Original Paper
Accepted: September 11, 2006 Published online: November 27, 2006 Use of Sedation for Routine Diagnostic Upper
Gastrointestinal Endoscopy: A European Society
of Gastrointestinal Endoscopy Survey of National
Endoscopy Society Members

S.D. Ladas L. Aabakken J.-F. Rey A. Nowak S. Zakaria K. Adamonis N. Amrani J.J.G.H.M. Bergman J. Boix Valverde S. Boyacioglu I. Cremers J. Crowe P. Deprez P. Díte M. Eisen R. Eliakim E.D. Fedorov Z. Galkova T. Gyokeres L.T. Heuss A. Husic-Selimovic F. Khediri K. Kuznetsov T. Marek M. Munoz-Navas B. Napoleon S. Niemela O. Pascu N. Perisic R. Pulanic E. Ricci F. Schreiber L.B. Svendsen W. Sweidan A. Sylvan R. Teague M. Tryfonos D. Urbain J. Weber M. Zavoral European Society of Gastrointestinal Endoscopy, Munich , Germany Key Words
(59%). Common sedatives in use are midazolam (82%), diaz- Upper gastrointestinal endoscopy ؒ Sedated gastroscopy ؒ epam (38%) or propofol (47%). Monitoring equipment is not available ‘in most of the endoscopy units’ in 46% (13/28) of the countries. Though they were available in 91% of the na-tional representatives’ endoscopy units, they are rarely Abstract
(21%) used to monitor unsedated routine diagnostic UGI en- Background/Aims: Sedation rates may vary among coun-
doscopy. Conclusions: In about 50% of ESGE-related coun-
tries, depending on patients’ and endoscopists’ preferenc- tries, less than 25% of patients are sedated for routine diag- es. The aim of this survey was to investigate the rate of using nostic UGI endoscopy. Major issues to improve include premedication for routine diagnostic upper gastrointestinal availability of monitoring equipment and the use of a con- (UGI) endoscopy in endoscopy societies, members of the European Society of Gastrointestinal Endoscopy (ESGE).
Methods: We evaluated a multiple-choice questionnaire
which was e-mailed to representatives of national endos-
copy societies, which are members of the ESGE. The ques-
tionnaire had 14 items referring to endoscopy practices in
each country and the representatives’ endoscopy units. Re-
Routine diagnostic upper gastrointestinal (UGI) en- sults: The response rate was 76% (34/45). In 47% of the doscopy is the standard practice to diagnose oesopha-
countries, less than 25% of patients undergo routine diag-
geal, gastric and duodenal disease and take biopsies when nostic UGI endoscopy with conscious sedation. In 62% of indicated. The examination usually lasts less than 5 min the responders’ endoscopy units, patients are not asked and has very low complication and mortality rates [1, 2] . their preference for sedation and do not sign a consent form Routine diagnostic UGI endoscopy may be done with or Tel. +30 210 532 6442, Fax +30 210 532 6422 without conscious sedation [3] . The decision of using premedication for gastroscopy is influenced by national Frequency distribution was calculated for each variable. When applicable, comparisons were made between results of the repre- and cultural differences among countries, as well as pa- sentatives’ endoscopy units and representatives’ views about en- tients’ wishes and endoscopists’ attitude to the examina- doscopy practices in their countries, using the ␹ 2 test with Yates’ correction as appropriate. Missing data were taken into account. The use of sedation improves the tolerance and accep- A p value ! 0.05 was considered significant.
