Nurse-Administered Propofol Sedation in Nonagerians: Extending the Panacea

is more relevant when nonanesthesiologists are involved in its administration. The growing use of propofol (2,6 diisopropyl phenol) as a safe sedative agent during GI endoscopy in the setting of nurse-administered propofol (NAPS) or otherwise termed as gastroenterologist directed propofol has been gaining acceptance in the GI community globally. Propofol has advantages of quick onset, favorable pharmacodynamics, mild antiemetic properties, rapid termination of effect and expedited recovery [2] . Several landmark studies have been published establishing its safety and advantage over other sedative agents [5, 6] . A recent worldwide multicentric survey of NAPS included more than 521,000 patients. Mask ventilation rates were 0.4: 1,000 patients for upper endoscopy and 0.1: 1,000 patients for colonoscopy. Endotracheal intubations, neurologic injuries, and death occurred in 4, 1, and 3 patients, respectively. The 3 patients that died had significant comorbid illnesses such as widely metastatic malignancy and polysubstance abuse [7, 8] . Owing to its narrow therapeutic margin of index, propofol sedation especially in the elderly needs special attention. Heuss et al. [9] addressed this issue earlier in a prospective study of conscious sedation for propofol in elderly patients. Compared with younger patients, there was a significant increase in risk for a short oxygen desaturation ! 90% and a decrease in oxygen saturation The rising patient demographics in the aging population worldwide are reflected in the increasing use of endoscopy to manage gastrointestinal (GI)-related clinical problems. These age-related disorders include cancer, biliary tract disease, feeding issues, or GI ischemia [1] . Compared to other age groups, sedation during endoscopy in the advanced age presents a major challenge, the primary concern being the safety window given that these patients have poor physiological reserve as well as other associated comorbidities. When sedating the aged, issues of health remain, thereby questioning the risks and benefits involved. Cardiopulmonary risks include poor response of heart rate to hypotension, reduced ventilatory response to hypoxia and hypercarbia resulting in apnea, impairments in thermoregulation and water balance resulting in increased vulnerability to hypovolemia and hypothermia [2] . Similarly, changes in volume of distribution and bioavailability coupled with limited renal and hepatic clearance alter the pharmacodynamics of drugs. This results in heightened sensitivity to sedative agents necessitating dose titration and interval duration modifications [3, 4] . Other concerns include increased risk of aspiration, postprocedure delirium and prolonged recovery times. Therefore, the choice of safe sedative agents becomes important given the fact that most of the endoscopic procedures aim for a continuum of minimal to moderate sedation. This Published online: September 2, 2008