Table 3 Summary of recommendations for individuals capable of administering sedation
From: Sedation practices for routine gastrointestinal endoscopy: a systematic review of recommendations
Subject | Number of documents | Document developers | Comments |
|---|---|---|---|
Moderate sedation | |||
Can be administered by a nurse who is directed by a physician | 4 | – | |
Should be administered by a practitioner other than the endoscopist | 1 | GESA [20] | Trained medical/dental practitioner (with advanced life support skills) |
Deep sedation | |||
Should be administered by an anesthesia professional | 3 | ASGE [21] | Anesthesiologist, Certified Registered Nurse Anesthetist (CRNA), or Anesthesiologist Assistant (as determined by institutional policies) |
GESA [20] | Anesthetist or other appropriately trained and credentialed medical specialist within his/her scope of practice | ||
SGNA [41] | Anesthesiologist | ||
Propofol | |||
Should not be administered by nurses | 3 | CSGNA [44] | Not within scope of practice |
GESA [20] | Intravenous anesthetics should be administered by a second medical or dental practitioner | ||
BSG [29] | – | ||
Non-anesthesiologist propofol administration can be considered | 8 | GSGMD [36] | Administered by a non-physician, who has sedation as their sole task, under the instruction of a physician can be considered |
DSRPGSA [19] | Can be administered by a nurse under direction of a non-anesthetist physician | ||
AGA [22] | Gastroenterologist-directed administration is safe | ||
SSGE [33] | Administration by non-anesthesiologist is safe | ||
SSGE [31] | Administration by endoscopist/trained nurse safe and may improve efficiency | ||
CAG [47] | Administration by endoscopists and/or trained endoscopy nurses is safe; anesthesiologist not required for low-risk patients | ||
ASGE [49] | Administration by non-anesthesiologists improves practice efficiency for healthy, low-risk patients undergoing routine GI endoscopy | ||
ISDE [48] | Administration by trained non-anesthesiologists is safe | ||
An anesthesiologist should be readily available when non-anesthesiologist propofol sedation is used | 2 | DSRPGSA [19] | Must be in immediate vicinity |
SSGE [31] | Available within 5 min | ||
Patient and procedure factors to consider when determining whether an anesthesiologist is required | |||
ASA class | 7 | ASA ≥ III | |
GSGMD [36] | ASA IV-V | ||
Mallampati class or facial features | 1 | ESGE [24] | Mallampati class ≥3 Dysmorphic facial features or oral abnormalities (mouth opening < 3 cm, high arched palate, macroglossia, micrognathia) |
Other factors suggestive of difficult intubation or ventilation | 5 | SSGE [31] | Short neck, sleep apnea |
ESGE [24] | Pharyngolaryngeal tumors, history of stridor, snoring, obstructive sleep apnea, neck or cervical spine abnormalities, tracheal deviation, advanced rheumatoid arthritis | ||
DSRPGSA [19] | BMI ≥35, non-compliance with fasting guidelines, respiratory assessment score ≥ 4 | ||
CAG [47] | Difficulty anatomy for ventilation (obesity, thick neck) | ||
ISDE [48] | Difficult anatomy for ventilation (obesity, thick neck) | ||
Patients with other high risk conditions | 2 | DSRPGSA [19] | Acute upper GI hemorrhage, sub-acute bowel obstruction/ileus, achalasia, sleep apnea, SpO2 < 95% with supplemental oxygen |
SSGE [31] | Chronic decompensated serious diseases | ||
Long or complex procedures | 5 | DSRPGSA [19] | > 1 h |
SSGE [31] | Complex therapeutic procedures | ||
CAG [47] | Prolonged or high-risk interventional procedures | ||
ESGE [24] | Long-lasting procedures | ||
ISDE [48] | Long-lasting or high-risk interventional procedures | ||
Other risk factors | 3 | ESGE [24] | Chronic narcotic use, intolerant to sedatives, difficult to sedate |
DSRPGSA [19] | Previous problems with anesthesia | ||
ISDE [48] | Uncooperative patients | ||
Sedation practice in general | |||
The role of nurses in the administration of sedation | 5 | CSGNA [44] | Competent Registered Nurses can administer sedation when directed by a physician |
ASGH [37] | An individual must be present who is responsible for sedation administration (can be a trained assistant, nurse, member of the general medical staff, or anesthesiologist) | ||
ASGE [21] | Licensed practical nurses and unlicensed assistive personnel not qualified to administer sedation | ||
GESA [20] | Appropriately trained nurse may administer sedatives under direction of the physician | ||
SAGES [30] | Nurses administering sedation must work within their scope of practice | ||
Intravenous sedation should be administered by an anesthesiologist | 1 | FSDE [35] | Non-anesthesiologist IV sedation should only be used in clinical trials |
Patients and procedure factors to consider when determining whether an anesthesiologist is required | |||
ASA class | 5 | GSGMD [36] | ≥III |
IV-V | |||
Mallampati class or facial features | 2 | GSGMD [36] | Mallampati grade 3 or 4, mouth opening < 2 cm, hyoid-to-chin distance < 4 cm |
SSGE [31] | Mallampati grade 4, mouth opening < 3 cm, decreased hyoid-chin distance, protruding incisors, macroglossia, gothic plate, tonsillar hypertrophy, retrognathia, micrognathia, trismus, severe dental malocclusion, dysmorphic face (Trisomy 21, Pierre-Robin sequence) | ||
Other factors suggestive of difficult intubation or ventilation | 5 | GSGMD [36] | Craniofacial malformation; lingual, laryngeal, or hypopharyngeal tumor; severely restricted mobility of the cervical spine |
GESA [20] | Morbid obesity, significant obstructive sleep apnea, known or suspected difficult endotracheal intubation, potential for aspiration | ||
ASGE [27] | Anatomical variants portending increased risk for airway obstruction | ||
SSGE [31] | History of laryngeal stridor, sleep apnea, short thick neck, limited cervical extension, cervical spine conditions, trauma, severe tracheal deviation | ||
AGA [22] | Morbid obesity | ||
Patients with other high risk conditions | 3 | GESA [20] | Elderly; severely limiting heart, cerebrovascular, lung, liver, or renal disease; acute GI bleeding; severe anemia |
ASGE [27] | Multiple medical comorbidities or at risk for airway compromise | ||
BSG [29] | Outflow obstruction or any serious form of cardiac or pulmonary compromise | ||
Long or complex procedures | 4 | GSGMD [36] | Difficult endoscopic intervention |
AGA [22] | ERCP, stent placement in upper GI tract, EUS, complex therapeutic procedures (e.g. ESD, plication of the cardioesophageal junction, EGD with drainage of pseudocyst) | ||
ASGE [27] | Complex endoscopic procedures | ||
SSGE [31] | Urgent, prolonged, or therapeutically complex procedures | ||
Other risk factors | 5 | AGA [22] | History of alcohol or substance abuse, pregnancy, neurological/neuromuscular disorders, uncooperative or delirious patients |
GESA [20] | Previous sedation-related adverse events | ||
ASGE [27] | Anticipated intolerance to sedatives | ||
SSGE [31] | Intolerance or allergy to standard sedatives | ||
BSG [29] | Severe learning difficulties, patients who have previously failed or are likely to fail sedation including alcoholic or drug addicted patients, poor venous access; uncooperative or phobic patients | ||