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Endoscopy Practice and Safety

Editor: Peter B. Cotton ed.

3. Sedation, Analgesia, and Monitoring for Endoscopy

John J. Vargo

Top of page Synopsis  Next section

This chapter will review the definitions encompassing the spectrum of sedation as outlined by the American Society of Anesthesiologists. Particular emphasis will be given to the reversal of deeper than intended states of sedation. Extended monitoring of respiration with transcutaneous carbon dioxide measurement and capnography will then be reviewed. The application of bispectral index (BIS) monitoring, which represents a complex mathematical evaluation of electroencephalographic parameters of frontal cortex activity will then be reviewed. Trials utilizing topical anesthetics, the bolus administration of meperidine and midazolam via dosing nomograms as well as the use of droperidol will then be addressed. The emerging use of the anesthetic agent propofol by non-anesthesiologists for endoscopy will then be critically reviewed.

Top of page Introduction  Previous section Next section

'Sedation and analgesia' represents a continuum ranging from minimal sedation or anxiolysis through general anesthesia. In this era of open access endoscopy, candidacy for sedation and analgesia still must take into account a thorough preprocedure assessment including a history of present illness, past medical history, and a physical examination [1]. New practice guidelines put forth by the American Society of Anesthesiologists Committee for Sedation and Analgesia by Non-Anesthesiologists, have classified both moderate and deep sedation and analgesia to the continuum of sedation (Fig. 1) [2].

Moderate sedation  Previous section Next section

In most endoscopic cases, moderate sedation is the goal. This is defined by the patient giving a purposeful response after verbal or tactile (not painful) sensation, and no compromise of the patient's airway, ventilation, or cardiovascular function.

Deep sedation/analgesia  Previous section Next section

In this state, patients may respond only to painful stimuli. Additionally, the patient's airway and spontaneous ventilation may become compromised, and hence, personnel must be designated for the complete and uninterrupted observation of the patient's respiratory and cardiovascular status.

An important component of these guidelines is that the endoscopy team must have the ability to rescue the patient from deeper than expected levels of sedation/analgesia.

Top of page Advances in monitoring during sedation  Previous section Next section

Cardiorespiratory complications are a leading cause of morbidity and mortality associated with gastrointestinal endoscopy. Both ventilatory depression and oxygen desaturation stemming from the medications used to achieve sedation and analgesia are thought to be important risk factors for these complications.

Standard pulse oximetry  Previous section Next section

Pulse oximetry has become a defining standard of care during sedation and analgesia for endoscopy, owing to the evidence that clinical observation alone is inaccurate in the detection of hypoxemia and that supplemental oxygen can minimize the degree of desaturation and hopefully its deleterious effects. To date, neither pulse oximetry nor supplemental oxygen administration has yet been shown to decrease the severity or incidence of cardiopulmonary complications.

CO2 monitoring  Previous section Next section

It is important to point out that pulse oximetry does not measure alveolar hypoventilation, which is measured by hypercapnea or a rise in arterial carbon dioxide pressure.[3–6] Although oxygen administration may prevent hypoxemia and its deleterious effects, it will not detect the development of hypercapnea. Deleterious consequences of alveolar hypoventilation include myocardial depression, acidosis, intracranial hypertension, narcosis, and arterial hypertension or hypotension.

Transcutaneous CO2 monitoring  Previous section Next section

Transcutaneous CO2 monitoring (PtCO2) is a non-invasive method for measuring arterial CO2. An electrode is placed on the skin, which is heated to 'arterialize' the microcirculation. CO2 then diffuses through the skin and into an electrolyte solution at the skin/electrode interface, and so produces carbonic acid. A pH reading is then taken and the CO2 value is obtained via the Henderson-Hasselbach equation.

Nelson et al. randomized 395 patients undergoing ERCP to standard monitoring coupled with transcutaneous CO2 monitoring guiding sedation and analgesia (group 1) or to standard monitoring alone in which the endoscopist was blinded to the PtCO2 data (group 2) [3]. Significantly more group 2 patients experienced carbon dioxide retention > 40 mmHg above baseline values. Predictors for peak PtCO2 included baseline PtCO2 value, the use of naloxone, the maximum fall in oxygen saturation via pulse oximetry, maximum supplemental oxygen rate, and the combination of a benzodiazepine and an opioid for sedation and analgesia. There was a poor correlation between clinical observation and objective measures of ventilation.

Capnography  Previous section Next section

Capnography is based on the principle that carbon dioxide absorbs light in the infrared region of the electromagnetic spectrum. Quantification of the absorption leads to the generation of a curve, which represents a real-time display of the patient's respiratory activity. In a case series of 49 patients undergoing prolonged upper endoscopic procedures, capnography was found to be more sensitive than pulse oximetry or visual assessment in the detection of apneic episodes [5]. In a series of 80 colonoscopy patients who were randomized to undergo the procedure with and without supplemental oxygen, extended monitoring with capnography was employed [6]. The endoscopist and nursing personnel were blinded to the capnography data. Though the number of apneic events was similar between the two groups, significantly more episodes of apnea were missed in the group receiving oxygen (7% vs. 42%, p < 0.001). Moreover, significantly more patients receiving supplemental oxygen received sedation following an apneic episode. Capnography has also been utilized to allow the safe titration of propofol by a qualified gastroenterologist during ERCP and Endoscopic Ultrasonography (EUS).

