Twenty-four-hour ambulatory blood pressure monitoring in very elderly patients: Comparison of in-hospital versus home follow-up results.

Elevated blood pressure (BP) is frequently diagnosed in very elderly hospitalized patients. Accurate diagnosis of hypertension is challenging in the hospital environment, due to the "white coat effect," and both overtreatment and undertreatment can adversely affect clinical outcome. Twenty-four-hour ambulatory blood pressure monitoring (ABPM) has the potential to avoid the "white coat effect" and accurately guide the management of hypertension. However, effects of the hospital environment on ABPM are unknown in the very elderly. We set out to enroll 45 patients, age ≥70 years, with elevated conventional BP during hospitalization in this observational study. It was prespecified by protocol to assess initially the difference between 24-hour BP during hospital-admission and home follow-up. Subsequent analysis should investigate the change in anxiety (Hospital Anxiety and Depression Scale-A [HADS-A]) after discharge, the correlation with change in 24-hour BP after discharge, and the prevalence of orthostatic hypertension. Thirty-one patients were included in the final analysis (age 83.5 ±â€Š4.4 years; 71% female). Twenty-four-hour BP decreased significantly after hospital discharge (systolic from 133.5 ±â€Š15.6 to 126.2 ±â€Š14.4 mm Hg [millimeter of mercury], P = .008; diastolic from 71.0 ±â€Š9.0 to 68.3 ±â€Š8.6 mm Hg, P = .046). Anxiety level (HADS-A) decreased significantly after discharge, from 7.5 (interquartile range [IQR]: 4.0-13.8) to 5.0 (IQR: 4.0-8.0, P = .012). The change in anxiety was a predictor of change in systolic BP after discharge (F[1,20] = 5.9, P = .025). Sixty-one percent of the patients had significant orthostatic hypotension during hospital stay. In conclusion, 24-hour BP in very elderly patients is lower in the home environment than during hospitalization. This phenomenon seems to be directly linked to a lower anxiety-level at home. Reassessing hypertension at home may decrease the need for (intensified) antihypertensive medical therapy in a substantial number of patients. This is particularly important in the very elderly, who have a high prevalence of symptomatic and asymptomatic orthostatic hypotension, making them prone to hazardous effects of antihypertensive therapy.

Sedation during bronchoscopy: data from a nationwide sedation and monitoring survey.

BACKGROUND: There is limited knowledge on practice patterns in procedural sedation and analgesia (PSA), the use of propofol, and monitoring during flexible bronchoscopy (FB). The purpose of this study was to assess the current practice patterns of FBs and to focus on the use of propofol, the education of the proceduralist, and the involvement of anaesthesiologists during FB. METHODS: An anonymous questionnaire was sent to 299 pulmonologists. Only respondents who were active physicians in adult respiratory medicine performing FB were subsequently analysed. RESULTS: The response rate was 78 % and 27,149 FB in the previous 12 months were analysed. The overall sedation-related morbidity rate was 0.02 % and mortality was 7/100'000 FB. Sedation was used in 95 % of bronchoscopies. The main drugs used for PSA were propofol (77 %) and midazolam (46 %). In 84 % of PSAs propofol was used without the attendance of an anaesthesiologist. The use of propofol was associated with high volume bronchoscopists (p < 0.010) and career-young pulmonologists (p < 0.001). While monitoring vital parameters has become standard practice, pulmonologists reported a very low rate of systematic basic education and training in the field of PSA (50 %). CONCLUSIONS: In Switzerland, PSA during FB is mostly performed with propofol without the attendance of an anaesthesiologist and the use of this drug is expected to increase in the future. While monitoring standards are very high there is need for policies to improve education, systematic training, and support for pulmonologists for PSA during FB.

Feasibility of breath monitoring in patients undergoing elective colonoscopy under propofol sedation: A single-center pilot study.

