December 11th, 2009
Should Propofol Be Used for Routine Endoscopy?
Propofol is a remarkable drug that has revolutionized sedation for patients undergoing endoscopic procedures. It can produce rapid and, when necessary, deep sedation, and its effects can be reversed within seconds to minutes. Because it has proven to be more effective than hypnotics (such as versed) and narcotics (such as fentanyl), an estimated 40% of all endoscopic sedation in the U.S. is now being performed with propofol.
Unfortunately, because propofol is labeled an anesthetic, GI docs in most hospital endoscopy units are blocked from using the drug by the hospitals’ anesthesia departments, which set sedation policies. Such policies persist, largely because of ongoing turf wars, despite documentation of more than 500,000 cases of safe propofol administration by nurses under GI-doc supervision.
Given the restrictions on propofol use, many endoscopists have resorted to calling in anesthesiologists or anesthetists to administer the drug in routine cases. But does this response meet the highest standards of professionalism? In my opinion, the turf war is wrong, but it does not justify introducing the cost of an anesthesia provider into routine endoscopic procedures.
I suspect many of you have strong opinions about this one way or the other, so please weigh in on the subject.
21 Responses to “Should Propofol Be Used for Routine Endoscopy?”
M. Brian Fennerty, MD
Editor-in-Chief
NEJM Journal Watch Gastroenterology
Biography | Disclosures | Summaries
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As an anesthesiologist and a GP, perhaps I should comment. Propofol is a good anesthetic and sedative, but it is by no means the best drug for a given procedure. It has a rapid onset. In inexperienced hands this could cause problems. The operator must be able to rescue a patient from too deep an anesthetic level. This would require basic airway skills: bag, mask, oral airway, perhaps an LMA (laryngeal mask airway).
Benzodiazepines, often combined with opioids, have traditionally been used for conscious sedation. They generally have a slower onset, but the sedation/anesthesia can be just as deep and require the same airway support as with larger doses of propofol. The slowness in onset, however, may confer some safety advantage because the clinician has more time to inject a reversal agent (e.g. naloxone for opioids).
In a bolus dose, propofol has a characteristic short delay (about a minute) before sedation is seen. This may prompt the operator to inject another bolus dose. This often leads to overdose.
I find it safer to start a slow, nearly continuous infusion of propofol. This can be done by injecting small amounts, 10 mg at a time, and waiting between each dose. This takes longer, but the final depth of sedation is easier to control.
In conclusion, I feel that propofol can be used safely by non-anesthetists for sedation. However, like any other medication, there is a learning curve involved. The operator must realize that propofol has different characteristics than the traditional agents and must be used with great caution (i.e. slower dosing of small amounts) until experience is gained.
While I am sympathetic to Dr. Fennerty’s concerns, I think a balanced anesthesiologist perspective is also useful:
1. Propofol has great utility as a total IV anesthetic, but does require airway skills that may not always be common in GI/endoscopy suites. I do about 20-35 propofol endoscopies a month, and while I may be more aggresive than most nurse protocols, my use of rescue mask controlled ventilation is 1-2%.
2. Propofol has no analgesia like fentanyl and limited conscious amnesia like midazolam. These limitaions are significant patient satisfaction issues. Addition of either drug will increase airway obstruction noticeably.
3. 500k “safe cases” sounds good until you look at minimum Spo2 readings, rates of ventilation rescue, or even lowest BIS numbers which are often concerning in the minority of cases I have seen where they are reported.
4.When my patients often remark on getting the “Michael Jackson drug”, I point out that this is also the drug Geo. W Bush got for his colonoscopy. I believe that he had a an anesthesia provider for his procedure.
If a patient gets propofol and has no memory or pain they have usually experienced an IV general anesthetic. If we are going to shift to non-anesthesia providers we need rigorous, intellectually-honest data and debate before we proceed.
What? Turf wars with regard to GI procedures? I’m shocked, shocked.
The way GI docs have railed against, for example, CT colonography, it seems a bit disingenuous for them to complain of turf wars.
How many patients who are not insured, or who are under-insured, will be able to pay the extra costs associated with an anesthesiologist? Perhaps slower recovery time is ok… doing more GI procedures with propofol because it’s faster should not the the only goal.
