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Anesthetic strategy for obese patients during gastroscopy: deep sedation or conscious sedation? A prospective randomized controlled trial

A Letter to the Editor to this article was published on 11 June 2021

Abstract

Objective

This paper aims to compare the incidence of SpO2 values < 95% and < 90% of the obese patients between conscious sedation and deep sedation and whether conscious sedation was superior to the deep sedation for obese patients during diagnostic gastroscopy.

Methods

Obese patients undergoing diagnostic gastroscopy were randomly assigned to two different intervention groups: group CS (conscious sedation) or group DS (deep sedation). Group CS patients were managed by conscious sedation [Modified Observer Assessment of Alertness/Sedation (MOAA/S) at 4–5] protocol, and group DS patients were managed by deep sedation (MOAA/S at ≤ 2) protocol. Propofol and sufentanil (0.1 and 0.05 mg/kg) were, respectively, infused for sedation and analgesia in CS and DS protocols. The primary endpoints were to compare the incidence of SpO2 values < 95% and < 90% of the patients between the two groups. The incidence of successful sedation, satisfaction scores of patients and endoscopist were assessed as secondary endpoints.

Results

115 obese patients (59 in group CS and 56 in group DS) were enrolled in this study. The incidences of SpO2 < 95% and < 90% in group CS (42.4% and 6.8%) were significantly lower than those in group DS (69.6% and 19.6%, with P = 0.003 and 0.041, respectively). The incidence of successful sedation was similar between groups (86.4% vs 89.3%, P = 0.641). Patient satisfaction scores and endoscopist satisfaction scores were both similar between groups (P = 0.548 and 0.171).

Conclusion

Conscious sedation with propofol and sufentanil (0.1 mg/kg) reduced the incidence of hypoxic events without affecting gastroscopy procedure and satisfaction compared with the deep sedation for obese patients during diagnostic gastroscopy.

Trial registration

ChiCTR-1900024894; registration date, July 31, 2019. http://www.chictr.org.cn.

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Fig. 1

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

References

  1. 1.

    Banks M, Graham D, Jansen M, Gotoda T, Coda S, di Pietro M, Uedo N, Bhandari P, Pritchard DM, Kuipers EJ, Rodriguez-Justo M, Novelli MR, Ragunath K, Shepherd N, Dinis-Ribeiro M. British Society of Gastroenterology guidelines on the diagnosis and management of patients at risk of gastric adenocarcinoma. Gut. 2019;68:1545–75.

    Article  Google Scholar 

  2. 2.

    Zaanan A, Bouché O, Benhaim L, Buecher B, Chapelle N, Dubreuil O, Fares N, Granger V, Lefort C, Gagniere J, Meilleroux J, Baumann AS, Vendrely V, Ducreux M, Michel P. Thésaurus National de Cancérologie Digestive (TNCD). Gastric cancer: French intergroup clinical practice guidelines for diagnosis, treatments and follow-up (SNFGE, FFCD, GERCOR, UNICANCER, SFCD, SFED, SFRO). Dig Liver Dis. 2018;50:768–79.

    Article  Google Scholar 

  3. 3.

    ASGE Standards of Practice Committee, Evans JA, Chandrasekhara V, Chathadi KV, Decker GA, Early DS, Fisher DA, Foley K, Hwang JH, Jue TL, Lightdale JR, Pasha SF, Sharaf R, Shergill AK, Cash BD, DeWitt JM. The role of endoscopy in the management of premalignant and malignant conditions of the stomach. Gastrointest Endosc. 2015;82:1–8.

    Article  Google Scholar 

  4. 4.

    Lahner E, Zagari RM, Zullo A, Di Sabatino A, Meggio A, Cesaro P, Lenti MV, Annibale B, Corazza GR. Chronic atrophic gastritis: Natural history, diagnosis and therapeutic management. A position paper by the Italian Society of Hospital Gastroenterologists and Digestive Endoscopists [AIGO], the Italian Society of Digestive Endoscopy [SIED], the Italian Society of Gastroenterology [SIGE], and the Italian Society of Internal Medicine [SIMI]. Dig Liver Dis. 2019;51:1621–32.

    Article  Google Scholar 

  5. 5.

    Meining A, Semmler V, Kassem AM, Sander R, Frankenberger U, Burzin M, Reichenberger J, Bajbouj M, Prinz C, Schmid RM. The effect of sedation on the quality of upper gastrointestinal endoscopy: an investigator-blinded, randomized study comparing propofol with midazolam. Endoscopy. 2007;39:345–9.

    CAS  Article  Google Scholar 

  6. 6.

