Retrospective Study
Copyright ©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Endosc. Apr 16, 2021; 13(4): 97-110
Published online Apr 16, 2021. doi: 10.4253/wjge.v13.i4.97
Identifying who best tolerates moderate sedation: Results from a national database of gastrointestinal endoscopic outcomes
Monica Passi, Farial Rahman, Sandeep Gurram, Sheila Kumar, Christopher Koh
Monica Passi, Sheila Kumar, Digestive Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD 20892, United States
Farial Rahman, Christopher Koh, Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD 20892, United States
Sandeep Gurram, Urologic Oncology Branch, National Cancer Institute, National Institutes of Health, Bethesda, MD 20892, United States
Author contributions: Koh C is the guarantor of this article; Passi M, Rahman F and Koh C designed the study and were involved in devising the study concept; Passi M, Kumar S and Gurram S were involved in the acquisition of the study data; Passi M and Rahman F were involved in the statistical analysis and interpretation of study results; Passi M, Rahman F, Koh C, and Gurram S were involved in the drafting and revision of the manuscript; all authors have read and approve the final manuscript.
Institutional review board statement: This study is a retrospective analysis of a publicly available, de-identified data repository (Clinical Outcomes Research Initiative National Endoscopic Database) and therefore is IRB-exempt.
Informed consent statement: This study is a retrospective analysis of a publicly available, de-identified data repository. Informed consent is not indicated.
Conflict-of-interest statement: All the authors have no conflict of interest related to the manuscript.
Data sharing statement: No additional data are available.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Monica Passi, MD, Academic Fellow, Digestive Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, 10 Center Drive Clinical Research Center, 5-2740, Bethesda, MD 20892, United States. mpassi305@gmail.com
Received: January 6, 2021
Peer-review started: January 6, 2021
First decision: February 11, 2021
Revised: February 19, 2021
Accepted: March 11, 2021
Article in press: March 11, 2021
Published online: April 16, 2021
Processing time: 95 Days and 23.3 Hours
Abstract
BACKGROUND

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.

AIM

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

METHODS

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.

RESULTS

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).

CONCLUSION

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

Keywords: Gastrointestinal endoscopy; Anesthesia; Moderate (conscious) sedation; Sedation tolerance

Core Tip: Limited society guidelines currently exist to aid endoscopists in the selection of the most appropriate sedation method. Rather, it is at the discretion of the endoscopist on a case-by-case basis, with many decisions made based on gut feeling and previous personal experience. With the growing focus on patient satisfaction as a metric for reimbursement and an increased focus on healthcare cost containment initiatives, identifying which patients can safely and effectively undergo endoscopy without anesthesia-administered sedation is becoming exceedingly important. Existing studies on this topic to date have been small scale, single-center data with inconsistent findings. Robust data to drive practice patterns have been lacking. As such, we have capitalized upon nationwide data found in the Clinical Outcomes Research Initiative National Endoscopic Database to clarify these discrepancies and to identify patient and procedure characteristics that may predict better patient tolerance to endoscopy with moderate sedation.