tance of the examination [5] , but increases the cost of the procedure, and it is responsible for about 50% of the com-plication rate of gastroscopy [6] . There are numerous published studies evaluating factors affecting patients’ tolerance to unsedated routine diagnostic UGI endosco- py, others comparing patients’ preference for sedated ver- We received 34 (75.6%) replies (see appendix 2), 29 out sus non-sedated endoscopy, or comparing medications of 36 (88.6%) European and 5 out of 9 (56%) Mediterra-used for conscious sedation. Several of these studies have nean and Middle Eastern endoscopy societies, which are recently been reviewed in Endoscopy [5–7] . However, members of the ESGE. The average annual number of only a few national studies of European countries have routine diagnostic UGI endoscopies performed was more investigated the rate of using conscious sedation for rou- than 2,000 in 79.4%, 1,000–2,000 in 14.7% and 500–1,000 tine diagnostic UGI endoscopy in their country [2, 8–11] , in 5.8% of the endoscopy units of the responders.
and none evaluating Europe as a whole.
Therefore, we have organized this study using a struc- tured questionnaire, which was sent by e-mail to the Eu- To the best knowledge of the responders, in 47.1% ropean Society of Gastrointestinal Endoscopy (ESGE) (16/34) of the countries, less than 25% of the patients contact persons, i.e. representatives of national endosco- undergo routine diagnostic UGI endoscopy with con- py societies. The questionnaire included 14 multiple- scious sedation, but 20.6% (7/34) of the responders could choice questions focusing on practices of routine diag- not provide this information. As is shown in figure 1 , nostic UGI endoscopy in each country and the represen- there are no actual differences in the rates of using seda- tion for gastroscopy between those reported for the country and those of the representatives’ endoscopy units. However, since values were less than 5 in more than two cells of the contingency table, the statistical analysis was made by using two categories, i.e. ! 50% A structured questionnaire was developed consisting of 14 and 1 50% of gastroscopies with sedation ( ␹ 2 = 2.15, p = multiple-choice questions investigating the use of conscious seda- 0.14). In addition, 61.8% (21/34) of the responders do not tion for routine diagnostic UGI endoscopy, sedation preference and administration, sedatives used, monitoring and the use of a ask the preference of their patients for sedated or unsedat- consent form for gastroscopy (see appendix 1).
ed routine diagnostic UGI endoscopy, but in 84.6% Six questions had two identical multiple-choice question arms, (22/26) of these endoscopy units, the patients may re- one referring to practices in the country and the second arm to practices in the representatives’ own endoscopy units. The re- With regard to the question ‘If you are not using con- maining eight questions were focused on endoscopy practices of the representatives’ endoscopy units. Endoscopy practices in the scious sedation in certain patients, how do you select country were answered ‘to the best knowledge’ of the national them?’, 23.5% did not reply, 58.8% believe that ‘it is the representative of the ESGE, who was secretary or president of his/ patient’s preference’, 14.7% that ‘the patient is elderly’, 26.5% that ‘the patient is not anxious’, or a combination The ESGE has 45 members, which are national endoscopy so- cieties or endoscopy sections of the respective national Society of Gastroenterology. Thirty-six of these societies represent Europe- At least two sedatives were reported to be in use in ev- an and 9 Mediterranean or Middle Eastern countries. An e-mail ery country. There was no significant difference in the was sent to all 45 national representatives of their society of the rates of brands of sedatives used in the countries and the ESGE inviting them to participate in the survey. The invitation responders’ endoscopy units ( ␹ 2 = 1.19, degrees of free- included a cover letter explaining the purpose of the study and the dom = 4, p = 0.88), the majority using either midazolam structured multiple-choice questionnaire. The questionnaire was e-mailed on March 20th, 2005, and a reminder e-mail was sent on (82.4%), diazepam (38.2%) or propofol (47.0%) ( fig. 2 ). In about one third of the countries or representatives’ en- Fig. 1. Frequency of using sedation for rou-
tine diagnostic gastroscopy in national
endoscopy society members of the ESGE
(n = 34 countries), in European national (n = 29 countries) and in the endoscopy units of the national representatives of the ESGE (n = 34). Less than 25% of patients undergo diagnostic gastroscopy with se-dation in about 50% of the countries. There was no significant difference in the rate of sedated gastroscopy between those report- ed for the country and those reported for the representatives’ endoscopy units (p = 0.14). IDNK = ‘I do not know’.
