Episode Transcript
[00:00:00] Speaker A: Foreigners.
[00:00:10] Speaker B: My name is Dr. Jabed Ahmed. I am a gastro trainee from North West London and a member of the BSG Education Committee.
Welcome to the new BSG podcast From Top to Bottom. Over the next few episodes we will be speaking to authors involved in various BSG guidelines which are available to our BSG members.
We hope these episodes will provide a new way to stay up to date with the latest guidance coming out.
Today I will be speaking to Professor Reena Sidhu who is a consultant gastroenterologist and honorary professor with the University of Sheffield. She is first author of the BSG Guidelines on sedation in Gastrointestinal Endoscopy.
The guidelines provide evidence based recommendations on adult patients undergoing gastrointestinal endoscopy with or without sedation.
Various topics are covered such as commonly used drugs for sedation, monitoring requirements and prevention and management of adverse events which we will hopefully discuss in this podcast.
Hello Professor Sidi.
[00:01:09] Speaker A: Hi there. Thank you so much, Jabed for this very kind invite. I'm delighted to be here and to do this podcast.
[00:01:15] Speaker B: No problem. So we'll get straight into it. So how have you seen the use of sedation change by Endoscopists over the last five years?
[00:01:24] Speaker A: Yeah, so I think it's changed in many different aspects. Certainly the number of procedures, the complexity has increased. We're really getting closer to a surgical interface with third space endoscopy. We're also dealing with an increasingly comorbid population and on reflection, the doses of sedation has altered compared to what we used 20 years ago.
You know, they used to use Diazepam in large doses, which we don't do anymore due to safety concerns. I think the final thing about how sedation has changed, it's also about the patient. Patient expectations are different.
So I think all of this, it's really important and these guidelines hopefully would cover a lot of those aspects.
[00:02:12] Speaker B: So moving on to I guess, the different types of sedation. So we know concomitant use of Entonox with sedation is seen in the clinical setting for colonoscopy, but it's not a specific recommendation in the guidelines. What are your thoughts on this?
[00:02:27] Speaker A: Yeah, so Entonox, it can be really effective as a combination and nitrous oxide works as an analgesic. So it targets your brain pain processing pathways in very few and clever ways.
So it's, it has NMDA receptor inhibition which are involved in transmitting pain signals. It also dampens the brain's ability to perceive pain.
And nitrous oxide also stimulates the release of endogenous opiates in the brainstem.
So these natural painkillers help to reduce the sensation of pain.
So it works really well and synergistically with sedation. And it's a really good combination, which certainly I use also very frequently in my practice.
Finally, I think the use of nitrous oxide is also a distraction to the patient, so they're focused on doing something while, for example, we're trying to get round the colon.
[00:03:26] Speaker B: And it's mentioned in the guidelines that high quality evidence on selecting patients for deep sedation or general anesthesia is lacking. What can we do as a gastroenterology body to sort of address this or change this?
[00:03:39] Speaker A: Yeah, so selection of patients for deep sedation can be complex, but I guess if you break it down and simplify it, you can break it down into patient and procedural factors.
So the guidelines do suggest that if you have upper airway, anatomical abnormalities, previous sedation, rate of complications, obstructive sleep apnea, these are important factors to consider.
And also then procedure wise, such as if you expect to see large upper GI contents, foreign body removal, varicel bleeds, then you really need to think about deep sedation and airway protection.
But you're absolutely right. We really need more prospective randomized control trials that directly compare outcomes between deep sedation, general anesthesia and conscious sedation across these patient different groups and procedures.
And I think also studies that are well designed with clear inclusion exclusions, standardised sedation protocols, and also long term follow up in terms of recovery, complications and more importantly also about patient satisfaction.
I think the other thing that we lack is developing risk stratification tools.
So having a validated tool and more scoring systems, which then can predict which patients would be more likely to benefit from one sedation approach compared to the other, would help and also somewhat personalize their career.
And these tools should contain things like asa, comorbidity, procedure complexity and preferences. And then I think finally, any large registry would really help.
We need large number of patients to generate good outcome data. So I think all of these factors are really important to then help us compare the different sedation types for specific patients.
[00:05:39] Speaker B: Thank you. In the guidelines it mentions remimazolam, which sounds quite promising, but why do you think it's not as popular as midazolam in its uptake?
[00:05:47] Speaker C: Yeah.
[00:05:48] Speaker A: So both remimazolam and midazolam are benzodiazepines. So for those of you not familiar, and they enhance your GABA A receptor activity. So remimazolam is much quicker acting and it's broken down by the tissue esterases.