The goals of clinical decision making should stand on four legs – clinical outcomes, patient safety, cost and patient satisfaction. In reading the above, it is not clear that the use of propofol provides any real advantages over other options.
a patients perspective –
As a esophageal cancer survivor,having undergone about a dozen endoscopies (some for diagnosis, many for dilations following esophagectomy) I would like to weigh in on the case for access to propofol. I have been fortunate and have good insurance so am now getting propofol for endoscopy. Comparing the scopes I have had with versed to propofol, the speed of the reversal of sedation is a huge benefit. Following versed scopes I have missed important information from the doc due to continued amnesia. Also, with versed I have had continued drowsiness the remainder of the day. With propofol I am back to myself before leaving the center or hospital, so while I don’t drive or return to work, I am able to be productive at home in the afternoon following a scope.
How about evidence from Europe, no anesthesia needed for colonoscopy, should this option be discussed fairly with the patient?
Interesting article and also pretty thought provoking in fact. Merely wanted to drop you a line to say that I think your website is a wonderful reference. Undeniably one for my book marks. Keep up the great work. Best wishes, Adam
I am an anaesthetist of 40 yrs. experience. I am high on safety and not aggressive. I used propofol sedation for small urological endoscopic procedures in the O.R. for years. It was done with oxymetry and capnography on each patient. Delivery was with a pump with a bolus and continuing I.V. drip. The capnograph was vital in anticipating impending upper airway obstruction easily resolved with jaw thrust and also central apnea due to overdosage which could usually be avoided by stopping the infusion and watching the breathing waveform recover without bagging. I used to keep track of recollections and basically they were nil. Patience acceptance was totally excellent. Movement was minimal.
I now find myself doing G.I. endoscopies only as I near retirement. Although my more daring colleagues (by my standards) use repeated boluses I do not because of the absence of capnography in the oscopy suite. I find that waiting for a fall in oxymetry puts you too far behind the 8 ball.
With a capnograph and a pump, I would feel confident in using propofol only with no Midazolam or fentanyl and feel this would be the optimal anaesthesia. Midazolam and Fentanyl was the gold standard but it is a poor second to a proper delivery of propofol.
Recovery from Propofol is very fast and no subsequent problems should be encountered after discharge to the floor unlike the other 2 agents which could have unforeseen resedation problems while unobserved on the floor. The problems would all be in the suite while under monitoring and proper responses could be effected.
As for the question of non anaesthetist delivering it, I have reservations. If a practitioner of my experience has reservations, it should give some thing to think about to a nurse etc.. who would be contemplating it. Capnography and staying ahead of problems are the best way to avoid problems. Airway problems can degenerate fast and rapid pro active action is sometimes needed to avert a fatal situation. Bagging is not always easy in non optimal situations like this. As last resort, rapid intubation can save the day and one must have the skill, equipment and meds. ready .
I am a pilot of considerable experience and feel I want to be like an airline pilot, not a regional or bush pilot when I give anaesthesia. Some of my colleagues say ;”well I have insurance and I never had problems in years”. Not good enough for me. I want a 1 in a million problem ratio not 1 in a 100,000. I use to be young and cocky and had no problems for 30 yrs. but a few later problems humbled me and got me back to what we say in aviation. ” Use you superior judgment and and be defensive so you don’t have to use your superior skills”.
Ask yourself the question seriously. Would you want somebody who espouses my philosophy or a cocky bush pilot who has never had a problem yet giving you your sedation ?
As a Gastroenterologist, I have given non-anesthesia team assisted Propofol for over 11 years for more than 5000 patients with no adverse outcomes. 2 patients needed bag ventilation in the first 5 years, none since then.
Use of any sedation is a skill; and whatever agent anyone uses, they need to match their skill level to the task at hand. Versed (Midazolam) is now considered standard agent for non-anesthesiologist sedation, but when it was first introduced, more than 100 deaths were reported to FDA. No such parallel is noted with propofol, perhaps because the early adopters are highly motivated and focused and KNOW that the anesthesia community will not come to their side if any such events were to happen.
Deaths and serious events with use of Propofol by Anesthesia personnel are observed on a rare but regular basis. Many anesthesia specialists have been used to give Propofol for induction of general anesthesia and then intubation. In GI endoscopy, intubation is not done, but by force of habit, higher induction range boluses are given by these specialists, that leads to frequent apnea, as admitted by the anesthesiologist Nathan L. Williams, who commented earlier on Dec 11,2009:
“my use of rescue mask controlled ventilation is 1-2%.” My observation of other anesthesiologist suggests that it is the norm.
To compare, my use of rescue mask ventilation is 0 in last 3000 cases. I believe this is a statistically significant difference. Every patient has been comfortable, amnestic and stable during and after the procedure.
