Professional Statements and Societal Positions Guidelines
Practice Guidelines and Position Statements
American Society of Anesthesiologists
In 2014, the American Society of Anesthesiologists (ASA) updated its statement on the safe use of propofol:
"The Society believes that the involvement of an anesthesiologist in the care of every individual undergoing anesthesia is optimal. However, when this is not possible, non-anesthesia personnel who administer propofol should be qualified to rescue individuals whose level of sedation becomes deeper than initially intended and who enter, if briefly, a state of general anesthesia."
"Rescue" was defined as correcting "adverse physiologic consequences of the deeper-than-intended level of sedation (such as hypoventilation, hypoxia, and hypotension) and returns the individual to the originally intended level."
In 2016, ASA updated its statement on anesthetic care during interventional pain procedures. ASA indicated that:
"Many individuals can undergo interventional pain procedures without the need for supplemental sedation in addition to local anesthesia. For most individuals who require supplemental sedation, the physician performing the interventional pain procedure(s) can provide moderate (conscious) sedation as part of the procedure. For a limited number of individuals, a second provider may be required to manage moderate or deep sedation or, in selected cases other anesthesia services….
Significant anxiety may be an indication for moderate (conscious) sedation or anesthesia services. In addition, procedures that require the individual to remain motionless for a prolonged period of time and/or remain in a painful position may require sedation or anesthesia services. Examples of such procedures include but are not limited to sympathetic blocks (celiac plexus, paravertebral and hypogastric), chemical or radiofrequency ablation, percutaneous discectomy, trial spinal cord stimulator lead placement, permanent spinal cord stimulator generator and lead implantation, and intrathecal pump implantation. Major nerve/plexus blocks are performed less often in the chronic pain clinic, but the Committee believes that these blocks may more commonly require moderate (conscious) sedation or anesthesia services (e.g., brachial plexus block, sciatic nerve block, and continuous catheter techniques)."
In 2014, ASA updated its statement on respiratory monitoring during endoscopic procedures. The statement advised that "Monitoring for exhaled carbon dioxide should be conducted during endoscopic procedures in which sedation is provided with propofol alone or in combination with opioids and/or benzodiazepines, and especially during these procedures on the upper gastrointestinal tract."
American Society for Gastrointestinal Endoscopy
Guidelines on sedation during gastrointestinal endoscopy were released in 2018 by the American Society for Gastrointestinal Endoscopy (ASGE). The guidelines stated that anesthesia provider assistance during gastrointestinal endoscopy should be considered in the following situations: prolonged or therapeutic endoscopic procedures requiring deep sedation, anticipated intolerance to standard sedatives, increased risk for adverse event because of severe comorbidity (ASA class IV or V), and increased risk for airway obstruction because of anatomic variant. The guidelines made the following recommendations for the use of propofol during endoscopies:
- "A sedation team with appropriate education and training [including] at least 1 person … qualified in advanced life support skills….
- Trained personnel [for] uninterrupted monitoring of individual's clinical and physiologic parameters….
- Physiologic monitoring must include pulse oximetry, electrocardiography, and intermittent blood pressure measurement. Monitoring oxygenation by pulse oximetry is not a substitute for monitoring ventilatory function. Capnography should be considered because it may decrease the risks during deep sedation…
- Personnel should have the ability to rescue a individual who becomes unresponsive or unable to protect his or her airway or who loses spontaneous respiratory or cardiovascular function.
- Age-appropriate equipment for airway management and resuscitation must be immediately available.
- A physician should be present throughout propofol sedation and remain immediately available until the individual meets discharge criteria."
In 2015, ASGE published quality indicators for all gastrointestinal endoscopic procedures. Specific to this evidence review, ASGE stated: "Individuals administering moderate sedation should be able to rescue individuals who enter a state of deep sedation, whereas those administering deep sedation should be able to rescue inidividuals who enter a state of general anesthesia."
In 2013, ASGE published guidelines for endoscopic modification for geriatric individuals. Specific to this evidence review, ASGE recommended "standard monitoring procedures in the elderly during moderate sedation with heightened awareness of this population's increased response to sedatives."
In 2014, ASGE issued guidelines on the safety of the endoscopy unit, which made several recommendations on procedural sedation: "Staff Recommendations for intra-procedure care based on level of sedation
- No sedation-One assistant …other than the physician performing the procedure should be present to assist with the technical aspects of the procedure.