BIS monitoring  Previous section Next section

Bispectral index (BIS) monitoring represents a complex mathematical evaluation of electroencephalographic parameters of frontal cortex activity, corresponding to varying levels of sedation. The BIS scale varies from 0 to 100 (0, no cortical activity or coma; 40–60, unconscious; 70–90, varying levels of conscious sedation; 100, fully awake). Theoretically this index should reflect the same level of sedation regardless of the medications used, except for ketamine. In a preliminary observational study involving 50 patients undergoing ERCP, colonoscopy, and upper endoscopy, BIS levels were found to correlate with a commonly used score for the degree of sedation [7]. A BIS range of 75–85 demonstrated a probability of >= 96% that the patient would exhibit an acceptable sedation score. However, there was increasing variability of the BIS score with deeper levels of sedation. Additionally, there was no correlation between the BIS score and standard physiologic parameters such as pulse oximetry, blood pressure, or heart rate.

Top of page Topical anesthetics: are they worth the effort?  Previous section Next section

Prospective, randomized controlled trials addressing the use of topical anesthetics during upper endoscopy for improved patient tolerance have been mixed (Fig. 2) mixed [8–13]. Existing study designs differ in the presence of double-blinding, the type of topical anesthetic employed, endoscope diameter, and the use of conscious sedation. Soma et al. recently conducted a study of 201 Japanese patients who were randomized to receive either 2% lidocaine or placebo [8]. No conscious sedation was employed. Multivariate analysis found that the use of topical anesthesia reduced the relative risk of discomfort by 44% (95% CI: 0.31–1.01). Patient age less than 40 was associated with a higher relative risk of discomfort (RR 2.22, 95% CI: 1.04–4.74). Subgroup analysis found that patients less than 40 years of age who were pretreated or those undergoing endoscopy for the first time benefited most from topical anesthesia.

Top of page Titration vs. bolus administration of sedation and analgesia  Previous section Next section

Practice guidelines call for the call for the careful titration of sedative medications using small, incremental doses and allowing sufficient time between doses to assess effect [1]. Morrow et al.,utilizing a dosing nomogram based on the age and weight, performed a prospective, randomized, double-blind trial comparing bolus vs. titration dosing of meperidine and midazolam for outpatient colonoscopy [14]. Exclusion criteria included age < 18 years or > 65 years, active use of narcotics or benzodiazepines, pulmonary disease requiring home oxygen, end-stage liver or kidney disease, and a New York State Heart Association class III or IV congestive heart failure. The groups were well matched in terms of demographics. Patient tolerance scores were equivalent between both groups. Physician time was significantly shorter in the bolus group (20.1 vs. 32.2 min, p < 0.001). Episodes of oxygen desaturation occurred significantly more often in the titration group. Further evaluation of bolus administration is needed for patients undergoing upper endoscopy and prolonged therapeutic procedures such as ERCP and endoscopic ultrasonography.

Top of page Propofol  Previous section Next section

Propofol is classified as an ultrashort acting sedative hypnotic agent that provides amnesia, but minimal levels of analgesia. Propofol rapidly crosses the blood–brain barrier, and causes a depression in consciousness that is thought to be related to a potentiation of the γ-aminobutyric acid activity in the brain. Typically, the time from injection to the onset of hypnosis is 30–60 s, which is essentially the time for one arm–brain circulatory pass [15]. The plasma half-life ranges from 1.3 to 4.13 min. Dose reduction is required in patients with cardiac dysfunction and in the elderly due to decreased clearance of the drug. Propofol potentiates the effects of narcotic analgesics and sedatives such as benzodiazepines, barbiturates, and droperidol and therefore the dose requirements may be reduced.

Problems with propofol  Previous section Next section

Pain at the injection site is the most frequent local complication, occurring in up to 5% of patients.

Episodes of severe respiratory depression necessitating temporary ventilatory support have occurred in large series utilizing propofol for endoscopic procedures [16–18]. Capnography has been successfully used to graphically assess the respiratory activity in patients receiving gastroenterologist-administered propofol for therapeutic upper endoscopy [19,20]. Monitoring with graphic assessment of respiratory activity detected early phases of respiratory depression, resulting in a timely decrease in the propofol infusion without significant hypoxemia, hypercapnea, hypotension, or arrhythmias.

Specific training for use of propofol  Previous section Next section

Propofol has a narrow therapeutic window—its administration, even in the hands of an anesthesiologist, does not prevent the occurrence of severe respiratory compromise [2]. It cannot be overemphasized enough that personnel specifically trained in the administration of propofol with expertise in emergency airway management need to be present during the procedure, constantly monitoring the patient's physiologic parameters. In this author's opinion, the use of propofol usually results in a state of deep sedation and analgesia. It is our practice to utilize nasopharyngeal capnography to detect early signs of respiratory depression such as apnea, which would otherwise, go undetected by standard pulse oximetry [19,20]. The presence of a person who is dedicated to the administration of propofol and the uninterrupted monitoring of the patient's physiologic parameters is another important requirement [19,20].