The other issue is routine use of supplemental oxygen by almost all anesthesia personnel, and lately many GI docs, that makes pulse oximetry useless for early detection of hypoventilation.
Supplemental oxygen should never be used in anyone with baseline normal saturation from the outset. It provides no benefit and gives an erroneous “normal” saturation reading for a prolonged period of time despite hypoventilation. This gives a false sense of security and at times, more sedation is given, not realizing that apnea has already happened.
Airway management is essential as the main reason for the desaturation is sedation induced obstruction of the airway from reduced muscle tone.
I hear the same arguments as to how it is so risky and the anesthesiologists are superior. “Facts do not cease to exist because they are ignored.”
I concede to the supremacy of the anesthesiologist in providing General anesthesia, but I may have given at least 100 times more sedation for GI procedures compared to any typical anesthesia person.
Additional cost for anesthesia involvement in routine colonoscopy alone is over a billion dollars. How can anyone turn a blind eye to that? Just because YOU do not have to pay for it?
Suppose currently EGD is paid $150 if the gastroenterologist gives the sedation. If the anesthesia is involved, they get paid anywhere from $200 to $300.
Is it hard to see it coming that one day the powers to be would say that the true cost is $150 and the GI should get paid $50 and anesthesia $100. The anesthesia would say that they are getting a 50-60% cut. The question is, would the GI doc do the procedure for $50 ? If not, how would they get out of the arrangement where they have become cozy with the anesthesia for a number of years and have lost their privileges to give moderate sedation?
This is my first time visiting your blog. I do envy you since you seem to get a lot more comments then I do. Do you have any secret tips on how I can get more comments or do I just have to be paitent? Anyway, keep up the good work.
I just had my first colonoscopy this week. I requested Propofol, (which will not be covered by insurance), over Versed. I felt so much more comfortable going into the procedure knowing that I would be in a deeper sedation. The fear of being too conscious and feeling too much of the procedure – which is a concern with Versed – would have probably led me to forgo the procedure altogether. I hate to say it, but I probably wouldn’t have had the colonoscopy if I couldn’t have the Propofol. When I showed up in the surgical room with my anesthesiologist, all of the nurses said how lucky I was to have the Propofol and that they didn’t see it very often in their practice. (Probably because it is not covered by insurance – which it SHOULD be.) As a patient, I believe that patient comfort and pain control should be way, way up there in considering which meds to administer.
Just had a colonoscopy using only propofol. It was great and I was recovered an hour after procedure. I was given versed for my procedure five years ago. It was terrible and took me two days to get my senses back. I read several postings regarding negative effects of versed, so I told them not to administer it in the cocktail. I’m so glad I did.
I recently had a colonoscopy for the second time. The first time I was given Versed and Phentnyl with no issues. This time I was given Propofol by a CRNA and when the procedure started I vomited and aspirated it. My BP dropped dramatically and my 02 sats and then I had a laryngospasm. I had to be intubated. Does this type of reaction happen often or does someone think that the CRNA did something wrong?
This is a follow up to my 2010 comment of 2010 seen above. I have since then obtained a capnograph in our Endoscopy suite and now exclusively give sedation for endoscopies. I use propofol exclusively. I think it is a wonderful drug that far outclasses Versed/fentanyl of the past. It is fast onset, can be maintained as long as needed and is half eliminated in 8 minutes as opposed to hours for the alternative.
I disagree with Gipropofolmd that Oxygen should not be given because it masks early detection of respiratory depression. It is not a valid reason. Oxygen has obvious advantages and there is an obvious substitute to detect apnea : capnography. Oxygen supplementation should be given to buy more time in case of emergencies and onset of respiratory depression should be detected from the capnograph NOT the onset of a falling SPO2. As I mentioned above, I would not give deep sedation without a capnograph for that reason.
As for the turf war enough said. I have similar record as he mentioned for himself. I never used rescue mask ventilation although I have now done as many cases as he has done since that’s all I have done in the last few years. Also I do not believe that my colleagues do worse than he does . 1-2% rescue ventilation is not and should not be the norm in well trained hands. Mandatory monitoring with capnography should be the norm to detect early respiratory depression before the fall in SPO2 under supplemental oxygenation. If detected early, in the presence of oxygen supplementation, the combination of jaw thrust and fast propofol elimination should give enough time to preclude desaturation before it happens.
