comfort, and technical suc- tion (e.g., age, comorbidity, body mass, during endoscopy. Also, major scientific cess. race, response to prior sedation or concur- societies involved in gastrointestinal en- Sedation levels entail a continuum of rent use of oral narcotics or benzodiaze- doscopy have published guidelines with states ranging from minimal sedation pines), the precise dose that will be need- recommendations in this respect. The So- or anxiolysis to general anesthesia ed for any given patient is impossible to ciedad Española de Endoscopia Digestiva (●" Table 1): foretell with accuracy. This is due to the (SEED) is no exception and published in Minimal sedation or anxiolysis: A drug-in- fact that response to sedatives in individ- 2006 their sedation guidelines, which induced state during which patients re- ual patients is variable. For instance, blood cluded all major indications, contraindi- spond normally to verbal commands. drug levels may show up to five-fold dif- cations, drug classes, and other related to- While cognition and coordination may ferences in age-matched patients receiv-

pics [1]. Presently, the SEED Board of Di- have functional alterations, ventilation ing identical doses. Also, even if blood This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. rectors has decided to update these guide- and cardiovascular functioning are usual- drug levels are similar, the perceived ex- lines by publishing a new version with re- ly preserved. periences of patients may differ a lot [3]. vised major aspects and the addition of recent findings.

Table 1 Sedation levels. Modified from the American Society of Anesthesiologists (ASA).

Guidelines development approach Sedation level Minimal seda- Moderate Deep sedation General anesthesia ! tion (anxiolysis) sedation Cooperation was requested from a num- Responsiveness Normal Verbal or tac- Repeated pain- Unresponsive to ber of endoscopists experienced and in- tile stimuli ful stimuli painful stimuli terested in sedation at various hospitals Airway Normal No interven- Intervention Intervention usually throughout Spain. Following the develop- tion requiredr may be required required ment of a table of contents, each one of Spontaneous Normal Adequate May be inade- Usually inadequate them drafted a chapter based on an upda- ventilation quate Cardiovascular Normal Normal Usually main- May be impaired ted literature revision, including evi- function tained

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regarding monitorization instrument Table 2 Indications for sedation/analgesia. operation, data interpretation, and lim- Type of procedure Sedation level itations. Rigid and flexible sigmoidoscopy; Sedation not considered routinely required (moderate or 3. Prior assessment of patient risks: seda- rectal endosonography superficial sedation optional for anxious patients when tion-specific history taking. ASA anes- pain is anticipated and during therapeutic procedures) thesia risk classification. Mallampati Diagnostic, non-complex gastroscopy Moderate sedation required scale. Recognizing situations where the and colonoscopy presence of an anesthesiologist is advi- Complex or prolonged procedures Deep sedation required sable during sedation. such as ERCP or EUS) 4. Knowledge of drugs used for sedation: Modified from Overview of Endoscopic Sedation, SGNA Position Statement pharmacological and pharmacody- namic characteristics, administration regimens, dosage, synergies, interac- For a given exploration type required se- fication for basic life support. Endoscopy tions, and side effects. Drug prepara- dation levels may vary from one patient units where sedation is applied must tion and administration mode (boluses, to the next. In addition, one patient may have at least one person certified in ad- infusion pumps). require different sedation levels within a vanced cardiopulmonary resuscitation 5. Understanding of sedation levels and given procedure. For instance, a patient techniques. Theoretical and practical se- related assessment scales. undergoing colonoscopy may experience dation skills for endoscopy should be in- 6. Recognition and management of com- more pain and require more sedation at cluded in the specialty curriculum. plications. Airway management. certain points during an examination. In Multiple clinical practice guidelines are 7. Sedation during pregnancy and lacta- prolonged or complex procedures, or un- available that include sedation recom- tion. der other circumstances, deep sedation mendations for digestive endoscopy, but 8. Patient transfer to the recovery area. or even anesthesia may be required. How- it was not until the last decade that sever- Post-sedation monitoring. Unit dis- ever, basic, routine endoscopic gastroin- al European and US societies eventually charge criteria. Subsequent recom- testinal procedures may be performed established specific rules regarding seda- mendations. with moderate sedation [5] (●" Table 2). tion training [11,12] 9. Knowledge of clinical practice guide- Different studies have shown that in basic The Sociedad Española de Endoscopia Di- lines and recommendations by scienti- endoscopic procedures superficial seda- gestiva has been offering training courses fic societies. tion is adequate, whereas deep sedation on deep sedation for endoscopists for four 10. Legal aspects of sedation. achieves better outcomes for longer, years now. These courses allowed a wide- Practical training: Practical skills should more complex exams [6– 10]. Finally, the spread use of sedation, mainly using pro- be acquired in certified units and must in- staff responsible for sedation must always pofol, in endoscopy units. clude the following: be ready and able to rescue patients pro- General rules for sedation to be met by all 1. Pre-sedation history taking and risk gressing to sedation levels deeper than in- endoscopy unit staff members: assessment. tended. 1. Understanding the minimal sedation 2. Indication and administration of all equipment that needs to be available in drugs necessary for each procedure at Recommendations an endoscopy unit. the appropriate dosage to achieve the ▶ Sedation level and drug type depend on 2. Having a unit-specific sedation protocol desired sedation level. procedure characteristics, individual according to recommendations in clini- 3. Patient and vital sign monitoring dur- patient-related factors, patient prefer- cal practice guidelines. ing sedation. ences, and need for patient cooperation 3. Understanding the characteristics of 4. Implementing appropriate corrective (evidence level 4, recommendation drugs to be used for sedation. maneuvers for desaturation or any grade D). 4. Recognizing the various sedation levels other events that may arise. ▶ For non-complex diagnostic or thera- and possessing skills to rescue patients 5. Patient monitoring in the recovery peutic gastroscopy and colonoscopy anytime from a deeper-than-intended room and discharge time scheduling

superficial sedation suffices (evidence level. using the various assessment scales This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. level 1+, recommendation grade A). 5. Having the necessary skills for airway available. ▶ For complex or prolonged procedures management and certification on basic In Spain both basic and advanced life sup- (ERCP, EUS, etc.) deep sedation is to be life support, to be renewed every three port certificates should be officially recog- preferred (evidence level 1+, recom- years. nized by one of the scientific societies and mendation grade A ). Sedation training for endoscopists must health care institutions included in the include both theoretical and practical Consejo Español de Reanimación Cardio- education [13,14]. Pulmonar (CERCP) – intensive medicine Skills required to perform sedation Theoretical contents must include the fol- (SEMYCIUC), cardiology (SEC), anesthesia during gastrointestinal endoscopy. lowing: (SEDAR) and emergency medicine General rules for sedation. 1. Required documentation: sedation- (SEMES). Sedation training for endoscopists specific informed consent; medical re- ! cord; sedation record; databases. All scientific societies agree that specific 2. Materials and means necessary in an training is required for practitioners in- endoscopy unit: examination room, volved in sedation, as well as official certi- preparation and recovery room. Skills

