Safety of Gastrointestinal Endoscopy With Conscious Sedation in Patients With and Without Obstructive Sleep Apnea

Safety of endoscopist-administered deep sedation with propofol in patients ASA III

INTRODUCTION

Deep sedation controlled by the endoscopist is safe in patients with low anesthetic risk (ASA I-II). However, scarce evidence is available in patients with intermediate risk (ASA III).

OBJETIVE

To evaluate the safety of deep sedation with propofol controlled by the usual endoscopy staff (endoscopist, nurse, assistant) in outpatients classified as ASA III and the risk factors for the occurrence of complications during deep sedation in these patients.

DESIGN

This observational and single-centre cross-sectional study includes consecutive patients undergoing non-complex procedures in which deep sedation is administered by the endoscopy staff. Patients were divided into group I (ASA=III) and group II (ASA<III).

RESULTS

A total of 562 patients were included, 80 (14.2%) group I. Complications related to deep sedation were more frequent in group I (23.8% vs 14.5%; p=0.036), mainly mild desaturations (13.8% vs 7.5%; p=0.058). Emergency intervention or exitus were not registered. The adjusted analysis identified age as the one independent baseline risk factor for developing global adverse events.

CONCLUSION

ASA III patients developed more sedation-related complications that ASA I-II patients. However these complications were mild and do not prevent to correctly perform the procedure.

Patient characteristics and procedural outcomes of moderate sedation for endoscopic procedures in patients with obesity: A retrospective, propensity score-matched study

Background  Endoscopic procedures are performed commonly with moderate sedation. Obesity can pose a challenge in its safe administration. This study was aimed at assessing outcomes of endoscopy procedures performed with moderate sedation in obese patients. Patients and methods  This was a retrospective study of patients undergoing esophagogastroduodenoscopy (EGD) and/or colonoscopy with moderate sedation from July 17, 2017 to December 31, 2019. Demographics, comorbidities, outpatient medications and procedure-related outcomes (procedure time, recovery time, cardiopulmonary adverse events, 7-day post-procedure hospitalization, cecal intubation time, withdrawal time, tolerance of moderate sedation and sedation medications administered) were compared for patient with and without obesity after propensity score matching. Standard statistical methods were used for analysis. Results  A total of 7601 procedures were performed with moderate sedation for 5746 patients. Propensity score matching identified 1360 and 1740 pairs of EGDs and colonoscopies with moderate sedation for patients with and without obesity. Recovery time was found to be shorter for obese patients undergoing EGD (OR: 0.989, 95 % CI: 0.981-.998; P  = 0.01). Obese patients did not differ from non-obese patients in any other procedure-related outcomes for EGDs or colonoscopies. Conclusions  Outcomes for endoscopy procedures performed with moderate sedation were noted to be similar between obese and non-obese patients. These findings suggest that moderate sedation can be used safely for endoscopic procedures in patients with obesity.

An algorithm for the sedation of patients with obstructive sleep apnea by non-anesthesiologists

OBJECTIVE

Patients with obstructive sleep apnea (OSA) are at risk for adverse events when moderate sedation is administered by nurse protocols (NAMS) under the guidance of non-anesthesiologists. An algorithm was applied for the appropriate section of patients to receive NAMS and the application of continuous positive airway pressure (CPAP).

METHODS

An algorithm was developed for patients with OSA who were scheduled for gastroenterology, radiology, and cardiology procedures using NAMS. Those with normal airways and without contraindications for NAMS were classified as CPAP-independent (CPAP-I; not routinely used) or CPAP-dependent (CPAP-D; always used). CPAP machines were brought in by CPAP-D patients or supplied by the hospital and set at a patient's routine setting or 10 cm H₂O if not known. CPAP-D patients for procedures for which CPAP could not be applied were done under anesthesia care. We retrospectively examined this program for the 2008-2018 period.

RESULTS

Since the inception of this protocol in 2008, 803 patients with OSA safely underwent procedures using either personal CPAP or CPAP provided by the hospital.

CONCLUSIONS

Patients with OSA can safely have NAMS for procedures when CPAP is applied based on a protocol that considers airway evaluation, the procedure, and whether there is dependence upon CPAP.

Predictors of Intraprocedural Respiratory Bronchoscopy Complications

PURPOSE

Sleep apnea can increase adverse outcomes during ambulatory surgery but not during gastrointestinal endoscopy. We hypothesize that STOP-BANG is associated with intraprocedural bronchoscopy respiratory complications.

METHODS

Consecutive patients undergoing bronchoscopy under moderate sedation were prospectively administered the STOP-BANG questionnaire. Participants were assessed for intraprocedural complications including hypoxemia (oxygen saturation≤85%), bradypnea (respiratory rate<8), premature procedure cessation as well as the use of nonrebreather mask, bag-mask ventilation, jaw lift/chin tilt, nasal/oral airway, and naloxone administration. Associations were assessed via logistic regression. Least absolute shrinkage and selection operator was used for multivariable model variable selection.