AIM: To determine whether a newly developed respiratory rate monitor can practically and accurately monitor ventilation under propofol sedation in combination with standard monitoring. METHODS: Patients [American Society of Anesthesiologists (ASA) Classification I-III] scheduled for elective colonoscopy under propofol sedation were monitored with a new device that measures the respiratory rate based on humidity in expired air. Patients with clinically significant cardiac disorders or pulmonary disease and patients requiring emergency procedures were excluded from study participation. All of the patients also received standard monitoring with pulse oximetry. This was a single-center study conducted in a community hospital in Switzerland. After obtaining written informed consent from all subjects, 76 patients (51 females and 25 males) were monitored during colonoscopy under propofol sedation. The primary endpoint was the occurrence of any respiratory event (apnea or hypopnea). Apnea was defined as the cessation of breathing for a minimum of 10 s. Significant apnea was defined as the cessation of breathing for more than 30 s. Hypopnea was defined as a reduction in the respiratory rate below 6/min for a minimum of 10 s. Any cases of significant apnea triggered interventions by the endoscopy team. The interventions included withholding propofol, verbal stimulation of the patients, and increased oxygen supplementation or the chin lift maneuver. A secondary endpoint was the correlation of apnea or hypopnea with hypoxemia (measured as a decrease in SaO2 of at least 5% from baseline or less than 90%). RESULTS: At least one respiratory event was detected in thirty-seven patients (48.7%). In total, there were 73 respiratory events, ranging from one to six events in a single patient. Significant apnea (> 30 s) occurred in five patients (6%). Only one episode of apnea led to a relative SaO2 reduction (from 98% to 93%) after a 50 s lag time. No event requiring assisted ventilation was recorded. Our analysis revealed that the total propofol dose was an independent risk factor for respiratory events (P = 0.01). Artifacts developed with the same frequency with the new device as with conventional pulse oximetry. Compared with pulse oximetry alone, this new monitoring device detected more respiratory events and may provide earlier warning of impending respiratory abnormalities. CONCLUSION: Apnea commonly occurs during endoscopy under sedation and may precede hypoxemia. We recommend this respiration rate monitor as an alternative to capnography to aid in detecting ventilatory problems.

Endoscopy teams' judgment of discomfort among patients undergoing colonoscopy: "How bad was it really?".

QUESTIONS UNDER STUDY / PRINCIPLES: Colonoscopies are complex procedures that depend greatly on the patient's cooperation and on the correct judgment of a tolerable amount of discomfort by the endoscopy team, even in sedated patients. Little is known regarding the accuracy of the patient comfort level assessments made by medical staff. METHODS: We prospectively evaluated the degree of agreement between the assessments made by the endoscopists and endoscopy nurses and the assessments made by patients regarding their comfort level during the procedure. A total of 222 patients scheduled for routine colonoscopies assessed their preprocedural anxiety and the tolerability of the procedure. Endoscopists and nurses assessed the difficulty of the examination and the patient's level of discomfort. Assessments were performed using a 100-mm VAS. RESULTS: Overall, patients rated the procedure as tolerable. For 12% (27/222) of the patients, the examination was less tolerable (VAS >50 mm). The patients' judgment of tolerability was not related to the initial level of anxiety (r = 0.15). The scores of the endoscopists and nurses were better correlated with each other (r = 0.58) than with the patients' self-assessments (r = 0.37 and 0.35, respectively). Both endoscopists and nurses tended to overestimate the patients' discomfort. However, in 9% (19/222) of cases, the level of patient discomfort was considerably underestimated by at least one member of the team. CONCLUSION: Our study shows that the estimation of a patient's discomfort during a colonoscopy is difficult and that the comfort level may not be accurately determined in a considerable number of patients, including sedated patients.

Carbon dioxide accumulation during analgosedated colonoscopy: comparison of propofol and midazolam.