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Recommendations: tive and analgesic effects are less predict- ▶ All endoscopy team members involved able than with other opiates. Naloxone. Opioid antagonist. When used in sedation must be certified in both together with benzodiazepines and opi- theoretical and practical sedation tech- Fentanyl: Analgesic potency is much high- ates, and the patient develops respiratory niques (evidence level 4, recommenda- er than meperidine’s, and its pharmaco- depression, naloxone should be adminis- tion grade D). dynamic profile is better because of a tered first because of its greater effect on shorter half-life. It may induce respiratory depression, which persists longer than Naloxone analgesia. It fits the duration of endo- Traditional sedation ▶ Initial dose: 0.1 –0.2mg scopic procedures as 20 –25min after (benzodiazepines and opiates). ▶ Additional doses: 0.2mg at 2–3min dosing most patients show stabilized vital Drugs. Dosage. Antagonists ▶ Onset of action: 1 –2min ! signs and may be discharged. In addition ▶ Peak effect: 5 min This has been the commonest form of se- to respiratory depression high doses may ▶ Duration of effect: 30 –45min dation for gastrointestinal endoscopy result in bradycardia and hipotension, when performed by non-anesthetist doc- which should be borne in mind. While respiratory depression. tors. Drugs may be administered alone or meperidine was the most commonly in combination, and as intravenous bolu- used opiate among endoscopists in the Recommendations ses (see boxes). Usually, the goal of tradi- past, it is now being gradually replaced ▶ When benzodiazepines are used mida- tional sedation is the achievement of su- by fentanyl [18,19]. zolam is recommended (evidence level perficial sedation. Its use is particularly 2++, recommendation grade B). ▶ suited for basic diagnostic techniques, pri- Fentanyl Moderate sedation using currently marily gastroscopy and colonoscopy [15]. available drugs for routine endoscopic ▶ Initial dose: 50– 100 mcg In elderly patients or individuals with re- procedures (colonoscopies and gastro- ▶ Additional doses: 25 mcg every nal, liver or respiratory failure caution and scopies) is highly satisfactory for pa- 2– 5min until desired effect1 reduced doses are advised [16]. tients and physicians alike given their ▶ Onset of action: 1 –2min Benzodiazepines: Both midazolam and low risk for adverse events (evidence ▶ Peak effect: 3 –5min diazepam may be considered. Midazolam level: 1–, recommendation grade: A). ▶ Duration of effect: 30 –60min has a rapid onset and a short duration of ▶ If a patient has respiratory depression action, and provides useful though vari- during sedation with benzodiazepines able amnestic effects. Because of this it is Antagonists: They counteract the effects and/or opiates and does not respond to now the benzodiazepine of choice [16, of benzodiazepines and opiates in pa- stimulation or oxygen ventilation, the 17]. It has minimal cardiovascular effects. tients with oversedation not reversed fol- administration of antagonists for said lowing appropriate ventilation and stimu- drugs is recommended (evidence level – Midazolam lation. Its routine use to speed up recov- 2 , recommendation grade D). ery after endoscopy is not recommended ▶ Time to recovery following routine ▶ Initial dose: 1–2mg [16]. Their half-life is shorter than that of endoscopy is shorter when fentanyl ▶ Additional doses: 0.5–1mgevery antagonized compounds, hence reseda- rather than meperidine is used 2min tion is possible. (evidence level 1, recommendation ▶ Onset of action: 1 –2min grade B) ▶ Peak effect: 3 –4min Flumazenil. A benzodiazepine antagonist. ▶ Duration of effect: 15 –80min It should not be administered to patients with seizures on benzodiazepines or high Sedation with propofol. Dosage Opiates: Meperidine and fentanyl are intracranial pressure. and mode of administration most commonly used. Caution is advisa- ! – ble when given to patients receiving other Flumazenil Propofol (2 6-diisopropylphenol) is a central nervous system depressants, and drug structurally unrelated to other seda- ▶ Initial dose: 0.2 mg in 30 sec administration should be avoided in indi- tives and with pharmacokinetic charac- This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. ▶ Additional doses: up to four 0.2-mg viduals on monoamine oxidase inhibitors. teristics that, in many respects, make it doses may be given at 60-sec inter- an ideal drug for gastrointestinal endos- vals (max. dose 1mg) Meperidine: Meperidine has a wide mar- copy. Its main features include a rapid on- ▶ Onset of action: 1 –2min gin of safety; however, nausea is more set of action (30– 40 seconds) and short ▶ Peak effect: 3 min common wghen compared to fentanyl, half-life (4– 5 minutes). This fast action is ▶ Duration of effect: variable, and metabolites accumulate particularly based on its formulation’s high liposolubi- 10 –120min in patients with renal disease. Both seda- lity. Also, its antiemetic properties and ab- Meperidine sence of many undesirable effects that are common with other drugs allow a really ▶ Initial dose: 25– 50mg fast, pleasing awakening and provide pa- ▶ Additional doses: 25mg every tients with outstanding perceived com- 5– 10min as needed. fort. Its safety profile when used by ▶ Onset of action: 5 min endoscopists or trained nurses has been ▶ Peak effect: 6 –7min 1 Caution with repeated doses because of risk for consistently demonstrated in clinical ▶ Duration of effect: 60 –180min plasma redistribution trials, showing a rate of complications

