Sedation for endoscopy: the safe use of propofol by general practitioners

In reply: We thank Clarke and Mackay and Hughes for their interest and comments. We accept that a sample larger than the 28 000 endoscopies we reported1 would be required to establish the true incidence of death or other catastrophic complications of our sedation service. As the mortality rate is expected to be so low, it would take many years to achieve an adequate sample size. It is even difficult to determine the mortality from endoscopy in Australia, as quantifying all the endoscopies performed is problematic, and the Royal Australian and New Zealand College of Anaesthetists believes that not all deaths occurring from endoscopy are reported to anaesthetic mortality committees.2

It is essential that any sedation service is carefully planned, and that all doctors providing sedation receive adequate training and follow the protocols and guidelines of the endoscopy centre. However, we challenge the opinion that only anaesthetists should use propofol. We have not been able to find any clinical safety studies that demonstrate that only anaesthetists are able to use propofol safely. We believe the results of our study show that, when propofol is used in the manner described in the article, the rate of ventilatory and other complications is low (but clearly not zero).

There is no reason to believe that the propofol component of the sedation regimen increased the rate of ventilatory problems. Indeed, it might, through its short duration of action, minimise such problems. To arbitrarily exclude the use of propofol by appropriately trained GP sedationists would deny many patients the manifest benefits of this drug. Importantly, our GPs have been shown capable of successfully managing the problems of airway obstruction and apnoea that were encountered — whatever the cause. We agree with Mackay and Hughes that the GP sedationists need to have the anaesthesia skills necessary to maintain patient ventilation, as well as an excellent understanding of all the drugs they use.

Anaesthetists play a major role in improving safety standards in the provision of sedation for endoscopy through codifying the standards required,3 assisting the training of staff, and delivering sedation services to high-risk patients. But many patients can be successfully sedated without a specialist anaesthetist being present. We argue there is no evidence that these patients should receive a suboptimal regimen. Most specialist anaesthetists have a more valuable role to fill than providing sedation for straightforward endoscopies.