AIM: To characterize the profiles of alveolar hypoventilation during colonoscopies performed under sedoanalgesia with a combination of alfentanil and either midazolam or propofol. METHODS: Consecutive patients undergoing routine colonoscopy were randomly assigned to sedation with either propofol or midazolam in an open-labeled design using a titration scheme. All patients received 4 µg/kg per body weight alfentanil for analgesia and 3 L of supplemental oxygen. Oxygen saturation (SpO2) was measured by pulse oximetry (POX), and capnography (PcCO2) was continuously measured using a combined dedicated sensor at the ear lobe. Instances of apnea resulting in measures such as stimulation of the patient, a chin lift, a mask maneuver, or withholding of sedation were recorded. PcCO2 values (as a parameter of sedation-induced hypoventilation) were compared between groups at the following distinct time points: baseline, maximal rise, termination of the procedure and 5 min after termination of the procedure. The number of patients in both study groups who regained baseline PcCO2 values (± 1.5 mmHg) five minutes after the procedure was determined. RESULTS: A total of 97 patients entered this study. The data from 14 patients were subsequently excluded for clinical procedure-related reasons or for technical problems. Therefore, 83 patients (mean age 62 ± 13 years) were successfully randomized to receive propofol (n = 42) or midazolam (n = 41) for sedation. Most of the patients were classified as American Society of Anesthesiologists (ASA) II [16 (38%) in the midazolam group and 15 (32%) in the propofol group] and ASA III [14 (33%) and 13 (32%) in the midazolam and propofol groups, respectively]. A mean dose of 5 (4-7) mg of IV midazolam and 131 (70-260) mg of IV propofol was used during the procedure in the corresponding study arms. The mean SpO2 at baseline (%) was 99 ± 1 for the midazolam group and 99 ± 1 for the propofol group. No cases of hypoxemia (SpO2 < 85%) or apnea were recorded. However, an increase in PcCO2 that indicated alveolar hypoventilation occurred in both groups after administration of the first drug and was not detected with pulse oximetry alone. The mean interval between the initiation of sedation and the time when the PcCO2 value increased to more than 2 mmHg was 2.8 ± 1.3 min for midazolam and 2.8 ± 1.1 min for propofol. The mean maximal rise was similar for both drugs: 8.6 ± 3.7 mmHg for midazolam and 7.4 ± 3.2 mmHg for propofol. Five minutes after the end of the procedure, the mean difference from the baseline values was significantly lower for the propofol treatment compared with midazolam (0.9 ± 3.0 mmHg vs 4.3 ± 3.7 mmHg, P = 0.0000169), and significantly more patients in the propofol group had regained their baseline value ± 1.5 mmHg (32 of 41 vs 12 of 42, P = 0.0004). CONCLUSION: A significantly higher number of patients sedated with propofol had normalized PcCO2 values five minutes after sedation when compared with patients sedated with midazolam.

Propofol sedation alone or in combination with pharyngeal lidocaine anesthesia for routine upper GI endoscopy: a randomized, double-blind, placebo-controlled, non-inferiority trial.

BACKGROUND: In patients undergoing routine upper EGD, propofol is increasingly used without pharyngeal anesthesia because of its excellent sedative properties. It is unclear whether this practice is non-inferior in regard to ease of endoscopic intubation and patient comfort. OBJECTIVE: To assess the relevance of local pharyngeal anesthesia regarding the ease of EGD performance in patients sedated with propofol as monotherapy. DESIGN: Randomized, double-blind, placebo-controlled, non-inferiority trial. SETTING: One community hospital and one university hospital in Switzerland. PATIENTS: We enrolled 300 consecutive adult patients undergoing elective EGD. INTERVENTION: Pharyngeal anesthesia with 4 squirts of lidocaine spray versus placebo spray immediately before propofol sedation. MAIN OUTCOME MEASUREMENTS: Number of gag reflexes (primary endpoint), number of intubation attempts, and degree of salivation during intubation (secondary endpoints) assessed by the endoscopists and staff. RESULTS: In the lidocaine group, 122 patients (82%) had no gag events, and 25 patients had a total of 39 gag events, whereas in the placebo group 104 patients (71%) had no gag events, and 43 patients had a total of 111 gag events. The rate ratio of gagging with quasi-likelihood estimation of placebo compared with lidocaine was 2.85 (95% confidence interval [CI], 1.42-6.19; P = .005). In adjusted logistic regression analysis, the odds ratio for gagging for placebo pharyngeal anesthesia compared with lidocaine was 1.9 (95% CI, 1.03-3.54). The number of intubation attempts and the degree of salivation were similar in both groups. Two patients in the placebo group experienced oxygen desaturation and needed short-term mask ventilation. LIMITATIONS: The level of sedation and possible long-term side effects of pharyngeal anesthesia were not assessed. CONCLUSION: Topical pharyngeal anesthesia reduces the gag reflex in patients sedated with propofol even though it does not seem to have an influence on the ease of the procedure and on patient or endoscopist satisfaction in adequately sedated patients.

Endoscopist-directed administration of propofol: a worldwide safety experience.

BACKGROUND & AIMS: 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.

Propofol use by gastroenterologists-the European experience.

