DOI QR코드

DOI QR Code

2021 Korean Society of Gastrointestinal Endoscopy Clinical Practice Guidelines for Endoscopic Sedation

  • Hong Jun Park (Department of Internal Medicine, Yonsei University Wonju College of Medicine) ;
  • Byung-Wook Kim (Department of Internal Medicine, Incheon St. Mary's Hospital, College of Medicine, The Catholic University of Korea) ;
  • Jun Kyu Lee (Department of Internal Medicine, Dongguk University Ilsan Hospital) ;
  • Yehyun Park (Department of Internal Medicine, Ewha Womans University Seoul Hospital) ;
  • Jin Myung Park (Department of Internal Medicine, Kangwon National University School of Medicine, Kangwon National University Hospital) ;
  • Jun Yong Bae (Department of Internal Medicine, Seoul Medical Center) ;
  • Seung Young Seo (Department of Internal Medicine, Jeonbuk National University Hospital) ;
  • Jae Min Lee (Department of Internal Medicine, Korea University Anam Hospital) ;
  • Jee Hyun Lee (Department of Pediatrics, Seoul Metropolitan Children's Hospital) ;
  • Hyung Ku Chon (Department of Internal Medicine, Wonkwang University College of Medicine and Hospital) ;
  • Jun-Won Chung (Department of Internal Medicine, Gachon University, Gil Medical Center) ;
  • Hyun Ho Choi (Department of Internal Medicine, Uijungbu St. Mary's Hospital, College of Medicine, The Catholic University of Korea) ;
  • Myung Ha Kim (Yonsei Wonju Medical Library, Yonsei University Wonju College of Medicine) ;
  • Dong Ah Park (Division of Healthcare Technology Assessment Research, National Evidence-based Healthcare Collaborating Agency) ;
  • Jae Hung Jung (Department of Urology, Yonsei University Wonju College of Medicine/Center of Evidence Based Medicine Institute of Convergence Science) ;
  • Joo Young Cho (Division of Gastroenterology, Department of Internal Medicine, Cha University Gangnam Medical Center) ;
  • Endoscopic Sedation Committee of Korean Society of Gastrointestinal Endoscopy (Korean Society of Gastrointestinal Endoscopy)
  • Received : 2021.11.15
  • Accepted : 2021.12.13
  • Published : 2022.03.30

Abstract

Sedation can resolve anxiety and fear in patients undergoing endoscopy. The use of sedatives has increased in Korea. Appropriate sedation is a state in which the patient feels subjectively comfortable while maintaining the airway reflex for stable spontaneous breathing. The patient should maintain a state of consciousness to the extent that he or she can cooperate with the needs of the medical staff. Despite its benefits, endoscopic sedation has been associated with cardiopulmonary complications. Cardiopulmonary complications are usually temporary. Most patients recover without sequelae. However, they may progress to serious complications, such as cardiovascular collapse. Therefore, it is essential to screen high-risk patients before sedation and reduce complications by meticulous monitoring. Additionally, physicians should be familiar with the management of emergencies. The first Korean clinical practice guideline for endoscopic sedation was developed based on previous worldwide guidelines for endoscopic sedation using an adaptation process. The guideline consists of nine recommendations based on a critical review of currently available data and expert consensus when the guideline was drafted. These guidelines should provide clinicians, nurses, medical school students, and policy makers with information on how to perform endoscopic sedation with minimal risk.

Keywords

Acknowledgement

Any costs for literature searching, conferences, and other statistical activities were covered by a research fund provided by the KSGE. The KSGE supported the development of these guidelines.

