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Deep Sedation and Anaesthesia in Complex Gastrointestinal Endoscopy ENDOSCOPY Frontline Gastroenterol: first published as 10.1136/flgastro-2018-101145 on 9 January 2019. Downloaded from REVIEW Deep sedation and anaesthesia in complex gastrointestinal endoscopy: a joint position statement endorsed by the British Society of Gastroenterology (BSG), Joint Advisory Group (JAG) and Royal College of Anaesthetists (RCoA) Reena Sidhu,1 David Turnbull,2 Mary Newton,3 Siwan Thomas-Gibson,4 David S Sanders,1 Srisha Hebbar,5 Rehan J Haidry,6,7 Geoff Smith,8 George Webster6 ► Additional material is ABSTRACT published online only. To view Summary points In the UK, more than 2.5 million endoscopic please visit the journal online (http:// dx. doi. org/ 10. 1136/ procedures are carried out each year. Most ► The availability of anaesthetist-led flgastro- 2018- 101145). are performed under conscious sedation with deep sedation and anaesthesia in the benzodiazepines and opioids administered by For numbered affiliations see end UK for complex endoscopy needs to be the endoscopist. However, in prolonged and of article. expanded. complex procedures, this form of sedation may ► Adequate preassessment and patient Correspondence to provide inadequate patient comfort or result Dr Reena Sidhu, Academic Unit triage is key prior to consideration of deep of Gastroenterology, Royal in oversedation. As a result, this may have a sedation and anaesthesia. Hallamshire Hospital, Sheffield negative impact on procedural success and patient ► Current guidelines dictate that delivery Teaching Hospitals NHS Trust, outcome. In addition, there have been safety of propofol sedation in the UK must Sheffield S10 2JF, UK; reena. concerns on the high doses of benzodiazepines be provided by a qualified anaesthetist sidhu@ sth. nhs. uk http://fg.bmj.com/ and opioids used particularly in prolonged supported by a qualified assistant Received 12 November 2018 and complex procedures such as endoscopic (Operating Department Practitioner or Revised 5 December 2018 Anaesthetic Nurse). Accepted 16 December 2018 retrograde cholangiopancreatography. Diagnostic ► A local standard operating procedure and therapeutic endoscopy has evolved rapidly needs to be in place to ensure that over the past 5 years with advances in technical minimum standards of environment, skills and equipment allowing interventions and on 6 March 2019 by guest. Protected copyright. staffing and delivery of all types of procedural capabilities that are moving closer to deep sedation and anaesthesia are fg. bmj. com minimally invasive endoscopic surgery. It is vital maintained. that safe and appropriate sedation practices follow the inevitable expansion of this portfolio to accommodate safe and high-quality clinical equipment required, the environment, staffing outcomes. This position statement outlines the and monitoring requirements. Considerations current use of sedation in the UK and highlights for different endoscopic procedures in both the role for anaesthetist-led deep sedation emergency and elective setting are also detailed. © Author(s) (or their employer(s)) practice with a focus on propofol sedation The role for training, audit, compliance and future 2019. No commercial re-use. See although the choice of sedative or anaesthetic developments are discussed. rights and permissions. Published by BMJ. agent is ultimately the choice of the anaesthetist. It outlines the indication for deep sedation and INTRODUCTION To cite: Sidhu R, Turnbull D, Newton M, et al. Frontline anaesthesia, patient selection and assessment Endoscopic procedures provide for the Gastroenterology and procedural details. It considers the setup for a diagnosis, screening and treatment of 2019;10:141–147. deep sedation and anaesthesia list, including the many gastroenterological conditions. In Sidhu R, et al. Frontline Gastroenterology 2019;10:141–147. doi:10.1136/flgastro-2018-101145 141 ENDOSCOPY Frontline Gastroenterol: first published as 10.1136/flgastro-2018-101145 on 9 January 2019. Downloaded from the UK, this should be an anaesthetist. Propofol has Summary points been shown to provide a better quality of procedural sedation and improve patient satisfaction, procedural Training in conscious sedation for endoscopy should ► outcome and recovery when compared with standard be included as an essential competency to be achieved 8 9 conscious sedation. However, the use of propofol at Annual Review of Competency Progression for has been widely debated due to its narrow therapeutic endoscopy trainees. index, the lack of an antidote and risk of cardiorespira- ► Local training programmes for deep sedation and anaesthesia within endoscopy should be encouraged for tory complications especially in the elderly. Neverthe- anaesthetic trainees. less, meta-analyses of