524 Nurse-Administered Propofol Continuous Infusion Sedation (NAPCIS) for Colonoscopy in Difficult to Sedate Patients

INTRODUCTION: Certain types of patients are considered difficult to sedate for colonoscopy using standard moderate sedation drugs such as midazolam and fentanyl. These include those with a history of alcohol abuse, those who regularly use marijuana, those taking high doses of opioids, and those suffering from post-traumatic stress disorder (PTSD). In the past, these types of potentially problematic patients were commonly referred for colonoscopy under general anesthesia. We recently demonstrated that Nurse-Administered Propofol Continuous Infusion Sedation (NAPCIS) is effective and safe for the sedation of healthy patients undergoing colonoscopy. NAPCIS confers the benefit of propofol-based sedation without the added expense for anesthesia professionals. Given the higher sedative potency of propofol compared to midazolam/fentanyl, NAPCIS may also be effective in difficult-to-sedate patients. METHODS: We retrospectively included patients from one of four difficult-to-sedate groups who had undergone NAPCIS colonoscopy: (1) Alcohol abusers; (2) Marijuana abusers; (3) Heavy opioid users and (4) PTSD sufferers, and compared against control patients who had undergone concurrent NAPCIS colonoscopy. RESULTS: Compared with the control group (n = 656), the marijuana group (n = 226) required higher mean doses (adjusted for subject weight) for both fentanyl (0.4 mcg/kg vs 0.6 mcg/kg; P < 0.001) and propofol (4.7 mg/kg vs 5.0 mg/kg; P = 0.025). The PTSD group (n = 67) required higher fentanyl dosages (0.4 mcg/kg vs 0.6 mcg/kg; P = 0.009). The alcohol (n = 22) and opioid groups (n = 133) showed no differences in sedative doses compared to controls. The procedural success rates for all 4 groups were uniformly high (98.6-100.0%) and similar to that seen in the controls (99.1%). Procedure times and recovery times were similar for all study and control groups. In the control group, there were 10 mild adverse events (mild desaturation, agitation due to undersedation or transient bradycardia). There was 1 case of mild desaturation each in the marijuana, PTSD and alcohol groups, 1 case of bradycardia in the opioid group and 1 case of hypotension in the marijuana group. Statistically, there were no differences in complication rates between the controls and the 4 study groups. There were no serious complications or deaths. CONCLUSION: NAPCIS is a safe and effective means of providing sedation for colonoscopy in difficult-to-sedate patients, most of whom would have been referred for general anesthesia if NAPCIS was unavailable.