Contraindications of propofol  Previous section Next section

Specific contraindications to propofol administration include allergies to propofol or any of the emulsion components, pregnant or lactating females, and patients with an American Society of Anesthesiologists IV or V physical status classification [15].

Clinical trials of propofol  Previous section Next section

Propofol or midazolam?  Previous section Next section

Upper endoscopy  Previous section Next section

In a randomized study, 90 patients received a bolus administration of propofol or midazolam both before and during upper endoscopy [21]. The propofol treatment arm was superior in terms of patient tolerance, maximum level of sedation achieved, and shorter recovery room times. In contrast, a smaller series of 40 patients randomized to receive the same medications before upper endoscopy found that propofol provided a more rapid recovery room time, but was also associated with pain at the injection site, reduced patient acceptance, and a shorter amnesia span [22].

ERCP  Previous section Next section

Two randomized, controlled trials have compared propofol alone to midazolam specifically for ERCP [16,23]. In one study, an anesthesiologist administered propofol; in the second study, an assisting physician who was not involved in the endoscopic procedure administered propofol. In both studies, patients receiving propofol exhibited significantly improved quality of sedation and shorter recovery times. Untoward effects such as hypotension and hypoxemia occurred equally in both treatment groups. However, it is important to point out that in both series, one patient in the propofol group developed prolonged apnea that necessitated discontinuation of the procedure and temporary ventilatory support.

Upper endoscopy and colonoscopy  Previous section Next section

Koshy et al. compared the combination of propofol and fentanyl to midazolam and meperidine in a non-randomized group of 274 patients undergoing upper endoscopy and colonoscopy [24]. Propofol and fentanyl led to better patient comfort and deeper sedation without an increase in untoward side-effects. There was not, however, a significant difference in the recovery times between the two groups.

Propofol with or without midazolam  Previous section Next section

A prospective, randomized trial compared the efficacy of propofol alone to the combination of midazolam and propofol in 239 patients undergoing therapeutic upper endoscopy or ERCP [25]. While sedation efficacy and the incidence of hypotension and hypoxemia were comparable in both groups, patients receiving midazolam and propofol exhibited a significantly longer mean recovery time.

Patient-controlled administration of propofol  Previous section Next section

Patient-controlled sedation and analgesia (PCS) with propofol has recently gained in popularity. Kulling et al. randomized 150 patients to three sedation arms: PCS with propofol/alfentanil (group I), continuous propofol/alfentanil infusion (Group II), and nurse-administered midazolam/meperidine (Group III) [26]. Group I exhibited a higher degree of patient satisfaction and more of a complete recovery at 45 min when compared to conventional sedation and analgesia. In a similar study, Ng and colleagues randomized 88 patients undergoing colonoscopy to PCS with propofol alone or midazolam [27]. Patients receiving propofol PCS exhibited significantly shorter recovery times (43.3 min vs. 61.0 min) and improved satisfaction with overall level of comfort. PCS for ERCP however, has not been as successful. In a pilot study utilizing a software system designed to deliver a 'ceiling' for the plasma propofol concentration, only 80% of patients received a safe and fully effective sedation [28].

Nurse-administered propofol  Previous section Next section

The safety and experience with propofol administered by registered nurses has been addressed in a case series including 2000 patients undergoing elective EsophagoGastroDuodenoscopy (EGD) and/or colonoscopy [17]. All patients were ASA class I or II. No extended monitoring was used and all patients received 3 L of nasal cannula oxygenation. The propofol dosage was an initial bolus of 20–40 mg, followed by 10–20 mg to maintain sedation. Five episodes of oxygen desaturation to < 85%, four of which required temporary mask ventilation, occurred. Four of these episodes occurred during upper endoscopy. Propofol has been compared in a prospective, randomized trial to midazolam and meperidine in 80 ASA Class I or II outpatients undergoing elective colonoscopy [18]. Propofol was superior in terms of the rapidity and depth of sedation, recovery times, and overall satisfaction. Additionally, patients receiving propofol exhibited improved recovery of psychometric function

Gastroenterologist-administered propofol  Previous section Next section

Vargo et al. completed a randomized, controlled trial of gastroenterologist-administered propofol vs. meperidine and midazolam for elective ERCP and EUS [20]. In this study, a separate gastroenterologist, who was trained in propofol administration, was utilized. Additionally, capnography was used to detect apnea or hypercapnea, and thus adjust the propofol dosing accordingly. This study was also the first to address issues of cost effectiveness from an institutional standpoint. Visual analog scales (VAS) were used to address patient and endoscopist satisfaction. Patients randomized to propofol exhibited a faster mean recovery time (18.6 vs. 70.5 min), could perform independent transfer following the procedure and were able to achieve a baseline return to a baseline food intake and activity level (71% vs. 16%). Cost effectiveness data with a sensitivity analysis found that nurse-administered propofol to be the dominant strategy, when compared to standard sedation and analgesia.

