Abstract
Prior to performing an endoscopic procedure on an obese patient, it is imperative that the physician obtain a thorough history and physical. Special attention should be placed on cardiopulmonary processes, such as undiagnosed obstructive sleep apnea, obesity hypoventilation syndrome, and pulmonary hypertension. These and other commonly obesity-related illnesses place the obese patient at greater risk while undergoing moderate or deep sedation. Proper training in basic and advanced life support, as well as a thorough understanding of cardiopulmonary monitoring and interpretation of untoward events, is required to safely conduct both diagnostic and therapeutic endoscopic procedures. This chapter will highlight the proper documentation and patient education required prior to performing an endoscopic procedure as well as the technical aspects within the endoscopic suite. Special attention will be placed on commonly used medication and monitoring technology to safely and effectively carry out the procedure.
This is a preview of subscription content, log in via an institution.
Buying options
Tax calculation will be finalised at checkout
Purchases are for personal use only
Learn about institutional subscriptionsReferences
Ogden CL, Carroll MD, Kit BK, Flegal KM. Prevalence of childhood and adult obesity the United States, 2011-2012. JAMA. 2014;311(8):806–14.
World Health Organization. Global status report on noncommunicable diseases. 2014. Geneva, Switzerland. http://www.who.int/nmh/publications/ncd-status-report-2014/en/. Accessed 2 Jun 2017.
Jirapinyo P, Thompson CC. Sedation challenges: obesity and sleep apnea. Gastrointest Endosc Clin N Am. 2016;26(3):527–37.
Harris ZP, Liu J, Saltzman JR. Quality assurance in the endoscopy suite: sedation and monitoring. Gastrointest Endosc Clin N Am. 2016;26(3):553–62.
2017 UptoDate. The modified Mallampati classification for difficult laryngoscopy and intubation. Accessed 2 Jun 2017.
Samsoon GL, Young JR. Difficult tracheal intubation: a retrospective study. Anaesthesia. 1987;42(5):487–90.
Committee on Standards and Practice Parameters, Apfelbaum JL, Connis RT, Nickinovich DG, American Society of Anesthesiologists Task Force on Preanesthesia Evaluation, Pastnernak LR, et al. Practice advisory for preanesthesia evaluation: an updated report by the American Society of Anesthesiologists Task Force on Preanesthesia evaluation. Anesthesiology. 2012;116(3):522–38.
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(4):1004–17.
Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy, Lichtenstein DR, Jagannath S, Baron TH, Anderson MA, Banerjee S, Dominitz JA, et al. Sedation and anesthesia in GI endoscopy. Gastrointest Endosc. 2008;68(5):815–26.
Moller JT, Pedersen T, Rasmussen LS, Jensen PF, Pedersen BD, Ravlo O, et al. Randomized evaluation of pulse oximetry in 20,802 patients. I. Design, demography, pulse oximetry failure rate, and overall complication rate. Anesthesiology. 1993;78(3):436–44.
Pedersen T, Moller AM, Pedersen BD. Pulse oximetry for perioperative monitoring: systematic review of randomized, controlled trials. Anesth Analg. 2003;96(2):426–31.
Waring JP, Baron TH, Hirota WK, Goldstein JL, Jacobson BC, Leighton JA, et al. Guidelines for conscious sedation and monitoring during gastrointestinal endoscopy. Gastrointest Endosc. 2003;58(3):317–22.
Qadeer MA, Vargo JJ, Dumot JA, Zuccaro G, Stevens T, Parsi MA, et al. Capnography prevents hypoxemia during ERCP and EUS: a randomized controlled trial (abstract). Gastrointest Endosc. 2008;67(5):AB84.
Gross JB, Bachenberg KL, Benumof JL, Caplan RA, Connis RT, Coté CJ, et al. Practice guidelines for the perioperative management of patients with obstructive sleep apnea: a report by the American Society of Anesthesiologists Task Force on perioperative management of patients with obstructive sleep apnea. Anesthesiology. 2006;104(5):1081–93.
Cohen LB. Patient monitoring during gastrointestinal endoscopy: why, when, and how? Gastrointest Endoscopy Clin N Am. 2008;18(4):651–63.
Al-Sammak Z, Al-Falaki MM, Gamal HM. Predictor of sedation during endoscopic retrograde cholangiopancreatography—bispectral index vs clinical assessment. Middle East J Anesthesiol. 1891;2005:141–8.
Qadeer MA, Vargo JJ, Patel S, Dumot JA, Lopez AR, Trolli PA, et al. Bispectral index monitoring of conscious sedation with the combination of meperidine and midazolam during endoscopy. Clin Gastroenterol Hepatol. 2008;6(1):102–8.