References

  1. Dumonceau JM, Riphaus A, Beilenhoff U, 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 2013;45:496-504. 
  2. Gotoda T, Akamatsu T, Abe S, et al. Guidelines for sedation in gastroenterological endoscopy (second edition). Dig Endosc 2021;33:21-53. 
  3. American Association for the Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association Institute, et al. Multisociety sedation curriculum for gastrointestinal endoscopy. Gastrointest Endosc 2012;76:e1-e25. 
  4. Schilling D, Leicht K, Beilenhoff U, et al. Impact of S3 training courses "Sedation and emergency management in endoscopy for endoscopy nurses and assisting personnel" on the process and structure quality in gastroenterological endoscopy in practices and clinics - results of a nationwide survey. Z Gastroenterol 2013;51:619-627. 
  5. Berzin TM, Sanaka S, Barnett SR, et al. A prospective assessment of sedation-related adverse events and patient and endoscopist satisfaction in ERCP with anesthesiologist-administered sedation. Gastrointest Endosc 2011;73:710-717. 
  6. Qadeer MA, Lopez AR, Dumot JA, Vargo JJ. Hypoxemia during moderate sedation for gastrointestinal endoscopy: causes and associations. Digestion 2011;84:37-45. 
  7. Frieling T, Heise J, Kreysel C, Kuhlen R, Schepke M. Sedation-associated complications in endoscopy--prospective multicentre survey of 191142 patients. Z Gastroenterol 2013;51:568-572. 
  8. Wani S, Azar R, Hovis CE, et al. Obesity as a risk factor for sedation-related complications during propofol-mediated sedation for advanced endoscopic procedures. Gastrointest Endosc 2011;74:1238-1247. 
  9. Mador MJ, Nadler J, Mreyoud A, et al. Do patients at risk of sleep apnea have an increased risk of cardio-respiratory complications during endoscopy procedures? Sleep Breath 2012;16:609-615. 
  10. Dumonceau JM, Riphaus A, Schreiber F, et al. Non-anesthesiologist administration of propofol for gastrointestinal endoscopy: European Society of Gastrointestinal Endoscopy, European Society of Gastroenterology and Endoscopy Nurses and Associates guideline--updated June 2015. Endoscopy 2015;47:1175-1189. 
  11. ASGE Standards of Practice Committee, Early DS, Lightdale JR, et al. Guidelines for sedation and anesthesia in GI endoscopy. Gastrointest Endosc 2018;87:327-337. 
  12. Friedrich K, Stremmel W, Sieg A. Endoscopist-administered propofol sedation is safe - a prospective evaluation of 10,000 patients in an outpatient practice. J Gastrointestin Liver Dis 2012;21:259-263. 
  13. Kim SY, Moon CM, Kim MH, et al. Impacts of age and sedation on cardiocerebrovascular adverse events after diagnostic GI endoscopy: a nationwide population-based study. Gastrointest Endosc 2020;92:591-602.e16. 
  14. Mehta PP, Kochhar G, Kalra S, et al. Can a validated sleep apnea scoring system predict cardiopulmonary events using propofol sedation for routine EGD or colonoscopy? A prospective cohort study. Gastrointest Endosc 2014;79:436-444. 
  15. Cha JM, Jeun JW, Pack KM, et al. Risk of sedation for diagnostic esophagogastroduodenoscopy in obstructive sleep apnea patients. World J Gastroenterol 2013;19:4745-4751. 
  16. Hinkelbein J, Lamperti M, Akeson J, et al. European Society of Anaesthesiology and European Board of Anaesthesiology guidelines for procedural sedation and analgesia in adults. Eur J Anaesthesiol 2018;35:6-24. 
  17. Mallampati SR, Gatt SP, Gugino LD, et al. A clinical sign to predict difficult tracheal intubation: a prospective study. Can Anaesth Soc J 1985;32:429-434. 
  18. Dietrich CG, Kottmann T, Diedrich A, Drouven FM. Sedation-associated complications in endoscopy are not reduced significantly by implementation of the German S-3-guideline and occur in a severe manner only in patients with ASA class III and higher. Scand J Gastroenterol 2013;48:1082-1087. 
  19. Enestvedt BK, Eisen GM, Holub J, Lieberman DA. Is the American Society of Anesthesiologists classification useful in risk stratification for endoscopic procedures? Gastrointest Endosc 2013;77:464-471. 
  20. Muravchick S. The elderly outpatient: current anesthetic implications. Curr Opin Anaesthesiol 2002;15:621-625. 
