Preprocedural Assessment for Sedation in Gastrointestinal Endoscopy.

The role of the anesthesia service in sedation for gastrointestinal endoscopy (GIE) has been steadily increasing. The goals of preprocedural assessment are determined by the specific details of the procedure, the issues related to the illness that requires the endoscopy, comorbidities, the goals for sedation, and the risk of complications from the sedation and the endoscopic procedure. Rather than consider these issues as separate entities, they should be considered as part of a continuum of preparation for GIE. This is told from the perspective of an anesthesiologist who regularly participates in the full range of sedation for GIE.

Basic requirements for monitoring sedated patients: blood pressure, pulse oximetry, and EKG.

The American Society of Anesthesiologists published monitoring requirements for non-anesthesia providers performing sedation and analgesia in 2002. This manuscript covered not only the monitoring of patients under sedation and analgesia but pre-procedure evaluation and preparation, personnel availability and training, emergency equipment availability, use of supplemental oxygen, sedative-analgesic agents, and discharge criteria. Current recommendations for monitoring include patient responsiveness, blood pressure, respiratory rate, heart rate, and oxygen saturation. Oxygen saturation is a critical vital sign, but there can be a significant delay between inadequate ventilation and desaturation. Supplemental oxygen can dangerously increase this disconnect. Thus, one must monitor adequacy of ventilation by direct observation, auscultation, and/or end-tidal CO(2) monitoring. The most important admonition is that 'ventilation' and 'oxygenation' are not the same.

Propofol infusion platforms: opportunities and challenges.

Several propofol infusion platforms have been devised to address the inherent safety problems associated with propofol administration. Patient-controlled and target-controlled infusion systems have been described in the literature, and the Sedasys closed-loop feedback system is in FDA review. No matter what the infusion platform, there are important safety concerns that should be addressed whenever propofol is administered by non-anesthesiologists. There must be safeguards in the facility's sedation protocol for non-anesthesiologists that involve training, documentation, auditing/oversight, quality improvement and involvement of the facility's pharmacy and therapeutics committee. Definitions of levels of sedation and recommendations from the American Society of Anesthesiologists on rescue, identification and management of potential complications, as well as monitoring and training of personnel are also presented.

Six sigma methodology can be used to improve adherence for antibiotic prophylaxis in patients undergoing noncardiac surgery.

BACKGROUND: Six Sigma methodology is a data management process that can be used to achieve a goal of near perfection in process performance. An audit of 615 surgeries over 2 mo revealed only 38% of noncardiac patients admitted on the day of surgery at our institution received perioperative antimicrobial prophylaxis within the target interval of < or =60 min before incision. METHODS: Six Sigma methodology was used to improve our process of timing of antimicrobial prophylaxis administration. A multidisciplinary team was assembled which identified seven process inputs by which patients receive antimicrobial prophylaxis. Interventions for improvement included reinforcement of use of preoperative antibiotic order forms, eliminating administration of antibiotics in the preoperative admission area, and sending appropriate antibiotics and IV tubing with the patient to the operating room. We concurrently developed a control plan to sustain this improvement using a recently deployed electronic anesthesia record keeping system using real-time measurement and reporting capabilities of antimicrobial prophylaxis administration. After defining the new process and undertaking a system-wide educational effort, implementation was begun with data collection and analysis occurring over the next 7 mo. RESULTS: For the 8-mo postintervention interval, there was a significant improvement with 86% of 1716 surgical patients receiving their antibiotic prophylaxis within the specified time frame (P < 0.01). The time interval for antibiotic administration before surgical incision also decreased from a preintervention mean of 88 (CI 56-119 min) to 38 min (CI 25-51 min) (P < 0.01). CONCLUSION: We conclude that Six Sigma methods were used to successfully improve our process for timing of perioperative antibiotic prophylaxis before surgical incision. An electronic anesthesia record keeping system is a useful tool to monitor this process improvement.

Quality measurement: who is measuring outcomes and what are patients being told?

Change is inevitable, but participation is optional. An array of quality measures is being used by various government entities, health care purchasers and payers, and other groups. Many of the quality-measurement initiatives have not only gained the attention of large employers, but are also beginning to pique the public's interest. Novel approaches to measuring and rewarding quality are also emerging, such as pay-for-performance schemes and the use of APR-DRGs. Health care organizations that participate in the quality-measurement process and provide input will benefit by the type of measures that are ultimately created. It is much better to be part of the development process than to have insurer- or employer-designed quality measures imposed on your institution. At the very least, health care organizations would be wise to serve as watchdogs to ensure that currently proposed quality measures truly measure high-quality care.

Quality and resource utilization in managing preoperative evaluation.

The evaluation of patients before surgery is a component of anesthesia practice that must be performed to ensure the safe delivery of anesthesia for every patient. How an anesthesia group performs this evaluation differs from institution to institution as the structure of preoperative clinics in hospitals across the country can be quite variable. However, the major question that anesthesiologists must ask when approaching this area of practice is: "Can a system for preoperative evaluation that uses the expertise of anesthesiologists,surgeons, and internists to deliver high quality, cost conscious, and efficient patient preparation for surgery be developed.

Gastroenterologist-administered propofol versus meperidine and midazolam for advanced upper endoscopy: a prospective, randomized trial.

BACKGROUND & AIMS: Propofol is increasingly used for gastrointestinal endoscopy because of its rapid recovery profile. There has been no prospective, randomized comparison of gastroenterologist-administered propofol to meperidine and midazolam for endoscopic retrograde cholangiopancreatography and endoscopic ultrasonography. Additionally, its cost-effectiveness has not been studied. METHODS: Seventy-five randomized patients received either gastroenterologist-administered propofol (n = 38) or meperidine/midazolam (n = 37) for endoscopic retrograde cholangiopancreatography and endoscopic ultrasonography. Monitoring with capnography allowed for rapid titration of propofol at the earliest signs of respiratory depression. Visual analogue scales measured tolerance and satisfaction. A cost-effectiveness analysis was performed by using return to baseline for both activity and food intake 24 hours after the procedure as the effectiveness measure. RESULTS: The groups had similar physiological outcomes and satisfaction. Patients receiving propofol had shorter recovery times (P < 0.001) and a higher recovery of both baseline activity level and dietary intake 24 hours after the procedure (P = 0.028). With incremental cost-effectiveness analysis, gastroenterologist-administered propofol cost an additional $403.00 per additional patient at 100% of baseline for both activity level and food intake when compared with standard sedation and analgesia. Sensitivity analysis indicated that the only model in which propofol administration would become the dominant strategy was with its administration by a registered nurse. CONCLUSIONS: Gastroenterologist-administered propofol using monitoring with capnography is similar to meperidine/midazolam for both physiological outcomes and patient/endoscopist satisfaction. Propofol leads to significantly improved recovery of baseline activity and food intake 24 hours after the procedure. Our model suggests that propofol would be more cost-effective than meperidine and midazolam for endoscopic retrograde cholangiopancreatography and endoscopic ultrasonography if registered nurse administration were possible.