Chen SC, Rex DK. An initial investigation of bispectral monitoring as an adjunct to nurse-administered propofol sedation for colonoscopy. Am J Gastroenterol. 2004;99(6):1081–6.
American Society of Anesthesiologists. Continuum of depth of sedation: definition of general anesthesia and levels of sedation/analgesia (15 Oct 2014). https://www.asahq.org/quality-and-practice-management/standards-and-guidelines/. Accessed 2 Jun 2017.
Nisbet AT, Mooney-Cotter F. Comparison of selected sedation scales for reporting opioid-induced sedation assessment. Pain Manag Nurs. 2009;10(3):154–64.
Consales G, Chelazzi C, Rinaldi S, De Gaudio AR. Bispectral index compared to Ramsay score for sedation monitoring in intensive care units. Minerva Anestesiol. 2006;72(5):329–36.
Drummond JC. Monitoring depth of anesthesia: with emphasis on the application of the bispectral index and the middle latency auditory evoked response to the prevention of recall. Anesthesiology. 2000;93(3):876–82.
Hasanein R, El-Sayed W. Ketamine/propofol versus fentanyl/propofol for sedating obese patients undergoing endoscopic retrograde cholangiopancretography (ERCP). Egyptian J Anesth. 2013;29(3):207–11.
Da B, Buxbaum J. Training and competency in sedation practice in gastrointestinal endoscopy. Gastrointest Endosc Clin N Am. 2016;26(3):443–62.
Nelson DB, Barkun AN, Block KP, Burdick JS, Ginsberg GG, Greenwald DA, et al. Propofol use during gastrointestinal endoscopy. Gastrointest Endosc. 2001;53(7):876–9.
Bryson HM, Fulton BR, Faulds D. Propofol. An update of its use in anesthesia and conscious sedation. Drugs. 1995;50(3):513–59.
AstraZeneca. Diprivan 1% (package insert). Wilmington: AstraZeneca; 2000.
Baxter Pharmaceutical Products. Propofol (package insert). New Providence; 2002.
Vuyk J. Pharmacokinetics and pharmacodynamic interactions between opioids and propofol. J Clin Anesth. 1997;9(6):23S–6S.
Marinella JA. Propofol for sedation in the intensive care unit: essentials for the clinician. Respir Med. 1997;91(9):505–10.
Kirkpatrick T, Cockshott ID, Douglas EJ, Nimmo WS. Pharmocokinetics of propofol (diprivan) in elderly patients. Br J Anaesth. 1988;60(2):146–50.
Walker JA, McIntyre RD, Schleinitz PF, Jacobson KN, Haulk AA, Adesman PW, et al. Nurse-administered propofol sedation without anesthesia specialists in 9152 endoscopic cases in an ambulatory surgery center. Am J Gastroenterol. 2003;98(8):1744–50.
Vargo JJ, Zuccaro G, Dumot JA, Shermock KM, Morrow JB, Conwell DL, et al. Gastroenterologist-administered propofol versus meperidine and midazolam for advanced upper endoscopy: a prospective, randomized trial. Gastroenterology. 2002;123(1):8–16.
Rex DK, Overley C, Kinser K, Coates M, Lee A, Goodwine BW, et al. Safety of propofol administered by registered nurses with gastroenterologists supervision in 2000 endoscopic cases. Am J Gastroenterol. 2002;97(5):1159–63.
Heuss LT, Schnieper P, Drewe J, Pfimlin E, Beglinger C. Risk stratification and safe administration of propofol by registered nurses supervised by the gastroenterologist: a prospective observational study of more than 2000 cases. Gastrointest Endosc. 2003;57(6):664–71.
Heuss LT, Drewe J, Schnieper P, Tapparelli CB, Pflimlin E, Beglinger C. Patient controlled versus nurse administered sedation for colonoscopy: a prospective randomized trial. Am J Gastroenterol. 2004;99(3):511–8.
Gillham MJ, Hutchinson RC, Carter R, Kenny GN. Patient-maintained sedation for ERCP with a target-controlled infusion of propofol: a pilot study. Gastrointest Endosc. 2001;54(1):14–7.
Fanti L, Agostoni M, Casta A, Guslandi M, Giollo P, Torri G, Testoni PA. Target-controlled propofol infusion during monitored anesthesia in patients undergoing ERCP. Gastrointest Endosc. 2004;60(3):361–6.
Stonell A, Leslie K, Absalom AR. Effect-site target targeted patient-controlled sedation with propofol: comparison with anaesthetist administration for colonoscopy. Anaesthesia. 2006;61(3):240–7.
Pambianco DJ, Vargo JJ, Pruitt RE, Hardi R, Martin JF. Computer-assisted personalized sedation for upper endoscopy and colonoscopy: a comparative, multicenter randomized study. Gastrointest Endosc. 2011;73(4):765–72.