  21. Boss GR, Seegmiller JE. Age-related physiological changes and their clinical significance. West J Med 1981;135:434-440. 
  22. Shaker R, Ren J, Bardan E, et al. Pharyngoglottal closure reflex: characterization in healthy young, elderly and dysphagic patients with predeglutitive aspiration. Gerontology 2003;49:12-20. 
  23. Lukens FJ, Loeb DS, Machicao VI, Achem SR, Picco MF. Colonoscopy in octogenarians: a prospective outpatient study. Am J Gastroenterol 2002;97:1722-1725. 
  24. ASGE Standards of Practice Committee, Chandrasekhara V, Early DS, et al. Modifications in endoscopic practice for the elderly. Gastrointest Endosc 2013;78:1-7. 
  25. Darling E. Practical considerations in sedating the elderly. Crit Care Nurs Clin North Am 1997;9:371-380. 
  26. Peacock JE, Lewis RP, Reilly CS, Nimmo WS. Effect of different rates of infusion of propofol for induction of anaesthesia in elderly patients. Br J Anaesth 1990;65:346-352. 
  27. Horiuchi A, Nakayama Y, Tanaka N, Ichise Y, Katsuyama Y, Ohmori S. Propofol sedation for endoscopic procedures in patients 90 years of age and older. Digestion 2008;78:20-23. 
  28. Heuss LT, Schnieper P, Drewe J, Pflimlin E, Beglinger C. Conscious sedation with propofol in elderly patients: a prospective evaluation. Aliment Pharmacol Ther 2003;17:1493-1501. 
  29. Bell GD, Spickett GP, Reeve PA, Morden A, Logan RF. Intravenous midazolam for upper gastrointestinal endoscopy: a study of 800 consecutive cases relating dose to age and sex of patient. Br J Clin Pharmacol 1987;23:241-243.
  30. Cha JM, Kozarek RA, La Selva D, et al. Risks and benefits of colonoscopy in patients 90 years or older, compared with younger patients. Clin Gastroenterol Hepatol 2016;14:80-86.e1. 
  31. Kazama T, Takeuchi K, Ikeda K, et al. Optimal propofol plasma concentration during upper gastrointestinal endoscopy in young, middle-aged, and elderly patients. Anesthesiology 2000;93:662-669. 
  32. Martinez JF, Aparicio JR, Company L, et al. Safety of continuous propofol sedation for endoscopic procedures in elderly patients. Rev Esp Enferm Dig 2011;103:76-82. 
  33. Hayee B, Dunn J, Loganayagam A, et al. Midazolam with meperidine or fentanyl for colonoscopy: results of a randomized trial. Gastrointest Endosc 2009;69:681-687. 
  34. Cohen LB, Hightower CD, Wood DA, Miller KM, Aisenberg J. Moderate level sedation during endoscopy: a prospective study using low-dose propofol, meperidine/fentanyl, and midazolam. Gastrointest Endosc 2004;59:795-803. 
  35. Korean Medical Association. 2016 clinical recommendations for propofol-based sedation for physicians in Korean healthcare clinics and hospitals (in Korean). 2016 [Internet]. Seoul: KMA; c2016 [cited 2022 Jan 24]. Available from: https://www.nsdoctor.co.kr/file_download.php?idx=2384 
  36. Cohen LB, Dubovsky AN, Aisenberg J, Miller KM. Propofol for endoscopic sedation: a protocol for safe and effective administration by the gastroenterologist. Gastrointest Endosc 2003;58:725-732. 
  37. Fatima H, DeWitt J, LeBlanc J, Sherman S, McGreevy K, Imperiale TF. Nurse-administered propofol sedation for upper endoscopic ultrasonography. Am J Gastroenterol 2008;103:1649-1656. 
  38. Heuss LT, Froehlich F, Beglinger C. Nonanesthesiologist-administered propofol sedation: from the exception to standard practice. Sedation and monitoring trends over 20 years. Endoscopy 2012;44:504-511. 
  39. Jensen JT, Vilmann P, Horsted T, et al. Nurse-administered propofol sedation for endoscopy: a risk analysis during an implementation phase. Endoscopy 2011;43:716-722. 
  40. Daza JF, Tan CM, Fielding RJ, Brown A, Farrokhyar F, Yang I. Propofol administration by endoscopists versus anesthesiologists in gastrointestinal endoscopy: a systematic review and meta-analysis of patient safety outcomes. Can J Surg 2018;61:226-236. 
  41. Kulling D, Orlandi M, Inauen W. Propofol sedation during endoscopic procedures: how much staff and monitoring are necessary? Gastrointest Endosc 2007;66:443-449. 
  42. Vargo JJ, Niklewski PJ, Williams JL, Martin JF, Faigel DO. Patient safety during sedation by anesthesia professionals during routine upper endoscopy and colonoscopy: an analysis of 1.38 million procedures. Gastrointest Endosc 2017;85:101-108. 