    Barends CRM, Absalom AR, Struys MMRF. Drug selection for ambulatory procedural sedation. Curr Opin Anaesthesiol. 2018;31:673–8.

    CAS  Article  Google Scholar 

  7. 7.

    Dossa F, Dubé C, Tinmouth J, Sorvari A, Rabeneck L, McCurdy BR, Dominitz JA, Baxter NN. Practice recommendations for the use of sedation in routine hospital-based colonoscopy. BMJ Open Gastroenterol. 2020;7:e000348.

    Article  Google Scholar 

  8. 8.

    ASGE Standards of Practice Committee, Early DS, Lightdale JR, Vargo JJ, Acosta RD, Chandrasekhara V, Chathadi KV, Evans JA, Fisher DA, Fonkalsrud L, Hwang JH, Khashab MA, Muthusamy VR, Pasha SF, Saltzman JR, Shergill AK, Cash BD, DeWitt JM. Guidelines for sedation and anesthesia in GI endoscopy. Gastrointest Endosc. 2018;87:327–37.

    Article  Google Scholar 

  9. 9.

    Conigliaro R, Fanti L, Manno M, Brosolo P. Italian Society of Digestive Endoscopy (SIED) Sedation Group. Italian Society of Digestive Endoscopy (SIED) position paper on the non-anaesthesiologist administration of propofol for gastrointestinal endoscopy. Dig Liver Dis. 2017;49:1185–90.

    Article  Google Scholar 

  10. 10.

    Dumonceau JM, Riphaus A, Schreiber F, Vilmann P, Beilenhoff U, Aparicio JR, Vargo JJ, Manolaraki M, Wientjes C, Rácz I, Hassan C, Paspatis G. Non-anesthesiologist administration of propofol for gastrointestinal endoscopy: European Society of Gastrointestinal Endoscopy, European Society of Gastroenterology and Endoscopy Nurses and Associates Guideline-Updated June 2015. Endoscopy. 2015;47:1175–89.

    Article  Google Scholar 

  11. 11.

    Hillman DR, Walsh JH, Maddison KJ, Platt PR, Kirkness JP, Noffsinger WJ, Eastwood PR. Evolution of changes in upper airway collapsibility during slow induction of anesthesia with propofol. Anesthesiology. 2009;111:63–71.

    CAS  Article  Google Scholar 

  12. 12.

    Perel A. Non-anaesthesiologists should not be allowed to administer propofol for procedural sedation: a Consensus Statement of 21 European National Societies of Anaesthesia. Eur J Anaesthesiol. 2011;28:580–4.

    Article  Google Scholar 

  13. 13.

    Shin S, Lee SK, Min KT, Kim HJ, Park CH, Yoo YC. Sedation for interventional gastrointestinal endoscopic procedures: are we overlooking the “pain”? Surg Endosc. 2014;28:100–7.

    Article  Google Scholar 

  14. 14.

    McQuaid KR, Laine L. A systematic review and meta-analysis of randomized, controlled trials of moderate sedation for routine endoscopic procedures. Gastrointest Endosc. 2008;67:910–23.

    Article  Google Scholar 

  15. 15.

    Sasaki T, Tanabe S, Ishido K, Azuma M, Katada C, Higuchi K, Koizumi W. Recommended sedation and intraprocedural monitoring for gastric endoscopic submucosal dissection. Dig Endosc. 2013;25(Suppl 1):79–85.

    Article  Google Scholar 

  16. 16.

    McVay T, Fang JC, Taylor L, Au A, Williams W, Presson AP, Al-Dulaimi R, Volckmann E, Ibele A. Safety analysis of bariatric patients undergoing outpatient upper endoscopy with non-anesthesia administered propofol sedation. Obes Surg. 2017;27:1501–7.

    Article  Google Scholar 

  17. 17.

    Laffin AE, Kendale SM, Huncke TK. Severity and duration of hypoxemia during outpatient endoscopy in obese patients: a retrospective cohort study. Can J Anaesth. 2020;67:1182–9.

    Article  Google Scholar 

  18. 18.

    Zhao YJ, Liu S, Mao QX, Ge HJ, Wang Y, Huang BQ, Wang WC, Xie JR. Efficacy and safety of remifentanil and sulfentanyl in painless gastroscopic examination: a prospective study. Surgical Laparoscopy Endoscopy & Percutaneous Techniques. 2015;25:e57–60.

    Article  Google Scholar 

  19. 19.

