Table 3.
Summary of recommendations for individuals capable of administering sedation
| Subject | Number of documents | Document developers | Comments |
|---|---|---|---|
| Moderate sedation | |||
| Can be administered by a nurse who is directed by a physician | 4 | ASGE [21, 27, 32], SGNA [41] | – |
| 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 | ||
AGA American Gastroenterological Association, ASGE American Society for Gastrointestinal Endoscopy, ASGH Austrian Society of Gastroenterology and Hepatology, BSG British Society of Gastroenterology, CAG Canadian Association of Gastroenterology, CSGNA Canadian Society of Gastroenterology Nurses and Associations, DSRPGSA Danish Secretariat for Reference Programmes for Gastroenterology, Surgery and Anaesthetics, ESGE European Society of Gastrointestinal Endoscopy, FSDE French Society of Digestive Endoscopy, GESA Gastroenterological Society of Australia; GSGDMD German Society for Gastroenterology, Digestive and Metabolic Diseases, ISDE Italian Society of Digestive Endoscopy, SAGES Society of American Gastrointestinal and Endoscopic Surgeons, SGNA Society of Gastroenterology Nurses and Associates, SSGE Spanish Society of Gastrointestinal Endoscopy