  43. Khiani VS, Soulos P, Gancayco J, Gross CP. Anesthesiologist involvement in screening colonoscopy: temporal trends and cost implications in the medicare population. Clin Gastroenterol Hepatol 2012;10:58-64.e1. 
  44. Cooper GS, Kou TD, Rex DK. Complications following colonoscopy with anesthesia assistance: a population-based analysis. JAMA Intern Med 2013;173:551-556. 
  45. Wernli KJ, Brenner AT, Rutter CM, Inadomi JM. Risks associated with anesthesia services during colonoscopy. Gastroenterology 2016;150:888-894; quiz e18. 
  46. Practice guidelines for moderate procedural sedation and analgesia 2018: a report by the American Society of Anesthesiologists Task Force on moderate procedural sedation and analgesia, the American Association of Oral and Maxillofacial surgeons, American College of Radiology, American Dental Association, American Society of Dentist Anesthesiologists, and Society of Interventional Radiology. Anesthesiology 2018;128:437-479. 
  47. Dumonceau JM, Riphaus A, Aparicio JR, et al. European Society of Gastrointestinal Endoscopy, European Society of Gastroenterology and Endoscopy Nurses and Associates, and the European Society of Anaesthesiology guideline: non-anesthesiologist administration of propofol for gi endoscopy. Endoscopy 2010;42:960-974. 
  48. Riphaus A, Macias-Gomez C, Deviere J, Dumonceau JM. Propofol, the preferred sedation for screening colonoscopy, is underused. Results of an international survey. Dig Liver Dis 2012;44:389-392. 
  49. Lee CK, Dong SH, Kim ES, et al. Room for quality improvement in endoscopist-directed sedation: results from the first nationwide survey in Korea. Gut Liver 2016;10:83-94. 
  50. Bell GD, Bown S, Morden A, Coady T, Logan RF. Prevention of hypoxaemia during upper-gastrointestinal endoscopy by means of oxygen via nasal cannulae. Lancet 1987;1:1022-1024. 
  51. Bell GD, Quine A, Antrobus JH, et al. Upper gastrointestinal endoscopy: a prospective randomized study comparing continuous supplemental oxygen via the nasal or oral route. Gastrointest Endosc 1992;38:319-325. 
  52. Bowling TE, Hadjiminas CL, Polson RJ, Baron JH, Foale RA. Effects of supplemental oxygen on cardiac rhythm during upper gastrointestinal endoscopy: a randomised controlled double blind trial. Gut 1993;34:1492-1497. 
  53. Crantock L, Cowen AE, Ward M, Roberts RK. Supplemental low flow oxygen prevents hypoxia during endoscopic cholangiopancreatography. Gastrointest Endosc 1992;38:418-420. 
  54. 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. 
  55. Griffin SM, Chung SC, Leung JW, Li AK. Effect of intranasal oxygen on hypoxia and tachycardia during endoscopic cholangiopancreatography. BMJ 1990;300:83-84. 
  56. Gross JB, Long WB. Nasal oxygen alleviates hypoxemia in colonoscopy patients sedated with midazolam and meperidine. Gastrointest Endosc 1990;36:26-29. 
  57. Haines DJ, Bibbey D, Green JR. Does nasal oxygen reduce the cardiorespiratory problems experienced by elderly patients undergoing endoscopic retrograde cholangiopancreatography? Gut 1992;33:973-975. 
  58. Iwao T, Toyonaga A, Shigemori H, Sumino M, Oho K, Tanikawa K. Supplemental oxygen during endoscopic variceal ligation: effects on arterial oxygenation and cardiac arrhythmia. Am J Gastroenterol 1995;90:2186-2190. 
  59. Jurell KR, O'Connor KW, Slack J, et al. Effect of supplemental oxygen on cardiopulmonary changes during gastrointestinal endoscopy. Gastrointest Endosc 1994;40:665-670. 
  60. Kim H, Hyun JN, Lee KJ, Kim HS, Park HJ. Oxygenation before endoscopic sedation reduces the hypoxic event during endoscopy in elderly patients: a randomized controlled trial. J Clin Med 2020;9:3282. 
  61. Patterson KW, Noonan N, Keeling NW, Kirkham R, Hogan DF. Hypoxemia during outpatient gastrointestinal endoscopy: the effects of sedation and supplemental oxygen. J Clin Anesth 1995;7:136-140. 
  62. Rozario L, Sloper D, Sheridan MJ. Supplemental oxygen during moderate sedation and the occurrence of clinically significant desaturation during endoscopic procedures. Gastroenterol Nurs 2008;31:281-285. 