In the representatives’ endoscopy units Fig. 2. Frequency of brands of sedatives in
use for sedated routine diagnostic UGI en-
doscopy in 34 countries. There was no sig-nificant difference in the rate of the brands of sedatives used between those reported for the country and those reported for the representatives’ endoscopy units (p = 0.88). IDNK = ‘I do not know’.
doscopy units, more than one category of personnel is of the cases, the endoscopist or a nurse (20%) administer responsible for administering sedation, including the en- sedation, but in 35% of the cases, an anaesthesiologist doscopist, nurse, assistant and anaesthesiologist. How- may be involved ( fig. 3 ). In 8 out of 12 countries where an ever, sedation is given exclusively in 12 countries or units anaesthesiologist administers sedation, the rate of sedat- by the endoscopist (35.3%), in 5 by an anaesthesiologist ing patients was less than 25% of gastroscopies. These (14.7%) and in 2 by a nurse (5.9%). Overall, in about 60% rates were not significantly different between practices in In the representatives’ endoscopy units Fig. 3. Frequency of the responsible per-
sonnel administering sedation for routine
diagnostic UGI endoscopy in national so-ciety members (34 countries) of the ESGE and in the endoscopy units (n = 34) of the national representatives of the ESGE. IDNK/NA: ‘I do not know’/not available.
In the representatives’ endoscopy units Fig. 4. Frequency of availability of moni-
toring equipment ‘in the majority of en-
doscopy units’ of endoscopy society mem-
bers (34 countries) of the ESGE and the endoscopy units (n = 34) of the national representatives of the ESGE. Significantly pared with ‘availability in most endoscopy units’ in the countries (p ! 0.003). IDNK/NA: ‘I do not know’/not available.
the country and responders’ endoscopy units ( ␹ 2 = 0.16, Availability of Monitoring Equipment To the best knowledge of the representatives, monitor- Local pharyngeal anaesthesia is given in 82.4% ing equipment is not available in the majority of the en- (28/34) of the unsedated and in 58.8% (20/34) of the se- doscopy units in 46.4% (13/28) of the countries, but 17.7% dated patients ( ␹ 2 = 1.95, p = 0.16). In the majority of (6/34) replied that this information was not available. On cases (27/34), antispasmodics are occasionally or never the contrary, 91.2% (31/34) of the endoscopy units of the used for routine diagnostic UGI endoscopy. Finally, responders have monitoring equipment ( ␹ 2 = 9.11, p ! 58.8% (20/34) of the responders replied that not all pa- 0.003) ( fig. 4 ). In 21.9% (7/32) of these units, both sedated tients sign a consent form before routine diagnostic UGI and unsedated patients are monitored, while in 71.9% (23/32) of the units, only sedated patients are monitored. Fig. 5. Frequency of monitoring oxygen
saturation, heart rate, blood pressure and/or ECG in endoscopy units (n = 34) of the representatives of national endoscopy so- cieties of the ESGE. Not replied = inclusion of two endoscopy units where monitoring equipment is not available.
The rate of monitoring oxygen saturation, heart rate, with data from their own endoscopy unit, which is a rep-blood pressure and/or ECG in the representatives’ endos- resentative sample of large endoscopy units in the coun- copy units is shown in figure 5 . In 93.3% (28/30) of these try, but variation may exist from one unit to another even units, at least both oxygen saturation and heart rate are within the same country.