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equal to or lower than traditional sedation modynamic effects [23, 24]. This is parti- has shown any benefits versus sedation [20,21]. In contrast, its main drawback is a cularly useful for weakened patients, with propofol administered by the same very narrow therapeutic window that most particularly with heart disease and staff aiding in the procedure [27, 28]. Ex- renders precise dose titration mandatory. impaired ejection fraction. It may also be ploration characteristics and patient risks Furthermore, its pharmacokinetics is in- appropriate for younger patients or drug must be considered when making such a fluenced by multiple factors – drugs, to- addicts with foreseeable higher propofol decision (●" Fig.1). Non-invasive, non- bacco, alcohol, age, obesity, and other cir- requirements. complex diagnostic exams in ASA I-III cumstances may influence patient re- Contraindications: Propofol is contraindi- patients with no risk factors may be effec- sponse to propofol. From the above, indi- cated in patients allergic to propofol and tively and safely performed in the absence vidualized dosing is key, with titration ac- in patients with a low ejection fraction or of dedicated sedation staff, with no cording to observed clinical response. In at risk for bronchoaspiration. The pres- increase in the number of people inside addition, as this drug may bring about sig- ence of soy and egg components in the the room. In complex therapeutic proce- nificant hemodynamic changes, its use is emulsion initially advised against its use dures and/or examinations in advanced advised under close supervision by train- in patients with allergy to these foods. ASA (>III) individuals or subjects at risk ed healthcare personnel and using ade- However, there is now evidence that pro- regarding sedation (short neck, sleep ap- quate surveillance with at least arterial pofol may be safely used in subjects with nea, severe decompensated chronic con- ●" O2 saturation, heart rate, respiratory rate, egg allergy provided they never devel- ditions, etc.) ( Table 3) sedation-related and blood pressure monitoring [15]. oped anaphylaxis [25]. It is nevertheless adverse events are more common, hence Administration modes depend on the ex- prudent to assess such cases on an indi- the presence of an additional qualified amination’s duration and complexity, and vidual basis and consider the use of alter- practitioner responsible for sedation is on the unit’s staff. Overall, it is recom- native medications. Special care should be highly advisable. Help from an anesthe- mended that sedation be induced with re- used with ASA IV patients, where the tist, intensivist or qualified nurse is repeated boluses every 20– 30 seconds for presence of an anesthetist or other op- commended in such cases [29]. short, non-complex explorations (mainly tions should be considered. Required qualifications: The staff per- diagnostic gastroscopy). The initial bolus forming sedation and the members of the depends on patient characteristics, Recommendations endoscopy unit where propofol is used weight, and age – in a young, healthy ASA ▶ Propofol is an ideal drug to provide se- must have knowledge, experience and I patient sedation may be induced with a dation for endoscopic examinations training regarding this drug, as previously 40– 60-mg bolus, whereas lower initial (evidence level 1 +, recommendation discussed. The whole staff must be quali- doses (10 –20mg) are recommended for grade A). fied for basic life support, and at least one elderly, weak subjects; successive doses ▶ The use of propofol by endoscopists or member should be certified in advanced of 10 –20mg will then be administered trained nurses is as safe as traditional life support; otherwise, an anesthesiolo- until the patients spontaneously closes sedatives when monitoring is adequate gist or intensivist should be available his or her eyes with absent response to (evidence level 1 ++, recommendation within five minutes. verbal stimuli. With this induction assi- grade A ) Roles of staff responsible for sedation: tional doses are usually not needed for a ▶ The use of propofol by endoscopy staff These include the design and manage- short diagnostic exam. For longer explora- in ASA III patients is feasible and safe in ment of the whole sedative administra- tions (colonoscopy, therapeutic gastro- experienced endoscopy units (evidence tion process. Depending on the type of ex- scopy) a staff member should be present level 3, recommendation grade D). ploration to be performed and on patient to administer booster doses or perhaps ▶ Propofol dosing must be tailored ac- characteristics, the following should be propofol using an infusion pump.Infusion cording to patient response and base- assessed: 1) sedation level necessary, 2) rate varies from 2 to 8mg/kg/hr depend- line status (evidence level 1++, recom- induction and maintenance doses, 3) ad- ing on individual response and examina- mendation grade A). ministration mode, 4) maintenance and tion-related discomfort. A formula to es- ▶ Midazolam administration before pro- patient monitoring using the relevant timate infusion rate based on response pofol allows to reduce dosage and ad- scales (●" Table 4) [17,30], 5) control of ac- to initial induction has been recently re- verse effects, particularly hypotension tivity or breathing movements (with the ported [22]. Using a syringe pump deep in cardiac patients or in hypovolemia, aid of capnography, bispectral index or This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. sedation is induced at a constant rate of but recovery is delayed (evidence level narcotrend when available) [31]. 200mL/hour (150 –100mL/hour for 1+, recommendation grade B). Preparing propofol for IV administration weak or elderly patients) for 1% propofol requires special care as this is a lipophilic (10mg/mL). Once deep sedation is drug with a high risk for bacterial or fun- reached the pump is stopped and a calcu- Human and material resources gal contamination [32]. Strict handling in- lation is made where the infused volume necessary for effective, safe cludes: opening a vial for each patient im- in mL is multiplied by four. The resulting sedation. Monitoring. When is mediately before administration, dispos- amount will be used as infusion rate in an anesthesiologist essential? ing of vial remnants and infusion pumps, mL/hour. ! and changing adapters, conduits and syr- Combined use with midazolam: Under Human resources: inges for each case. some circumstances so-called balanced Sedation guidelines and propofol label in- Material resources: sedation becomes useful. A prior adminis- dicate that deep sedation should be admi- The Unit should have all sorts of sedation- tration of midazolam (1–2 mg two min- nistered by qualified personnel other than related materials available, including: utes in advance) reduces propofol require- those carrying out the examination 1) Sedatives and their antagonists. 2) IV ments and propofol-related adverse he- [18, 26]. However, no scientific evidence systems and infusion pumps. 3) Oximetry,

