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2013 European Curriculum Sedation Training
2013 European Curriculum Sedation Training
2013 European Curriculum Sedation Training
Authors J.-M. Dumonceau1, *, A. Riphaus2, *, U. Beilenhoff3, P. Vilmann4, P. Hornslet4, J. R. Aparicio5, M. Dinis-Ribeiro6, E. Giostra7,
M. Ortmann8, J. T. A. Knape9, S. Ladas10, G. Paspatis11, C. Y. Ponsioen12, I. Racz13, T. Wehrmann14, B. Walder15
Bibliography 1. Introduction dural sedation and analgesia (PSA) has been im-
DOI http://dx.doi.org/ ! plemented in the capital region in cooperation
10.1055/s-0033-1344142
For more than 30 years, sedation using benzodia- with anesthesiologists [20]; sedation quality was
Online-Publikation: 23.5.2013
zepines, combined or not with opioids, has been found to be high following the implementation
Endoscopy 2013; 45: 496504
Georg Thieme Verlag KG used as a standard regimen for gastrointestinal phase of NAAP in an endoscopy suite [21]. There-
Stuttgart New York endoscopy; it is usually referred to as traditional fore common training practice standards for all
ISSN 0013-726X sedation. Sedation management in gastrointesti- methods of sedation used in endoscopy have
nal endoscopy varies between European coun- been shown to be beneficial in improving clinical
Corresponding authors:
J.-M. Dumonceau, MD PhD
tries according to the different legal frameworks practice as well as structural quality.
Division of Gastroenterology and different healthcare systems. In the majority European and national societies have already de-
and Hepatology of European countries, endoscopists administer veloped evidence-based and consensus-based
Geneva University Hospitals sedation with support from endoscopy nurses, guidelines for sedation and monitoring in gastro-
Gabrielle Perret Gentil Str. 4 while in some countries such as France only anes- intestinal endoscopy that give a comprehensive
1211 Geneva thesiologists administer intravenous sedation. In outline of structural requirements, medication
Switzerland
some countries any sedation can be administered options, patient monitoring and discharge, and
Fax: +41223729366
jmdumonceau@hotmail.com
by all trained clinicians, while in other countries the role of endoscopy staff [10 16]. Anesthesiol-
administration of propofol can only be performed ogy and gastroenterology societies have both de-
A. Riphaus, MD by anesthesiologists. Therefore, because of na- manded special training for staff administering
KRH Klinikum Agnes Karll tional legal restrictions, non-anesthesiologist ad- sedation of any type [13, 17], and especially for
Laatzen ministration of propofol (NAAP) has been estab- NAAP [10, 14 16].
Department of Internal lished in only a few European countries, including The joint endorsement of the present Curriculum
Medicine Gastroenterology
Austria, Denmark, Germany, Greece, the Nether- by medical and nursing endoscopy societies em-
Hildesheimer Str. 158
30880 Laatzen
lands, Sweden, and Switzerland [1 9]. phasizes that a multidisciplinary approach is the
Germany Irrespective of the type of sedation used, quality best response to current needs [13, 15, 16]. In the
Fax: +49511-82082751 management requires pharmacologically appro- United States of America, a multisociety sedation
ariphaus@web.de priate training for all clinical staff involved in se- curriculum for gastrointestinal endoscopy has re-
dation practice. Individual qualifications, human cently been introduced [22].
resources and technical requirements have al- The Curriculum presented here is based on the
ready been addressed in different guidelines [5, consensus of physicians (gastroenterologists, an-
10 17]. esthesiologists) and nurses who have previously
The German courses based on the national seda- been involved in the development of European
tion curriculum combine sedation and emergen- and national sedation guidelines for endoscopy
cy management, irrespective of the agent used sedation, national curricula for endoscopy seda-
for sedation (e. g., propofol, benzodiazepine, or tion, and the organization of national and local
combined medications) [18]. The nationwide im- courses for endoscopy sedation.
plementation of these courses has significantly
improved quality with regard to structure in Ger-
man gastrointestinal endoscopy departments 2. Aims of the European Curriculum
[19]. In Denmark, a training program for proce- !
This European Curriculum is intended for
teachers and institutions organizing sedation
* Both authors contributed equally. courses.