several randomised controlled ► Activity and complications must be audited and trials have reported similar rates of adverse events presented at regular morbidity and mortality meetings. compared with traditional sedative agents whether 8 10 ► There is pressing need for increased collaboration administered by anaesthetists or non-anaesthetists. between the Royal College of Anaesthetists, British A recent multicentre German study of over 300 000 Society of Gastroenterology and Joint Advisory Group patients undergoing endoscopy, on sedation-related and collaboration between endoscopists, anaesthetists complications (ProSed 2) showed that while overall and managerial teams locally to implement deep sedation related complications were generally low sedation and anaesthesia provision for complex (0.01%), it was lowest among patients receiving 11 endoscopy in the UK. propofol monotherapy. Providing anaesthetist-led deep sedation and anaes- thesia services is a challenge faced by endoscopic units the UK, conscious sedation for endoscopic procedures around the world. The barriers to delivery include is usually provided by the endoscopist using short- capacity, funding and staffing.12–14 In the UK, propo- acting benzodiazepines and opioids or nitrous oxide.1 fol-based sedation for endoscopy is provided only Conscious sedation is defined as being of a level in by anaesthetists, following the British Society of which patients may perform ‘a purposeful response Gastroenterology (BSG) and Royal College of Anaes- to verbal or light tactile stimulation’ and as such do thetists (RCoA) guidelines.15 The capacity of anaes- not require the involvement of anaesthetist for healthy thetic departments is stretched by demand, and this patients.2 may be one of the hurdles that will be required to be The use of conscious sedation helps to improve the addressed for the introduction of deep sedation and patient experience and procedural success. However, anaesthesia programmes into endoscopy units in the studies have demonstrated that for difficult or UK. prolonged procedures such as device-assisted enteros- This position statement outlines the indications for copy (DAE), endoscopic retrograde cholangiopancrea- anaesthetist-led deep sedation and anaesthesia with tography (ERCP) and resection of upper gastrointestinal a focus on propofol sedation for complex gastroin- neoplasia, procedure tolerance remains poor despite testinal endoscopy. Patient selection, preassessment inappropriately high doses of sedation.3–5 There have and procedure specifics are discussed. The statement also been concerns raised regarding sedation practice provides a structure for the delivery of a deep sedation http://fg.bmj.com/ in the UK including the potential of oversedation and and anaesthesia services. respiratory compromise in patients, with minimal monitoring for potential apnoea. A 2004 report by the Selecting patients for anaesthetist-led deep sedation and National Confidential Enquiry into Patient Outcome anaesthesia and Death (NCEPOD) reported in patients under- Sedation helps to improve patient tolerability and going therapeutic endoscopy, the sedation given was overall endoscopic experience. It is recommended that on 6 March 2019 by guest. Protected copyright. inappropriate in 14% of cases, usually through an a local policy is developed in order that all patients overdose of benzodiazepines.6 The NCEPOD report being considered for sedation are adequately assessed also highlighted that only 47% of endoscopists had at the point of referral. attended a sedation course. Despite this historical data, The objective of preprocedural assessment is patient the number of sedation courses available for endosco- evaluation and patient optimisation together with pists remains limited in the UK.7 It is not unreasonable consideration of procedural issues and patient consent. to conclude that current UK sedation models are insuf- In a retrospective study of more than 1 million patients ficient to manage the increasing complexity of new undergoing endoscopy and colonoscopy, higher Amer- endoscopic procedures and the increasing comorbid- ican Society of Anesthesiologist’s (ASA) class were ities of patients. associated with an increased risk of adverse events.16 Anaesthetist-led deep sedation or anaesthesia for The definition of ASA class is included within online endoscopy can be achieved using propofol. Propofol supplementary appendix 1.17 Old age, comorbidity and is a short-acting intravenous anaesthetic agent that can obesity are identified risk factors for cardiopulmonary be used to provide sedation and amnesia. It should be complications during endoscopy. As obese patients are delivered by persons with appropriate training and in more prone to airway obstruction, the use of the Berlin 142 Sidhu R, et
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