On the other hand, I do believe that it is possible to teach non anaesthesia ancillary staff to do nearly as well as us if the proper people are selected trained and supervised. I think an anaeshesiologist would be better suited to train pesonnel than a GI man. He probably would undestand the need for oxygenation and capnography better. Also, although we all agree it is rare,the need of a ventilatory rescuer is a must . It could be the GI person or the ancillary staff as long as they have and maintain proficiency in bagging and intubation by frequent on hand training in the O.R..
Lastly, as for the $ issue, obviously this is a US doctor as I make about $135 per case in Canada. A nurse would be cheaper by 50% but imponderables exists like cancellations, sick time etc… We do not get paid under those circumstances but they would, thus decreasing the savings effected. If Gipropofolmd reads this, I do not mind discussing collegially these issues with him or any other persons interested in discussing these issues at jrlafr@yahoo.com.
Propanol is CRAP. It is used to expedite treatments for the doctors benefits not the patients. This week in New York autopsy results released on “Joan Rivers” showed she died from Propanol that shut down her brain. In many cases bonified Anesthesiologists no longer administer directly to the patient. They leave it up to techs with little experience and no knowledge of safety protocols in over doses. Insist you have an Anesthesiologist at your side. If they can’t or wont accommodate then find a new doctor and leave.
Thank you Dr. Bari for saying what no other doctor will admit, while Propofol is nice for the patients it’s the DOCTOR who really benefits. With an unconscious patient you can be quick and rough..wham, bam, thank you m’am, and if something untoward happens during the procedure..oh well, the patient won’t remember any of it anyway.
I’ve had two endoscopies and refused Propofol or Versed for both of them for personal reasons. Both times the doctors had slight freak-outs on me saying that they just couldn’t do it without me being unconscious (or being given amnesia by Versed). Frankly, it makes me nervous when a doctor badly wants me unconscious during a procedure. It makes me think, are they not confident in their own skill??
They both agreed in the end to use only Fentanyl, I suppose because I was already there on the table and they didn’t want to lose out on doing the procedure. I did fine and I guess they just had to take their time and be a little more careful and gentle than usual. Probably added a whole five more minutes to the procedures, oh and they also lost out on the hefty anesthesia fee that comes with the Propofol administration.
propofol is tricky to use, especially in the elderly patients, which are recommended to get regular endo- and colonoscopy
if not induced and monitored properly, resulting periods of low blood pressure could lead to side effects, not limited to oxygen deficiency, but rather a long term post recovery deficits affecting cognitive functioning. The statistics of the GI doctors might not reflect that, especially in the populations suffering from the neurodegenrative disorders.
the “lighter” sedative should be used for “procedures” rather than surgeries (in which case sometimes epideral is used for elderly population)
the comfort of patients vs. safety, should be a no-brainer.
midazolam and fentanyl (both at low doses) should be sufficient
yes, it might take longer to induce the patient, but its a safer alternative
I have had multiple EGD’s over the years and prefer Versed &Fentanyl. Propofol was used the first time in a hospital with no MD gas-passer and just a certified nurse. Cost was closer to $500-800 more. Had cysto. 2-3 mo. ago and needed Narcan for respiratory depression. As for EGD’s ” it is my choice and not their’s”.
I can speak from both a patient perspective as well as the nurse in the endo lab. I would prefer to never have another procedure unless propofol is used, the post op is much better for the patient, I have adverse effects with fentanyl, headache that lasts several hours as well as nausea. I also believe after working 20+ years in GI that having an anesthetist, either MD or CRNA is an asset for the GI physician. I always viewed the endoscopist as driving a car, you look at your left mirror then the right, then where you are going. When the GI physician is administering conscious sedation, he is supervising a nurse, watching the monitors, watching the patient and trying to watch for polyps as we move forward. I truly believe after using conscious sedation for years and now propofol with a CRNA administering the patient gets the better exam. I am sure there are physicians that push on thru to get as many done as possible, but the majority of physicians that I have experienced give a better exam as they have less to worry with having the additional provider for anesthesia watching over the patient. I also believe the use of propofol in the GI lab is over priced, it does require an anesthetist but not at the same cost as general surgery with intubated patient that last over an hour, I think this is what needs to be addressed by both parties the anesthesia associations and the GI associations. After all a lot of the comments are from anesthesiologist now doing GI as they are near retirement, it is much easier than general surgery. Pricing a bit lower than general surgery would make the insurance companies a bit happier I would hope and more likely to accept it as a norm.