Dumonceau J-M et al. European Curriculum for Sedation Training in Gastrointestinal Endoscopy Endoscopy 2013; 45: 496504
Guidelines 497
It focuses on training in all types of sedation practices in gastro- A 3-day introductory course
intestinal endoscopy. Its aims are: A minimum of 2 weeks of clinical training in the students own
To set standards for the training of non-anesthesiologists, clinical setting or a clinical setting that fulfils the training re-
physicians and nurses, who are going to administer sedation quirements.
during gastrointestinal endoscopy procedures
To expand the specific knowledge, competence, and skills nec- 5.2. Course structure
essary for endoscopists and nursing staff for endoscopy seda- The 3-day introductory course combines theory and practice,
tion, and management of its complications, in order to ensure with a focus on practical training. Therefore at least half of the
patient comfort and safety time should be spent in practical training sessions. Practical
To support individual endoscopy departments, national socie- training needs to be performed in small groups (from 4 to a
ties, and official bodies in developing local or national recom- maximum of 8 persons). Each section is followed by a formal
mendations and curricula. test to document cognitive or skills competence.
In most European countries, basic and advanced life support
skills have to be updated periodically, therefore competency in
3. Methodology life support (e. g., basic life support [BLS] or advanced cardiac
! life support [ACLS], according to national law) is a prerequisite
The development of the current curriculum was based on the for anyone undertaking training in sedation for gastrointestinal
consensus of experts [23]. Six authors (A.R., B.W., J.M.D., P.H., P. endoscopy. The introductory course will also include a refresh-
V., U.B.) first met in Geneva (May 2011) and then in Bochum er in these techniques.
(July 2012). They agreed on the methodology to be applied and The clinical training consists of a learning phase of at least
on a set of preliminary salient points to write a preliminary draft. 2 weeks with a mentor and with individual assessment of
Subsequently, all authors were invited to take part in the elabora- competencies (see Learning outcomes in Appendix 1). Sum-
tion of the current Position Statement. They considered the mative assessment should be performed independently of one
soundness and applicability of the draft statements by means of another by at least three independent supervisors (to ensure
an online session for voting and comments [24]. After integration that each supervisor bears individual responsibility for the
of comments, the final draft was submitted to voting and partici- capability of the candidate), after a minimum of 30 student-
pants were asked if they agreed or disagreed with each state- documented cases (including diagnostic and therapeutic pro-
ment. The voting process with all contributions regarding con- cedures), or more if trustworthy professional performance has
tent as well as voting results and evaluation of the consensus not been achieved.
size were documented (strong consensus was defined as 95 %
agreement, consensus as > 75 % agreement, majority agreement
as agreement within the range 51 % to 75 % inclusive, and no con- 6. Teaching staff
sensus as 50 % agreement of participants). Strong consensus !
was achieved for every single item. All the authors approved the The course organizers (a team of endoscopists, anesthesiologists,
final version of the manuscript. and nurses) and the additional teaching staff for the course
The Curriculum is based on national guidelines and curricula for should be competent in their areas of teaching, both in theory
training in sedation and management of its complications [10, and in practice.
13, 18, 20], as well as the ESGE ESGENA ESA guideline for Suggested teachers are:
NAAP sedation in gastrointestinal endoscopy [15, 16], as the re- A team of endoscopists and anesthesiologists
commendations and principles presented here apply to all seda- Anesthesiology nurses in countries where this specialty exists,
tion practices for gastrointestinal endoscopy. and/or
Endoscopy nurses (qualified in endoscopy sedation in coun-
tries where this specialty exists)
4. Target group A lawyer or legal adviser to cover legal and professional issues
! (e. g., delegation and its implications)
This Curriculum is intended for the following staff working in Other personnel as deemed relevant by the course
gastrointestinal endoscopy: management team
Non-anesthesiologist physicians practicing gastrointestinal Clinical mentor(s)/assessor(s) in the students own
endoscopy department.
Nurses and other allied professionals who are (according to For courses which also include training in NAAP, the trainer
national law) involved in sedation for gastrointestinal endos- responsible for bedside training and competence assessment
copy including postinterventional care under the supervision should be a physician with previous experience of > 300 cases of
of a physician practicing gastrointestinal endoscopy propofol sedation [15, 16].
According to recent guidelines, it is recommended that patients
be continuously monitored by an independent person dedicated
to PSA [11, 13, 15, 16]. 7. Course content
!