Propofol also acts on the GABA A receptors. Now, Remimezolam, you can use it for both procedural sedation and deep sedation as well. And the evidence shows that it is comparable to propofol and there's less cardiovascular side effects, hypotension and shorter recovery. And there's also some evidence that it's actually better in those who have got chronic liver disease. But, you know, Javit, compared to other countries, changes in the uk, slower, I'm sorry to say, than other countries, but I do feel, you know, it will gain popularity and I think the more centers that are aware start to stock it, will be using it more.
[00:06:44] Speaker B: And in relation to Entonox, the guideline mentions the aim to move towards a green endoscopy. And there's a recommendation for catalytic destruction systems to reduce environmental escape and reducing greenhouse gas emissions becoming more essential or commonplace.
How do you see that coming about?
[00:07:03] Speaker A: Yeah, so there's been quite a few initiatives, like the ending Entonox waste project, and it highlights that a significant proportion of nitrous oxide emissions is not just from patient use, but really leaks from outdated manifold systems.
So I think NHS Trust need to explore solutions like the catalytic cracking technologies and really needs to be an overall gases strategy for each trust and part of the wider picture. But then if you compare gastroenterology to other specialties like obstetric and gynecology, we use so much less Entonox, you know, compared to obstetrics. But I think in years to come we will have no choice but to move away from this altogether. I don't know when, because there isn't a similar alternative.
But, yeah, I think we will move away altogether.
[00:07:58] Speaker B: Do you think it'll be possible to standardize sedation reversal agents such as into a box, similar to how we manage low blood sugar with the hypobox that they have.
[00:08:09] Speaker A: So that's a really good suggestion. But if we look at the net data, so, for example, between January to December 2022, the percentage of colonoscopies where they used either an IV opiate or a sedative, and where a reversal agent was needed, it was only 0.02%.
And for gastroscopies the figure was 0.05%.
So really, in the UK, we're doing quite well. The complication rates are very low.
So overall, small amounts, thankfully. So I guess my question back to you is, do we really need a reversal box?
And I think as long as the staff know where the reversal agents are kept, easy access to them. I think that would be adequate in my mind.
[00:08:57] Speaker B: Sure. Thank you. So, moving on to other medications, the guideline isn't explicit in mentioning specific oxygen liter units for different patient cohorts.
What? Why do you think exact figures are not possible to be written into guidelines?
[00:09:14] Speaker A: So when we started this journey of the guidelines, initially we had stipulated different units, different doses for drugs, and you know, for many different aspects. But if you think of respiratory conditions, there are several different respiratory conditions and where the saturation acceptance might be different.
And really if a patient is having a respiratory arrest, the basic principles would apply to all. So for that reason we've not stipulated any specific ranges or targets.
[00:09:48] Speaker B: Sure. Thank you. And is there any evidence of carbon dioxide in the upper GI tract?
[00:09:54] Speaker C: Yeah.
[00:09:55] Speaker A: So there's been a systematic review published, I think in GIE that found that carbon dioxide insufflation does reduce post procedural discomfort compared to room air and even for upper GI procedures.
And there have been, I think, four randomized control trials with about nearly 400 patients who had upper GI ESDs that were included. And they did find that the post procedural pain was decreased in those that had carbon dioxide.
[00:10:29] Speaker C: Yeah.
[00:10:30] Speaker A: So basically, you know, it rapidly absorbs, it does improve patient tolerance.
So they certainly benefit for OGD and ERCPs as well.
So I think the other thing to just mention about the use of CO2 is that it can cause artifactual elevation in your end tidal CO2. So if you are using capnography, you know, it's just to bear that in mind as well, to ensure that when you look at the capnography, you interpret it with caution.
[00:10:59] Speaker B: Great, thank you. So, moving on to documentation. The guidance doesn't explicitly say how to record sedation for double procedures. So if you were to do a gastroscopy followed by a colonoscopy, can I confirm how you recommend it should be recorded?
[00:11:16] Speaker C: Yeah.
[00:11:16] Speaker A: So we do doubles all the time and you know, having double procedures really helpful with a room turnaround.
So generally I would record what was given at what time for what procedure and then the top up doses subsequently. So for example, if the patient had 50 and 2 for the gastroscopy, I would document the time and put that in a gastroscopy report and then in a colonoscopy report. If they only had Entonox, I would just mention in the free text that they already had sedation and no additional doses were given. On the other hand, if they are given top up doses, I would then just put that in the colonoscopy report.
[00:11:51] Speaker B: And nursing reported comfort scores are commonly not placed on the endoscopy report. Do you think there is value in including these scores along with the endoscopist comfort scores?
[00:12:03] Speaker A: Yeah, absolutely, there's a real value in including nursing reported comfort scores along with endoscopies.
