Non-Anesthesiologist Administered Propofol: Lessons Learned From Florida

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Dear Sir:

We applaud the efforts of Rex et al¹ in their attempt to identify the cost savings associated with endoscopist-directed propofol sedation. Although the results of their study are impressive, we have concerns that make correlation with the entire gastroenterologic community impractical and dangerous.

These data are predominately from research-derived databases and academic centers, locations where an attending gastroenterologist is paired with a fellow. Whether directed or implied, 1 physician would have been responsible for the sedation, while the other was in charge of the endoscopy. Because gastroenterologists perform their procedures alone in the private sector, there is the possibility that the distraction caused by the required frequent propofol dosing might hinder their ability to perform a thorough examination.

Furthermore, the study did not define a sedation goal. If the end point was moderate sedation, then the study's conclusions are not in question. However, most gastroenterologists often do not have moderate sedation in mind when requesting propofol administered by an anesthesiologist. If the goal is deep sedation (which often becomes periods of general anesthesia), then this difference is important.

Lessons learned from Florida's experience with office-based surgery safety over the last 20 years are relevant. During the 1990s, numerous surgeons testified to the safety of office-based surgery and denied the need for regulatory safety standards. Additionally, there were articles in the plastic surgery literature attesting to safety in these accredited offices.² When adverse incident reporting became mandatory in 2000, the alarmingly high death rate resulted in an immediate moratorium and stricter regulations.³ Of note, some of these deaths involved propofol administered by registered nurses under the direction of the surgeon.⁴

For the sake of our patients and based on these concerns, I hope the gastroenterologic community does not believe that the conclusions of this study can be extrapolated without reservation. The community gastroenterologist is not likely to be able to provide the same environment of qualifications, safety standards, and backup rescue as those in the study group. If we do not learn from history, we are doomed to repeat it. This lesson is worth heeding.

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References 

1. Rex DK, Deenadayalu VP, Eid E, et al. Endoscopist-directed administration of propofol: a worldwide safety experience. Gastroenterology. 2009;137:1229–1237
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2. Morello DC, Colon GA, Fredricks S, et al. Patient safety in accredited office surgical facilities. Plast Reconstr Surg. 1997;99:1496–1499
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3. Vila H, Soto R, Cantor AB, Mackey D. Comparative outcomes analysis of procedures performed in physician offices and ambulatory surgery centers. Arch Surg. 2003;138:991–995
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4. Florida Board of Medicine Surgical Care Committee Report October 9, 2009. Deaths Reported on Adverse Incident Report, Page 1.
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