The course integrates theory with practice and covers the follow-
5. Course duration and structure ing areas:
! Relevant anatomy and physiology of the heart and respiratory
5.1. The course duration tract, including definitions of hypoxemia, hypocapnia and
The course duration should be as follows:
Dumonceau J-M et al. European Curriculum for Sedation Training in Gastrointestinal Endoscopy Endoscopy 2013; 45: 496504
498 Guidelines
hypercapnia, and their relationship to the risk profile of the problems; this may be particularly important when endoscopy
individual patient. with sedation is performed and complications arise [25]. Debrief-
Basic pharmacology, pharmacokinetics, indications and con- ing, possibly enhanced by the review of videotaped simulations,
traindications of drugs commonly used for endoscopy sedation may help participants to improve both technical and non-techni-
and pain control (e. g. benzodiazepines and opioids as well as cal skills.
their antagonists, and propofol, ketamine, nitrous oxide, and Originally developed in the field of anesthesiology [26], medical
oxygen) simulation exercises are now finding wider use in related fields
Different sedation methods, including possibilities and limita- such as intensive care medicine and emergency care. Studies of
tions, possible side effects, prevention and management of endoscopic sedation performed with simulators are rare. Kies-
complications slich et al. used this type of simulator to train staff in two differ-
Selection of patients appropriate for administration of seda- ent scenarios of gastrointestinal bleeding with significant blood
tion by non-anesthesiologists, including the use of health care loss and oversedation [27]. After debriefing on the first scenario,
questionnaires to help in patient selection the authors were able to show a significant improvement in
Equipment and staff requirements necessary to ensure patient endoscopic performance and crisis management during the sec-
safety before, during, and after endoscopic interventions ond scenario.
The use of different scores to assess patient risk status (e. g., Using full-scale simulators for this course allows training on dos-
American Society of Anesthesiologists [ASA] classification, risk ing and drug effects, and in management of different types of pa-
score to predict difficult mask ventilation), and the relation- tients and their risk factors, of falls in oxygen saturation, blood
ship amongst patient risk status, foreseen sedation, and an- pressure or heart rate, of cardiac arrhythmias, and of apnea [15,
ticipated difficulty of the endoscopic procedure 16].
Patient preparation and surveillance, including safe position-
ing, intravenous access, monitoring, and oxygen administra-
tion 9. Assessment of theory and practice
Stages of sedation !
Management of sedation complications Several methods can be used for the formative and summative
Documentation of sedation (e. g., assessment at regular inter- assessments (see Glossary) of theory and practice (
" Table 1).
Dumonceau J-M et al. European Curriculum for Sedation Training in Gastrointestinal Endoscopy Endoscopy 2013; 45: 496504
Guidelines 499
Table 1 Methods available for the assessment of the theoretical and practical parts of endoscopy sedation courses.
Dumonceau J-M et al. European Curriculum for Sedation Training in Gastrointestinal Endoscopy Endoscopy 2013; 45: 496504
500 Guidelines
(see
" Tables 2, 3 and 4) Different sedation concepts including dosing and application
Identification of risk situations that require the presence of an methods
anesthesiologist Hygiene guidelines for drug application and storage
Implementation of special informed consent for sedation Patient care and monitoring/observation criteria.
according to national standards
Patient preparation (informing and instructing the patient, Complication management
patient positioning, standard monitoring) Cardiorespiratory insufficiencies, shock
Preparation of drugs, including hygiene guidelines for drug Need for advanced upper airway management (e. g., Wendel or
preparation and syringe labeling Guedel tube; see ESGE guideline about NAAP). Techniques of
life support (e. g., BLS, ACSL)
Identification of risk situations that require the presence of an
anesthesiologist.
Dumonceau J-M et al. European Curriculum for Sedation Training in Gastrointestinal Endoscopy Endoscopy 2013; 45: 496504
Guidelines 501
Table 6 Stages of sedation: modified from the classification of the American Society of Anesthesiologists.
Dumonceau J-M et al. European Curriculum for Sedation Training in Gastrointestinal Endoscopy Endoscopy 2013; 45: 496504
502 Guidelines
Critically judge their own limitations concerning knowledge Demonstrate understanding of definitions of adverse events
and skills in sedation in gastrointestinal endoscopy and complication (e. g., hypoxia, apnea, shock) and should be
Prepare the patient according to the planned procedure (e. g., able to link this to the risk profile of the individual patient
correct positioning) Identify conditions associated with increased risks of bron-
Prepare the appropriate standard monitoring equipment chial aspiration (e. g., acute upper gastrointestinal bleeding,
(pulse oximetry and noninvasive blood pressure measurement delayed gastric emptying) and to initiate relevant precaution-
for all patients undergoing sedation, electrocardiography ary maneuvers and treatment
[ECG] for patients with a history of cardiac and/or pulmonary Identify clinical and technical signs of cardiorespiratory
disease) insufficiency and allergic reactions (e. g., airway obstruction,
Prepare equipment for airway management (different tubes hypoxemia, hypotonia, apnea, laryngospasm) and to initiate
such as Guedel and laryngeal tubes, mask) and resuscitation relevant precaution maneuvers and treatment
equipment Identify the need for simple and advanced airway manage-
Prepare drugs according to the relevant guidelines, for health ment during the intra- and post-interventional phase (e. g.,
and safety as well as for hygiene. chin lift, Wendel or Guedel tube) and to initiate relevant
treatment
Intraprocedural sedation management and patient care Support, perform and/or organize techniques of life support
After completing the course the participant should be able to: according to professional skills and responsibilities (e. g., BLS,
Demonstrate understanding of the relevant anatomy and ACSL)
physiology of the heart and respiratory tract Identify intra- and post-interventional risk situations that
Demonstrate understanding of the basics of pharmacology require the presence of an anesthesiologist.