I think sadly, studies have shown that nurses often report higher levels of patient discomfort than endoscopists.
It might be because the endoscopist is just focused on completing the procedure.
And I guess this discrepancy suggests that if you rely just on the endoscopist, this may actually underrepresent the patient's clinical experience.
So I think including both perspectives would enhance the care that you give patients quality insurance. It can also support service improvement by identifying in what areas do patients have more discomfort. And more importantly, we're then aligning this with a patient centered care and goals as comfort we know is a key metric in the global rating scale or GRS for endoscopy services.
And I think over the last five or 10 years we've moved towards patient comfort, patient satisfaction. So I think, you know, that's really important.
There is the modified Gloucester scale here, so that's something that can easily be done.
[00:13:23] Speaker B: So moving on to the patient, it was interesting reading about the utilisation of auditory and visual distraction, such as with VR headsets. Do you see this becoming more commonplace in the future?
[00:13:35] Speaker C: Yeah.
[00:13:36] Speaker A: So I think patient anxiety is an important aspect of the patient's whole experience.
And if the patient has got pre procedural anxiety, we know that this can increase discomfort and reduce their tolerance of the procedure.
In terms of auditory distractions, we've been using music for years.
I'm sure lots of endoscopists like to have their Spotify playing in the background.
And we know that systematic reviews have shown that music can reduce anxiety and reduce pain.
VR on the other hand, provides an auditory and a visual distraction.
Some of them help to transport the patient into like a calming environment, like a beach or a forest with a different music.
And it can reduce perception of pain, anxiety and also reduce the need for sedation and analgesics.
Studies have shown, for example, there's one pilot study on unsettated colonoscopy VR and it showed comparable satisfaction compared to those who received standard sedation.
And then another study also showed that VR was well tolerated and didn't interfere with communication or procedural success.
I think the main issue is that all of these VR studies are all very small. So we need larger studies before it then can become mainstream.
And then the other issues about local setup of VR and the trust has to then, you know, I guess invest some money in making this available in your local unit.
[00:15:15] Speaker B: And anecdotally, a lot of patients may not read the written information sent to them prior to the procedure. And then endospice may be faced with that common misconception that they have of being put to sleep during the procedure.
Is there a role for further information at other points of the patient journey prior to their procedure, such as in the waiting room or during the pre procedure check in?
[00:15:38] Speaker A: Yeah, so certainly we know that the patient experience is negatively affected when there's a mismatch between their perception of what's going to happen and the actual experience. And it's not just the sedation but also the sensory experience of the procedure.
So I think having a detailed explanation in the outpatient department or when you first meet them is really important.
Whenever I talk to a patient and I mention conscious sedation, I say it out really loud and clearly, conscious sedation. And I explain what that means, that you know, you're not fully asleep.
So I think yeah, the pre procedure discussion in clinic is really key.
And the information that you provide prior to them attending hospital has to be in a medium that's suitable for that patient.
And a video in a waiting room, I think that's also really helpful. And then finally, when the nurses pre assess them, reinforcement by the nursing staff is really important. And then finally, whichever sedation type or not that is chosen, it has to be a shared decision with the endoscopist and the patient to make sure that they feel empowered as well.
[00:16:56] Speaker B: Moving on to the special cases that's mentioned in the guidelines, in particular pregnancy. In essence, there is no specific changes that are needed for sedation administration. But do clinicians do alternative regimes from your experience?
[00:17:12] Speaker A: No, not really. But I would say that if you are going to do an endoscopy in a pregnant patient, think once, think twice. Is it really needed?
Can you do an alternative?
For example in an IBD patient in a second trimester, an MRI might be a suitable alternative in terms of if they need a flexible sigmoidoscopy, an entonox is definitely a good alternative.
So yeah, before you think about scoping a pregnant patient, make sure it's appropriate in the first place.
But otherwise, yeah, no different regimens.
[00:17:52] Speaker B: And the guidelines mentions a single dose is safe in pregnancy.
Just wanted to clarify, is that for one procedure or one time? So one visit to Endoscopy?
[00:18:03] Speaker C: Yeah.
[00:18:04] Speaker A: So single dose in pregnancy typically refers to one time administration of drug in a single procedure or a clinical episode.
It's because the safety profile is based on the isolated exposure and that is considered low risk when clinically justified, as we already highlighted and carefully monitored.
So single doses, repeated or prolonged use, even at low doses, may carry different risks and would need a separate risk benefit assessment.
That's why the guidance is, you know, single dose, single episode. The other thing to add is avoid large cumulative doses.
