Driving After Endoscopic Procedural Sedation: Is a 24-hour Ban Too Long?

Ultra-short-acting sedative agents such as propofol are increasingly favored over traditional sedation for patients undergoing gastrointestinal (GI) endoscopic procedures, due in part to the quick recovery of normal physical and mental abilities.

But ambulatory anesthesia guidelines still advise patients to refrain from driving, unescorted public transit use and other consequential activities for 24 hours after the procedure — a non-evidence-based interval derived from older benzodiazepine sedation regimens.

The inconvenience and cost of a daylong interruption of the activities of daily living may deter some patients from complying with colonoscopy screenings and other beneficial exams.

An added complication: Post-anesthesia recovery measures such as the Aldrete score used by most endoscopy units only assess basic physiology and gross motor function, not higher-level cognition and neuromuscular coordination, making them unsatisfactory to judge psychomotor status. (One study found that GI endoscopy patients who met Aldrete discharge criteria after sedation with midazolam and meperidine actually had recovered only 60%-70% of their baseline psychomotor functions.)

A Cleveland Clinic research project aims to address these issues. The study uses a driving simulator to compare psychomotoric performance and discharge readiness among endoscopy patients who have received propofol or nonpropofol sedation.

“Our hypothesis is that patients receiving propofol-mediated sedation will be at baseline for driving skills when they reach an Aldrete score of nine or 10,” says principal investigator John Vargo, MD, MPH, the Digestive Disease & Surgery Institute’s Director of Enterprise Endoscopy Operations, head of the Section of Advanced Endoscopy and Director of Endoscopic Research and Innovation. “If we can identify a segment of those patients, we would do a larger prospective study to validate that, and then it becomes very interesting. Potentially, those are patients who could drive themselves home after their procedure rather than having to arrange for transportation.”

Guidelines and impacts

Dr. Vargo, an international authority in therapeutic endoscopy and past president of the American Society for Gastrointestinal Endoscopy, has conducted procedural sedation research for 25 years.

“We have noted, as have others, that when utilizing propofol as the sedative agent, patients recover much more rapidly than they do with traditional sedation,” he says. “That being said, most requirements have us keeping those patients away from driving, operating machinery and similar activities until the next day.”

Guidelines can be vague regarding discharge criteria after procedural sedation. The American Society of Anesthesiologists’ practice guidelines for moderate procedural sedation says only that patients should be:

• Alert and oriented.
• Advised to avoid making life-changing decisions and taking part in activities that may affect their safety until sedative effects have worn off.
• Discharged in the presence of a responsible adult.

A delayed return to normal activities has economic and other consequences for endoscopy patients. One study found that colonoscopy patients required a median time of 19.9 hours to feel completely back to normal after the procedure was complete.

Assuming that recovery period necessitates taking a day off from work, the value of lost salary per patient would be $183.68, using the 2019 national hourly average wage. With an estimated 19 million colonoscopies performed annually in the United States, the aggregate cost of lost wages due to extended recovery time from sedation is $3.5 billion. That amount does not include lost wages for an accompanying escort or related costs for transportation or childcare.

“I’ve had some patients who hired a driver to take them home,” Dr. Vargo says. “We’ve had patients arrive for their procedure without any support at all and we’ve had to admit them to an observation unit overnight. The expense and inconvenience related to extended sedation recovery potentially could be an impediment to colon cancer screening.”

Previous sedation recovery research

Psychomotor recovery after endoscopic sedation — in particular, the restoration of fine neuromuscular skills and judgment needed to safely operate a motor vehicle — has not been comprehensively evaluated. The results of several small studies indicate that propofol-mediated sedation may enable a quick return to driving.

A 2006 German study using a driving simulator to assess psychomotor status in 100 GI endoscopy patients randomized to either propofol or midazolam-plus-pethidine sedation found that the propofol cohort achieved baseline-comparable driving scores two hours after the procedure. The benzodiazepine/opioid group performed significantly poorer on the simulator at two hours. The results prompted the researchers to suggest a reduction of the recommended 24-hour driving ban after propofol sedation, conditioned on validation of their results with larger studies.

Similarly, a 2012 Japanese study of 48 colonoscopy patients sedated with propofol found that driving skills as measured on a simulator had recovered to baseline levels one hour after the procedure ended. The authors recommended larger studies with varying patient populations before generalizing their results, but reported that they no longer prohibit driving or require a driver for healthy patients undergoing routine endoscopy with propofol sedation.

Study goals

The Cleveland Clinic study has a target enrollment of 100 patients undergoing propofol or nonpropofol sedation for any of a variety of ambulatory endoscopic procedures including colonoscopy, endoscopic retrograde cholangiopancreatography, endoscopic ultrasound and balloon enteroscopy.

Patients take a pre-procedure driving simulator test to establish baseline values. The three-minute test exposes patients to a variety of situations encountered in urban driving such as navigating traffic, avoiding hazards and obeying speed limits. After endoscopy completion, patients repeat the driving test when their Aldrete score reaches discharge level of nine or 10.

“My hope is to identify a subset of patients who are able to drive home or leave unaccompanied after their procedure,” Dr. Vargo says. “That would improve the patient experience and, from a societal perspective, could represent a significant cost savings.

“For patients whose driving simulator results show they are not psychomotorically recovered, we hope to identify subunits of that activity that are the most sensitive indicators for reliably detecting that signal,” he says. “If we can find among the driving simulator tasks a portfolio of strong predictors of psychomotor status, we potentially could develop a smartphone or web-based app that patients can utilize to determine when they’re able to carry out activities of daily living.

“No matter what we find, it will add to the currently small knowledge base about postsedation psychomotor recovery,” Dr. Vargo says. “I hope our results will generate ideas for additional experiments that we and others can conduct.”