The administration of propofol as a sedative in gastrointestinal endoscopies became very popular in many European countries during the last years. Nevertheless there are huge regional differences in the way that the drug is used. Switzerland, the country with highest propagation of gastroenterologist guided propofol sedation, serves as a case study of its safe use in daily practice. The experiences of this spread are summarized in this article.

Capsule endoscopy of the upper gastrointestinal tract -- the need for a second endoscopy.

BACKGROUND AND AIMS: Capsule endoscopy (CE) has been recognised as an important investigational tool in the diagnosis of gastrointestinal disease. Studies have shown that CE can identify lesions in the upper gastrointestinal tract as well as in the small intestine. However, contrary to conventional oesophagogastroscopy results, the role of CE findings in the diagnostic algorithm of disorders such as gastrointestinal bleeding has not been well understood. We evaluated the frequency of lesions identified in the oesophagus and the stomach as well as their significance. METHODS: We retrospectively evaluated patients who had undergone video CE over the last 2 years at our institution. Indication and findings in the oesophagus and the stomach were analysed and compared to previous oesophagogastroscopy findings. Patients in whom lesions were identified were followed up retrospectively for the significance of these findings. RESULTS: 95 patients were included in the analysis (47 males, 48 females, mean +/- SD age of 54.62 +/- 19.2 years). The commonest indication for CE was gastrointestinal bleeding (45%), the second commonest anaemia (28%). CE identified significant lesions in the stomach of 11/95 (11.57%) patients. These lesions had been overlooked in 9/95 (9%) of patients by conventional oesophagogastroscopy prior to CE examination (p value < 0.05). Eight of 95 (8%) patients had oesophageal abnormalities detected by CE. The diagnosis changed the treatment of 8/11 (82%) patients with significant lesions. CONCLUSIONS: CE has an undefined role in evaluating upper gastrointestinal lesions. Significant lesions missed at oesophagogastroscopy were identified during CE examination. This study underpins the importance of a second conventional endoscopy in the diagnostic algorithm.

Trained registered nurses/endoscopy teams can administer propofol safely for endoscopy.

BACKGROUND & AIMS: Propofol has advantages as a sedative for endoscopic procedures. Its administration by anesthesia specialists is associated with high cost. Administration by nonanesthesiologists is controversial because of concerns about safety, particularly respiratory depression. METHODS: Three endoscopy units developed programs to train registered nurses supervised only by endoscopists in the administration of propofol for endoscopic procedures. The rate of adverse respiratory events was tracked from the inception of the programs. To estimate whether training nurses to give propofol on a widespread basis might be effective, we evaluated the individual safety records of all nurses and endoscopists involved in propofol delivery at the 3 centers. RESULTS: Among a total of 36,743 cases of nurse-administered propofol sedation (NAPS) at the 3 centers, there were no cases requiring endotracheal intubation or resulting in death, neurologic sequelae, or other permanent injury. The rate of respiratory events requiring assisted ventilation was not significantly different among the 3 centers and ranged from just <1 per 500 cases to just <1 per 1000 cases among the 3 centers. There was no individual nurse or physician for whom the rate of respiratory events requiring assisted ventilation differed from the overall rate of events at the respective centers. CONCLUSIONS: Trained nurses and endoscopists can administer propofol safely for endoscopic procedures. Nurse-administered propofol sedation is one potential solution to the high cost associated with anesthetist-delivered sedation for endoscopy.

Combined pulse oximetry/cutaneous carbon dioxide tension monitoring during colonoscopies: pilot study with a smart ear clip.

BACKGROUND: We compared the accuracy and practicability of a new combined ear sensor device measuring pulse oximetry and transcutaneous carbon dioxide tension. METHODS: Validation studies were done by comparing the results of the combined sensor with arterial blood gas measurements. In an observational part, monitoring data were obtained from 25 patients undergoing colonoscopy, sedated with midazolam and alfentanil and from 8 patients without sedation. RESULTS: There was an excellent correlation between the oxygen saturation and carbon dioxide tension measurements comparing the combined sensor with arterial blood gas analysis (R 0.96 and 0.93, respectively). A mean rise in transcutaneous carbon dioxide tension of 7.6 mm Hg was detectable during sedation with midazolam/alfentanil and of 2.3 mm Hg without sedation. CONCLUSION: Combined POX/PcCO2 monitoring at the ear lobe is a novel approach to improve patient safety during sedation and may be helpful in preventing an unintentional slide into a state of deep sedation with impairment of ventilation.

