Procedural sedation and analgesia and the propofol affair

Editor, Taking into account recent newspaper headlines, fear seems to be the predominant issue. Feelings of fear are nourished by (news coverage of) terrorism, the financial crisis, ethnic violence, xenophobia and by other ‘news’, the full impact of which the reader cannot possibly appreciate in most cases. Even scientific societies should base their communications on evidence and experience which sometimes inadvertently perpetrate suspicion, paranoia and populism. Evaluating information is not easy: not only are times constantly changing, but so are demands, resources, organisation and developments in medicine – a very best all-round medical practice does not exist. The development of guidelines for medical practice, founded on a scientific base that is as good as possible in order to support the practice of quality improvement, has proven to be very beneficial. However, guidelines are not the Holy Grail. They offer direction for medical practice allowing reasonable interpretation taking into account local circumstances and progress in views, opinion and judgement. The European Society of Gastrointestinal Endoscopy – European Society of Gastroenterology and Endoscopy Nurses and Associates – European Society of Anaesthesiology (ESGE – ESGENA – ESA) guideline for non-anaesthesiologist administration of propofol (NAAP) for gastro-intestinal endoscopy as published in the European Journal of Anaesthesiology (EJA) of December last year is such a guideline.1 It does no more than provide details on procedural sedation and/or analgesia (PSA) in gastroenterological endoscopy based on, and in compliance with, earlier guidelines such as the European Board of Anaesthesiology-endorsed guidelines for sedation and/or analgesia of 2007.2 In a Special Article published in the August 2011 issue of the EJA, Perel,3 firstly, brings to our attention that not all recommendations in the ESGE–ESGENA–ESA guideline for NAAP are at the 1++ level and, secondly, highlights the local US market-applicable FDA statement on propofol which argues against the ESGE–ESGENA–ESA guidelines, thus following what is, in my opinion, a populist campaign aimed at forbidding the administration of propofol for sedation by non-anaesthesiologists. This is in the face of the abundant literature on experience and safety of propofol administration by non-anaesthesiologists from Europe,4 from Japan5 and, in particular, from the USA.6,7 This campaign is endangering the comfort, the safety and indeed the lives of many patients who require sedation for a medical procedure. In trying to stop the use of propofol for sedation and to keep sedation exclusively within the domain of anaesthesiology, Perel has failed to acknowledge the reality: today, the vast majority of PSA procedures are already performed by non-anaesthesiologists, both in Europe and in the USA. That cannot be stopped. That situation must be optimised. The ESGE–ESGENA–ESA guideline gives direction; no more, and no less than that. The ESGE–ESGENA–ESA guideline on NAAP gives gastroenterologists and anaesthesiologists a unique opportunity to achieve a better quality and safety in sedation practice in Europe than that exists today. Specialists from both disciplines can now show their leadership and cooperate to implement the guideline based on clinical experience and evidence and to bring sedation to a higher level of quality in the near future. It is to be hoped that visionary anaesthesiologists and experts from other disciplines do not feel discouraged by the contents of the Special Article3 and will work together in a constructive atmosphere to continuously improve quality and safety for the many thousands of patients who require comfort and safe care during their diagnostic or therapeutic procedure under sedation. A great opportunity to show leadership!