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New ASGE guideline on sedation, anesthesia in GI endoscopy differs from ASA on capnography
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The American Society for Gastrointestinal Endoscopy has released updated guidelines on the use of sedation and anesthesia for GI endoscopic procedures.
While the new recommendations mirror those from the American Society of Anesthesiologists (ASA) on timing of sedation, they notably differ on the use of capnography for patient monitoring during endoscopic procedures with moderate sedation, according to guideline co-author John R. Saltzman, MD, director of endoscopy at Brigham and Women’s Hospital, and professor of medicine in the gastroenterology division at Harvard Medical School.
“The document is in agreement with the ASA guidelines and states ‘patients should fast a minimum of 2 hours after ingestion of clear liquids and 6 hours after ingestion of light meals before sedation is administered,’” Saltzman told Healio Gastroenterology and Liver Disease. “Previously there has not been a clear universal practice standard regarding the timing of sedation post ingestion of clear liquids and meals.”
The guideline also notes that providers can use ASA classification to risk-stratify patients for sedation prior to their procedure.
“The ASA class has been associated with risk of adverse events during GI procedures,” Saltzman said. “Data from the CORI database ‘has demonstrated that increasing class is associated with increased risk of unplanned cardiopulmonary events during endoscopy.’ This emphasizes the importance of accurately assessing the ASA classification.”
Regarding patient monitoring during procedures, the guideline recommends the use of pulse oximetry during all sedated endoscopic procedures. Further, the ASGE departs from the ASA on the use of capnography.
“In contrast to ASA recommendations regarding capnography, ASGE states, ‘integrating capnography into patient monitoring protocols for endoscopic procedures with moderate sedation has not been shown to improve patient safety: however, there is evidence to support its use in procedures targeting deep sedation,’” Saltzman said. “The ASGE ‘suggest(s) that capnography monitoring be considered for complex endoscopic procedures or patients with multiple medical comorbidities, or at risk for airway compromise.’ This is a pragmatic data-based recommendation of the ASGE.”
Among the recommendations for minimal to moderate sedation, the document supports the use of benzodiazepines and opioids for certain patients.
“There continues to be a role for moderate sedation using a benzodiazepine and opioid in patients undergoing routine upper endoscopy and colonoscopy without risk factors for sedation-related adverse events,” Saltzman said.
Similarly, the document reviews in detail the data about deep sedation using propofol.
“There is a detailed review of the efficacy and safety of the use of both non-anesthesiologist- and anesthesiologist-administered propofol sedation for endoscopic procedures,” he said. “The guideline recommends ‘anesthesia provider-administered sedation be considered for complex endoscopic procedures for patients with multiple medical comorbidities or at risk for airway compromise.’ It also suggests that propofol sedation is appropriate ‘when it is expected to improve patient safety, comfort, procedural efficiency, and/or successful procedure completion.’”
A summary of the guideline’s major recommendations includes:
- Risks of sedation related to medical conditions should be assessed in all patients prior to endoscopic procedures;
- The use of benzodiazepines and opioids is safe and effective for minimal to moderate sedation for upper endoscopy and colonoscopy in low-risk patients;
- Combining an appropriate adjunctive agent with conventional sedative drugs is suggested in certain cases;
- Providers should be trained to administer endoscopic sedation and know how to diagnose and manage sedation-related adverse events;
- Blood pressure, oxygen saturation, and heart rate should be routinely monitored, as should clinical observation for changes in cardiopulmonary status during all endoscopic procedures using sedation. Supplemental oxygen should be considered for moderate sedation, and should be administered during deep sedation or if hypoxemia is anticipated or develops;
- Capnography monitoring should be considered for patients undergoing endoscopy with deep sedation;
- Anesthesia provider–administered sedation should be considered for complex endoscopic procedures, and for patients with multiple medical comorbidities or risk factors for comprised airway; and
- Propofol-based sedation should be used when expected to improve safety, comfort, efficiency and procedural success.
Saltzman emphasized that this new guideline “provides a foundation for endoscopists to safely sedate their patients during endoscopic procedures.” – by Adam Leitenberger
Disclosures: Saltzman reports no relevant financial disclosures. Please see the full guideline for a list of all other authors’ relevant financial disclosures.
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