Mehta PP, Kochhar G, Kalra S, Maurer W, Tetzlaff J, Singh G, et al. Can a validated sleep apnea scoring system predict cardiopulmonary events using propofol sedation for routine EGD or colonoscopy? A prospective cohort study. Gastrointest Endosc. 2014;79(3):436–44.
Wani S, Azar R, Hovis CE, Hovis RM, Coté GA, Hall M, Waldbaum L, et al. Obesity is a risk factor for sedation-related complications during propofol-mediated sedation advanced endoscopic procedures. Gastointest Endosc. 2001;74(6):1238–47.
Qadeer MA, Lopez AR, Dumot JA, Vargo JJ. Risk factors for hypoxemia during ambulatory gastrointestinal endoscopy in ASA I-II patients. Dig Dis Sci. 2009;54(5):1035–40.
Dhariwal A, Plevris JN, Lo NT, Finlayson ND, Heading RC, Hayes PC. Age, anemia, and obesity-associated oxygen desaturation during upper gastrointestinal endoscopy. Gastrointest Endosc. 1992;38(6):684–8.
National Heart, Lung, and Blood Institute. Health information for the public. Health topics. sleep apnea. What is sleep apnea? Updated 10 Jul 2012. https://www.nhlbi.nih.gov/health/health-topics/topics/sleepapnea. Accessed 3 Jun 2017.
American Academy of Sleep Medicine. Obstructive sleep apnea syndrome (780.53-0). The International Classification of Sleep Disorders, Revised: Diagnostic and coding manual. Westchester: American Academy of Sleep Medicine; 2001. p. 52–8.
Young T, Skatrud J, Peppard PE. Risk factors for obstructive sleep apnea in adults. JAMA. 2004;291(16):2013–6. Review
Chung F, Subramanyam R, Liao P, Sasaki E, Shapiro C, Sun Y. High STOP-BANG score indicates a high probability of obstructive sleep apnoea. Br J Anaesth. 2012;108(5):768–75.
Kuruba R, Koche LS, Murr MM. Preoperative assessment and perioperative care of patients undergoing bariatric surgery. Med Clin North Am. 2007;91(3):339–51, ix.
Frey WC, Pilcher J. Obstructive sleep-related breathing disorders in patients evaluated for bariatric surgery. Obes Surg. 2003;13(5):676–83.
Chung F, Elsaid H. Screening for obstructive sleep apnea before surgery: why is it important? Curr Opin Anaesthesiol. 2009;22(3):405–11.
Coté GA, Hovis CE, Hovis RM, Waldbaum L, Early DS, Edmundowicz SA, et al. A screening instrument for sleep apnea predicts airway maneuvers in patients undergoing advanced endoscopic procedures. Clin Gastroenterol Hepatol. 2010;8(8):660–665.e1.
Chung F, Yegneswaran B, Liao P, Chung SA, Vairavanathan S, Islam S, et al. STOP questionnaire: a tool to screen patients for obstructive sleep apnea. Anesthesiology. 2008;108(5):812–21.
Chung F, Memtsoudis SG, Ramachandran SK, Nagappa M, Opperer M, Cozowicz C, et al. Society of Anesthesia and Sleep Medicine guidelines on preoperative screening and assessment of adult patients with obstructive sleep apnea. Anesth Analg. 2016;123(2):452–73.
Friedman SE, Andrus BW. Obesity and pulmonary hypertension: a review of pathophysiologic mechanisms. J Obes. 2012;2012:1. doi:10.1155/2012/505274.
Humbert M, Sitbon O, Chaouat A, Bertocchi M, Habib G, Gressin V, et al. Pulmonary arterial hypertension in France: results from a national registry. Am J Respir Crit Care Med. 2006;173(9):1023–30.
McQuillan BM, Picard MH, Leavitt M, Weyman AE. Clinical correlates and reference intervals for pulmonary artery systolic pressure among echocardiographically normal subjects. Circulation. 2001;104(23):2797–802.
Ramakrishna G, Sprung J, Ravi BS, Chandrasekaran K, McGoon MD. Impact of pulmonary hypertension on the outcomes of noncardiac surgery: predictors of perioperative morbidity and mortality. J Am Coll Cardiol. 2005;45(10):1691–9.
Kaw R, Pasupuleti V, Deshpande A, Hamieh T, Walker E, Minai OA. Pulmonary hypertension: an important predictor of outcomes in patients undergoing non-cardiac surgery. Respir Med. 2011;105(4):619–24.