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Examination characteristics Risk conditions Table 3 Recommendations for anesthetic care 1. Type of examination (gastro/colon/EUS/ERCP) 1. Baseline physical status (ASA) during gastrointestinal endoscopy. 2. Procedure length (short or long) 2. History of disease 3. Complexity (requeres precision) 3. Intubation limitations (Mallampati) 4. Invasiveness (pain, intolerance) 4. Risk for bronchoaspiration 1. Endoscopic procedures that are urgent, prolonged o therapeutically complex, subject to deep sedation or general anesthesia. ASA I-III ASA > III – Emergency care for active gastrointestinal No risk conditions Risk conditions bleeding Simple diagnostic procedure – Bronchoaspiration risk from gastrointestinal tract obstruction – Complex therapy for biliary, gastroduode- nal or colonic conditions 2.Intolerance, paradoxical reactions or Sedation by certified staff Exclusive certified staff (exclusive?) (Anesthesiologist?) allergy to standard sedation schedules. 3.Increased risk of complications because of severe comorbidity (ASA 4 or higher) Fig. 1 Examination characteristics and risk conditions influencing the numbers and qualifications of the staff required for sedation 4.Increased risk for airway obstruction 5.Prior history of laryngeal stridor 6.History of severe sleep apnea ECG, and blood pressure monitors. A cap- the room (evidence level 2+, recom- 7.Evidence of dysmorphic face: – Trisomy 21 nograph and bispectral index/narcotrend mendation grade C ). – ▶ Pierre-Robin syndrome are desirable, particularly for higher-risk For complex therapeutic procedures 8.Mouth abnormalities examinations [31]. 4) Resuscitation having an additional, qualified person – Mouthopeninglessthan3cminadults equipment. 5) Defibrillator. 6) Basic and responsible for sedation is advisable – Protruding incisors advanced respiratory care systems. 7) (evidence level 4, recommendation – Macroglossia Drugs for cardiopulmonary resuscitation. grade D ). – Gothic palate – Good venous access, patient preoxygena- ▶ For procedures performed in patients Tonsillar hypertrophy – Mallampati scale=4 tion for 5 minutes before sedative dosing, with adcanced ASA scores (>III) or with 9.Neck abnormalities a readily available independent aspirator, risk factors for sedation (short neck, – Decreased hyoid-chin distance and a well-checked crash cart are all key sleep apnea, chronic decompensated (<3cm in adults) components. serious diseases, etc.) the presence of – Short, thick neck Appropriate gurneys and transportation an anesthesiologist or intensivist is to – Limited cervical extension means are also essential that provide be recommended (evidence level 4, – Cervical spine conditions or traumas space for resuscitation maneuvers, protec- recommendation grade D). (e.g., advanced rheumatoid arthritis) – tion against falls, and ergonomy for both ▶ In endoscopy units where deep seda- Severe tracheal deviation patients and staff. tion is used an anesthesiologist or in- 10.Mandible abnormalities – Retrognathia The widespread use of sedation in endos- tensivist should be available within – Micrognathia copy units makes mandatory an architec- 5 minutes (evidence level 2+, recom- – Trismus tural design adapted to the use of deep se- mendation grade C). – Severe dental malocclusion ▶ ’ dation techniques. Given propofol s high risk of contami- ASA, American Society of Anesthesiologists. The increasing use of propofol, which pro- nation the aseptic technique must be vides deep sedation with a rapid recovery, maximized during handling, particu- requires resuscitation systems available larly avoiding multidose containers and Sedation-related complications. until the patient fully regains conscious- reusable infusion materials (evidence Prevention, diagnosis, and ness and the health status present before level 1++, recommendation grade A). management the procedure. To achieve maximal effi- ▶ Endoscopy units should be fitted with !

ciency in the Unit a recovery ward with all items necessary for safe, effective The overall rate of complications of diges- This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. 1.5 –2.0 boxes per operating endoscopy sedative dosing, as well as monitoring tive endoscopy is low (0.02% –0.54 %), room is considered a must [33]. The re- and cardiopulmonary resuscitation with mortality at 0.0014 %. Of these, covery ward should be staffed with nurses equipment (evidence level 2++, re- 0.27% are cardiopulmonary, sedation- and fitted with cardiopulmonary support commendation grade B). related complications. These are most systems, monitors, gurneys, accessory ▶ A recovery room with nurses, gurneys, common in patients with associated dis- rails, oxygen outlets, and aspiration inlets. oxygen, aspiration, monitors, and car- eases and develop equally in procedures diopulmonary support devices is advi- surveilled by both anesthetists and non- Recommendations: sable (evidence level 4, recommenda- anesthetist clinicians. Most common com- ▶ Deep sedation with propofol for basic tion grade D). plications include hypoxemia, hypoten- endoscopic procedures and patients sion, arrhythmia, vasovagal events, and with ASA I-II risk may be carried out bronchopulmonary aspiration [26,34] effectively and safely in the absence of Cardio-respiratory complications: The dedicated sedation staff and with no most common and serious of all complica- increase in the number of people inside tions, their rate was 0.9 % in a retrospec-