and pharmacokinetics of the following drugs, including
different sedation concepts, their possibilities and limitations, Post-interventional monitoring and care
possible side effects, and prevention and treatment of compli- After completing the course, the participant should be able to:
cations: Assess patient status with regard to cardiorespiratory activity,
Benzodiazepines and their antagonists pain, and sedation level, by using standardized methods and
Opioids and their antagonists scores (see Appendix 2)
Propofol Identify adverse events and complications requiring additional
Oxygen monitoring and treatment and initiate relevant precautionary
Plan, perform and state reasons for individually adapted maneuvers and treatment
nursing and medical actions performed during the individual Use standardized medical and nursing protocols for docu-
procedure menting:
Use the appropriate equipment for patient monitoring, vital signs
including: sedation level ( " Tables 5 and 6)
continuous pulse oximetry and automated noninvasive pain level (e. g., visual analogue scale from 0 to 10 with
blood pressure measurement at baseline and then at 3 5- 0 equivalent to no pain)
minute intervals changes in patient health status
ECG for patients with a history of cardiac and/or pulmonary adverse events and complications
disease related adequate patient care and medical action
Assess patient status by using standardized methods and home discharge ( " Table 7)
pain level
changes in the patients health status Appendix 2: Clinical assessment scores
adverse events and complications !
related adequate patient care and medical action The following scores should be used in clinical assessment:
Administer sedation and rescue drugs taking into the account 1. Pre-procedure risk assessment of possible cardiovascular and
the pharmacokinetics, the patients individual risk assessment, respiratory problems during endoscopy ( " Table 2)
Apply health and safety guidelines (e. g., safe positioning, safe 3. Independent risk factors for difficult mask ventilation
injection practices) (
" Table 4)
Apply hygiene-relevant guidelines for drug application and 4. Modified Richmond agitation sedation score ( " Table 5)
Complication management 6. Minimal criteria for patient discharge after sedated endoscopy
After completing the course the participant should be able to: (
" Table 7)
Dumonceau J-M et al. European Curriculum for Sedation Training in Gastrointestinal Endoscopy Endoscopy 2013; 45: 496504
Guidelines 503
Dumonceau J-M et al. European Curriculum for Sedation Training in Gastrointestinal Endoscopy Endoscopy 2013; 45: 496504
504 Guidelines
21 Jensen JT, Vilmann P, Horsted T et al. Nurse-administered propofol seda- licobacter Study Group (EHSG), European Society of Pathology (ESP),
tion for endoscopy: a risk analysis during an implementation phase. and the Sociedade Portuguesa de Endoscopia Digestiva (SPED). Endos-
Endoscopy 2011; 43: 716 722 copy 2012; 44: 74 94
22 Vargo JJ, DeLegge MH, Feld AD et al. Multisociety sedation curriculum 25 Lightdale JR, Weinstock P. Simulation and training of procedural seda-
for gastrointestinal endoscopy. Gastrointest Endosc 2012; 76: e1 e25 tion. Tech Gastrointest Endosc 2011; 13: 167 173
23 Dumonceau J-M, Hassan C, Riphaus A et al. European Society of Gastro- 26 Gaba DM, Howard SK, Flanagan B et al. Assessment of clinical perform-
intestinal Endoscopy (ESGE) Guideline Development Policy. Endos- ance during simulated crises using both technical and behavioral rat-
copy 2012; 44: 626 629 ings. Anesthesiology 1998; 89: 8 18
24 Dinis-Ribeiro M, Areia M, de Vries AC et al. Management of precancer- 27 Kiesslich R, Moenk S, Reinhardt K et al. Combined simulation training: a
ous conditions and lesions in the stomach (MAPS): guideline from the new concept and workshop is useful for crisis management in gastro-
European Society of Gastrointestinal Endoscopy (ESGE), European He- intestinal endoscopy. Z Gastroenterol 2005; 43: 1031 1039
Dumonceau J-M et al. European Curriculum for Sedation Training in Gastrointestinal Endoscopy Endoscopy 2013; 45: 496504