Emerging strategies in outpatient endoscopy sedation management: Recent trends and developments

Abstract

In this article we comment on the article by Walayat et al. Outpatient endoscopy has become vital in modern healthcare, providing efficient diagnostic and therapeutic interventions with minimal patient disruption. This study highlighted the key developments in sedation management, focusing on risk stratification and procedural settings to enhance safety. The findings demonstrate that a rigorous triage tool effectively reduces adverse events related to sedation and reversals. By identifying patients at higher risk, this tool helps mitigate complications during procedures. Importantly, appropriate risk stratification allows complex procedures to be performed under conscious sedation, significantly improving patient outcomes and optimizing resource allocation, particularly in constrained healthcare environments.

Key Words: Conscious sedation; Endoscopy; Risk stratification; Risk factors

Core Tip: Effective risk stratification tools play a crucial role in mitigating sedation-related complications during outpatient endoscopic procedures. By promptly identifying high-risk patients and directing them to suitable settings, such as ambulatory surgery centers or hospital outpatient departments, clinicians can enhance patient safety and procedural outcomes. This approach can have a significant impact on improving patient outcomes and resource allocation in limited healthcare settings. Future research should prioritize prospective trials to validate these findings and establish standardized protocols for risk assessment across diverse healthcare settings.

TO THE EDITOR

In this letter we comment on the article by Walayat et al[1] published in the recent issue of the World Journal of Gastroenterology. Endoscopy has become a fundamental component of diagnostic and therapeutic procedures in contemporary medicine. Routine stands as the predominant endoscopic procedure, primarily employed for the prevention of gastrointestinal tumors. The evolution and development trend in anesthesia methods for outpatient gastrointestinal endoscopy towards safer and more efficient methods. Initially, procedures were often conducted under minimal sedation or even without sedation, relying on patient cooperation and topical anesthetics. However, as endoscopic techniques advanced and procedural complexities increased, there was a growing demand for more effective sedation strategies. During endoscopy, sedation serves to enhance patient comfort, alleviate anxiety, and aid in completing the procedure effectively[2]. This led to the widespread adoption of conscious sedation, typically combining benzodiazepines and opioids, which allowed for adequate patient relaxation and pain control without necessitating deep sedation or general anesthesia. This personalized approach not only optimizes sedation effectiveness but also minimizes the risk of complications[3]. Moreover, the integration of newer agents and techniques, such as propofol administration by trained anesthesiology personnel under careful monitoring, has further refined anesthesia practices in outpatient settings[4]. Research indicates that during colonoscopy the use of propofol for sedation seems to result in a reduced likelihood of cardiopulmonary complications when contrasted with conventional sedatives[5]. The appropriate level of sedation may differ based on patient and procedural factors, and sedative doses should be adjusted accordingly to ensure a safe, comfortable, and technically successful endoscopic procedure[6].

While generally safe, endoscopy carries a low risk of adverse events, occurring in less than 1% of cases. However, this risk significantly increases in patients with severe underlying conditions[7]. Sedation carries several associated risks, such as hypoxemia, respiratory depression, hypotension, aspiration pneumonia, arrhythmia and vasovagal syncope[8-10]. The incidence of major sedation-related complications, defined as the need for intensive care support, resuscitation, or death, has been found to be 0.01%. In comparison, minor complications, such as increased restlessness, oxygen saturation below 90% for over 10 seconds, a drop in blood pressure exceeding 20%, a decrease in heart rate more than 20 beats per minute, or tachycardia greater than 100 beats per minute was 0.3%[10]. Concurrently, patients increasingly prefer anesthesia during these procedures[11]. The short consultation time with outpatient physicians may heighten the risk of postoperative sedation-related complications among high-risk patients. Hypoxemia is a common complication during sedation. Risk factors for this condition include a baseline oxygen saturation below 95%, urgent indications for the endoscopic procedure, prolonged procedure duration, challenges with esophageal intubation, and the presence of comorbidities. According to American Society of Anesthesiologists (ASA) and American Society for Gastrointestinal Endoscopy guidelines, supplemental oxygen should be provided if hypoxemia is expected or occur[12]. Therefore, employing systematic classification tools to assess patients can effectively reduce the risk of sedation-related complications. Screening patients prone to hypoxemia beforehand allows for timely implementation of preventive interventions.