RESULTS

The 223 participants-mean age 61.1±15.5 years, body mass index 25.4kg/m (interquartile range: 22.4 to 30.7), 50.7% female, and 45.3% inpatient-had a high rate of respiratory complications (37.7%). There were no associations between STOP-BANG score and respiratory complications [odds ratio (OR)=1.07, 95% confidence interval (CI): 0.92-1.25]. Asthma was protective in univariable models (OR=0.26, 95% CI: 0.04-0.98), whereas endobronchial ultrasound (OR=2.34, 95% CI: 1.35-4.10) and the number of procedure types (OR=1.24, 95% CI: 1.01-1.51) was associated with increased complications. The following factors were associated with respiratory complications in both multivariable and univariate analyses: increasing age (OR=1.28/decade, 95% CI: 1.03-1.61), baseline oxygen use per each liters per minute (OR=1.57, 95% CI: 1.21-2.09), and bronchoscopy duration (OR=1.20/10 min, 95% CI: 1.08-1.33).

CONCLUSION

Bronchoscopy respiratory complications are common. STOP-BANG was not associated with increased immediate bronchoscopy complication risk. Increasing age, oxygen use, and bronchoscopy duration were associated with respiratory complications; increased vigilance in these circumstances may prevent complications.

Drug-Induced Sleep Endoscopy Performed in the Endoscopy Suite: A Resource Utilization Analysis

Objectives

To analyze the resource utilization of performing drug-induced sleep endoscopy (DISE) procedures in an endoscopy suite (ES) setting as compared with the operating room (OR).

Study Design

A retrospective review of DISE procedures performed by a single attending surgeon from 2016 to 2018.

Setting

Tertiary hospital.

Subjects and Methods

All patients undergoing sleep endoscopy without concurrent surgical procedures were included. No exclusion criteria were incorporated. Analysis assessed for differences in procedure-related expenditures, patient characteristics, anesthesia and surgeon time, and access to care.

Results

A total of 87 sleep endoscopies were included: 65 (74.7%) performed in the ES and 22 (25.3%) in the OR. Patient groups were similar in age and apnea-hypopnea index severity ( P > .05). Patient body mass index was significantly higher for the ES group ( P = .03). Total facility time, postoperative recovery time, anesthesia care time, and time in the surgical room were significantly decreased in the ES setting ( P < .01). Surgical time was similar between the groups ( P > .05). For ES procedures, total cost was reduced by 74% ( P < .01). DISE in the ES resulted in a mean $5080 less in health system charges versus the OR group ( P < .01). There were no treatment-related complications in either setting.

Conclusion

The resource utilization profile of performing DISE can be significantly improved by transferring these procedures from the OR to the ES setting.

Occurrence of Cortical Arousal at Recovery from Respiratory Disturbances during Deep Propofol Sedation

Recent evidences suggest that non-arousal mechanisms can restore and stabilize breathing in sleeping patients with obstructive sleep apnea. This possibility can be examined under deep sedation which increases the cortical arousal threshold. We examined incidences of cortical arousal at termination of apneas and hypopneas in elderly patients receiving propofol sedation which increases the cortical arousal threshold. Ten elderly patients undergoing advanced endoscopic procedures under propofol-sedation were recruited. Standard polysomnographic measurements were performed to assess nature of breathing, consciousness, and occurrence of arousal at recovery from apneas and hypopneas. A total of 245 periodic apneas and hypopneas were identified during propofol-induced sleep state. Cortical arousal only occurred in 55 apneas and hypopneas (22.5%), and apneas and hypopneas without arousal and desaturation were most commonly observed (65.7%) regardless of the types of disordered breathing. Chi-square test indicated that incidence of no cortical arousal was significantly associated with occurrence of no desaturation. Higher dose of propofol was associated with a higher apnea hypopnea index (r = 0.673, p = 0.033). In conclusion, even under deep propofol sedation, apneas and hypopneas can be terminated without cortical arousal. However, extensive suppression of the arousal threshold can lead to critical hypoxemia suggesting careful respiratory monitoring.

Snoring during Bronchoscopy with Moderate Sedation Is a Predictor of Obstructive Sleep Apnea

Background

Snoring is the cardinal symptom of obstructive sleep apnea (OSA). Snoring and upper airway obstruction associated with major oxygen desaturation may occur in populations undergoing flexible bronchoscopy.

Methods

To evaluate the prevalence of patients at a high risk of having OSA among patients undergoing bronchoscopy with sedation and to investigate whether snoring during the procedure predicts patients who are at risk of OSA, we prospectively enrolled 517 consecutive patients who underwent the procedure with moderate sedation. Patients exhibiting audible snoring for any duration during the procedure were considered snorers. The STOP-Bang (Snoring, Tiredness, Observed apnea, high blood Pressure-Body mass index, Age, Neck circumference and Gender) questionnaire was used to identify patients at high (score ≥3 out of 8) or low risk (score <3) of OSA.