Top of page Droperidol  Previous section Next section

Droperidol, a narcoleptic of the butyrophenone class, produces a dissociative state while enhancing the effects of other sedative medications. It is routinely used in some centres as a premedication for patients undergoing ERCP. Other indications include: a history of alcohol use or withdrawal, narcotic use, and a history of paradoxical agitation to conventional conscious sedation. In a retrospective study involving 1102 procedures, droperidol was found to be a safe adjunct to the combination of narcotics and benzodiazepines [29].

In a prospective, double-blind, placebo-controlled trial, in 140 patients undergoing elective upper endoscopy, droperidol led to a 10% reduction in procedure time and significantly reduced meperidine and midazolam requirements [30]. However, four patients in the droperidol group received naloxone for excessive drowsiness. Rizzo et al. addressed the use of different doses of droperidol in patients undergoing EUS [31]. When compared to placebo, 5 mg of droperidol led to significantly less medication costs, while at the same time, not affecting the mean recovery time.

Complications  Previous section Next section

Complications attributable to droperidol occurred in 1.5% of procedures and was comprised mainly of hypotension, responsive to IV fluids. Reports of QT interval prolongation and torsades des pointes have occurred, at or below the recommended doses resulting in death. Some of these cases have occurred in patients without risk factors for QT interval prolongation. This prompted the Food and Drug Administration to issue a 'black box' warning which will severely curtail the use of this drug in the endoscopy suite [32].

Top of page Outstanding issues and future trends  Previous section Next section

The importance of preprocedural assessment and appropriate monitoring cannot be overemphasized. The endoscopist must have a thorough knowledge of the pharmacology of the agents used for sedation and the training necessary to recognize and manage oversedation. Numerous regulatory groups are carefully scrutinizing the practice of sedation and analgesia. It appears that ventilatory monitoring will be required for at least a subset of our patients. Although both hypercapnea and apnea can be reliably measured, the most important questions to be answered are: will such monitoring affect patient outcomes, and which patients are at risk for apnea and alveolar hypoventilation?

The use of propofol for gastrointestinal endoscopy has been shown to be safe in experienced hands. Its narrow therapeutic window demands that specially trained personnel who are not directly involved in the endoscopic procedure administer it. Controversy exists over nurse-administered propofol. Currently only a minority of states allow this practice. The use of anesthesia personnel to administer propofol while safe and increasing the throughput of the endoscopy suite is quite costly. It is doubtful that third-party payers will approve of this practice on a large scale. Extended monitoring with capnography appears to offer an advantage over conventional monitoring in that it can detect early phases of respiratory depression, which can allow for a timely adjustment in the propofol infusion and thus prevent significant respiratory depression. Emerging cost effectiveness data suggests that propofol is superior to conventional sedation and analgesia, even with the use of added personnel. In the future, 'smart machines' which utilize software-driven algorithms, based on the physiologic feedback from standard and extended monitoring devices may lead to the practical, safe, and universal acceptance of propofol in the endoscopy suite.

Top of page References  Previous section

 1 ASGE Standards of Practice Committee. Sedation and monitoring of patients undergoing gastrointestinal endoscopic procedures. Gastrointest Endosc 1995; 42: 626–9. PubMed

 2 Gross, JB, Bailey, PL, Caplan, RA, Connis, RT, Cote, CJ & Davis, FG et al. Practice guidelines for sedation and analgesia by non-anesthesiologists. Anesthesiology 2002; 96: 1004–17. PubMed

 3 Nelson, DB, Freeman, ML, Silvis, SE, Cass, OW & Yashke, PN et al. A randomized, controlled trial of transcutaneous carbon dioxide monitoring during ERCP. Gastrointest Endosc 2000; 51: 288–95. PubMed

 4 Vargo, JJ, Zuccaro, G, Dumot, JA, Conwell, DL, Morrow, JB & Shay, SS. Automated assessment of respiratory activity is superior to pulse oximetry and visual assessment for the detection of early respiratory depression during therapeutic upper endoscopy. Gastrointest Endosc 2002; 55: 826–31. PubMed

 5 Vargo, JJ, Zuccaro, G, Dumot, JA, Morrow, JB, Conwell, DL, Shermock, K, Trolli, PA & Maurer, WG. A prospective, randomized trial of gastroenterologist-administered propofol versus meperidine and midazolam for complex upper endoscopic procedures. Gastrointest Endosc 2001: 53: AB79.

 6 Zuccaro, G, Radaelli, F & Vargo, J et al. Routine use of supplemental oxygen prevents recognition of prolonged apnea during endoscopy. Gastrointest Endosc 2000: 51: AB141.

