Erkin ÖZTAŞ, Diğdem Özer ETİK, Dilek OĞUZ

Endoskopik sedasyon ve premedikasyon

Endoskopik sedasyon; temelde hastada işlemle ilgili oluşan ve/veya oluşacak olan rahatsızlık hissi ve kaygılı durumu azaltmak ve bunun sonucunda da hastaların işlemi daha kolay tolere edebilmelerini sağlamak amaçlı kullanılır. Ayrıca endoskopiste doğru endoskopik inceleme ve işlem için uygun hasta durumu ve zaman sağlar. Dezavantajlarından bazıları ise endoskopik işlemle ilişkili kardiyopulmoner komplikasyonları ve endoskopik işlemin maliyetini arttırmasıdır. Sedasyon amaçlı kullanılan bazı ilaçların anestezi uzmanı olmayan personelce (endoskopist, yardımcı hemşire) kullanımı da bazı yasal sorunları gündeme getirebilir. Sedasyon kelimesi tek bir durumu ifade etmek için kullanılmaz, belirli aşamaları içeren devamlılığı söz konusudur (continuum sedation). Buna göre sedasyonun 4 evresi vardır. Hastaya sedasyon amaçlı ilaç verildiğinde, verilen ilaca, doza, hastanın özelliklerine ve işlem süresine bağlı olarak en hafif etki (anksiyolitik etki)?den sırasıyla orta dereceli sedasyon, derin sedasyon ve genel anesteziye kadar uzanan klinik tabloyla karşılaşılabilir. Endoskopik işlemlerde hedeflenen evre, genellikle orta derecede sedasyon evresidir. Beklenmedik şekilde derin sedasyon ve genel anestezi durumu gelişen hastaya kardiyo-pulmoner sistem desteği gerekebilir ve uygun müdahale yapılamazsa hastada seyir beklenmedik şekilde ölümcül olabilir. Bu nedenle sedasyon uygulayan kişi, hastanın resüstasyonu ve kurtarılması konusunda gerekli eğitimi almış olmalıdır ve bu tür girişimleri tereddütsüz yapabilmelidir.

Anahtar Kelimeler:

Endoskopi, sedasyon, eğitim

Endoscopic sedation and premedication

Endoscopic sedation is intended primarily to reduce a patient?s anxiety and discomfort, consequently improving their tolerability and satisfaction during the procedure. It also gives the endoscopist the chance to obtain the optimal endoscopic investigation, best position of the patient and adequate time to complete the procedure. In contrast to these advantages, sedation adds to the overall cost of an endoscopic procedure, and increases the risk of cardiopulmonary complications. In addition, the use of some sedative agents by practitioners (such as endoscopists or nurses) other than anesthesiologists could lead to legal problems. The word ?sedation? is not used in reference to only one condition; on the contrary, this term is used to define a process containing multiple stages (continuum sedation). There are four stages of sedation. When sedative agents are applied to a patient, four different stages of sedation can be observed based on the type of the agent, its dosage and the patient?s characteristics: anxiolytic effect (the minimum effect), moderate sedation, deep sedation and general anesthesia. Generally, moderate sedation is the goal during endoscopic procedures. When deep sedation or general anesthesia occurs in a patient unexpectedly, cardiopulmonary resuscitation can be vital; otherwise, the condition can become fatal if appropriate intervention can not be done. Consequently, practitioners must possess the skills necessary to resuscitate or rescue a patient whose level of sedation is deeper than planned.

Keywords:

Endoscopy, sedation, education,

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Cohen LB, Delegge MH, Aisenberg J, et al. AGA Institute. AGA Institute review of endoscopic sedation. Gastroenterology 2007;133:675-701.
Lichtenstein DR, Jagannath S, Baron TH, et al. Sedation and anesthesia in GI endoscopy. Standards of Practice Committee of the American So- ciety for Gastrointestinal Endoscopy, Gastrointest Endosc 2008;68:815- 26.
Regula J, Sokol-Kobielska E. Sedation in endoscopy: when and how. Best Pract Res Clin Gastroenterol 2008;22:945-57.
Gross JB, Bailey PL, Connis RT, et al. American Society of Anesthesiolo- gists Task Force on Sedation and Analgesia by Non-Anesthesiologists. Practice guidelines for sedation and analgesia by non-anesthesiologists. Anesthesiology 2002;96:1004-17.
Mallampati SR, Gatt SP, Gugino LD, et al. A clinical sign to predict dif- ficult tracheal intubation: a prospective study. Can Anaesth Soc J 1985;32:429-34.
Qureshi WA, Adler DG, Davila RE, et al. ASGE guideline: guidelines for endoscopy in pregnant and lactating women. Gastrointest Endosc 2005;61: 357-62.
Bailey PL, Pace NL, Ashburn MA, et al. Frequent hypoxemia and apnea after sedation with midazolam and fentanyl. Anesthesiology 1990;73:826-30.
Knape JT, Adriaensen H, van Aken H et al. Guidelines for sedation and/or analgesia by nonanaesthesiology doctors. Eur J Anaesthesiol 2007;24:563-7.
Rex DK, Heuss LT, Walker JA, Qi R. Trained registered nurses/endos- copy teams can administer propofol safely for endoscopy. Gastroentero- logy 2005; 129:1384-91.
Clarke AC, Chiragakis L, Hillman LC, Kaye GL. Sedation for endoscopy: the safe use of propofol by general practitioner sedationists. Med J Aust 2002; 176:158-61.
Heuss LT, Schnieper P, Drewe J, et al. Safety of propofol for conscious sedation during endoscopic procedures in high-risk patients - a prospec- tive, controlled study. Am J Gastroenterol 2003;98:1751-7.
Byrne MF, Baillie J. Nurse-assisted propofol sedation: the jury is in. Gas- troenterology 2005;129:1781-2.
Joint Statement of a Working Group from the American College of Gastro- enterology (ACG), the American Gastroenterological Association (AGA), and the American Society for Gastrointestinal Endoscopy (ASGE). Recom- mendations on the administration of sedation for the performance of en- doscopic procedures. http://www.gastro.org/wmspage.cfm?parm1_371.
Rex DK, Heuss LT, Walker JA, Qi R. Trained registered nurses/endos- copy teams can administer propofol safely for endoscopy. Gastroentero- logy 2005;129:1384-91.
Tohda G, Higashi S, Wakahara S, et al. Propofol sedation during endos- copic procedures: safe and effective administration by registered nurses supervised by endoscopists. Endoscopy 2006;38:360-7.
Cohen LB, Hightower CD, Wood DA, et al. Moderate level sedation du- ring endoscopy: a prospective study using low-dose propofol, meperidi- ne/fentanyl, and midazolam. Gastrointest Endosc 2004;59:795-803.
Cohen LB, Dubovsky AN, Aisenberg J, Miller KM. Propofol for endosco- pic sedation: a protocol for safe and effective administration by the gas- troenterologist. Gastrointest Endosc 2003;58:725-32.
Rudner R, Jalowiecki P, Kawecki P, et al. Conscious analgesia/sedation with remifentanil and propofol versus total intravenous anesthesia with fentanyl, midazolam, and propofol for outpatient colonoscopy. Gastro- intest Endosc 2003;57:657-63.
Rosow C, Manberg PJ. Bispectral index monitoring. Anesthesiol Clin North America 2001;19:947-66.
Chung F, Chan V, Ong D. A post anesthetic discharge scoring system for home readiness after ambulatory surgery. J Clin Anesth 1995;7:500-6.