A recent article & editorial (KJ Wernli et al. Gastroenterol 2016; 150: 888-94 & 801-2) shows that the use of propofol, delivered by an anesthetist, is associated with a small increase risk of adverse events. This finding goes against assumptions that there would be reduced complications with an anesthesia expert in the room who could manage resuscitation and airway problems.
The study analyzed claims data from more than 3 million colonoscopies in the U.S between 2008-2011 in 40-64 year-olds.
- Use of anesthesia was associated with a 13% increase in the risk of any complications within 30 days.
- The increased risk included perforation (OR 1.07), hemorrhage (OR 1.28), and abdominal pain (OR 1.07). Interestingly, the perforation risk was increased only in those undergoing polypectomy (OR 1.26) indicating that some confounders may have been difficult to eliminate.
- Complications secondary to anesthesia were present as well (OR 1.15) and stroke (OR 1.04).
This is not the first study to associate anesthesia with increased risk of aspiration and mechanical complications (Cooper G et al. JAMA Intern Med 2013; 173: 551-6). It is certainly possible that the increased risk is due in part to patient selection, despite attempts to control for this.
It is also important to note that better sedation has not resulted in improved colonoscopy outcomes like increased polyp detection.
Will these results change anything? No.
The small increased safety risk (detectable only in studies of millions of patients), if accurate, is not going to stop the use of anesthesia services for two reasons.
- Patient satisfaction
- Financial incentives
Patient satisfaction. Propofol results in excellent sedation, often with complete absence of pain combined with rapid recovery and an antiemetic effect.
Financial incentives. Many endoscopists are able to employ an anesthetist and generate additional revenue by billing for sedation (in addition to the costs of the endoscopist), whereas this is not allowed with the combination of intravenous opioids/benzodiazepines used for ‘deep sedation.’ Even in the many who do not receive revenue for these services, the rapid recovery expedites patient care and room turnover.
My take: While propofol administered by anesthetists is a little less safe and more expensive, it is here to stay, at least until incentives are created to reconsider this approach.