With exponential growth in the number of procedures being done under anesthesia, especially in the gastrointestinal suite, providers are wondering about the best way to provide safe, efficient and affordable care but also prevent adverse events (AEs), such as aspiration. A review of the current gastroenterology literature about AEs using propofol sedation reveals some insights and tips.
“We need to realize that sedation for endoscopic procedures is as much an art as it is a science,” said Sekar Bhavani, MD, associate program director of the Anesthesiology Institute at the Cleveland Clinic. Dr. Bhavani discussed risks and patient harm associated with deep propofol sedation at “Driving Change in Ambulatory Anesthesia,” a joint meeting held by the Society of Ambulatory Anesthesia and the American Society of Anesthesiologists.
“Anesthesia-directed care is often associated with propofol sedation, and its use in the GI suite is fraught with more danger than in the main OR [operating room],” Dr. Bhavani noted.
A prospective cohort study published in Gastroenterology (2016;150:888-894) examined outcomes following a routine colonoscopy, using the Commercial Claims and Encounters Database. Researchers analyzed regional differences and complications, such as perforation, colonic bleeding, abdominal pain and stroke. Use of anesthesia services was higher on the East Coast (particularly in Florida) at 73.4%, and lower on the West Coast (particularly in Washington) at 15.4%. In the Northeast, use of anesthesia services was associated with a 12% increase in risk for complications. In the West, use of anesthesia services was associated with a 60% increase in risk. The increase was greatest for patients in regions with a low prevalence of use of anesthesia services, even after adjusting for patient and procedural characteristics.
“Perforation and abdominal pain were related to the absence of patient feedback, which would have prevented the endoscopist from having those outcomes,” Dr. Bhavani said. “When we achieve our aim of providing relief from pain and anxiety, we must not lose sight of the need for doing what is safe for our patients.”
Propofol and Swallowing
In addition, a prospective study in Anesthesia & Analgesia (2016;122:48-54) examined the effect of propofol on swallowing, based on a well-established target-controlled infusion protocol. It indicated that NPO (nothing by mouth) status, swallowing frequency, cough reflex and gastric residual volume all play a role in risks for aspiration and respiratory complications in the GI suite. The study also found an association between dysphagia and age, obesity and target-controlled infusion dose. The study did not consider the quantity or quality of the volume of aspiration.
“If we want to decrease the risk of aspiration, we need to look at all the aspects of care that we provide and the effects of all the anesthesia agents on swallowing,” Dr. Bhavani said.
Opioid and benzodiazepine use, which is associated with impairment of oral coordination and swallowing frequency, also may increase risk. A recent study in Gastrointestinal Endoscopy (2016;83:857-865) found that morphine and benzodiazepines made swallowing more difficult, especially in older patients who are frail and have multiple comorbidities.
During the session, Dr. Bhavani was asked about routine intubation for all patients undergoing endoscopy.
“Intubation doesn’t necessarily prevent aspiration,” he said. “But it does help prevent hypercapnia and maintain oxygenation for certain patients. The risk of intubation has to be balanced against the risk of aspiration.”
In general, anesthesiologists should consider and potentially reassess the need for opioids, benzodiazepines and topical sprays to reduce instances of aspiration, according to Dr. Bhavani. In addition, a patient’s positioning plays a role, as supine patients are more likely to aspirate. Similarly, NPO guidelines make a difference, particularly if preoperative evaluations can assess gastric volume. Monitors can better track the depth of sedation and ventilation, and carbon dioxide insufflation could make a difference in postoperative pain and regurgitation.
“Simply put, all [anesthetic] medications affect swallowing and set the potential for aspiration,” Dr. Bhavani said.