Endoscopic sedation training in gastroenterology fellowship
Article Outline
- The nonanesthesiologist-administered propofol controversy
- Propofol use in endoscopy: benefits and costs
- Sedation training in gastroenterology fellowship
- Recommendations for current gastroenterology fellows
- Disclosure
- References
- Copyright
Abbreviation: NAAP, nonanesthesiologist-administered propofol
Sedation in endoscopy has recently been much debated, yet it is not usually a topic formally addressed during fellowship. Recommendations recently published in a consensus statement will inevitably steer changes in sedation practices. In this month's Fellows' Corner, Dr. Tyler Berzin, a gastroenterology fellow at Beth Israel Deaconess Medical Center, experienced in the study of endoscopic sedation, summarizes the key elements stirring the propofol controversy and offers advice on training in the safe administration of anesthesia.
Juan Carlos Bucobo, MD
Fellows' Corner Editor
Interventional Endoscopy Fellow
Cedars-Sinai Medical Center
Los Angeles, California, USA
The nonanesthesiologist-administered propofol controversy
In December 2009, the 4 major gastroenterology societies in the United States issued a consensus statement supporting the expansion of nonanesthesiologist-administered propofol (NAAP) for GI endoscopy.1 Sedation practices in GI endoscopy are continuously evolving, and the current propofol debate has sparked renewed interest in evaluating the cost-effectiveness, efficiency, and safety of various sedation strategies. For gastroenterology fellows, the changing landscape of endoscopic sedation has important implications for GI training and will affect future practice.
The arguments for and against NAAP have generally fallen on either side of predictable fault lines. Gastroenterology societies have emphasized that gastroenterologists have long-term experience with moderate sedation using a variety of sedative agents. Several important studies, including a recently published worldwide safety survey of 646,080 procedures with endoscopist-directed propofol sedation, have provided additional evidence supporting the safety of NAAP.2
Anesthesiology groups have countered that propofol often induces deep (vs moderate) sedation, characterized by the lack of airway protection, and thus requires practitioners experienced with advanced airway management.3 The U.S. Food and Drug Administration label for propofol specifies that the agent is intended for monitored anesthesia care or general anesthesia and is to be administered “only by persons trained in the administration of general anesthesia.” Propofol use by gastroenterologists is currently considered off-label.
Propofol use in endoscopy: benefits and costs
In the United States, sedation administered by nurse anesthetists or anesthesiologists, often by using propofol, is now used in approximately one third of upper endoscopies and colonoscopies, a figure that continues to grow each year.4 Two key factors have driven the increasing popularity of propofol sedation. The first is practice efficiency; propofol has a rapid onset of action and a 2-minute half-life, allowing quicker induction and recovery times and potential improvements in endoscopy unit efficiency. The second factor is a more subjective impression among gastroenterologists that patient and endoscopist satisfaction with propofol is significantly higher than with other sedation modalities, although clinical evidence is less definitive in this regard.
The use of propofol varies dramatically from state to state, based almost entirely on whether local regulations allow anesthesiologists to bill separately for sedation in routine endoscopic procedures. In states such as New York, anesthesiologists participate in routine endoscopic sedation, propofol use is extremely common, and gastroenterologists reap the advantages of more rapid patient turnover between procedures. A key disadvantage to this practice is that separate reimbursement for anesthesiologists substantially increases the overall cost of surveillance colonoscopy and could even tip the economic balance for colorectal cancer screening toward CT colonography or other emerging technologies.
Given the evolving United States health care overhaul and the general push toward cost containment, it seems unlikely that anesthesiologist-administered sedation for routine endoscopic procedures in average-risk patients is sustainable. However, economic pressures are also driving increased efficiency and more rapid patient turnover in endoscopic practice. Rapid induction and rapid recovery are ideal characteristics for endoscopic sedation, and it is likely that endoscopic sedation practice will continue to gravitate toward propofol or similar agents (eg, fospropofol, a water-soluble prodrug of propofol, which is the subject of an ongoing clinical investigation). It is therefore very likely that gastroenterologists will need to become increasingly comfortable with the use of newer rapid-acting agents in routine endoscopic sedation.
Sedation training in gastroenterology fellowship
Endoscopic sedation occupies a unique and sometimes peripheral niche in gastroenterology training as a lone “nongastroenterologic” topic. In the 60-page text of the “Gastroenterology Core Curriculum,” a document published by the 4 major GI societies outlining “best practices in gastroenterology training,” the full discussion of sedation training consists of all of 2 sentences.5 In my own gastroenterology fellowship, sedation training has consisted almost entirely of a required online module and quiz on moderate sedation and casual, intraprocedure discussions with the gastroenterologists who taught me endoscopy.
Endoscopic sedation is a core competency of gastroenterology, and as our professional societies continue to lobby for the expansion of NAAP, it is increasingly vital that gastroenterologists actively position themselves as experts in this arena. Improving and expanding educational offerings on sedation strategies and the principles of airway management, both during and after gastroenterology fellowship, are important steps in this direction.
Didactic and hands-on workshops on endoscopic sedation training are becoming increasingly available. The American Society for Gastrointestinal Endoscopy now offers a yearly course on sedation and monitoring intended for gastroenterologists and endoscopy nurses. Digestive Disease Week and other major gastroenterology meetings are sponsoring symposia focused on endoscopic sedation.
The GI consensus statement supporting NAAP suggests that additional training could include a combination of didactic training, airway workshops, sedation training by using patient simulators, and preceptorship under gastroenterologists or anesthesiologists already using propofol for sedation.
Recommendations for current gastroenterology fellows
Gastroenterology fellows are already accustomed to facing difficult decisions regarding whether to pursue additional training in specific areas including inflammatory bowel disease, capsule endoscopy, motility, ERCP, and EUS. Trainees should now consider similar questions regarding whether and how to develop additional expertise in endoscopic sedation during gastroenterology fellowship. Pursuing clinical research in endoscopic sedation (eg, safety, new monitoring technologies) may also offer an excellent opportunity for fellows to develop additional expertise in this field.
After fellowship, individuals with specific interests and expertise in endoscopic sedation may be well-positioned to help academic and private gastroenterology practices address important issues of sedation safety, NAAP, and quality improvement in endoscopy.
For GI fellows interested in developing expertise in endoscopic sedation, including NAAP and other emerging strategies, the following recommendations may be considered:
Disclosure
The author disclosed no financial relationships relevant to this publication.
References
- Position statement: nonanesthesiologist administration of propofol for GI endoscopy. Gastrointest Endosc. 2009;70:1053–1059
- Endoscopist-directed administration of propofol: a worldwide safety experience. Gastroenterology. 2009;137:1229–1237
- Statement on Safe Use of Propofol. American Society of Anesthesiology, 2004 [updated October 21, 2009; cited December 24, 2009] www.asahq.org/publicationsAndServices/standards/37.pdfAccessed December 24, 2009
- Projected growth rate of anesthesiologist-delivered sedation in colonoscopy and EGD in the United States: 2009-2011. Gastrointest Endosc. 2009;69:AB111
- . The Gastroenterology Core Curriculum, Third Edition. Gastroenterology. 2007;132:2012–2018
PII: S0016-5107(10)00041-6
doi:10.1016/j.gie.2010.01.027
© 2010 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.
