Redefining Quality in Endoscopic Sedation

The popularity of anesthesia-assisted sedation is attributable to two closely interwoven elements of this practice: namely the drug propofol, and the presence of an additional individual to assist with drug administration and patient monitoring. Propofol, a short-acting sedative hypnotic agent, has a rapid onset of action and quick offset. Patients awaken rapidly from propofol with a feeling of clearheaded recovery. Propofol is capable of producing deep sedation and general anesthesia, distinguishing it from the benzodiazepines that exhibit a ceiling effect with regard to the depth of sedation. Consequently, propofol’s attraction as an agent for procedural sedation is a direct result of its pharmacokinetic and pharmacodynamic properties. Notwithstanding propofol’s desirable properties, we must also acknowledge the valuable contribution of the anesthesia provider. This individual improves practice efficiency by assisting with the pre-procedural assessment, preparation of the patient including placement of the intravenous catheter and monitoring electrodes, intraprocedural monitoring and administration of drugs, and recovery room care. As a result, operating efficiency is improved and staffing costs may be reduced. These benefits come at a price, however. The average cost of anesthesiaassisted sedation during an endoscopic procedure is roughly $400 per case [1]. This cost is ultimately passed on to patients in the form of higher health insurance premiums, and this must be considered when examining the overall effectiveness of anesthesia services. In this issue of Digestive Disease and Sciences, Nayar and colleagues report the results of their retrospective analysis comparing the outcomes of 1,000 endoscopic ultrasound (EUS) procedures performed with anesthesiaassisted propofol sedation and 1,000 EUS procedures performed under conventional sedation using a benzodiazepine and an opioid [2]. The two groups were noncontemporaneous, with the conventional sedation and anesthesia care cohorts enrolled sequentially during two consecutive 2-year intervals, beginning on January 1, 1999. As anticipated, sedation induction time and recovery time were significantly shorter in the group receiving propofol (3.1 and 35 min) compared to those receiving standard sedation (5.8 and 70 min). Unexpectedly, intra-procedural time was significantly reduced in the propofol group (28 min) compared to patients sedated with a benzodiazepine and an opioid (61 min). Patient satisfaction was higher with propofol (9.5) compared to traditional sedation (8.3) using a ten-point visual analogue scale (10 = best), although both patient cohorts reported good levels of satisfaction. Notably, the rate of sedation-related complications was numerically higher in the anesthesia group compared to patients receiving standard sedation, although the difference was not statistically significant. A total of six complications were observed in the anesthesia care group, including perforation [1], aspiration [1], apnea requiring endotracheal intubation [3], and hypotension [1]. In contrast, only one complication (prolonged somnolence) was recorded in the moderate sedation group. The treatment groups were similar with respect to age, gender, BMI, study indication, and ASA physical classification, although numerically, there were fewer ASA 1 and 2 s, and more L. B. Cohen (&) The Mount Sinai School of Medicine, New York, NY 10029, USA e-mail: Lawrence.Cohen@nyga.md