 7 Bower, AL, Ripepi, A, Dilger, J, Bopari, N, Brody, FJ & Ponsky, JL. Bispectral index monitoring of sedation during endoscopy. Gastrointest Endosc 2000; 52: 192–6. PubMed

 8 Soma, Y, Saito, H, Kishibe, T, Takahashi, T, Tanaka, H & Munakata, A. Evaluation of topical pharyngeal anesthesia for upper endoscopy including factors associated with patient tolerance. Gastrointest Endosc 2001; 53: 14–8. PubMed

 9 Cantor, D & Baldridge, E. Premedication with meperidine and diazepam for upper gastrointestinal endoscopy precludes the need for topical anesthesia. Gastrointest Endosc 1986; 32: 339–41. PubMed

10 Hedenbro, JL, Ekelund, M, Jansson, O & Lindblom, A. A randomized, double-blind, placebo-controlled study to evaluate topical anesthesia of the pharynx in upper gastrointestinal endoscopy. Endoscopy 1992; 24: 585–7. PubMed

11 Chuah, SY, Crowson, CP & Dronfield, MW. Topical anesthesia in upper gastrointestinal endoscopy. BMJ 1991; 303: 695. PubMed

12 Gordon, MJ, Mayes, GR & Meyer, GW. Topical lidocaine in preendoscopic medication. Gastroenterology 1976; 71: 564–9. PubMed

13 Lachter, J, Jacobs, R, Lavy, A, Weisler, A, Suissa, A, Enat, R & Edelman, S. Topical anesthesia for easing endoscopy: a double-blind, randomized, placebo-controlled study. Gastrointest Endosc 1990; 36: 19–21. PubMed

14 Morrow, JB, Zuccaro, G, Conwell, DL, Vargo, JJ & Dumot, JA et al. Sdeation for colonoscopy using a single bolus is safe, effective, and efficient: a prospective, randomized, double-blind trial. Am J Gastroenterol 2000; 95: 2242–7. PubMed

15 Vargo, JJ. Propofol in the endoscopy suite: panacea or Pandora's box? Clin Pers Gastroenterol 2001; 2: 117–9.

16 Wehrmann, T, Kokapick, S & Lembcke, B et al. Efficacy and safety of intravenous propofol sedation for routine ERCP: a prospective, controlled study. Gastrointest Endosc 1999; 49: 677–83. PubMed

17 Rex, DK, Sipe, BW, Kniser, KM & Rahmani, EY. Safety of propofol administered by registered nurses with gastroenterologist supervision in 2,000 endoscopic cases. Am J Gastroenterol 2002; 97: 1159–63. PubMed

18 Sipe, BW, Rex, DK, Latinovich, D, Overly, C, Kisner, K, Bratcher, L & Kareken, D. Propofol versus midazolam/meperidine for outpatient colonoscopy: administration by nurses supervised by endoscopists. Gastrointest Endosc 2002; 55: 815–25. PubMed

19 Vargo, JJ, Zuccaro, G & Dumot, JA et al. Gastroenterologist-administered propofol for therapeutic upper endoscopy with graphic assessment of respiratory activity: a case series. Gastrointest Endosc 2000; 52: 250–5. PubMed

20 Vargo, JJ, Zuccaro, G & Dumot, J et al. Gastoenterologist-administered propofol versus meperidine and midazolam for ERCP and EUS. A randomized, controlled trial with cost effectiveness analysis. Gastroenterology 2002; 123: 8–16. PubMed

21 Carlsson, U & Grattidge, P. Sedation for upper gastrointestinal endoscopy: a comparative study of propofol and midazolam. Endoscopy 1995; 27: 240–3. PubMed

22 Patterson, KW, Casey, PB & Murray, JP et al. Propofol sedation for outpatient upper gastrointestinal endoscopy: comparison with midazolam. Br J Anaesth 1991; 67: 108–11. PubMed

23 Jung, M, Hofmann, C, Kiesslich, R & Brakertz, A. Improved sedation in diagnostic and therapeutic ERCP: propofol is an alternative to midazolam. Endoscopy 2000; 32: 233–8. PubMed

24 Koshy, G, Nair, S & Norkus, EP et al. Propofol versus midazolam and meperidine for conscious sedation in GI endoscopy. Am J Gastroenterol 2000; 95: 1476–9. PubMed

25 Seifert, H, Schmitt, T & Gultekin, T et al. Sedation with propofol plus midazolam versus propofol alone for interventional endoscopic procedures: a prospective, randomized study. Aliment Pharmacol Ther 2000; 14: 1207–14. PubMed

26 Kulling, D, Fantin, AC, Biro, P, Bauerfeind, P & Fried, M. Safer colonoscopy with patient-controlled analgesia and sedation with propofol and alfentanil. Gastrointest Endosc 2001; 54: 1–7. PubMed

27 Ng, JM, Kong, CF & Nyam, D. Patient-controlled sedation with propofol for colonoscopy. Gastrointest Endosc 2001; 54: 8–13. PubMed

28 Gillham, M, Hutchinson, R, Carter, R & Kenney, NC. Patient-maintained sedation for ERCP with a target-controlled infusion of propofol: a pilot study. Gastrointest Endosc 2001; 54: 14–7. PubMed

29 Wilcox, CM, Forsmark, CE & Cello, JP. Utility of droperidol for conscious sedation in gastrointestinal endoscopic procedures. Gastrointest Endosc 1989; 36: 112–5.

