We have all been there during our careers in endoscopy- the anxious patient who has already told you they have a ‘strong gag reflex’ and need to be ‘knocked out’ in order to have their OGD, and before you’re half was down the oesophagus the paroxysms of retching and attempts to pull out the endoscope make you rue the decision to give just 2mg midazolam in the interests of safety. Quickly all effort is focussed on merely completing the procedure rather than optimising quality, and in the end no-one is happy- the patient decries the worst experience of his life, and you regret both putting him through that nightmare but also not getting optimal views of the upper GI tract. Lose lose.
The quality of our endoscopic procedures can pivot on our use of sedation, which has always involved navigating a careful path between patient comfort and safety concerns, primarily due to airway compromise following over-sedation. As endoscopists we are acutely aware of the confidential enquiry report[1] highlighting the dangers of inappropriate sedation, and the position of over-sedation with midazolam on the list of ‘never events,’ yet we know that excessive caution is both unkind to the patient and counter-productive for the procedure.
The above example is in the context of our most basic investigation- a diagnostic OGD- but issues relating to appropriate sedation have become even more important as the length and complexity of our endoscopic procedures has increased over the years, including ERCP, interventional EUS, complex polypectomy (upper and lower GI) and small bowel enteroscopy. How can we appropriately sedate these patients for procedures that may last over an hour, while maintaining high safety standards and minimising complications from airway compromise?
This is the question addressed by the recent position paper released jointly by the British Society of Gastroenterology, JAG and the Royal College of Anaesthetists, published in Frontline Gastroenterology (FG). I was fortunate enough to interview Dr George Webster, senior author of the paper, for a FG podcast, which I strongly encourage you to listen to as well as reading the paper itself. During the discussion, we address the current landscape of sedation practices in the UK and worldwide, and the issues arising from increasingly complex procedures that led to the release of this joint position statement. Dr Webster helpful describes frameworks and checklists we can use to risk-stratify patients pre-procedure to identify those at risk of airway compromise, such as the STOP-BANG checklist for obstructive sleep apnoea, and situations where anaesthetic-led deep sedation or general anaesthesia may be beneficial.
Clearly setting up an endoscopy list with these services available will have its challenges, not least getting on board anaesthetic colleagues who may approach the problem from a different angle and with different backgrounds of experience. In the podcast and in the paper, Dr Webster helpfully describes the essential features of delivering a deep sedation service (which may not seem as insurmountable as you’d imagine) and how you could begin to engage in discussions with the relevant stakeholders to get a service off the ground.
So do have a listen and read the paper. Alternatively, sign up to the excellent Endoscopy Live 2019 event taking place on 7th-8th March in Gateshead (link here), where these issues and much more will be discussed and demonstrated, and you could even track down Dr Webster himself for further advice on how to establish a safe and effective endoscopy service with deep sedation.