• Adult
• Humans
• Colonoscopy/methods
• Conscious Sedation/methods
• Fentanyl/pharmacology
• Ketamine/pharmacology
• Midazolam/pharmacology
• Outpatients

Determination of sedation type during gastrointestinal procedures is generally based on risk assessment via the American Society of Anesthesiologists (ASA) classification system, but the reliance of anesthesia risk on clinical factors remains largely uninvestigated. We aim to determine the association between various clinical factors and choice of sedation type during gastrointestinal procedures.

This single-center, retrospective cohort study used electronic medical records to identify patients receiving colonoscopy or endoscopy at Rhode Island Hospital. The electronic medical record was queried for history of alcohol abuse, opioid abuse, polysubstance abuse, prescriptions for psychotropic or opioid medications and ASA classification. Logistic regression was used to measure how patient characteristics correlated with sedation type.

Totally, 2,033 patients were included in the study; 1,080 patients received moderate sedation and 853 received monitored anesthesia care (MAC). Three hundred fifty-four (60.2%) MAC patients had a history of alcohol abuse compared to 234 (39.8%) moderate sedation patients (P < 0.2334); 178 (62.9%) MAC and 105 (37.1%) moderate sedation patients had a history of opioid abuse (P < 0.001); 203 (73.6%) MAC and 73 (26.4%) moderate sedation patients had a history of polysubstance abuse (P < 0.001); and 815 (75.1%) MAC patients had psychiatric comorbidities versus 270 (24.9%) in the moderate sedation group (P < 0.001). In the MAC cohort, alcohol, opioid, polysubstance abuse and psychiatric history were associated with previous failure of moderate sedation (P < 0.0001).

For a subset of patients, clinical factors including alcohol, opioid, polysubstance abuse and psychiatric history, in addition to ASA classification, play an important role in sedation management.

• ASA classification
• Clinical factors
• Gastrointestinal procedures
• Sedation management
• Sedation type

• Alcohol use disorder
• Analgesia
• Conscious sedation
• Opioid use disorder
• Orthopedic manipulation
• Sedation

With increasing volume and cost of gastrointestinal endoscopic procedures, the proper selection of patients for moderate sedation becomes increasingly relevant. The current literature lacks consistent findings that allow for appropriate selection of patients for moderate sedation.

To analyze a nationwide registry of patients to identify patient and procedural factors associated with lower sedation requirements for endoscopy.

The Clinical Outcomes Research Initiative National Endoscopic Database was queried to assess adult patients undergoing moderate sedation for esophagogastroduodenoscopy (EGD) and colonoscopy from 2008 to 2014. Patients were stratified into two groups [low dose (LD) and high dose sedation] based on sedation requirements. Anthropometric, procedural, and anesthesia data were compared, and multivariable analysis was performed to identify factors associated with LD sedation.

Of the 371102 patients included in the study, 63137 where stratified into the LD sedation group and 307965 were in the high dose group. Moderate sedation was managed primarily by endoscopists (50%) and anesthesia providers (47%). Patients undergoing EGDs and procedures performed in the inpatient setting, in ambulatory surgery centers, intensive care units or hospital wards, required less sedation than colonoscopies, outpatient procedures and procedures done in endoscopy suites, respectively (P < 0.0001 for all). On multivariable analysis, factors predictive of tolerance with lower sedation requirements for EGDs and colonoscopies were female gender, age ≥ 50, non-White race, Hispanic descent, body mass index ≤ 25 kg/m², and higher American Society of Anesthesia Class (P < 0.0001 for all).

Clinicians should consider these patient profiles in determining which patients will better tolerate moderate sedation vs those better suited for alternative sedation methods.

• Gastrointestinal endoscopy
• Anesthesia
• Moderate (conscious) sedation
• Sedation tolerance

• Efficacy
• Outcome
• Risk Factor
• Safety

• Anesthesia
• Conscious Sedation
• Endoscopy, Gastrointestinal
• Fentanyl
• Humans
• Hypnotics and Sedatives/adverse effects
• Propofol/adverse effects
• Retrospective Studies

• Adult
• Aged
• Analgesics, Opioid/administration & dosage
• Analgesics, Opioid/adverse effects
• Conscious Sedation/adverse effects
• Conscious Sedation/methods
• Dose-Response Relationship, Drug
• Endoscopy, Digestive System
• Fentanyl/administration & dosage
• Fentanyl/adverse effects
• Humans
• Hypnotics and Sedatives/administration & dosage
• Hypnotics and Sedatives/adverse effects
• Meperidine/administration & dosage
• Meperidine/adverse effects
• Midazolam/administration & dosage
• Midazolam/adverse effects
• Middle Aged
• Risk Assessment
• Risk Factors
• Treatment Outcome