30 Barthel, JS, Marshall, JB, King, PD, Afridi, SA, Gibb, LG & Madsen, R. The effect of droperidol on objective markers of patient cooperation and vital signs during esophagogastroduodenoscopy: a randomized, double blind, placebo-controlled prospective investigation. Gastrointest Endosc 1995; 42: 45–50. PubMed

31 Rizzo, J, Bernstein, D & Gress, F. A randomized, double-blind, placebo-controlled trial evaluating the cost effectiveness of droperidol as a sedative for EUS. Gastrointest Endosc 1999; 50: 178–82. PubMed

32 FDA information on Droperidol

Copyright © Blackwell Publishing, 2004

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  A (very) brief history of endoscopy
  Professionalism and quality
Unit design
  Space planning
   Daily room volumes
   Procedure room size
   Preparation and recovery ratios
   Separate entrances
   Common space problems
  Physical infrastructure
  Intake and recovery areas
   Intake areas
   Managing clothes and valuables
   Recovery facilities
  Procedure room reprocessing and storage
   Standard procedure rooms
   Scope reprocessing and storage
   Patient flow issues
   Complex procedure rooms
   Storage of supplies and medications
   Travel carts for emergencies
Unit management
  Major areas of responsibility
  Staffing design
   Staffing emergencies
  Procedure schedules
   Relative time requirements
   Barriers to efficiency
   How many endoscopes?
   Endoscope repair costs
  Endoscope reprocessing
  Coding and billing
Outstanding issues and future trends
  Capsule endoscopy
  Colon screening technologies
  Endoscopy by non-specialists
  Growth of advanced endoscopy
  Moderate sedation
  Deep sedation/analgesia
Advances in monitoring during sedation
  Standard pulse oximetry
  CO2 monitoring
   Transcutaneous CO2 monitoring
  BIS monitoring
Topical anesthetics: are they worth the effort?
Titration vs. bolus administration of sedation and analgesia
  Problems with propofol
  Specific training for use of propofol
  Contraindications of propofol
  Clinical trials of propofol
   Propofol or midazolam?
   Upper endoscopy
   Upper endoscopy and colonoscopy
   Propofol with or without midazolam
   Patient-controlled administration of propofol
   Nurse-administered propofol
   Gastroenterologist-administered propofol
Outstanding issues and future trends
Gastrointestinal endoscopes
  Endoscope design
   Control section
   Insertion tube
   Connector section
   Light source/processors
  Endoscope equipment compatibility
  Endoscope categories
   Esophagogastroduodenoscope (gastroscope)
   Wireless capsule endoscopy
Gastrointestinal endoscopic accessories
  Tissue sampling
   Biopsy forceps
   Single-bite cold-biopsy forceps
   Biopsy cup jaws
   Multi-bite forceps
   Other specialty forceps
   Monopolar hot biopsy forceps
   Reusable vs. disposable biopsy
   Cytology brushes
   Needle aspiration
  Polypectomy snares
  Retrieval devices
  Injection devices
   Injection needles
   Spray catheters
   ERCP catheters
  Hemostatic and ablation devices
   Contact and non-contact thermal devices
   Heater probe
   Laser fibers
   Argon plasma beam coagulator
   Mechanical hemostatic devices
   Band ligation
   Metallic clip application via flexible endoscopes
   Marking with clips
   Detachable loops
  Transparent cap
  Dilation devices
   Push-type fixed-diameter dilators
   Hurst and Maloney dilators
   Savary-type dilators
   American Dilation System dilators
   TTS fixed diameter dilators
   Threaded-tip stent retrievers
   Radial expanding balloon dilators
   TTS dilators
  Achalasia balloon dilators
Outstanding issues and future trends
  Fiberoptic imaging
   Teaching attachments and photography
   Image capture
   Standardized image terminology
   Structured reporting
   The opportunities and challenges of the digital revolution
Digital imaging
  Imaging the gastrointestinal tract using a videoendoscope requires several steps
  Color models
Digitization of color
Color depth
Pixel density
File size
  What detail is needed?
  File compression
  Compression techniques
   Lossless compression
   Lossy compression
  Image file formats
  Color and black and white compression
  JPEG 2000 and beyond
DICOM standard
  Information Objects
   Patient name attributes
  DICOM conformance
  DICOM in endoscopy
  Expanding the scope of DICOM
How much compression is clinically acceptable?
  Studies of compression acceptability
   Vakil and Bourgeois
   Kim (personal communication)
  Developments in compression
Still pictures or live video?
  Video storage developments
What images should be recorded in practice?
  Lesion documentation
  Recording negative examinations
  Structured image documentation
  Costs of image documentation
Image enhancement
  Color manipulation
  Narrow band imaging and spectroscopy
Terminology standardization
  OMED standardized terminology
  Minimal standard terminology—MST
   Problems with MST
Outstanding issues and future trends
Editor's note
Relevant thermal effects in biological tissues
  Thermal devitalization
  Thermal coagulation
  Thermal desiccation
  Thermal carbonization
  Thermal vaporization
Generation of temperature in thermal tissue
  Heater probe
  High-frequency surgery
   General principles of high-frequency electric devices
   Electric arcs
Principles of high-frequency surgical coagulation
  Monopolar coagulation instruments