- Moderate sedation (also known as conscious sedation)-Sedation should be directed by a physician who is credentialed and privileged to do so and can be administered by an RN. During the period in which the individual is sedated, the RN must monitor the individual for vital sign changes, hypoxemia and comfort. The RN may assist with minor, interruptible tasks. In the event that more intense technical assistance is required, a second assistant (RN, LPN, or UAP [unlicensed assistive personnel]) should be available to join the care team for the technical aspects of the procedure.
- Deep sedation-Most institutions require that deep sedation be administered by ananesthesiaprofessional such as an anesthesiologist, Certified Registered Nurse Anesthetist (CRNA), or Anesthesiologist Assistant who is credentialed and privileged to do so. In this situation, theanesthesiaprovider should be responsible for administering sedation and monitoring the individual. A second staff person (RN, LPN, or UAP) is required to assist with technical aspects of the procedure."
"Recommendations for Individual Monitoring”
- All individuals undergoingendoscopyshould be monitored, the frequency of which depends on procedural and individual factors (e.g., type of sedation, duration and complexity of procedure, individual’s condition). At a minimum, monitoring should be performed before the procedure, after administration of sedatives, at regular intervals during the procedure, during initial recovery, and just before discharge.
- Units should have procedures in place to rescue individuals who are sedated deeper than intended.
- When the target level is moderate sedation (also known as conscious sedation):
- The individual assigned responsibility for inidividual monitoring may perform brief, interruptible tasks.
- Minimal monitoring requirements include electronic assessment of blood pressure, respiratory rate, heart rate, and pulse oximetry combined with visual monitoring of the individual's level of consciousness and discomfort.
- Currently, there are inadequate data to support the routine or required use of capnography during endoscopic procedures in adults when moderate sedation is the target.
- When deep sedation is targeted:
- The individual responsible for inidividual monitoring must be dedicated solely to that task and may not perform any other function during the procedure.
- The use of capnography in EUS [endoscopic ultrasound], ERCP [endoscopic retrograde cholangiopancreatography], and colonoscopy to assess the adequacy of ventilation may reduce the incidence of hypoxemia and apnea, but its impact on the frequency of other sedation-related adverse events such as bradycardia and hypotension is unknown. As such, capnography may be considered for the performance ofendoscopyunder deep sedation. However, there is no safety data to date to support the universal use of capnography in such cases.
- Documentation of the clinical assessments and monitoring data during sedation and recovery is required."
In 2009, ASGE-along with the American Association for the Study of Liver Diseases, American College of Gastroenterology, and American Gastroenterological Association-issued a joint position statement on non-anesthesiologist administration of propofol (NAAP) for gastrointestinal endoscopy. The societies found that NAAP was as safe and effective as anesthesiologist-administered propofol. They asserted that proper training and proper individual selection were necessary for the safe practice of NAAP sedation.
European Society of Gastrointestinal Endoscopy et al
The European Society of Gastrointestinal Endoscopy, as well as the European Society of Gastroenterology and Endoscopy Nurses and Associates, updated their guidelines on NAAP in 2015. Table 2 summarizes the main recommendations.
Table 2. Recommendations on NAAP for GI Endoscopy
1. Before NAAP, individual assessment of physical status, age, body mass index, Mallampati's classification, and obstructive sleep apnea risk factors
2. Primary involvement of an anesthesiologist for high risk individualsa
3. Capnographic monitoring in high risk individuals, intended deep sedation, and long procedures
4. Propofol monotherapy except in particular situations
5. Administration of propofol through intermittent bolus infusion or perfusor systems, including target-controlled infusion and individual-controlled sedation
6. Individual listen to self-selected music during upper and lower GI endoscopy procedures
7. Do not use pharyngeal anesthesia during propofol sedation for upper GI endoscopy
8. Use post-anesthetic discharge scoring system to determine individualdischarge
9. For individuals of ASA class >2, upon discharge, individualshould be accompanied by a responsible person and refrain from driving, drinking alcohol, operating heavy machinery, or engaging in legally binding decisions for 24 hours. Advice should be provided verbally and in written form
10. For individuals of ASA classes 1-2 who have received low-dose propofol monotherapy, a 6-hour limit is suggested
ASA: American Society of Anesthesiologists; GI: gastrointestinal; NAAP: non-anesthesiologist-administered propofol; QOE: quality of evidence; SOR: strength of recommendation.
aASA class ≥3, with a Mallampati's class ≥3 or other conditions that put them at risk of airway obstruction, in individuals receiving significant amounts of narcotic analgesics, or in long-lasting procedures.