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A marginal yet possible, potentially severe Table 4 Rating scales that may be used to assess sedation level during endoscopy. complication is the transmission of bacte- RAMSAY SCORE rial, fungal or viral infections (including IAnxious, agitated, restless hepatitis C virus) because of multidose IICooperative, oriented, calm containers and propofol contamination. IIISedated but responds to verbal commands Can we identify patients with higher car- IVAsleep but rapidly responds light tactile stimuli VAsleep but slowly responds to stimuli diopulmonary risk? Multiple risk factors VIAsleep, unresponsive to stimuli have been associated with a greater fre- Observer Assessment of Alertness and Sedation (OAAS) quency of cardiopulmonary complica- Level 6– Agitated tions. Some are patient-related, including Level 5– Readily responds to name spoken (alertness) a history of ischemic heart disease or ar- Level 4– Lethargic response to name spoken rhythmia, lung disease, hospitalization, Level 3– Responds only when name called loudly or repeatedly baseline O2 saturation <95%, age older Level 2– Responds only to prodding or shaking than 70 years, and ASA III and IV [35,36, – Level 1 Does not respond to prodding or shaking 39– 41]. Other factors are associated to – Level 0 Does not respond to noxious stimuli procedure type and are more common in emergency procedures or oral endoscopy [38,42]; finally, they may also be related tive nation-wide study of over 300 000 vers must be initiated using a laryngeal to drug dosage, and oxygen administra- procedures carried out in the USA [35]. mask or orotracheal intubation; need for tion status [35]. Hypoxemia: Oxygen desaturation defined the latter is exceptional [38]. A thorough assessment prior to sedation by satO2<90% is the most common com- Hypotension: Defined by a maximal blood may identify these factors and allow ac- plicatione, possibly more common than pressure <90 mmHg, it develops more tions to prevent complications. The best usually thought as it is not recorded on commonly in cases where sedatives and way to prevent them is by adequate train- many occasions. Incidence is highly vari- pain killers are associated or when propo- ing and having expert staff – both doctors able (4–50 %). The risk is greater during fol is used; it usually has no clinical impli- and nurses – to manage sedation [38]. oral endoscopy since a deeper level of se- cations. Management usually includes dation is needed, the airway is compres- electrolyte IV infusion. Recommendations: sed, and laryngospasm occasionally de- Arrhythmia: Arrhythmia develops in 4– ▶ Supplementary oxygen administration velops. The combined administration of 72% of sedations; most are sinus tachycar- during endoscopic procedures reduces benzodiazepines and opiates increases dia events possibly related to procedure- the incidence of hypoxemia but may the risk for respiratory depression [36]. In associated stimuli, but other clinically rel- delay apnea recognition and increase recent studies with oxygenated, moni- evant arrhythmias may occur (extrasys- hypercapnia; hence, besides using a tored patients the incidence of desatura- toles, bradycardia, ectopic rhythms, etc.). pulse oximeter, visual monitoring of tion events during endoscopies per- Their development depends on patient breathing movements is advisable, and formed under propofol was lower than age, presence of concurrent, particularly a capnograph is recommended [3] 10% [37], and the need for endotracheal heart diseases, endoscopy type, and anxi- (evidence level 1 +, recommendation intubation remained marginal. ety. Electrocardiographic changes appear grade B). Does oxygen administration prevent hy- in 4–42 % of cases, most commonly ST ▶ In situations with an increased risk for poxemia? All guidelines issued by nation- segment alterations that remain unchang- bronchoaspiration, as is the case with al scientific societies advise that supple- ed by oxygen administration and are be- active upper GI bleeding or gastric re- mentary oxygen be used during endo- lieved to be unrelated to ischemia. Should tention, orotracheal intubation is re- scopic procedures. However, oxygen ad- bradycardia occur (<50bpm) atropine quired before the endoscopic proce- ministration may delay apnea recognition must be provided (0.5 mg IV, to a maxi- dure (evidence level 2 +, recommenda- and increase hypercapnia, hence a pulse mum of 2–3mg) tion grade B ). oximeter is also recommended to provide Aspiration: This occurs in few cases visual monitoring for breathing move- (0.10 %) and usually defies recognition. This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. ments, as well as capnography when fea- However, the risk for bronchopulmonary Pre-, intra-, and post-sedation sible [35]. aspiration is much higher in patients monitoring. Records If desaturation develops sedatives must be with active upper gastrointestinal bleed- ! discontinued and the patient must be ing or gastric retention; in such cases oro- Having a sedation form available is advi- stimulated using increased oxygen flow, tracheal intubation is recommended be- sable to record clinical data and vital signs jaw thrust to secure the airway, secretion fore the endoscopic procedure. before, during and after sedation. Similar- aspirations, and a Guedel tube when re- Phlebitis: The frequency of phlebitis is low ly, all incidents occurring during sedation, quired. If benzodiazepines and/or opiates but higher when diazepam is used in as well as actions taken to solve them, were used their action may be reverted small-caliber veins. Some propofol pre- should be recorded. This record form with flumazenil and/or naloxone. When parations irritate venous walls, and extra- should be attached to the patient’s medi- desaturation is severe and persistent, ven- vasation results in pain and swelling; lido- cal record. The following sequence is advi- tilation should be provided using an oxy- caine may be added to the infusion to pre- sable: gen mask (Ambu), but this is only neces- vent this; cold application is advisable sary in 0.1% of cases. Should these meas- should extravasation develop. ures fail, respiratory resuscitation maneu-

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1.Pre-sedation monitoring Level of consciousness: An assessment hours following sedation is highly advisa- Anamnesis: The patient’s individual risks will be made of the response to verbal or ble, including a phone number to contact should be assessed. The aim is identifying tactile stimuli. Several scales or instru- the endoscopy unit should any adverse all factors that may increase sedation- ments are available to help us establish events or concerns arise after discharge. associated risks. Except for specific cases the level of consciousness, including the neither referral for a pre-anesthetic bispectral index/narcotrend [17,30]. This Recommendations: check-up nor additional studies such as assessment must be performed every 3 – ▶ Sedation requires monitoring before, chest x-rays or electrocardiography are 5 minutes by the person responsible for during and after the endoscopic proce- necessary. Good history taking immedi- sedation in order to maintain the desired dure until the patient is no longer at ately before a procedure is currently con- sedation level and rescue the patient risk (evidence level 4, recommendation sidered a proper replacement for conven- from a deeper level if needed. grade D). tional pre-sedation visits, which to date ▶ All actions and incidents occurring have not been proven essential [43]. 3.Monitoring after procedure during sedation must be recorded and Medical history: Confirm the patient has completion attached to the patient’s medical re- been fasting for 6– 8 hour for solids and Post-sedation surveillance: All patients cords (evidence level 4, recommenda- 2–4 hours for liquids, and is accompanied having undergone sedation must be ade- tion grade D). by a responsible adult. Record the medical quately monitored until they recover their ▶ With exceptions, a pre-anesthetic visit history likely to complicate sedation: se- baseline status, out of danger, and ready and check-up including chest x-rays vere cardiopulmonary or neurological to be discharged from the endoscopy and ECG is not necessary for gastro- disease; sleep apnea; prior adverse events unit. Once the endoscopic procedure is intestinal endoscopic procedures with sedation/anesthesia or a history of completed, and the defensive reflexes re- (evidence level 4, recommendation difficult intubation; alcohol or other drug covered, patients may be transferred to a grade D). abuse; allergies to medications and, speci- recovery room with the above-mentioned ▶ To undergo sedation patients must fast fically, to egg and soy; potential risk for staff and equipment. 6– 8 hour for solids and 2–4 hours for bronchoaspiration (intestinal occlusion, As already discussed, the use of scores is liquids (evidence level 4, recommenda- active gastrointestinal bleeding, gastric recommended to assess discharge time. tion grade D). stasis, etc.). In practice, Aldrete’s scale is the most ▶ It is recommended that Aldrete’sor Physical exploration: Vital signs (blood commonly used score – 9or10– to decide other similar scales be used to establish pressure, heart rate, oxygen saturation) this [51] (●" Table 5). The fact that this discharge time for patients, who should and prior level of consciousness; assess scale assesses physical parameters rather leave the endoscopy unit accompanied the presence of obesity and of anatomic than psychomotor activity should be tak- by a responsible adult (evidence level 4, changes in the neck and oropharynx that en into account. It is for this reason that recommendation grade D). might ultimately hinder intubation (Mal- discharged patients should be in the com- ▶ Stay time in the recovery room will be lampati classification) [44]. pany of a responsible adult. It is recom- longer for patients having received se- According to medical record and exami- mended that sedation be avoided for out- dative antagonists (evidence level 4, nation findings the patient’s risk regard- patients with no companions. recommendation grade D). ing sedation is evaluated using the ASA It is also relevant to bear in mind that, as classification [14]. the hal-life of sedatives is longer than Peripheral vein cannulation and supple- that of their agonists, when the latter are mentary oxygen administration: Supple- administered patients will need to stay mentary oxygen administration is recom- longer in the recovery room to prevent mended prior to the procedure (nasal potential resedation events. Providing cannula or mouth opener with oxygen precise written instructions for the 24 tubing) as it reduces the incidence of arterial desaturation. Table 5 Modified Aldrete Scale. 2.Monitoring during sedation This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. Score The patient must remain monitored throughout the procedure. Using a pulse Activity Moves4limbsvoluntarilyortocommands 2 oximeter is mandatory in all instances. Moves2limbsvoluntarilyortocommands 1 Unable to move limbs 0 For deep sedation as well as for patients Breathing Able to breathe deeply and cough freely 2 with severe heart disease surveillance Dyspnea or limited breathing 1 with blood pressure (every 3–5 minutes), Apnea 0 electrocardiogram, and ventilatory func- Circulation Blood pressure<20% of pre-sedation level 2 – tion recorders is compulsory [38,45 50]. Blood pressure 20 – 49% of pre-sedation level 1 Ventilation may be assessed by observing Blood pressure>50% of pre-sedation level 0 breathing movements or, if available, with Awareness Wide awake 2 a capnograph. However, the use of a cap- Responds to calling 1 nograph has not proven indispensable. Does not respond 0