  Electro-hydro-thermo probes
  Bipolar coagulation instruments
Principles of high-frequency surgical cutting with particular regard to polypectomy
Technical aspects of polypectomy
  Polypectomy snares
  The polypectomy snare handle
  Polypectomy snare catheters
Safety aspects of high-frequency surgery
Argon plasma coagulation
  The principle of argon plasma coagulation
  Equipment for argon plasma coagulation
  Safety aspects of argon plasma coagulation
  Principle of Nd:YAG laser
  Specific characteristics of Nd:YAG lasers in flexible endoscopy
Safety aspects of Nd:YAG laser in flexible endoscopy
Sterilization and disinfection
  High-level disinfection
  What level of disinfection is required?
   Critical items
   Semi-critical items
  The practical problem
  The organisms
  The critical points in reprocessing
Risks of infections associated with endoscopic procedures
  Mechanisms of infection
  Clinical infections
   Infecting organisms
   Vegetative bacteria
   Clostridium difficile
   Mycobacterium tuberculosis
   Atypical mycobacteria
   Serratia marcescens
   Helicobacter pylori
   Human immunodeficiency virus (HIV)
   Hepatitis B
   Hepatitis C (HCV)
   What to do in practice about CJD?
   New variant CJD (vCJD)
   Other infections
  The endoscopic procedures
   Upper gastrointestinal endoscopy
   Lower gastrointestinal endoscopy
   Endoscopic retrograde cholangiopancreatography
   Percutaneous endoscopic gastrostomy
   Endoscopic ultrasound
  Host factors
   Immune competence
   The degree of tissue damage
   Intrinsic sources of infection
   Damaged valves and implants
Antibiotic prophylaxis for endoscopic procedures
  Principles of prevention of bacterial endocarditis
  High risk cardiovascular conditions [43]
  Moderate risk cardiovascular conditions [43]
  Recommendations for antibiotic prophylaxis
   Who should receive antibiotics?
   Clinical problems where opinions diverge
   What antibiotic regimen?
Antibiotic prophylaxis for ERCP
  Prophylactic antibiotic regimens for ERCP
Principles of effective decontamination protocols
  Cleaning is essential
  Effectiveness of recommended protocols
  Endoscope structure
   Common features
   External features
   Common internal features
   Special internal features
   Cleaning equipment
   Cleaning fluids
   Soaking time
   General maintenance
   Work areas
Reprocessing regimens
  Disinfect before and after procedures
  Manual cleaning
  Manual disinfection
  At the end of the list
  Endoscopic accessory equipment
   Cleaning accessories
   Special accessory items
   Sclerotherapy needles
   Water bottles and connectors
Problem areas in endoscope reprocessing
  Rinsing water
   Poor quality water
   Infections from rinsing water
   Bacteria free water
   Water testing
   Recommendations for rinsing water
Variation in cleaning and disinfection regimens depending upon the supposed infective status of the patient
Compliance with cleaning and disinfection protocols
The investigation of possible endoscopy infection transmission incidents
  Common causes
  Golden rules for investigating potential infection incidents
  The investigation process
  Transmission of viral disease
Automatic flexible endoscope reprocessors (AFERs)
  Machine design and principles
   Water supply
   Alarm function
   Fume containment
   Disinfectant supply
   Reprocessing time
   AFERs cannot guarantee to sterilize endoscopes
   Plumbing pathway
   Rinse and dry cycle
   Regular bacteriological surveillance
Quality control in endoscope reprocessing
  Quality control measures
Microbiological surveillance in endoscopy
  Testing procedures
  Interpretation of cultures
  Microbiological surveillance of AFERs
Outstanding issues and future trends
The contract with the patient; informed consent
  Educational materials
What are 'risks' and 'complications'?
  Threshold for 'a complication'
  Timing of unplanned events
  Direct and indirect events
  Data set for unplanned events
General issues of causation and management
  Technical and cognitive performance
  Fitness for procedures
   ASA score
   Other risk indices
  Prompt recognition and management
   Act promptly
  Specific unplanned events
   Failure to diagnose
   Risk factors
   Risk factors
   Cardiopulmonary and sedation complications
   Allergic reactions
   IV site issues
   Miscellaneous and rare events
Preventing unplanned events
Outstanding issues and future trends
Gastroenterologist–pathologist communication
  Endoscopist communication responsibility
  Pathologist communication responsibility
  Question-orientated approach
  Common terminology
Endoscopic biopsy specimens
  Specimen handling and interpretation issues
   Number of biopsies per container
   Tissue processing
   Prep-induced artifact
   Endoscopy-induced artifacts
   Biopsy-induced artifacts
   Crush artifact
   Burn/cautery artifact
   Endoscopic mucosal resection
   Core biopsy
  Regular stains
Exfoliative and fine-needle cytology
  Specimen handling; staining and fixation
   Cytological diagnosis
  Fine-needle aspiration
Organ system overview
   Where and when to biopsy
   Gastroesophageal reflux disease
   Barrett's esophagus
   Infective esophagitis
   Herpes simplex virus
   Adenocarcinoma and squamous cell carcinoma
   Where and when to biopsy
   Inflammatory conditions; gastritis
   H.pylori gastritis
   Hypertrophic folds
   Mass lesions
  Small bowel
   Celiac sprue
