Aliment Pharmacol Ther 2001; 15: 217±220.
Changing patterns of sedation use for routine out-patient diagnostic gastroscopy between 1989 and 1998 H. E. M ULCAH Y, E. HENNESSY, P. CONN OR, B. RHODES, S. E. PATCHETT, M. J. G . FARTH ING & P. D. FAIRCLOUGH Digestive Diseases Research Centre, St Bartholomew's and Royal London School of Medicine and Dentistry, London, UK Accepted for publication 25 September 2000
SUMMARY
Background: Knowledge of sedation trends for upper gastrointestinal endoscopy is important for health service planning, particularly in view of rapidly increasing demands on endoscopy services. However, no data are available on sedation trends in Britain over the past 10 years. Aim: To determine sedation use for routine gastroscopy in a single endoscopy unit between 1989 and 1998. Methods: This was a retrospective study of 9795 consecutive adults (mean age 56 years, range 18± 100 years; 4512 females) who had undergone a gastroscopy between 1989 and 1998. Clinical, pharmacological and endoscopic data were retrieved from a computerized database.
INTRODUCTION
Diagnostic gastroscopy is one of the most common invasive out-patient procedures performed in the Western World and accounts for 90% of all upper gastrointestinal endoscopic procedures.1 Intravenous sedation usage varies widely between different countries and cultures. Sedation is rarely used in Japan or other Asian countries, the Middle East and South America. Unsedated endoscopy is also the norm in most European countries including Germany, Greece, Spain, Sweden and Switzerland.2 In contrast, up to 98% of American Correspondence to: Dr H. Mulcahy, Department of Gastroenterology, King's College Hospital, Denmark Hill, London SE5 9RS, UK. E-mail:
[email protected] Ó 2001 Blackwell Science Ltd
Results: Over the 10-year study period, the sedation rate remained constant for patients undergoing therapeutic endoscopy (P 0.99) and those undergoing in-patient diagnostic examinations (P 0.63). In contrast, the sedation rate for out-patient diagnostic endoscopy decreased by 54%, from a high of 70% in 1990 to 32% in 1998 (P < 0.0001). Logistic regression analysis showed that the decline in sedation use was greater in females (P < 0.0001) than males and in procedures performed by non-consultant compared to consultant staff (P 0.01). Conclusions: If our results form part of a national trend, they will have important implications for cardiopulmonary monitoring strategies, recovery room practices and for complication rates due to the use of sedation for upper gastrointestinal endoscopy.
patients undergoing gastroscopy receive sedation.3 According to studies performed in the late 1980s, it was also standard practice to use sedation in Britain, with 90% of endoscopists reporting that they sedated at least three-quarters of all patients.4 Sedation is estimated to be directly responsible for between 30 and 50% of all equipment, supply and labour costs associated with diagnostic upper gastrointestinal endoscopy.5 Knowledge of sedation trends is therefore important for health service planning, particularly in view of the rapidly increasing demands on endoscopy services. However, no data are available on sedation trends in Britain over the past 10 years. The aim of our study was to determine sedation use for routine diagnostic gastroscopy in a single endoscopy unit over a 10-year period. 217
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PATIENTS AND METHODS
This was a retrospective review of 9795 consecutive adult patients (mean age 56 years, range 18±100 years; 4512 females) who underwent a gastroscopy between 1989 and 1998 in a single endoscopy unit within a university hospital. Clinical, pharmacological and endoscopic details were obtained from a computerized database and missing data were retrieved from a hospital-wide patient database service and from individual patients' medical records. Patients attending for gastroscopy were sent a standard lea¯et that described the procedure and explained that patients could choose to have the examination performed with or without sedation. On arrival in the endoscopy department, nursing staff further explained the procedure, including the risks and bene®ts of sedation, and patients were again offered sedation. In general, patients fasted for 4 h or more and were examined in the left lateral position using one of a number of endoscopes (Olympus, Keymed, Southendon-Sea, UK) with insertion tubes ranging from 6.0 mm to 9.8 mm in diameter. Statistical analysis Continuous data are presented as means and 95% con®dence intervals. Differences in midazolam dose over time were assessed by a one-way analysis of variance. Categorical data were analysed using a v2-test for trend and multivariate analyses were performed using a multiple logistic regression model, with sedation use as the dependent variable. All analyses were performed using the Statistical Package for the Social Sciences (SPSS, Chicago, Illinois). RESULTS
Sedation use remained constant over the 10-year study period for patients undergoing therapeutic endoscopy (v2-test for trend; P 0.99) and for in-patients undergoing diagnostic examinations (P 0.63; Figure 1). However, for 6526 out-patients attending for diagnostic gastroscopy, the sedation rate decreased by 54%, from a high of 70% in 1990 to 32% in 1998 (P < 0.0001). We performed multiple logistic regression analyses to correct for confounding variables and identify factors signi®cantly associated with declining sedation use for diagnostic out-patient examinations. More females
Figure 1. Sedation rate over time for 9795 patients attending for upper gastrointestinal endoscopy strati®ed by procedure type and out-patient status.
