Key points

Background

Endoscopic sedation improves technical procedure quality while reducing patient discomfort and is now used nearly universally for gastroenterologic endoscopic procedures in the United States. Depending on the agent and dose administered, 4 levels of sedation may be achieved: minimal sedation (anxiolysis), moderate sedation (ie, conscious sedation), deep sedation, and general anesthesia. According to the American Society of Anesthesiologists (ASA), these stages should be viewed as a fluid continuum and are defined by patients’ degree of spontaneous ventilation, maintenance of cardiovascular function, and response to verbal and tactile stimuli ( Table 1 ). The concept of sedation as a continuum is crucial, as patients may easily and inadvertently drift beyond intended sedation targets and require rescue to restore ventilatory or cardiovascular function.

Sedating and analgesic medications are not without hazard. Opiates, benzodiazepines, and propofol alter one’s level of consciousness, depress spontaneous ventilation, and increase cardiopulmonary risk. In a retrospective analysis involving 324,737 patients undergoing endoscopic sedation, Sharma and colleagues found that 0.9% of cases overall were associated with an unplanned cardiopulmonary complication, with higher incidence in more complicated procedures (esophagogastroduodenoscopy [EGD] 0.6%, colonoscopy 1.1%, endoscopic retrograde cholangiopancreatography [ERCP] 2.1%). Risk factors for these adverse events included ASA class III or greater ( Table 2 ), advanced age, inpatient status, and trainee involvement in the procedure.

Recognizing the importance of preventing sedation-associated complications, there is great interest in determining the best practices for extended monitoring during endoscopy. In principle, the goal should be to titrate sedatives or anesthetics to the minimal amount necessary to achieve patient comfort and safety for the endoscopic procedure. As individuals vary in their response to sedating medications, vigilant monitoring is, therefore, required. The major components for effective sedation monitoring include both appropriate personnel and monitors of physiologic parameters , including hemodynamics, oxygenation, ventilation, and depth of sedation. In the present article, the authors review the evidence base for extended monitoring practices as well as key guidelines and recommendations from the American Society for Gastrointestinal Endoscopy (ASGE) and the ASA ( Table 3 ).

Background

Endoscopic sedation improves technical procedure quality while reducing patient discomfort and is now used nearly universally for gastroenterologic endoscopic procedures in the United States. Depending on the agent and dose administered, 4 levels of sedation may be achieved: minimal sedation (anxiolysis), moderate sedation (ie, conscious sedation), deep sedation, and general anesthesia. According to the American Society of Anesthesiologists (ASA), these stages should be viewed as a fluid continuum and are defined by patients’ degree of spontaneous ventilation, maintenance of cardiovascular function, and response to verbal and tactile stimuli ( Table 1 ). The concept of sedation as a continuum is crucial, as patients may easily and inadvertently drift beyond intended sedation targets and require rescue to restore ventilatory or cardiovascular function.

Sedating and analgesic medications are not without hazard. Opiates, benzodiazepines, and propofol alter one’s level of consciousness, depress spontaneous ventilation, and increase cardiopulmonary risk. In a retrospective analysis involving 324,737 patients undergoing endoscopic sedation, Sharma and colleagues found that 0.9% of cases overall were associated with an unplanned cardiopulmonary complication, with higher incidence in more complicated procedures (esophagogastroduodenoscopy [EGD] 0.6%, colonoscopy 1.1%, endoscopic retrograde cholangiopancreatography [ERCP] 2.1%). Risk factors for these adverse events included ASA class III or greater ( Table 2 ), advanced age, inpatient status, and trainee involvement in the procedure.

Recognizing the importance of preventing sedation-associated complications, there is great interest in determining the best practices for extended monitoring during endoscopy. In principle, the goal should be to titrate sedatives or anesthetics to the minimal amount necessary to achieve patient comfort and safety for the endoscopic procedure. As individuals vary in their response to sedating medications, vigilant monitoring is, therefore, required. The major components for effective sedation monitoring include both appropriate personnel and monitors of physiologic parameters , including hemodynamics, oxygenation, ventilation, and depth of sedation. In the present article, the authors review the evidence base for extended monitoring practices as well as key guidelines and recommendations from the American Society for Gastrointestinal Endoscopy (ASGE) and the ASA ( Table 3 ).

Direct monitoring and personnel

All patients undergoing sedation during endoscopy must be directly monitored by a trained member of the endoscopy team for the duration of the procedure. Direct monitoring refers to both visual assessment of patients as well as review of hemodynamic data collected in real-time through medical devices. Visual assessment may include observing respiratory patterns, depth of chest rise, skin and mucosal coloration, level of consciousness, and facial expressions as a reflection of patient stability and comfort. Devices that monitor relevant hemodynamic parameters are discussed in detail later. In all cases, direct monitoring should begin immediately before the administration of sedation and should continue through procedural recovery. Patients who require agents such as naloxone or flumazenil for opiate or benzodiazepine reversal, respectively, may require several hours of subsequent observation.

The personnel requirements for direct monitoring during endoscopic sedation depend on the depth of sedation and procedural complexity. Although the Joint Commission does not define specific degree qualifications or levels of education for a direct monitoring assistant, the ASGE recommends a registered nurse (RN) with appropriate training for patients receiving moderate sedation. This training should include a working knowledge of the stages of sedation, the skills to monitor and interpret physiologic parameters related to sedation, and the ability to initiate appropriate interventions in the event of a complication. The assistant must be certified in basic or advanced cardiac life support (ACLS). According to a 2006 nationwide survey, RNs are responsible for direct monitoring in approximately 90% of endoscopy sites in the United States.

During moderate sedation cases, a single assistant (typically an RN) may perform direct patient monitoring as well as brief assistive tasks for the endoscopist, such as endoscopic biopsy or application of abdominal pressure. Complex endoscopic cases, such as ERCP or endoscopic ultrasound (EUS)/fine-needle aspiration, should include an additional team member whose sole purpose is technical assistance in order to allow the RN to exclusively focus on direct patient monitoring and administration of sedation. The additional technical member may be an RN, licensed practical nurse (LPN), or unlicensed assistive person (UAP) who has received appropriate training. In these cases there should be at least one additional ACLS certified member of the team who has the ability to secure an airway and provide bag mask ventilation if needed (this is generally the endoscopist). Finally, in cases that include an anesthesia provider, either an anesthesiologist or a certified registered nurse anesthetist, that individual will assume complete responsibility for direct monitoring and an RN, LPN, or UAP may be enlisted to provide technical endoscopic assistance if indicated.

Hemodynamic monitoring