  63. Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy, Lichtenstein DR, Jagannath S, et al. Sedation and anesthesia in GI endoscopy. Gastrointest Endosc 2008;68:815-826. 
  64. American Society of Anesthesiologists Task Force on sedation and analgesia by non-anesthesiologists. Practice guidelines for sedation and analgesia by non-anesthesiologists. Anesthesiology 2002;96:1004-1017. 
  65. ASGE Ensuring Safety in the Gastrointestinal Endoscopy Unit Task Force, Calderwood AH, Chapman FJ, et al. Guidelines for safety in the gastrointestinal endoscopy unit. Gastrointest Endosc 2014;79:363-372. 
  66. Cohen LB, Delegge MH, Aisenberg J, et al. AGA Institute review of endoscopic sedation. Gastroenterology 2007;133:675-701. 
  67. Waring JP, Baron TH, Hirota WK, et al. Guidelines for conscious sedation and monitoring during gastrointestinal endoscopy. Gastrointest Endosc 2003;58:317-322. 
  68. Maurer WG, Walsh M, Viazis N. Basic requirements for monitoring sedated patients: blood pressure, pulse oximetry, and EKG. Digestion 2010;82:87-89. 
  69. Lucendo AJ, Gonzalez-Huix F, Tenias JM, et al. Gastrointestinal endoscopy sedation and monitoring practices in Spain: a nationwide survey in the year 2014. Endoscopy 2015;47:383-390. 
  70. Riphaus A, Rabofski M, Wehrmann T. Endoscopic sedation and monitoring practice in Germany: results from the first nationwide survey. Z Gastroenterol 2010;48:392-397. 
  71. Willey J, Vargo JJ, Connor JT, Dumot JA, Conwell DL, Zuccaro G. Quantitative assessment of psychomotor recovery after sedation and analgesia for outpatient EGD. Gastrointest Endosc 2002;56:810-816. 
  72. Aldrete JA. Modifications to the postanesthesia score for use in ambulatory surgery. J Perianesth Nurs 1998;13:148-155. 
  73. Aldrete JA, Kroulik D. A postanesthetic recovery score. Anesth Analg 1970;49:924-934. 
  74. Chung F. Are discharge criteria changing? J Clin Anesth 1993;5 (Suppl 1):64S-68S. 
  75. Chung F, Chan VW, Ong D. A post-anesthetic discharge scoring system for home readiness after ambulatory surgery. J Clin Anesth 1995;7:500-506. 
  76. Amornyotin S, Chalayonnavin W, Kongphlay S. Recovery pattern and home-readiness after ambulatory gastrointestinal endoscopy. J Med Assoc Thai 2007;90:2352-2358. 
  77. Trevisani L, Cifala V, Gilli G, Matarese V, Zelante A, Sartori S. Post-anaesthetic discharge scoring system to assess patient recovery and discharge after colonoscopy. World J Gastrointest Endosc 2013;5:502-507. 
  78. Gurunathan U, Rahman T, Williams Z, et al. Effect of midazolam in addition to propofol and opiate sedation on the quality of recovery after colonoscopy: a randomized clinical trial. Anesth Analg 2020;131:741-750. 
  79. Thompson R, Seck V, Riordan S, Wong S. Comparison of the effects of midazolam/fentanyl, midazolam/propofol, and midazolam/fentanyl/propofol on cognitive function after gastrointestinal endoscopy. Surg Laparosc Endosc Percutan Tech 2019;29:441-446. 
  80. Zhang K, Xu H, Li HT. Safety and efficacy of propofol alone or in combination with other agents for sedation of patients undergoing colonoscopy: an updated meta-analysis. Eur Rev Med Pharmacol Sci 2020;24:4506-4518. 
  81. Hsu YH, Lin FS, Yang CC, Lin CP, Hua MS, Sun WZ. Evident cognitive impairments in seemingly recovered patients after midazolam-based light sedation during diagnostic endoscopy. J Formos Med Assoc 2015;114:489-497. 
  82. Horiuchi A, Nakayama Y, Hidaka N, Ichise Y, Kajiyama M, Tanaka N. Low-dose propofol sedation for diagnostic esophagogastroduodenoscopy: results in 10,662 adults. Am J Gastroenterol 2009;104:1650-1655. 
  83. Horiuchi A, Nakayama Y, Fujii H, Katsuyama Y, Ohmori S, Tanaka N. Psychomotor recovery and blood propofol level in colonoscopy when using propofol sedation. Gastrointest Endosc 2012;75:506-512. 
  84. Horiuchi A, Nakayama Y, Kajiyama M, et al. Safety and effectiveness of propofol sedation during and after outpatient colonoscopy. World J Gastroenterol 2012;18:3420-3425. 
  85. Watkins TJ, Bonds RL, Hodges K, Goettle BB, Dobson DAM, Maye JP. Evaluation of postprocedure cognitive function using 3 distinct standard sedation regimens for endoscopic procedures. AANA J 2014;82:133-139.