Endoscopist-directed administration of propofol: a worldwide safety experience.
OBJECTIVE
Endoscopist-directed propofol sedation (EDP) remains controversial. We sought to update the safety experience of EDP and estimate the cost of using anesthesia specialists for endoscopic sedation.


METHODS
We reviewed all published work using EDP. We contacted all endoscopists performing EDP for endoscopy that we were aware of to obtain their safety experience. These complications were available in all patients: endotracheal intubations, permanent neurologic injuries, and death.


RESULTS
A total of 646,080 (223,656 published and 422,424 unpublished) EDP cases were identified. Endotracheal intubations, permanent neurologic injuries, and deaths were 11, 0, and 4, respectively. Deaths occurred in 2 patients with pancreatic cancer, a severely handicapped patient with mental retardation, and a patient with severe cardiomyopathy. The overall number of cases requiring mask ventilation was 489 (0.1%) of 569,220 cases with data available. For sites specifying mask ventilation risk by procedure type, 185 (0.1%) of 185,245 patients and 20 (0.01%) of 142,863 patients required mask ventilation during their esophagogastroduodenoscopy or colonoscopy, respectively (P < .001). The estimated cost per life-year saved to substitute anesthesia specialists in these cases, assuming they would have prevented all deaths, was $5.3 million.


CONCLUSIONS
EDP thus far has a lower mortality rate than that in published data on endoscopist-delivered benzodiazepines and opioids and a comparable rate to that in published data on general anesthesia by anesthesiologists. In the cases described here, use of anesthesia specialists to deliver propofol would have had high costs relative to any potential benefit.
Rex
Douglas K
DK
Division of Gastroenterology/Hepatology, Indiana University Medical Center, Indianapolis, Indiana 46202, USA. drex@iupui.edu
Deenadayalu
Viju P
VP
Eid
Emely
E
Imperiale
Thomas F
TF
Walker
John A
JA
Sandhu
Kuldip
K
Clarke
Anthony C
AC
Hillman
Lybus C
LC
Horiuchi
Akira
A
Cohen
Lawrence B
LB
Heuss
Ludwig T
LT
Peter
Shajan
S
Beglinger
Christoph
C
Sinnott
James A
JA
Welton
Thomas
T
Rofail
Magdy
M
Subei
Iyad
I
Sleven
Rodger
R
Jordan
Paul
P
Goff
John
J
Gerstenberger
Patrick D
PD
Munnings
Harold
H
Tagle
Martin
M
Sipe
Brian W
BW
Wehrmann
Till
T
Di Palma
Jack A
JA
Occhipinti
Kaitlin E
KE
Barbi
Egidio
E
Riphaus
Andrea
A
Amann
Stephen T
ST
Tohda
Gen
G
McClellan
Timothy
T
Thueson
Charles
C
Morse
John
J
Meah
Nizam
N
D000758:Anesthesia / Q000009:adverse effects / Q000191:economics; D018686:Anesthetics, Intravenous / Q000008:administration & dosage / Q000009:adverse effects* / Q000191:economics; D002983:Clinical Competence; D003257:Consumer Product Safety; D003362:Cost-Benefit Analysis; D004724:Endoscopy / Q000191:economics; D014943:Global Health; D017048:Health Care Costs; D006801:Humans; D007442:Intubation, Intratracheal; D008397:Masks; D017410:Practice Guidelines as Topic; D015742:Propofol / Q000008:administration & dosage* / Q000009:adverse effects / Q000191:economics; D012121:Respiration, Artificial / Q000295:instrumentation; D018570:Risk Assessment
D018686:Anesthetics, Intravenous; D015742:Propofol