Establishing Safe and Effective Protocols for Endoscopic Procedural Sedation using Propofol Target-controlled Infusion and Transnasal Humidified Rapid-insufflation Ventilatory Exchange: A Quality Improvement Project

Background: Gastrointestinal endoscopic procedures, including endoscopy, colonoscopy, and endoscopic ultrasound, are vital for both diagnostic and therapeutic purposes. These are typically performed under sedation, often using intermittent boluses of propofol. However, this conventional technique can cause plasma concentration fluctuations, leading to interruptions in the procedure with agitation and adverse effects such as respiratory depression or hypotension. Target-controlled infusion (TCI) of propofol enables precise titration based on pharmacokinetic models and patient response, minimizing these fluctuations. Incorporating transnasal humidified rapid-insufflation ventilatory exchange (THRIVE) further improves oxygenation and patient safety during sedation. This project aimed to improve and standardize sedation practices for endoscopic procedures by implementing TCI and THRIVE and to highlight their benefits over conventional bolus techniques. Methods: The project was conducted in three phases: local data were collected first to support evidence-based improvements and procedural outcomes comparing bolus sedation with TCI. Analysis of outcomes with the implementation of standardized protocols and education of fellow anesthesiologists was done in the second phase. In the third phase, we completed the loop with compliance monitoring and continued education of the benefits of TCI among anesthesiologists. Results: The TCI group showed a significantly lower incidence of agitation compared to the bolus group (22.7% vs. 66.7%, P = 0.002) and a significantly shorter mean time to wake up, measured by Observer’s Assessment of Alertness/Sedation = 5 (4.48 ± 2.46 min vs. 6.92 ± 3.83 min, P = 0.015). Although the mean propofol consumption per minute was similar (8.23 ± 4.38 mg/min for TCI vs. 7.76 ± 5.05 mg/min for bolus, P = 0.735), TCI provided more stable sedation with fewer interruptions. These findings contributed to a rise in TCI adoption from 50% to 87% following education and protocol implementation. Conclusion: The use of TCI and THRIVE resulted in smoother recoveries, reduced agitation, and improved procedural conditions. This initiative effectively standardized sedation practices while reinforcing the importance of ongoing education and protocol adherence.