Results

Of the 517 patients, 165 (31.9%) snored during bronchoscopy under sedation. The prevalence of a STOP-Bang score ≥3 was 61.9% (320/517), whereas 200 of the 352 nonsnorers (56.8%) and 120 of the 165 snorers (72.7%) had a STOP-Bang score ≥3 (p=0.001). In multivariable analysis, snoring during bronchoscopy was significantly associated with a STOP-Bang score ≥3 after adjustment for the presence of diabetes mellitus, chronic obstructive pulmonary disease, chronic kidney disease, and stroke (adjusted odds ratio, 1.91; 95% confidence interval, 1.26–2.89; p=0.002).

Conclusion

Two-thirds of patients undergoing bronchoscopy with moderate sedation were at risk of OSA based on the screening questionnaire. Snoring during bronchoscopy was highly predictive of patients at high risk of OSA.

Polysomnographic assessment of respiratory disturbance during deep propofol sedation for endoscopic submucosal dissection of gastric tumors

AIM

To investigate that polysomnographic monitoring can accurately evaluate respiratory disturbance incidence during sedation for gastrointestinal endoscopy compare to pulse oximetry alone.

METHODS

This prospective observational study included 10 elderly patients with early gastric cancer undergoing endoscopic submucosal dissection (ESD) under propofol sedation. Apart from routine cardiorespiratory monitoring, polysomnography measurements were acquired. The primary hypothesis was tested by comparing the apnea hypopnea index (AHI), defined as the number of apnea and hypopnea instances per hour during sedation, with and without hypoxemia; hypoxemia was defined as the reduction in oxygen saturation by ≥ 3% from baseline.

RESULTS

Polysomnography (PSG) detected 207 respiratory disturbances in the 10 patients. PSG yielded a significantly greater AHI (10.44 ± 5.68/h) compared with pulse oximetry (1.54 ± 1.81/h, P < 0.001), thus supporting our hypothesis. Obstructive AHI (9.26 ± 5.44/h) was significantly greater than central AHI (1.19 ± 0.90/h, P < 0.001). Compared with pulse oximetry, PSG detected the 25 instances of respiratory disturbances with hypoxemia 107.4 s earlier on average.

CONCLUSION

Compared with pulse oximetry, PSG can better detect respiratory irregularities and thus provide superior AHI values, leading to avoidance of fatal respiratory complications during ESD under propofol-induced sedation.

Practice Guidelines for Moderate Procedural Sedation and Analgesia 2018

Supplemental Digital Content is available in the text.

Safety of gastrointestinal endoscopy with conscious sedation in obstructive sleep apnea

AIM

To perform a systematic review and meta-analysis to assess the safety of conscious sedation in patients with obstructive sleep apnea (OSA).

METHODS

A comprehensive electronic search of MEDLINE and EMBASE was performed from inception until March 1, 2015. In an effort to include unpublished data, abstracts from prior gastroenterological society meetings as well as other reference sources were interrogated. After study selection, two authors utilizing a standardized data extraction form collected the data independently. Any disagreements between authors were resolved by consensus among four authors. The methodological quality was assessed using the Newcastle Ottawa tool for observational studies. The primary variables of interest included incidence of hypoxia, hypotension, tachycardia, and bradycardia. Continuous data were summarized as odds ratio (OR) and 95%CI and pooled using generic inverse variance under the random-effects model. Heterogeneity between pooled studies was assessed using the I² statistic.

RESULTS

Initial search of MEDLINE and EMBASE identified 357 citations. A search of meeting abstracts did not yield any relevant citations. After systematic review and exclusion consensus meetings, seven studies met the a priori determined inclusion criteria. The overall methodological quality of included studies ranged from moderate to low. No significant differences between OSA patients and controls were identified among any of the study variables: Incidence of hypoxia (7 studies, 3005 patients; OR = 1.11; 95%CI: 0.73-1.11; P = 0.47; I² = 0%), incidence of hypotension (4 studies, 2125 patients; OR = 1.10; 95%CI: 0.75-1.60; P = 0.63; I² = 0%), incidence of tachycardia (3 studies, 2030 patients; OR = 0.94; 95%CI: 0.53-1.65; P = 0.28; I² = 21%), and incidence of bradycardia (3 studies, 2030 patients; OR = 0.88; 95%CI: 0.63-1.22; P = 0.59; I² = 0%).

CONCLUSION

OSA is not a significant risk factor for cardiopulmonary complications in patients undergoing endoscopic procedures with conscious sedation.

Sedation in the Endoscopy Suite

OPINION STATEMENT

Sedation practices in the endoscopy suite have changed dramatically in the decades since the introduction of routine colonoscopy and esophagogastroduodenoscopy (EGD). Patients initially received moderate sedation (or even no sedation), but now frequently receive monitored anesthesia care (MAC). This significant shift has introduced anesthesiologists to the endoscopy suite along with new sedative medications and safety concerns. Appreciating the ramifications of this change requires an understanding of sedation depth, patient selection, drug use, sedation delivery, patient monitoring, recovery from sedation, and patient outcomes. Furthermore, the changing landscape of healthcare quality and reimbursement challenges us to provide the best possible care for our patients in the most economical way possible. The endoscopy suite is a unique sedation environment, and it is the purpose of this article to review those elements that contribute to a uniquely demanding work environment.