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Background & AimsEndoscopist-directed propofol sedation (EDP) remains controversial. We sought to update the safety experience of EDP and estimate the cost of using anesthesia specialists for endoscopic sedation. MethodsWe reviewed all published work using EDP. We contacted all endoscopists performing EDP for endoscopy that we were aware of to obtain their safety experience. These complications were available in all patients: endotracheal intubations, permanent neurologic injuries, and death. ResultsA total of 646,080 (223,656 published and 422,424 unpublished) EDP cases were identified. Endotracheal intubations, permanent neurologic injuries, and deaths were 11, 0, and 4, respectively. Deaths occurred in 2 patients with pancreatic cancer, a severely handicapped patient with mental retardation, and a patient with severe cardiomyopathy. The overall number of cases requiring mask ventilation was 489 (0.1%) of 569,220 cases with data available. For sites specifying mask ventilation risk by procedure type, 185 (0.1%) of 185,245 patients and 20 (0.01%) of 142,863 patients required mask ventilation during their esophagogastroduodenoscopy or colonoscopy, respectively (P < .001). The estimated cost per life-year saved to substitute anesthesia specialists in these cases, assuming they would have prevented all deaths, was $5.3 million. ConclusionsEDP thus far has a lower mortality rate than that in published data on endoscopist-delivered benzodiazepines and opioids and a comparable rate to that in published data on general anesthesia by anesthesiologists. In the cases described here, use of anesthesia specialists to deliver propofol would have had high costs relative to any potential benefit. Michael B. Wallace, Section Editor Abbreviations used in this paper: ASA, American Society of Anesthesiologists, EDP, endoscopist-directed propofol sedation, EGD, esophagogastroduodenoscopy, MAC, monitored anesthesia care ⁎ Division of Gastroenterology/Hepatology, Indiana University Medical Center, Indianapolis, Indiana ‡ Regenstrief Institute, Inc, Indianapolis, Indiana § Gastroenterology Consultants, P.C., Medford, Oregon ∥ Capitol Gastroenterology Consultants Medical Group, Inc, Carmichael, California ¶ Mugga Wara and Brindabella Endoscopy Centres, Brindabella Specialist Centre, Garran, ACT, Australia # Department of Gastroenterology, Showa Inan General Hospital, Komagene, Japan ⁎⁎ Division of Gastroenterology, Department of Medicine, Mt Sinai Medical Center, New York, New York ‡‡ University Hospital of Basel, Department of Gastroenterology, Basel, Switzerland §§ Valdosta Medical Clinic, Valdosta, Georgia ∥∥ Stormont-Vail HealthCare, Topeka, Kansas ¶¶ Reid Memorial Hospital, Richmond, Indiana ## Jeddah Center for Liver and Digestive Diseases, Erfan & Badego General Hospital, Jeddah, Saudi Arabia ⁎⁎⁎ The Oregon Clinic, West Hills Gastroenterology, Portland, Oregon ‡‡‡ Section of Gastroenterology, Department of Medicine, LSU Health Sciences Center, Shreveport, Louisiana §§§ Rocky Mountain Gastroenterology Associates, Lakewood, Colorado ∥∥∥ Digestive Health Associates, Durango, Colorado ¶¶¶ The Centre for Digestive Health, Nassau, Bahamas ### Clinica Anglo Americana, Lima, Peru ⁎⁎⁎⁎ Northside Gastroenterology, Indianapolis, Indiana ‡‡‡‡ Deutsche Klinik Für Diagnostik, Wiesbaden, Germany §§§§ Division of Gastroenterology, University of South Alabama College of Medicine, Mobile, Alabama ∥∥∥∥ Clinica Pediatrica, University of Trieste, Italy ¶¶¶¶ Department of Internal Medicine I, Klinikum Region Hannover Siloah, Hannover, Germany #### North Mississippi Medical Center, Tupelo, Mississippi ⁎⁎⁎⁎⁎ Department of Gastrointestinal Endoscopy, Fukui Kosei Hospital, Fukui, Japan ‡‡‡‡‡ Wichita Falls Endoscopy Center, Wichita Falls, Texas §§§§§ Stanton Medical Centre, Yellowknife, Northwest Territories, Canada ∥∥∥∥∥ Your GI Center, Lake Jackson/Pearland, Texas
To view this article's video abstract, go to the AGA's YouTube Channel. This article has an accompanying continuing medical education activity on page 1518. Learning Objective: Upon completion of reading this article, successful learners will be able to identify facts about propofol important for its use by non-anesthesiologists. Conflicts of interest The authors disclose the following: J.A. Walker is CEO of Dr. NAPS, LLC; T. Wehrmann received speaker's fees and research support from Fresenius-Kabi, Germany; A. Riphaus received speaker's fees from Fresenius-Kabi, Falk Pharma and Nycomed, Germany, and research support from Fresenius-Kabi, Germany. The remaining authors disclose no conflicts. Douglas K. Rex had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. PII: S0016-5085(09)00999-8 doi:10.1053/j.gastro.2009.06.042 © 2009 AGA Institute. Published by Elsevier Inc. All rights reserved.
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ABSTRACT
Endoscopist-Directed Administration of Propofol: A Worldwide Safety Experience