Make the Right Choice for Safe Sedation

Gastroenterology

By: Adam Jacob

Published: 1/16/2019

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It's best to base the consciousness level on the patient and the procedure.


PLEASING PUSH Patients report higher satisfaction following endoscopic procedures after sedation with propofol than with other sedation medications such as midazolam and fentanyl.   |  Pamela Bevelhymer, RN, BSN, CNOR

Administering anesthesia in our GI procedure rooms typically comes down to deciding between moderate sedation with midazolam and fentanyl or deep sedation with propofol. The optimal choice is made on a case-by-case basis, depending on each patient's health status and the procedure we're about to perform.

The decision-making process begins with a baseline health assessment that checks patients for comorbid conditions — cardiac and pulmonary issues, diabetes and kidney problems — that could increase sedation risks. Patients also undergo a heart, lung and airway exam performed by an anesthesiologist. Although routine health screenings raise many red flags, we also have protocols in place to double-check a patient's condition. If we discover a concerning medical condition at the last minute, we determine if the procedure can proceed or if we should delay it in order to first medically address the issue.

CLINICAL EFFICIENCY
Keeping Pace With Propofol
RAPID RETURNS Propofol sedation typically leads to faster recoveries than the commonly used midazolam-fentanyl combination.

We've found that paying to have anesthesia providers administer propofol is cost-neutral as long as your clinical staff capitalizes on the drug's potential to get patients ready for discharge faster and move more cases through your procedure rooms. Research that has focused on endoscopy unit throughput when propofol was used often failed to demonstrate a significant difference in the number of cases performed or how long patients spent in the unit because staff had to complete necessary, but time-consuming, tasks such as procedural documentation and patient education.

Even if the patient is fully awake and ready for discharge, your staff might not be prepared to send them home. There's potential for greater clinical efficiencies when propofol is used, but adequate staffing and streamlined workflows are necessary to achieve the greatest benefit from its rapid recovery potential.

— Adam Jacob, MD

After a comprehensive health assessment, we're ready to assign patients to one of these two treatment options:

  • Moderate sedation. For straightforward procedures like an upper endoscopy or colonoscopy, most patients with no serious health issues and normal heart, lung and airway function generally receive endoscopist-directed nurse sedation with midazolam and fentanyl.

The midazolam-fentanyl combination of is a well-established, effective and generally safe approach to mild and moderate sedation during routine upper and lower endoscopy when patients are appropriately monitored. Be sure that specific antagonists of opiates (naloxone) and benzodiazepines (flumazenil) that reverse the sedative effects of midazolam and fentanyl are readily available in every endoscopy unit.

During procedures with light to moderate sedation, we monitor the patient's heart rate, oxygenation level with continuous pulse oximetry, non-invasive blood pressure and concentration of end-tidal CO2 with capnography.

  • Deep sedation. Patients with health conditions that make procedures more medically complex or who are scheduled to undergo more involved procedures such as endoscopic retrograde cholangiopancreatography (ERCP) receive anesthesia-directed deep sedation with propofol. Deep sedation might also be required if, for example, multiple biopsies or the anticipated removal of multiple polyps is expected to extend the time of a colonoscopy. In-room anesthesia is provided by CRNAs with oversight by an anesthesiologist, who also attends to patients' post-procedural care.

Propofol is considered by some to be the ideal sedating agent for endoscopic procedures due to its rapid onset, short half-life and easy ability titrate doses to achieve the desired level of sedation. It can be used to achieve mild, medium and deep sedation, and recovery is typically much quicker than with the midazolam-fentanyl combination. Patients who regularly use sedatives and narcotics are often insensitive to standard benzodiazepine sedation and may also benefit from propofol sedation.

For procedures involving deep sedation with propofol, we monitor the patient's heart rate and non-invasive blood pressure, and employ continuous pulse oximetry, continuous ECG and capnography.

Constantly evolving

A team here at the Mayo Clinic regularly reviews indications for sedation levels and improves the triaging of patients to moderate or deep sedation based on procedure type, medical complexity and history of difficult sedations. Everything we do, from the time a patient is first contacted to the last touch before discharge, is designed to make sure all patients receive safe sedation and appropriate care. OSM

Constantly evolving

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