McLaughlin VV, Archer SL, Badesch DB, Barst RJ, Farber HW, Lindner JR, et al. ACCF/AHA 2009 expert consensus document on pulmonary hypertension a report of the ACCF task force on expert consensus documents and the AHA developed in collaboration with the ACCP; ATS; and the PHA. J Am Coll Cardiol. 2009;53(17):1573–619.
Fadell EJ, Richman AD, Ward WW, Hendon JR. Fatty infiltration of the respiratory muscles in the pickwickian syndrome. N Engl J Med. 1962;266:861–3.
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(1):63–71.
Robinson RW, Zwillich CW, Bixler EO, Cadieux RJ, Kales A, White DP. Effects of oral narcotics on sleep-disordered breathing in healthy adults. Chest. 1987;91(2):197–203.
Shailaja S, Nichelle SM, Shetty AK, Hegde BR. Comparing ease of intubation in obese and lean patients using intubation difficulty scale. Anesth Essays Res. 2014;8(2):168–74.
Kheterpal S, Han R, Tremper KK, Shanks A, Tait AR, O’Reilly M, et al. Incidence and predictors of difficult and impossible mask ventilation. Anesthesiology. 2006;105(5):885–91.
Langeron O, Masso E, Huraux C, Guggiari M, Bianchi A, Coriat P, Riou B. Prediction of difficult mask ventilation. Anesthesiology. 2000;92(5):1229–36.
Dixon BJ, Dixon JB, Carden JR, Burn AJ, Schachter LM, Playfair JM, et al. Preoxygenation is more effective in the 25 degrees headup position than in the supine position in severely obese patients: a randomized controlled study. Anesthesiology. 2005;102(6):1110–5; discussion 5A.
Shiga T, Wajima Z, Inoue T, Sakamoto A. Predicting difficult intubation in apparently normal patients: a meta-analysis of bedside screening test performance. Anesthesiology. 2005;103(2):429–37.
Juvin P, Lavaut E, Dupont H, Lefevre P, Demetriou M, Dumoulin JL, Desmonts JM. Difficult tracheal intubation is more common in obese than in lean patients. Anesth Analg. 2003;97(2):595–600.
American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Practice guidelines for management of the difficult airway: an updated report by the American Society of Anesthesiologists Task Force on Management of the Difficult Airway. Anesthesiology. 2003;98(5):1269–77.
Shah PN, Sundaram V. Incidence and predictors of difficult mask ventilation and intubation. J Anaesthesiol Clin Pharmacol. 2012;28(4):451–5.
Salimi A, Farzanegan B, Rastegarpour A, Kolahi AA. Comparison of the upper lip bite test with measurement of thyromental distance for prediction of difficult intubations. Acta Anaesthesiol Taiwan. 2008;46(2):61–5.
Singer AJ, Kahn SR, Thode HC Jr, Hollander JE. Comparison of forearm and upper arm blood pressures. Prehosp Emerg Care. 1999;3(2):123–6.
Hanley MJ, Abernethy DR, Greenblatt DJ. Effect of obesity on the pharmacokinetics of drugs in humans. Clinical Pharmacokinet. 2010;49(2):71–87.
Vargo JJ. Procedural sedation and obesity: waters left uncharted. Gastrointest Endosc. 2009;70(5):980–4.
American Association for Study of Liver Diseases, American College of Gastroenterology, American Gastroenterological Association Institute, American Society for Gastrointestinal Endoscopy, Society for Gastroenterology Nurses and Associates, Vargo JJ, MH DL, Feld AD, Gerstenberger PD, Kwo PY, Lightdale JR, et al. Multisociety sedation curriculum for gastrointestinal endoscopy. Gastrointest Endosc. 2012;76(1):e1–25.
Lee T, Lee CK. Endoscopic sedation: from training to performance. Clin Endosc. 2014;47:141–50.
Administering emergency oxygen. Online resources. The American National Red Cross. 2011. https://www.redcross.org/images/MEDIA_CustomProductCatalog/m4240191_AirwayAdjunctsFactandSkill.pdf. Accessed 3 Jun 2017.
Author information
Authors and Affiliations
Corresponding author
Editor information
Editors and Affiliations
Rights and permissions
Copyright information
© 2018 Springer International Publishing AG
About this chapter
Cite this chapter
Kudsi, J., Balogh, J., Tariq, N. (2018). Sedation for Endoscopy in the Obese Patient. In: Chand, B. (eds) Endoscopy in Obesity Management. Springer, Cham. https://doi.org/10.1007/978-3-319-63528-6_3
Download citation
DOI: https://doi.org/10.1007/978-3-319-63528-6_3
Published:
Publisher Name: Springer, Cham
Print ISBN: 978-3-319-63527-9
Online ISBN: 978-3-319-63528-6
eBook Packages: MedicineMedicine (R0)