Safety of gastrointestinal endoscopy with conscious sedation in obstructive sleep apnea

Korean clinical practice guidelines for diagnostic and procedural sedation

Safe and effective sedation depends on various factors, such as the choice of sedatives, sedation techniques used, experience of the sedation provider, degree of sedation-related education and training, equipment and healthcare worker availability, the patient's underlying diseases, and the procedure being performed. The purpose of these evidence-based multidisciplinary clinical practice guidelines is to ensure the safety and efficacy of sedation, thereby contributing to patient safety and ultimately improving public health. These clinical practice guidelines comprise 15 key questions covering various topics related to the following: the sedation providers; medications and equipment available; appropriate patient selection; anesthesiologist referrals for high-risk patients; pre-sedation fasting; comparison of representative drugs used in adult and pediatric patients; respiratory system, cardiovascular system, and sedation depth monitoring during sedation; management of respiratory complications during pediatric sedation; and discharge criteria. The recommendations in these clinical practice guidelines were systematically developed to assist providers and patients in sedation-related decision making for diagnostic and therapeutic examinations or procedures. Depending on the characteristics of primary, secondary, and tertiary care institutions as well as the clinical needs and limitations, sedation providers at each medical institution may choose to apply the recommendations as they are, modify them appropriately, or reject them completely.

British Society of Gastroenterology guidelines on sedation in gastrointestinal endoscopy

Over 2.5 million gastrointestinal endoscopic procedures are carried out in the United Kingdom (UK) every year. Procedures are carried out with local anaesthetic r with sedation. Sedation is commonly used for gastrointestinal endoscopy, but the type and amount of sedation administered is influenced by the complexity and nature of the procedure and patient factors. The elective and emergency nature of endoscopy procedures and local resources also have a significant impact on the delivery of sedation. In the UK, the vast majority of sedated procedures are carried out using benzodiazepines, with or without opiates, whereas deeper sedation using propofol or general anaesthetic requires the involvement of an anaesthetic team. Patients undergoing gastrointestinal endoscopy need to have good understanding of the options for sedation, including the option for no sedation and alternatives, balancing the intended aims of the procedure and reducing the risk of complications. These guidelines were commissioned by the British Society of Gastroenterology (BSG) Endoscopy Committee with input from major stakeholders, to provide a detailed update, incorporating recent advances in sedation for gastrointestinal endoscopy.This guideline covers aspects from pre-assessment of the elective 'well' patient to patients with significant comorbidity requiring emergency procedures. Types of sedation are discussed, procedure and room requirements and the recovery period, providing guidance to enhance safety and minimise complications. These guidelines are intended to inform practising clinicians and all staff involved in the delivery of gastrointestinal endoscopy with an expectation that this guideline will be revised in 5-years' time.

Predictor of respiratory disturbances during gastric endoscopic submucosal dissection under deep sedation

BACKGROUND

Sedation is commonly performed for the endoscopic submucosal dissection (ESD) of early gastric cancer. Severe hypoxemia occasionally occurs due to the respiratory depression during sedation.

AIM

To establish predictive models for respiratory depression during sedation for ESD.

METHODS

Thirty-five adult patients undergoing sedation using propofol and pentazocine for gastric ESDs participated in this prospective observational study. Preoperatively, a portable sleep monitor and STOP questionnaires, which are the established screening tools for sleep apnea syndrome, were utilized. Respiration during sedation was assessed by a standard polysomnography technique including the pulse oximeter, nasal pressure sensor, nasal thermistor sensor, and chest and abdominal respiratory motion sensors. The apnea-hypopnea index (AHI) was obtained using a preoperative portable sleep monitor and polysomnography during ESD. A predictive model for the AHI during sedation was developed using either the preoperative AHI or STOP questionnaire score.

RESULTS

All ESDs were completed successfully and without complications. Seventeen patients (49%) had a preoperative AHI greater than 5/h. The intraoperative AHI was significantly greater than the preoperative AHI (12.8 ± 7.6 events/h vs 9.35 ± 11.0 events/h, P = 0.049). Among the potential predictive variables, age, body mass index, STOP questionnaire score, and preoperative AHI were significantly correlated with AHI during sedation. Multiple linear regression analysis determined either STOP questionnaire score or preoperative AHI as independent predictors for intraoperative AHI ≥ 30/h (area under the curve [AUC]: 0.707 and 0.833, respectively) and AHI between 15 and 30/h (AUC: 0.761 and 0.778, respectively).

CONCLUSION

The cost-effective STOP questionnaire shows performance for predicting abnormal breathing during sedation for ESD that was equivalent to that of preoperative portable sleep monitoring.

Absence of Complications after Endoscopic Mucosal Biopsy

BACKGROUND

There is no clarity with regard to the occurrence of serious complications from EGD-driven mucosal biopsy. This is important for considering both clinically indicated procedures and mucosal sampling for research.

METHODS

We sought to quantify rates of serious complications from esophagogastroduodenoscopy (EGD) with biopsy. We studied 13,233 patients undergoing outpatient EGD with biopsy over 5 years in 2 North Dakota community hospitals, based on the reasoning that serious complications would cause hospitalization within 30 days. We reviewed the records of all patients with a diagnostic or procedure code or admission within 30 days after the outpatient EGD with biopsy.

RESULTS

Of the 13,233 patients who underwent outpatient EGD with biopsy, 411 were admitted within 30 days, most of them because of their underlying diagnosis. Two patients were admitted due to complications that resulted because of additional simultaneous procedures. No patient was admitted because of complications that could be ascribed to conscious sedation, upper GI endoscopic access, or mucosal biopsy.

CONCLUSIONS

These data confirm that EGD biopsy is safe within community settings and suggest that the risk/benefit ratio for performing EGD biopsy for research is likely to be favorable if the research has scientific merit. Serious complications or perforation following EGD biopsy did not occur in 13,233 patients in community hospitals in North Dakota.