All patients must undergo a pre-procedural evaluation before endoscopic procedures to assess sedation risk and manage potential issues related to their medical conditions. This assessment includes a thorough medical history and a focused physical examination at the time of the procedure. Important considerations from the medical history that may influence sedation include previous snoring, stridor, or sleep apnea; any drug allergies and current medications; past adverse reactions to sedation or anesthesia; the timing and type of last oral intake; and a history of tobacco, alcohol, or substance use[13].

Highlighting effective risk stratification

The study underscores the pivotal role of a triage tool in risk stratification, directing higher-risk patients to appropriate settings such as academic tertiary care center's Ambulatory Procedure Centers (APCs)[1]. By categorizing patients based on factors such as age, body mass index (BMI), and comorbidities, healthcare providers can tailor sedation protocols to individual needs, thereby minimizing adverse events. This approach not only safeguards patient safety but also enhances procedural efficiency by preemptively addressing potential complications.

The study analyzed 119860 endoscopic procedures conducted under conscious sedation between April 2013 and September 2019, excluding those that needed deep sedation. Most procedures (81.23%) took place at free-standing ambulatory endoscopy digestive health centers (AEC-DHCs), while the remaining 18.77% were performed at APCs. Sedation reversal events were infrequent, with 17 occurrences (0.017%) at AEC-DHCs and 9 (0.04%) at APCs, a difference that was not statistically significant (P = 0.06). Notably, a higher percentage of females required reversal at AEC-DHCs (64.7%) compared to APCs (22%), which was statistically significant (P = 0.04). Differences in mean age and BMI between the groups were not significant. AEC-DHC patients had a lower ASA class average (1.66 vs 2.22 in APCs, P = 0.20). Midazolam doses differed significantly between settings (5.9 mg at AEC-DHCs vs 8.9 mg at APCs, P = 0.01). Flumazenil and naloxone were used for reversal, with variations in usage proportions between the sites. The most common procedures requiring reversal at AEC-DHCs were esophagogastroduodenoscopy (EGD) and colonoscopy, whereas endoscopic ultrasound (EUS) predominated at APCs. Data from the United Kingdom National Endoscopy Database indicated that reversal agents were used in 0.02% of colonoscopies, 0.05% of gastroscopies, and 0.08% of endoscopic retrograde cholangiopancreatography (ERCP) procedures involving opiates or sedatives[14].

Hypoxia is the most common sedation-related adverse event, which can arise due to a combination of factors, including airway obstruction by the endoscope, anesthesia-induced upper airway collapse, and respiratory depression or lung compression due to intestinal gas insufflation. Indications for reversal mainly included hypoxia at both settings, with no recorded adverse outcomes. A recent retrospective study involving over 1 million patients who underwent endoscopy and colonoscopy validated the correlation between ASA classification and the likelihood of adverse events during gastrointestinal procedures. This classification could potentially aid in risk assessment for gastrointestinal endoscopy[15]. Other research revealed that higher ASA class correlates with a heightened incidence of unplanned cardiopulmonary events during endoscopy. A recent study involving patients undergoing ERCP revealed that those with a performance status of 4 had a significantly higher risk of adverse events, particularly cardiopulmonary issues, compared to those with a performance status of 0-3[16].

Endoscopic procedures can also lead to complications, such as aspiration and hypoxemia. Another small study of 250 inpatients found that older patients (over 65 years) undergoing sedated endoscopy had a higher risk of lower respiratory infections and pneumonia compared to patients who did not undergo sedated endoscopy[17]. In the future, we hope to further investigate the related risks associated with diagnostic or interventional endoscopic procedures by conducting a controlled study.

Comparative analysis across settings

Significantly, the study compared sedation reversal rates between the APCs and free-standing AEC-DHCs. While both settings exhibited low overall reversal rates, differences in patient demographics and procedural characteristics highlight nuanced considerations. Based on the sedation practices observed at AEC-DHCs and APCs, the indications for sedation reversal were primarily driven by specific clinical procedures. Procedures at AEC-DHCs requiring sedation reversal included colonoscopies, EGD and EGD/colonoscopies, whereas procedures at APCs included EGDs, EGD with gastrostomy tube placement, ERCPs and EUS. At AEC-DHCs, the need for sedation reversal was predominantly attributed to hypoxia in 76% of cases, followed by excessive somnolence in 18%, and hypotension in 6% (n = 1). In contrast, at APCs, hypoxia accounted for 78% of sedation reversals, with hypotension contributing to 22%. The absence of sedation-related deaths or long-term adverse outcomes following sedation reversal at both facilities is noteworthy, highlighting the robustness and safety of their sedation protocols. This outcome underscores the meticulous application of their triage tool and the effective management of procedural sedation risks in gastrointestinal endoscopy settings. For instance, higher midazolam doses at APCs suggest a tailored approach in managing patient sedation needs based on procedural complexity and patient acuity.

