Propofol for ERCP - An Update
By Dr Stuart Cairns, Guideline co-author.
Increasingly challenging diagnostic and therapeutic endoscopic procedures are being performed in adults. There is therefore a need for more prolonged, safe and satisfactory sedation to be administered in these patients. There is increasing evidence that this can be provided safely and appropriately by propofol when administered by those trained in its use.
The use of propofol in endoscopy units is now widespread in most of the western world (inspite of a degree of contention over exact methods). In the UK its use is still sporadic, partly because there has been a lack of guidance for its use here. This guidance has therefore been produced jointly by the Royal College of Anaesthetists and BSG Endoscopy to attempt to rectify this situation.
The guidance aims to cover UK practice using propofol sedation only in adult patients during complex endoscopic procedures. ERCP has been used as a specific example of a group of patients who can clearly benefit from its use. In the U.S. and much of Europe propofol is administered by non-anaesthetists but the RCoA do not support this practice at present and so the guidance states it is to be administered by an appropriately trained anaesthetist or by a Physicians Assistant (Anaesthesia) – closely supervised by a consultant anaesthetist. This is to provide an optimal safety margin in the use of propofol. The presence of this individual to manage the sedation independently thus allows the endoscopist to concentrate fully on the procedure. There will be circumstances where general anaesthesia (GA) for ERCP may be more appropriate for some patients but this guidance has been produced to support the use of propofol sedation in clearly defined circumstances where there is not a need for the same level of personnel, equipment and facilities as would be mandatory for a full GA. As such it is purpose is to define what the requirements are for providing propofol sedation in an endscopy suite or similar environment.
The guidance states that where local facilities and appropriate staff are available it is acceptable practice to use propofol outside the operating theatre environment and without either an anaesthetic machine or an operating department practitioner (ODP). It is hoped that this ability to provide propofol sedation within endoscopy units will improve the quality of the patient experience, enable the completion of a greater proportion of ERCPs at first attempt and increase throughput without the manpower and financial restraints of needing operating theatre time to do it. It is a particularly welcome development and a significant step forward in this time of increasing demand and tightening financial constraint.
The guidance recommends single agent sedation with propofol. This is because use of propofol with agents such as opioids is very effective but leads to a narrower therapeutic window with a greater risk of need for airway support. To enable the safe use of propofol within the endoscopy suite this is a major consideration. Implementation of this guidance will require local negotiation. For the anaesthetists involved working outside the theatre environment and without direct assistance from trained anaesthetic assistants this can be a challenging new aspect of service provision. Those with experience in ITU and A+E may have more experience in this manner of working (with ITU and A+E nursing staff in place of anaesthetic assistants). As such they may be more amenable to considering working with and training-up competent endoscopy nursing staff to extend their roles in this context. Regardless of background what is needed from the anaesthetists who are willing and competent to work in this field is enthusiasm and a desire to expand the boundaries of their working practice.
Encouraging anaesthetists in your facility to visit your endoscopy unit to observe the practice of endoscopy using the current midazolam/opiate combination will give them a very much clearer idea of the newer requirements for sedation in this environment and their potential to make a major contribution to this service. This joint RCoA/BSGE guidance provides a way to introduce propofol sedation into UK endoscopic practice and so enhance the quality of the patient's experience safely and economically.
Guidance for the use of propofol sedation for adult patients undergoing ERCP and other complex upper GI endoscopic procedures - A joint BSG and Royal College of Anaesthetist (RCoA) Guideline.
Stuart Cairns, Jonathan Green and David Cressey
Small Bowel Endoscopy in the UK
Dr Mark McAlindon - UK Capsule Endoscopy Users' Group - November 2011
A working party report on the provision of service and training for small bowel endoscopy in the UK by the UK Capsule Endoscopy Users' Group
In the UK, small bowel endoscopy service development has been driven locally rather than being planned, regulated and monitored. The working party aimed to establish the availability and uptake of services, clarify the current tarrifs and assess current provision of training in order to anticipate future demand, service needs and training requirements. This was done using surveys, personal contact and an estimation of need using current accepted indications and Hospital Episode Statistics data.
45% of UK gastroenterology services offered in-house capsule endoscopy. 91.3% of survey responders referred patients for capsule endoscopy; 67.7% felt that local availability would increase referrals. Suspected small bowel bleeding and Crohn's disease were considered appropriate indications by the majority. Demand is increasing in spite of restricted use in 21.6% of centres. Only two regions performed more than the minimum estimate of need of 45 procedures per 250 000 population. Eight centres perform regular device-assisted enteroscopy and 14 services are in development. 74% of trainees were interested in training and whilst most training in image interpretation are doctors (67%), 28% are nurses. The current basic tariff of £533 for capsule endoscopy (HRG code FZ42Z) and balloon-assisted enteroscopy of £630 (HRG code FZ24C) represent substantial shortfalls in the true cost of the procedures.
Thus, capsule endoscopy is used by the majority of UK gastroenterologists but appears to be underutilised. Current demand for device-assisted enteroscopy seems likely to be matched if new services become established. Future demand is likely to increase, however, suggesting the need to formalise training and accreditation for both doctors and nurses.
Antibiotic Prophylaxis in Endoscopy
Antibiotic prophylaxis in gastrointestinal endoscopy
(2009) Allison MC, Sandoe JAT, Tighe R, Simpson IA, Hall RJ, Elliott TSJ,
Prepared on behalf of the Endoscopy Committee of the British Society of Gastroenterology
The revised BSG guidelines recommending a marked reduction of pre-procedure antibiotic usage are available for download below. The practice of administering antibiotics to prevent endocarditis is no longer recommended. Prophylaxis remains indicated prior to endoscopic gastrostomy/jejunostomy procedures. A selective policy for prophylaxis pre-ERCP is recommended, being indicated for those in whom relief of biliary obstruction is unlikely to be achieved at a single procedure (e.g. dilatation of dominant stricture in multifocal sclerosing cholangitis, or unilateral stenting of cholangiocarcinoma). Prophylaxis is also recommended for patients with severe neutropenia (<0.5x10*9/l) and/or severe immunocompromise from major haematological malignancy who undergo endoscopic procedures with a high risk of bacteraemia (e.g. oesophageal dilatation, variceal sclerotherapy, ERCP in obstructed system).
All endoscopists will be aware of the current controversy and differing guidelines on endocarditis prophylaxis for GI procedures. A working group of the BSG Endoscopy Committee met in March 2006 to revise the 2001 guidance.
NICE has now considered this issue as well. It has come out against the use of antibiotic prophylaxis to prevent endocarditis during gastrointestinal endoscopy. Its guidance on endocarditis prophylaxis was unveiled on 26 March 2008: