Friday, 3 November 2017

The need for sedation

The level of competency to perform high-quality endoscopy and to remove high-risk lesions is also dependent on the competency of the support team and the available equipment: a highly competent endoscopist requires equally competent support staff and the right equipment and supplies to perform the procedure and deal with any problems that might arise (such as clips for uncontrolled bleeding).

 It is recognised that the methodology does not currently exist to reliably recognise who has achieved the proposed levels of competence. Thus, until a competency–based assessment process is available the clinical lead of the service should be satisfied that: 

 the professionals have the necessary competence;

 the unit has the necessary equipment; and

 in the event of a serious adverse event, it will be possible to manage the patient locally or transfer the patient safely to another institution with the expertise and facilities to care for the patient. 

A review of capabilities may identify shortcomings that can be addressed with further training or investment . This training and investment should occur before screening begins.

The need for sedation

The use of sedation for lower gastrointestinal endoscopic procedures varies between European countries. Three main patterns are readily discernible:

 infrequent use of sedation;

 frequent use of conscious sedation with opiates and benzodiazepines; 

and almost exclusive use of deep sedation with propofol or general anaesthesia.

This variation suggests there is no perfect approach, and emphasises the need to take into account historic cultural differences when implementing screening endoscopy. A review of the benefits and risks of sedation showed no clear advantage for a particular approach: conscious sedation provides a high level of physician and patient satisfaction and a low risk of serious adverse events with all currently available agents (McQuaid & Laine 2008).

The risk of an adverse cardio-respiratory event is lower if the patient does not have sedation (Eckardt et al. 1999; Rex, Imperiale & Portish 1999; Lieberman et al. 2000; Rex 2000b). Thus, there is less need for monitoring equipment and recovery facilities if sedation is not used. Therefore sedationless endoscopy can occur in more remote settings, and it requires lower set-up costs. However, if no sedation is offered, the patient must accept a higher chance of unacceptable discomfort and the endoscopist a lower chance of completing the procedure because of patient discomfort. These downsides might affect the uptake and impact of screening: potential screenees are worried about comfort, and incomplete procedures may miss important pathology. 

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