Guidelines to triage patients to conscious sedation (CS) or monitored anaesthesia care (MAC) for colonoscopy do not exist. We aimed to identify the CS failure rate, predictors of failure, and its impact on the adenoma detection rate (ADR). Strict (based on patient experience) and expanded (based on doses of sedative medications) definitions of CS failure were used. Patient and procedure-related variables were extracted. Multivariable logistic regression identified predictors for CS failure and the ADR. Among 766 patients, 29 (3.8%) and 175 (22.8%) patients failed CS by strict and expanded definitions, respectively. Female gender (OR 3.50; 95% CI: 1.37–8.94) and fellow involvement (OR 4.15; 95% CI: 1.79–9.58) were associated with failed CS by the strict definition. Younger age (OR 1.27, 95% CI: 1.07–1.49), outpatient opiate use (OR 1.71; 95% CI 1.03–2.84), use of an adjunct medication (OR 3.34; 95% CI: 1.94–5.73), and fellow involvement (OR 2.20; 95% CI: 1.31–3.71) were associated with failed CS by the expanded definition. Patients meeting strict failure criteria had a lower ADR (OR 0.30; 95% CI: 0.12–0.77). Several clinical factors may be useful for triaging to MAC. The ADR is lower in patients meeting strict criteria for failed CS.

• early gastric cancer
• endoscopic resection
• multicenter prospective study
• real-world evidence
• short-term outcome

• Adenocarcinoma/pathology
• Adenocarcinoma/surgery
• Adult
• Aged
• Aged, 80 and over
• Cohort Studies
• Endoscopic Mucosal Resection
• Female
• Humans
• Japan
• Male
• Middle Aged
• Stomach Neoplasms/pathology
• Stomach Neoplasms/surgery
• Time Factors
• Treatment Outcome

• H24-16 Daiwa Securities Health Foundation
• 25-A-12 National Cancer Center Research and Development from the Japanese Ministry of Health, Labour and Welfare
• 28-K-1 National Cancer Center Research and Development from the Japanese Ministry of Health, Labour and Welfare
• 29-A-13 National Cancer Center Research and Development from the Japanese Ministry of Health, Labour and Welfare
• H21-022 Clinical Cancer Research from the Japanese Ministry of Health, Labour and Welfare

The safety and efficacy of deep sedation (DS) in MitraClip^® procedures have been shown previously. However, clinical experience demonstrates that in some patients DS is difficult to achieve. We hypothesize that some patient characteristics can predict difficult DS.

We prospectively analysed 69 patients undergoing MitraClip^® procedures using DS. Application of DS was graded as simple (group 1) or difficult (group 2) depending on a cumulative score based on one point for each of the following criteria: decrease in oxygen saturation, retention of carbon dioxide, disruptive body movements, and the need for catecholamines. Patients with one point or less were classified as group 1, and patients with two or more points were classified as group 2.

In 58 of 69 patients (84.1%), the performance of DS was simple, while in 11 patients (15.9%), DS was difficult to achieve. Patients with difficult DS were characterized by a higher body mass index (33.7 ± 6.0 kg/m² vs. 26.1 ± 4.1; p = 0.001), younger age (67 ± 13 years vs. 75 ± 13 years; p = 0.044), and reduced left ventricular ejection fraction (36% ± 10 vs. 45% ± 14; p = 0.051) and presented more often with an obstructive sleep apnoea syndrome (6.9% vs. 45.5%; p = 0.003). In the multivariate analysis, body mass index was an independent predictor of difficult DS. Using a body mass index of 31 kg/m² as a cut-off value, the sensitivity of predicting difficult DS was 73%, and the specificity was 88%. Using a body mass index of 35 kg/m² as a cut-off value, the specificity increased to 97%, with a sensitivity of 36%.

In patients with a higher body mass index who undergo MitraClip^® procedures, DS might be difficult to perform.

• Aged
• Aged, 80 and over
• Body Mass Index
• Cardiac Surgical Procedures/methods
• Female
• Humans
• Hypnotics and Sedatives/administration & dosage
• Male
• Middle Aged
• Mitral Valve/surgery
• Risk Factors

• Forschungskommission of the Heinrich-Heine-University Duesseldorf, Medical Faculty

To develop a prediction model aimed at identifying patients that may require higher than usual sedation doses during colonoscopy.

A retrospective chart review on 5000 patients who underwent an outpatient colonoscopy at St. Paul’s Hospital from 2009 to 2010 was conducted in order to develop a model for identifying patients who will require increased doses of sedatives. Potential predictor variables including age, gender, endoscopy indication, high sedation requirements during previous endoscopies, difficulty of the procedure, bowel preparation quality, interventions, findings as well as current use of benzodiazepines, opioids and alcohol were analyzed. The outcome of study was the use of high dose of sedation agents for the procedure. In particular, the high dose of sedation was defined as fentanyl greater than 50 mcg and midazolam greater than 3 mg.