Given that the configurations of APCs and AEC-DHCs equipment can vary by region, it is essential to further investigate the risks associated with different endoscopic procedures, as well as the anesthetic assessments and support they require. The British Society of Gastroenterology Endoscopy Committee recommend that deep sedation may be required for specific upper gastrointestinal procedures, including polypectomy/resection of neoplasia, endoscopic bariatric surgery, foreign body retrieval, complex ERCP, therapeutic EUS and combined EUS + ERCP procedures. Conversely, minimal to moderate sedation is generally sufficient for diagnostic EUS and level 1/level 2 ERCP procedures[14]. A rational stratification system can not only identify potential complication risks in patients but also guide anesthetists in adjusting medication dosages and implementing preventive measures, thereby efficiently completing endoscopic procedures while minimizing the anesthesia risk for patients. Therefore, patients should be flexibly allocated to different locations with varying conditions based on the anesthetic support available, procedural factors and local resources.

Technological advancements and safety measures

Advancements in sedation management technologies play a pivotal role in shaping current trends. From improved monitoring systems to refined pharmacological agents, these innovations bolster patient safety while optimizing procedural outcomes. Integration of real-time monitoring tools and adherence to standardized sedation protocols exemplify ongoing efforts to mitigate risks and ensure consistent quality of care across diverse settings. The well-designed risk stratification tool further safeguards patient medical safety and effectively reduces the incidence of sedation-related complications.

Future directions

Looking ahead, the evolution of outpatient endoscopy sedation management hinges on several promising avenues. Enhanced predictive models utilizing artificial intelligence (AI) may further refine risk assessment, offering personalized sedation strategies tailored to patient-specific factors. In one study, an AI-assisted system was developed that can identify remaining areas to be examined in real-time during endoscopic surgery, helping anesthesiologists to use anesthetics appropriately and maintain the patient at an optimal level of sedation[18]. The computer-aided diagnosis system significantly reduces patients' recovery time and effectively minimizes the anesthesia risks associated with excessive sedation. AI has already been applied in various aspects of anesthesiology such as depth of anesthesia monitoring, control of anesthesia delivery, and pain management. Various techniques, including machine learning, neural networks, and fuzzy logic, have been employed for anesthetic risk prediction in perioperative care[19]. With the rapid development of AI technology, it is expected to provide more favorable support for the advancement of medical technology in the future.

In addition to the risks of complications during the anesthesia process, it is also important to pay attention to long-term complications that may arise after anesthesia. A recent study found that sedation and older age are independent risk factors for cardiac and cerebrovascular events, with approximately 2.23% of patients experiencing these adverse events within 14 days after diagnostic gastrointestinal endoscopy[20]. Further collaborative research on the profound effects of sedation protocols in patients will provide valuable insights for optimizing surgical outcomes and enhancing patient satisfaction.

CONCLUSION

As editorial board members, it is imperative to recognize the transformative impact of research on outpatient endoscopy sedation management. This study underscores the critical role of risk stratification tools in mitigating sedation-related risks and optimizing patient outcomes across diverse clinical settings[1]. By fostering interdisciplinary dialogue and embracing technological innovations, we can collectively advance standards of care in outpatient endoscopy, ensuring safe and effective sedation practices for the benefit of patients worldwide.

The risk stratification tool efficiently categorizes patients, ensuring medical safety while maximizing the identification of patients suitable for safe outpatient procedures. This approach substantially enhances the utilization of healthcare resources in medically underdeveloped areas, preserves healthcare expenditures, and improves operational efficiency. However, research plays an important role in continually refining endoscopy sedation management. Further optimization of the design of randomized trials is essential for validating our observations and establishing criteria for high-risk patients.

In essence, the governance of sedation should be a collaborative approach involving sedation practitioners, anesthetists, medical staff, operators, nurses and administrators working together. Therefore, the pursuit of excellence in outpatient endoscopy sedation management remains an ever-evolving journey—one that demands ongoing collaboration, innovation, and a steadfast commitment to patient-centered care.