[00:18:43] Speaker B: I see. Thank you. And I couldn't find any studies comparing TNE to throat spray only. Ogd, do you have any thoughts on this type of endoscopy?
[00:18:55] Speaker C: Yeah.
[00:18:56] Speaker A: So you're right, there's definitely a noticeable gap in direct comparison studies between TNE and throat spray. Only because most of the literature compares T and E to sedated apogee endoscopy and focuses then on the benefits of TNE in terms of tolerability and safety.
So we do know that T and E is generally better tolerated than unsedated oral apogee endoscopy. Patients report less gagging, retching, and it's because the nasal route avoids stimulating the posterior pharynx. But there have been some studies that have also shown that, you know, with tne, patients can drive home themselves, return to work the same day and avoid sedation related risks. But T and E is not suitable for everyone if you've got nasal pathology or coagulopathy.
So, yeah, I think we do need head to head trials comparing T and E to throat spray only upper GI endoscopy. But the general clinical consensus leads to, you know, the fact that T and E offers superior comfort and recovery in the unsedated patients.
I think having formal studies comparing the two would be really valuable. And again, using validated comfort scores and patient reported outcomes, the guidelines recommend two.
[00:20:17] Speaker B: Endoscopy assistants for sedated procedures.
Could you use one endoscopy assistant for a throat spray only procedure?
[00:20:26] Speaker A: Yeah, so this is an interesting question. So if I think about when I do a gastroscopy and what the nurses and the support worker do in a room. So there's the airway management suction and then there is biopsies.
And sometimes you need to adjust the monitoring equipment, like the saturations, documentation, room turnaround, I would argue you still need two personnel assisting you. It's quite hard to manage the airway and take biopsies. There's only two hands and to do that safely as well, particularly, you know, even if the patient's unsedated, if they start gagging or, you know. Yeah, I would say too.
[00:21:08] Speaker B: Sure. No. Thank you. So, then, moving on to training.
The guidance states that 35% of trainees attend a sedation course and only 49% of trainees state receiving sedation training. Would you recommend all trainees attending a sedation course, for example, mandating the national age sedation course as part of a JAG accreditation?
[00:21:32] Speaker C: Yeah.
[00:21:33] Speaker A: So sedation forms only a small part of many JAG courses. I think having a separate sedation course would really be helpful.
There are several sedation courses run more by anaesthetics, but they have a price tag attached to it. And if you need to then renew your certification, it does add on to a trainee's study leave budget.
I think every trust should have a sedation committee and the sedation committee in a trust should have provision for training locally and this could include in terms of bls, ILS and in terms of sedation as well.
ESGE is also doing some work on this.
There is the ESGE curriculum and there is some debate on providing some sort of certification, but all of this is work in progress. So I think the short answer is that we do need more sedation courses, whether we have an overarching course that's national, and then I think a lot of the training needs to be done locally as well.
[00:22:44] Speaker B: In terms of a summary question, overall, the guidelines have 54 recommendations.
If you were to highlight the top five a new Endospice should take away, what would they be?
[00:22:56] Speaker A: Yeah, it's quite a lot of recommendations, isn't it?
So I think the few main points for me, in an acutely unwell patient who needs an emergency upper GI endoscopy, it's really important. Document a ceiling of care for that patient, are they suitable for critical care?
And don't be afraid to get anaesthetics involved, even if they are not suitable for intensive care. And I think a lot of trainees need to get over that. Don't be afraid to call anaesthetics, then. The second issue is pre assessment. I think it's widely varied across the uk, so that needs streamlining to identify high risk patients and also to feed specific groups of patients and procedures into a deep sedation service.
And in trusts that don't have a deep sedation service, I do hope, as a team, that the guidelines would provide a basis for a business case for your trust to develop a deep sedation service.
And then other things are like better recognition of obstructive sleep apnea using validated tools like Stop Bang.
And then finally to improve what training we provide for sedation across the uk.
And then I think the last thing, if I may add a sixth point, there's not much evidence for the use of capnography in endoscopy. Most of the data and meta analyses have been from dental studies using procedural sedation. So I think we need more studies in endoscopy because certainly the guidelines do suggest the use of capnography for, you know, complex or prolonged procedures.
So I think, you know, that's something else that might also in the future be included in part of training and sedation.
So as a trainee, you know what to, you know, how to look at the trace and what to do with it.
[00:24:54] Speaker B: Professor Siddhu, thank you so much for speaking to me today on the BSG podcast From top to bottom. I know I've learned a lot and I'm sure our listeners have too. Thank you very much.
[00:25:04] Speaker A: You're very welcome.
[00:25:06] Speaker B: Thank you, listeners. And please check out the other episodes available and look out for upcoming new episodes very soon.
