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Creation of a score to predict risk of high conscious sedation requirements in patients undergoing endoscopy

Published:November 19, 2019DOI:https://doi.org/10.1016/j.gie.2019.11.015

      Background and Aims

      The administration of intravenous conscious sedation to patients undergoing GI endoscopy carries a risk of cardiopulmonary adverse events. Our study aim was to create a score that stratifies the risk of occurrence of either high-dose conscious sedation requirements or a failed procedure.

      Methods

      Patients receiving endoscopy via endoscopist-directed conscious sedation were included. The primary outcome was occurrence of sedation failure, which was defined as one of the following: (1) high-dose sedation, (2) the need for benzodiazepine/narcotic reversal agents, (3) nurse-documented poor patient tolerance to the procedure, or (4) aborted procedure. High-dose sedation was defined as >10 mg of midazolam and/or >200 μg of fentanyl or the meperidine equivalent. Patients with sedation failure (n = 488) were matched to controls (n = 976) without a sedation failure by endoscopist and endoscopy date.

      Results

      Significant associations with sedation failure were identified for age, sex, nonclonazepam benzodiazepine use, opioid use, and procedure type (EGD, colonoscopy, or both). Based on these 5 variables, we created the high conscious sedation requirements (HCSR) score, which predicted the risk of sedation failure with an area under the curve of 0.70. Compared with the patients with a risk score of 0, risk of a sedation failure was highest for patients with a score ≥3.5 (odds ratio, 17.31; P = 2 × 10−14). Estimated area under the curve of the HCSR score was 0.68 (95% confidence interval, 0.63-0.72) in a validation series of 250 cases and 250 controls.

      Conclusions

      The HCSR risk score, based on 5 key patient and procedure characteristics, can function as a useful tool for physicians when discussing sedation options with patients before endoscopy.

      Abbreviations:

      AUC (area under the curve), BMI (body mass index), CI (confidence interval), CS (conscious sedation), HCSR (high conscious sedation requirements), MAC (monitored anesthesia care), OR (odds ratio)
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      References

