Sedation in gastrointestinal endoscopy in Singapore

Dear Editor,

I refer to the editorial “Ensuring safe sedation during gastroendoscopy”¹ and the original article “Academy of Medicine, Singapore clinical guideline on the use of sedation by non-anaesthesiologists during endoscopy in the hospital setting”²  in your journal in January 2022.

The American Society of Gastrointestinal Endoscopy (ASGE) and the European Society of Gastrointestinal Endoscopy (ESGE) have neatly written guidelines on training and usage of propofol for sedation in gastrointestinal endoscopy.^3-5 In these established guidelines, non-anaesthesia personnel using propofol have to undergo a formal structured training programme consisting of theory, practical and preceptorship. There is no similar formal training for the use of propofol in gastrointestinal endoscopy in Singapore.

In Singapore’s public hospitals, non-anaesthesiologists who wish to partake in procedural sedation undergo a formal sedation course organised by the respective hospitals. Propofol sedation is not taught in such a course. Endoscopists who perform gastrointestinal endoscopy in Singapore’s public hospitals do not use propofol, and hence, they do not have the training, knowledge, skills or experience in using propofol for gastrointestinal endoscopy.

In the Singapore Medical Council (SMC) Ethical Code and Ethical Guidelines (ECEG) (2016),⁶ under “Good clinical care”, a doctor must practise within the limits of his or her own competence and must not engage in unsupervised practice of an area of medicine without having the appropriate knowledge and skills or the required experience. Also, under “Good clinical care”, the doctor must offer patients treatments that are beneficial. Treatments are not legitimate just because there is little evidence of harm or because they are widely employed.

In judgement delivered by the Chief Justice in the Court of Three Judges in Wong Meng Hang v Singapore Medical Council and other matters [2018] SGHC 253, the Chief Justice emphasised that they relied on prohibitions stated on the manufacturer’s instruction sheet in arriving at the finding that the doctors involved had known they were not qualified to administer propofol. The doctors involved had ignored the explicit warnings on the manufacturer’s instruction sheet, which indicated that propofol was not to be administered except by someone trained as an anaesthetist or intensivist.⁷

Now, I would like to point out some puzzling points in the original article by Ang et al.²

In the Introduction, the authors wrote that the Singapore Ministry of Health (MOH) guideline on the use of sedation by non-anaesthesiologists⁸ “does not address the issues pertinent to the hospital setting”. However, the authors did not identify what these issues are and how they are addressed in their own article.

Statement 6 of the article states that “Propofol sedation for gastrointestinal endoscopy can be safely and effectively administered by trained non-anaesthesiologist”. However, the strength of recommendation is rated as weak. It is puzzling why the authors are recommending something for which the strength of recommendation is weak.

Statement 15 of the article states that “Training in sedation should be structured. There should be assessment of competencies prior to the independent administration of sedation”. Similarly, Statement 16 states that “Non-anaesthesiologists using propofol for sedation should have additional training with respect to propofol. They should have training for resuscitation with emphasis on airway management”.

At the end of Statement 16, the authors made some contradictory and alarming statements. They mentioned that currently propofol is already being administered by non-anaesthesiologists in private practice. A similar statement was mentioned in the editorial.¹ As stated above, endoscopists working in public hospitals in Singapore (past and present) have no training, knowledge, skills or experience in the use of propofol for gastrointestinal endoscopy. Endoscopists moving their practice from public hospitals to private hospitals will have had no formal structured training or knowledge, nor will they have prior skill and experience in using propofol for gastrointestinal endoscopy. There is also no avenue for endoscopists in private practice to acquire any formal qualifications to use propofol since no such formal training course exists in Singapore.

The revelation that endoscopists in private practice are using propofol for gastrointestinal endoscopy is puzzling and alarming on 3 counts. First, it clearly contradicts Statement 15 and 16 of the authors’ own article.² Second, it violates the SMC ECEG (2016)⁶ mentioned before. Third, it violates case law established by the Court of Three Judges in Wong Meng Hang v Singapore Medical Council and other matters.⁷ Moreover, it is uncertain if the legal and professional standards of informed consent have been fulfilled when these endoscopists use propofol on the patients.

Last, but not least, I am unable to find any references or evidence of the medical benefit of non-anaesthesiologist-administered propofol in the article.²

I will therefore like to strongly suggest that the authors revise their original article to address glaring contradictions, unfinished statements and also provide clear evidence of the medical benefit of non-anaesthesiologist-administered propofol.

MOH should convene a group of non-partisan doctors to look into any evidence-based medical benefit of having non-anaesthesiologist-administered propofol for gastrointestinal endoscopy, before deciding if there is a need to change current practice.

In conclusion, MOH and the medical community must take proactive steps to ensure doctors practise according to mainstream international standards and the SMC ECEG.

REFERENCES

1. Teo EK. Ensuring safe sedation during gastroendoscopy. Ann Acad Med Singap 2022;51:1-2.
2. Ang TL, Seet E, Goh YC, et al. Academy of Medicine, Singapore clinical guideline on the use of sedation by non-anaesthesiologists during gastrointestinal endoscopy in the hospital setting. Ann Acad Med Singap 2022;51:24-39.
3. Vargo JJ, Cohen LB, Rex DK, et al. Position statement: nonanesthesiologist administration of propofol for GI endoscopy. Gastrointest Endosc 2009;70:1053-9.
4. ASGE Standards of Practice Committee, Early DS, Lightdale JR, et al. Guidelines for sedation and anesthesia in GI endoscopy. Gastrointest Endosc 2018;87:327-37.
5. Dumonceau JM, Riphaus A, Schreiber F, et al. Non-anesthesiologist administration of propofol for gastrointestinal endoscopy: European Society of Gastrointestinal Endoscopy, European Society of Gastroenterology and Endoscopy Nurses and Associates Guideline–Updated June 2015. Endoscopy 2015;47:1175-89.
6. Singapore Medical Council. Ethical Code and Ethical Guidelines. 2016 Edition. Available at: https://www.healthprofessionals.gov.sg/docs/librariesprovider2/guidelines/2016-smc-ethical-code-and-ethical-guidelines—(13sep16).pdf. Accessed on 1 February 2022.
7. Wong Meng Hang vs Singapore Medical Council and other matters [2018] SGHC 253, para 86-88.
8. Guidelines on Safe Sedation Practice for Non-Anaesthesiologists in Medical & Dental Clinics, Stand-Alone Ambulatory Surgical Centres, and Stand-Alone Endoscopy Suites in Singapore. Review Paper (First released May 2014, Updated July 2021). Available at: https://www.ams.edu.sg/view-pdf.aspx?file=media%5c6241_fi_759.pdf&ofile=09July21+Updated+Guidance+on+Safe+Sedation+Practice.pdf. Accessed on 1 February 2022.