Patient-controlled versus nurse-administered sedation with propofol during colonoscopy. A prospective randomized trial.

OBJECTIVES: Patient-controlled sedation (PCS) with propofol, is well tolerated and reduces recovery time and staff required during endoscopic interventions. "Who" administers the drug proves economically crucial. With the aim of maintaining safety, medical quality, and patient satisfaction, this study investigates PCS versus nurse-administered propofol sedation (NAPS) in a cohort of consecutive patients. METHODS: One hundred and fourteen patients, aged 22-90 yr, undergoing only colonoscopy participated in this prospective randomized trial. Patients were randomly assigned to either PCS or NAPS. If patients declined randomization for different reasons of reluctance to PCS they were assigned to a standard nurse-sedated control group. All patients received pethidine presedation for analgesia. Visual analogue scales followed patient anxiety level, tolerability, pain, and satisfaction, and endoscopist's assessment of the procedure. RESULTS: Given the choice, 35% of the patients who were rather younger and more anxious declined randomization to PCS. The mean total dose of propofol needed in this group was higher, but the patients had a tendency to rate the global tolerance and the pain of the examination as less comfortable compared to the two randomized groups. Self-administration of propofol created a significantly different drug profile and higher medication costs. With regard to the safety parameters there was no difference between PCS and NAPS. In their global assessments, the patients and endoscopists tended to prefer NAPS. CONCLUSIONS: Individual patient characteristics and attitudes toward self-control are crucial for PCS. While being a viable option for patients who are able and willing to handle, this technique is not applicable in a considerable portion of everyday patients.

The dawning of a new sedative: propofol in gastrointestinal endoscopy.

BACKGROUND: Using gentler endoscopes and improved sedation, great strides have been made in enhancing patients' comfort and acceptance of endoscopic procedures. Because morbidity and mortality have been associated with benzodiazepines in endoscopic sedation, safer alternatives were sought. Propofol (2,6-diisopropylphenol), a rapid and short-acting anesthetic, initially used in the 1980's for general anesthesia induction and maintenance, is a promising candidate. METHODS: This review article examines experiences and literature references of propofol's use in endoscopic procedures. Three critical questions are posed: What are the major advantages and potential risks of propofol? When should propofol be used? Who should administer propofol, how should it be administered, and what type of monitoring is required? RESULTS: With considerable inter-patient variability, the propofol dose must be carefully titrated according to the individual patient's response. Factors influencing dosage include age, ASA class, patient's height and procedure duration. Propofol's primary risk is its narrow therapeutic range which necessitates careful patient monitoring. CONCLUSIONS: Propofol's advantages over benzodiazepines and narcotics include a more rapid onset of action, full relief of discomfort and rapid recovery to alertness without residual sedative effects or anterograde amnesia, thereby making this drug a cost-effective and, with proper monitoring, safe choice.

Cutaneous carbon dioxide monitoring in adults.

PURPOSE OF REVIEW: Arterial blood gas analysis is the 'gold standard' method to measure the arterial partial pressure of carbon dioxide (PaCO2). However, arterial sampling including arterial catheterization is invasive and expensive. Cutaneous carbon dioxide tension (PcCO2) measurement is used as a noninvasive surrogate measure of PaCO2, which is used to either estimate PaCO2 or determine trend changes in the measurement. There has been considerable progress in the technical aspects of PcCO2 monitoring in the last few years. In this article, we evaluate recent developments and the renewed interest in the subject of PcCO2 monitoring in adults and discuss the technical aspects, clinical applications and the future outlook for this technique in the clinical setting. RECENT FINDINGS: With evolution in technology, PcCO2 monitoring is now less cumbersome than before. Combined PcCO2 measurement and pulse oximetry is now possible with a single earlobe sensor. SUMMARY: The clinical settings in which PcCO2 monitoring can be applied include patient monitoring during and after anaesthesia, patients receiving noninvasive ventilation, post extubation, endoscopy under sedation, the sleep laboratory and the lung function laboratory. Although there is an overlap of the clinical indications when both PcCO2 and end-tidal carbon dioxide monitoring may be used, it is our opinion that both these methods have independent indications and are sometimes also complementary to each other in patient care.

