Introduction

Combination of benzodiazepines and opioids are effective for achieving moderate sedation for endoscopic procedures and can be delivered safely by endoscopists in patients with ASA Class I–III. Non-anaesthesiologist administration of propofol (NAAP)is only available in a few European countries and there is evidence that low-risk procedures can presumably be done with conventional moderate sedation regimens.^1.2

Aims & Methods

This study aimed to evaluate efficacy, safety and patient overall satisfaction in endoscopic procedures with moderate sedation by gastroenterologists (GIs).
A single-centre prospective study was carried out between April 2021 and February 2023, where 317 patients with indication for endoscopic procedure with sedation by GIs were evaluated and finally 264 included. Fifty-three patients were excluded for failure to obtain informed consent 38%(n=20), cognitive or hearing impairment 19% (n=10), ASA-IV or V 11%(n=6), presence of stoma 11%(n=6), absence of assistance after sedation 8%(n=4), anticipated intolerance or reaction to sedatives 4%(n=2), predicted difficult airway and ventilation 4%(n=2), poor bowel preparation unable to perform the exam 4%(n=2). Midazolam induction dose started at 0.05mg/kg, plus analgesia with pethidine at initial dose of 25 mg (maximum 50 mg), titrated until achieving score 3 or 4 in Ramsay scale. Nurse-assessed Gloucester comfort scale was used for patient comfort during procedures. Patients’ satisfaction was evaluated based on a final self-completion survey: satisfaction (5 levels); remembering the start of procedure (yes/no); remembering staying awake during procedure (yes/no), pain scale (0 to 10) and repeating the procedures under the same conditions (yes/no/maybe). Statistical analysis was performed using SPSS v27 (SPSS Inc., Chicago, IL, USA).

Results

The 264 patients included had mean age 64±13 years with 53%(n=139) men. The mean BMI was 27.1±5.3 kg/m². ASA classification: Class II 58%(n=156) and class III 20.8%(n=56). Anxiety or depression disorder was noted in 21%(n=54) and obstructive sleep apnea syndrome in 6%(n=16). Use of benzodiazepines was noted in 21%(n=58) and opioids in 5%(n=14).
In total, 309 endoscopic procedures were performed: 28%(n=87) gastroscopies and 72%(n=222) colonoscopies. Midazolam induction dose per protocol was met in 59% patients (n=156). Median midazolam dose at gastroscopy was 3.0 (3.0-5.0)mg and colonoscopy 5.0 (3.0-6.0)mg; median dose of pethidine was 25mg (0-50). Sedation target (Ramsay score ≤4) was reached in 44%(n=140) and absence or slight pain was verified in 74%(n=236) cases. Adverse events were noted in 8%(n=22), the majority mild, characterized by hypotension and/or transient hypoxemia rectified with oxygen therapy; one patient needed 24 hours hospitalization due to atrial fibrillation requiring chemical cardioversion. Most patients were at least satisfied with their procedures 82,5%(n=189/229), with no pain experienced in 53% cases (n=128/240). Among those who referred pain (0 to 10), the median was 3.0 (2.0-5.0). Even though the majority did remember the start 72%(n=191) or the course 56%(n=148) of the procedures, 82%(n=216) would repeat it under the same conditions.

Conclusion

Moderate sedation by gastroenterologists is safe and effective and should be implemented in low-risk procedures with patients ASA I-III, especially in countries where NAAP is unavailable. Compliance with midazolam induction dose to achieve the sedation target is important for patient satisfaction.

References

1. Early, D. S. et al. Guidelines for sedation and anesthesia in GI endoscopy. Gastrointestinal Endoscopy 87, 327–337 (2018).
2. Dumonceau, J. M. et al. European curriculum for sedation training in gastrointestinal endoscopy: Position statement of the european society of gastrointestinal endoscopy (ESGE) and European society of gastroenterology and endoscopy nurses and associates (ESGENA). Endoscopy 45, 496–504 (2013).