Monitorization data must be included in Arterial O2 saturation Saturation>95% in room air 2 the medical record form. Needsoxygentomaintainsaturation>90% 1 Saturation<90% with oxygen 0

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being reported in the frequency of ad- Table 6 FDA (Food and Drug Administration) pregnancy categories. verse events among the various specialists Category Description Drugs used during in charge of sedation [66]. endoscopy and sedation In pediatric endoscopy and in selected A Adequate and well-controlled human studies have failed None cases, sedation is an alternative as effective to demonstrate a risk to the fetus in the first trimester of as general anesthesia. Oral premedication pregnancy with midazolam (0.5mgr/kg) [69,70] or B Animal reproduction studies have failed to demonstrate Meperidine ketamine (5mgr/Kg) [71] could facilitate a risk to the fetus and there are no adequate and well- Propofol the separation of parents and cannulation controlled studies in pregnant women Naloxone of venous access, further reducing the re- OR Glucagon quired doses of sedatives Animal studies have shown an adverse effect, but ade- Lidocaine quate and well-controlled studies in pregnant women Mepivacaine Single or combined sedatives have been have failed to demonstrate a risk to the fetus in any tri- used for endoscopy-related sedation in mester. children. A combination of sedatives does C Animalreproductionstudieshaveshownanadverse Midazolam not increase the potential for adverse effect on the fetus and there are no adequate and well- Fentanyl events as compared to sedation with only controlled studies in humans, but potential benefits may Morphine one drug, but does increase the intricacy warrant use of the drug in pregnant women despite po- Flumazenil of the sedation process [69 –71]. As in tential risks. Simethicone adults, propofol doses are reduced when D There is positive evidence of human fetal risk based on Diazepam adverse reaction data from investigational or marketing combined with midazolam and/or fenta- experience or studies in humans, but potential benefits nyl [69,70]. The combination of midazo- may warrant use of the drug in pregnant women despite lam and ketamine provides better seda- potential risks. tion for endoscopy versus midazolam or X Studies in animals or humans have demonstrated fetal midazolam/fentanyl, as well as a faster re- abnormalities and/or there is positive evidence of human covery [71]. The use of midazolam alone fetal risk based on adverse reaction data from investiga- has been reported as likely ineffective tional or marketing experience, and the risks involved in [67]. use of the drug in pregnant women clearly outweigh potential benefits. Propofol has been shown to shorten induction time and recovery from sedation Sedation in special situations: is similar to that of other adults [53]. Usual versus midazolam [72] or midazolam/me- Pregnancy, lactation, pediatric age sedatives may be safely administered to peridine [73]. ! women during lactation with no particul- A recent systematic review suggests that Sedation during pregnancy: The safety of ar risk to the infant provided a number of propofol-based sedation is the most effec- endoscopic procedures under sedation recommendations are followed [59] – tive regimen for digestive endoscopy in during pregnancy has not been thorough- Among opiates fentanyl is preferable to the pediatric setting [67] – Propofol en- ly studied. The fetus is particularly re- meperidine; fentanyl levels in breastmilk sured an excellent level of successful pro- sponsive to hypoxia and hypotension in are low enough to lack pharmacologic ef- cedures, better time management, and the mother [52]; it is because of this that fects [60,61] whereas meperidine does maximum patient comfort, particularly elective non-obstetric procedures, includ- concentrate in breastmilk and may thus when midazolam was previously admi- ing GI endoscopy, are recommended only reduce infant alertness and interfere with nistered. In most studies propofol was ad- for a clear indication, and should be de- feeding [59,62]. As regards midazolam, ministered by non-anesthetist clinicians layed to the second trimester when possi- breastfeeding should be delayed at least 4 (including endoscopists) with no increase ble [52,53] in order to reduce the poten- hours following its dosing; breastmilk in adverse events; the authors conclude tial risks associated with perioperative should be expressed and disposed of be- that propofol may be safely administered stress, the procedure itself, and the effects fore feeding the child. Propofol concentra- by trained physicians. Repeated deep se- of all drugs administered. However, nu- tion in breastmilk is only 0.015 % of plas- dation with propofol in infants/toddlers merous studies have confirmed the rela- ma levels, hence lactation needs not be has proven to be safe [74,75], although This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. tive harmlessness of a single clinica expo- withheld after this drug [60]. human research on this subject is scarce sure to anesthesia and surgery during the Sedation in children: In contrast to adults and potential risks should be weighed first trimester [54 –57]. children require sedation for most inva- [76]. Beyond infancy, in the absence of or- Today’s sedative and anesthetic agents sive procedures as anxiety must be usual- gan-specific dysfunction or disease seda- have no proven teratogenicity (●" Table 6). ly controlled, movements restrained, and tive effects and clearance is proportional Meperidine and propofol (class B) or fenta- pain and discomfort avoided. Sedation re- to adults. nyl and midazolam (class C) may be used quirements outside operating rooms, by safely during pregnancy. Pregnancy-relat- multiple specialists, and for a variety of di- Recommendations: ed physiological changes increase respon- agnostic procedures are increasing in the ▶ Indications should be unequivocal dur- siveness to thiopental and volatile anes- pediatric setting [63]. Limited anesthetic ing pregnancy, and procedures should thetics, whose induction doses should be resources, increased efficiency in patient be postponed when possible until the reduced. In contrast, no reduction is re- management, and both patient and physi- second trimester (evidence level 4, required for propofol induction dosing [58]. cian convenience drive a steady increase commendation grade D). Sedation and lactation: The responsive- in pediatric sedation by non-anesthetist ▶ Benzodiazepines, opiates, and propofol ness of breastfeeding women to sedatives clinicians [64,65], with no differences may be used during pregnancy. Propo-