    Yin N, Xia J, Cao YZ, Lu X, Yuan J, Xie J. Effect of propofol combined with opioids on cough reflex suppression in gastroscopy: study protocol for a double-blind randomized controlled trial. Bmj Open. 2017;7:e014881.

    Article  Google Scholar 

  20. 20.

    Nuttall FQ. Body mass index: obesity, BMI, and health: a critical review. Nutr Today. 2015;50:117–28.

    Article  Google Scholar 

  21. 21.

    Training Committee, American Society for Gastrointestinal Endoscopy. Training guideline for use of propofol in gastrointestinal endoscopy. Gastrointest Endosc. 2004;60:167-72.

    Article  Google Scholar 

  22. 22.

    Wang SY, Welch TD, Sangha RS, Maloney RW, Cui Z, Kaplan AV. Dofetilide-associated QT prolongation: total body weight versus adjusted or ideal body weight for dosing. J Cardiovasc Pharmacol. 2018;72:161–5.

    CAS  Article  Google Scholar 

  23. 23.

    Shin S, Park CH, Kim HJ, Park SH, Lee SK, Yoo YC. Patient satisfaction after endoscopic submucosal dissection under propofol-based sedation: a small premedication makes all the difference. Surgical Endoscopy. 2017;31:2636–44.

    Article  Google Scholar 

  24. 24.

    American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists. Practice guidelines for sedation and analgesia by non-anesthesiologists. Anesthesiology. 2002;96:1004-17.

    Article  Google Scholar 

  25. 25.

    Cohen LB, Delegge MH, Aisenberg J, Brill JV, Inadomi JM, Kochman ML, Piorkowski JD, AGA Institute. AGA Institute review of endoscopic sedation. Gastroenterology. 2007;133(2):675–701.

    CAS  Article  Google Scholar 

  26. 26.

    Aldrete JA. The post-anesthesia recovery score revisited. J Clin Anesth. 1995;7(1):89–91.

    CAS  Article  Google Scholar 

  27. 27.

    Allam S, Anderson KJ, O'Brien C, Macpherson JA, Gambhir S, Leitch JA, Kenny GN. Patient-maintained propofol sedation using reaction time monitoring: a volunteer safety study. Anaesthesia. 2013;68:154–8.

    CAS  Article  Google Scholar 

  28. 28.

    Ominami M, Nagami Y, Shiba M, Tominaga K, Sakai T, Maruyama H, Kato K, Minamino H, Fukunaga S, Tanaka F, Sugimori S, Kamata N, Machida H, Yamagami H, Tanigawa T, Watanabe T, Fujiwara Y, Arakawa T. Comparison of propofol with midazolam in endoscopic submucosal dissection for esophageal squamous cell carcinoma: a randomized controlled trial. J Gastroenterol. 2018;53:397–406.

    CAS  Article  Google Scholar 

  29. 29.

    Gotoda T, Okada H, Hori K, Kawahara Y, Iwamuro M, Abe M, Kono Y, Miura K, Kanzaki H, Kita M, Kawano S, Yamamoto K. Propofol sedation with a target-controlled infusion pump and bispectral index monitoring system in elderly patients during a complex upper endoscopy procedure. Gastrointest Endosc. 2016;83:756–64.

    Article  Google Scholar 

  30. 30.

    Yoo YC, Park CH, Shin S, Park Y, Lee SK, Min KT. A comparison of sedation protocols for gastric endoscopic submucosal dissection: moderate sedation with analgesic supplementation vs analgesia targeted light sedation. Br J Anaesth. 2015;115:84–8.

    CAS  Article  Google Scholar 

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Acknowledgements

The authors are grateful to all participants for their cooperation.

Funding

This study was supported by a grant from the Science and Technology Department of Jiaxing City, China (No. 2019AD32148). The granting institution did not play any role in the design collection, analysis, or interpretation of the data for the study, or in the writing of the manuscript.

Author information

Affiliations

Authors

Contributions

SK was involved in project development, data collection, and major manuscript writing. JL and HZ were involved in the project development and manuscript editing. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Hong-mei Zhou.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Ethics approval

The Ethics Committee of the Second Affiliated Hospital of Jiaxing University approved this randomized controlled trial (JXEY-2019JX178).

Consent to participate

Written informed consent was obtained from each patient.

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Kang, S., Lu, J. & Zhou, Hm. Anesthetic strategy for obese patients during gastroscopy: deep sedation or conscious sedation? A prospective randomized controlled trial. J Anesth 35, 555–562 (2021). https://doi.org/10.1007/s00540-021-02951-7

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Keywords

  • Conscious sedation
  • Obesity
  • Hypoxemia
  • Gastroscopy
  • Propofol