        • iData Research
        75 million endoscopies performed annually according to iData Research procedure analysis. May 28, 2018.
        (Available at:) (Accessed September 12, 2019)
        • Khiani V.S.
        • Soulos P.
        • Gancayco J.
        • et al.
        Anesthesiologist involvement in screening colonoscopy: temporal trends and cost implications in the Medicare population.
        Clin Gastroenterol Hepatol. 2012; 10: 58-64.e1
        • Early D.S.
        • Lightdale J.R.
        • Vargo J.J.
        • et al.
        Guidelines for sedation and anesthesia in GI endoscopy.
        Gastrointest Endosc. 2018; 87: 327-337
        • Predmore Z.
        • Nie X.
        • Main R.
        • et al.
        Anesthesia service use during outpatient gastroenterology procedures continued to increase from 2010 to 2013 and potentially discretionary spending remained high.
        Am J Gastroenterol. 2017; 112: 297-302
        • Qadeer M.A.
        • Lopez A.R.
        • Dumot J.A.
        • et al.
        Hypoxemia during moderate sedation for gastrointestinal endoscopy: causes and associations.
        Digestion. 2011; 84: 37-45
        • Tobias J.D.
        • Leder M.
        Procedural sedation: a review of sedative agents, monitoring, and management of complications.
        Saudi J Anaesth. 2011; 5: 395-410
        • Coté G.A.
        • Hovis C.E.
        • Hovis R.M.
        • et al.
        A screening instrument for sleep apnea predicts airway maneuvers in patients undergoing advanced endoscopic procedures.
        Clin Gastroenterol Hepatol. 2010; 8: 660-665.e1
        • Gross J.B.
        • Bailey P.L.
        • Connis R.T.
        • et al.
        Practice guidelines for sedation and analgesia by non-anesthesiologists.
        Anesthesiology. 2002; 96: 1004-1017
        • Amornyotin S.
        Sedation-related complications in gastrointestinal endoscopy.
        World J Gastrointest Endosc. 2013; 5: 527-533
        • Adams M.A.
        • Prenovost K.M.
        • Dominitz J.A.
        • et al.
        Predictors of use of monitored anesthesia care for outpatient gastrointestinal endoscopy in a capitated payment system.
        Gastroenterology. 2017; 153: 1496-1503.e1
        • Moons K.M.
        • Altman D.G.
        • Reitsma J.B.
        • et al.
        Transparent reporting of a multivariable prediction model for individual prognosis or diagnosis (tripod): explanation and elaboration.
        Ann Intern Med. 2015; 162: W1-W73
        • Agrawal D.
        • Rockey D.C.
        Propofol for screening colonoscopy in low-risk patients: are we paying too much?.
        JAMA Intern Med. 2013; 173: 1836-1838
        • Inadomi J.M.
        Editorial: Endoscopic sedation: Who, which, when?.
        Am J Gastroenterol. 2017; 112: 303-305
        • Rex D.K.
        • Vargo J.J.
        Anesthetist-directed sedation for colonoscopy: a safe haven or siren's song?.
        Gastroenterology. 2016; 150: 801-803
        • Sipe B.W.
        • Rex D.K.
        • Latinovich D.
        • et al.
        Propofol versus midazolam/meperidine for outpatient colonoscopy: administration by nurses supervised by endoscopists.
        Gastrointest Endosc. 2002; 55: 815-825
        • Cohen L.B.
        • DeLegge M.H.
        • Aisenberg J.
        • et al.
        AGA Institute review of endoscopic sedation.
        Gastroenterology. 2007; 133: 675-701
        • Byrne M.F.
        • Chiba N.
        • Singh H.
        • et al.
        Propofol use for sedation during endoscopy in adults: a Canadian Association of Gastroenterology position statement.
        Can J Gastroenterol. 2008; 22: 457-459
        • Cohen L.B.
        • Benson A.A.
        Issues in endoscopic sedation.
        Gastroenterol Hepatol. 2009; 5: 565-570
        • Singh H.
        • Poluha W.
        • Cheang M.
        • et al.
        Propofol for sedation during colonoscopy.
        Cochrane Database Syst Rev. 2008; : CD006268
        • Hassan C.
        • Rex D.K.
        • Cooper G.S.
        • et al.
        Endoscopist-directed propofol administration versus anesthesiologist assistance for colorectal cancer screening: a cost-effectiveness analysis.
        Endoscopy. 2012; 44: 456-464
        • Zakeri N.
        • Coda S.
        • Webster S.
        • et al.
        Risk factors for endoscopic sedation reversal events: a five-year retrospective study.
        Frontline Gastroenterol. 2015; 6: 270-277
        • Lebwohl B.
        • Hassid B.
        • Ludwin S.
        • et al.
        Increased sedation requirements during endoscopy in patients with celiac disease.
        Dig Dis Sci. 2012; 57: 994-999
        • Verbeeck R.K.
        Pharmacokinetics and dosage adjustment in patients with hepatic dysfunction.
        Eur J Clin Pharmacol. 2008; 64: 1147
        • Rex D.K.
        • Chen S.C.
        • Overhiser A.J.
        Colonoscopy technique in consecutive patients referred for prior incomplete colonoscopy.
        Clin Gastroenterol Hepatol. 2007; 5: 879-883
        • Vemulapalli K.C.
        • Rex D.K.
        Water immersion simplifies cecal intubation in patients with redundant colons and previous incomplete colonoscopies.
        Gastrointest Endosc. 2012; 76: 812-817
        • Cadoni S.
        • Falt P.
        • Gallittu P.
        • et al.
        Water exchange is the least painful colonoscope insertion technique and increases completion of unsedated colonoscopy.
        Clin Gastroenterol Hepatol. 2015; 13: 1972-1980.e3
        • Papachristou G.I.
        • Gleeson F.C.
        • Papachristou D.J.
        • et al.
        Endoscopist administered sedation during ERCP: impact of chronic narcotic/benzodiazepine use and predictive risk of reversal agent utilization.
        Am J Gastroenterol. 2007; 102: 738
        • Lee S.-Y.
        • Son H.J.
        • Lee J.M.
        • et al.
        Identification of factors that influence conscious sedation in gastrointestinal endoscopy.
        J Korean Med Sci. 2004; 19: 536-540
        • DeLegge M.H.
        The difficult-to-sedate patient in the endoscopy suite.
        Gastrointest Endosc Clin North Am. 2008; 18: 679-693
        • Peña L.R.
        • Mardini H.E.
        • Nickl N.J.
        Development of an instrument to assess and predict satisfaction and poor tolerance among patients undergoing endoscopic procedures.
        Dig Dis Sci. 2005; 50: 1860-1871
        • Wong R.C.
        The menu of endoscopic sedation: all-you-can-eat, combination set, á la carte, alternative cuisine, or go hungry.
        Gastrointest Endosc. 2001; 54: 122-126
        • Morgan J.
        • Roufeil L.
        • Kaushik S.
        • et al.
        Influence of coping style and precolonoscopy information on pain and anxiety of colonoscopy.
        Gastrointest Endosc. 1998; 48: 119-127
        • Yacavone R.F.
        • Locke G.R.
        • Gostout C.J.
        • et al.
        Factors influencing patient satisfaction with GI endoscopy.
        Gastrointest Endosc. 2001; 53: 703-710
        • Schutz S.M.
        • Lee J.G.
        • Schmitt C.M.
        • et al.
        Clues to patient dissatisfaction with conscious sedation for colonoscopy.
        Am J Gastroenterol. 1994; 89: 1476-1479
        • Braunstein E.D.
        • Rosenberg R.
        • Gress F.
        • et al.
        Development and validation of a clinical prediction score (the SCOPE score) to predict sedation outcomes in patients undergoing endoscopic procedures.
        Aliment Pharmacol Ther. 2014; 40: 72-82