Safety of propofol for conscious sedation during endoscopic procedures in high-risk patients-a prospective, controlled study.

OBJECTIVES: Propofol, a rapidly-acting hypnotic agent, is increasingly being used for endoscopic sedation. Serious adverse effects, including respiratory and cardiovascular depression, make many endoscopists reluctant to use propofol in critically ill patients. This study characterizes propofol's safety profile in consecutive high-risk patients (American Society of Anesthesiologists [ASA] classes III and IV) compared with matched subjects (ASA classes I and II). METHODS: During a 19-month period, 1370 at risk-patients were sedated with propofol, of whom 47% (614 ASA III, 28 ASA IV) were age matched with 642 consecutive patients of the same gender and age assigned to ASA classes I and II and undergoing the same endoscopic procedures (395 gastroscopies, 201 colonoscopies, 14 combined). Registered nurses performed all sedations by propofol dose titration while carefully monitoring arterial oxygen saturation, heart rate, and blood pressure. RESULTS: No major complications occurred among the critically ill patients. There was, however, an increased risk for a short relevant oxygen desaturation (<90%) of 3.6% for ASA III and IV versus 1.7% for ASA I and II (p = 0.036). In four versus one case, short mask ventilation was necessary. Also, a greater proportion of patients showed a > or =5% oxygen saturation decrease. There was no pronounced influence on arterial pressure or heart rate and no perforations in 336 colonoscopies. CONCLUSIONS: With careful monitoring, propofol sedation during GI endoscopies is safe, even for high-risk patients. Considering their higher comorbidity and tendency toward oxygen desaturation, they need particularly careful monitoring, and the required dose is, on mean, 10-20% lower than in ASA classes I and II.

Open access to part-time specialist training -- the Swiss experience.

INTRODUCTION: Gender shift in the medical profession evokes an increasing demand for innovative work and training curricula. In 1992 a regulation was introduced in Switzerland that permitted part-time specialist training without any eligibility restriction. This survey investigates the extent of part-time specialist training after 10 years. METHODS: The anonymous data of all 776 physicians who applied for a specialisation diploma in 2001 were analysed with regard to periods of part-time training, gender and specialty. A questionnaire-based survey collected the available part-time training posts in 1503 accredited institutions (96%). RESULTS: 115 (15%) of all applicants, 33% of the female and 6% of the male completed at least one period of part-time training in their curricula. 24% of the accredited institutions offered at least one part-time training position. The majority of these posts is restricted to specialties like psychiatry, paediatric psychiatry, internal medicine, gynaecology, anaesthesia and paediatrics, areas traditionally preferred by women, while other specialties do not offer part-time training positions to a comparable extent. CONCLUSIONS: Part-time specialty training is well established and more frequently used in Switzerland than in countries of the EU. However, as the distribution of part-time training positions develops very different among specialties, even a liberal access policy is not able to reduce the imbalance in gender distribution amongst the medical specialties.

Risk stratification and safe administration of propofol by registered nurses supervised by the gastroenterologist: a prospective observational study of more than 2000 cases.

BACKGROUND: Conscious sedation is standard for GI endoscopy. Propofol increasingly is used as an alternative drug to avoid unwanted effects of the commonly used benzodiazepines. Although propofol in the hands of nonanesthesiologists is still controversial, this study characterized the safety profile of propofol administered by nurses under supervision of the gastroenterologist. METHODS: All patients undergoing any endoscopic procedure between September 2000 and December 2001 in the gastroenterology department of an academic tertiary medical center were eligible for inclusion in this prospective observational study. Sedation was voluntary. Demographic data, type of endoscopic procedure, and clinical features were recorded. A structured personal history led to a 5-class risk stratification based on the criteria of the American Society of Anesthesiologists. A total of 3475 procedures were performed in 2574 patients using propofol administered by registered nurses. RESULTS: No major complications occurred because of the use of propofol, but overall decreases in the mean values for oxygen saturation (-2%), arterial pressure (-18%), and pulse rate (-10%) were observed. Severe respiratory depression requiring intervention occurred in less than 0.3% of all patients given propofol. CONCLUSION: The administration of propofol by registered nurses, with careful monitoring under the supervision of the gastroenterologist, is safe for conscious sedation during GI endoscopic procedures.