Is a global sedation protocol available for surveillance colonoscopy?

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Patient comfort and colonoscopy

The pre-colonoscopic preparation of patients assists in lowering anxiety levels and promoting better tolerance of colonoscopy itself.[1][2][3][4][5][6][7][8][9]

Sedation or analgesia is important in maintaining patient comfort. However, sedation and monitoring practice across the world is significantly variable. A study in 21 centres in 11 countries was carried out, using a standard questionnaire for each patient.[10] Of 6004 patients undergoing colonoscopy in the study, 53% received conscious/moderate sedation, 30% deep sedation while 17% received no sedation. Most commonly used agents for sedation were midazolam 47%, opioids 33%, an anaesthetist was present in 85% of colonoscopies when deep sedation was involved.

An Australian study of anaesthetists’ practice[11]also failed to reveal a standard practice profile in this country. In this study, the choice of drugs was quite wide but propofol was used by all but one respondent, (200 surveys were sent to Fellows of Australian and New Zealand College of Anaesthetists of whom 113 or 57% responded). However, only 4% used propofol exclusively. Patients undergoing colonoscopy were more likely to receive propofol/midazolam/fentanyl (p<0.001). Pulse oximetry is used in all patients in Australia for deep sedation and an anaesthetist is required to be present during the procedure. This practice of anaesthetist oversight is not necessarily practised overseas.[10]

Most studies on patient satisfaction do not address individual patient satisfaction with sedation directly, but rather satisfaction with the overall procedure.[12][13]A prospective cohort study[12] reporting 86.6% satisfaction and a literature review,[13] reporting 95% early satisfaction with colonoscopy (and 73-100% of patients willing to return for repeat testing) are seen as indicative of acceptance of the procedure. An RCT Phase III study of propofol strongly supported the agent’s use for sedation in colonoscopy.[14] A Cochrane Review[15] supports propofol administration for sedation in colonoscopy for generally healthy individuals and observes that it can shorten recovery times, lead to earlier discharge, meet patient satisfaction and have no increase in side-effects when compared to traditional sedatives, opioids and benzodiazepines. The review suggests that more standardised studies are needed to compare propofol sedation and its administration by anaesthetists and non-anaesthetists. A retrospective survey[16] encourages less highly specialised staff for monitoring sedated patients.

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Is a global sedation protocol available for surveillance colonoscopy?

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Carefully judged doses of sedation with appropriate monitoring of vital signs and quality technical performance of colonoscopy[17], provide for a most satisfactory outcome for patients undergoing endoscopy. There are a range of other aids, coping, education and videotapes etc[18]; however, overall, carefully controlled sedation provides patient comfort, satisfaction and successful outcome.[15][11][18]

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Evidence summary and recommendations

Practice point(s)

Controversy continues with regard to choice of drugs for sedation and monitoring patients during colonoscopy.

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Conclusions

Sedation for colonoscopy is widely practised and, while a number of drugs are available to assist patient comfort, some services do not choose to use them[10]. There is controversy regarding risks and benefits of available drugs and appropriate monitoring during sedation.[14]

While clinicians appear to be fully cognisant of the relative safety of the drugs and monitoring systems required, controversies remain and a well-designed and -conducted RCT would appear necessary to find whether these variations have an effect on outcomes following colonoscopy.

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References

  1. F Ersoz, AB Toros, G Aydogan, H Bektas, O Ozcan, S Arikan. Assessment of anxiety levels in patients during elective upper gastrointestinal endoscopy and colonoscopy. Turk.J Gastroenterol. 2010 Mar;21(1):29-33.
  2. J Morgan, L Roufeil, S Kaushik, M Bassett. Influence of coping style and precolonoscopy information on pain and anxiety of colonoscopy. Gastrointest.Endosc 1998 Aug;48(2):119-127.
  3. P Agre, RC Kurtz, BJ Krauss. A randomized trial using videotape to present consent information for colonoscopy. Gastrointest.Endosc. 1994;40(3):271-276.
  4. Condon A, Graff L, Elliot L, Ilnyckyj A. Acceptance of colonoscopy requires more than test tolerance. Can J Gastroenterol. 2008 Jan 1;22(1):41-47.
  5. A Luck, S Pearson, G Maddern, P Hewett. Effects of video information on precolonoscopy anxiety and knowledge: a randomised trial. Lancet. 1999 Dec;354(9195):2032-2035.
  6. P Bytzer, B Lindenberg. Impact of an information video before colonoscopy on patient satisfaction and anxiety - a randomized trial. Endoscopy. 2007;39(8):710-714.
  7. A Costa, LM Montalbano, A Orlando, C Ingoglia, C Linea, M Giunta et al. Music for colonoscopy: A single-blind randomized controlled trial. Dig.Liver Dis. 2010;42(12):871-876.
  8. ML Bechtold, SR Puli, MO Othman, CR Bartalos, JB Marshall, PK Roy. Effect of music on patients undergoing colonoscopy: a meta-analysis of randomized controlled trials. Dig.Dis.Sci. 2009;54(1):19-24.
  9. A Hayes, M Buffum, E Lanier, E Rodahl, C Sasso. A music intervention to reduce anxiety prior to gastrointestinal procedures. Gastroenterol.Nurs. 2003;26(4):145-149.
  10. 10.0 10.1 10.2 F Froehlich, JK Harris, V Wietlisbach, B Burnand, JP Vader, JJ Gonvers. Current sedation and monitoring practice for colonoscopy: an International Observational Study (EPAGE). Endoscopy. 2006;38(5):461-469.
  11. 11.0 11.1 U Padmanabhan, K Leslie. Australian anaesthetists' practice of sedation for gastrointestinal endoscopy in adult patients. Anaesth.Intensive Care. 2008;36(3):436-441.
  12. 12.0 12.1 HH Ko, H Zhang, JJ Telford, R Enns. Factors influencing patient satisfaction when undergoing endoscopic procedures. Gastrointest.Endosc. 2009;69(4):883-891.
  13. 13.0 13.1 L Chartier, E Arthurs, MJ Sewitch. Patient satisfaction with colonoscopy: a literature review and pilot study. Can J Gastroenterol. 2009;23(3):203-209.
  14. 14.0 14.1 LB Cohen, E Cattau, A Goetsch, A Shah, JP Weber, DK Rex et al. A randomized, double-blind, phase 3 study of fospropofol disodium for sedation during colonoscopy. J Clin.Gastroenterol. 2010;44(5):345-353.
  15. 15.0 15.1 H Singh, W Poluha, M Cheung, N Choptain, KI Baron, SP Taback. Propofol for sedation during colonoscopy. Cochrane Database Syst.Rev. 2008;(4):CD006268.
  16. D Kulling, M Orlandi, W Inauen. Propofol sedation during endoscopic procedures: how much staff and monitoring are necessary? Gastrointest.Endosc. 2007;66(3):443-449.
  17. F Radaelli, G Meucci, G Sgroi, G Minoli. Technical performance of colonoscopy: the key role of sedation/analgesia and other quality indicators. Am J Gastroenterol. 2008;103(5):1122-1130.
  18. 18.0 18.1 LJ Brandt. Patients' attitudes and apprehensions about endoscopy: how to calm troubled waters. Am J Gastroenterol. 2001 Feb;96(2):280-284.

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