Published national surveys have documented major Finally, with regard to the question ‘Do you use sup- differences among countries in the rate of using sedation plemental oxygen via nasal probe?’, 11.8% (4/34) replied for routine diagnostic gastroscopy. In the USA, 50% of that they give oxygen to all patients and 79.4% (27/34) the endoscopists offer unsedated gastroscopy, but 85% of that they give oxygen only in case of oxygen desaturation them do no more than 25 unsedated gastroscopies per or to high-risk patients, but 8.8% (3/34) representatives year [12] . In Europe, there are only few publications on did not replied to this question.
this topic. In Finland, only 1.5% of the endoscopists use sedation in about 25% of their patients [8] . In Spain, se-dation is used in 17% of gastroscopies [9] , and in Ger- Discussion
many, most endoscopists use sedation in 10–50% of their patients [10] . In the UK, the sedation rate decreased by The present electronic survey had a high response rate 58%, from 70% in 1990 to 32% in 1998 [11] , while in Swit- (76%), and we believe that it provides valuable data on zerland, it was increased, and in 2003, 77% of the endos-routine diagnostic UGI endoscopy practice in Europe, copists sedated their patients [2] . These sedation rates are the Mediterranean area and the Middle East. The results close to those recorded for the respective countries in the of the survey show that there are major differences in present questionnaire, both for the country and the na-practices of gastroscopy between countries of this area of tional representatives’ own endoscopy units. The results of our survey show that in about 50% of the countries, less A limitation of our study is that the current national than 25% of patients undergo routine diagnostic UGI en- gastroscopy practice is recorded according ‘to the best doscopy with sedation. When analyzing data from the 29 knowledge’ of the person filling out the questionnaire. European countries only, this percentage did not change. These persons are the secretaries or presidents of their However, a wide variation in the rate of sedated gastros-national endoscopy societies and are therefore most reli- copy was confirmed, since in 9% of the countries and 27% able to provide estimated data about gastroscopy prac- of the representatives’ endoscopy units, the sedation rate tices in their country. In addition, they have provided us was higher than 75%.
This reported low sedation rate in about half of the Pharyngeal anaesthesia reduces the patient’s discom- countries may be related to cultural differences and en- fort during unsedated gastroscopy [22] and has an ad- doscopists’ attitudes to unsedated gastroscopy and could ditive beneficial effect on the sedated patient’s tolerance explain why the majority of the responders do not ask the preference of their patients for sedation, though in 86% Routine diagnostic UGI endoscopy carries very low of the representatives’ endoscopy units, patients may re- complication and mortality rates. The present survey quire to be sedated. Patients also have a strong preference has shown that not all patients sign an inform consent for unsedated gastroscopy in several countries. When re- in about 60% of the countries. However, informed con- sponders answered the question ‘How do you select pa- sent is the cornerstone of good medical practice and pa- tients for unsedated gastroscopy?’, 60% replied ‘It is the tients have the right to be informed about the nature of patient’s preference’. Unsedated gastroscopy is faster and the procedure, the risks, benefits and alternative diag- less costly than sedated gastroscopy [3, 13] . Cost savings nostic tests [6, 24, 25] . Besides, properly informed pa-and increasing pressure to carry out more procedures no tients seldom sue. Busy endoscopy units and long wait- doubt are factors influencing endoscopists’ preference ing lists for gastroscopy are not an excuse of skipping for unsedated gastroscopy [5, 6] . It would have been de- proper patient information [26, 27] and not asking their sirable if endoscopists could identify those patients who preference for sedation.
are likely to be tolerant to routine diagnostic UGI endos- Since most complications of gastroscopy are of cardio- copy without sedation [6] . All published studies investi- pulmonary nature, especially in sedated patients, moni- gating predictive factors for a comfortable unsedated toring is important to diagnose and prevent them [4, 6] . gastroscopy agree that reduced pharyngeal sensitivity, With the increasing rate of using propofol, which can in-old age and low preprocedural anxiety level are the most duce deep sedation, the rate of respiratory depression reliable predictive factors [14–16] . These criteria have could increase, and therefore, monitoring these patients been used by several of the responders of our survey in is mandatory [19, 20] . According to our survey, monitor-selecting patients for unsedated routine diagnostic UGI ing equipment is available in 91% of the responders’ en-endoscopy.
