Sedation during endoscopy for patients at risk of obstructive sleep apnea

Khiani, Vijay; Salah, Wajeeh; Maimone, Santo; Cummings, Linda C.; Chak, Amitabh

doi:10.1016/j.gie.2009.05.036

Cited by 54 publications

(39 citation statements)

References 14 publications

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“…However, for moderate sedation in left lateral position, unrecognized sleep apnea [59] did not appear to predict transient hypoxia or AEs in one routine endoscopy study [37]; another study found that BMI in ASA I-II patients predicted the number of hypoxemic episodes [43]. Increased BMI and obstructive sleep apnea can predict perioperative morbidity after surgery [60] and may increase risk and make airway maintenance more difficult in deep sedation [42], especially for the semiprone positioning that is standard for ERCP.…”

Section: Case Context and Comorbidity Quantificationmentioning

confidence: 99%

“…APACHE II (Acute Physiology And Chronic Health Evaluation) scores, cardiopulmonary disease, and, recent myocardial infarction (MI) specifically, may also predict AEs [26,30,[36][37][38][39]; APACHE II is a complex instrument, with dimensions that include a physiology score (12 inputs), an age score and organ failure points, with a number of elements (e.g. PaO 2 and arterial pH) that are not available for most endoscopies.…”

Section: Case Context and Comorbidity Quantificationmentioning

confidence: 99%

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Risk assessment and reduction

Romagnuolo

2014

Ercp

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One of the most important concerns about ERCP is its high risk in comparison to other endoscopic procedures. With post-ERCP pancreatitis rates, in good hands, ranging from 2 to 5% for low-risk procedures and 10 to 20% for high-risk procedures (even after risk-reducing maneuvers), and a mortality of about 1 in 1000 (mainly due to severe pancreatitis), this seems to be an appropriate concern; bleeding (about 1%), perforation (<0.5%), infection (1-2%), and cardiorespiratory AEs can also occur [1]. The risk involved in an individual ERCP case can vary widely. Thus, a biliary stent change in a healthy middle-aged man can be orders of magnitude different than manometry, dual sphincterotomy with pancreatic stenting in a young women with prior post-ERCP pancreatitis; not all ERCPs are the same and not all ERCPists have had the same case spectrum in their training and practice. This AE profile makes it important to ensure training is appropriate for both the endoscopist and the team/unit, to ensure indications are sound, noninvasive alternatives are appropriately considered, and patients are appropriately consented with respect to the risks, benefits, and alternatives.A critical step toward reducing risks is to understand their predictors [2,3]. Some factors may be modifiable and their identification allows time for that modification to occur. For the ones that are not modifiable, identifying the risks Key points• The most common adverse events (AEs) after endoscopic retrograde cholangiopancreatography (ERCP) are pancreatitis, cardiopulmonary events, bleeding, infection, and perforation, and rarely these events can cause disability or be fatal.• The actual risks in an individual case depend upon the context of the procedure, the characteristics of the patient, the skills of the procedure team, and the appropriate use of prophylactic interventions.• Understanding these interacting issues and managing them are key to making wise clinical decisions and improving patient education and informed consent.

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Section: Case Context and Comorbidity Quantificationmentioning

confidence: 99%

Section: Case Context and Comorbidity Quantificationmentioning

confidence: 99%

Risk assessment and reduction

Romagnuolo

2014

Ercp

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“…Indeed, patients with sleep apnea have added risk factors, but once known and incorporated in the management plan, current monitoring and care has produced equally good outcomes in this subset of the patients compared to non-sleep apnea patients [13][14][15] .…”

Section: Myth: Sedation For Gi Procedures In Sleep Apnea Patients Is mentioning

confidence: 99%

Myths, fallacies and practical pearls in GI lab

Kumar¹

2014

WJGE

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Many prevalent practices and guidelines related to Gastrointestinal endoscopy and procedural sedation are at odds with the widely available scientific-physiological and clinical outcome data. In many institutions, strict policy of pre-procedural extended fasting is still rigorously enforced, despite no evidence of increased incidence of aspiration after recent oral intake prior to sedation. Supplemental oxygen administration in the setting of GI procedural sedation has been increasingly adopted as reported in the medical journals, despite clear evidence that supplemental oxygen blunts the usefulness of pulse oximetry in timely detection of sedation induced hypoventilation, leading to increased number of adverse cardiopulmonary outcomes. Use of Propofol by Gastroenterologist-Nurse team is erroneously considered dangerous and often prohibited in various institutions, at the same time worldwide reports of remarkable safety and patient satisfaction continue to be published, dating back more than a decade. Of patient monitoring practices that have been advocated to be standard, many merely add cost, not value. Advances in the technology often are not incorporated in a timely manner in guidelines or clinical practices, e.g. , Capsule endoscopy or electrocautery during GI procedures do not interfere with proper functioning of the current pacemakers or defibrillators. Orthopedic surgeons have continued to recommend prophylactic antibiotics for joint replacement patients prior to GI procedures, without any evidence of need. These myths are explored for a succint review to prompt a change in clinical practices and institutional policies. Core tip: Many prevalent endoscopic procedural practices and policies are not only unsupported by clinical and scientific evidence, but are counterproductive. Rather than enhancing patient safety and comfort, these increase risk and expense, introduce unnecessary delays. Evidence to reach proper decisions about these topics has been available for a while, but is not appropriately acknowledged and implemented. Avoiding these pitfalls can have a significant positive impact because these policies cover routine events, actions and decisions, including: required prolonged pre-procedural fasting, routine supplemental oxygen during sedation, prohibition of Propofol use by nonanesthesia personnel, multiple monitoring practices and prophylactic recommendations.Kumar P. Myths, fallacies and practical pearls in GI lab. World J Gastrointest Endosc 2014; 6(12): 584-591 Available from: URL:

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“…Although the problem frequently arises in clinical practice, only a few studies, mainly retrospective, have evaluated the cardiovascular complications in patients with OSAS who were subjected to a digestive endoscopic procedure under light-to-moderate sedation [9][10][11][12][13][14]. In some studies, a clinical questionnaire was used before endoscopy to stratify patients into categories of high or low probability for OSAS.…”

mentioning

confidence: 99%

“…In some studies, a clinical questionnaire was used before endoscopy to stratify patients into categories of high or low probability for OSAS. The Berlin questionnaire [15] was used by Khiani [9] and Mador [12]. Assessing the incidence of desaturations (<92%) during endoscopy, Khiani found no differences between groups at low and high risk for OSAS.…”

mentioning

confidence: 99%