Comparison of differing sedation practice for upper endoscopic ultrasound using expert observational analysis of the procedural sedation.
OBJECTIVE
To compare the quality between 2 commonly used sedation practices for upper endoscopic ultrasound (EUS) by using expert observational analysis of the sedation practice.


METHODS
After institutional review board approval, 50 adults undergoing EUS had videotape observation of the procedural sedation: 25 received benzodiazepine/opiate administered by the endoscopy team as per the standard protocol at our institution, and 25 received propofol administered by a dedicated anesthesiologist. Quantitative analysis of the video was performed using the Dartmouth Operative Conditions Scale (DOCS). The DOCS is a tool previously developed to quantify the adequacy of procedural sedation through an objective measurement of the patient state during the sedation process. In this study, the DOCS was used in a novel way to compare the quality of sedation provided by different sedation protocols. Data were collected on patient demographics, patient and provider satisfaction, efficiency, side effects, and safety measures.


RESULTS
Videotape analysis using the DOCS revealed that 52% (13/25) of the standard group exhibited an uncontrolled patient state (significant undersedation and/or oversedation) on 1 or more occasion during their EUS procedure compared with 28% (7/25) of the propofol group. Patients in the standard group spent 7.1% of the procedure in an uncontrolled patient state, whereas patients in the propofol group experienced an uncontrolled state approximately 1.0% of the procedure time. Overall efficiency as measured by time in both the procedure room and in recovery was superior in the propofol group. These patients spent 12 less minutes on average in the procedure room and were ready for discharge in about half the time (56 minutes versus 109 minutes). The propofol group experienced significantly less in-hospital and at-home nausea and vomiting and felt back to baseline status more quickly. Finally, patient satisfaction was improved in the propofol group: 60% felt the procedure was better than anticipated versus 21% in the standard group.


CONCLUSIONS
Expert videotape analysis of the patient state during procedural sedation allows direct comparison of sedation methodologies using small numbers of patients. In our institution, endoscopist-directed sedation using a midazolam/narcotic combination for EUS proved inferior to sedation using propofol given by an anesthesiologist. Specifically, a midazolam/narcotic combination provided less effective intraprocedural conditions, was less efficient both before and after the procedure, and was less satisfactory to patients as compared with propofol. Results of this type of analysis can be used to drive appropriate system redesign and improve patient care.
Trummel
John Michael
JM
Department ofAnesthesiology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA. john.trummel@hitchcock.org
Surgenor
Stephen D
SD
Cravero
Joseph P
JP
Gordon
Stuart R
SR
Blike
George T
GT
D000368:Aged; D016292:Procedural Sedation; D003625:Data Collection; D016099:Endoscopy, Gastrointestinal; D019160:Endosonography; D006801:Humans; D006993:Hypnotics and Sedatives / Q000627:therapeutic use*; D008875:Middle Aged; D019370:Observation; D010818:Practice Patterns, Physicians'; D015742:Propofol / Q000627:therapeutic use*; D011446:Prospective Studies; D014743:Videotape Recording
D006993:Hypnotics and Sedatives; D015742:Propofol