This Guideline is an official statement of the European Society of Gastrointestinal Endoscopy (ESGE) and the European Society of Gastroenterology and Endoscopy Nurses and Associates (ESGENA). It addresses the administration of propofol by non-anesthesiologists for gastrointestinal (GI) endoscopy. Main Recommendations 1 We recommend that the type of endoscopic procedure and the patient’s American Society of Anesthesiologists (ASA) physical status, age, body mass index, Mallampati’s classification, and risk factors for obstructive sleep apnea (OSA) be assessed before each procedure with non-anesthesiologist administration of propofol (NAAP) (strong recommendation, moderate quality evidence). 2 We suggest primary involvement of an anesthesiologist in patients of ASA class ≥ 3, with a Mallampati’s class ≥ 3 or other conditions that put them at risk of airway obstruction (e. g. pharyngolaryngeal tumors), in patients who chronically receive significant amounts of narcotic analgesics, or in cases where a long-lasting procedure is anticipated (weak recommendation, low quality evidence). 3 We suggest consideration of capnographic monitoring during NAAP in specific situations including high risk patients, intended deep sedation, and long procedures (weak recommendation, high quality evidence). 4 We suggest propofol monotherapy except in particular situations (weak recommendation, high quality evidence). 5 We recommend administering propofol through intermittent bolus infusion or perfusor systems, including target-controlled infusion (TCI), and consideration of patient-controlled sedation (PCS) in particular situations (strong recommendation, high quality evidence). 6 We suggest that patients listen to self-selected music during upper and lower GI endoscopy procedures (weak recommendation, moderate quality evidence). 7 We do not suggest using pharyngeal anesthesia during propofol sedation for upper GI endoscopy (weak recommendation, moderate quality evidence). 8 We suggest using the post-anesthetic discharge scoring system (PADSS) to determine when patient recovery is sufficient to allow discharge (weak recommendation, low quality evidence). 9 Minimum discharge criteria should be fulfilled before discharging a patient. We recommend that patients who have received combined regimens, and all patients of ASA class > 2, should upon discharge be accompanied by a responsible person and refrain for 24 hours from driving, drinking alcohol, operating heavy machinery, or engaging in legally binding decisions. Advice should be provided verbally and in written form to the patient, including a 24-hour contact phone number (strong recommendation, low quality evidence). 10 For patients of ASA classes 1 – 2 who have received low dose propofol monotherapy, a 6-hour limit is suggested (weak recommendation, low quality evidence).

Propofol sedation by non-anesthesiologists is an upcoming sedation regimen in several countries throughout Europe. Numerous studies have shown the efficacy and safety of this sedation regimen in gastrointestinal endoscopy. Nevertheless, this issue remains highly controversial. The aim of this evidence- and consensus-based set of guideline is to provide non-anesthesiologists with a comprehensive framework for propofol sedation during digestive endoscopy. This guideline results from a collaborative effort from representatives of the European Society of Gastrointestinal Endoscopy (ESGE), the European Society of Gastroenterology and Endoscopy Nurses and Associates (ESGENA) and the European Society of Anaesthesiology (ESA). These three societies have endorsed the present guideline.

For more than 30 years, sedation using benzodiazepines, combined or not with opioids, has been used as a standard regimen for gastrointestinal endoscopy; it is usually referred to as traditional sedation. Sedation management in gastrointestinal endoscopy varies between European countries according to the different legal frameworks and different healthcare systems. In the majority of European countries, endoscopists administer sedation with support from endoscopy nurses, while in some countries such as France only anesthesiologists administer intravenous sedation. In some countries any sedation can be administered by all trained clinicians, while in other countries administration of propofol can only be performed by anesthesiologists. Therefore, because of national legal restrictions, non-anesthesiologist administration of propofol (NAAP) has been established in only a few European countries, including Austria, Denmark, Germany, Greece, the Netherlands, Sweden, and Switzerland [1] [2] [3] [4] [5] [6] [7] [8] [9]. Irrespective of the type of sedation used, quality management requires pharmacologically appropriate training for all clinical staff involved in sedation practice. Individual qualifications, human resources and technical requirements have already been addressed in different guidelines [5] [10] [11] [12] [13] [14] [15] [16] [17]. The German courses based on the national sedation curriculum combine sedation and emergency management, irrespective of the agent used for sedation (e. g., propofol, benzodiazepine, or combined medications) [18]. The nationwide implementation of these courses has significantly improved quality with regard to structure in German gastrointestinal endoscopy departments [19]. In Denmark, a training program for procedural sedation and analgesia (PSA) has been implemented in the capital region in cooperation with anesthesiologists [20]; sedation quality was found to be high following the implementation phase of NAAP in an endoscopy suite [21]. Therefore common training practice standards for all methods of sedation used in endoscopy have been shown to be beneficial in improving clinical practice as well as structural quality. European and national societies have already developed evidence-based and consensus-based guidelines for sedation and monitoring in gastrointestinal endoscopy that give a comprehensive outline of structural requirements, medication options, patient monitoring and discharge, and the role of endoscopy staff [10] [11] [12] [13] [14] [15] [16]. Anesthesiology and gastroenterology societies have both demanded special training for staff administering sedation of any type [13] [17], and especially for NAAP [10] [14] [15] [16]. The joint endorsement of the present Curriculum by medical and nursing endoscopy societies emphasizes that a multidisciplinary approach is the best response to current needs [13] [15] [16]. In the United States of America, a multisociety sedation curriculum for gastrointestinal endoscopy has recently been introduced [22]. The Curriculum presented here is based on the consensus of physicians (gastroenterologists, anesthesiologists) and nurses who have previously been involved in the development of European and national sedation guidelines for endoscopy sedation, national curricula for endoscopy sedation, and the organization of national and local courses for endoscopy sedation. ^* Both authors contributed equally.

Background and study aims Endoscopic ultrasound-guided through-the-needle biopsy (TTNB) of pancreatic cystic lesions (PCLs) is associated with a non-negligible risk for adverse events (AEs). We aimed to identify the hierarchic interaction among independent predictors for TTNB-related AEs and to generate a prognostic model using recursive partitioning analysis (RPA). Patients and methods Multicenter retrospective analysis of 506 patients with PCLs who underwent TTNB. RPA of predictors for AEs was performed and the model was validated by means of bootstrap resampling. Results Mean cysts size was 36.7 mm. Most common diagnoses were intraductal papillary mucinous neoplasm (IPMN, 45 %), serous cystadenoma (18.8 %), and mucinous cystadenoma (12.8 %). Fifty-eight (11.5 %) AEs were observed. At multivariate analysis, age (odds ratio [OR] 1.32, 1.09–2.14; p = 0.05), number of TTNB passes (OR from 2.17, 1.32–4.34 to OR 3.16, 2.03–6.34 with the increase of the number of passes), complete aspiration of the cyst (OR 0.56, 0.31–0.95; p = 0.02), and diagnosis of IPMN (OR 4.16, 2.27–7.69; p < 0.001) were found to be independent predictors of AEs, as confirmed by logistic regression and random forest analyses. RPA identified three risk classes: high-risk (IPMN sampled with multiple microforceps passes, 28 % AEs rate), low-risk (1.4 % AE rate, including patients < 64 years with other-than-IPMN diagnosis sampled with ≤ 2 microforceps passes and with complete aspiration of the cyst) and middle-risk class (6.1 % AEs rate, including the remaining patients). Conclusion TTNB should be selectively used in the evaluation of patients with IPMN. The present model could be applied during patient selection as to optimize the benefit/risk of TTNB.