   Infective enteropathies
   Whipple's disease
   Mycobacterium avium–intracellulare
   Giardia lamblia
   Mass lesions
   Defining 'normal'
   Inflammatory colitides
   Normal colonoscopy
   Abnormal colonoscopy
   Inflammatory bowel disease
   Pseudomembranous colitis
   Ischemic colitis
   Mass lesions
Special stains
  Histochemical stains
  Immunohistochemical stains
  In situ hybridization
  Flow cytometry
  Electron microscopy
  Molecular pathology
Outstanding issues and future trends
The endoscopy facility and personnel
  Endoscopy facility
   Endoscopy instruments
   Ancillary equipment
   The endoscopist
   Nursing and ancillary personnel
The pediatric patient and procedural preparation
  Patient preparation
   Psychological preparation
   Medical preparation
   Recommendations for fasting
   Bowel preparation
   Antibiotic prophylaxis
  Informed consent
Endoscopic procedures currently performed in pediatric patients
  Indications and limitations
  Patient sedation
  Endoscopic technique
   Therapeutic endoscopy
   Other endoscopic modalities
   Small bowel enteroscopy
   Wireless capsule endoscopy
   Endoscopic ultrasonography
   Endoscopic retrograde cholangiopancreatography (ERCP)
Selected gastrointestinal pathologies in pediatric patients
  Eosinophilic esophagitis
  Food allergic enteropathy and colitis
  Foreign body ingestion
  Helicobacter pylori gastritis
  Polyps in the pediatric patient
  Lymphonodular hyperplasia
Outstanding issues and future directions
General principles of endoscopy training
  Traditional standard means of instruction
   Is self-teaching still acceptable?
  What to teach and how to teach it
  Defining competency and how to access it
   Linking diagnosis and therapy
   How competent?
   Varying rates of learning
   Learning beyond the training period
Training and competency in specific endoscopic procedures
  Esophagogastroduodenoscopy (EGD)
   Published guidelines for training in EGD
   Defining competence for EGD
   Data on acquisition of competency in diagnostic EGD
   Competency and EGD outcome
  Therapeutic EGD techniques
   Standard upper GI endoscopy techniques
   Hemostasis techniques
   Bleeding team
   Retaining competence
   Other specialized therapeutic upper GI endoscopy techniques
  Flexible sigmoidoscopy
   Published guidelines for training in flexible sigmoidoscopy
   Published guidelines for training in colonoscopy
   Defining competence for colonoscopy
   Technical components
   Cognitive objectives
   Minimum training requirements to achieve competency for colonoscopy
   The Cass study
   Competency and colonoscopy outcome
   Acceptable outcomes
   Rate of skills acquisition for colonoscopy
   Cases per week
   Too many cases?
  Therapeutic colonoscopy (biopsy, polypectomy, hemostasis techniques, stricture dilation, stent deployment)
   Standard therapeutic techniques (integral to performance of diagnostic colonoscopy)
   Advanced therapeutic colonoscopy techniques
  Diagnostic and therapeutic ERCP
   Published guidelines for training in ERCP
   Non-technical training
   Defining competence for ERCP
   Technical success
   Varying case difficulty
   Minimum training requirements to achieve competency for ERCP
   Case numbers
   What is a case?
   Competency and ERCP outcome
   Improving after training
   Annual volume
   Competence affects complication rates
   Rate of acquisition of ERCP skills
   Therapeutic ERCP
   Rate of acquisition of therapeutic skills
  Diagnostic and therapeutic EUS
   Defining competency in EUS
   Learning curve for EUS
   Therapeutic EUS
   EUS training opportunities
Complementary methods for instructions in GI endoscopy
  Advances in didactic methods
   Group instruction
   Laboratory demonstrations
  Endoscopy simulators
   Static models
   Courses with static models
   Ex vivo artificial tissue models: the 'phantom' Tübingen models
   Ex vivo animal tissue simulators: EASIE and Erlangen models
   Live animals
   Computer simulation
   GI Mentor™
   Current status of simulators
   Costs of simulators
   EUS models and simulators
  Use of training resources: summary
Endoscopy training 2010—a glimpse into the future
Credentialing and granting of privileges
   ASGE guidelines
Renewal of privileges and privileging in new procedures
  New procedures
Privileging for non-gastroenterologists and non-physician providers
The future of credentialing and privileging
  The use of new technology for credentialing
The role of endoscopic societies in training and credentialing
  Society courses
  Hands-on courses
  Research in training
  Influencing credentialing
Outstanding issues and future trends
Achieving competence—the goal of training
What experience is necessary in training? The fallacy of numbers
Beyond numbers: tools to measure competence
What level of competence is good enough? How is it recognized?
Endoscopic performance beyond training
Issues in measuring endoscopic performance
The report card agenda
The quality of endoscopy units
Outstanding issues and future trends
Most endoscopists are not interested
Is the problem declining?
Newly recognized infections
Compliance with guidelines
What can be done to remedy this sorry state of affairs?
  Infection control staff
  Microbiological surveillance
   British practice
The role of industry
Manual cleaning is key

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