requested sedation than males in the early years of study, but the decline in sedation was greater in females over the 10 years (P < 0.0001). Sedation use was identical in both sexes during the last year of study (Figure 2A). The decline in sedation use was similar amongst all age groups over time (P 0.43; Figure 2B). Sedation rates were lower throughout the entire study period for patients endoscoped for the ®rst time compared to those attending for repeat examination (P < 0.0001; Figure 2D), but the percentage decline in sedation use was similar for both groups over the 10 years (P 0.50). There was a gradual decrease in sedation use by non-consultant endoscopists over the 10-year period, but no decrease in sedation use by consultants until 1998 (Figure 2D). The overall reduction in sedation rate over time was greater among non-consultants compared to consultants (P 0.01). Finally, 3532 out-patients undergoing diagnostic endoscopy actually received sedation prior to examination. The mean dose of midazolam used per sedated patient decreased from 5.0 mg to 2.9 mg over the 10-year period (ANOVA; P < 0.0001; Figure 3). DISCUSSION
Intravenous benzodiazapines are known to reduce patient discomfort and increase tolerance to upper gastrointestinal endoscopy, and sedated patients appear more willing to undergo a repeat procedure if Ó 2001 Blackwell Science Ltd, Aliment Pharmacol Ther 15, 217±220
CHANGING PATTERNS OF SEDATION USE
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Figure 2. Sedation rate over time for 6526 patients attending for out-patient upper gastrointestinal endoscopy strati®ed by (A) patient gender; (B) patient age; (C) previous gastroscopy experience and; (D) grade of endoscopist.
Figure 3. Mean midazolam dose administered to 3532 outpatients undergoing sedated diagnostic endoscopy between 1989 and 1998. Error bars represent 95% con®dence intervals.
necessary.6 However, these sedatives frequently cause signi®cant oxygen desaturation, occasionally a cardiopulmonary complication and rarely death. Arrowsmith et al. reported that one in 200 American patients undergoing endoscopy experience a cardiorespiratory complication as a direct result of sedation.7 In contrast, Ó 2001 Blackwell Science Ltd, Aliment Pharmacol Ther 15, 217±220
Hedenbro and Ekelund did not detect any serious cardiopulmonary events during 13 353 consecutive unsedated endoscopies.8 Unsedated endoscopy also has social and economic advantages, allowing the patient to leave the department as soon as the procedure is completed, and to drive or return to work immediately. In addition, a lack of antegrade amnesia allows meaningful post-procedure discussion with the endoscopist, reducing the need for subsequent consultation. Finally, unsedated endoscopy results in decreased electronic monitoring, recovery room, pharmacy and staff costs, and signi®cantly reduces overall costs associated with this procedure.5 Our results indicate that there has been a large decrease in sedation usage among patients attending our unit for out-patient diagnostic endoscopy over the past 10 years, with less than one third now requesting sedation. The decrease was seen especially during the latter study years and was found in all patient groups, but this study did not allow us to identify factors that in¯uence individual patients to choose sedation or not. A Swedish study reported that 66% of patients decline sedation, primarily because they believe that the increased discomfort associated with unsedated endoscopy is compensated for by a lack of post-procedure
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drug effects.9 However, further studies in diverse ethnic and social groups are required to determine whether these results are applicable to a wide range of populations. Interestingly, patients in our unit examined by non-consultant staff tended to have especially low sedation rates, with less than 30% in this group requesting sedation at the latter end of the study. This may indicate that younger gastroenterology personnel are at the forefront of instituting initiatives towards unsedated endoscopy, but the possibility that consultant staff perform a high proportion of their examinations on anxious patients who are prone to request sedation is equally plausible. Overall, this study shows a sharp and sustained reduction in sedation use for upper gastrointestinal endoscopy over the past 10 years in a single endoscopy unit, but data from many other units are clearly required to determine whether our results form part of a national trend. If this is the case then it will have important implications for cardiopulmonary monitoring strategies, recovery room practices and for sedationrelated complication rates. ACKNOWLEDGEMENTS
The authors would like to thank Maria Kiely, Anna Riches, Marie Narsoomamodem, Tara Ogbourn and Nicolette Briggs for their assistance during this study
and Liam Mulcahy for his helpful comments during manuscript preparation. REFERENCES 1 Quine MA, Bell GD, McCloy RF, Charlton JE, Devlin HB, Hopkins A. Prospective audit of upper gastrointestinal endoscopy in two regions of England: safety, staf®ng, and sedation methods. Gut 1995; 36: 462±7. 2 Lazzaroni M, Bianchi Porro G. Preparation, premedication and surveillance. Endoscopy 1998; 30: 53±60. 3 Keeffe EB, O'Connor KW. Survey of endoscopic sedation and monitoring practices. Gastrointest Endosc 1990; 36: S13±8. 4 Daneshmend TK, Bell GD, Logan RFA. Sedation for upper gastrointestinal endoscopy: results of a nationwide survey. Gut 1991; 32: 12±5. 5 Mokhashi MS, Hawes RH. Struggling toward easier endoscopy. Gastrointest Endosc 1998; 48: 432±40. 6 Froehlich F, Schwizer W, Thorens J, Kohler M, Gonvers JJ, Fried M. Conscious sedation for gastroscopy: patient tolerance and cardiorespiratory parameters. Gastroenterology 1995; 108: 697±704. 7 Arrowsmith JB, Gerstman BB, Fleischer DE, Benjamin SB. Results from the American Society for Gastrointestinal Endoscopy/U.S. Food and Drug Administration collaborative study on complication rates and drug use during gastrointestinal endoscopy. Gastrointest Endosc 1991; 37: 421±7. 8 Hedenbro JL, Ekelund M. Endoscopic perforation in unsedated patients undergoing endoscopy. Br J Surg 1996; 83: 845±6. 9 Hedenboro JL, Lindblom A. Patient attitudes to sedation for diagnostic upper endoscopy. Scand J Gastroenterol 1991; 26: 1115±20.
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