As the debate rages on over who should administer propofol sedation for endoscopic procedures, here's a radical proposal: Adopt a 2-tiered system whereby patients at the highest risk would be sedated by CRNAs and anesthesiologists, while lower-risk patients would be sedated by an RN whose sole responsibility is to provide sedation and monitor the patient, under the supervision of the endoscopist. In such a scenario, both the nurse and the supervising physician would have to be trained and competent in rescuing patients from deep sedation and general anesthesia. When you consider the ongoing turf battle, maybe this isn't such a crazy proposal. It keeps patient safety as the central issue in propofol administration.

Who can safely administer propofol?
Is the administration of propofol by such non-anesthesia providers as GIs or RNs comparable in efficacy and safety to anesthesia-administered propofol? That depends on who you listen to.

The answer's yes, according to a joint statement issued in December 2009 by several GI societies. Their review of the published literature showed that non-anesthesia administered propofol (NAAP) used in standard endoscopic procedures (upper endoscopy and colonoscopy) is superior to standard sedation regimens, with shorter sedation and recovery times. Research also shows that patient satisfaction with propofol sedation ranges from equivalent to slightly superior when compared to standard sedation.

The GI societies concluded that the use of anesthesiologist-administered propofol for healthy individuals undergoing elective endoscopy without risk factors for sedation-related complications is very costly, with no demonstrated improvement in patient safety or procedural outcome. They qualified their endorsement of NAAP sedation by stating that non-anesthesia personnel should have supervised, hands-on training (in upper and lower airway complication management, for example) by an anesthesiologist or qualified endoscopist before administering propofol, and that only healthy, low-risk patients should be chosen for procedures with NAAP sedation.

Despite the GI groups' endorsement of NAAP, anesthesia professionals, some accrediting bodies and the Food and Drug Administration still frown upon the practice. In a 2004 joint statement, the American Society of Anesthesiologists and the American Association of Nurse Anesthetists said propofol sedation should be administered only by persons trained in the administration of general anesthesia, a position with which the American Association for Accreditation of Ambulatory Surgery Facilities concurs. This restriction is in accord with specific language included in the propofol package insert. Divergent policies at the state and institutional level further obfuscate the issue of who can safely administer propofol sedation for routine endoscopic procedures.

Is propofol safe for advanced endoscopy?
While questions over the safety of propofol sedation in routine endoscopy have been hotly debated for years, there is little information on the use of propofol in advanced endoscopic procedures. In a recently published study, my colleagues and I set out to report the incidence of sedation-related complications associated with propofol administered by CRNAs for advanced endoscopic procedures — endoscopic retrograde cholangiopancreatography (ERCP), endoscopic ultrasound (EUS) and small-bowel enteroscopy — which require deeper levels of sedation because of their longer duration and greater need for patient cooperation. We focused on the frequency of airway modifications (AMs), and also evaluated independent clinical predictors of AMs during advanced endoscopy.

We conducted the study at Barnes-Jewish Hospital, the primary medical facility of the Washington University at St. Louis, where the standard practice is to administer propofol-based sedation by CRNAs (under the medical direction of an anesthesiologist) who have extensive experience monitoring and rescuing patients under deep sedation and general anesthesia. The CRNAs determined the sedative dosing, with the goal of achieving a patient unresponsive to endoscopic intubation without the use of topical anesthesia in the upper airway; we achieved this goal in 87.2% of the 799 patients enrolled in the study. We performed 154 AMs in 14.4% of patients, including chin lift, modified facemask ventilation and nasal airway. A chin lift maneuver was considered any chin or jaw manipulation performed to improve upper airway patency for optimal airflow. A modified mask airway consisted of the use of a customized oxygen enrichment device to deliver higher oxygen flows as compared to a nasal cannula. No patients required bag-mask ventilation or endotracheal intubation.

Hypoxemia, defined as pulse oximetry <90%, was the most commonly reported adverse event, occurring in 12.8% of procedures. Termination of the procedure due to airway difficulty occurred in 5 cases (0.6%), and hypotension requiring the transient use of vasopressors occurred in 4 cases (0.5%). Following multivariate regression analysis, we identified 3 independent predictors of AMs: male sex, increased BMI and an ASA class of 3 or higher.

Our findings underscore the importance of having a trained professional who is solely responsible for the maintenance of sedation and patient monitoring while administering propofol, since these patients are often under deep sedation or possibly general anesthesia for extended periods. In the interest of patient safety, propofol should be administered by personnel who are capable of managing a range of issues, including laryngospasm, hypoxemia and hypotension, and are capable of laryngeal intubation. Our experience also demonstrates that universal intubation for ERCP procedures, as practiced in several institutions, is redundant and not required for a safe outcome, provided the personnel administering sedation are skilled in titrating propofol in a non-intubated patient.