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fol induction doses need not be re- the other hand, patients must be moni- lam provides rapid sedation induction duced (evidence level 1–, recommen- tored during recovery until their dis- and earlier patient recovery after the pro- dation grade B). charge from the endoscopy unit. This cedure. Regarding opiates, fentanyl signif- ▶ If midazolam is used during breast- longer time is the factor that most signifi- icantly shortens induction and patient re- feeding breastmilk must be expressed cantly may impact efficiency. Further- covery versus meperidine [80,81]. This and discarded, and feeding must be de- more, the use of sedation requires appro- shortening of times results in increased layed to at least 4 hours after sedation; priately trained personnel to monitor pa- efficiency at the endoscopy unit. Induc- among opioids fentanyl is to be prefer- tients during sedation and recovery, in- tion and recovery times for both basic red to meperidine. Breastfeeding needs cluding an anesthesiologist for some and advanced endoscopy are shorter not be delayed after sedation with pro- cases, which further boosts costs. with propofol than with benzodiazepines pofol (evidence level 3, recommenda- Therefore, before an endoscopy sedation and opioids [82,83]. Sedation with propo- tion grade D). program is implemented the characteris- fol administered by a non-anesthetist ▶ In the pediatric setting sedation may be tics of the involved unit and its patient clinician may improve efficiency when an option as effective as general anes- population should be properly analyzed compared to sedation with opiates and thesia. Oral premedication with mida- in order to decide which of the above se- benzodiazepines [82, 83]. Also, the ad- zolam may result in easier separation dation strategies fits better our needs and ministration of propofol by an anesthetist from parents, easier venous access means. during a routine endocopic procedure for cannulation, and lower sedative dose Assessing the cost-effectiveness of endos- a healthy, low-risk patient (ASA

and adenoma resection rates [78]. tion characteristics. If most are younger duction and recovery times. This re- This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. However, these undeniable benefits of se- individuals or persons with minor condi- duction results in increased efficiency dation may be burdened with increased tions any of the above sedation strategies at the endoscopy unit (evidence level exploration costs and reduced efficiency may be used without influencing efficien- 2++, recommendation grade B ) . in the endoscopy unit. Sedation increases cy. In contrast, if the patient population ▶ Sedation induction time is shorter with cost by rising pharmacy (drugs and IV includes mostly elderly or multidiseased propofol than with benzodiazepines fluids) and both fungible (venous access individuals (ASA>III), the use of anesthet- and opiates (evidence level 1+, recom- catheters, drip systems, oxygen adminis- ics such as propofol will often require the mendation grade A ). tration devices, etc.) and non-fungible help of an anesthetist in the unit, which ▶ Recovery time after sedation is shorter (monitoring equipment) material expen- will increase overall costs and decrease ef- when propofol is used alone (evidence ses. However, even more relevant than ficiency. level 1+, recommendation grade A ). cost increases is the impact sedation may If a benzodiazepine is to be used, midazo- ▶ Sedation with propofol administered have on procedure length. Endoscopic lam is the drug of choice for endoscopy- by non-anesthetist clinicians may im- procedures under sedation require addi- related sedation because of its short onset prove endoscopy unit efficiency as tional time for previous venous access of effect and shorter half-life as compared compared to sedation with opiates and cannulation and sedation induction. On to other drugs in this class [79]; midazo-

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benzodiazepines (evidence level 1+, training and skills, including sedation ▶ The endoscopist must be aware of the recommendation grade A 1+). without a specialist’s degree in Anesthe- limits of his or her own competence, ▶ Routine propofol administration by an siology and Resuscitation. However, these and seek the help of a competent col- anesthesiologist to healthy, low-risk clinicians must be aware of their own lim- league (anesthetist or otherwise) patients (ASA