doscopy units, but in 72% of these units, unsedated pa- Sedation is given by the endoscopist or a nurse in the tients are not monitored. However, in as much as 46% of majority of the countries and the representatives’ endos- the countries, monitoring is not available in the majority copy units. Whether endoscopists and nurses had any of endoscopy units. The lack of monitoring could also be theoretical and practical training in using drugs for seda- a factor influencing the low sedation rate reported for tion is not known, but it is critically important for the these countries.
safety of the patients [2] . A variety of sedatives are in use, Data recorded for each country are estimates of the including diazepam, midazolam, meperidine, fentanyl respective national representative, and data of the re-and propofol, the most popular being midazolam and sponders’ endoscopy units are self-reported, and there-propofol. In the past few years, there is an increasing use fore, may be biased by incomplete information about of propofol for sedated endoscopy, because it provides ad- practices of gastroscopy in the country or personal views equate sedation with shorter recovery times [17] , but may and preferences of the national representative. Despite cause severe respiratory depression [18, 19] . It is of note these limitations of our survey, the results convincingly that in 8 out of 12 countries where an anaesthesiologist show that in Europe, the Mediterranean are and the Mid-may give sedation and propofol is included in the list dle East, there is a strong preference of endoscopists and of the preferred sedatives, the sedation rate is less than patients for unsedated routine diagnostic UGI endoscopy 25%. An explanation for this could be that endoscopists in the majority of the countries, availability of monitor-have limited experience in using propofol and may there- ing equipment is low, and informed consent is not used fore require sedation to be given by an anaesthesiologist in all patients undergoing routine diagnostic gastrosco- [20] .
py. It could also be that endoscopists and registered nurs- Though in the UK 23% of the endoscopists used an es are not professionally trained to administer sedation anticholinergic agent routinely in 1990 [21] , antispas- and monitor their patients. The above important issues modic drugs are rarely or never used nowadays, since should be taken into account by the ESGE [6] in the plan-they are not of proven value for gastroscopy. However, ning of special postgraduate courses to improve stan-local pharyngeal anaesthesia is used in the majority of dards of care of patients undergoing gastrointestinal en-cases in 82% of unsedated and 59% of sedated patients. doscopy.
Appendix 1
Questionnaire on sedation for routine diagnostic UGI endoscopy.
The questionnaire below refers only to routine diagnostic upper endoscopy (gastroscopy).
Country:Name of society:Name of person who completed this form:E-mail: What percentage of patients receive conscious sedation for UGI endoscopy? Do you ask all your patients whether they prefer sedated or unsedated UGI endoscopy (after explaining to them about the If the answer to the above question is ‘No’, can the patient himself: Which medication do you use for conscious sedation for UGI endoscopy? If the answer to the above question is ‘Yes’, do you routinely monitor patients undergoing UGI endoscopy? Which parameters do you routinely monitor? Do you use supplemental oxygen via a nasal probe? If you are not using conscious sedation in certain patients, how do you select them? Do most of your colleagues routinely use local pharyngeal anesthesia (xylocaine)? Who is the responsible person to administer conscious sedation for UGI endoscopy? Do you routinely use IV antispasmodics (hyoscine) for UGI endoscopy? Do all patients sign an inform consent before undergoing UGI endoscopy? What is the average annual number of UGI endoscopy procedures in your unit? Appendix 2
The data included in the present electronic survey have been provided by representatives of national endos- copy society members of the ESGE from the following countries: Austria, Belgium, Bosnia and Herzegovina, Croatia, Cyprus, Czech Republic, Denmark, Egypt, Estonia, Finland, France, Greece, Hungary, Ireland, Israel, Italy, Lithuania, Luxemburg, Morocco, The Netherlands, Norway, Palestine, Poland, Portugal, Romania, Russia, Serbia and Montenegro, Spain, Sweden, Switzerland, Tunisia, Turkey, Ukraine, United Kingdom.
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