Analysis of 5282 patients (mean age 57 ± 12, 49% female) was performed. Most common indication for the procedure was screening colonoscopy (57%). Almost half of our patients received doses exceeding Fentanyl 50 mcg and Midazolam 3 mg. Logistic regression models identified the following variables associated with high sedation: Younger age (OR = 0.95 95%CI: 0.94-0.95; P < 0.0001); abdominal pain (OR = 1.45, 95%CI: 1.08-1.96); P = 0.01) and Inflammatory Bowel Disease (OR = 1.45, 95%CI: 1.04-2.03; P = 0.02) as indications for the procedure; difficult procedure as defined by gastroenterologist (OR = 1.73, 95%CI: 1.48-2.03; P < 0.0001); past history of abdominal surgery (OR = 1.33, 95%CI: 1.17-1.52; P <0.0001) and previous colonoscopy (OR = 1.39, 95%CI: 1.21-1.60; P = 0.0001) and alcohol use (OR = 1.26, 95%CI: 1.03-1.54; P = 0.02). Age and gender adjusted analysis yielded inflammatory bowel disease as an indication (OR = 3.17, 95%CI: 1.58-6.37; P = 0.002); difficult procedure as defined by an endoscopist (OR = 5.13 95%CI: 2.97-8.85; P = 0.0001) and current use of opioids, benzodiazepines or antidepressants (OR = 2.88, 95%CI: 1.74-4.77; P = 0.001) having the highest predictive value of high sedation requirements. Our prediction model using the following pre-procedural variables including age, gender, indication for the procedure, medication/substance use, previous surgeries, previous high sedation requirements for colonoscopy yielded an area under the curve of 0.76 for Fentanyl ≥ 100 mcg and Midazolam ≥ 3 mg.

Pre-procedural planning is the key in conducting successful, efficient colonoscopy. Logistic regression analysis of 5000 patients who underwent out-patient colonoscopy revealed the following factors associated with increased sedation requirement: Younger age, female gender, difficult endoscopy, specific indications as well as cardiopulmonary complications and current use of opioids/benzodiazepines. Age and gender adjusted analysis yielded similar results. These patients are more likely to need a longer recovery periods post-endoscopy, which could result in additional time and personnel requirements. The final predictive model has good predictive ability for Fentanyl ≥ 100 mcg and Midazolam ≥ 3 mg and fair predictive ability for Fentanyl ≥ 50 mcg and Midazolam ≥ 2 mg. The external validity of this model is planned to be tested in another center.

• Colonoscopy
• Sedation
• Sedation tolerance
• Fentanyl
• Midazolam
• Predictive model

To investigate the effects of direct to colonoscopy pathways on information seeking behaviors and anxiety among colonoscopy-naïve patients.

Colonoscopy-naïve patients at two tertiary care hospitals completed a survey immediately prior to their scheduled outpatient procedure and before receiving sedation. Survey items included clinical pathway (direct or consult), procedure indication (cancer screening or symptom investigation), telephone and written contact from the physician endoscopist office, information sources, and pre-procedure anxiety. Participants reported pre-procedure anxiety using a 10 point scale anchored by “very relaxed” (1) and “very nervous” (10). At least three months following the procedure, patient medical records were reviewed to determine sedative dose, procedure indications and any adverse events. The primary comparison was between the direct and consult pathways. Given the very different implications, a secondary analysis considering the patient-reported indication for the procedure (symptoms or screening). Effects of pathway (direct vs consult) were compared both within and between the screening and symptom subgroups.

Of 409 patients who completed the survey, 34% followed a direct pathway. Indications for colonoscopy were similar in each group. The majority of the participants were women (58%), married (61%), and internet users (81%). The most important information source was family physicians (Direct) and specialist physicians (Consult). Use of other information sources, including the internet (20% vs 18%) and Direct family and friends (64% vs 53%), was similar in the Direct and Consult groups, respectively. Only 31% of the 81% who were internet users accessed internet health information. Most sought fundamental information such as what a colonoscopy is or why it is done. Pre-procedure anxiety did not differ between care pathways. Those undergoing colonoscopy for symptoms reported greater anxiety [mean 5.3, 95%CI: 5.0-5.7 (10 point Likert scale)] than those for screening colonoscopy (4.3, 95%CI: 3.9-4.7).

Procedure indication (cancer screening or symptom investigation) was more closely associated with information seeking behaviors and pre-procedure anxiety than care pathway.

• Direct access colonoscopy
• Colonoscopy/utilization
• Information seeking behavior
• Referral and consultation
• Health care delivery
• Anxiety

• Adult
• Aged
• Aged, 80 and over
• Case-Control Studies
• Cholangiopancreatography, Endoscopic Retrograde/adverse effects
• Cholangiopancreatography, Endoscopic Retrograde/methods
• Deep Sedation/adverse effects
• Female
• Humans
• Hypnotics and Sedatives
• Male
• Midazolam
• Middle Aged
• Patient Safety
• Physicians
• Propofol
• Retrospective Studies
• Risk Factors

• Anesthesia
• Endoscopy
• Monitored anesthesia care (MAC)
• Sedation

• Celiac disease
• Inflammatory bowel disease
• MEDLINE
• Research
• Trends