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14 American Society of Anestesthesiologists 29 Vargo JJ. DeLegge MH, Feld AD, Gerstenberger nal position statement. Alimentary Pharma- Task Force on Sedation and Analgesia by PD et al. Multisociety sedation curriculum col Ther 2010; 3: 425–442 Non Anesthesiologists. Practice guidelines for gastrointestinal endoscopy. Gastrointest 47 Vargo J, Cohen LB, Rex DK et al. Position for sedation and analgesia by non-anesthe- Endosc 2012; 76: e1– e25 Statement: Nonanesthesiologist Adminis- siologists. Anesthesiology 2002; 96: 1004 – 30 Ramsay MA, Huddleston P, Hamman B et al. tration of Propofol for GI Endoscopy. Gastro- 1017 The patient state index correlates well with enterology 2009; 137: 2161–2167 15 Sedation and anesthesia in GI endoscopy. the Ramsay sedation score in ICU patients. 48 Ladas SD, Satake Y, Mostafa I et al. Sedation ASGE Guideline.. Gastrointest Endosc 2008; Anesthesiology 2004; 101: A338 Practices for Gastrointestinal Endoscopy in 68: 815–826 31 Gottlieb KT, Banerjee S, Barth BA et al. Moni- Europe, North America, Asia, Africa and 16 López Rosés L. Sedación moderada. En: de la toring equipment for endoscopy. Gastroin- Australia. Digestion 2010; 82: 74–76 Morena E, Cacho G. Sedación en Endoscopia test Endosc 2013; 77: 175–180 49 Lichtenstein DR, Jagannath S, Baron TH et al. Digestiva. Madrid: EDIMSA; 2011: 111–118 32 King CA, Ogg M. Safe injection practices for Sedation and anesthesia in GI endoscopy. 17 Cohen LB, Delegge MH, Aisenberg J et al. AGA administration of propofol. AORN J 2012; Standards of Practice Committee. Gastroin- Institute review of endoscopy sedation. Gas- 95: 365–372 test Endosc 2008; 68: 815–826 troenterology 2007; 133: 675–701 33 Chris JJ, Mulder CJJ, Jacobs MAJ et al. Guide- 50 Queshi WA, Rajan E, Adler DG et al. ASGE 18 Simón MA, Bordas JM, Campo R et al. Docu- lines for designing a digestive disease Guideline: Guidelines for endoscopy in mento de consenso de la Asociación Españo- endoscopi unit: Report of the World Endos- pregnant and lactating women. Gastrointest la de Gastroenterología sobre sedoanalgesia copy Organization. Dig Endosc 2013; 25: Endosc 2005; 61: 357–362 en la endoscopia digestiva. Gastroenterol 365–375 51 Aldrete JA. The post-anesthesia recovery Hepatol 2006; 29: 131–149 34 Lee CK, Lee SH, Chung IK et al. Balanced pro- score revisited. J Clin Anesth 1995; 7: 89–91 19 Robertson DJ, Jacobs DP, Mackenzie TA et al. pofol sedation for therapeutic GI endoscopic 52 Palanisamy A. Maternal anesthesia and fetal Clinical trial: a randomized study compar- procedures: a prospective, randomized neurodevelopment. Int J Obstet Anesth ing meperidina (pethidine) and fentanyl in study. Gastrointest Endosc 2011; 73: 206– 2012; 21: 152–162 adult gastrointestinal endoscopy. Aliment 214 53 Shergill AK, Ben-Menachem T, Chandrase- Pharmacol Ther 2009; 29: 817–823 35 Sharma VK, Nguyen CC, Crowell MD et al. A khara V et al. ASGE Standard of Practice 20 Bo LL, Bai Y, Bian JJ et al. Propofol vs tradi- national study of cardiopulmonary un- Committee, Guidelines for endoscopy in tional sedative agents for endoscopic retro- planned events after GI endoscopy. Gastro- pregnant and lactating women. Gastrointest grade cholangiopancreatography: a meta-a- intest Endosc 2007; 66: 27–34 Endosc 2012; 76: 18–24 nalysis. World J Gastroenterol 2011; 17: 36 Cohen LB. Patient monitoring during gastro- 54 Cohen-Kerem R, Railton C, Oren D et al. Preg- 3538–3543 intestinal endoscopy: why, when, and how? nancy outcome following non-obstetric sur- 21 Qadeer MA, Vargo JJ, Khandwala F et al. Pro- Gastrointest Endosc Clin N Am 2008; 18: gical intervention. 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Comunicación a las XXXV Jornadas worldwide safety experience. Gastroente- 57 Konieczko KM, Chapple JC, Nunn JF. Fetotoxic de la Sociedad Española de Endoscopia Di- rology 2009; 137: 1229–1237 (quiz 518-9) potential of general anaesthesia in relation gestiva. Madrid 14–16 Noviembre 2013 39 Agostoni M, Fanti L, Gemma M et al. Adverse to pregnancy. Br J Anaesth 1987; 59: 449– 23 Chun SY, Kim KO, Park DS et al. Safety and ef- events during monitored anesthesia care for 454 ficacy of deep sedation with propofol alone GI endoscopy: an 8-year experience. Gastro- 58 Higuchi H, Adachi Y, Arimura S et al. Early or combined with midazolam administrated intest Endosc 2011; 74: 266–275 pregnancy does not reduce the C(50) of pro- by nonanesthesiologist for gastric endo- 40 Dietrich CG, Kottmann T, Diedrich A et al. Se- pofol for loss of consciousness. Anesth Analg scopic submucosal dissection. Gut Liver dation-associated complications in endos- 2001; 93: 1565–1569 2012; 6: 464–470 copy are not reduced significantly by imple- 59 Sachs HC Committee on drugs. The transfer 24 Julián-Gómez L, Rodríguez-Gómez SJ, mentation of the German S-3-guideline and of drugs and therapeutics into human breast Fuentes-Coronel A et al. Ensayo clínico com- occur in a severe manner only in patients milk: an update on selected topics. Pedia- parando propofol vs propofol más midazo- with ASA class III and higher. Scand J Gastro- trics 2013; 132: e796–809 lam en endoscopia digestiva alta diagnósti- enterol 2013; 48: 1082–1087 60 Nitsun M, Szokol JW, Saleh HJ et al. Pharma- ca: resultados preliminares. Endoscopy 41 Gonzalez-Huix LladoF, Gine GalaJJ, Loras cokinetics of midazolam, propofol, and fen- 2011: 43–40 AlastrueyC et al. Position statement of the tanyl transfer to human breast milk. Clin 25 Murphy A, Campbell DE, Baines D et al. Aller- Catalan Society of Digestology on sedation Pharmacol Ther. 2006; 79: 549–557 gic reactions to propofol in egg-allergic chil- in gastrointestinal endoscopy. Gastroenterol 61 Steer PL, Biddle CJ, Marley WS et al. Concen- dren. Anesth Analg 2011; 113: 140–144 Hepatol 2012; 35: 496–511 tration of fentanyl in colostrum after an an- This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. 26 Dumonceau JM, Riphaus A, Aparicio JR et al. 42 Rex DK, Heuss LT, Walker JA et al. Trained re- algesic dose. Can J Anaesth. 1992; 39: 231– European Society of gastrointestinal Endos- gistered nurses/endoscopy teams can ad- 235 copy, European Society of Gastroenterology minister propofol safely for endoscopy. Gas- 62 Bar-Oz B, Bulkowstein M, Benyamini L et al. and Endoscopy Nurses and Associates, and troenterology 2005; 129: 1384 –1391 Use of antibiotic and analgesic drugs during European Society of Anaesthesiology Guide- 43 Munro J, Booth A, Nicholl J. Routine preo- lactation. Drug Saf 2003; 26: 925–935 line: Non-anesthesiologist administration of perative testing: a systematic review of the 63 Havidich JE, Cravero JP. The current status of propofol for GI endoscopy. Endoscopy 2010; evidence. Health Technol Assessment 1997; procedural sedation for pediatric patients in 42: 960–974 1: 1–62 out-of-operating room locations. Curr Opin 27 Külling D, Orlandi M, Inauen W. Propofol se- 44 Mallampati SR, Gatt SP, Guigino LD et al. A Anaesthesiol 2012; 25: 453–460 dation during endoscopic procedures: how clinical sign to predict difficult tracheal in- 64 Lalwani K, Michel M. Pediatric sedation in much staff and monitoring are necessary? tubation: a prospective study. Can Anesth North American children’s hospitals: a sur- Gastrointest Endosc 2007; 66: 443–439 Soc J 1985; 32: 429–434 vey of anesthesia providers. Paediatr An- 28 Jain R, Ikenberry SO, Anderson MA et al. ASGE 45 Vargo JJ, Cohen LB, Rex DK et al. 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