Anesthesiologists

The assistance of anesthesiologists is required for general anesthesia and in most states for use of propofol. It should be considered in patients needing deep sedation such as those having prolonged therapeutic procedures, anticipated intolerance of standard sedatives, and those at increased risk for sedation-related complications as mentioned previously (ASGE, 2002). The presence of one or more of sedation-related risk factors, coupled with the potential for deep sedation, will increase the likelihood of adverse, sedation-related events. In this situation, if the practitioner is not trained in the rescue of patients from deep sedation, then an anesthesiologist should be consulted (Table 3-4).

Propofol

Because of its rapid induction and recovery from anesthesia, propofol has created a niche for itself in the ambulatory setting. In Maryland, this must be administered by an anesthesiologist, nurse anesthetist, or specifically trained and dedicated physician. Propofol is an IV sedative-hypnotic approved by the US Food and Drug Administration in 1989. It has a distribution half-life of 2 to 10 minutes, with a mean induction time of 30 to 40 seconds after a 2.0 to 2.5 mg/kg bolus (Massachusetts Poison Control System, 1997). Discontinuation of propofol anesthesia usually results in a rapid decrease in plasma concentrations and prompt awakening. Longer anesthesia cases may produce higher plasma concentrations and thus prolong awakening time.

There are several "pros and cons" for the use of propo-fol in the endoscopy setting. The short onset of action and rapid elimination time makes this an ideal drug for short out-patientprocedures. Faster recovery time has been shown to improve operational efficiency of endoscopy units. Propofol provides amnesia and sedation as well as decreasing the hypertensive effects of airway manipulation. The airway management requirements need careful monitoring because the patient can go from breathing independently to apneic in a matter of seconds. Hypotension has been reported and a constant infusion is required to maintain sedation. Propofol may not be ideal for the longer therapeutic procedures as the plasma level increases, awakening time delays. In addition, propofol has no analgesic qualities, therefore narcotics need to be administered concomitantly.

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