Wednesday, 27 December 2017

Sedation and comfort

Flexible sigmoidoscopy 

Although flexible sigmoidoscopy is not currently recommended by the EU for colorectal cancer screening, previous results of ongoing trials indicate that screening is feasible and the procedure is well accepted by screenees ( UK Flexible Sigmoidoscopy Screening Trial Investigators 2002; Segnan et al. 2005; Weissfeld et al. 2005; Segnan et al. 2007; Hoff et al. 2009). No sedation for FS was used in these studies


Colonoscopy can be an uncomfortable and distressing experience. These adverse effects can be reduced by careful patient preparation and sedation. 

Sedation improves patient tolerance of colonoscopy, particularly sedation using propofol combined with other sedative agents such as midazolam and analgesics such as pethidine and fentanyl (McQuaid & Laine 2008) (I). However, excessive sedation is considered to be an important contributor to cardio-respiratory related deaths following endoscopy in high-risk patients, particularly the elderly

According to Rex (Rex 2000b), most of the risk of colonoscopy is related to sedation. Cardiorespiratory complications are infrequent for patients without known heart or lung disease, but monitoring of oxygenation and blood pressure should be performed for all sedated patients.

Although hypoventilation, cardio-pulmonary events and vasovagal reactions may be related to pain and distension caused by the endoscopic procedure, in most cases they are more closely associated with the use of sedatives and opioids. Reduction in risk for these reactions has been observed in a study aimed to determine the incidence of such events when sedation is given only as required. All procedures in this study were performed by senior gastroenterologists with optimal equipment and nursing staff. Patients undergoing colonoscopy without sedation had less decline in blood pressure and fewer hypoxic episodes than sedated patients (Eckardt et al. 1999) 

Heavily sedated patients are more difficult to turn, and this may compromise caecal intubation and mucosal visualisation.

The available evidence indicates that the quality and safety of colonoscopy in patients that receive propofol sedation is comparable to that in patients receiving light, conscious sedation (or no sedation), provided patients given sedation are assessed properly prior to their procedure (McQuaid & Laine 2008; Singh et al. 2008) 

Propofol seems to be better than benzodiazepines or narcotics on recovery, discharge time and patient satisfaction and equivalent on procedure time, caecal intubation rate and adverse events (I). However, in many countries an anaesthesiologist is required for propofol administration.

It is recommended that there be local policies and processes in place to optimise sedation and patient support in order to maximise tolerance and minimise risk of complications

The following categories and data relevant to sedation should be monitored: 
1. No sedation; 
2. Conscious sedation and substances used;  
3. Propofol sedation or general anaesthesia, and substances used; and 
4. Insufflation gas: air or C02

Auditable outcomes: Sedation levels, patient feedback on comfort, dignity and privacy, and adverse incidents related to sedation, including use of reversal agents. 

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